WM0401320_Monitoring Well Permit Application_20211015

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
PLEASE TYPE OR PRINT CLEARLY
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery wells.
1. Date: 10-12-21
2. County: Yadkin
3. What type o'
4. Applicant: Moxleys Oil Company, Inc,
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
ell are you applying for? (monitoring or recovery):
Monitoring
Telephone: [phone]
Applicant's Mailing. Address: 101 N. Cherry Street, Winston-Salem, North Carolina 27101
Applicant's Email Address (if available): bedgeOironpointfinancial.com
Contact Person (if different than Applicant): Mr: Bart Edge
Telephone:. _ 910.616.9256
Contact Person's Mailing Address: 101 N. Cherry Street, Winston-Salem, North Carolina 27101
Contact Person's'Etnai! Address (if available): bedgetcironpointfinanciai.com
Property Owner (if different than Applicant): Yadkin Nursing Care Center. Inc. Telephone: [phone]
Property Owner's Mailing Address; P.O. Box 969, Yadkinville, North Carolina 27055
Property Owner's Email Address (if available): nick.elledge(c' triadgroupinccorn
Property Physical Address (Including PIN Number) 903/904 Wes( Main Street (130231)
City Yadkinville
County Yadkin
Reason for Well(s): Comprehensive Site Assessment
Zip Code 27055
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
9. Type of facility or site for which the well(s) is(are) needed:
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
10. Are there any current water quality permits or incidents associated with this faciiiiy or site? If so, list permit and/or incident no(s)
No
Gasoline Station
11. Type of contaminants being monitored or recovered: Gasoline
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? No
Existing Monitoring or Recovery Well Construction Permit No(s).: NIA
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 20-50 eat
14. Are thereany water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: 3D Environmental Investigations, LLC Certification No.: 3162-A
Well Contractor Address: 2157 Mocksville Highway. Statesville, North Carolina 28625
PROPOSED WELL CONSTRUCTION INFORMATION
1. As required by 15A NCAC 02C .0105(1)(7), attach a well construction diagram of each well showing the following:
a. Borehole and well diameter e. Type of casing material and thickness
b. Estimated well depth f. Grout horizons
c. Screen intervals g. Well head completion details
d. Sand/gravel pack intervals

Continued on Reverse
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated
material: 1
3. Number of wells to be constructed in bedrock: 0
5. How will the well(s) be secured? Bolted cover and
Locking cap
6. Estimated beginning construction date: 10/20/21
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3) 7, Estimated construction completion date: 10/30/21
1.
ADDITIONAL INFORMATION
As required by 15A NCAC 02C .0105(t)(5), attach a scaled map of the site showing the locations of the following:
a. All property boundaries, at least one of which is referenced to a minimum of two landmarks such as identified roads,
intersections, streams, or lakes within 500 feet of the proposed well or well system.
b. All existing wells, identified by type of use, within 500 feet of the proposed well or well system,
c. The proposed well or well system.
d. Any test borings within 500 feet of proposed well or well system,
e. Ail sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or fuel
storage areas, animal feedlots as defined in G.S. 143-215.10B(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant hereby agrees that the proposed well(s) will be constructed in accordance with approved specifications and conditions of
this Well,Constion Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
Subchapter 2C) and accepts full responsibility for compliance with these rules
Project Manager
Signature of Applicant or *Agent
Bart Edge on behalf of Moxlevs Oil Company, Inc.
Printed name of Applicant or *Agent
Title of Applicant or *Agent
* if signing as Agent, attach authorization agreement stating
that you have the authority to act as the Agent.
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the applicant to construct
wells as outlined in this Well Construction Permit application and that it shall be the responsibility of the applicant to ensure that the
well(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
Signature of Property Owner (if different th Applicant) Printed name of Property Owner (if different than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water Resources' Regional Office:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
6-9800
797
GW-22MR Rev. 3-1-2016

SB-1
MW-1°
DW-1 a
APPROXIMATE LOCATION OF SOIL BORING
APPROXIMATE LOCATION OF SHALLOW MONITORING WELL
APPROXIMATE LOCATION OF DEEP MONITORING WELL
DRAWN
JAB
CHECKED
JSL
SCALE
SHOWN
DATE
JULY 2021
DATE
JULY 2021
PROJECT
1021039.002
FILE NAME
Figure 2.SKF
Progress
ENVIRONMENTAL GROUP, INC.
P.O. Box 5884
WINSTON-SALEM, NORTH CAROLINA27113
PHONE [phone] FAX [phone]
FIGURE 2
PROPOSED SOIL BORING AND
MONITORING WELL LOCATIONS MAP
WILLIAMS AND GENTRY-B
913 WEST MAIN STREET
YADKINVILLE, NORTH CAROLINA

Progress O`
ENVIRONMENTAL 120 Fayette Street
Wi
Winston-Salem, North Carolina 27101
[phone]
Project: Williams and Gentry - B Site
Location: Yadkmville, NC
Boring/We11 ID:
MW-g
Date: October 2021
Project Manager: J. Rallsieper
Job No.: 1021039.001
Start Date: 10/21/21 Hole Diameter: 6.25"
Complete Date: 10/21/21 Casing Diameter: Remarks.
Drilling Method: Sonic Drilling
IDle
0Q„
WW
a
Water
Table
a
Geologic Description
Well Diagram
Ground
Surface
10
•
(4.0') Grout
(20 0')
PVC Casing
2"
(14.0')
♦
Bentonite
10 —
20
(15.0')
PVC Screen
2"
=
—
(17.0')
Quartz
20
#2
Sand —
30
30
40
Monitoring Well Installed to 35 feet bls
40
50 —
60
50
60
Geologist:
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