WM0401349_Monitoring Well Permit Application_20220215

AECOM
February 11, 2022
AECOM Technical Services of North Carolina, Inc.
6000 Fairview Road, Suite 200
Charlotte, NC 28210
Mr. Jim Gonsiewski
Winston-Salem Regional Office
Division of Water Resources
Water Quality Regional Operations Section
Re: Monitoring Well Permit Applications
LIF-46 through LIF-69
Colonial Pipeline Company - Lexington Booster Station
667 Helmstetler Road, Lexington, Davidson County, NC
NCDEQ Incident Number: 95267
Dear Mr. Gonsiewski:
[phone] tel
On behalf of Colonial Pipeline Company, AECOM Technical Services of North Carolina, Inc. (AECOM)
has prepared the attached permit application in accordance with 15A NCAC 2C .0105. This well permit
application is for the construction of 24 temporary monitoring points (LIF-46 through LIF-69) in
association with NCDEQ Incident Number 95267, the Colonial Pipeline Company Lexington Booster
Station (site) located at 667 Helmstetler Road, Lexington, Davidson County, North Carolina. The proposed
temporary well locations are to be located on the following properties:
• LIF-46 through LIF-52:
Joey and Shaina Smith, 676 Helmstetler Road, Lexington, NC 27295
PIN 6705-04-50-7757
• LIF-53 through LIF-69:
Irvin Lavon Grubb, Helmstetler Drive, Lexington, NC 27295
PIN 6705-03-31-5952
Included herein are the Applications for Permit to Construct a Monitoring or Recovery Well System packets
for each of the aforementioned properties. Each packet includes Form GW-22MR, a map of the proposed
well locations, general well construction diagrams, and signed access agreements.
Upon approval, please forward the monitoring well construction permit(s) to me at
[e-mail]. If you have any questions or require additional information, please do not
hesitate to call me at 412-977-4074.
Sincerely,
AECOM TECHNICAL SERVICES OF NORTH CAROLINA, INC.
#_? 7--da
Jeffrey T. Hvozdik, PG
Project Manager

DocuSign Envelope ID: 45573339-74AB-4C75-92BE-C3FEC4D4DBDF
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: February 4, 2022
2. County: Davidson
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Colonial Pipeline Company Telephone: [phone]
Applicant's Mailing Address: 3925 Anderson Farm Rd, Powder Springs, GA 30109
Applicant's Email Address (if available): jmorrison(a colpipe.com
5. Contact Person (if different than Applicant): Jeff Hvozdik (AECOM) Telephone: [phone]
Contact Person's Mailing Address: 6000 Fairview Road, Suite 200, Charlotte, NC 28210
Contact Person's Email Address (if available): jeff.hvozdik(a�aecom.com
6. Property Owner (if different than Applicant): Joey Van Smith, and Shaina Hope Craver Smith Telephone:
Property Owner's Mailing Address: 676 Helmstetler Rd, Lexington, NC 27295
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 676 Helmstetler Rd, Lexington, NC 27295
City Lexington County Davidson Zip Code 27295
8. Reason for Well(s): Assessment, groundwater contamination
(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: Pipeline booster station
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
10. Are there any current water quality permits or incidents associated with this facility or site? If so, list permit and/or incident no(s).
NCDEQ Incident Number 95267
11. Type of contaminants being monitored or recovered: Petroleum
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 51
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0400963, WM0400885, WM0401041, WM0401042, WM0401043,
WM0401241, WM0401242, WM0401243, WM0401244, WM0401245, WM0401250, WM0401251
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 380
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? 6
If yes, give distance(s): —420 feet SW (WSW-20), —270 feet E (WSW-01), —360 feet NE (WSW-22), —430 feet NE (WSW-18),
—500 feet NW (WSW-24), —460 feet NNW (WSW-3),
15. Well Contractor: Geologic Exploration Certification No.: Varies by individual driller
Well Contractor Address: 176 Commerce Boulevard, Statesville, NC 28625
PROPOSED WELL CONSTRUCTION INFORMATION
1. As required by 15A NCAC 02C .0105(f)(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

DocuSign Envelope ID: 45573339-74AB-4C75-92BE-C3FEC4D4DBDF
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Temp wells will
material: 0 (6 temporary only) be abandoned immediately following sampling
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: Nov. 2021
4. Total Number of wells to be constructed: 0 7. Estimated construction completion date: Nov. 2021
(add answers from 2 and 3)
1.
ADDITIONAL INFORMATION
As required by 15A NCAC 02C .0105(f)(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. All 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 Construction 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
Manager, operations
DocuSigned by:
trim , SKA,
Si tsidf:or,ihnt or *Agent
Bri an
Smith
Printed name of Applicant or *Agent
(ter-
Signatur of Prdperty Owner (if different than Applicant) Printed neer-n-1 of Property Owner (if different than Applicant)
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
wfjl(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
r tl )
3e 5
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]
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, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016
Raleigh Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension
GW-22M (Rev. 5/11)

LEGEND
•®•O0-•DD•
0
LIF-3
10.10
Release Point
Deep Monitoring Well Location
Intermediate Monitoring Well Location
Shallow Monitoring Well Location
Grab Sample Location
Water Supply Well - In Use
Water Supply Well - Not In Use
Water Supply Well - Abandoned
Proposed LIF boring
Approximate Location of Pipeline
Parcel Lines
Roadway Centerlines
Major Hydrography
Minor Hydrography
LIF Boring Location, Identification and UVOST
RE Results
Inferred extent of LIF boring results >1% RE
Limit of LNAPL
Notes:
Site features based on "Site Plan" from Apex CAD
No. CPC18000.006, 1/30/18
Pipeline location based on images provided by
Colonial Pipeline Company on 8/1/19
Parcel lines and centerlines obtained from Davidson
County Information Technology/GIS (http://www2.-
co.davidson.nc.us/GIS/Web_GISDownloads.aspx)
on 2/7/19
Hydrography obtained from City of Lexington
(https://lexington.connectgis.com/Map.aspx) on
2/14/19
UVOST - Ultra -Violet Optical Screening Tool
RE - Reference Emitter
LIF - Laser -Induced Fluorescence
LNAPL - Light Non -Aqueous Phase Liquid
MW-19
•
P-4
WSW-21
•
GP-5
LIF-3 0
13.70
153.30
f
LIf-6
2.00
LIF-43
1.50
LIF-10
LIF-7
LIF-11
MW-10 LIF-
19.80
LIF-14
LIF-20
LIF-44
0110.20
WSW-20 •
LIF-455
64.50
MW-28
2
LIF-15
0.20
LIF-36
0.8
LIF-24
MW-2
LIF-39
3 4/
LIF- 1
3. 0
MW-26N
LIF-25
0 1
0
LIF-f8
LIF-f7
44.50
LIF-�
0.7�
•
GP-8
•
MW-14
17.80
LIF-41--
•LIF-48 • LIF-52
LIF-47 •LIF-51
LIF-46 •
AC
-19
LIF-32
5 n
3.80
MW-21M /18! LIF-8
LIF-30
38E z.u0
GP-11
0.8
OLIF-16
0.9
0 LIF-22
0.9
GP- LIF-13 0 LIF-37
0.8
0 LIF-38
LIF 5 1.30
MW-15DD
i
GP-1
MW-15
MW-15D
GP-13
•
WSW-22 ED
WSW-01 e
0 80
APPROX. SCALE, ft.
Z
d
Proposed LIF Boring Location Map

DocuSign Envelope ID: 45573339-74AB-4C75-92BE-C3FEC4D4DBDF
LIF DIRECT PUSH WELL CONSTRUCTION
GROUND SURFACE
-35'
APPROXIMATELY 40'TOTAL DEPTH
5'
NOTE: DRAWING NOT TO SCALE
GEOPROBE RODS, NOMINAL 2-INCH
SOIL
UVOST-EC TOOLI2G
LIF DPT WELL CONSTRUCTION DIAGRAM
AECO4
AECOM TECHNICAL SERVICES
OF NORTH CAROLINA, INC.
6000 FAIRIEW ROAD, SUITE 200
CHARLOTTE, NC 28210
TEL:[phone]
Colonial Pipeline Company
667 Helmstetler Road
Lexington, Davidson County, NC
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g cc
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FEET.

DocuSign Envelope ID: 7B6F12D5-EE69-42FB-B436-CC19B6588DC5
IYVR I n VNRVLIIYN UCrNR 1 1Y1CIY 1 yr iPY V.rwi 1MENTAL 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: February 4, 2022
2. County: Davidson
3.
4. Applicant: Colonial Pipeline Company
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring
Applicant's Mailing Address: 3925 Anderson Farm Rd, Powder Springs, GA 30109
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Jeff Hvozdik (AECOM)
Telephone: [phone]
Telephone: [phone]
Contact Person's Mailing Address: 6000 Fairview Road, Suite 200, Charlotte, NC 28210
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Irvin Lavon Grubb Telephone: [phone]
Property Owner's Mailing Address: 775 Helmstetler Rd, Lexington, NC 27295
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) N side of Shermans Crossing near Helmstetler Rd (PIN 6705-03-31-5952)
City Lexington County Davidson Zip Code 27295
8. Reason for Well(s): Assessment, groundwater contamination
(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: Pipeline booster station
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
10. Are there any current water quality permits or incidents associated with this facility or site? If so, list permit and/or incident no(s).
NCDEQ Incident Number 95267
11. Type of contaminants being monitored or recovered: Petroleum
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 51
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0400963, WM0400885, WM0401041, WM0401042, WM0401043,
WM0401241, WM0401242, WM0401243, WM0401244, WM0401245, WM0401250, WM0401251
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 150
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? 7
If yes, give distance(s): -430 feet S (WSW-20), -375 feet ESE (WSW-01), -400 feet ENE (WSW-22), -440 feet NE (WSW-18),
-325 feet N (WSW-24), -325 feet N (WSW-3), -400 feet N (WSW-4)
15. Well Contractor: Geologic Exploration Certification No.: Varies by individual driller
Well Contractor Address: 176 Commerce Boulevard, Statesville, NC 28625
PROPOSED WELL CONSTRUCTION INFORMATION
1. As required by 15A NCAC 02C .0105(f)(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

DocuSign Envelope ID: 7B6F12D5-EE69-42FB-B436-CC19B6588DC5
rrwrvor=v t..vivo i rcUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated
material: 0 (17 temporary only)
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 0
(add answers from 2 and 3)
5. How will the well(s) be secured? Temp wells will
be abandoned immediately following sampling
6. Estimated beginning construction date: Nov. 2021
7. Estimated construction completion date: Nov. 2021
1.
ADDITIONAL INFORMATION
As required by 15A NCAC 02C .0105(f)(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. All 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 Construction 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
Manager Operations
DocuSigned by:
brim, im, S 1444,
Sign�atureofAAppliccant or *Agent
c 3BrFiFan Smith
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).
See attached signed access agreement
Signature of Property Owner (if different than Applicant)
Irvin Lavon Grubb
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]
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
A.4.4.6„
nl
1411
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
.
41:4
• IP
ngtan
GW-22MR Rev. 3-1-2016
Raleigh Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension
GW-22M (Rev. 5/11)

DocuSign Envelope ID: 7B6F12D5-EE69-42FB-B436-CC19B6588DC5
LEXINGTON, NC
LOC. 832
PERMIT AGREEMENT
Receipt is hereby acknowledged Five Hundred and No/100 dollars ($500.00) paid by COLONIAL
PIPELINE COMPANY, 1885 Sanctuary Parkway, Alpharetta, Georgia, a Delaware and Virginia
corporation hereinafter "Colonial" and IRVIN LAVON GRUBB hereinafter "Landowner", whether
one or more, the receipt and sufficiency of which is hereby acknowledged, do hereby grant,
consent and give permission to "Colonial", its agents or assign to enter lands owned by said
"Landowner", it successors and assigns, for the purpose of installing monitoring equipment and
the right to periodically obtain water samplings from "Colonial's" installed equipment or from
streams, seeps, and existing wells on "Landowner's" property, "Landowner" agrees to allow
"Colonial" its agents or assigns reasonable access and ingress to aforementioned testing or
sampling areas and wells on "Landowner's" property so as not to interfere or damage personal
or real property of this Permit Agreement. "Landowner's property is described as follows:
Davidson County Tax Parcel 1802500000057 Lexington, North Carolina
In further consideration for this permit herein granted, "Colonial" agrees to pay "Landowner" its
tenants or assigns for any actual damage caused to any personal or real property on said land
caused by the exercise of these rights herein granted.
"Colonial" shall operate the testing and water monitoring so long as required by the North Carolina
Department of Environmental and Natural Resources (NCDENR). When testing is no longer
required, this permit shall terminate and "Colonial" shall, at "Colonial's expense, remove
equipment, and restore the land to its condition as existed prior to "Colonial" entering the
property.
r�-
Dated this 2 day of July, 2015
"LANDOWNER"
Irvin Lavon Grubb
/IX
Colonial Pipeline Company

DocuSign Envelope ID: 7B6F12D5-EE69-42FB-B436-CC19B6588DC5
LEGEND
•®•O0-•DD•
Release Point
Deep Monitoring Well Location
Intermediate Monitoring Well Location
Shallow Monitoring Well Location
Grab Sample Location
Water Supply Well - In Use
Water Supply Well - Not In Use
Water Supply Well - Abandoned
Proposed LIF boring
Approximate Location of Pipeline
Parcel Lines
Roadway Centerlines
Major Hydrography
Minor Hydrography
• LIF Boring Location, Identification and UVOST
LIF-3 RE Results
10.10
- - - Inferred extent of LIF boring results >1% RE
Limit of LNAPL
Notes:
Site features based on "Site Plan" from Apex CAD
No. CPC18000.006, 1/30/18
Pipeline location based on images provided by
Colonial Pipeline Company on 8/1/19
Parcel lines and centerlines obtained from Davidson
County Information Technology/GIS (http://www2.-
co.davidson.nc.us/GIS/Web_GISDownloads.aspx)
on 2/7/19
Hydrography obtained from City of Lexington
(https://lexington.connectgis.com/Map.aspx) on
2/14/19
UVOST - Ultra -Violet Optical Screening Tool
RE - Reference Emitter
LIF - Laser -Induced Fluorescence
LNAPL - Light Non -Aqueous Phase Liquid
MW-19
P-4
WSW-21
GP-5
•
//-
LIF-69 LIF 68
• LIF-67
LIF 63 •
LIF-62
••
66 LIF-65 LIF 64
• LIF-61 LIF-60 •
• • � 59 LIF-58 LIF-57
•
LIF-3 0
13.70
153.30
f
LIf-6
2.00
LI F
1.50
LIF-10
LIF-7
LIF-11
MW-10 LIF-
19.80
LIF-14
LIF-20
LIF-44
0110.20
WSW-20 6
LIF-455
64.50
MW-28
2`?
LIF-15
0.20
LIF-36
0.8
LIF-24
LIF-39
3 4/
LIF- 1
3. 0
MW-26N
LIF-25
0 1
0
LIF-f8
LIF-f7
44.50
0
LIF-�
0.7�
•
GP-8
MW-14
17.80
LIF-32
•LIF-56
•
LIF-55 • LIF-54
I F-53
LIF-19
GP- LIF 13 0 LIF-37
0.8
0 LIF-38
5 A 0 LIF-5 1.30
/\ 3.80
MW-21 M LIF-8
LIF-30
0 2.00
GP-11
0.8
OLIF-16
0.9
LIF-22
0.9
i
GP-1
MW-15DD
MW-15
MW-15D
GP-13
WSW-22 ED
WSW-01 e
0 80
APPROX. SCALE, ft.
Z
d
Proposed LIF Boring Location Map

DocuSign Envelope ID: 7B6F12D5-EE69-42FB-B436-CC19B6588DC5
LIF DIRECT PUSH WELL CONSTRUCTION
GROUND SURFACE
—35'
APPROXIMATELY 40'TOTAL DEPTH
5'
NOTE: DRAWING NOT TO SCALE
GEOPROBE RODS, NOMINAL 2-INCH
SOIL
UVOST-EC TOOLI2G
LIF DPT WELL CONSTRUCTION DIAGRAM
AECOM TECHNICAL SERVICES
A:COM OF NORTH CAROLINA, INC.
6000 FAIRIEW ROAD, SUITE 200
CHARLOTTE, NC 28210
TEL: [phone]
Colonial Pipeline Company
667 Helmstetler Road
Lexington, Davidson County, NC
cc
SHEET: