WM0401355_Monitoring Well Permit Application_20220419

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: 04/14/2022
2. County: Watauga
3.
4.
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring
Applicant: NCDEQ — DWM — UST Section Telephone: [phone]
Applicant's Mailing Address: 217 West Jones St, Raleigh, NC 27603
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Matthew James
Contact Person's Mailing Address: 115 MacKenan Dr., Cary, NC 27511
Contact Person's Email Address (if available): [e-mail]
Telephone: [phone]
6. Property Owner (if different than Applicant): Robert & Geraldine Ward Telephone: [phone]
Property Owner's Mailing Address: PO Box 624, Valle Crucis, NC 28691
Property Owner's Email Address (if available): N/A
7. Property Physical Address (Including PIN Number)3553 NC Hwy 194 S — 1970-9720-62000
City: Valle Crucis County Watagua Zip Code 28679
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: Former UST
(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).
Yes Incident # 19273
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? Two
Existing Monitoring or Recovery Well Construction Permit No(s).: None
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 50 ft
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? YES
If yes, give distance(s): —500
15. Well Contractor: M&W Drilling Certification No.: 2332-A
Well Contractor Address: PO Box 7024 Knoxville, TN
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

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated
material: w
5. How will the well(s) be secured? Locking well cap
and bolt down cover
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: May1
4. Total Number of wells to be constructed: 2
(add answers from 2 and 3)
7. Estimated construction completion date: May 1
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
71t Project Manger
Signature of Applic nt or *Agent Title of Applicant or *Agent
Matthew James * If signing as Agent, attach authorization agreement
stating Printed name of Applicant or *Agent 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 Access Agreement See Access Agreement
Signature of Property Owner (if different than 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]
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)

1/ Engineers I Planners 1 Surveyors
115 MacKenan Drive I Cary, NC 27511 1 t: 919.469.3340 I license #: C-0832
www.withersravenel.com
WithersRavenel
MAST GENERAL STORE
3565 NC HWY 194 S
SUGAR GROVE, WATAUGA COUNTY, NC
GENERAL LOCATION MAP
DRAWN BY:
DCV
APPROVED BY:
MJ
SCALE:
1"=3000'
DATE:
09/23/21
FIGURE NO.:
1
PROJECT NO.:
02173214.06
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ciDISSOLVED BENZENE IN GROUNDWATER
(DASHED WHERE INFERRED)
NOTES:
1.) AERIAL OBTAINED FROM THE LOCAL COUNTY GIS DEPARTMENT.
PAVED
PARKING
AREA
COMMERCIAL
PROPERTY
RESIDENTIAL
PROPERTY
GRAPHIC SCALE
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TYPE II WELL CONSTRUCTION
(TYPICAL OF TWO)
LOCKING WELL CAP
ASPHALT SURFACE
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2—INCH DIAMETER PVC SCREEN
(0.01' SLOT)
• —PVC BOTTOM CAP
DIAMETER OF BORING VARIES
a. W i t h e rs Rave n e l
/ Our People. Your Success.
MAST GENERAL STORE- INCIDENT # 19273
3565 NC HWY 194 S
VALLE CRUCIS, WATAGUA COUNTY, NC
DRAWN BY:
MJ
SCALE:
NTS
FIGURE NO.
1
APPROVED BY:
MJ
DATE:
04/14/22
JOB NO:
02173214.06
PROPOSED MONITORING WELL DIAGRAM

. 4 r
Envlronmenraf
Qua fir),
North Carolina Department of Environmental Quality
Division of Waste Management
Roy Cooper
Governor
Elizabeth S. Biser
Secretary
Site Access Agreement Page 2 of 2
NCDEQ Access Agreement for Watauga County Parcel # 1970-97-2062-000
3553 NC Hwy 194 S
Sugar Grove, Watauga County, NC
Mast General Store
3565 NEC Hwy 194 5
Sugar Grove, Watauga County. NC
NCDEQ Incident # 19273
WR Project # 02173214.06
6. The activities to be carried out by the Department or its contractor are for the primary benefit of the
Department and of the State of North Carolina. My benefits accruing to the owner are incidental.
The Department or its contractor is not and shall not be construed to be an agent, employee. or
contractor of the landowner.
I/We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's we1I(s) and equipment during the investigation.
Attest:
11/4I rift 'ill
hh lye t{-Signature
a 4
Type/Print Name(s) of Owner/Agent
8 a-g-1 3..-
Phone Number
Owner(s) Mailing Address
City, State, Zip Code
3-- 3Y-
Date
b
- '4