WM0801189_Application_20220419

Geological Resources, Inc.
April 19, 2022
Mr. Geoff Kegley
NCDEQ - Department of Water Resources
127 Cardinal Drive Extension
Wilmington, North Carolina, 28405 via email: [e-mail]
Re: Monitoring Well Permit Application
Sky Mart (Minuteman 45)
3211 Holden Beach Rd., SW
Supply, NC, 28462
Incident No. 43104
GRI Project No. 4712
Dear Mr. Kegley:
Geological Resources, Inc. (GRI) presents this monitoring well permit application for the installation of
two Type II monitoring wells for the above referenced site. An Access Agreement approved by the
property owner is included.
If you have questions or comments, please contact me at [phone] or
[e-mail].
Sincerely,
Geological Resources, Inc.
&JAo#*"P&k--o"
Rae Troiano Brown, P.G.
Project Manager
attachment
3502 Hayes Road Monroe, North Carolina 28110
Phone [phone] [phone] • Fax [phone]

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: 03/11/2022
2. County: Brunswick County
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): monitoring
4. Applicant: Chris Birchfield Telephone: [phone]
5.
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Applicant's Mailing Address: 3502 Hayes Road, Monroe, NC 28110
Applicant's Email Address (if available): ckb(c-)geologicalresourcesinc.com
Contact Person (if different than Applicant): Rae Troiano Brown Telephone: [phone]
Contact Person's Mailing Address: 3502 Hayes Road, Monroe, NC 28110
Contact Person's Email Address (if available): rtb geologicalresourcesinc.com
Property Owner (if different than Applicant): Cletis Delano, LLC Telephone: [phone]
Property Owner's Mailing Address: 2742 Sea Aire Drive SW, Supply, NC 28462
Property Owner's Email Address (if available): unknown
Property Physical Address (Including PIN Number) 3211 Holden Beach Rd. SW,
City Supply County Brunswick Zip Code 28462
Reason for Well(s): suspected contamination, assessment
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
Type of facility or site for which the well(s) is(are) needed: petroleum retail facility
(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, 43104
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? Yes, 5
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 25-40 Feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Geological Resources, Inc. Certification No.: 3270A
Well Contractor Address: 3502 Haves Road, Monroe, NC 28110
PROPOSED WELL CONSTRUCTION INFORMATION
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 5. How will the well(s) be secured?
material: 2 Bolted manhole cover and locking well cap
3. Number of wells to be constructed in bedrock: 0
6. Estimated beginning construction date: April 2022
4. Total Number of wells to be constructed: 2
(add answers from 2 and 3) 7. Estimated construction completion date: April 2022
ADDITIONAL INFORMATION
1. 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
Signature of Applicant or *Agent
Junior Project Manager
Title of Applicant or *Agent
Christopher Birchfield * 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 attached RTE) (see attached RTE)
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 Raleigh Regional Office GW-22MR Rev. 3-1-2016
Phone: [phone] Barrett Drive
Fax: [phone] Raleigh, NC 27609 Wilmington Regional Office
Phone: [phone] Cardinal Drive Extension
Fayetteville Regional Office Fax: [phone] Wilmington, NC 28405
225 Green Street, Suite 714 Phone: [phone]
Fayetteville, NC 28301-5094 Washington Regional Office Fax: [phone]
Phone: [phone] Washington Square Mall
Fax: [phone] Washington, NC 27889 Winston-Salem Regional Office
Phone: [phone] W. Hanes Mill Road
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
05

RIGHT TO ENTER AGREEMENT
FOR
CONDUCTING SUBSURFACE INVESTIGATIONS
STATE OF NORTH CAROLINA
COUNTY OF BRUNSWICK
We, the undersigned, being all of the fee simple owners of certain tract or parcel designated as 2026-
0905-7300 of the County of BRUNSWICK, recognizing the benefits to said property by reason of
conducting subsurface investigations hereby grant to Sky Investments, Inc. and the agents the right to
enter said property in accordance with the requirements of the State of North Carolina. Sky
Investments, Inc. agents may include Geological Resources, Inc.
The undersigned hereby covenant and warrant that they are the sole owners of said property; that they
solely have the right to grant this right to enter for conducting subsurface investigations against the
lawful claims of all persons whomsoever.
It is agreed that Sky Investments, Inc. shall be responsible for restoring any damage done to the ground
of said property by its employees or its agents during the subsurface investigation and monitoring
period, and that Sky Investments, Inc. shall abandon monitoring wells on said property in accordance
with NCDEQ requirements at the conclusion of the monitoring period.
It is agreed that Sky Investments, Inc. shall hold harmless the owner of the aforementioned property for
any personal injury that might be sustained during the course of conducting or proximately resulting
from the conduct of subsurface investigations.
Right to Enter denied.
Right to Enter granted.
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Date
3502 Hayes Road Monroe, North Carolina 28110
Phone [phone] [phone] • Fax [phone]

LEGEND
0
TYPE II MONITORING WELL
-- —
SUBJECT PROPERTY
BOUNDARY LINE
ADJACENT PROPERTY
BOUNDARY LINE
UTILITY/POWER POLE
O
FUEL DISPENSER
DE
ELECTRIC LINE (OVERHEAD)
SIGN
SIGN
0
DUMPSTER
0
PAD —MOUNTED TRANSFORMER
------
UNDERGROUND STORAGE
TANK BASIN
Note:
This Site Map is based on data from
the Brunswick County CIS of NO.
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SITE MAP
0 15 .30 60
SkyMart/Minuteman 45 3211 Holden Beach Rd., SW
Incident No. 43104 Supply, Brunswick County,
( IN FEET) GRI Project No. 4712 NC
Geological Resources, Inc. 1 inch — 30 ft Date: 09/26/19 Drawn by: DTH Figure: 2