WM0401363_Monitoring Well Permit Application_20220505

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: 5/3/22
2. County: Davidson
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Geological Resources, Inc. Telephone: [phone]
Applicant's Mailing Address: 3502 Hayes Road, Monroe NC 28110
Applicant's Email Address (if available): rtb(a�geologicalresourcesinc.com
5. Contact Person (if different than Applicant): Rae Troiano Brown Telephone: [phone]
Contact Person's Mailing Address: 3502 Haves Road, Monroe NC 28110
Contact Person's Email Address (if available): rtb(ageologicalresourcesinc.com
6. Property Owner (if different than Applicant): John and Shirley Dingus Telephone: [phone]
Property Owner's Mailing Address: 218 Evans Road, Thomasville NC 27360
Property Owner's Email Address (if available): NA
7. Property Physical Address (Including PIN Number) PIN 6757-04-64-8582; 218 Evans Road
City Thomasville
FOR OFFICE USE ONLY
PERMIT NOW MOt40 (a—TSSUEDDATE S/ f
County Davidson
Zip Code 27360
8. Reason for Well(s): assessment ground water 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: 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).
No
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? 23
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401081 and WM0401292 (attached)
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 60'
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 Hayes Road, Monroe NC 28110
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 5. How will the well(s) be secured?
material: 1 Bolted manhole cover with locking well cap
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: May 2022
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: May 2022
(add answers from 2 and 3)
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
fed/1044U ature of Applicant or *Agent
Rae Troiano Brown
Proiect Manager, P.G.
Title of Applicant or *Agent
* 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
John Dingus
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]
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
Phone: [phone]
Fax: [phone]
ngton
GW-22MR Rev. 3-1-2016

RIGHT TO ENTER AGREEMENT
FOR
CONDUCTING SUBSURFACE INVESTIGATIONS
STATE OF NORTH CAROLINA
COUNTY OF DAVIDSON
We, the undersigned, being all of the fee simple owners of certain tract or parcel designated as
1633100000007 of the County of DAVIDSON, recognizing the benefits to said property by reason of
conducting subsurface investigations hereby grant to Rex Oil Company and the agents the right to enter
said property in accordance with the requirements of the State of North Carolina. Rex Oil Company
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 Rex Oil Company 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 Rex Oil Company shall abandon monitoring wells on said property in accordance with NCDEQ
requirements at the conclusion of the monitoring period.
It is ai•reed that Rex Oil Company 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.
Tight to Enter granted.
phone : ) % Q- '5c/ d
Date
3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]

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TYPE II MONITORING WELL
TYPICAL CONSTRUCTION DETAILS
CONCRE?E PAD
GROUND SURFACE
GROUT CElA7V r
BENTONITE SEAL
SAND FILTER PACK
45' bgs
4:11
tl,
4
w�
z 26' bgs
1://1)
J`
/✓✓� g
, ▪ • !,,r 2 8 b s N
t
:▪ ;)s; 30' bgs
MANHOLE COVER
LOCKING WELL CAP
2 /NCH DIAMETER
SCHEDULE 40 PVC CASING
0 010 INCH SLOTTED
2 INCH D/AML7ER
SCHEDULE 40 PVC SCREEN
END CAP