WM0401366_Monitoring Well Permit Application_20220516

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: 5/11/2022
2. County: Davie
3.
4. Applicant: Joey Rusher
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring
Applicant's Mailing Address: PO Box 1483 Salisbury, NC 28145
Telephone: [phone]
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Sam McKay (Consultant -Geological Resources, Inc.) Telephone: [phone]
Contact Person's Mailing Address: 3502 Hayes Road, Monroe, NC 28110
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Sampson-Bladen Oil
Property Owner's Mailing Address: PO Box 469 Clinton, NC 28328
Telephone: [phone]
Property Owner's Email Address (if available): [e-mail]
7. Property Physical Address (Including PIN Number) 1532 Yadkinville Road Parcel #H40000001301
City Mocksville County Davie Zip Code 28028
8. Reason for Well(s): Assessment
(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: UST — Gas 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).
48104
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? No
Existing Monitoring or Recovery Well Construction Permit No(s).: N/A
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 15'
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Unknown
If yes, give distance(s):
15. Well Contractor: Sam Bowers of Geological Resources, Inc. Certification No.: 3220-A
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
material: 1
3. Number of wells to be constructed in bedrock: 0
5. How will the well(s) be secured? Locking cap and
manhole
6. Estimated beginning construction date: 5/16/2022
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3) 7. Estimated construction completion date: 6/17/2022
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
Signature of Applicant or *Agent
Sam McKay, III; Geological Resources, Inc.
Printed name of Applicant or *Agent
Project Manager
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 Signed RTE ( Right to Enter agreement)
Signature of Property Owner (if different than Applicant)
Sampson-Bladen Oil
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

RIGHT TO ENTER AGREEMENT
FOR
CONDUCTING SUBSURFACE INVESTIGATIONS
STATE OF NORTH CAROLINA
COUNTY OF DAVIE
RUSHCO FOOD STORE #8
GRI PROJECT NO. 5725
We, the undersigned, being all of the fee simple owners of certain tract or parcel designated as
H4000000I301 of the County of Davie. recognizing the benefits to said property by reason of conducting
monitoring well installations hereby grant to the NCDEQ/(Ruscho Food Store #8) and their agents the right
to enter said property in accordance with the requirements of the State of North Carolina. The
NCDEQ/(Ruscho Food Store #8) 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 the monitoring well installations against the lawful
claims of all persons whomsoever.
It is agreed that the NCDEQ/(Ruscho Food Store #8) shall be responsible for restoring any damage done to
the ground of said property by its employees or its agents during the monitoring well installations and
monitoring period, and that the NCDEQ/(Ruscho Food Store #8) shall abandon the monitoring wells on
said property in accordance with NCDEQ requirements after the incident has been closed.
It is agreed that the NCDEQ/(Ruscho Food Store #8) 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.
Phone: e 5 /4 /3
2/707-
Date
3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]

LEGEND
(o)
UNDERGROUND STORAGE TANK
FUEL DISPENSER
Note:
1. This Site Map is based on data from the Davie
County, NC GIS Office.
GRASS
r-1r—lr-1
J
8K—Gallon
Premium UST
8K—Gallon
Regular USTs
(2)
0
Rushco
0
Food
`-'
Store
❑
❑
YAD
KINVILLE ROAD
GRASS
Geological Resources, Inc.
0 15 30
60
( IN FEET )
1 inch =30 ft
SITE MAP
Rushco Food Store 8
Incident No. N/A
CH Project No. 5725
1532 Yadkinville Road
Mocksville, North Carolina
Davie County
Dote:
06/27/2021
Drawn by:
DTH
Figure: 2

YPE II MONITORING WELL
TYPICAL CONSTRUCTION DETAILS
CONCRETE PAD
GROUND SURFACE
GROUT CEMENT
BENTON/TE SEAL
SAND FILTER PACK
e
•
MANHOLE COVER
LOCKING WELL CAP
2 INCH DIAMETER
SCHEDULE 40 PVC CASING
0.070 /NCH SLOTTED
2 /NCH DIAMETER
SCHEDULE 40 PVC SCREEN
END CAP