WM0401389_Monitoring Well Permit Application_20220822

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: 8/18/2022
2. County: Guilford
3. What type of well are you applying for? (monitoring or recovery):
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
Monitoring
4. Applicant: NCDEQ DWM State Lead Branch, Kristie Oseguera Telephone: [phone]
Applicants Mailing Address: 1637 Mail Service Center Raleigh NC 27699-1637
Applicants Email Address (if available): Kristie.osequera a(�ncdenr.gov
5.. Contact Person (if different than Applicant): Laura Elliott, Terracon Telephone: [phone]
Contact Person's Mailing Address: 7327-G W Friendly Ave Greensboro, NC 27410
Contact Person's Email Address (if available): Iaura.elliottAterracon.com
6. Property Owner (if different than Applicant): United Institutional Baptist Church (Trustees Shirley Wilson & Felton Ray)
Telephone: [phone]
Property Owner's Mailing Address: 802 E Market Street Greensboro, NC 27401
Property Owner's Email Address (if available): 802uibc(a�gmail.com
7. Property Physical Address (Including PIN Number) 700 E Market Street - PIN 7864856869
City Greensboro County Guilford Zip Code 27401
8. Reason for Well(s): UST Groundwater Incident #14204 Former Wick's Mini Mart
(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
(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: the Guilford County MW Permit has been applied for 8/17/22
11. Type of contaminants being monitored or recovered: organics
(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).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Unknown
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: Carolina Soil Investigations Certification No.: 2856
Well Contractor Address: Olin. NC
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: 2
3. Number of wells to be constructed in bedrock: 0
5. How will the well(s) be secured? Locking well cap
and bolted flush mount manhole cover
6. Estimated beginning construction date: 8/25/22
4. Total Number of wells to be constructed: 2 7. Estimated construction completion date: 8/25/22
(add answers from 2 and 3)
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. 143-215.106(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Agent for NCDEQ
Signature of Applicant or *Agent Title of Applicant or *Agent
Laura Elliott, Terracon * 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
well(s) as outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
See attached access agreement United Institutional Baptist Church, Trustees
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: (252
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
C 27105
9800
7

Waste Management
ENVIRONMENTAL QUALITY
Mr. Scott Ryals
Environmental Engineer
DWM UST Section
1637 Mail Service Center
Raleigh, NC 27699-1637
RE: State -Lead Acceptance
Former Wick's Mini Mart
700 E Market Street
Greensboro, Guilford County, NC
Incident Number 14204
Dear Mr. Ryals
July 22, 2022
•
ROY COOPER
Governor
ELIZABETH RISER
Secretary
MICHAEL SCOTT
Director
ReCEtvED
A118 n 3 2oz2
Dfilc;jv: +1y-
cCPON
I am/We are the owner(s) of a parcel of property, located at or near the incident in question, and
hereby permit the Department of Environmental Quality (Department) or its contractor to enter upon said
property for the purpose of conducting an assessment and/or remediation of the groundwater and/or soils
under the authority of G.S. 143-215.94G.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction aitd maintenance of the site and access shall be borne by the Department or
its contractor in accordance with the acceptance of the site into the State -Lead Program. The
Department or its contractor shall protect and prevent damage to the surrounding lands. Any damages
will be restored by the Department or its contractor to as close to the pre -work condition as practicably
possible.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the shortest
feasible route to the nearest public road. The Department or its contractor will notify the landowners
48 hours prior to entry and may enter upon the land at reasonable times and have full right of access
during the period of the investigation.
4. Any claims which may arise against the Department, or its contractor shall be governed by Article 31
of Chapter 143 of the North Carolina General Statutes, Tort Claims Against State Departments and
Agencies, and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon request and
is a public record, in accordance with G.S. 132-1.
�Nothing Compares_
State of North Carolina I Environmental Quality I Waste Management
1646 Mail Service Center 1217 West Jones Street I Raleigh, NC 27699-1646
919 707 8200 T

b. 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. Any 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. No representations or warranties, either expressed or implied, have been
made to me/by the Department, the State of North Carolina, or its/their contractor(s) regarding the
results that may be obtained or the quality of work to be performed
I/We agree not to interfere with, remove or any ways damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely, , , k
,77seetrYt. I.
/1
Signature
Shiley W;Csd'7
7eJ7n 5. 7a.t/
Type/Print Name of Owner or Agent
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Phone Number / E-mail Address
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RE: State -Lead Acceptance
Former Wick's Mini Mart
700 E Market Street
Greensboro, Guilford County, NC
Incident Number 14204
Address
sb��o it/G 2')'01
City/State/tip Code
Of3/ Dat
- "Nothing Compares:-L.—
State of North Carolina I Environmental Quality I Waste Management
1646 Mail Service Center 1217 West Jones Street I Raleigh, NC 27699-1646
919 707 8200 T

Two Type II Monitoring wells
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Neat Cement surrounding
Riser 0-16 feet bgs
Bentonite seal 16-18 feet bgs
Sand 18-30 feet bgs
Screened Interval 20-30 feet bgs
Total Depth Est. 30 feet bgs
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