WM0501518_Permit (Issuance)_20221107

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E, ROGERS, JR.
Director
NORTH CAROLINA
Environmental Quality
November 7, 2022
NCDEQ, Division of Waste Management, UST
Attn: Scott Ryals
1646 Mail Service Center
Raleigh, NC 27699
Mr. Greg Hans, Environmental Division Manager
CES Group Engineers, LLP
3525 Whitehall Park Drive, Suite 150
Charlotte, NC 28273
Subject: Monitoring Well Construction
Permit # WM0501518
Hull Grocery Center
205 S. White Street
Whitakers, NC 27891 —Nash County
Mr. Hans:
In accordance with the application received on October 24, 2022, we are forwarding herewith
Monitoring Well Construction Permit No. WM0501518 dated November 7, 2022, issued for the
construction of one monitor well on the Subject property. Please be aware that some counties have well
construction programs, and you may be required to obtain a well construction permit before
installation.
This Permit will be effective from the date of its issuance and shall be subject to the conditions and
limitations as specified therein. Please note the addition of stipulation #3 to the permit enclosed. If you have
any questions about this permit, please contact Tyler Clark at [phone].
Enclosure
cc: RRO Files/Laserfiche
DE
Sincerely,
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
North Carolina Department of Environmental Quality I Envision of Water Resources
512 North Salisbury Street 11611 Mail Service Center I Raleigh, North Carolina 27699-1611
919 707 9000

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and other applicable Laws,
Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
NCDEQ, Division of Waste Management, UST Section
FOR THE CONSTRUCTION OF ONE MONITOR WELL owned by NCDEQ, DWM-UST at mailing
address 1646 Mail Service Center, Raleigh, NC 27699. The wells will be located on the properties
owned by Gloria Hull, 2209 James Slaughter Road, Fuquay-Varina, NC 27526. This Permit is issued in
accordance with the application received on October 24, 2022, in conformity with specifications and
supporting data, all of which are filed with the Department of Environmental Quality and are
considered integral parts of this Permit.
This Permit is for well construction only and does not waive any provision or requirement of any other applicable law or
regulation. Construction of any well under this Permit shall be in strict compliance with the North Carolina Well
Construction Regulations and Standards (15A NCAC 02C .0100), and other State and Local Laws and regulations pertaining
to well construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to an adjudicatory hearing upon
written request within 30 days of receipt of this Permit. The request must be in the form of a written petition conforming
to Chapter 150E of the North Carolina General Statutes and filed with the Office of Administrative Hearings, 6714 Mail
Service Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit is final and binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to other specified conditions,
limitations, or exceptions as follows:
1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these wells are being
installed as part of an investigation for contamination from an underground storage tank or dry cleaner
incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement issued by another
agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as part of the Permit
application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A NCAC 02C .0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of Water Quality's
Information Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with 15A NCAC 02C
.0113 and a well abandonment record (GW-30) shall be submitted to the Division of Water Quality's
Information Processing Unit within 30 days of the well abandonment.
7. If the well penetrates any water -bearing zone that contains contaminated waters, the upper three feet of the
well shall be grouted within one day after the casing is set or the well abandoned.
Permit issued the 7d' of November 2022
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
Scott Vinson, Regional Supervisor
Division of Water Resources
By Authority of the Environmental Management Commission
Permit No. WM0501518
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11611 Mail Service Center I Raleigh, North Carolina 27699-161 1
919 707 9000

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: 10/24/2022
2. County: Nash
FOR OFFICE USE ONLY
PERMIT NO. W/Vitar01.511 ISSUED DATE 0/ 17 / &o I- —
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: NCDEQ Telephone. [phone]
Applicant's Mailing Address: 1646 Mail Service Center, Raleigh, NC 27699
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Greg Hans Telephone: [phone]
Contact Person's Mailing Address: 3525 Whitehall Park Drive, Suite 150, Charlotte. NC 28273
Contact Person's Email Address (if available): ghansCM.ces-group.net
6. Property Owner (if different than Applicant): Gloria J. Hull Telephone [phone]
Property Owner's Mailing Address: 2209 James Slaughter Road, Fuauav-Varina, NC 27526
Property Owner's Email Address (if available): NA
7. Property Physical Address (Including PIN Number) 205 S White Street PIN 022068
City Whitakers County
Nash
Zip Code 27891
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: USTs
(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 known
11. Type of contaminants being monitored or recovered: organics / metals
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? No known
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet) Source Area
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No known
If yes give distance(s):
15. Well Contractor: Regional Probing Certification No. 3322
Well Contractor Address: PO Box 1161, Wake Forest, North Carolina 27588
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? 2 x 2 pad, well
material: One
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: One
covers, locking j-pluq
6. Estimated beginning construction date: 11/7/2022
(add answers from 2 and 3) 7. Estimated construction completion date: 11/7/2022
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 assumes total responsibility for ensuring that the well(s) wdl be located constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Environmental Division Manager
Signature of Applicant or *Agent Title of Applicant or *Agent
Greg Hans * 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 with NCDEQ State Trust Fund)
Signature of Property Owner Of 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
-L-h6-9800
797
r FAjcltxille -y, �r
GW-22M1R (Rev. 5-26-2022)

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Project No:
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Drawing No:
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Scale: NT5
Drawn ay:
Date: 10/2V42
PROJECT TITLE:
'Nur
RAT. r CENTER
•litakera. NC
RICHMOND
ENVIRONMENTAL
SERVICES, INC.
Raleigh, North Carolina

E\%MOM! EVTALPROTECTION
HAZARDOUS SITES RESPONSE PROGRAM
TYPICAL
FLUSH -MOUNT GROUNDWATER MONITORING WELL
CONSTRUCTION DIAGRAM
(SPACING DEPENDS
ON WELL DEPTH:
BOLTED MANHOLE COVER
CONCRETE PAD
MANHOLE SLEEVE
LOCKING WELL CAP
2" SCHEDULE 40 PVC PIPE
BENTONITE GROUT
BENTONITE SEAL
TYPE
SAND PACK
GRAIN SIZE
2" SLOTTED SCHEDULE
40 PVC SCREEN
BOTTOM CAP
BOTTOM OF BORING
ANNULUS

Waste Management
ENVIRONMENTAL QUALITY
June 30, 2022
Mr. Scott Ryals
Environmental Engineer
DWM UST Section
1637 Mail Service Center
Raleigh, NC 27699-1637
RE: State -Lead Acceptance
R W Hill Service Center
205 S White Street
Ro , Nash County, NC
Incident Number 8968
ROY COOPER
Governor
ELIZABETH BISER
Secretary
MICHAEL SCOTT
Director
Dear Mr. RyaIs
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 and 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 C.S. 132-1.
%Nothing Compares
Slate of North Carolina i Environmental Quality Waste Managerncnt
1645 Mail Service Center! 217 West Jones Suer. ; Raleigh, NC 27699 1646
91970782.10 T

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. 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,
f
i ,
6Lt !:
Signature
l,LL
Type/Print Name of Owner or Agent
_ Q19- 2t2- 8?0
Phone Number / E-mail Address
si
Addr ss
Luk7 Octg,
(-Ur: , &14-r-CL. 4)C c--11 g67
ity/Stab /Zip Code
Date
RE: State -Lead Acceptance
R W,HilrService Center 14-/-64-L
205 5 White Street
(Aivq-c Rnck4iiauat4lash County, NC 72�
Incident Number 8968
�'NothIng Compares:-L,
State of North Carolina I Environmental Quality , Waste Management
i 646 Mail Service Center 12!7 West Jones Street Raleigh, NC 27699-1646
919 707 8200 T