WQ0029894_Final Permit_20230119 (6)

DocuSign Envelope ID: 9313E5A3-DB6B-4936-814A-03BD6BB697F1
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR. NORTH CAROLINA
Director Environmental Quality
January 19, 2023
Bowers & Burrow, Inc.
P.O. Box 137
Henderson, N 27536-0137
Subject: Monitoring Well Construction
Permit # WM0501536
105 Old Epsom Road
Henderson, NC 27536 — Vance County
Mr. Hallett:
In accordance with the application received on December 16, 2022, we are forwarding herewith
Monitoring Well Construction Permit No. WM0501536 effective December 31, 2022, issued for the
construction of a monitor well system (installation of one well). 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
NORTH CAROLINA
Department M Environmental Quality
Sincerely,
cu Signed by:
&AAA-SSA,
f. A� ail ltit al f or�
916E6AB32144F.
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11611 Mail Service Center I Raleigh, North Carolina 27699-1611
919.707.9000

DocuSign Envelope ID: 9313E5A3-DB6B-4936-814A-03BD6BB697F1
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
Mr. William Regenthal, Geological Resources, Inc.
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of one monitoring well
owned by Bowers & Burrow, Inc. P.O. Box 137, Henderson, N 27536-0137. The well will be
located at 105 Old Epsom Road, Henderson, NC 27536, on property owned by Mohamed M.
saleh. This Permit is issued in accordance with the application received on December 16, 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 150B 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 19th of January 2023
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
DocuSigned by:
VouA.t,SSA, f. AILM1 ut L For
B2916E6AB32144F_
Scott Vinson, Regional Supervisor
Division of Water Resources
By Authority of the Environmental Management Commission
Permit No. WM0501536
£D_E
NORTH CAROLINA
Departmentof Environmental Duel
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11611 Mail Service Center I Raleigh, North Carolina 27699-1611
919.707.9000

DocuSign Envelope ID: 9313E5A3-DB6B-4936-814A-03BD6BB697F1
GR
Geological Resources, Inc.
December 21, 2022
Mr. Scott Vinson
NCDEQ, Division of Water Quality
Raleigh Regional Office
3800 Barrett Drive
Raleigh, North Carolina 27609
Re: Monitoring Well Permit Application
Carolina Market
501 Old Epsom Road
Henderson, Vance County
Incident No: 46124
Dear Mr. Rice:
Please find enclosed a monitoring well permit application for the installation of one Type II monitoring
well at the Carolina Market site located at 501 Old Epsom Road in Henderson, Vance County. GRI plans
on installing the monitoring well immediately upon receipt of the approved well permit.
Your prompt attention to this matter will be greatly appreciated. If you have any questions or require
additional information please do not hesitate to contact me at [phone].
Sincerely,
!mil/
William Regenthal, P. G.
Project Manager
enclosures
cc: file
3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]

DocuSign Envelope ID: 9313E5A3-DB6B-4936-814A-03BD6BB697F1
Iwr I I -I VNRVLIIYN UCrNR I IYICIY I '.jr LIY V TAL 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: 12/16/2022
2. County: Vance
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Carolina Market — Bowers & Burrows, Inc. Telephone: [phone]
Applicant's Mailing Address: PO Box 137, Henderson NC 27536-0137
Applicant's Email Address (if available): NA
5. Contact Person (if different than Applicant): William Regenthal
Telephone: [phone]
Contact Person's Mailing Address: Geological Resources, Inc., 113 W Firetower Road, Suite G, Winterville NC 28590
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Mohamed M Saleh Telephone: NA
Property Owner's Mailing Address: 606 Park Avenue, Henderson NC 27536
Property Owner's Email Address (if available): NA
7. Property Physical Address (Including PIN Number) 105 Old Epsom Road PIN #008805002
City Henderson County Vance Zip Code 27536
8. Reason for Well(s): Ground Water 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
(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).
Incident #46124
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).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 0'
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: Justin Radford 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

DocuSign Envelope ID: 9313E5A3-DB6B-4936-814A-03BD6BB697F1
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
6. Estimated beginning construction date: rcb 2022 Jan 2023
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: rcb 2022 Jan 2023
(add answers from 2 and 3)
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
as agent for Bowers and Burrows, Inc.
Signature of Applicant or *Agent
William Regenthal, P. G.
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 Constr tion Permit application and that it shall be the responsibility of the applicant to ensure that the
wel js)`oonf m to the Wel ruction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
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 Quality's Aquifer Protection Section 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
585 Waughtown Street
Winston-Salem, NC 27107
Phone: [phone]
Fax: [phone]
GW-22MR (Rev, 7/11)

DocuSign Envelope ID: 9313E5A3-DB6B-4936-814A-03BD6
LEGEND
- - PROPERTY BOUNDARY
ss
— E — E —
STORM SEWER L/NE
OVERHEAD ELECTR/C LINE
UNDERGROUND STORAGE TANK
EXCA VAT/ON BOUNDARY
STORM DRAIN
UTILITY/POWER POLE
CONCRETE SURFACE
BB697F1
Note:
This Site Mop is based on data from the Vance
County G/S of NC.
—E—E—E—E EE-
GRASS
Proposed Well Location /
UST Basin
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GRASS
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ASPHAL T
CAROL/NA M/N/
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RES/DENT
ER
0
10
20
40
(IN FEET)
1 inch = 20 ft
SITE MAP
Coro//no Market
Incident No. N/A
GR/ Project No. 4195
501 O/d Epsom Road
Henderson, Vance County,
NC
Geological Resources, Inc.
Dote:
08/15/17 Drown by. DTH
Figure: 2

DocuSign Envelope ID: 9313E5A3-DB6B-4936-814A-03BD6BB697F1
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DocuSign Envelope ID: 9313E5A3-DB6B-4936-814A-03BD6BB697F1
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NCDEQ Community Mapping System
501 Old Epsom Road, Header: X CL
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Epsom Road
UST Incident No. 8209
Glen Boyd Motors
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200ft
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DocuSign Envelope ID: 9313E5A3-DB6B-4936-814A-03BD6BB697F1
YPE II MONITORING WELL
TYPICAL CONSTRUCTION DETAILS
CONCRETE PAD
GROUND SURFACE
GROUT CEMENT
BENTONI TE SEAL
SAND FILTER PACK
6
0 - 5'
5 - 9'
9-30'
Total Depth - 30'
•
MANHOLE COVER
LOCKING WELL CAP
a4
0 - 10'
10-30'
2 INCH DIAMETER
SCHEDULE 40 PVC CASING
0.070 INCH SLOTTED
2 INCH DIAMETER
SCHEDULE 40 PVC SCREEN
END CAP