WQ0029894_Final Permit_20230119

DocuSign Envelope ID: 79BC685F-70CB-4432-9FFD-C4EDE75942B1
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
NORTH CAROLINA
Environmental Quality
January 19, 2023
Linda Blalock
NCDEQ State Lead
Mail Service Center 1646
Raleigh, NC 27699-1646
Subject: Monitoring Well Construction
Permit # WM0501531
Hobgood Service Center
Hobgood, NC 27846 — Halifax County
Ms. Blalock:
In accordance with the application received on January 17, 2023, we are forwarding herewith
Monitoring Well Construction Permit No. WM0501531 effective January 19, 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:
&AA-ssa
f. �1.a�l,ltit,�,for
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: 79BC685F-70CB-4432-9FFD-C4EDE75942B1
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
Linda Blalock — NCDEQ State Lead
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of one monitoring well owned
Linda Blalock, NCDEQ State Lead, Mail Service Center 1646, Raleigh, NC 27699-1646. The well will be
located on the unaddressed property on Pine Street, Hobgood, NC 27843, owned by Robert G.
Anthony, Jr. - Trustee. This Permit is issued in accordance with the application received on January
17, 2023, 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:
siO ALSSa f. itkatA.Vd.) fer
B2916E6AB32144F_
Scott Vinson, Regional Supervisor
Division of Water Resources
By Authority of the Environmental Management Commission
Permit No. WM0501531
£D_E
NORTH CAROLINA
Department of 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: 79BC685F-70CB-4432-9FFD-C4EDE75942B1
ATC
ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598
January 16, 2023
Mr. Timothy Clark
North Carolina Department of Environmental Quality
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Re: Permit to Construct Monitoring Well
Hobgood Service Center
219 Commerce Street
Hobgood, Halifax County, North Carolina
NCDEQ Incident #5499
Dear Mr. Clark:
Enclosed please find one application for a permit to construct one permanent
groundwater monitoring well. The permanent groundwater monitoring well will be
located at an unaddressed property (PIN #0801677) in Hobgood, Halifax County, North
Carolina. The permit application, site map with the proposed location of the monitoring
well, well construction details, and other relevant information are enclosed as
attachments. Please review this package and return the approved permit to this office or
via email to ashley.winkelman(a�oneatlas.com.
If you have any questions or require additional information, please contact our office at
[phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Ashley M. Winkelman, P.G.
Senior Project Manager

DocuSign Envelope ID: 79BC685F-70CB-4432-9FFD-C4EDE75942B1
19Vrt1 ri ..P FWL119/1 LJCrP rrl lviCIY 1 '.jr CiivlrwIJMENTAL 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: 1/16/2023
2. County: Halifax
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant: Linda Blalock — NCDEQ State Lead
Permanent Monitoring Well
Telephone: [phone]
Applicant's Mailing Address: Mail Service Center 1646, Raleigh, NC 27699-1646
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Ashley Winkelman, ATC
Telephone: [phone]
Contact Person's Mailing Address: 2725 E. Millbrook Road, Suite 121, Raleigh, NC 27604
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Robert G. Anthony, Jr. - Trustee Telephone: [phone]
7.
8.
9.
10.
Property Owner's Mailing Address: 207 Columbia Place West, Chapel Hill, NC 27516
Property Owner's Email Address (if available): [e-mail]
Property Physical Address (Including PIN Number)
City Hobgood County
Unaddressed property on Pine Street
Halifax
Reason for Well(s): Groundwater Contamination
Zip Code
(PIN 0801677)
27843
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
Type of facility or site for which the well(s) is(are) needed: Underground storage tank
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
Are there any current water quality permits or incidents associated with this facility or site? If so, list permit and/or incident no(s).
NCDEQ Incident #5499
11. Type of contaminants being monitored or recovered: Petroleum hydrocarbons
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes, 4 monitoring wells (MW-1 — MW-4)
and 1 recovery well (RW-1)
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0501163
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 95 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): —350 feet N of proposed well
15. Well Contractor: Geologic Exploration, Inc. Certification No.: 4459-A
Well Contractor Address: 176 Commerce Boulevard, Statesville, NC 28625
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.
b.
c.
d.
Borehole and well diameter
Estimated well depth
Screen intervals
Sand/gravel pack intervals
e.
f.
g.
Type of casing material and thickness
Grout horizons
Wet head completion details
Continued on Reverse

DocuSign Envelope ID: 79BC685F-70CB-4432-9FFD-C4EDE75942B1
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
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3)
5. How will the well(s) be secured? Locking well cap,
flush -mount steel protective casing
6. Estimated beginning construction date: 3/20/2023
7. Estimated construction completion date: 3/20/2023
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. Ali 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. Al! 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 lank 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
ti
Signature of Applicant or *Agent
Ashley Winkelman
Printed name of Applicant or *Agent
Agent for State Lead Site — Incident #5499 (Will include power
of Attorney upon request)
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 attached access agreement See attached access agreement
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]
Wllgion
GW-22M (Rev. 5/11)
GW-22MR Rev. 3-1-2016

DocuSign Envelope ID: 79BC685F-70CB-4432-9FFD-C4EDE75942B1
ATC
ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 E. Millbrook Road, Suite 121
Raleigh, North Carolina 27604
Telephone [phone]
Fax [phone]
www.atcgroupservices.com
April 25, 2022
Kay Mann Anthony
Robert G. Anthony, Jr.
207 Columbia Place West
Chapel Hill, NC 27516
Re: Access Agreement for Environmental Assessment
Hobgood Service Center
W. Commerce Street and S. Pine Street
Hobgood, Halifax County, North Carolina
NCDEQ Incident No: 5499
To Whom It May Concern:
ATC Associates of North Carolina, P.C. (ATC), on behalf of the North Carolina Department of
Environmental Quality (NCDEQ), is conducting an environmental assessment at the former Hobgood
Service Center site located at the corner of West Commerce Street and South Pine Street in Hobgood,
Halifax County, North Carolina. As part of assessment activities, ATC is requesting permission to
install one monitoring well on your property located along South Pine Street (no numerical address
given - Parcel ID 0801677) in Hobgood, North Carolina, which is located southwest, across South Pine
Street, of the above referenced site. A map showing the location of your property in reference to the
site property is included.
You, as the property owner, will not be held responsible or held liable for any damages or expenses for
injury to persons or property while ATC is on the premises.
Please provide your authorization and approval by signing the attached signature page in the enclosed
envelope by May 25, 2022. Acknowledgment of this form is required by NCDEQ. Denial of site access
will be forwarded to NCDEQ for their pursuit of site access.
If you have any questions regarding these activities, please feel free to contact Ms. Ashley Winkelman
with ATC at [e-mail] or 919-871-0999 or Ms. Linda Blalock with NCDEQ at
[e-mail] or 919-707-8165.
Sincerely,
ATC Associates of North Carolina, P.C.
J
Ashley M. Winkelman, P.G.
Senior Project Manager

DocuSign Envelope ID: 79BC685F-70CB-4432-9FFD-C4EDE75942B1
ATC
ENVIRONMENTAL• GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 E. Millbrook Road, Suite 121
Raleigh, North Carolina 27604
Telephone [phone]
Fax [phone]
www.atcgroupservices.com
Response to access request for property located along South Pine Street (no numerical address given -
Parcel ID 0801677) for Incident #5499:
)(Access approved
❑ Access denied
Name gC/2-7— . /9n l l a /,/ 2 , — fl(A)/(t e I6 0 G,,n
Signature U6^�i► 4 a - Pp / d/�
E-mail r (ti / / h 5 4 e7--
Phone number
2(— Da0.) Cr
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DocuSign Envelope ID: 79BC685F-70CB-4432-9FFD-C4EDE75942B1
TYPICAL TYPE II MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
NOT TO SCALE
LOCKABLE WELL CAP
L1
A y
A
L2
L4
V
L3
V
V
L1 = 0 FT.
L2 = 5 FT.
L3 = 10 FT.
L4 = 15 FT.
4
PROTECTIVE CASING AND CONCRETE PAD
CASING MATERIAL
CASING DIAMETER
CASING LENGTH
PAD DIMENSIONS
HEIGHT ABOVE GROUND
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
BACKFILL AROUND CASING
MATERIAL
THICKNESS
SEAL
TYPE OF SEAL
THICKNESS
FILTER PACK
TYPE OF FILTER
DISTANCE ABOVE SCREEN
TOTAL FILTER PACK LENGTH
WELL SCREEN
SCREEN MATERIAL
DIAMETER
LENGTH
SLOT SIZE
DEPTH TO BOTTOM OF
MONITORING WELL
4 DEPTH TO BOTTOM OF
BOREHOLE
DIAMETER OF BOREHOLE
Steel
8 inches
12 inches
2 feet x 2 feet
flush mounted
sch 40 PVC
2 inches
flush threaded
15 feet
cement -sand grout
1 feet
bentonite
3 feet
#2 silica sand
1 feet
11 feet
sch 40 PVC
2 inches
10 feet
0.010 inches
15 feet
15 feet
8.25 inches
TITLE Permanent Monitoring Well Diagram
(Example of typical MW installation displayed above)
Hobgood Service Center
219 Commerce Street
Hobgood, NC
AT(
2725 East Millbrook Road, Suite 121
Raleigh, North Carolina 27604
FILE
PREP. BY
JR
REV. BY
AW
DATE
1/13/2023
PROJECT NO.
SLC0549903

DocuSign Envelope ID: 79BC685F-70CB-4432-9FFD-C4EDE75942B1
Parcel ID 0801677
125 250 375 500
Feet
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9 Monitoring Well - Existing
Monitoring Well - Proposed
500 Foot Radius
Hobgood Service Station
Halixfax County Parcels
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