WM0501549_Application_20230503 (2)

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: 5/2/2023
2. County:
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): monitoring
4. Applicant: Tony Southerland Telephone: [phone]
Applicant's Mailing Address: 1105 Southerland Rd Clayton, NC 27527
Applicant's Email Address (if available):
5. Contact Person (if different than Applicant): Ryan Kerins Telephone: [phone]
Contact Person's Mailing Address: 100 E. Ruffin St Mebane, NC 27302
Contact Person's Email Address (if available): rdkerins(@terraguestpc.com
6. Property Owner (if different than Applicant):
Property Owner's Mailing Address:
Property Owner's Email Address (if available):
Telephone:
7. Property Physical Address (Including PIN Number) 4549 Wilsons Mills Rd PIN#169609-07-9370
City Smithfield County Johnston Zip Code 27577
8. Reason for Well(s): groundwater contamination
(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).
NCDWM-UST Incident 29463
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? 8
Existing Monitoring or Recovery Well Construction Permit No(s).: Unknown
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 0-30'
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): 299
15. Well Contractor: Wes Sorrells Terraquest Environmental Certification No.: 3577
Well Contractor Address: 100 E Ruffin St Mebane, NC 27302
PROPOSED WELL CONSTRUCTION INFORMATION
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?
material: 3 Bolted manhole with locked well cap
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 5/2023
4. Total Number of wells to be constructed: 3 7. Estimated construction completion date: 5/2023
(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. 143-215.10B(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) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Signature of Applicant or *Agent
Ryan Kerins
Printed name of Applicant or *Agent
Project Manger
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
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.
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 Raleigh Regional Office Wilmington Regional Office
2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension
Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 28405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [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]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]

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SITE HISTORY (UST/AST SYSTEM INFORMATION)
Date: V7109
Incident Name _J.D'sCountryStore Incident No-29463
FacilltyIDNo:0-013454
Capacity
UST
Product (Gallons) Date Installed
Date Closed
Release Discovered
_ T1
Gasoline 6,000 1215/71
7i9107
Yes
Ttb
Gasoline 3,000 1215/71
7/9/07
Yes
T2
Gasoline 12,000 1/1/02
NIA
No
T3
Gasoline 8,000 1/1/02
NIA
No
T4
Diesel 5,000 1/1/02
N/A
No
T5
Gasoline 6,000 7112107
NIA
NIA
T51b
Diesel 4,000 7/12/07
N/A
NIA
Capacity
AST
Product (Gallons) Date Installed
Date Closed
Release Discovered
AST1
Kerosene 550 6101
in -use
No
- AST2
Off -Road Diesel 550 6101
in -use
No
AST3
Off -Road Diesel 1,000 6101
in -use
No
AST4
Kerosene 550 1/81
6/01
No
Notes_
1. Information obtained from the INC UST Database Records, onsite observations,
and responsible party.
2. No release from the other USTs orASTs has been discovered.
3. Installation and closure dates for the ASTs are aooroximate. The ASTs are
owned by Stancil Oil
Com Danv_
GRAPHIC SCALE
0' 15' 30' 60'
1 " = 30'

FIGURE 2 - TYPICAL TYPE II MONITORING WELL DETAIL
8" MANHOLE COVER
rel
LOCKING CAP
GENERAL INFORMATION
/ CEMENT GROUT Groundwater monitoring wells are simple 2"
diameter wells used to monitor groundwater
quality. They are constructed using Schedule 40
PVC piping and screen as shown in the diagram
to the left. Upon completion, an 8" round
8'
/
manhole cover is installed over the well for
protection. In the event that the well is
9'
BENTONITE SEAL installed in an area where there exists the
possibility that it could be damaged such as an
10'
-
TOP OF SCREEN agricultural field, an aboveground or stickup
_
manhole will be used. After the manhole is set,
—
a small concrete pad is poured around the
—_
manhole. Both the manhole and pad are flush
—
with the ground surface, except as noted, and
—
will not interfere with driving, mowing, foot
—_
traffic, etc. Type II monitoring wells are used
—
for sampling groundwater from shallow,
—
unconfined aquifers. They are used to
determine the horizontal extent of contamination.
—
Well Driller:
—_
Terraquest Environmental Consultants, P.C. -
-
Jonathan R. Grubbs #3001
-
GRAVEL PACK
30'
-
BOTTOM OF SCREEN
BOTTOM OF BORING
6„
TEP4MIUest
ENVIRONMENTAL CONSULTANTS, P.C.