WM0401458_This is the application_20230628

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.
Date: 6/23/2023
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: Huffman Oil Company; James Barnwell Telephone: [phone]
Applicant's Mailing Address: P.O. Box 730 Burlington, NC 27216
Applicant's Email Address (if available): ibarnwe113(o)huffmanoil.net
5. Contact Person (if different than Applicant): Wayne Watterson Telephone: [phone]
Contact Person's Mailing Address: 8646 W. Market Street, Suite 105, Greensboro, NC 27409
Contact Person's Email Address (if available): wwatterson(a�smeinc.com
6. Property Owner (if different than Applicant): N.C. Department of Transportation Telephone: [phone]
Property Owner's Mailing Address: Division Engineer's Office P.O. Box 14996 Greensboro, NC 27415
Property Owner's Email Address (if available): warcher(a�ncdot.gov Wright R. Archer, 111, P.E. Division Engineer
7. Property Physical Address (Including PIN Number) 10475 US Highway 158 (Parcel No. 170538)
City Reidsville County Rockingham Zip Code 27320
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).
10475 US Highway 158: LUST Incident No. 47755, McCollum Shell
11.
Type of contaminants being monitored or recovered: volatile organic compounds
(ex: organics, nutrients, heavy metals, etc.)
12.
Are there any existing wells associated with the proposed well(s)? If yes, how many?
Yes (six)
Existing Monitoring or Recovery Well Construction Permit No(s).: NA
13.
Distance from proposed well(s) to nearest known waste or pollution source (in feet):
75
14.
Are there any water supply wells located less than 500 feet from the proposed well(s)?
Yes
If yes, give distance(s): 250, 270, 480 feet
15.
Well Contractor: Innovative Environmental Technologies, Inc. Certification No.:
3287-A
Well Contractor Address: 232 Hiahwav 49 South. Concord. NC 28025
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? 2'x2' concrete
material: One : MW-6; Bolt -down cover, locked ex Landable cap _
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: Jule 2023
4. Total Number of wells to be constructed: One 7. Estimated construction completion date: 7/31/23 _
(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 A cant assUotalonsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.Agent for Owner
Signature Applicant or Agent Title of Applicant or *Agent
_ Lvndal Butler S&ME Inc. * 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.
cSee attached siuned Encroachment hcreement _ NC De ,artment of Transi ortation
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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GW-22M/R (Rev. 5-26-2022)

5TATE,'
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
Roy COOPER
GOVERNOR
June 6, 2023
Rockingham County
J. ERIc BOYETTE
SECRETARY
SUBJECT: Encroachment Agreement- Huffman Oil Company-McCollum's Grocery -
Approval to install a monitoring well for environmental assessment near
McCollum's Grocery at address 10475 US 158.
-E073-079-23-00223-
James Barnwell, V.P. Retail
Huffman Oil Company
P.O. Box 730
Burlington, NC 2216
Dear Mr. Barnwell,
Attached is a Right of Way Encroachment which has been properly executed.
The Department of Transportation does not guarantee the right of way on this road, nor will it be
responsible for any claim for damages brought by any property owner by reason of the installation.
Approval is contingent upon adhering to the attached special provisions.
If you need additional information, please contact Clint Foulks at the Reidsville District Office at 336-
520-6060 or [e-mail].
Sincerely /
W.R. Archer, II1, PE !�
Division Engineer
WA/j j
Attachments
Cc: J.R. Julian, District Engineer
Mailing Address: Telephone: [phone] Location:
NC DEPARTMENT OF TRANSPORTATION Customer Service: 1-877-368-4968 1584 YANCEYVILLE ST.
DIVISION ENGINEER'S OFFICE FAX: [phone] GREENSBORO, NC 27405
PO BOX 14996 Websile: www.nedot.gov
GREENSBORO, NC 27415

ev-?3071z3"?Z3
REGTA 1 �H CAROLINA
ROUTE NC-158 PROJECT McCallum's Grocery COUNTY OF Rockingham
DEPARTMENT OF TRANSPORTATION RIGHT OF 0A ENT AGREEMENT
FO N UTILITY EN,, eROACHM T N
-Al NO � , ll S� 6NElAV i Al
Huffman Oil Company DIVISI()N OF 1II61W.-
P,0. Box 730, Burlington, NC 2215-0730 DISTRICT ENGINEERS OFFICE
THIS AGREEMENT, made and entered into this the day of 3 k;.J 20 by and between the Department
of Transportation, party of the first part, and Huffman oil Company
party of the second part,
WITNESSFTH
THAT WHEREAS, the party of the second part desires to encroach on the right of way S the public road designated as
Route(sj AtE'-158 located on the south side of tiC-158 adjacent to the eastbound lane
with the construction anftr erection of: One monitoring well as shown on the attached plans, for the purpose of environmental assessment.
WHEREAS, it is to the material advantage of the party of the second part to effect this encroachment, and the
party of the first part in the exercise of authority conferred upon it by statute, is willing to permit the encroachment
within the limits of the right of way as indicated, subject to the conditions of this agreement;
NOW, THEREFORE, IT IS AGREED that the patty of the first part hereby grants to the party of the second
part the right and privilege to make this encroachment as shown on attached plan sheet(s), specifications and
special provisions which are made a part hereof upon the following conditions, to wit:
That the said party of the second part binds and obligates himself to install and maintain the encroaching facility in such safe
and proper condition that it will not interfere with or endanger travel upon said highway, nor obstruct nor interfere with the proper
maintenance thereof, to reimburse the party of the first part for the cost incurred for any repairs or maintenance to its roadways
and structures necessary due to the installation and existence of the facilities of the party of the second part, and if at any time the
party of the first part shall require the removal of or changes in the location of the said facilities, that the said party of the second
part binds himself, his successors and assigns, to promptly remove or alter the said facilities, in order to conform to the said
requirement, without any cost to the party of the first part
That the parry of the second part agrees to provide during construction and any subsequent maintenance proper signs, signai
lights, Bagmen and other warning devices for the protection of traffic in conformance with the latest Manual on Uniform_rraffia
ontro..l for Streets and Hi hwa s and Amendments or Supplements thereto. Information as to the above rules and
regulations may be obtained from the Division Engineer of the party of the first part
That the party of the second part hereby agrees to indemnify and save harmless the party of the first part from all damages
and claims for damage that may arise by reason of the installation and maintenance of this encroachment.
It is clearly understood by the patty of the second part that the party of the first part will assume no responsibility for any
damage that may be caused to such facilities, within the highway rights of way limits, in carrying out its construction and
maintenance operations.
That the parry of the second part agrees to restore Ali areas disturbed during installation and maintenance to the satisfaction of
the Division Engineer of the party of the first part. The party of the second part agrees to exercise every reasonable precaution
during construction and maintenance to prevent eroding of soil; silting or pollution of rivers, streams, lakes, reservoirs, other water
impoundments, ground surfaces or other property; or pollution of the air. There shall be compliance with applicable rules and
regulations of the North Carolina Division of Environmental Management, North Carolina Sedimentation Control Commission, and
with ordinances and regulations of various counties, municipalities and other official agencies relating to pollution prevention and
control. When any insta3lation or maintenance operation disturbs the ground surface and existing ground cover, the parry of the
second part agrees to remove and replace the sod or otherwise reestablish the grass cover to meet the satisfaction of the Division
Engineer of the parry of the first part,
That the patty of the second part agrees to assume the actual cost of any inspection of the work considered to be necessary
by the Division Engineer of the party of the first part.
That the parry of the second part agrees to have available at the encroaching site, at all times during construction, a copy of
this agreement showing evidence of approval by tale party of the first part. The party of the first part reserves the right to stop all
work unless evidence of approval can be shown,
Provided the work contained in this agreement is being performed on a completed highway open to traffic; the party of the
second part agrees to give written notice to the Division Engineer of the patty of the first part when all work contained herein has
been completed. lltaiess specifically requested by the party of the first part, written notice of completion of work on highway
projects under construction will not be required,
That in the case of noncompliance with the terms of this agreement by the party of the second part, the party of the first part
reserves the right to stop a€i work until the facility has been brought into compliance or removed from the right of way at no cost to
the party of the first part,
That it is agreed by both parties that this agreement shall become void if actual construction of the work contemplated herein
is not begun within one (1) year from the date of authorization by the party of the first part unless written waiver is secured by the
party of the second part from the party of the first part,
FORM R1W 16.1A (Revised February 2021)

RAN (161A) : Party of the Second Part certifies that this agreement is true and accurate copy of the form
RMf (161A) incorporating all revisions to date.
IN WITNESS WHEREOF, each of the parties to this agreement has caused the same to be executed the day and
year first above written.
DEPARTMENT OF
TRANSPORTATION
BY,
DIVISION ENGINEER
INSTRUCTIONS
When the applicant is a corporation or a municipality, this agreement must have the corporate seal and
be attested by the corporation secretary or by the empowered city official, unless a waiver of corporate
seal and attestation by the secretary or by the empowered City official is on file in the Raleigh office of the
State Utilities Manager. In the space provided in this agreement for execution, the name of the
corporation or municipality shall be typed above the name, and title of all persons signing the agreement
should be typed directly below their signature.
When the applicant is not a corporation, then his signature must be witnessed by one person. The
address should be included in this agreement and the names of all persons signing the agreement
should be typed directly below their signature.
This agreement must be accompanied, in the form of an attachment, by plans or drawings showing the
following applicable information:
1. All roadways and ramps.
2. Right of way lines and where applicable, the control of access lines.
3. Location of the proposed encroachment.
4. Length and type of encroachment.
5. Location by highway survey station number. If station number cannot be obtained, location
should be shown by distance from some identifiable point, such as a bridge, road,
intersection, etc. (To assist in preparation of the encroachment plan, the Department's
roadway plans may be seen at the various Highway Division Offices, or at the Raleigh
office.)
6. Drainage structures or bridges if affected by encroachment.
7. Typical section indicating the pavement design and width, and the slopes, widths and
details for either a curb and gutter or a shoulder and ditch section, whichever is applicable.
B. Horizontal alignment indicating general curve data, where applicable
g. Vertical alignment indicated by percent grade, P.I. station and vertical curve length, where
applicable
10, Amount of material to be removed and/or placed on NCDOT right of way, if applicable.
11. Cross -sections of all grading operations, indicating slope ratio and reference by station
where applicable.
12. All pertinent drainage structures proposed. Include all hydraulic data, pipe sizes, structure
details and other related information.
13. Erosion and sediment control.
14. Any special provisions or specifications as to the performance of the work or the method of
construction that may be required by the Department must be shown on a separate sheet
attached to encroachment agreement provided that such information cannot be shown on
plans or drawings.
15. The Department's Division Engineer should be given notice by the applicant prior to actual
starting of installation included in this agreement.
16. Method of handling traffic during construction where applicable.
17. Scale of plans, north arrow, etc.

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SOURCES: 2018 AERIAL PHOTOGRAPHS AND 2020 ROCKINGHAM COUNTY, NC PARCEL DATA OBTAINED AND DOWNLOADED FROM NC ONEMAP.
LEGEND
MONITORING WELL LOCATION
PRODUCT LINE
© DISPENSER 0 20 90
iA TANK IDENTIFICATION
{ SOIL BORING LOCATION
Fy PROPOSED MONITORING WELL LOCATION GRAPHIC SCALE (IN FEET)
PROPOSED MONITOR WELL LOCATION SCALE: FIGURE N
4 Incident No. 47755 AS SHOWN
DATE:
McCOLLUM SHELL MAY 2023 2
10475 US HIGHWAY 158 PROJECTNUM8FR
REIDSVILLE, NORTH CARLINA 213522

EXAMPLE COMPLETION REPORT OF WELL
Sheet 1 of 1
PROJECT: McCollum's Grocery
PROJECT NO: 213522
WATER LEVEL:
PROJECT LOCATION: 10475
Hwy 158, Reidsville. North
Carolina
LATITUDE:
DRILLING CONTRACTOR:
LONGITUDE:
DRILLING METHOD:
TOP OF CASING ELEVATION:
DATE COMPLETED:
DATUM:
LOGGED BY:
STRATA
WELL
x
❑ o
m
DETAILS
* -r:i
WELL CONSTRUCTION DETAILS
DESCRIPTION
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PROTECTIVE CASING
0
0.00
GS
Diameter:
Type:
Interval:
RISER CASING
5
Diameter: 2"
Type:
Interval 0.3 - 15.0
GROUT
Type: Grout
10
Interval: 0.3 - 12.0
12.00
SEAL
Type 3/8 in. holeplug
14.00
Interval: 12.0 -14.0
15 -: `
15.00
FILTERPACK
Type: #2 Sand
Interval: 14.0 - 30.0
20
SCREEN
Diameter: 0.010
Type: PVC
Interval: 15.0 - 30.0
25
0
a
LEGEND
U
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FILTER PACK TOC TOP OF CASING
30
30.00
BENTONITE GS GROUND SURFACE
■ BS BENTONITE SEAL
® CEMENT GROUT BOC BASE OF OUTER CASING
a
TSC TOP OF SCREEN
® FORMATION BSC BOTTOM OF SCREEN
4
1 STATIC WATER LEVEL TD TOTAL DEPTH
W
N
M
Q
CG CEMENTGROUT
J
COMPLETION REPORT OF
o
SWE
MONITORING WELL
ENAPONME ALSERRVICES
Sheet 1 of 1

May 25, 2023
North Carolina Department of Transportation
Division 7, Right of Way Office
1101 E. Wend over Ave.
Suite 200
Greensboro, North Carolina 27405
Attention: Mr, Alan Rothrock aianrothrock@ncdot.00v
Reference: Right -of -Way Encroachment Agreement for Non -Utility Encroachment
on Primary and Secondary Highways (Revision 01)
McCollum's Grocery; Incident No. 47755
10475 Hwy 158
Reidsville, Rockingham County, North Carolina
S&ME Project No. 213522
Dear Mr. Rothrock:
S&ME, Inc. (S&ME) is under contract with Huffman Oil Company to perform assessment of a petroleum release
from an underground storage tank (UST) release associated with North Carolina Department of Environmental
Quality (NCDEQ) UST Incident No. 47755. The release was discovered on March 16, 2022. Based on a review of
the Rockingham County Geographic Information website, the subject incident is located on the property
addressed as 10475 US Hwy 158, Reidsville, North Carolina and identified by Parcel Identification Number (PIN)
7972-03-30-8930-00; hereinafter referred to as the subject property (see attached Figure 1). As part of the
assessment activities, S&ME is requesting an encroachment in the NCDOT right-of-way, south of NC-158 (see
attached Figure 2) to install a monitoring well. This work is being performed at the request of the NCDEQ.
S&ME, Inc. (S&ME) proposes to install one groundwater monitoring well as part of our tasks for this project. The
monitoring well is needed to assess groundwater quality near the location where groundwater contamination is
present. The following information is our proposed location and description for the groundwater monitoring well:
Installation of one monitoring well on the NCDOT Right -of -Way southwest of NC 158. The location of the
proposed monitoring well is shown on the attached Figure 2.
The groundwater monitoring well will be advanced to a depth of approximately 40 feet below ground surface.
The groundwater monitoring well will be two-inch diameter flush -mount monitor well finished at the surface
with a square concrete pad measuring two feet by two feet (see attached diagram and photograph).
S&ME will utilize a North Carolina licensed driller to install the monitoring well;
The field crew will have the proper signage, traffic cones and number of personnel necessary to safely perform
work and monitor and/or direct traffic if needed;
Investigative derived waste (drill cuttings) generated during the installation of the monitor well will not be
placed on the NCDOT right of way;
S&ME will contact the District Engineer prior to the start of work to notify of the anticipated start date;
S&ME, Inc. 18646 West Market Street, Suite 105 1 Greensboro, NC 27409 1 p 336,288.7180 1 www.smeinc.corn

i
i r Right of Way Encroachment Agreement for Non -Utility Encroachment
i on Primary and Secondary Highways (Revision 01)
McCollum's Grocery; Incident No. 47755
10475 Hwy 158
Reidsville, Rockingham County, North Caro3ina
S&ME Project No. 213522
S&ME will contract a private utility locator and also use NC One Call to mark out subsurface utilities prior to
commencing worm.
The installation of the monitoring well will take less than one day to complete. We anticipate that S&ME
personnel may occasionally return to the monitoring well to collect groundwater samples, at the direction of
NCDEQ.
Please find enclosed one original of North Carolina Department of Transportation (NCDOT) form R/W 16.1A Right
of Way Encroachment Agreement for Non -Utility Encroachments on Primary and Secondary Highways, which was
obtained from the NCDOT website and signed by a representative of Huffman Oil Company. Also included are
four copies of our package which includes a figure showing the proposed location of the groundwater monitor
well, a diagram of a typical monitor well construction, figure of the approximate location of the proposed
monitoring well location and an example of a completed flush mount monitoring well.
Please contact us if you have any questions about this project or require additional information.
Sincerely,
S&ME, Inc.
Cody McMechen, G.I.T. Wayne Watterson, P.E.
Staff Professional Principal Engineer
[e-mail] [e-mail]
Attachments: Attachment I- NCDOT Form R/W 16.1A
Attachment II- Figures
Attachment III- Diagram of a Typical Flush -Mount Monitoring Well
Attachment IV- Photographs
May 25, 2023

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SOURCES: 2018 AERIAL PHOTOGRAPHS AND 2020 ROCKINGHAM COUNTY, NC PARCEL DATA OBTAINED AND DOWNLOADED FROM NC ONEMAP.
LEGEND
0 APPARENT WATER SUPPLY WELL STRUCTURE NOTE: WELL INFORMATION SUMMARIZED ON TABLE 1
® WATER METER
wsw-1 - CONFIRMED WELL IDENTIFICATION 0 400 800
GRAPHIC SCALE (IN FEET)
RECEPTOR MAP
McCOLLUM SHELL
10475 US HIGHWAY 158
REIDSVILLE, NORTH CARLINA
SCALE: FIGURE NO.
AS SHOWN
DATE:
MAY 2023 4
PROJECT NUMBER
213522