WM0401462_Monitoring well construction permit application_20230724

Geological Resources, Inc.
July 18, 2023
Mr. Lon Snider
NCDEQ, Division of Water Resources
Winston-Salem Regional Office
450 W. Hanes Mill Road, Suite 300
Winston-Salem, North Carolina 27105-7407
Re: Monitoring Well Permit Application
New Country Food Mart
6861 US Highway 64 West
Lexington, Davidson County
GRI Project No. 6382
Dear Mr. Snider:
Please find enclosed a monitoring well permit application for the installation of one monitoring well at
the New Country Food Mart facility located at 6861 US Highway 64 West in Lexington, Davidson 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,
P. P6*�X
W. Scott Ball
Senior 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]

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: 7/17/2023
2. County:
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4.
A
Applicant: United Oil of the Carolinas
Telephone: [phone]
Applicant's Mailing Address: PO Box 68, Gastonia NC 28054
Applicant's Email Address (if available): lewisa-uootc.com
Contact Person (if different than Applicant): Scott Ball Telephone: [phone]
Contact Person's Mailing Address: Geological Resources, Inc., 3502 Hayes Rd., Monroe NC 28110
Contact Person's Email Address (if available): wsbageologicalresourcesinc.com
6. Property Owner (if different than Applicant): Cheema & Associates Inc. Telephone: [phone]
Property Owner's Mailing Address: 3945 Stafford Run Court, High Point NC 27265
Property Owner's Email Address (if available): gmsargodhaa-yahoo.com
7. Property Physical Address (Including PIN Number) 6861 US Highway 64 West PIN 5796-01-09-3843
City Lexington County Davidson Zip Code 27295
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: 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).
None
11. Type of contaminants being monitored or recovered:
(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).: NA
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 0.0
14. Are there any water supply wells located less than 500 feet from the proposed well(s)?
If yes, give distance(s):
Unknown
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

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Locking
material: 1 expansion cap and bolt down manhole cover
3. Number of wells to be constructed in bedrock:
6. Estimated beginning construction date: July/Aug 2023
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: July/Aug 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. 143-215.1013(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.
President, United oil of the Carolinas, Inc
Signature of Applicant or *Agent Title of Applicant or "Agent
D. Lewis C. Efird
Printed name 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.
See attached RTE Ghazanfar Mahmood
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]
GW-22M/R (Rev. 5-26-2022)

RIGHT TO ENTER AGREEMENT
FOR
CONDUCTING SUBSURFACE INVESTIGATIONS
STATE OF NORTH CAROLINA
COUNTY OF DAVIDSON
GRI JOB NO. 6382
NEW COUNTRY FOOD MART
We, the undersigned, being all of the fee simple owners of certain tract or parcel designated as 5796-01-
09-3843 of the County of Davidson, recognizing the benefits to said properties by reason of conducting
underground storage tank (UST) removal activities hereby grant to United Oil of the Carolinas (United Oil)
and their agents the right to enter said property in accordance with the requirements of the State of North
Carolina. United Oil's agents may include Geological Resources, Inc.
The undersigned hereby covenant and warrant that they are the sole owners of said property; that they
solely have the right to grant this right to enter for conducting the UST closure activities against the lawful
claims of all persons whomsoever.
It is agreed that United Oil shall hold harmless the owner of the aforementioned property for any personal
injury that might be sustained during the course of conducting or proximately resulting from the conduct
of UST closure activities.
Right to Enter denied.
V Right to Enter granted.
Cheema & Associates Inc. (Ghazanfar Mahmood)336-307-0020
Print
Phone
07-03-23
Signature Date
3502 Hayes Road Monroe, North Carolina 28110
Phone [phone] [phone] • Fax [phone]

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