WM0801232_Application_20231016

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 h
1. Date: May 17, 2023
2, County: Brunswick
�r a permit to construct monitoring or recovery wells.
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant.
Circle K Stores, Inc.
Telephone [phone]
Applicant's Mailing Address 1100 Situs Court, Suite 100 Raleigh, North Carolina 27605
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Maureen Jackson Telephone: [phone]
Contact Person's Mailing Address: 2725 E. Millbrook Road, Suite 121 Raleigh, North Carolina 27604
Contact Person's Email Address (if available). maureen Jackson .oneatlas.com
6. Property Owner (if different than Applicant)Southport Car and Boat Wash, LLC Telephone: Unknown
Property Owner's Mailing Address: 1820 Spencer Mountain Road Gastonia. North Carolina 28054-9600
Property Owner's Email Address (if available): Unknown
T Property Physical Address (Including PIN Number) 1 118 N. Howe Street (PIN #209607673993)
City Southport County Brunswick Zip Code 28461
8. Reason for Well(s): petroleum release assessment for Circle K Store #2720467 (UST incident #48965)
(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).
UST incident #48965
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? - Yes - 5)
Existing Monitoring or Recovery Well Construction Permit No(s) .: N/A
13. Distance from proposed well(oto nearest known waste or pollution source (in feet): Approx. 40 feet d�
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No c
If yes, give distance(s) N/A
15, Well Contractor: Geologic Exploration Certification No.: 1176
Well Contractor Address: 176 Commerce Blvd. Statesville, North Carolina 28625
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. Groin horizons
c. Screen intervals g. Well head completion details
J. 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: 1 Steel traffic bearine cover, sealing and locking cap
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: June 2023
4. Total Number of wells to be constructed: t 7. Estimated construction completion date: June 0 -
(add answers from 2 and 3)
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,
�chaptef-2accepts full responsibility for compliance with these rules
S na�r�e/�of�App scant or •�Agent Title o p�'plicant orb -Agent -
//`�/`y`t �� ' If signing as Agent, attach authorization agreement stating
Printed Kaimee of Applican r 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
wells as outlined in this Well Construction Permit application and that it shall be the responsibility of the applicant to ensure that the
well confo o the Well struction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
46:ZZZ
Si atu a wn diffe'rer lh rtt Printed name of Property wrier (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]
yetteville Regional Office
5 Green Street, Suite 714
F�Pyetteville, NC 28301-5094
one: [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]
linston-Salem Regional Office
0 W. Hanes Mill Road
ite 300
nston-Salem, NC 27105
Phone: [phone]
AR Rev. 3-1-2016