WM0100564_Monitoring Well Construction Application_20230816

FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
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: August 16, 2023
2. County: Henderson
3.What type of well are you applying for? (Monitoring or recovery): Monitoring
4. Applicant: Tiffany Bauman on behalf of ExxonMobil Telephone: [phone]
Applicant’s Mailing Address: 22777 Springwoods Village Pky. Spring, TX 77389
Applicant’s Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Jeremy Blumberg Telephone: [phone]
Contact Person’s Mailing Address: 1 Beacon Street, Suite 8100, Boston, MA 02108
Contact Person’s Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Duane and Margaret McKibbin Family LTD PRTNR Telephone:
Property Owner’s Mailing Address: 745 Ashe Street, Hendersonville, NC 28792
Property Owner’s Email Address (if available): [e-mail]
7. Property Physical Address (Including PIN Number) 9579259550
City Hendersonville County Henderson Zip Code 28792
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: Active retail petroleum
(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).
Incident #9644
11. Type of contaminants being monitored or recovered:Organics
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Ten monitoring wells
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): Between 50-100 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)?No
If yes, give distance(s):
15. Well Contractor:SAEDACCO Certification No.:
Well Contractor Address: 9088 Northfield Drive, Fort Mill, SC 29707
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
WM0100564 12/7/2023
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)

2. Number of wells to be constructed in unconsolidated
material: Two

3. Number of wells to be constructed in bedrock:

4. Total Number of wells to be constructed: Two
(add answers from 2 and 3)
5. How will the well(s) be secured? cap and metal cover

6. Estimated beginning construction date: 9/26

7. Estimated construction completion date: 9/28

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.

Consultant for ExxonMobil. Project Manager
Signature of Applicant or *Agent Title of Applicant or *Agent

Jeremy Blumberg * 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.

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]
GW-22M/R (Rev. 5-26-2022)
GW-22MR (6/11)
GW-22M (Rev. 5/11)
Tiffany Bauman
Portfolio Manager, Americas Environmental Programs
MW-13
MW-12
MW-11
AS-3
SVE-3
NOTES:
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LEGEND
PROPERTY BOUNDARY
MONITORING WELL
SOIL VAPOR EXTRACTION WELL
VAPOR MONITORING POINT
AIR SPARGE WELL
GROUNDWATER ELEVATION
ABANDONED/DESTROYED MONITORING WELL
CHEMICAL INJECTION WELL
//
UNDERGROUND STORAGE TANK
OVERHEAD POWER LINE
ABANDONED/DESTROYED CHEMICAL INJECTION WELL
MiHP LOCATION
SOIL BORING LOCATION
PROPOSED MONITORING WELL
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DRAWN BY
DATE:
PROJECT NO.
CHECKED BY
REVISED:
FIGURESITE PLAN
EXXONMOBIL SERVICE STATION #4-5552
1920 4 SEASONS BOULEVARD
HENDERSONVILLE, NORTH CAROLINA
20212946
CTH
MR
07/18/2023
1
0
SCALE IN FEET
30 60
SCALE: 1" = 30'
NOTES:
1.BASE MAP PREPARED FROM A DRAWING
"MONITORING WELL LOCATION SURVEY"
PROVIDED BY TWT (TAYLOR WISEMAN &
TAYLOR), CHARLOTTE, NC; DATED
AUGUST 21, 2019.
24-INCH
24-INCH
BOLT-DOWN MANHOLE
CENTERED IN 2-FEETx2-FEET
CONCRETE PAD
MONITORING
WELL
(2-FEET X 2-FEET MINIMUM)
CONCRETE PAD
2-INCH DIAMETER SCHEDULE 40 PVC WELL CASING
6-INCH DIAMETER BOREHOLE
GROUND SURFACE
LOCKING CAP
2-INCH 0.010" SLOTTED SCHEDULE 40 PVC WITH
SOCKET CONNNECTION
12-INCH DIAMETER MANHOLE WITH BOLT DOWN LID
GROUT
SLOPED AWAY FROM
MANHOLE FOR
DRAINAGE
CEMENT PAD
BENTONITE SEAL
#2 SAND PACK
6"
1'-0"
5'-0"
25'-6" BGS
20'-0"
The information included on this graphic representation has been compiled from a variety of
sources and is subject to change without notice. Kleinfelder makes no representations or
warranties, express or implied, as to accuracy, completeness, timeliness, or rights to the use of
such information. This document is not intended for use as a land survey product nor is it designed
or intended as a construction design document. The use or misuse of the information contained on
this graphic representation is at the sole risk of the party using or misusing the information.
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FIGURE
DRAWN BY:
PROJECT NO.
CHECKED BY:
REVISED:
DATE:
WELL CONSTRUCTION DETAIL
(MW-12 AND MW-13)
EXXONMOBIL SERVICE STATION #4-5552
1920 4 SEASONS BOULEVARD
HENDERSONVILLE, NORTH CAROLINA
20212946
CTH
MR
08/21/2023
1
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