WM0401510_Monitoring well construction permit application WM040141510_application_20240214

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: 02/07/2024
2. County:
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant: Midway Oil and Gas Com
.1
91
7
Applicant's Mailing Address: PO Box 100, Mebane, NC 27302
Telephone: [phone]
Applicant's Email Address (if available): mcleodoila-hotmail.com
Contact Person (if different than Applicant): Jason Ricks Telephone: [phone]
Contact Person's Mailing Address: PO Box 128, Kernersville, NC 27285
Contact Person's Email Address (if available): Iricksapilotenviro.com
Property Owner (if different than Applicant): Nancy Del Rocio Gonzlez Telephone: [phone] or 336-264-9907
Property Owner's Mailing Address: 2330 Pleasant Brook Way, Burlington, NC 27302
Property Owner's Email Address (if available): kcdecor19Q__Qmail.com
Property Physical Address (Including PIN Number) 5546 NC Highway 119 North
City Burlington County Alamance Zip Code 27302
Reason for Well(s): UST related assessment
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
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).
48926
11. Type of contaminants being monitored or recovered: Petroleum -related
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 4
Existing Monitoring or Recovery Well Construction Permit No(s).: N/A
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): —100
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): —300 ft. (closest)
15. Well Contractor: 3D Environmental Investigations, LLC Certification No.: 3162-A
Well Contractor Address: 2157 Mocksville Highway
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: 1 Lockable Metal Cover
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 3/15/2024
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 3/15/2024
(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 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,
Subchapter 2C) and accepts full responsibility for compliance with these rules
/�
Signature Applicant or *Agent
Jason Ricks - Agent
Printed name of Applicant or "Agent
Agent
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
wells as outlined in this Well Construction Permit application and that it shall be the responsibility of the applicant to ensure that the
well(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
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]
AR Rev. 3-1-2016

PROPOSED MONITORING WELL CONSTRUCTION DIAGRAM
Project
Sam's Mart
Burlington, NC
Owner
Midway Oil and Gas Company
Lockable steel manway set in
Well No.
MW-7
concrete at the ground surface
Location
5546 NC Highway 119 North
MD Coordinators
State Permit No.
Pending
4 inch diameter
Topography Setting
drilled hole
Ground Elevation
Drilled By
TBD
Well casing,
Drilling Started
TBD
2 inch diameter,
Drilling Completed
Method of Drilling
Augers
Type of Rig
Geoprobe
to surface
{Grout
0-11 ft.
MONITORING WELL DATA
11 ft Top of bentonite
Bentonite
Well No.
MW-7
Hole Diameter
4 inches
13 ft Top of sand
Hole Depth
25 ft.
Casing Diameter
2 inch
Casing Length
10 ft.
Screen Diameter
2 inch
Screen Slot
0.01
15 ft. Screen
Screen Type
slot
Surface Elevation
No Data
Screen Top El.
No Data
Well Screen,
Screen Bottom El.
No Data
2 inch diamter
Well Status
Active
0.01 slot
Sand Pack
REMARKS
25 ft.
25 ft.
All Measuring Points are from the Top of
Casing Unless Otherwise Noted.
58f3-87cc-7f70-56dc

SITE ACCESS AGREEMENT
This Site Access Agreement (the "Agreement") is made and entered into by Nancy
Gonzalez ("Owner") and Pilot Geological, PLLC ("Consultant"), this the day of
_, 2024.
WHEREAS, Owner owns the property located at 5546 NC Highway 119 North,
Burlington, North Carolina (the "Property");
WHEREAS, the Consultant desires to enter upon the Property to the extent permitted in
this Agreement for the purposes of collecting soil and groundwater samples, collecting
groundwater samples from the water supply well, and including installing one groundwater
monitoring well (the "Work"); and Owner is willing to allow such access to the Property upon
the terns and conditions set forth in this Agreement. The monitoring well will have metal
covers that will be approximately 3 feet above grade and approximately 4-inches square set in a
2 foot by 2 foot concrete pad;
NOW, THEREFORE, in consideration of the covenants and agreements described below
and other good and valuable consideration, the receipt and sufficiency of which are
acknowledged, the parties agree:
1. Owner grants to Consultant and its agents and employees, contractors, and
subcontractors (collectively "Representatives") reasonable, non-exclusive access to the Property
from time to time for the sole purpose of performing the Work.
2. Consultant shall be responsible for obtaining, at its sole cost and expense, all
permits and other governmental authorizations, if any, necessary for the Work and shall comply
(and will cause their Representatives to comply) with all applicable laws, permits, and other
governmental authorizations and legal requirements. All fees related to the aforementioned
activities will be the responsibility of parties other than the Owner.
3. Owner understands that Representatives intend to perform Work on the Property
during a period of time as discussed with the Owner, and there may be a need for some follow up
work on the Property. Notwithstanding anything contained herein to the contrary, their
Representatives shall not be allowed to perform any Work on the Property without one (1)
business days' prior notice written or verbal to the Owner. Owner will not interfere with or
hinder the Consultant and its Representatives during their performance of the Work as limited to
the Work. Owner may have its employees or agents observe the Work at Owner's sole cost and
expense.
4. Consultant and its Representatives will perform all Work on the Property with
reasonable care and diligence to avoid accident, damage, or harm to persons or property.
Consultant will conduct the Work on the Property with minimum disturbance to Owner and
Owner's personnel, agents, and invitees and with minimum interference with use of and access
to the Property by Owner and Owner's personnel, agents, and invitees.
4823-4541-1289.v2

5. The Work shall be performed at the cost and expense of parties other than the
Owner. Consultant shall be solely responsible for the proper handling and disposal of any
contaminated equipment, soil, sediment, surface water, groundwater, or other materials removed
from the Property in connection with the Work. Note that per the North Carolina Department of
Environmental Quality (NCDEQ) guidance the drill cuttings and purge water are allowed to be
and will be spread on the property.
6. If Owner so requests, Consultant agrees to cause its Representatives to provide
Owner with a certificate of insurance evidencing liability insurance coverage in the amount of
not less than $1,000,000 prior to entering the Property and shall name Owner as additional
named insured in reference to such policy of insurance. Consultant shall restore the Property as
near as practicable to its condition existing immediately before Representatives' entry upon the
Property, normal wear and tear excepted. Consultant shall indemnify, defend and hold Owner
and its officers and employees harmless from all claims, injuries, demands, liabilities, losses,
damages, costs and expenses, including reasonable attorneys' fees and disbursements
(collectively, "Claims") for any bodily injury, property damage or construction liens caused by
the conduct or acts of Representatives.
7. Consultant hereby releases Owner, its subsidiaries, affiliates and their respective
members, directors, officers and agents from all present and future Claims that the Consultant
now has or may hereafter accrue on account of or in any way arising out of any and all known
bodily and personal injuries or property damage and the consequences thereof resulting or which
may result from Consultant's entry upon the Property or the negligent use of any equipment or
procedures while on, entering or leaving the Property. Claims arising out of the negligence or
willful misconduct of Owner are excluded from this Release.
8. This Agreement and the right of access granted by this Agreement shall terminate
upon the completion of the Work. The rights and obligations under Paragraphs 6, 7 and 11 will
survive termination of this Agreement. This Agreement and the right of access and the scope of
the Work may be extended or modified only by written amendment signed by each party.
9. Consultant shall provide Owner with a copy of all written reports which
Consultant obtains regarding environmental conditions on the Property, if requested. The reports
will be a matter of public record and can be obtained from the NCDEQ.
10. The undersigned represent that they are authorized to execute this Agreement on
behalf of, and to bind, Owner and Consultant and that the parties have the rights and capacities to
perform any acts authorized or contemplated by this Agreement. This Agreement shall be
governed by and interpreted in accordance with the laws of the State of North Carolina.
11. The access granted by this Agreement is being granted on the express condition
that Consultant's investigations will be limited to Work performed on the Property.
2
48234541-1289.v2

IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be properly
executed and sealed the day and year first above written.
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Title: Oq) n e ,
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Email: kCC�CCoy(sj 0 avv).GtO-CCU"
Jason Ricks
Title: Principal Geologist
Phone: [phone]
Email: 'ricks a ilotenviro.com
3
4823-4541-1289.v2

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LEGEND
Proposed Monitoring Well Location
Proposed Monitoring Well
Drawing 1
Google Earth_5545
Sam's Mart
tP
Highway 119 North
Interactive Mapping Software
ILOT
Burlington Alamance County, NC
,
Scale:1"=60'
L, :[4_4GI{A..r<<�
Pilot Project G-9207.3

I
LEGEND
Site Boundary
Approximate Monitoring Well Location
Approximate UST Location
tPDrawing 2Google EarthInteractive Mapping SoftwareScale:1"=20' ti :IiCA..rL L{
Sample Location Map
Sam's Food Mart
5545 Hwy 119 North
Mebane, Alamance County, NC
Pilot Project G-9207.3

tPDrawing 3Google EarthInteractive Mapping SoftwareScale : 1"= 300' ��
Receptor Survey Map
Sam's Food Mart
5545 Hwy 119 North
Mebane, Alamance County, NC
Pilot Project G-9207.3