WM0401526_Application_20240416

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: 02/13/24
2. County: Forsyth
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Speedway, LLC Telephone: [phone]
Applicant's Mailing Address: PO Box 1500, Springfield, OH 45501
Applicant's Email Address (if available):
5. Contact Person (if different than Applicant): Nathan Pinsker Telephone: [phone]
Contact Person's Mailing Address: 5438 Wade Park Boulevard, Suite 200, Raleigh, NC 27607
Contact Person's Email Address (if available): Nathan. Pinsker(a)aecom.com
6. Property Owner (if different than Applicant): Nancy W. Downing Telephone: Unknown
Property Owner's Mailing Address: 1829 Shoreham Dr. Charlotte NC 28211
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 3715 Peters Creek Parkway Winston-Salem NC 27127-7236
City Winston-Salem County Forsyth Zip Code 27127
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: Gasoline station
(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).
No
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? No
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): NA
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: Regional Probing Services Certification No.: 3322-A
Well Contractor Address: P.O. Box 1161, Wake Forest, NC 27588
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
material: 6
3. Number of wells to be constructed in bedrock:
5. How will the well(s) be secured? NA
6. Estimated beginning construction date: 4/23/24
4. Total Number of wells to be constructed: 6 7. Estimated construction completion date: 4/23/24
(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 Applicant assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Manager, Environmental Services
Signature of Applicant or *Agent Title of Applicant or *Agent
Samuel Kramer * 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 w�eII,(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
Nancy W. Downing
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)

Client: Speedway 6930 WELL ID: Temporary Well
Project Number:
A_ COM Site Location: 3715 Peters Creek Parkway Winston-Salem NC Date Installed:
Well Location: Coords: Inspector:
Method: Direct Push Technology (geoprobe) I Contractor: Regional Probing Services
Proposed Monitoring Well Construction Log
Top of Riser Pipe
Ground Surface (G.S.)
Length
Diameter (ID)
Type of Material PVC
Thickness Sch 40
Top of Sand
Top of Screen
Screen:
Length
Diameter (ID)
Slot Size
Type of Material
Thickness
Type/Size of Sand
Sand Pack Thickness
. Stabilized Water Level
Bottom of Screen
Bottom of Tail Pipe:
Bottom of Borehole
Borehole Diameter
Describe Measuring Point:
Signature
5'
PVC
#2
12'
2.5"
Depth from G.S. (feet) Elevation (feet)
Datum
Date
w
0.0
—19 ft
25 ft bgs
25 ft bgs
25 ft bqs

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