WM0401541_Monitoring well permit application_20240717

Docusign Envelope ID:599C9F55-C2EB-4E3D-8159-F09163C47018
IYVICI rl VhiRVLIIMM I.JCrNRI IVICIM I yr CI9vmwi4MENTAL 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.
FOR OFFICE USE ONLY
1. Date: 5/8/2024
2. County: Forsyth 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: 500 Speedway Drive, Enon, Ohio 45323
Applicant's Email Address(if available): Samuel.KramelD_7-11.COm
5. Contact Person (if different than Applicant): Nicole Long Telephone: [phone]
Contact Person's Mailing Address: AECOM, 6000 Fairview Road, Suite 200, Charlotte, NC 28210
Contact Person's Email Address(if available): Nicole.Long cDAECOM.com
6. Property Owner(if different than Applicant): Stephen T Williams Telephone Unknown
Property Owner's Mailing Address: 433 Roslyn Road,Winston-Salem, NC 27104
Property Owner's Email Address(if available): Unknown
7. Property Physical Address(Including PIN Number) 3600 S Main Street PIN: 6833-38-5457
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: 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).
N/A
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? 6 onsite 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): Unknown
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): N/A
15. Well Contractor: Geological Resources, Inc. Certification No.: 3270
Well Contractor Address: 2301 Haves 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

Docusign Envelope ID:599C9F55-C2EB-4E3D-8159-F09163C47018
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s)be secured? Grout
material: 1
3. Number of wells to be constructed in bedrock: N/A 6. Estimated beginning construction date: June 2024
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: June 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. 143-215.10B(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.
Project Manager-as limited field agent for Speedway
Signature of Applicant or*Agent Title of Applicant or*Agent
Nicole Long *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
DoausigwTiv.re that the well(s)will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
Fsfv" , WImsSr. Stephen T. Williams, Sr.
�&WuLreoof3Pxoperty 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 Washington Regional Office Winston-Salem Regional Office
225 Green Street, Suite 714 943 Washington Square Mall 450 W. Hanes Mill Road
Fayetteville, NC 28301-5094 Washington, NC 27889 Suite 300
Phone: [phone] Phone: [phone] Winston-Salem, NC 27105
Fax: [phone] Fax: [phone] Phone: [phone]
Fax: [phone]
Mooresville Regional Office
so
610 East Center Avenue
° t�
Mooresville, NC 28115
Phone: [phone]
Fax: [phone] / t
N or Is 1
,F 'Ile v �!
Will ngton
GW-22M/R(Rev.5-26-2022)

Docusmign Envelope ID:599C9F55-C2EB-4E3D-8159-F09163C47018
( - ) LEGEND
N —••— Approximate Property Boundary
to Clemmonsville Road Fence
O I Product Dispenser
to Former Product Dispenser
Underground Storage Tank
--OH/W-- OH/W--- --OH �
#1 8,000-Gal. Kerosene
W---oH/W- o W_ Concrete Side #2 8,000-Gal. Diesel
— — — / — OH/W--_OH/W OH —_OH i #3,#4 8,000-Gal. RUL Gasoline
W-- #5 8,000-Gal. PUL Gasoline
OH/W, o --off/W-- Overhead Wire
_
Cam Utility Pole/Power Pole
t Asphalt o :o:
p Light Post/Traffic Light
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_ ❑ Catch Basin/Stormwater Inlet
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Deep Monitoring Well
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Wooded Area
Store #6932
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Vent Pipes
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Commercial SCALE IN FEET: Speedway LLC. FIGURE 2
Speedway Store#6932 SITE PLAN
20 0 20 3600 South Main Street NOTE: ALL MAP FEATURES ARE APPROXIMATE Winston-Salem, North Carolina �
_
COM
IN SCALE AND LOCATION.
3 DATE: APRIL 2024 DRAWN BY: D.OLTEANU REVIEWED BY: N.LONG PROJECT NO.: 60726430-006
6

Docusign Envelope ID:599C9F55-C2EB-4E3D-8159-F09163C47018
t,eee,u. apeeuwuy#6932 WELL ID:
_ Project Number:
A=COM Site Location: 3600 S.Main Street, Winston-Salem NC 2 712 7 Date Installed:
Well Location: Coords: Inspector:
Method: Auger and Air Rotary Contractor:
WELL CONSTRUCTION DETAIL
Depth from G.S.(feet) Elevation(feet)
Datum
Top of Riser Pipe 0.0
Ground Surface(G.S.) 0.0
Riser Pipe:
Length 5
Diameter(ID) 1"
Type of Material PVC
Thickness Sch 40
Grout:
Type Neat Cement
Thickness
Top of Bentonite 10'
.............. ..............
!!! !! Bentonite Seal Thickness 2
i
.............. ..............
Top of Sand 12'
Top of Screen 15'
.Stabilized Water Level
Screen:
Length 10,
Diameter(ID) 2"
Slot Size 10 Slot
Type of Material PVC
Thickness Sch 40
Type/Size of Sand #2
Sand Pack Thickness 32
Bottom of Screen 25
Bottom of Tail Pipe: 25
Bottom of Borehole 25
Borehole Diameter 2.25"ID Geoprobe
Describe Measuring Point:
Signature Date