WM0501334_Application_20190102

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: January 2,2019 FOR OFFICE USE ONLY
2. County: Johnston PERMIT NO. VAegoI33y ISSUED DATE
3. What type of well are you applying for?(monitoring or recovery): Groundwater Monitoring a;
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4. Applicant: NCDEQ-DWM, UST Section, Federal&State Lead Program(TF#29447)Telephone: [phone] `*�
Applicant's Mailing Address: 217 West Jones Street, Raleigh, NC 27603 C cl
Applicant's Email Address(if available): [e-mail]
5 Contact Person (if different than Applicant): Kevin Buchanan Telephone: [phone] w ?
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Contact Person's Mailing Address: WithersRavenel, 115 MacKenan Drive,Cary, NC 27511
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Contact Person's Email Address(if available): [e-mail] p!
6 Property Owner(if different than Applicant): Town Of Selma, NC Telephone: [phone] z
Property Owner's Mailing Address: 114 N. Raiford Street, Selma, NC 27576(Attn: Mr. Elton Daniels,Town Manager)
Property Owner's Email Address(if available): [e-mail]
7. Property Physical Address(Including PIN Number) Intersection of S. Massey Street&Dogwood Drive(No NC PIN Available)
City Selma County Johnston Zip Code 27576
8. Reason for Well(s): Groundwater Monitoring
(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: State Lead UST Cleanup site(Incident#29447)
(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).
YES-Incident#29447(Selma Pawn Shop),"Monitoring Well Permit#WM0501329 Issued November 29,2018(Well not yet installed on seperate property)
11. Type of contaminants being monitored or recovered: Petroleum Hydrocarbons
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? YES-10 Existing Type II Monitoring Wells
Existing Monitoring or Recovery Well Construction Permit No(s).:
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)? NO
If yes,give distance(s):
15. Well Contractor: Cascade Environmental Services.Inc Certification No.: 2736
Well Contractor Address: 251 NC Highway 24/27 West,Midland_NC 28107
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 ORIGINAL

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2 Number of wells to be constructed in unconsolidated 5. How will the well(s)be secured?
material: 1 Locking cap @ TOC Steel flush-mount manhole set in concrete
3. Number of wells to be constructed in bedrock: 0 6 Estimated beginning construction date: 01/21/19
4. Total Number of wells to be constructed: 7. Estimated construction completion date: 01/21/19
(add answers from 2 and 3)
ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C .0105(0(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 Co struction Permit as gulated under the Well Construction Standards(Title 15A of the North Carolina Administrative Code..
chapt 2C)and accepts full responsibility for compliance with these rules
Agent for NCDEQ-DVVM,UST Section,TF#29447
Signaturd of Applicant or*Agent Title of Applicant or*Agent
Kevin B.Buchanan,Project Manager *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
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).
SEE ATTACHED EXECUTED ACCESS AGREEMENT Town of Selma,North Carolina
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 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 - ... `
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone] r`
Fax: [phone]
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ORIGINAL

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LEGEND
EXISTING TYPE II MONITORING WELL LOCATION
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PROPOSED TYPE II MONITORING WELL LOCATION \ & N.r
NOTES: `
1 2013 AERIAL OBTAINED FROM THE LOCAL COUNTY GIS DEPARTMENT yyy \ 4 MARATHON
2. NO TEST BORINGS IDENTIFIED WITHIN 500 FEET OF PROPOSED WELL. y \ GAS + 1 1J
3. KNOWN SOURCE OF PETROLEUM GROUNDWATER CONTAMINATION IS THE SELMA T SoQ.
PAWN SHOP(NCOEO TF#29447)LOCATED APPROXIMATELY 100 FEET SOUTHEAST \ + r+ �` GRAP SCALE
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OF PROPOSED WELL " \ '� �„,ssy��+ 50 00 2 0
4. POSSIBLE SOURCE OF GROUNDWATER CONTAMINATION-MARATHON
PETROLEUM,LOCATED APPROXIMATELY 380 FEET SOUTH OF PROPOSED WELL,
5. NO SEPTIC TANK SYSTEMS,PESTICIDE STORAGE AREAS,ANIMAL FEEDLOTS, — .
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LANDFILLS OR OTHER WASTE DISPOSAL AREAS ARE KNOWN TO BE WITHIN 500 '�-- -. - Inch—100 ft
FEET OF PROPOSED WELL LOCATION / Adll

TYPE II WELL CONSTRUCTION
(TYPICAL)
LOCKING WELL CAP
FLUSH MOUNT
GRASS SURFACE BOLT DOWN COVER
NATIVE
SOILS
8" DIA. STEEL SKIRT
r--NEAT CEMENT GROUT
2-INCH DIAMETER PVC CASING
TOP BENTONITE 3' A.
TOP SAND 4' PELLETIZED BENTONITE
(2' MIN.)
TOP SCREEN 5'
LEAN FILTER "TORPEDO" SAND
-'-2-INCH DIAMETER PVC SCREEN
(0.01' SLOT)
BOTTOM SCREEN 20' PVC BOTTOM CAP
DIAMETER OF BORING VARIES
NC ept of Envi o ental Quality DRA,NI,B, CAL E FIGUPE 1d0,
°�■ W i t h e r s R a v e n e� OWN OT SELMA NC PROPERTY
,. A` r 5 MASSEYSTREET&DOGWOOD DRIVE JSC NONE Z
1ANr )1 APPFU it 7 r 1A i L PkOJCI.T NCB.
'7 TYiPCAL WELL SECTION KBB 01/02/19 02170214.25
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Raleigh Regional Office

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Environmental
Quality
North Carolina Department of Environmental Quality
Division of Waste Management
Roy Cooper Michael S. Reagan
Governor Secretary
Mr. Mark Petermann, Incident Manager
NCDEQ-DWM, UST Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Dear Mr. Petermann:
Re: NCDEQ Access Agreement for Town of Selma, NC Property
South Massey Street at Intersection with Dogwood Drive
Selma,Johnston County, NC
NCDEQ TF Incident#39447(Selma Pawn Shop)
WR Project#02170214.25
1 am/We are the owner(s)of the parcel/Town Right of Way Property listed above,located at
or near the incident in question, and hereby permit the NC Department of Environmental Quality
(NCDEQ), or its contractor to enter upon said property for the purposes of conducting an
investigation of the groundwaters under the authority of G.S. 143-215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the
Department or its contractor. The Department or its contractor shall protect and prevent
damage to the surrounding lands.
3. Unless otherwise agreed,the Department or its contractor shall have access to the site by the
shortest feasible route to the nearest public road. The Department or its contractor may enter
upon the land at reasonable times and have full right of access during the period of the
investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article
31 of Chapter 143 of the North Carolina General Statutes, Tort Claims Against State
Departments and Agencies,and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon
request and is a public record, in accordance with G.S. 132-1.
91

Environmental
Quality
North Carolina Department of Environmental Quality
Division of Waste Management
Roy Cooper Michael S. Reagan
Governor Secretary
Site Access Agreement Page 2 of 2
NCDEQ Access Agreement for Town of Selma, NC Property
South Massey Street at Intersection with Dogwood Drive
Selma,Johnston County, NC
NCDEQ TF Incident#39447(Selma Pawn Shop)
WR Project#02170214.25
6. The activities to be carried out by the Department or its contractor are for the primary
benefit of the Department and of the State of North Carolina. Any benefits accruing to the
owner are incidental. The Department or its contractor is not and shall not be construed to
be an agent,employee, or contractor of the land owner.
/We agree not to interfere with,remove,or any way damage the Department's well(s)or its
contractor's well(s)and equipment during the investigation.
Attest:
Signature
Type/Print Name(s)of Owner/Agent
Phone Number
Owners)Mailing Address
City,State,Zip Code
12 rF
Date

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LEGEND
GROUNDWATER MONITORING WELL (EXISTING)
PROPOSED TYPE II MONITORING WELL* * GRAPHIC SCALE
W R 0 ALNOTE: w
PROPOSED WELL LOCATION VARIABLE WITHIN ENCROACHMENT, BASED ON 1 hlch-20 IL
UTILITY CLEARANCES.