WM0501309_Application_20181231

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: December 31,2018 FOR OFFICE USE ONLY
2. County: Johnston PERMIT NO. 0AC§_o/3.3el ISSUED DATE
3. What type of well are you applying for?(monitoring or recovery): Groundwater Monitoring
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4. Applicant: NCDEQ-DWM, UST Section, Federal&State Lead Program(TF#29447)Telephone: [phone] d
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Applicant's Mailing Address: 217 West Jones Street, Raleigh, NC 27603
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Applicant's Email Address(if available): [e-mail]
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5. Contact Person(if different than Applicant): Kevin Buchanan Telephone [phone]
Contact Person's Mailing Address: WithersRavenel, 115 MacKenan Drive, Cary, NC 27511 0 ,�
withersravenel.com Contact Person's Email Address(if available): kbuchanan @ q �
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6. Property Owner(if different than Applicant): Glennie-Rea Corporation Telephone: [phone] Z
Property Owner's Mailing Address: P.O. Box 607, Selma, NC 27576
Property Owner's Email Address(if available):
7. Property Physical Address(Including PIN Number) NC PIN 261405-08-9522,Johnston County Parcel#14042026,Lot 7,Massey Street
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 LIST 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 28,2018(Well not yet installed on seperate property)
11. Type of contaminants being monitored or recovered: Pertoleum 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): N/A
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: 2 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: 2 7. Estimated construction completion date: 01/21/19
(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 Pe mit as egulated under the Well Construction Standards(Title 15A of the North Carolina Administrative Code
r chapand accepts full responsibility for compliance with these rules
Agent for NCDEQ-DWM,UST Section,TF#29447
Signatufe 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 David R.Godwin,President,Glennie-Rea Corporation
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:
a
Asheville Regional Office Raleigh Regional Office Wilmington Regional Offices O
2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension—a Cs
Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 28405 N
Phone: [phone] Phone: [phone] Phone: [phone] c p
Fax: [phone] Fax: [phone] Fax: [phone]
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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 CL
Phone: [phone] Phone: [phone] Winston-Salem, NC 27105 c�
Fax: [phone] Fax: [phone] Phone: [phone] r x
Fax: [phone] z
Mooresville Regional Office o
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
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ORIGINAL �
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EXISTING TYPE II MONITORING WELL LOCATION
PROPOSED TYPE II MONITORING WELL LOCATION
NOTES:2013 AERIAL OBTAINED FROM THE LOCAL COUNTY GIS DEPARTMENT. \ l+ c
2. NO TEST BORINGS IDENTIFIED WITHIN 500 FEET OF PROPOSED WELL. SD
3 KNOWN SOURCE OF PETROLEUM GROUNDWATER CONTAMINATION IS THE SELMA w
PAWN SHOP(NCDEQ TF#29447)LOCATED APPROXIMATELY 100 FEET SOUTH&150 GRAPFVt SCALE
FEET SOJTHWESTOF PROPOSED WELLS. fi. io
0 50 1*100 200
4. POSSIBLE SOURCE OF GROUNDWATER CONTAMINATION-MARATHON • -
PETROLEUM,LOCATED APPROXIMATELY 500 FEET SOUTH OF PROPOSED WELLS. r a f
5. NO SEPTIC TANK SYSTEMS,PESTICIDE STORAGE AREAS,ANIMAL FEEDLOTS, MARATHON
LANDFILLS OR OTHER WASTE DISPOSAL AREAS ARE KNOWN TO BE WITHIN 500 i GAS 1 inch=100 fL
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FEET OF PROPOSED WELL LOCATIONS

TYPE II WELL CONSTRUCTION
(TYPICAL)
LOCKING WELL CAP
FLUSH MOUNT
GRASS SURFACE BOLT DOWN COVER
01
NATIVE
SOILS
B" DIA. STEEL SKIRT
.-:,,-----NEAT CEMENT GROUT
2—INCH DIAMETER PVC CASING
e
TOP BENTONITE 3'
TOP SAND 4' it PELLETIZED BENTONITE
TOP SCREEN 5' (2' MIN.)
LEAN FILTER "TORPEDO" SAND
—'-2—INCH DIAMETER PVC SCREEN
(0.01' SLOT)
BOTTOM SCREEN 20' PVC BOTTOM CAP
—i �--DIAMETER OF BORING VARIES
GLENNIE-REA CORPORATION PROPERTY SCALE FI
■■ JOHNSTONCOUNTY PARCEL 14042028
W i t h e rs R a v e n e t NC
'. NC PIN261405.OB-9522 JSC NONE 2
Engineers I Planners I Surveyors Po, _;, DATE PF
TYIPCAL WELL SECTION Ke6 12/31/18 02170214.25
1C\17\17-02f0\17Cl14,7D-11'L®-e.nc ft-W4A&-&e\C10\TF2N47 A--W Pw b 12312M&4.9-0...Md 31.901E-PjoWWL 041

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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 Johnston County Parcel # 14042026
Lot 7, Massey Street
Selma,Johnston County, NC
NCDEQ TF Incident# 39447(Selma Pawn Shop)
WR Project#02170214.25
1 am/We are the owner(s) of the parcels of 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 byArticle
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.
ORIGINAL

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 Johnston County Parcel# 14042026
Lot 7, Massey Street
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
f>2 e',Id" 1,.0
Type/Print Name(s)of Owner/Agent
5tct-9 S' -067
Phone Number
Pa Y3o k O 7
Owner(s)Mailing Address
-- sGl'W. NG z7S7�j
City,State,Zip Code
f Z.-70-1 9
Date
ORIGINAL

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%0 WithersRavenel
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115 PdacKenan Dnve,Cary,NC 27511
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Withers Ravenel,.l nc,
115 MacKenan Drive
Cary,NC 27511
Attn:Kevin Buchanan
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