WM0401257_Monitoring Well Permit and Application_20200917

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: 9/16/20
2. County: Randolph
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Sedia Systems (Wilson Troup) Telephone: [phone]
Applicant's Mailing Address: 1820 W. Hubbard Street, Suite 300, Chicago, IL 60622
Applicant's Email Address (if available): wtroup(a-)sediasystems.com
5. Contact Person (if different than Applicant): Scott Young Telephone: [phone]
Contact Person's Mailing Address: 1812 Center Park Drive, Suite D, Charlotte, NC 28217
Contact Person's Email Address (if available): syoung1(CDecslimited.com
6. Property Owner (if different than Applicant): MOM Brands Company, LLC (Amy Cernava) Telephone: [phone]
Property Owner's Mailing Address: 335 Commerce Place, Asheboro, NC 27203
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 335 Commerce Place — PIN-77553883982
City Asheboro County Randolph Zip Code 27203
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: Industrial
(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).
Unknown
11. Type of contaminants being monitored or recovered: VOCs & SVOCs
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? None
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): N/A
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Unknown
If yes, give distance(s):
15. Well Contractor: 3D Environmental Investigations, LLC (Walt Davis) Certification No.: 3162-A
Well Contractor Address: 2157 Mocksville Hiahway. Statesville. NC 28625
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

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured?
material: 5 Sample will be collected through Geoprobe Sampling
Point
3. Number of wells to be constructed in bedrock: 0
6. Estimated beginning construction date: TBD
4. Total Number of wells to be constructed: 5
(add answers from 2 and 3) 7. Estimated construction completion date: TBD
ADDITIONAL INFORMATION
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 WE0onstruction 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
ww�
Environmental Proiect Manager
Signature o plica or *Agent Title of Applicant or *Agent
Scott Young * 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 signed Access Agreement
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
3800 Barrett Drive
Wilmington, NC 28405
2090 U.S. Highway 70
Raleigh, NC 27609
Phone: [phone]
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Winston-Salem Regional Office
Washington Regional Office
450 W. Hanes Mill Road
Fayetteville Regional Office
943 Washington Square Mall
Suite 300
225 Green Street, Suite 714
Washington, NC 27889
Winston-Salem, NC 27105
Fayetteville, NC 28301-5094
Phone: [phone]
Phone: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
-22MR Rev. 3-1-2016
Raleigh Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension
GW-22M (Rev. 5/11)

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ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49-20514P
Scope of Work: Proposal for Environmental Assessment
Project: Commerce Place Property
Location: 335 and 401 Commerce Place, Asheboro, Mecklenburg County, North Carolina
As part of the proposed real estate transaction, ECS Southeast, LLP (ECS) has been requested by the
purchaser to conduct subsurface soil and groundwater sampling at the site. This sampling requires that
ECS procure a permit from the North Carolina Department of Environmental Quality (NCDEQ).
ECS respectfully requests that the owner of the property grant permission to ECS to access the property
to conduct the groundwater sampling. By signing below, the property owner authorizes ECS to conduct
the aforementioned sampling at the site.
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Property Owner (please print): MOM Brands Company, LLC �Lo�vti �`= lets i5�e%Gv�
Property Owner Telephone (please print): ` CJ �502
Property Owner Signature: Lti� Date:
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Grant Miller (Seller's Broker) - Colliers International 704-880-0717
ECS P oposal No. 49:20514P E
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2019
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COMMERCE PLACE PROPERTY
335 and 401 COMMERCE PLACE
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ASHEBORO, NORTH CAROLINA
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ECS PROJECT NO. 49:12274-A
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LEGEND
APPROXIMATE SITE BOUNDARY
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OAPPROXIMATE GROUNDWATER BORING LOCATION
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SOURCE:
FIGURE 2
PROPOSED SAMPLE LOCATION MAP
RANDOLPH COUNTY GIS WEBSITE
ACCESSED SEPTEMBER 14, 2020
COMMERCE
PLACE PROPERTY
335 and
401 COMMERCE PLACE
SCALE:
ASHEBORO, NORTH
CAROLINA
AS SHOWN
ECS PROJECT NO. 49:12274-A
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IDTHS
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FIGURE 3
PROPOSED TEMPORARY SCREEN
POINT SAMPLER s
COMMERCE PLACE PROPERTY
335 and 401 COMMERCE PLACE
ASHEBORO, NORTH CAROLINA
ECS PROJECT NO. 49:12274-A