WM0401263_Monitoring Well Permit Application_20201125

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: 11/16/20
2. County: Guilford
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Blake Jones Telephone: [phone]
Applicant's Mailing Address: 2275 Vansto Street Suite 200 Greensboro NC 27403
Applicant's Email Address (if available): b'ones(dj)kou!ycofl2.com
5. Contact Person (if different than Applicant): Randy H. Cavalier Telephone: [phone]
Contact Person's Mailing Address:. 4811 Koster Blvd, Greensboro, NC 27407
Contact Person's Email Address (if available): rcavallier@.ecslimited.com
6. Property Owner (€f different than Applicant): DEBNAM FAMILY TRUST, Marguerite Debn r;,: Telephone:
Property Owner's Mailing Address: 6 York Rite Court, Greensboro. NC 27407
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 2740 N. Church Street PIN 43670
City Greensboro County Guilford Zip Code 27405
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).
11
12
13
14
NO
Type of contaminants being monitored or recovered: Petroleum
(ex: organics, nutrients, heavy metals, etc.)
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).:
Distance from proposed well(s) to nearest known waste or pollution source (in feet): Unknown
Are there any water supply wells located less than 500 feet from the proposed weli(s)?
If yes, give distance(s):
15, Well Contractor: 3D Environmental Investigations, LLC Certification No.: 3162-A
Well Contractor Address: 2157 Mocksville Highway, Statesville, NC 28625
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)
Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured?
material: 5 NIA GW Borings
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 5
(add answers from 2 and 3)
6. Estimated beginning construction date; 11/25/20
Estimated construction completion date: 11/25/20
ADDITIONAL INFORMATION
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 Construction 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
Vice President -Construction Division
Signature of Applicant or *Agent Title of Applicant or *Agent
Blake Jones ' tf 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).
Marauerite Debnam. Trustee
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant)
DIRECTIONS
send lh complefe3 applicationZ�V646propnateDivision of Water Resources' Regional Office:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [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, NO 28115
Phone: [phone]
Fax: [phone]
3800 Barrett Drive
Raleigh, NO 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mail
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
OR Rev. 3-1-2016
Raleigh Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension
GW-22M (Rev. 5111)