WM0401269_Monitoring Well Permit Application_20201221

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.
Date: 12/17
2. County: Forsyth
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Durban Development, LLC (Jason Mathis) Telephone:
Applicant's Mailing Address: 106 Foster Avenue, Charlotte, North Carolina, 28203
Applicant's Email Address (if available): 0ason.math is a durbandevelopment.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(aecslimited.com
6. Property Owner (if different than Applicant): William F Sherrill Telephone:
Property Owner's Mailing Address: 6901 Konica Drive, Whitsett, North Carolina 27377
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 1500 West First Street — PIN-6825-64-0877
City Winston Salem County Forsyth Zip Code 27104
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).
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? No
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): N/A
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: 3D Environmental Investigations, LLC Certification No.: 3162-A
Well Contractor Address:
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)
2. Number of wells to be constructed in unconsolidated 5.
material: 5
3. Number of wells to be constructed in bedrock: 0
How will the well(s) be secured?
Wells are temporary and will be abandoned after
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
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 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,
a� Subchapter 2C) and accepts full responsibility for compliance with these rules
Environmental Project Manager
Signature of Applicant or *Agent
Scott Young
Printed name of Applicant or *Agent
Title of Applicant or *Agent
* If signing as Agent, attach authorization agreement stating
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]
Raleigh Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension
GW-22M (Rev. 5/11)

December 16, 2020 ECS SOUTHEAST, LLP
ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Project No.: 49:12193-B
Scope of Work: Environmental Assessment
Project: Vacant Restaurant Property
Location: 1S00 West First Street, Winston-Salem, Forsyth 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 soil and groundwater sampling. By signed below, the property owner authorizes ECS to
conduct the aforementioned sampling at the site.
Property Owner (please print): Jason Mathis (on behalf of Durban Acquisitions, Agent for Owner)
Property Owner Telephone (please print): 704-319-8347
Property Owner Signature: 7x_� Date: 12/17/20
ECS Project No. 49:12525-B
Page 1 1
�s

November 11, 2020
Re: 1500 W. First Street, Winston-Salem, North Carolina
Tax Parcel ID # 6825-64-0877.00
To Whom It May Concern:
I, William F. Sherrill, am the owner ("Owner") of the real property located at 1500 W.
First Street in Winston-Salem, North Carolina having Tax Parcel Identification Number of 6825-
64-0877.00 (the "Property"). I am under contract to sell the Property to Durban Acquisitions,
LLC ("Durban"). The undersigned Owner hereby provide its written consent for Durban and
any of its subsidiaries, affiliated entities and their agents, to act on behalf of the Owner to file
and/or apply for any investigations, permits and/or general entitlements necessary for acquisition
and development of the aforementioned Property for its intended use.
OWNER:
By:
Name: illiam F. Sherrill

4 \
�
r?
f7FL0DAl.F,N�E #
-' ATL 1 LA1 . -
.E.
FOMS1 UR
fAR A❑R
11W
AHGEld
{ 5;:,
5 0R
-+ J
So'
l
x
u eiL7�r
x
�
i
h F o5
lw
SITE
a
LOCATIONA.
��
xp
yyESFFiEL -AYE S
L � lid, � 1iU�
El!.iiA9f7N
4
1'e -t Salem
'
" a LYNB}li1R 7 ANZ
3
'I S A1VTfiORFlE•
�
w
� I•i
r-
o
r
$ � r J ' R'
xaaeoxFE.
1�
AI
.r.NF
SCALE 1 :2-4 OW
1
0.5
6 KILOMETERS 1
2
1000
900
6 METERS 1000
2000
1
0.5
0
1
RULES
1000 0
1000 2"
30M 40M B000 6000 70CC scoo 9000 10000
FEET
FIGURE 1
SOURCE:
SITE TOPOGRAPHIC MAP
USGS 7.5' TOPOGRAPHIC MAP
VACANT RESTAURANT PROPERTY
WINSTON SALEM WEST, NC
2019N
1500 WEST FIRST STREET
WINSTON-SALEM, FORSYTH COUNTY,
SCALE:
S
NORTH CAROLINA
AS SHOWN
ECS PROJECT NO.: 49:12193-B
TM

IN_
®110
Formlef
MIST
System
IF a
Vacant Cornmemial lbvlId�ng
(Former Gains Station)
LEGEND
on
;reaM
Parking Lot
SITE PARCEL BOUNDARY
® APPROXIMATE LOCATION OF PROPOSED GROUNDWATER SAMPLE
® APPROXIMATE LOCATION OF PROPOSED SOIL -GAS SAMPLE
*ECS is unaware of the UST location at this time. If USTs are identified by GPR, the
nearest groundwater sample boring shown above will be moved near the USTs. A soil
sample will also be collected from this location*
N
SOURCE: , FIGURE 2
GOOGLE EARTH _ PROPOSED SAMPLE LOCATION MAP
IMAGERY DATED 2018 s VACANT RESTAURANT PROPERTY
f 'j 1500 WEST FIRST STREET
`\ WINSTON-SALEM, FORSYTH COUNTY,
APPROXIMATE SCALE: \ NORTH CAROLINA
50 FT. 'TV ECS PROJECT NO.: 49:12193-B

GROUND
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
SURFACE
ESTIMATED
-15'-20'
FEET
1.5-INCH STEEL DIRE
NATURAL FORMATION
PUSH RISER
BACKFILL
2--INCH BORE
HOLE
GROUNDWATER
SLOTTED STEEL S
0.01-INCH SLOT W
SET TO INTERSECT GROI
ESTIMATED 4 FEET IN
WELL CONTRUCTION DL
REPRESENTATIVE OF DIRECT
OnIAIT CAMDI FI
NOT TO SCALE
CT
CREEN
DTHS
INDWATER
LENGTH
kGRAM IS
PUSH SCREEN
Z
N
FIGURE 3
PROPOSED TEMPORARY SCREEN
POINT SAMPLER s
VACANT RESTAURANT PROPERTY
1500 W EST FI RST STRE ET
WINSTON-SALEM, FORSYTH COUNTY,
NORTH CAROLINA
ECS PROJECT NO.: 49:12193-B