HomeMy WebLinkAboutWM0401271_Monitoring Well Permit Application_20210115NORTH 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: 1/14/21
2. County: Alamance
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant: Crosland Southeast (Nick Carroll)
Monitoring
Telephone: 704-790-8185
Applicant's Mailing Address: 121 West Trade Street, Suite 2550, Charlotte, NC 28202
Applicant's Email Address (if available): ncarrol@csere.com
5. Contact Person (if different than Applicant): Scott Young Telephone: 704-724-4814
Contact Person's Mailing Address: 1812 Center Park Drive, Suite D, Charlotte, NC 28217
Contact Person's Email Address (if available): syoung1@ecslimited.com
6. Property Owner (if different than Applicant): S, J, M and M, LLC Telephone: 336-584-3726
Property Owner's Mailing Address: 402 Huffman Mill Road, Burlington, NC 27215
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 2571 Maple Avenue — PIN-8874210767
City Burlington County Alamance Zip Code 28216
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: USTs
(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?
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
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)
2. 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
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
3. Number of wells to be constructed in bedrock: 0
1.
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. 143-215.10B(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 WI Constriction 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
Signature o
Appli
Environmental Project Manager
nt 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
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: (828) 296-4500
Fax: (828) 299-7043
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: (910) 433-3300
Fax: (910) 486-0707
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: (704) 663-1699
Fax: (704) 663-6040
3800 Barrett Drive
Raleigh, NC 27609
Phone: (919) 791-4200
Fax: (919) 571-4718
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: (252) 946-6481
Fax: (252) 975-3716
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Wilmington, NC 28405
Phone: (910) 796-7215
Fax: (910) 350-2004
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: (336) 776-9800
Fax: (336) 776-9797
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Proposal No.:
Scope of Work:
Project:
Location:
ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
49:22054P, Rev 1.0
Proposal for Baseline Environmental Assessment Services
Proposed 7-Eleven
2571 Maple Avenue, Burlington, Alamance 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):541 112.z. c) S'G a
Property Owner Telephone (please print
Property Owner Signature:
??4,e-26 3'37S
Date: <t V2eoin
4
ECS Proposal Nov 49:22054P, Rev .,0
Page j 8
1
1000
1
0_5
D
SCALE 1:24 000
KILOMETERS
1
Y
900
0.5
D
METERS
0
1030
2.000
1
1DOD 0 1000
.'I LES
2000 3000 1000 5D00
6030 7000 MCC 9000 10000
FEET
SOURCE:
USGS 7.5' TOPOGRAPHIC MAP
CHARLOTTE WEST, NC
2019
SCALE:
AS SHOWN
FIGURE 1
SITE TOPOGRAPHIC MAP
PROPOSED 7-ELEVEN
2571 MAPLE AVENUE
BURLINGTON, NORTH CAROLINA
1
TM
ECS PROJECT NO. 49:12801-A
401
APPROXIMATE 416
PROPOSED
ST BASIN
APPROXIMATE
PROPOSED
DISPENSER
ISLAND
0 0.005 0.01 0.02 m1
} i r i T I ri r 1 r
0 0.0075 0_015 0.03 km
APPROXIMATE SITE BOUNDARY
OAPPROXIMATE SOIL SAMPLE LOCATION
LEGEND
APPROXIMATE GROUNDWATER BORING LOCATION
SOURCE:
ALAMANCE COUNTY GIS WEBSITE
ACCESSED JANUARY 4, 2021
SCALE:
AS SHOWN
i i I
TM
FIGURE 2
PROPOSED SAMPLE LOCATION MAP
PROPOSED 7-ELEVEN
2571 MAPLE AVENUE
BURLINGTON, NORTH CAROLINA
ECS PROJECT NO. 49:49-12801-A
GROUND
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
�.,... "`
SURFACE
ESTIMATED
^'15'-20'
FEET
A
NATURAL FORMATION
BACKFILL
GROUNDWATER
1.5-INCH STEEL DIRE
PUSH RISER
2--INCH BORE
HOLE
SLOTTED STEEL S
0.01-INCH SLOT W
SET TO INTERSECT GROI
ESTIMATED 4 FEET IN
V
WELL CONTRUCTION DIA
REPRESENTATIVE OF DIRECT
Df1IAIT CAMDI GI
CT
CREEN
IDTHS
JNDWATER
LENGTH
GRAM IS
PUSH SCREEN
NOT TO SCALE
FIGURE 3
PROPOSED TEMPORARY SCREEN
POINT SAMPLER
PROPOSED 7-ELEVEN
2571 MAPLE AVENUE
BURLINGTON, NORTH CAROLINA
ECS PROJECT NO. 49:12801-A
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