WI0400242_APPLICATION FOR PERMIT_20120302

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality{ ' ,a
#_,!= P r OTECf1CPSEC,
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 5I Wells — In Situ Groundwater Remediation / Type 5T Vt c njg n
• Do not use this form for remediation systems that extract contaminated groundwater, treat it, and reinject the treated groundwater.
• Submit TWO copies of the completed application and all attachments to the address on the last page of this form.
• Any changes made to this form will result in the application package being returned.
A. Application Number (to be completed by DWQ):
I. GENERAL INFORMATION: \NE-04OOa qg.,
1. Applicant's Name (generally the responsible party): Jewel Cox (
ispcov, kobi 1 a,rpo rr for
2. Signing Official's Name*: Title:
* Signing Official must be in accordance with instructions in part VI on page 7.
3. Mailing address of applicant: 1016 W. Poplar Ave, Suite 106, Number 232
City: Collierville
State: TN Zip: 38017
Telephone number: 901.8 '9.9D69 Ci t? I — 23 3 q 112- Fax number: 262.313.1830
4. Property Owner's Name (if different from Applicant): Plantation Properties, Attn: Mr. Larry Nichols
5. Property Owner's mailing address: 988 Plantation Drive
City: Burlington State: NC Zip: 27215
6. Name and address of contact person who can answer questions about the proposed injection project:
Name: Scott Bostian _ Title: Senior Environmental Engineer
Company: ARCADIS
Address: 801 Corporate Center Drive., Suite 300
City: Raleigh
Telephone number:
Email Address:
State: NC Zip: 27607
919.854.1282 ext 222 Fax number: 919.854.5448
[e-mail]
IL PERMIT INFORMATION:
1. Project is: ( Modification of existing permit ( Renewal of existing permit without modification
( Renewal of existing permit with modification
2. If this application is being submitted for renewal or modification to an existing permit, provide:
existing permit number and the issuance date
For renewal without modifications, fill out sections I & II only, sign the certification on the last page of this
form, and obtain the property owner's signature to indicate consent (if the applicant is not the owner).
For all renewals, submit a status report including monitoring results of all injection activities to date.
Revised 6/09 UIC-5I/5T Page 1 of 7

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