WM0401293_Monitoring Well Permit_20210429

ROY COOPER
Governor
DIONNE DELLI-GATTI
Secretary
S. DANIEL SMITH
Director
Ms. Linda Blalock
NCDEQ-DWM, UST Section
Federal and State Lead Program
1646 Mail Service Center
Raleigh, North Carolina 27699
NORTH CAROLINA
Environmental Quality
May 10, 2021
SUBJECT: MONITORING WELL CONSTRUCTION
PERMIT NO. WM0401293
COUNTY: Surry
FILE NAME: Hawks Rental Property — TF#6538
Dear Ms. Blalock:
In accordance with your application received on April 29, 2021, we are forwarding herewith:
1. Monitoring Well Construction Permit No. WM0401293 for the construction of one (1)
monitoring well at 1714 Main Street in Bannertown in Surry County.
Henceforth, correspondence and data relating to this well shall be designated as specified in the
subject heading above. This Permit will be effective from the date of issuance and shall be subject
to the conditions and limitations as specified therein. If you have any questions regarding this
permit, please contact me or Jim Gonsiewski at [phone].
Sincerely,
DocuSiiggned by:
L-0ti l . 3Mitr
145B49E225C94EA...
Lon T. Snider
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ — WSRO
cc: Lois King
Matt James— WithersRavenel (Electronic Copy)
WSRO Electronic Files
Laserfiche Files
LD_E
NORTH CAROLINA
Department of Environmental quaky
North Carolina Department of Environmental Quality j Division of Water Resources
Winston-Salem Regional Office 1450 West Hanes Mill Road, Suite 300 I Winston-Salem, North Carolina 27105
336.776.9800

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES — WATER QUALITY REGIONAL OPERATIONS
SECTION
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and
other applicable Laws, Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
NCDEQ-DWM, UST Section
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of one monitoring
well owned by the NCDEQ-DWM, UST Section. The well will be located at 1714 Main Street in
Bannertown, North Carolina, in Surry County. This Permit is issued in accordance with the
application received on April 29, 2021 in conformity with specifications and supporting data, all
of which are filed with the Department of Environmental Quality and are considered integral parts
of this Permit.
This Permit is for well construction only, and does not waive any provision or requirement of any
other applicable law or regulation. Construction of any well under this Permit shall be in strict
compliance with the North Carolina Well Construction Regulations and Standards (15A NCAC
02C .0100), and other State and Local Laws and regulations pertaining to well construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to an
adjudicatory hearing upon written request within 30 days of receipt of this Permit. The request
must be in the form of a written petition conforming to Chapter 150B of the North Carolina General
Statutes and filed with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh,
North Carolina 27699-6714. Unless such a demand is made, this Permit is final and binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to other
specified conditions, limitations, or exceptions as follows:
LD_E
NORTH CAROLINA
Department of Environmental quaky
North Carolina Department of Environmental Quality j Division of Water Resources
Winston-Salem Regional Office 1450 West Hanes Mill Road, Suite 300 I Winston-Salem, North Carolina 27105
336.776.9800

1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these
wells are being installed as part of an investigation for contamination from an underground
storage tank or dry cleaner incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement
issued by another agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as part
of the Permit application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A NCAC
02C .0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of Water
Resources' Information Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with 15A
NCAC 02C .0113 and a well abandonment record (GW-30) shall be submitted to the
Division of Water Resources' Information Processing Unit within 30 days of the well
abandonment.
7. The County Health Department may require a county monitoring well construction permit.
Please contact the health department for their requirements.
Permit issued the loth day of May, 2021
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
LD_E
NORTH CAROLINA
Department of Environmental quaky
ELODocuSigned by:
ig
A. l . 3MiCP
145B49E225C94EA...
Lon T Snider, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
By Authority of the Environmental Management Commission
Permit No. # WM0401293
North Carolina Department of Environmental Quality j Division of Water Resources
Winston-Salem Regional Office 1450 West Hanes Mill Road, Suite 300 I Winston-Salem, North Carolina 27105
336.776.9800