WM0401299_Monitoring Well Permit Application_20210614

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, Chaptefl6i'(, General Statutes of Nurth Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery woks. _
.
Date- 06/04/21
2 County: Davidson 1.PERMIT NO.
FQR OFFICE USE ONLY
ISSUED DATE
g. What type of well are you applying foil (rrlohilor'ing or recovery): Monitoring -_
4. Applicant: Christopher Fitton Telephone: [phone]
Applicant's Mailing Address: 300N Maln Street:HOP Point NC 27281
Applicant's Email Address (if available): , efinanerhrlaw.Qom
Contact Person (if different than Applicant); Randy H. Cavallier
Contact Person's Mailing Address:
4811 Koger Give Greensboro NC 27407
Contact Person's Email Address (if available): rcaVallier©ecstimited com
Property Owner (If different than Applicant); Delaney Properties LLC
Telephone: [phone]
Telephone: Ab_r " 90 1 - 0146
Property Owner's Malting Address: )6R.. RIIb6e, • ( P -I FJ i Lel`'1 S & 29Alt
Property Owner's Email Address (if available):
7 Property Physical Address (Including PIN Number) 106 Forest Park lane (PIN) 6778-03-11-0158
City_ Thomasville County - Davidson Zip Code 27360
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: Commercial
(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).
NO
11. Type of contaminants being monitored or recovered: Petroleum (ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? It yes, how many? NO
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s) to nearest known waste or pollution source (In feet): Unknown
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: 3P Environmental Investigations, LLQ Certification No.: 3162-A
Weil Contractor Address: 2157 Mocksville Highway Statesville NC 28625
PROPOSED WELL CONSTRUCTION INFORMATION
As required by 15A NCAC 02e .0105(f)(7), attach e well construction diagram of each well showing the following
a. Borehole and well diameter
h. Estimated well depth
c Screen Intervals
d. Sand/gravel pack Intervals
e. Type of casingmaterial and thickness
t Grout horizons
Well head completion details
Continued on Reverse
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)

2. Number of walls to be constructed In pnconsoildaled
mete/Jai: I
3 Number of wells to be constructed In bedrock ) L
f<. i
• q. Total Number of wells to be cbnslrUGed �,e,_,..;.
T ' • Estimated
ADDITIONAL I14k/RM:PI014
u&'fr
Iddd will Ri well(som 2 and 3)
How will the waits) he secured? :_-_:..t9 - • --- ----
Estimated beginning cort4itudtion date: 6l11)j
construction cgynpletron dale:
As required by 15A NCAC 020,0105(0(5), attach a scaled map,pf the site showing the Iodations of the following:
a. All property boundaries, at least one of which fa referenced to a minimum of two landmarks such as identified roads,
intersedlons, streams, or lakes within 500 feet of the proposed well or well systole.
b. Ali existing wells, identified by type of use, within 500 feet of the proposed well or well system.
c. The proposed wall or well system.
d. Any test borings within 500 feet of proposed well or well system,.
e. All sources of krwwn or potential groundwater Contamination (Guth as septic tank systems, pesticide, chemical or fuel
storage areas, animal feedlots as defined in G.S. 143-216.148(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system."
SIGNATURES
Applicant hereb . - -s that the proposed well(s) will be constructed in accordance with approved specifications and conditions of
Cons( on Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
Subchapter 20) and accepts full responsibility for compliance with these rules
JLt Lt:t�r FJ-"nt r "- C.i•.
Title of Applicant or 'Agent
• If signing as Agent, attach authorization agreement stating
that you have the authority to act as the Agent.
of Applicant or 'Agent
Printed name oftApplIcant or 'Agent
A'fifJ7,�1�
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).
Signature of Property Owneif 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: [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, NC 28116
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
3800 Barrett Drive
Raleigh, N,C 37699
s b� ,e' ' (919).:r-51--4209
Fax: [phone]
Washington Regional Office
943 Washington Square Mail
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Wilmington Regional Office-..�
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone; [phone]
Fax: [phone]
WinstonSalem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone. [phone]
Fax: [phone]
GW-22MR Rev. 3-1
GW-22M
GW-22M

TEMPORARY MONITORING WELL CONSTRUCTION DIAGRAM
\\\\\\\
Locking cap
1 ft. Casing Above Ground
,'_ GROUND SURFACE
?r �.=pis=?
3 inch diameter
drilled hole
Well casing,
1 inch diameter,
Open
16 ft
Bentonite
18
20 ft
Well Screen,
1 inch diamter
0.01 slot
.— o Sand Pack
35 ft.
35.5
All Measuring Points are from the Ground
Surface Unless Otherwise Noted.
Project Former Dorsett Printing
Owner
Well No.
Location
MD Coordinators
State Permit No.
Topography Setting
Ground Elevation
Drilled By
Drilling Started
Drilling Completed
Method of Drilling
Type of Rig
TW
Thomasville, NC
3D Environmental Investigations
6/11 /202
6/11 /202
Direct Push
Geoprobe
MONITORING WELL DATA
Well No.
Hole Diameter
Hole Depth
Casing Diameter
Casing Length
Screen Diameter
Screen Slot
Screen Type
Surface Elevation
Screen Top El.
Screen Bottom El.
Well Status
TW
3 inches
35.5 fee
inch
0fee
1 inch
0.0
REMARKS
Temporary Monitoring Well Diagram 3D 1 in

4
Location of Former Gas Station
SOURCE:
GOOGLE EARTH
2021
160 FEET
FIGURE 1
PROPOSED WELL LOCATION MAP
Former Dorsett Printing Corp
105 Forest Park Lane
Thomasville, Davidson County, NC
ECS PROJECT NO. 49-134970A