WM0401308_Monitoring Well Permit Application_20210730

DocuSign Envelope ID: 8FFD6A6C-C1 FA-4742-BC1 F-EDAABDCDA4C3
IYVRI rl VriRV LIIY/1 UCr/1R1 IYI CIY 1 yr COY Y�RvolMENTAL 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: 07/30/21
2. County: Forsyth
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant: Impact Brands, LLC
Monitoring
Telephone: [phone]
Applicant's Mailing Address: 206 West Fourth Street, Winston-Salem, NC 27101
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Randy H. Cavallier Telephone: [phone]
Contact Person's Mailing Address: 4811 Koger Blvd, Greensboro, NC 27407
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): J G Messic & Sons, Inc. Telephone: [phone]
Property Owner's Mailing Address: 511 Shepherd Street, Winston-Salem, NC 27103
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 1415 South Hawthorne Road (PIN) 6924-09-2612
City Winston-Salem County Forsyth Zip Code 27103
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: organics (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).:
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: 3D Environmental Investigations, LLC Certification No.: 3162-A
Well Contractor Address: 2157 Mocksville Highway, Statesville, NC 28625
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)

DocuSign Envelope ID: 8FFD6A6C-C1 FA-4742-BC1 F-EDAABDCDA4C3
2. Number of wells to be constructed in unconsolidated
material: 5 5. How will the well(s) be secured? Abandon after sample
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 8/11/21
4. Total Number of wells to be constructed: 5 7. Estimated construction completion date: 8/11/21
(add answers from 2 and 3)
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 Well Construction Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
DocuSigned by; Subchapter 2C) and accepts full responsibility for compliance with these rules
Member
Signa,w tpr *Agent Title of Applicant or *Agent
Aubrey Linville
* 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).
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: [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 28115
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
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Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
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GW-22MR Rev. 3-1-2016
GW-22M (Rev. 5/11)
GW-22MR (6/11)

ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:25739P
Scope of Work: Proposal for Environmental Assessment Services
Project: Food Lion Grocery Store
Location: 1415 South Hawthorne Road, 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, groundwater, and surface water sampling at the site. The
groundwater 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 signing below, the property owner authorizes ECS to
conduct the aforementioned sampling at the site.
Property Owner (please print): J G • PNV. C)L-` Ct-;7 1(NC . IONA r.
Property Owner Telephone (please print): 3 3(0_ -17 - I ipo
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Property Owner Signature: ��7� Date: 1

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® APPROXIMATE GROUNDWATER SAMPLE LOCATION
APPROXIMATE SITE BOUNDARY
LEGEND
SOURCE:
ECS PHASE I ESA
SCALE:
AS SHOWN
FIGURE 1
PROPOSED SAMPLE LOCATION MAP
1415 SOUTH HAWTHORNE ROAD
WINSTON-SALEM, FORSYTH COUNTY,
NORTH CAROLINA
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ECS PROJECT NUMBER 49-14500A

GROUND
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
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SURFACE
30 FEET
A
NATURAL FORMATION
BACKFILL
GROUNDWATER
1.5-INCH STEEL DIRE
PUSH RISER
2--INCH BORE
HOLE
SLOTTED PVC S(
0.01-INCH SLOT W
SET TO INTERSECT GROI
ESTIMATED 4 FEET IN
WELL CONTRUCTION DIA
REPRESENTATIVE OF DIRECT
Df1IAIT CAMDI GI
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DTHS
NDWATER
LENGTH
GRAM IS
PUSH SCREEN
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FIGURE 2
PROPOSED TEMPORARY SCREEN
POINT SAMPLER
1415 SOUTH HAWTHORNE ROAD
WINSTON-SALEM, FORSYTH COUNTY,
NORTH CAROLINA
ECS PROJECT NUMBER 49-14500A
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