WM0401314_Monitoring Well Permit Application_20211004

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, 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: 9/30/2021
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:
R&M Development Services, LLC — Mike LaRue
Monitoring
Telephone: [phone]
Applicant's Mailing Address: 940 Aquaview Drive, Kernersville, North Carolina 27284
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): ECS Southeast, LLP — Samantha Szakasits Telephone: [phone]
Contact Person's Mailing Address: 5260 Greens Dairy Road, Raleigh, NC 27616
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Purple Crow Investments, LLC — Danial Calhoun Telephone: [phone]
Property Owner's Mailing Address: 2900 Lowery Street, Winston Salem, North Carolina 27101
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 3709 Reynolda Road (PIN 6817-09-1802)
City Winston Salem County Forsyth Zip Code 27106
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 — Offsite REC
(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: VOCs
(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).: N/A
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approx. 46 feet Southeast
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: Quantex Drilling Certification No.: 3106-A
Well Contractor Address: PO Box 1388, Wendell, NC 27591
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? Not Applicable —
material: 3 temporary monitoring wells to be abandoned upon completion
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 3
(add answers from 2 and 3)
6. Estimated beginning construction date: TBD
7. Estimated construction completion date: TBD
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 idrrrrrarks 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 septictank 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,
Su ch ter 2C) and accepts full responsibility for compliance (with these rules
-e
De y 4 047 ed 54/0 s
Sign, ure of AEipli r *Ag t Title of Applicant o *Agent LL C
* 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).
,Cue% 5. LG 1Zu-
SEE ATTACHED
Purple Crow Investments, LL-C — Dania! Calhoun
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant)
DIRECTIONS
Please send the completed dppiication tothe 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]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

September 24, 2021
ECS SOUTHEAST, LLP
ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Project Name: Family Dollar Store
Location: 3709 Reynolda Road, Winston Salem, Forsyth County, North Carolina 28209
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 and submit the results to NCDEQ.
Property Owner (please print): ICE Co•.kkA0`)VN
Property Owner Telephone (pleasant;
3 4 S- OTh. gcl
Property Owner Signature: Date: `I / d i
ECS Proposal No. 49-26892P
Page 17

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SOURCE:
USGS TOPOGRAPHIC MAP
7.5 — MINUTE SERIES
RURAL HALL, NC
DATED 2013
SCALE: 1 : 24,000
CONTOUR INTERVAL = 10'
N
FIGURE 1
SITE TOPOGRAPHIC MAP
Family Dollar Store
3709 Reynolda Road
Winston-Salem, Forsyth County,
North Carolina
ECS Project Number: 49:10774-A

Benchmark
w
Barbershops
SOURCE:
GOOGLE EARTH
2020 IMAGERY
SCALE SHOWN ABOVE
Reynolda
upholstery
LEGEND
APPROXIMATE SITE PARCEL BOUNDARY
PROPOSED GROUNDWATER SAMPLE LOCATIONS
a
FIGURE 2
PROPOSED SAMPLE LOCATION MAP
Family Dollar Store
3709 Reynolda Road
Winston-Salem, Forsyth County,
North Carolina
TM
ECS Project Number: 49:10774-A

N0WATER SUPPLY WELLS 0RPOTENTIAL SOURCES
OFCONTAMINATION ARE KNOWN T0EXIST OTHER
THAN ILLUSTRATED ABOVE.
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S]UR[E:
NCDECi
DVVK4SITE LOCATOR TOOL
APPROXIMATE SCALE:
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FIGURE
POTENTIAL SOURCES MAP
Family Dollar Store
37O9Reyno|daRoad
VVinston'Sa|em,Forsyth County,
North Carolina

GROUND
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
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SURFACE
ESTIMATED
—25'-30'
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
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WELL CONSTRUCTION DI
REPRESENTATIVE OF DIRECT
Df1IAIT CAMDI GI
CT
CREEN
IDTHS
JNDWATER
LENGTH
AGRAM IS
PUSH SCREEN
NOT TO SCALE
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FIGURE 4
PROPOSED TEMP SCREEN POINT SAMPLER
Family Dollar Store
3709 Reynolda Road
Winston-Salem, Forsyth County,
North Carolina
ECS Project Number: 49:10774-A