WM0401327_Monitoring Well Permit Application_20211124

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: 11/17/2021
2. County: Guilford
3.
4.
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring
Applicant: McDonald's USA, LLC
Telephone: [phone]
Applicant's Mailing Address: 624 Holly Springs Road #420, Holly Springs, NC 27540
Applicant's Email Address (if available): jami.hays a(?us.mcd.com
5. Contact Person (if different than Applicant): Austin Deans
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): Pink Penguin, LLC
Property Owner's Mailing Address:
Property Owner's Email Address (if available): Not Applicable
7. Property Physical Address (Including PIN Number): 1702 Long Street
City: High Point County: Guilford Zip Code: 27262
Telephone:
PIN 6891735023
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 (Auto Service & Maintenance Shop)
(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).
Not Applicable
11. Type of contaminants being monitored or recovered: VOCs, SVOCs, and RCRA-8 Metals
(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).: Not Applicable
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approx. 500 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): Not Applicable
15. Well Contractor: TBD Certification No.: TBD
Well Contractor Address: TDB
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? Groundwater
material: 3
Sampling Probe
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: TBD
4. Total Number of wells to be constructed: 3 7. Estimated construction completion date: TBD
(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,
Subchapter 2C) and accepts full responsibility for compliance with these rules
'" I`LA)Di s U Sit I L--,C--
Signature of Applicant or *Agent Title of Applicant or *Agent
Sd-e_,n 1-1 * If signing as Agent, attach authorization agreement stating
Printed name of Applican 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).
See Attached
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]
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

November 3, 2021
ECS SOUTHEAST, LLP
ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:27716P
Scope of Work: Groundwater Assessment
Project: 32-0007 McDonald's High Point, North Carolina
Location: 1702 Long Street, High Point County, North Carolina
ECS Southeast, LLP (ECS) has been requested to collect groundwater samples to address a Recognized
Environmental Condition (REC) identified by a Phase I ESA completed at the referenced address. As part
of this assessment, ECS will need to access your property to collect the groundwater samples.
ECS respectfully requests that the owner of the property grant permission to ECS to access the property
to conduct the groundwater sampling. By signed below, the property owner authorizes ECS to conduct
the aforementioned sampling at the site.
Property Owner (please print): Jackie King
Property Owner Address (please print): 2310 N Centennial, Suite 106, High Point,NC 27265
Property Owner Telephone (please print): 336-689-2662
Property Owner Signature:
Date: 11/9/21
ECS Project No. 49:27716
Page I 1

SOURCE:
USGS TOPOGRAPHIC MAP
7.5 — MINUTE SERIES
HIGH POINT WEST, NC
DATED 2013
SCALE: 1 : 24,000
CONTOUR INTERVAL = 10'
FIGURE 1
E SITE TOPOGRAPHIC MAP
McDonald's High Point
1702 Long Street
High Point, Guilford County, North Carolina
ECS Project Number: 49:15219-A

SOURCE:
ECS PHASE I ESA
DATED OCTOBER 25, 2021
APPROXIMATE SCALE:
= 100 Feet
dtk
VW
LEGEND
APPROXIMATE SITE PARCEL BOUNDARY
PROPOSED GROUNDWATER SAMPLE LOCATIONS
FIGURE 2
PROPOSED SAMPLE LOCATION MAP
McDonald's High Point
1702 Long Street
High Point, Guilford County, North Carolina
ECS Project Number: 49:15219-A

NO WATER SUPPLY WELLS OR POTENTIAL SOURCES
OF CONTAMINATION ARE KNOWN TO EXIST OTHER
THAN ILLUSTRATED ABOVE.
SOURCE: "
NCDEQ
DWM SITE LOCATOR TOOL
APPROXIMATE SCALE:
= 300 Feet
FIGURE 3
POTENTIAL SOURCES MAP
McDonald's High Point
1702 Long Street
High Point, Guilford County, North Carolina
ECS Project Number: 49:15219-A

GROUND
SURFACE
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
SURFACE
ESTIMATED
^'30' FEET
NATURAL FORMATION
BACKFILL
GROUNDWATER
v
V
1.5-INCH STEEL DIRECT
PUSH RISER
2--INCH BORE
HOLE
SLOTTED STEEL SCREEN
0.01-INCH SLOT WIDTHS
SET TO INTERSECT GROUNDWATER
ESTIMATED 4 FEET IN LENGTH
WELL CONSTRUCTION DIAGRAM IS
REPRESENTATIVE OF DIRECT PUSH SCREEN
POINT SAMPLER
NOT TO SCALE
FIGURE 4
PROPOSED TEMP SCREEN POINT SAMPLER
McDonald's High Point
1702 Long Street
High Point, Guilford County, North Carolina
ECS Project Number: 49:15219-A