WM0401328_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: November 22, 2021
2. County: Davidson
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant: Samet
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
Monitoring
Telephone: [phone]
Applicant's Mailing Address: 309 Gallimore Dairy Road, Suite 102, Greensboro, NC 27409
Applicants Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Travis L. O'Quinn
Telephone: [phone]
Contact Person's Mailing Address: 1900 Center Park Drive, Suite A Charlotte, NC 28217
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): J C Little Holdings Telephone:
Property Owner's Mailing Address: 170 Rolling Park Drive, Lexington, NC 27295
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) Seven Oaks Drive (intersection of Clark Rd.) PIN: 5792-02-76-0455
City Lindwood County Davidson Zip Code 27299
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: Undeveloped property
(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).
Unknown
11. Type of contaminants being monitored or recovered: VOCs & SVOCs
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many?
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
Unknown
N/A
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Unknown
If yes, give distance(s):
15. Well Contractor: 3D Environmental Drilling Certification No.: 1362-A
Well Contractor Address: [e-mail]
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)
Signature of Apt licant or *Agent
-Cal. LD 1 .-5/611f7Cod
2. Number of wells to be constructed in unconsolidated
material: 4
5. How will the well(s) be secured? Samples will be
collected through Geoprobe Sampling Point
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: TBD
4. Total Number of wells to be constructed: 4
(add answers from 2 and 3)
7. Estimated construction completion date: TBD
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.
b.
c.
d.
e.
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.
All existing wells, identified by type of use, within 500 feet of the proposed well or well system.
The proposed well or well system.
Any test borings within 500 feet of proposed well or well system.
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 NJqII Construct' n 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
Title of Appli ant or *Agent
* 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 PFoperty`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

SOURCE:
US GEOLOGICAL SURVEY
CHARLOTTE WEST, NC
DATED 2019
SCALE:
AS SHOWN
FIGURE 1
TOPOGRAPHIC LOCATION MAP
LITTLE LAND DAVIDSON
CLARK ROAD AND SEVEN OAKS ROAD
LINWOOD, NORTH CAROLINA
TM
ECS PROJECT NO. 49:15250-C

1. Bells Auto Sales
2. Acme Poultry Farm (LUST)
3. Residential and Agrlcullural Structures
4. Potential termer gasoline stalion
Leaflet I PEavered by Erri 1 NC CGIA, hokum?
APPROXIMATE SITE BOUNDARY
LEGEND
OAPPROXIMATE GROUNDWATER BORING LOCATION
SOURCE:
ECS PHASE I ESA (Project No. 15250)
DATED NOVEMBER 9, 2021
SCALE:
AS SHOWN
FIGURE 2
PROPOSED SAMPLE LOCATIONS MAP
LITTLE LAND DAVIDSON
CLARK ROAD AND SEVEN OAKS ROAD
LINWOOD, NORTH CAROLINA
ECS PROJECT NO. 49:15250-C

GROUND
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
�.,... "`
SURFACE
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
WELL CONTRUCTION DIA
REPRESENTATIVE OF DIRECT
Df1IAIT CAMDI GI
CT
CREEN
IDTHS
JNDWATER
LENGTH
GRAM IS
PUSH SCREEN
NOT TO SCALE
FIGURE 3
PROPOSED TEMPORARY SCREEN
POINT SAMPLER
LITTLE LAND DAVIDSON
CLARK ROAD AND SEVEN OAKS ROAD
LINWOOD, NORTH CAROLINA
TM
ECS PROJECT NO. 49:15250-C