WM0401329_Monitoring Well Permit Application_20211129

DocuSign Envelope ID: E2415C28-A65C-4DDD-BC4A-D972AECBAB98
mar%I rI ‘,..NfWLIIYN UCrNrt I IYICIY I .jr- CIY V Irw JMENTAL 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: 11/22/2021
2. County: Forsyth
3.
4. Applicant:
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery):
Twin City Capital— Mr. Aubrey Linville
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): ECS Southeast, LLP — 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): KJEM, LLC.- Steven Hankins Telephone: [phone]
Property Owner's Mailing Address: 4400 Silas Creek Pkwy, Winston-Salem, NC 27104
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number): 3451 Gentry Circle (PIN 5893-04-2704)
City:
Clemmons County: Forsyth Zip Code: 27012
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 (Off -site UST)
(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
(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. 110 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): N/A
15. Well Contractor: TBD Certification No.: TBD
Well Contractor Address: TBD
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

DocuSign Envelope ID: E2415C28-A65C-4DDD-BC4A-D972AECBAB98
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated
material: 4
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 4
(add answers from 2 and 3)
5. How will the well(s) be secured? Not Applicable —
temporary monitoring wells to be abandoned upon
completion
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 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,
�oocusigned by: Subchapter 2C) and accepts full responsibility for compliance with these rules
1 V Ut;
—EE6 537E4 u 4t., .
Signature of Applicant or *Agent
Aubrey Linville
11/23/2021 I 91s4 ibJ VSJlanager
Title of Applicant 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).
See attached Property Owner Authorization KJEM, LLC
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]
W i ion -Sale
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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]
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GW-22MR Rev. 3-1-2016

DocuSign Envelope ID: E2415C28-A65C-4DDD-BC4A-D972AECBAB98
November 18, 2021
ECS SOUTHEAST, LLP
ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:27991
Scope of Work: Proposal for Environmental Assessment
Project Name: Gentry Circle Site
Location: 3451 Gentry Circle
Clemmons, Forsyth County, North Carolina 27012
As part of the proposed real estate transaction, ECS Southeast, LLP (ECS) has been requested by the
purchaser to conduct 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 groundwater sampling. By signed below, the property owner authorizes ECS to conduct
the aforementioned sampling at the site.
Steven
Property Owner (please print): Hanki ns
704-650-3964
Property Owner Telephone (please print):
f-DocuSigned by:
Property Owner Signature:
E433518CCAB D478_.
Date:11/20/2021 1 8:33 AM EST
ECS Proposal No: 49:27991
Page

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7
SOURCE:
USGS TOPOGRAPHIC MAP
7.5 — MINUTE SERIES
CLEMMONS AND WINSTON-SALEM, NC
DATED 2013
SCALE: 1 : 24,000
CONTOUR INTERVAL = 10'
FIGURE 1
SITE TOPOGRAPHIC MAP
Gentry Circle Site
3451 Gentry Circle
Clemmons, Forsyth County, North Carolina
ECS Project Number: 49:15582-A

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KC
RestaLrall!
tgurb-t nAnt
commercial building
SOURCE:
ECS PHASE I (NOVEMBER 2021)
2020 IMAGERY
SCALE SHOWN ABOVE
SITE PARCEL
BOUNDARY
LEGEND
SITE PARCEL BOUNDARY
GROUNDWATER SAMPLE LOCATIONS
SAMPLE LOCATION MAP
Gentry Circle Site
3451 Gentry Circle
Clemmons, Forsyth County, North Carolina
ECS Project Number: 49:15582-A

DocuSinn Envelnne Ir): E2415C28-A65C-4DDD-BC4A-D972AECBAB98
IP w.
t ili
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
Truby Drive Industrial Property
Near Truby Drive
Graham, Alamance County, North Carolina
ECS Project Number: 49:15290-A

DocuSign Envelope ID: E2415C28-A65C-4DDD-BC4A-D972AECBAB98
GROUND
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
�.,... "`
SURFACE
ESTIMATED
—40'
A
FEET
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
V
WELL CONSTRUCTION DI
REPRESENTATIVE OF DIRECT
Df1IAIT CAMDI GI
CT
CREEN
IDTHS
JNDWATER
LENGTH
AGRAM IS
PUSH SCREEN
NOT TO SCALE
FIGURE 4
PROPOSED TEMP SCREEN POINT SAMPLER
Gentry Circle Site
3451 Gentry Circle
Clemmons, Forsyth County, North Carolina
ECS Project Number: 49:15582-A