WM0401330_Monitoring Well Permit Application_20211201

DocuSign Envelope ID: ED274_BFA-A79E-4605.A60D-21S501D2E2A0-.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: 12/01/21
:t County: Davidson
FOR OFFICE
USE ONLY
PERMIT NO.0 V OBI (� 1�� `1"SSUED DATE 1� 1
:i. What type of well are you applying for? (monitoring or recovery): Monitoring
4 Applicant: Ms. Aubrey Linville Telephone: [phone]
Applicant's Mailing Address: 206 W. 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]
ti Property Owner (if different than Applicant): Quick Pit, Inc. Telephone:
Property Owner's Mailing Address: 600 E. Center Street, Lexington NC 27292
Property Owner's Email Address (if available):
Property Physical Address (Including PIN Number) 1910 Cotton Grove Road (PIN) 672_3-02-68-5362
City, ir_ ton County. DavidsQrD Zip Code 27292
8 Reason for Well(s): -. Assessment
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remedlation, etc.)
9 Type of facility or site for which the well(s) is(are) needed: Commercial
(ex: (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: Petroleum (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, NU 26625
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 a Type of casing material and thickness
b. Estimated well depth t Grout horizons
c Screen intervals q. Well head completion details
d. Sand/gravel pack intervals
Continued on Reverse

DocuSign Envelope ID: ED274BFA-A79E-4605-A60D-21B501D2E2A0
�.1/401 .. LVL .0.0111.i
Number of wells to be constructed in unconsolidated
material: 3
Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 3
RUCTION INFORMATION (Continued)
(add answers from 2 and 3)
How will the well(s) be secured? lock
6. Estimated beginning construction date:
7 Estimated construction completion date:
ADDITIONAL INFORMATION
12/02/21
1.2/Q2/21
As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:
a
h
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 Well Construction Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
DoousIgn.d by: Subchapter 2C) and accepts full responsibility for compliance with these rules
Member / Manager
leant or *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]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
`‘.4
I Li
I dyol
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

1\1 .4,_>t.r o ..r 10, 021
Proposal
Scope of \Nora;
Pr'niect:
i+•. 1 uuvvJ 3 J4J.)
ECS SOUTHEAST) LLP
PROPERTY OWNER ACCESS AUTHORIZATION
49:278481)
Proposal for Environmental Assessment Services
Quick Cube Facility
1910 Cotton Grove Road, Lexington, Davidson County, North Carolina
As part of the proposed real estate transaction, ECS Southeast, LLP (ECS) has been requested by t
purchaser to conduct subsurface groundwater sampling at the site. The groundwater sampling requir
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 propel
to conduct the groundwater sampling. By signing below, the property owner authorizes ECS to cond'
the aforementioned sampling at the site. If the NCDEQ does not accept the signature on this form,
additional signature will be required on the permit application itself,
Property Owner (please print):
Property Owner Telephone (please print):
Property Owner Signature:
Date: —,

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LEGEND
i Proposed Groundwater Sample
SOURCE:
GOOGLE EARTH
FIGURE 1
I420POSED SAMPLE LOCATION MAP
Quick Lube Facility
1910 Cotton Grove Road
Lexington, Davidson County, NC
ECS PROJECT NO. 49-15451A

DocuSign Envelope ID: ED274BFA-A79E-4605-A60D-21B501D2E2A0
ESTIMATED
20' FEET
GROUND
SURFACE
NATURAL FORMATION
BACKFILL
GROUNDWATER
Y
NOT TO SCALE
TOP ROD ABOVE THE LAND
SURFACE
1-INCH Steel Geoprobe
Rods
2--INCH BORE
HOLE
SLOTTED PVC SCREEN
0.01-INCH SLOT WIDTHS
SET TO INTERSECT GROUNDWATER
4 FEET IN LENGTH
WELL CONTRUCTION DIAGRAM IS
REPRESENTATIVE OF TEMPORARY MONITORING
WELL
FIGURE 2 . tlti;
PROPOSED TEMPORARY SCREEN
POINT SAMPLER
Quick Lube Facility
1910 Cotton Grove Road
Lexington, Davidson County, NC
ECS PROJECT NO. 49-15451A