WM0401334_Monitoring Well Permit Application_20211215

DocuSign Envelope ID 7p%r JL8-8366-4A26-BE6B-184CA6C35E87
.rN f[V JMENTAL QUALITY - DIVISION OF WATER RESOURCES
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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: 13 December 2021
2. County: Surry
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Temporary Monitoring Well
Applicant: Tom Wurzinger Telephone: [phone]
Applicant's Mailing Address: 1255 Roberts Blvd Suite 200 Kennesaw, Georgia 30144
Applicant's Email Address (if available): twurzinger(c�Geosyntec.com
5. Contact Person (if different than Applicant): Telephone:
Contact Person's Mailing Address:
Contact Person's Email Address (if available):
6. Property Owner (if different than Applicant): Alan Lindsay Telephone: [phone]
Property Owner's Mailing Address: 1804 MLK Parkway, Suite 110 Durham, NC 27707
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 266 and 272 Hickory Street ( PIN 502118207986)
City Mt Airy County Surry Zip Code 27030
8. Reason for Well(s): Due diligence for property transaction
(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 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).
Not to our knowledge
11. Type of contaminants being monitored or recovered: volatile organic compounds (ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? None
Existing Monitoring or Recovery Well Construction Permit No(s).: None
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: Cascade Drilling Certification No.: NCWC 4525-A
Well Contractor Address: 905 South Main St. New Ellenton, SC 29809
PROPOSED WELL CONSTRUCTION INFORMATION
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 9. Well head completion details
d. Sand/gravel pack intervals
Continued on Reverse
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)

DocuSign Envelope ID: 74674918-83BB-4A26-BE6B-184CA6C35E87
2. Number of wells to be constructed in unconsolidated
material: 3
5. How will the well(s) be secured? Locking well cap
3. Number of wells to be constructed in bedrock: 0
6. Estimated beginning construction date: 12/16/2021
Total Number of wells to be constructed: 3 7. Estimated construction completion date: 12/17/2021
(add answers from 2 and 3)
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
Senior Engineer
Signature of Applicant or *Agent Title of Applicant or *Agent
Thomas Wurzinger
Applicant or *Agent
* If signing as Agent, attach authorization agreement stating Printed name of
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 Weil Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
�J ocu g�nee y:
QA C1 t1jttiGLS Alan Lindsay
Signature of Proper il)ygnmafe_nt 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
6-9800
797
GW-22MR Rev. 3-1-2016

WELL CONSTRUCTION LOG
ABOVE GROUND COMPLETION
Well I.D.: TMW
Drilling Company:Cascade Drilling
Drillers: TBD
Geologist/Engineer: TBD
Signature: -
0
0
0
0
15'
25'
r:
25'
0
Height Above
Land Surface
DEPTH BLS
Land Surface
Seal End Depth
(SBDEPTH) --
Screen
Begin Depth
(SBDEPTH)
Total Depth
(TOTDEPTH) ___
Comments
Borehole
Di.m- -r
Measuring
Pt.
Eleva ion
(MPELEV)
INTERVAL LENGTH
Seal
Length
Sc een
Length
15
(SCRLENGTH)
Sump
Length
0
0
Site: Mt. Airy Due Dilligence
Project Number:
Installation Method: Direct Push
Casing Installation Date:
Well Type:
Well Completion Method: Temporary
Geologic Completion Zone:
Filter Pack
Length
0
(FPL)
0
0
Well Completion
Guard Posts ( Y / N) Date: N
Surface Pad Size: N/A ft x N/A
Protective Casing or Cover
Diameter/Type: N/A
Depth BGS: 25' Weep Hole (Y / N )
Grout
Composition/Proportions: N/A
Placement Method:
N/A
Seal Date:
Type:
Source:
Set-up/Hydration Time:
Placement Method: _
Vol. Fluid Added:
Filter Pack
Type: None
Source:
Amount Used:
Placement Method:
Well Riser Pipe
Casing Material: PVC
Casing Inside Diameters: 1" in.
Screen
Material: PVC 0.010
Inside Diameter: in.
Screen Slot Size: in.
Percent Open Area:
Sump or Bottom Cap (Y / N )
Type/Length:
Backfill Plug ( Y / N )
Material:
Placement Method:
Set-up/Hydration Time:
Total Water Volume During Construction
Introduced (Gal): Recovered
(Gal):
Reviewed
By: Date:
FLWP/Fonns/Field forms/Well Construction/Well Construction Logs

Proposed Phase II Sample Locations
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