WM0401386_Monitoring Well Permit Application_20220822

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: 8/16/2022
2. County: Guilford
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3, What type of well are you applying for? (monitoring or recovery):
Monitoring
4. Applicant: Craige Jenkins Liipfert & Walker, LLP (Hank Niblock)
Telephone: [phone]
Applicant's Mailing Address: 110 Oakwood Drive Suite 300 Winston-Salem, North Carolina 27103
Applicant's Email Address (if available): hniblock(a7craige;enkins,com
5. Contact Person (if different than Applicant): Ron Navarro Telephone: [phone]
Contact Person's Mailing Address: 5260 Greens Dairy Road. Raleigh. NC 27616
Contact Person's Email Address (if available): RNavarroPecslimited.com
6. Property Owner (if different than Applicant): Thomas and Janice Hancock Telephone: [phone]
Property Owner's Mailing Address: 4585 Big Country Dr, Asheboro, NC 27205
Property Owner's Email Address (if available): N/A
7, Property Physical Address (Including PIN Number) 1763 Mt. Hope Church Road (PIN 8804327039)
City McLeansville County Guilford Zip Code 27301
8. Reason for Well(s): Environmental Assessment for potential groundwater contamination m
(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
(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, solvent
(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).: No
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): approximately 30 feet from the adjoining
property with suspected contaminants
14. Are there any water supply wells located Tess than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Ground Zero Environmental Certification No.: NCWC 30127-A
Well Contractor Address: 110 Astarita Ave, Partlow, VA 22534

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
b. Estimated well depth
c, Screen intervals
d. Sand/gravel pack intervals
e. Type of casing material and thickness
f. Grout horizons
g, WeII head completion details
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Expansion cap
material: 4 temporary
3. Number of wells to be constructed in bedrock: 0
6. Estimated beginning construction date: Unknown
4, Total Number of wells to be constructed: 4 7. Estimated construction completion date: Unknown
(add answers from 2 and 3) (within 96 hours of installation)
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
Signature of Applicant or "Agent
Printed name of. Applicant or `Agent
a
Title of Appiicantior.iigent
If signing as Agent, attach authorization agreement stating
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)

DocuSign Envelope ID:810D1F57-307F-4604-6982-BA26C3179370
ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:32781P
Scope of Work: Proposal for Environmental Services
Project: Mt. Hope Church Road Site
Location: 1763 Mt. Hope Church Rd, McLeansville, North Carolina
As part of the proposed real estate transaction, ECS Southeast, LLP (ECS) has been requested by the
purchaser to conduct due diligence tasks including groundwater sampling at the site. The groundwater
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 above referenced tasks. By signed below, the property owner authorizes ECS to conduct
the aforementioned sampling at the site.
Property Owner (please print):
DocuSigned by:
y,(✓i V�}CQ 014.44.Ov1, 11)4.V1 c oc k.
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336-629-7820
Property Owner Telephone (please print);
8/12/2022
Property Owner Signature: Date:

Former Mt
Hope
TOxa[WWSNide►
automouve
repair- REC
SOURCE:
ECS PHASE I (July 2022)
2020 IMAGERY
SCALE SHOWN ABOVE
Legend
1 Suspect UST pipes - REC
2 Discarded Drums - REC
Proposed Groundwater
Sampling Point
• Proposed Soil Sampling Point
Proposed area to be scanned
by GPR/EM to delineate UST
FIGURE 1
PROPOSED SAMPLE LOCATION MAP
1763 Mt. Hope Church Road
McLeansville, NC
ECS Proposal Number: 49:32781P

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