WM0801205_Application_20220829

DocuSign Envelope ID: 11313981-EFCA-4D09-9DD1-F9A5591400D3
IYVR I r1 VNRVLIIYr► UCrNR I IYICIY I .jr- GIY V 11WIJMENTAL 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: 8/25/2022
2. County: Pender
3.
4. Applicant:
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery):
Monitoring
Tanner Postal Commercial Real Estate, LLC - Rob Tanner
Telephone: [phone]
Applicant's Mailing Address: 1200 N Federal Hwy Suite 200, Boca Raton, FL 33432
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): ECS Southeast, LLP — Samantha M. Szakasits 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):
Kay Dail Holland Telephone: [phone]
Property Owner's Mailing Address: PO Box 174, Chinquapin, NC 28521
Property Owner's Email Address (if available): [e-mail]
7. Property Physical Address (Including PIN Number): 13735 Highway 17 (PIN 3282-53-4438-0000)
City Hampstead County Pender Zip Code 28443
8. Reason for Well(s): Assessment of suspected contamination from northeastern adjoining property
(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 — Offsite REC
(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: 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).: No
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 500 feet Northeast
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: 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

DocuSign Envelope ID: 11313981-EFCA-4D09-9DD1-F9A5591400D3
rrcvrvomu rcUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated
material: 3
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 3
(add answers from 2 and 3)
5. How will the well(s) be secured? Not Applicable —
temporary monitoring wells to abandoned upon complete
6. Estimated beginning construction date: TBD
7. Estimated construction completion date: TBD
(within 96 hours of installation)
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,
�DocuSigneSubchapter 2C) and accepts full responsibility for compliance with these rules
�b� �AAndnt,V Authorized rep
'-CQ8CB1QQ209D43
Signature of Applicant or *Agent
Rob Tanner
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
Kay Dail Holland
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]
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

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oocu5lgn Envelope ID: 374A7BF9-AIF1-4F56-A2AB-2784c1680156
Page: 16
ECS SO
AST, 1LP
ECS SOUTHEAST, UP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49-33042P
Scope of Work: Proposal for Environmental Assessment Services
Project: Carolina Chickens — Phase II
Location: 13735 Highway 17, Hampstead, Pender County, North Carolina
PIN(s): 3282-53-4438-0000
As part of the proposed real estate transaction, ECS Southeast, LLP (ECS) has been requested by the
purchaser to conduct subsurface soil sampling and/or 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):
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Property Owner Address (please print): �Q ht,L /'i /,vie6271 °92
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Property Owner Telephone (please print): 7 7/ it
Property Owner Email (please print): /' rdietAdataS -r!/e city -le -CJest
Property Owner Signature:
EC5 Project No. 49-33042P
Page 1 1.

SOURCE:
USGS TOPOGRAPHIC MAP
7.5 — MINUTE SERIES
HAMPSTEAD, NC
DATED 2019
SCALE: 1 : 24,000
CONTOUR INTERVAL = 10'
N
FIGURE 1
SITE TOPOGRAPHIC MAP
Carolina Chickens— Phase II
13735 Highway 17
Hampstead, Pender County, North Carolina
ECS Project Number: 49:17804-A

SOURCE:
GOOGLE EARTH
2020 IMAGERY
SCALE SHOWN ABOVE
Legend
Proposed Sample Location
Site Parcel Boundary
I Powered by Esri I NC CGIA. Maxar. Microsoft
FIGURE 2
PROPOSED SAMPLE LOCATION MAP
Carolina Chickens — Phase 11
13735 Highway 17
Hampstead, Pender County, North Carolina
TM
ECS Project Number: 49:17804-A

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
Carolina Chickens — Phase II
13735 Highway 17
Hampstead, Pender County, North Carolina
ECS Project Number: 49:17804-A

GROUND
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
�.,... "`
SURFACE
ESTIMATED
—15'
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
I
FIGURE 4
PROPOSED TEMP SCREEN POINT SAMPLER
Carolina Chickens — Phase II
13735 Highway 17
Hampstead, Pender County, North Carolina
ECS Project Number: 49:17804-A