WM0401392_Monitoring Well Permit Application_20220901

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: 7/15/22
2. County: _ Davidso
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3, What type of well are you applying for? (monitoring or recovery): Monitoring
4_ Applicant: Ms. Brooke Bures — Trammell Crow Company Telephone: [phone]
Applicant's Mailing Address: 500 W. 2nd Street, Austin TX 78701
Applicant's Email Address (if available): Bures, Brooke Cad Austin <BBures[a)trammellcrow.com>
5. Contact Person (if different than Applicant): Randy H. Cavallier Telephone: [336) 362-5692
Contact Person's Mailing Address: 4811 Koger Blvd, Greensboro, NC 27407 _-
Contact Person's Email Address (if available): [e-mail]
6, Property Owner (if different than Applicant): Front Street Lexington LLC. Telephone: [phone]
Property Owner's Mailing Address: 450 N. Patterson Ave., Winston Salem NC 27101
Property Owner's Email Address (if available):
7, Property Physical Address (Including PIN Number) 1450 Brown Street (PIN) 1134600000002
City_ Lexington County Davidson Zip Code 27292
6, 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: Potential former landfill
(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: VOC, SVOC, metals (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. NC 28625
PROPOSED WELL CONSTRUCTION INFORMATION
i 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

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated (add answers from 2 and 3)
material: 5 5. How will the well(s) be secured? Lock
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 9/6/22
4. Total Number of wells to be constructed: -_ _ Estimated construction completion date: 9/6/22
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.
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
Sr Development Manager
Signature of Applicant or `Agent Title of Applicant or *Agent
Brooke $ures
Printed name of Applicant or `Agent
* 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).
A4" c � Pry -1-� A C�c5.f 4 c)-11 ► `1,,,.
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 (6/11)
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July 15, 2022
ECS SOUTHEAST, 11P
ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:32540P
Scope of Work: Environmental Assessment
Project: Brown Street Site
Location: 1450 Brown Street, Lexington, Davidson County, North Carolina
ECS Southeast, LLP (ECS) has been requested to collect soil and groundwater samples to address a
Recognized Environmental Condition (REC) identified by a Phase I ESA completed at the referenced
address. As part of this assessment, ECS will need to access your property to collect the soil and
groundwater samples.
ECS respectfully requests that the owner of the property grant permission to ECS to access the property
to conduct the soil and groundwater sampling. By signed below, the property owner authorizes ECS to
conduct the aforementioned sampling at the site.
Property Owner (please print): X- i c t
Property Owner Address (please print): i6o ek/, ,4;r zS i 411E ST"E- 3c o
� T ,SAcirro4 ic.t
Property Owner Telephone (please pjiatj; . 33(a • ZikS •spa
Property Owner Signature:r j
ECS Proposal No. 49:32540P
Page 1 1
Date: 81/41/_2-

f
Lexington Home
Brands Manufacturing
44111<0
Wooded
Proposed Well Location
dr
F+1
1
Powerline and sewerline
easements
Wooded
Powerline easements
SOURCE:
GOOGLE EARTH
2021
Reported IandfhI
area and surface
debris observed
(REC)
Grassed land
Grassed land
FIGURE 1
1450 BROWN STREET
LEXINGTON, DAVIDSON COUNTY, NC
ECS PROJECT NO. 49-17733A

TEMPORARY MONITORING WELL CONSTRUCTION DIAGRAM
Locking cap
Ft- Casing Above Ground
GROUND SURFACE
4.25 inch diameter
drilled hole
Well casing,
2 inch diameter,
Open
1 ft
Bentonite
23 ft
25 ft
Well Screen,
2 inch diamter
0.01 slot
:_ Sand Pack
35 ft.
35.5 ft.
All Measuring Points are from the Ground
Surface Unless Otherwise Noted.
Project Brown Street Site
Owner
Well No.
Location
MD Coordinators
State Permit Nu.
Topography Setting
Ground Elevation
Drilled By
Proposed Start
Proposed End
Method of Drilling
Type of Rig
1•ti,�1
.4
Lexington, NC
3D Environmental Investigation&
9/6/2022
9/6/2022
Auger
Geoprobe
MONITORING WELL DATA
Well No.
Hole Diameter
Hole Depth
Casing Diameter
Casing Length
Screen Diameter
Screen Slot
Screen Type
Surface Elevation
Screen Top El.
Screen Bottom EI-
Well Status
4.25 inches
Estimated 35.5 feet
2 inch
25 feet
2 inch
[1 01
REMARKS
Temporary Monitoring Well Diagram