WM0401394_Monitoring Well Permit Application_20220906

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:
8/31/2022
2. County: Surry
FOR OFFICE USE ONLY
PERMIT NOW TAU-10 ISSUED DATE61
3. What type of well are you applying for? (monitoring or recovery): Monitoring
Applicant: Jennifer Welch F\ Nck-A---tc,Y\c� � n Telephone: [phone]
Applicant's Mailing Address: 701 Green Valley Road, Greensboro, North Carolina 27408
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Brandon Stau Telephone: [phone]
Contact Person's Mailing Address: 40 La Riviere Dr. Suite 120A, Buffalo, New York 14202
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): David Steele Telephone: [phone]
Property Owner's Mailing Address: 620 East Main Street, Elkin, NC 28621
Property Owner's Email Address (if available): [e-mail]
7. Property Physical Address (Including PIN Number) 620 East Main Street (495116836845)
City Elkin County Surry
Zip Code 28621
8. 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: Textile operations and suspected historical USTs
(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).
N/A
11. Type of contaminants being monitored or recovered: TCL VOCs, PAHs, and RCRA Metals
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? N/A
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 5' - 20'
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Unknown
If yes, give distance(s): N/A
15 Well Contractor: Lawrence D. Opper Certification No.: NCWCC #3322-A
Well Contractor Address: P.O. Box 1161 Wake Forest, NC 27588
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
Continued on Reverse

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Ilt"San16e seal 9Td Well cep
material: 3 A rom led for over 8 boars
3.
1 umber of welts to be constructed in bedrock: 0
6. Estimated beginning construction date: slt6/2o22
4. tal Number of wells to be constructed: 3
(add answers from 2 and 3)
7. Estimated construction completion date: 9/16/2022
ADDITIONAL INFORMATION
As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:
9. 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 welt 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.
Any test borings within 500 feet of proposed well or well system.
e. An 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. 143-215.106(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or welt system.
SIGNATURES
The Applicant assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Project Manager
Signature of Applicant or *Agent
Brandon Stau
Printed:name of Applicant or *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 acknowledges that it shall be the responsibility of the Applicant to
nsure t at the ryeil(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
fiv
Signature of Property 6wner (if different than Applicant)
Title of Applicant or *Agent
* If signing as Agent, attach authorization agreement stating
that you have the authority to act as the Agent.
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 US. Highway 70
Swannanoa, NC 28778
Phone:, [phone]
Fax: [phone]
Fayettvitle Regional Office
225 Green Street, Suite 714
Fayettiiville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooregvilie Regional Office
510 Eat Center Avenue
Moore4ville, 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 Offic-e
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MJR (Rev. 5-26-2022)

WELL CONSTRUCTION DETAIL
PROJECT/LOCATION:
CLIENT:
620 E Main Street, Elkin, North Carolina
First National Bank
DATE COMPLETED:
9/16/2022
PROJECT No. 22067.22
SUPERVISED BY:
WELL No. TPMW1
RT
;IZALIZED S'1'1ZA'1'1GRAFIlY
o °g°g °eego
°.ns °°°° s
REFERENCE POINT
Elevation/Depth: NA
SURFACE SEAL
Type/Depth: NA
DEPTH OF SURFACE CASING: NA
RISER PIPE Size/Type: 1.0 inch/Schedule 40 PVC
DIAMETER OF BOREHOLE: 2.2 inches
TYPE OF FILL: NA
TOP OF SEAL Elevation/Depth: 0.0 ft.bqs
TYPE OF SEAL: Hydrated bentonite
TOP OF FILTER PACK Elevation/Depth: 1.0 ft. bqs
FILTER PACK MATERIAL: #00N silica sand
TOP OF SCREEN Elevation/Depth: 5.0 ft. bqs
SCREEN SIZE/TYPE: 0.010 inch/Schedule 40 PVC
BOTTOM OF SCREEN Elevation/Depth: 14.8 ft.bps
BOTTOM OF FILTER PACK
Elevation/Depth: 15.0 ft. bqs
BOTTOM OF PLUGGED BLANK SECTION
Elevation/Depth: 15.0 ft.bqs
TYPE OF FILLER
BELOW PLUGGED BLANK: Native soils
BOTTOM OF BOREHOLE
Elevation/Depth: 15.0 ft. bqs
NOTES

WELL CONSTRUCTION DETAIL
PROJECT/LOCATION:
CLIENT:
620 E Main Street, Elkin, North Carolina
First National Bank
DATE COMPLETED:
9/16/2022
PROJECT No. 22067.22
SUPERVISED BY:
WELL No. TPMW2
RT
GENERALIZED Ni RATIGRAPHY
r—
L
L
REFERENCE POINT
Elevation/Depth: NA
SURFACE SEAL
Type/Depth: NA
DEPTH OF SURFACE CASING: NA
RISER PIPE Size/Type: 1.0 inch/Schedule 40 PVC
DIAMETER OF BOREHOLE: 2.2 inches
TYPE OF FILL: NA
TOP OF SEAL Elevation/Depth: 0.0 ft.bgs
TYPE OF SEAL: Hydrated bentonite
TOP OF FILTER PACK Elevation/Depth: 1.0 ft. bgs
FILTER PACK MATERIAL: #00N silica sand
TOP OF SCREEN Elevation/Depth: 5.0 ft. bgs
SCREEN SIZE/TYPE: 0.010 inch/Schedule 40 PVC
BOTTOM OF SCREEN Elevation/Depth: 14.8 ft.bqs
BOTTOM OF FILTER PACK
Elevation/Depth: 15.0 ft. bqs
BOTTOM OF PLUGGED BLANK SECTION
Elevation/Depth: 15.0 ft.bqs
TYPE OF FILLER
BELOW PLUGGED BLANK: Native soils
BOTTOM OF BOREHOLE
Elevation/Depth: 15.0 ft. bqs
NOTES

WELL CONSTRUCTION DETAIL
PROJECT/LOCATION:
CLIENT:
620 E Main Street, Elkin, North Carolina
First National Bank
DATE COMPLETED:
9/16/2022
PROJECT No. 22067.22
SUPERVISED BY:
WELL No. TPMW3
RT
r
f;
z
--4111
</1.1./ !✓L
REFERENCE POINT
Elevation/Depth: NA
SURFACE SEAL
Type/Depth: NA
DEPTH OF SURFACE CASING: NA
RISER PIPE Size/Type: 1.0 inch/Schedule 40 PVC
DIAMETER OF BOREHOLE: 2.2 inches
TYPE OF FILL: NA
TOP OF SEAL Elevation/Depth: 0.0 ft.bqs
TYPE OF SEAL: Hydrated bentonite
TOP OF FILTER PACK Elevation/Depth: 1.0 ft. bqs
FILTER PACK MATERIAL: #00N silica sand
TOP OF SCREEN Elevation/Depth: 5.0 ft. bqs
SCREEN SIZE/TYPE: 0.010 inch/Schedule 40 PVC
BOTTOM OF SCREEN Elevation/Depth: 14.8 ft.bqs
BOTTOM OF FILTER PACK
Elevation/Depth: 15.0 ft. bqs
BOTTOM OF PLUGGED BLANK SECTION
Elevation/Depth: 15.0 ft.bqs
TYPE OF FILLER
BELOW PLUGGED BLANK: Native soils
BOTTOM OF BOREHOLE
Elevation/Depth: 15.0 ft. bqs
NOTES

SI
SUBSURFACE INVESTIGATIONS GEOLOGY, D.P.C.
FIGURE 2- SITE INVESTIGATION PLAN
620 E Main Street
Elkin, North Carolina
Drawn by: BMS
Checked by: DBR
assmicamemsalm
50 100
Apprarinwe Scale in leer
9
SIG Project # 22067.22

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