WM0401393_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:
Guilford
FOR OFFICE USE ONLY
PERMIT NO,W ► AO'4 0 I:Sr SSUED DATE r(( (1
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: GDP B2G High Point, LLC Telephone: [phone]
Applicants Mailing Address: 145 Otterkill Road, PO Box 55, Mountainville, New York 1 hck
Applicant's Email Address (if available):
5, Contact Person (if different than Applicant):
tiffany aAgdpartners.com >I 1 C `, et LA a i` \
Ron Navarro Telephone: [phone]
Contact Person's Mailing Address: 5260 Greens Dairy Road, Raleigh, NC 27616
Contact Person's Email Address (if available): RNavarroAecslimited.com
6. Property Owner (if different than Applicant): High Point South Main, LLC
Telephone: N/A
Property Owner's Mailing Address: PO Box 10009. Greensboro, NC 27404 %i v\ BJ\\ `5 S
Property Owner's Email Address (if available): N/A
7. Property Physical Address (Including PIN Number) 280t4'f e7 South Main Street (PIN 7709747262)
City Hiah Point County Guilford Zip Code 27263
8. Reason for Well(s): Assessment of suspected contamination from former operations of the subiect 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
(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. heavy 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).: No
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): approximately 15 feet from 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: 11100 Astarita Ave, Partlow, VA 22534

1.
PROPOSED WELL CONSTRUCTION INFORMATION
As required by 15A NCAC 02C ,0105(f)(7), attach a well construction diagram of each well showing the following:
Type of casing material and thickness
Grout horizons
Well head completion details
a.
b.
c.
d.
Borehole and well diameter
Estimated well depth
Screen Intervals
Sand/gravel pack intervals
e.
f.
9.
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated
material: 5
5. How will the well(s) be secured? Expansion cap
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: 5 7, Estimated construction completion date: Unknown
(add answers from 2 and 3) (within 96 hours of installation)
ADDITIONAL INFORMATION
1. 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 Title of Applicant or *Agent
\_UUk,1 j vrr
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).
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant)

ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:32231_REV1
Scope of Work: Proposal for Environmental Services
Project: South Main Street Site
Location: 2601 and 2607 S Main St, High Point, NC
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): V h f/J
Property Owner Telephone (please print): 334—. T33T g 6 s7
Property Owner Signature:
Date: 8131/zi

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GEOPRoBE6 SCREEN POINT 15 GROUNDWATER SAMPLER
STANDARD OPERATiNG PROCEDURE
Technical Botktie No. KU 141
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Legend
A Proposed sub -slab soil gas sampling
Proposed Groundwater Sampling
Point
SOURCE:
2020 IMAGERY
SCALE SHOWN ABOVE
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FIGURE 1
PROPOSED SAMPLE LOCATION MAP
South Main Street Site
2601 and 2507 S Main St
High Point, Guilford County, NC
ECS Proposal Number: 49:32231 REV1
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