WM0401397_Monitoring Well Permit Application_20220914

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: September 11, 2022
2. County: Watauga
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
Temporary Monitoring Well
4. Applicant: Arista Boone, LLC Telephone: [phone]
Applicant's Mailing Address: 520 Providence Highway I Suite 9 Norwood MA 02062
Applicant's Email Address (if available): douq a(2aristadevllc.com
5. Contact Person (if different than Applicant): Dan Matz
Telephone: [phone]
Contact Person's Mailing Address: 6004 Ponders Court, Greenville, South Carolina 29615
Contact Person's Email Address (if available): dan.matz as blecorp.com
6. Property Owner (if different than Applicant): HODGES, JOHN WAISTEL III Telephone: NA
Property Owner's Mailing Address: 121 CHERRY HILL RIDGE, JEFFERSON NC 28640
Property Owner's Email Address (if available): NA
7. Property Physical Address (Including PIN Number) 675 East King Street, Boone, Watauga County, North Carolina
Watauga County PIN 2910480637000
City Boone County Watauga Zip Code 28607
8. Reason for Well(s): Groundwater Assessment, suspected contamination
(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: Surrounding do/cleaners and automotive repair facilities. Former on -
Site automobile maintenance work..
(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: Organics - Petroleum and solvents
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? None known at this time
Existing Monitoring or Recovery Well Construction Permit No(s).: Not Applicable
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Adioininq
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: JG Drilling. Certification No.: Jeff Grant, 4328B
Well Contractor Address: 124 Pisgah Road, Easley, South Carolina 29642
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?
material: Five (5) Temporary Well
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 9-26-2022
4. Total Number of wells to be constructed: Five (5) 7. Estimated construction completion date: 9-26-2022
(add answers from 2 and 3)
ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C .0105(0(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 Ap scant hereby agrees that the proposed well(s) will be constructed in accordance with approved specifications and conditions of
this WWnstruction 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
Project Manager
Signature f�Applican r gent Title of Applicant or *Agent
Douglas Benoit * 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
John Hodges and Sara Hodges
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant)

1-INCH WELL DIAGRAM
NO CAP (TEMPORARY WELL)
GROUND SURFACE
NATIVE SOIL
1—INCH O.D. PVC RISER
1—INCH O.D. PVC SCREEN
2 TO 5 FEET LONG
(SLOT SIZE 0.010—INCH)
t
BOREHOLE DIAMETER 2 TO 3 INCHES
OPEN BOREHOLE
SAND TO APPROXIMATELY 2 FEET ABOVE SCREEN
NOTE
WELL IS RETRACTED AFTER SAMPLING
AND BORING ABANDONED WITH
BENTONITE GROUT.
JOB NO.:
NA
DATE
04-13-20
SCALE:
NOT TO SCALE
BUNNELL
LAMMONS
ENGINEERING
6004 Ponders Court, Greenville, SC 29615
Phone: [phone] Fax: [phone]
TYPICAL 1—INCH WELL
DIAGRAM
FIGURE

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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-22M (Rev. 5/11)
GW-22MR (6/11)

OWNER'S SIGNATURE PAGE
PROPOSED COMMERCIAL DEVELOPMENT
675 EAST KING STREET AND NEW ABUTTING LOT TO THE NORTH
By signing this document, the property Owners of the lots listed below in Boone, NC acknowledge that they each have
an executed Purchase & Sales ageement with Arista Development, LLC and that each seller authorizes Arista
Development LLC to sign various permit applications on their behalf for the proposed redevelopment of their
combined properties.
Parcel ID (5)
Address
Owner's Name (TRUST)
Date
Owner's SignaturegnX
2910-48-0637-000
121 CHERRY HILL RIDGE
JEFFERSON NC 28640
John Waltstel Hodges, Ill
rr
04WA) Y11� lu 2-, n
2`z
2910-48-0637.000
121 CHERRY HILL RIDGE
JEFFERSON NC 28640
Sara Gentry Hodgesz.,0/..ry46-sb--/r-
348 Bare Ridge Road
West Jefferson NC, 28694
Sky Country LLC