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HomeMy WebLinkAboutWM0401400_Monitoring Well Permit Application_20220920NORTH 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 welts. 1. Date: 9/16/2022 2. County: Guilford FOR OFFICE USE ONLY PERMIT NO. _____ ISSUED DATE 3. What type of well are you applying for? (monitoring or recovery): 4. Applicant: Koury Corporation — Mr. Alex Crow Monitoring Telephone: 336-299-9200 Applicant's Mailing Address: 2275 Vanstory Street, Suite 200, Greensboro, NC 27403 Applicant's Email Address (If available): acrow@kourycorp.com 5. Contact Person (If different than Applicant): Jonathan Garrick Telephone: 704-418-4096 Contact Person's Mailing Address: 1812 Center Park Drive, Suite D Charlotte. NC 28217 Contact Person's Email Address (If available): Igarrick(a.ecslimited.com 6. Property Owner (If different than Applicant): Q-Dog Properties (PIN 7872389680). John Doutt (PIN 7872487501) Telephone: Not Available Property Owner's Mailing Address: 3302 Liberty Road, Greensboro. NC 27406 Property Owner's Email Address (If available): Not Available 3300 Liberty Road and 7. Property Physical Address (Including PIN Number): 3302 Liberty Road, Greensboro, Guilford County, NC 27406 (PiN 7872389660 and 7872487501) 8. Reason for Well(s): Environmental Assessment 9. Type of facility or site for which the well(s) is(are) needed: UST, AST, Paint and Fireproofing office 10. Are there any current water quality permits or incidents associated with this facility or slte? If so, Ilst permit and/or Incident no(s). Not Applicable 11. Type of contaminants being monitored or recovered: VOCs. S1[OCs. TPH-GRO, TPH-DRO. PFAS (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).: Not Applicable 13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): property to the North (1200 ftj 14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No If yes, give distance(s): Not Applicable 15. Well Contractor: 3D Environmental Investigations Certification No.: 3162-A Well Contractor Address: 2157 Mocksville Highway. Statesville, NC 26626 PROPOSED WELL CONSTRUCTION INFORMATION 1. As required by 15A NCAC 02C .0105(0(7), attach a well construction diagram of each well showing the following: a. Borehole and well diameter b. Estimated well depth c, Screen Intervals d. Sand/gravel pack Intervals e. Type of casing material and thickness f. Grout horizons g. Well head completion details Continued on Reverse Sure of Property Owner (if different than Applicant) ohn A. Doutt I anager o Q-Dog Properties LLC DIRECTIONS PROPOSED WELL CONSTRUCTION INFORMATION (Continued) 2, Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Expandable material: 5 locking well cap forlemp well construction 3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 10/3/2022 4. Total Number of wells to be constructed: 5 (add answers from 2 and 3) 7. Estimated construction completion date: 10/3/2022 ADDITIONAL INFORMATION i. 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 't.E-�X Geoff Printed name of Applicant or `Agent Title of Applicant or `Agent !f 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 ell(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C). �1r oI-AJ A. Doutl Printed name of Property Owner (if different than Applicant) 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: (828) 296-4500 Fax: (828) 299-7043 Fayetteville Regional Office 225 Green Street, Suite 714 Fayetteville, NC 28301-5094 Phone: (910) 433-3300 Fax: (910) 486-0707 Mooresville Regional Office 610 East Center Avenue Mooresville, NC 28115 Phone: (704) 663-1699 Fax: (704) 663-6040 Raleigh Regional Office 3800 Barrett Drive Raleigh, NC 27609 Phone: (919) 791-4200 Fax: (919) 571-4718 Washington Regional Office 943 Washington Square Mall Washington, NC 27889 Phone: (252) 946-6481 Fax: (252) 975-3716 Wilmington Regional Office 127 Cardinal Drive Extension Wilmington, NC 28405 Phone: (910) 796-7215 Fax: (910) 350-2004 Winston-Salem Regional Office 450 W. Hanes Mill Road Suite 300 Winston-Salem, NC 27105 Phone: (338) 778-9800 Fax: (336) 776-9797 GW-22MR Rev. 3.1-2018 GW-22M (Rev. 5/11) 0.5 0 KILOMETERS --+ • -- �-, I--1 1 1000 500 0.5 0 METERS 0 1000 2 2000 1 000 0 1000 2000 MILES 3000 4000 5000 6000 FEET 7000 8000 9000 10000 SOURCE: USGS TOPOGRAPHIC MAP 7.5 — MINUTE SERIES GREENSBORO, NC DATED 2019 FIGURE 1 r SITE TOPOGRAPHIC MAP Liberty Road Property 3000, 3302, 3306, 3310, 3312, and 3314 Liberty Road Greensboro, NC ECS Project No. 49:17926-C _Ap SITE PARCEL -- BOUNQARY u^ P� NO WATER SUPPLY WELLS OR POTENTIAL SOURCES OF CONTAMINATION ARE KNOWN TO EXIST OTHER THAN ILLUSTRATED ABOVE. SOURCE: GOOGLEEARTH IMAGERY DATED ZO22&N[DECi DWM SITE LOCATOR TOOL APPROXIMATE SCALE: As Shown E c 5 FIGURE ~'Ar' POTENTIAL SOURCES MAP Liberty Road Property 30N\J3OJ,3306,3310'33l2'and 33l4 Liberty Road Greensboro, NC ECS Project No.49:17926'C LEGEND • APPROXIMATE MONITORING WELL LOCATION SOURCE: GOOGLE EARTH IMAGERY DATED 2022 Not to Scale FIGURE 3 SAMPLE LOCATION MAP Liberty Road Property 3000, 3302, 3306, 3310, 3312, and 3314 Liberty Road Greensboro, NC ECS Project No. 49:17926-C ESTIMATED "20' FEET GROUND SURFACE 0.5' — 6' PORTLAND CEMENT 6' — 8' BENTONITE SAND 8'-10' GROUNDWATER MONITORING WELL COVER 2.0-INCH SCH 40 PVC RISER 8.25 --INCH BORE HOLE 2.0-INCH SHC 40 PVC SLOTTED SCREEN 0.01-INCH SLOT WIDTHS SET TO INTERSECT GROUNDWATER ESTIMATED 10 FEET IN LENGTH NOT TO SCALE NM'S FIGURE 4 PROPOSED MONITORING WELLS Liberty Road Property 3000, 3302, 3306, 3310, 3312, and 3314 Liberty Road Greensboro, NC ECS Project No. 49:17926-C