WM0401399_Monitoring Well Permit Application_20220920

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 13. 2022
2. County: Randolph
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: City of Asheboro Telephone: _ (336; 62t--120' x223
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
Applicant's Mailing Address: PO Box 1106. Asheboro. NC 27204
Applicant's Email Address (if available): tnuttallf9d,asheboro.nc.us Cfrevor Nuttall)
5. Contact Person (if different than Applicant): David Duncklee
Telephone: [phone]
Contact Person's Mailing Address: Svnterra Corporation: 511 Keisler Drive. Suite 102; Cary, NC 27518
Contact Person's Email Address (if available): ddunckIeeVsynterracorp.com
6. Property Owner (if different than Applicant): Acme McCrary Corporation Telephone:
Property Owner's Mailing Address: Pq Box 1287, Asheboro. NC 27204
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 159 North Street, PIN 7751739323
City Asheboro County Randolph Zip Code 27203
8. Reason for Well(s) Groundwater 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: Inactive Textile Mill
(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).
UST active facility. facility #00-0-0000018663
11. Type of contaminants being monitored or recovered: organics. heavy metals
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? None
Existing Monitoring or Recovery Well Construction Permit No(s).• N/A _
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): none known
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: Geologic Exploration Certification No.: 2401
Well Contractor Address: 176 Commerce Blvd., Statesville 28625
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
b. Estimated well depth
c. Screen intervals
d. Sand/gravel pack intervals
e, Type of casing material and thickness
f. Grout horizons
g. WeII head completion details
Continued on Reverse

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated
material: 5
3. Number of wells to be constructed in bedrock: 0
5. How will the well(s) be secured? _ Well cover and
locked cap
6. Estimated beginning construction date: 9/28/22
4. Total Number of wells to be constructed: 5 7. Estimated construction completion date: 9/29/22
(add answers from 2 and 3)
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.
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,
and accepts full responsibility for compliance with these rules
le
Signature of Applicant l *Agent
Printed name of Applicant or *Agent
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Titlet c, of y51.e*..v
if signing as Agent, attach authorization agreement stating
that you have the authority to act as the Agent.
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of Applicant or * en
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).
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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 Rev. 3-1-2016
GW-22M (Rev. 5/11)

GROUNDWATER MONITORING WELL CONSTRUCTION DETAIL
Project Name: ACME McCrary Property Drilling Co: Geologic Exploration Well Number: 1,2,3,4,5
Location: 159 North Street, Asheboro, N Driller: Geoloic Exploration
Client: City of Asheboro
Geologist: Evan Hamo
Drilling Method: Air Rotary
Job Number: 00.5385.00
Date Completed: N/A
Static Water Level 20.00 b.TOC Survey Datum: MLS
Bolt -down Cast Iron Traffic Vault
8-inch Diameter
Grass, Asphalt/Concrete
Concrete Surface Pad
(2ftx2ftx6in)
Note:
Drawing Not to Scale
All Depths are Referenced to Ground Surface
"--
Top Of Casing
Land Surface
0.00 ft
Stickup
_ _ -- Surface Casing From 0.0 ft to 30.0 ft
Casing Type: .-VC
Inside Diameter: 2 inches
Diameter of Borehole (nominal)
BentonitelCement Grout
From
Bentonite Pellet Seal
From
in
0.5 ft to
29.0 ft
29.0 ft to 31.0 ft
Top of Screen Depth 30.0 ft
Screen Type: slotted
Screen Slot Size: 0.01
Screen Length: 10.0 ft
Filter Sand for Screen
Sand Type: Sand Pack
From
30.0 ft to 40.0 ft
Bottom of Well Depth 40.0 ft
Bottom of Boring Depth 40.5 ft
Total Depth of Well, b. Top of Casing Depth 40.5 ft
Shallow Monitoring Well Diagram (Well 1)

NOTES:
1. PROPERTY BOUNDARY PROVIDED BY NC ONE MAP AT
https:/lwww.nconemap.gov/pages/parcels, LAST UPDATED MARCH 9, 2022.
2. AERIAL PHOTOGRAPH PROVIDED BY ESRI ONLINE, COLLECTED APRIL 27, 2019.
L'
synTerra
CHARLOT
RANDOLPH
COUNTY
WILMINGTON
www.synterra co rp.co m
FIGURE 1
SITE LOCATION MAP
ACME MCCRARY PROPERTY
ASHEBORO, RANDOLPH COUNTY, NORTH CAROLINA
DRAWN BY: L. FOREMAN
REVISED BY: L. FOREMAN
CHECKED BY: E. HAMO
APPROVED BY: E. HAMO
PROJECT MANAGER: E. HAMO
DATE: 08/03/2022
DATE: 09/08/2022
DATE: 09/08/2022
DATE: 09/08/2022
GRAPHIC SCALE
75 0 75
150
QN FEET)

9/1/22, 2:23 PM
Randolph County GIS
Randolph County, NC
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Transportation
ROADS
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Secondary
Roads
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Disclaimer. This map was compiled from recorded deeds, plats and other public records and data.
Users of this data are hereby notified that the aforementioned public information sources should be
consulted for verification of the information. Randolph County, its agents and employees make no
warranty as to the accuracy of the information on this map.
Map Scale
1 inch = 282 feet
9/1/2022
https:l/gis.randolphcountync.gov/randolphts/#F 1/1