WM0401401_Monitoring Well Permit Application_20220928

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: 9/23/2022
2. County:
FOR OFFICE USE ONLY
PERMITNO.YJMpybj�0 ISSUEDDATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: NCDEQ DWM State Lead Branch, Thomas Chapman Telephone: [phone]
Applicant's Mailing Address: 1637 Mail Service Center Raleigh NC 27699-1637
Applicant's Email Address (if available): Thomas.chapman(dncdenr.gov
5. Contact Person (if different than Applicant): Laura Elliott. Terracon Telephone: [phone]
Contact Person's Mailing Address: 7327-G W Friendly Ave Greensboro, NC 27410
Contact Person's Email Address (if available): laufe.elllottoterracon.com
6. Property Owner (if different than Applicant): County of Forsyth (Smith Reynolds Airport) — Mark R. Davidson. AAE Airport
Director Telephone: [phone]
Property Owner's Mailing Address: Airport Department 3801 North Liberty Street, Suite 204, Winston-Salem, NC 27105
Property Owner's Email Address (if available): mark.davidson(rDsmithrevnolds.org
7. Property Physical Address (Including PIN Number) 4400 Lansing Road - PIN 6837-80-8891 000
City Winston-Salem County Forsyth Zip Code 27105
8. Reason for Well(s): UST Groundwater Incident #6291 Former Sam's Curb Market
(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: UST
(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).
Yes. Incident #6291 at 4215 North Liberty Street Winston-Salem NC
11. Type of contaminants being monitored or recovered: organics
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 7 Active MWs
Existing Monitoring or Recovery Well Construction Permit No(s).: Unknown
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 200 feet
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: Environmental Drilling & Probing Services (EDPS) Certification No.: 3307
Well Contractor Address: 17538 Green Hill Rd, Charlotte, NC 28278
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? Locking well cap
material: 1 and bolted flush mount manhole cover
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 10/25/22
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 10/25/22
(add answers from 2 and 3)
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 assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Agent for NCDEC
Signature of Applicant or *Agent Title of Applicant or *Agent
Laura Elliott. Terracon * 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
well(s) as outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
See attached access agreement Forsyth County. c(o Mark Davidson. Airport Director
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
Raleigh Regional Office
Swannanoa, NC 28778
3800 Barrett Drive
Wilmington Regional Office
Phone: [phone]
Raleigh, NC 27609
127 Cardinal Drive Extension
Fax: [phone]
Phone: [phone]
Wilmington, NC 28405
Fax: [phone]
Phone: [phone]
Fayetteville Regional Office
Fax: [phone]
225 Green Street, Suite 714
Washington Regional Office
Fayetteville, NC 28301-5094
943 Washington Square Mall
Winston-Salem Regional Office
Phone: [phone]
Washington, NC 27889
450 W. Hanes Mill Road
Fax: [phone]
Phone: [phone]
Suite 300
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
05
GW-22M/R (Rev. 5-26-2022)

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Mr. Thomas Chapman, Hydrogeologist
DWM UST Section'
Trust Fund Branch -State Lead Program
127 Cardinal Drive Extension
Wilmington, NC 28405
Dear Mr. Chapman:
RE: Off -Site Access Agreement
4400 Lansing Drive (PIN # 6837-80-8891)
Winston-Salem, Forsyth County-WSRO
Incident # 6291
I am/We are the owner(s) of a parcel of property, located at or near the incident in question, and
hereby permit the Department of Environmental Quality (Department) or its contractor to enter upon said
property for the purpose of conducting an investigation of the groundwaters under the authority of G.S. 143-
215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the Department or its
contractor. The Department or its contractor shall protect and prevent damage to the surrounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the shortest
feasible route to the nearest public road. The Department or its contractor may enter upon the land at
reasonable times and have full right of access during the period of the investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article 31 of
Chapter 143 of the North Carolina General Statutes, Tort Claims Against State Departments and
Agencies, and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon request and
is a public record, in accordance with G.S. 132-1.

Sam's Curb Market - Incident 4 - 6291
6. The activities to be carried out by the Department or its contractor are for the primary benefit of the
Department and of the State of North Carolina. Any benefits accruing to the owner are incidental.
The Department or its contractor is not and shall not be construed to be an agent, employee, or
contractor of the landowner.
I/We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
Mark R. Davidson, A.A.E., Airport Director
Signature
Forsyth County
Type/Print Name of Owner or Agent
336-607-6121
Phone Number
Airport Department
3801 North Liberty Street, Suite 204
Address
Winston-Salem, NC 27105
City/State/Zip Code
September 9, 2022
Date

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