WM0401417_Monitoring Well Permit Application_20221212

C-A V q /
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY -D]VrSION 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 ft
1. Date: 12/02/2022
2. County: Davidson
u a permit io construct monitoring or recovery wens.
FOR OFFICE USE ONLY
PERMIT NO.W MC1�fD N 1-� ISSUED DATEcif---
3. What type of well are you applying for? (monitoring or recovery): Monitorina
4. Applicant: NCDEQ. DWM, UST Section (Scott Rvals) Telephone: [phone]
Applicant's Mailing Address: 1646 Mail Service Center Raleigh NC2766-1646
Applicant's Email Address (if available): scott.rvals(a)ncdenr aov
5. Contact Person (if different than Applicant): Al Quarles Telephone: [phone]
Contact Person's Mailing Address: 7606 Whitehall Executive Center Drive Suite 200 Charlotte NC 28273
Contact Person's Email Address (if available): william.auarles cDoneatlas com
6. Property Owner (if different than Applicant): Ms. Martha Fritts Martin Telephone: [phone]
Property Owner's Mailing Address: 1648 Arrington Dr Lexington NC 27295
Property Owner's Email Address (if available): marthamartin(a)lexcominc net
7. Property Physical Address (Including PIN Number)_ 2509 Arrington Dr. PIN 1132200000014
City Lexington County Davidson Zip Code 27295
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: 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).
UST Incident #44919• Crossroads Center-C 134 Arnold Rd Lexington NC 27295
11. Type of contaminants being monitored or recovered: Volatile Organic Compounds
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 7
Existing Monitoring or Recovery Well Construction Permit No(s).: All on UST site property
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): approximately 100 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? no
If yes, give distance(s): n/a
15. Well Contractor: TBD Certification No.:
Well Contractor Address:
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? Well Vault and lock
material: 1
6. Estimated beginning construction date: TBD. Depending
3. Number of wells to be constructed In bedrock: 0 on driller availability
7. Estimated construction completion date: TBD
4. Total Number of wells to be constructed: 1 Depending on driller availability
(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.
4� (//�Gl/1 =••+ �r �v�� , .. , Professional Geologist
Signal Applicant or *Agent Title of Applicant or *Agent
Al Quarles • 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 aareement Martha Fritts Martin
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 Raleigh Regional Office Wilmington Regional Office
2090 U.S. Highway 70 3800 Barrett Ddve 127 Cardinal Drive Extension
Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 28405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [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]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MIR (Rev. 5-26-2022)

SITE VICINITY MAP
CROSSROADS CENTER-C
134 ARNOLD ROAD
LEXINGTON, DAVIDSON COUNTY, NORTH CAROLINA
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PROPOSED MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
NOT TO SCALE
LOCKABLE WELL C
L1
i
L2
L3
L1 =
-0.25
FT.
L2 =
5
FT.
L3 =
I
15
FT.
L4 =
20
FT.
(Example of typical MW installation displayed above)
134 Arnold Rd
Lexington, NC 27295
PROTECTIVE CASING AND CONCRETE PAD
CASING MATERIAL
sch 40 PVC
CASING DIAMETER
2 inch
CASING LENGTH
0-36 feet
PAD DIMENSIONS
2 ft x 2 ft
HEIGHT ABOVE GROUND flush mount
WELL CASING
MATERIAL
sch 40 PVC
DIAMETER
2 inches
JOINT TYPE
flush threaded
LENGTH
5 feet
BACKFILL AROUND CASING
MATERIAL
Grout
THICKNESS
3 feet
SEAL
TYPE OF SEAL
Bentonite
THICKNESS
1 feet
FILTER PACK
TYPE OF FILTER
#2 silica sand
DISTANCE ABOVE SCREEN
1 feet
WELLSCREEN
SCREEN MATERIAL
sch 40 PVC
DIAMETER
2 inches
LENGTH
15 feet
SLOT SIZE
0.01 inch
DEPTH TO BOTTOM OF
MONITORING WELL
20.0 feet
DEPTH TO BOTTOM OF
BOREHOLE
20.0 feet
DIAMETER OF BOREHOLE 8.5 inches
7606 Whitehall Executive Center Drive
Charlotte, North Carolina 28273
rlLt PREP. BY REV. BY DATE PROJECT NO.
AT I AQ 11/18/2022 SLC4491902

Right of Entry Agreement
Davidson County PIN 6737-03-20-8816
2509 Arrington Drive
Lexington, NC 27295
Scott Ryals, P.E.
Environmental Engineer
DW M UST Section
1646 Mail Service Center
Raleigh, NC 27699-1646
RE: Right of Entry Agreement
Crossroads Center-C, Incident No. 44919
134 Arnold Rd
Lexington, NC 27295
Dear Mr. Ryals,
October 4, 2022
I am/We are the owner(s) of a parcel of property, located at or nearthe incident in question,
and hereby permit the Department of Environment Quality (Department) or its contractor to enter
upon said property for the purpose of conducting an assessment and/or remediation of the
groundwater and/or soils under the authority of G.S. 143-215.94G.
I amble 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 the investigation and/or remediation of the site and access shall be borne by
the Department or its contractor in accordance with the acceptance of the site into the
State -Lead Program. The Department or its contractor shall protect and prevent damage
to the property and surrounding lands. Any damages will be restored by the Department
or its contractor to as close to the pre -work condition as practicably possible.
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
will notify the land owners 48 hours prior to entry and 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 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.

Right of Entry Agreement
Davidson County PIN 6737-03-20-8816
2509Arrington Drive
Lexington, NC 27295
October 4, 2022
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.
I/We agree not to interfere with, remove or any ways damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
�� -J" 2-.
Signat re
Type/Print Name of Owner or Agent
336-248-8661
'hone Number
f`'tDu"f{1at tvrAr H.l 42 le,<c (D,v`f*nc . r,$e._F
Email Address
1648 Arrington Drive
Mailing Address
Lexington, NC 27295
City/State/Zip Code
Date