WM0401414_Monitoring Well Permit Application_20221202

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.
Date: 11/28/22
2. County: Randolph
FOR OFFICE USE ONLY
PERMIT NO. tM b -C 0 14 I `IIISSUED DATE 11D-0
3. What type of well are you applying for? (monitoring or recovery): Monitoring (temporary)
4. Applicant: Primis Property, LLC (Jonathan A. Good) Telephone: [phone]
Applicant's Mailing Address: 101 East Washington St, Suite 400, Greenville, SC 29601
Applicant's Email Address (if available): Jongoodanaiearlefurman.com
5. Contact Person (if different than Applicant): Ron Navarro Telephone: [phone]
Contact Person's Mailing Address: 5260 Greens Dairy Rd, Raleigh, NC 27616
Contact Person's Email Address (if available): RNavarro(a)ecslimited.com
6. Property Owner (if different than Applicant): Americhem, Inc. Telephone: [phone] x1380
Property Owner's Mailing Address: 2000 Americhem Way, Cuyahoga Falls, OH 44221
Property Owner's Email Address (if available): NA
Property Physical Address (Including PIN Number) 7280 Liberty Park Ave (PIN 8735444200)
City Liberty County Randolph Zip Code 22P92Q 'a
8. Reason for Well(s): Phase II Environmental Site Assessment
cf
(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: Industrial
(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: Chlorinated Solvents (PCE, TCE, etc.) (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).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Adjoining, Approx. 200 ft to northwest
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? none observed
If yes, give distance(s):
15. Well Contractor: Ground Zero Environmental Certification No.: NCWC 30127-A
Well Contractor Address: 11100 Astarita Ave, Partlow, VA 22534
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
material: 3
3. Number of wells to be constructed in bedrock:
5. How will the well(s) be secured? Capped and locked
6. Estimated beginning construction date: December 2022
4. Total Number of wells to be constructed:3 7. Estimated construction completion date: December
(add answers from 2 and 3) 2022
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. 143-215.108(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 r fated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
2C) gr1d accepts full responsibility for compliance with these rules
ature of Applicant or gent
Authorized Manager. Primis Property III, LLC
Title of Applicant or *Agent
Agent * 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
See attached
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]
GW-22M (Rev. 5/11)
GW-22MR Rev. 3-1-2016
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
450 W.

Americhem (REC)
30m
100ft
SOURCE:
2020 IMAGERY
SCALE SHOWN ABOVE
Legend
Proposed Groundwater/Soil Gas
Sampling Location
REC Location
Parcel Boundary
Firs
Ponerei by E:ar I Nr. C.G{A. E,1axw. ►vl:cro5)
FIGURE 1
PROPOSED SAMPLE LOCATION MAP
7280 Liberty Park Avenue
Liberty, Randolph County, NC
ECS Proposal Number: 49:35004P

a
•
YJ
1
::.
111
. Lt
a.
1
Is-
- 1 1 II!L - .1
II ■
I
Aj E_-
tar=
I- f.: i
■
1.t L11. �413 � � 7' jJ
■

ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:35004P
Scope of Work: Proposal for Environmental Assessment
Project: Liberty Park Avenue Site
Location: 7280 Liberty Park Avenue, Liberty, Randolph County, NC 27298 (PIN 8735-44-
4200)
As part of the proposed real estate transaction, ECS Southeast, LLP (ECS) has been requested by the
purchaser to conduct due diligence tasks including groundwater and soil -gas sampling at the site. The
groundwater sampling requires that ECS procure a permit from the North Carolina Department of
Environmental Quality (NCDEQ).
ECS respectfully requests that the owner of the property grant permission to ECS to access the property
to conduct the above referenced tasks. By signed below, the property owner authorizes ECS to conduct
the aforementioned sampling at the site.
Property Owner (please print):
C�
Property Owner Telephone (please print): 33€ /28 - 4213 x' .3
Property Owner Signature
e! Am ff.S �Ci • l4Nv�i y
No use ec+i1N.S (3r,.o
AlMti€a Ci4(. M, Ate -
Date: rpr Lt71Z.2-
praliS ie.,t IS3g.Ati-rcilb pfZouiAa.A ` J4T iNg- f &vas' /0-eFL Iv 1
.1)0 maw— fN rezr= t.J Tw mire �s
p g_�y awti��a5 ��us,nie.�s
OYPR-A r©nr A'T 7Z..7? L.i ber I y PAR. k AVE)
�`�—_ "/ 2 2 1 Z 2....

GEOPROBE6 SCREEN POINT 15 GROUNDWATER SAMPLER
STANDARD OPERATING P11oanURE
Ttdhnkal aolkti. Me.MKJ111
WOW* * atoRet,1993
WARM Mew
i '
A mnorsitKr
A SuourNG
GEOPROBE6SCREEN POINT13GROUNDWATER $AMPLER