WM0401419_Monitoring Well Permit Application_20221209

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: 12/5/2022
2. County: Watauga
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant:
Toth & Associates — Mr. Moises Lozano
Telephone: [phone]
Applicant's Mailing Address: 1550 E. Republic Road. Springfield, MO 65804
Applicant's Email Address (if available): mlozano(c�tothassociates.com
5. Contact Person (if different than Applicant): Don Marlor Telephone: [phone]
Contact Person's Mailing Address: 1900 Hendersonville Road, Suite 10, Asheville, NC 28803
Contact Person's Email Address (if available): dmarlor(a7ecslimited.com
6. Property Owner (if different than Applicant): P+J Properties, Inc Telephone: Not Available
Property Owner's Mailing Address: PO Box 1292, Boone, NC 28607
Property Owner's Email Address (if available): Not Available
7. Property Physical Address (Including PIN Number): 1302 Blowing Rock Road, Boone, Watauga County, NC 286078 (PIN
29103362710001
8. Reason for Well(s): Environmental Assessment
9. Type of facility or site for which the well(s) is(are) needed: Gas Station and USTs
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).
Not Applicable
11. Type of contaminants being monitored or recovered: VOCs, SVOCs (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): On the subject property (75 ft)
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: JG Drilling Certification No.: 4328-B
Well Contractor Address: 124 Pisgah Road, Easley. South Carolina 29642
PROPOSED WELL CONSTRUCTION INFORMATION
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? Expandable
material: 5 locking well cap for temp well construction
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 12/12i2022
4. Total Number of wells to be constructed: 5 7. Estimated construction completion date: 12/12/2022
(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. 143-215.108(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 regulated under the Welt Construction Standards (Title 15A of the North Carolina Administrative Code,
Suapter 2C) and accepts full responsibility for compliance with these rules
Signature of Applica1o'lent
Moises Lozano
Printed name of Applicant or `Agent
Project Engineer
Title of Applicant or 'Agent
If 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
well(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
fl"� AAc.rli el 1*'- — 4."_ ex—✓i ii*` -) Imo' pjer�.t3 Xc. — cJe C-
Signature 6f Property, Owner n - • t) Printed name of Property Ot'vner (if different than pplicant)
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]
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mali
Washington, NC 27889
Phone: [phone]
Fax: [phone]
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

UST ACTIVE
FACILITY #00-
0-0000006461
UST
INCIDENT
47404
UST
INCIDENT
#44417
UST
INCIDENT
#37360
UST ACTIVE
FACILITY #00-
0-0000005105
SITE PARCEL
BOUNDARY
APPROX.
500 FOOT
RADIUS
NO WATER SUPPLY WELLS OR POTENTIAL SOURCES OF CONTAMINATION ARE KNOWN TO EXIST OTHER THAN ILLUSTRATED ABOVE.
SOURCE:
WATAUGA COUNTY GIS
DATED 2022 & NCDEQ
DWM SITE LOCATOR TOOL
APPROXIMATE SCALE:
As Shown
FIGURE 2
POTENTIAL SOURCES MAP
7-Brew
1302 Blowing Rock Road
Boone, NC
ECS Project No. 49:16704-B

POPLAR NlLL nR
0.5
Winkler Cem
0
SCALE 1:24 000
KILOMETERS
E.misten Cem
2
1000
500
0.5
0
METERS
0
1000
}
2000
1
1000 0
1000 2000
3000
MILES
4000 5000 6000
FEET
7000 8000
Boone Inc
Airport
9000 10000
SOURCE:
USGS TOPOGRAPHIC MAP
7.5 — MINUTE SERIES
BOONE, NC
DATED 2022
FIGURE 1
SITE TOPOGRAPHIC MAP
7-Brew
1302 Blowing Rock Road
Boone, NC
ECS Project No. 49:16704-B

• APPROXIMATE MONITORING WELL LOCATION
LEGEND
APPROXIMATE SITE PARCEL BOUNDARY
SOURCE:
WATAUGA COUNTY GIS
IMAGERY DATED 2022
Not to Scale
FIGURE 3
SAMPLE LOCATION MAP
7-Brew
1302 Blowing Rock Road
Boone, NC
ECS Project No. 49:16704-B

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
FIGURE 4
PROPOSED MONITORING WELLS
7-Brew
1302 Blowing Rock Road
Boone, NC
ECS Project No. 49:16704-B