WM0401426_Monitoring Well Permit Application_20230126

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: 1/23/23
2. County: Guilford
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant: LS High Point, LLC — Mr. Carey Graham
Applicant's Mailing Address: P.O. Box 3470, Myrtle Beach, SC 29578
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Travis O'Quinn
Monitoring
Telephone: [phone]
Telephone: [phone]
Contact Person's Mailing Address: 1812 Center Park Drive, Suite D Charlotte, NC 28217
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Jennifer Morrell — Simanco Inc. Telephone: [phone]
Property Owner's Mailing Address: P.O. Box 182, Trinity, NC, 27370
Property Owner's Email Address (if available): Not Available
7. Property Physical Address (Including PIN Number): 2176 Surrett Drive, High Point, Guilford County, NC 27263 (PIN
179350)
8. Reason for Well(s): Environmental Assessment
9. Type of facility or site for which the well(s) is(are) needed: Automotive Repair Shop
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): UST incident 100' east
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: 3D Environmental Investigations Certification No.: 3162-A
Well Contractor Address: 2157 Mocksville Highway, Statesville, NC 28626
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: 4
5. How will the well(s) be secured? Sample will be
conducted through Geoprobe Sampling Point
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 1/31/2023
4. Total Number of wells to be constructed: 4
(add answers from 2 and 3)
7. Estimated construction completion date: 1/31/23
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,
ubchapter 2C) and accepts full responsibility for compliance with these rules
Environmental Project Manager
Signature of Applicant or *Agent Title of Applicant or *Agent
Travis L. O'Quinn
* 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 Signed Access Agreement
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]
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, 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
Raleigh Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension
GW-22M (Rev. 5/11)

ECS SOUTHEAST, LIP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:35601P
Scope of Work: Proposal for Environmental Assessment Services
Project: Surrett Drive Site
Location: 2176 Surrett Drive, High Point, Gifford County, North Carolina
As part of the proposed real estate transaction, ECS Southeast, LIP (ECS) has been requested by the
purchaser to conduct subsurface groundwater quality 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 soil and groundwater sampling. By signing below, the property owner authorizes ECS to
conduct the aforementioned sampling at the site.
Property Owner (please print); Jennifer Morrell
Property Owner Telephone (please print): 980-277-0129
Property Owner Signature:
Date: 1/18/2023

1
0.5
0
I -I I -I I- 1 I -I I -I I
1000 500
0.5
1000 0 1000 2000
SCALE 1 :24 000
KILOMETERS
0
METERS
0
1000
2
MILES
3000 4000 5000 6000
7300 8000 000 100.00
FEET
SOURCE:
USGS TOPOGRAPHIC MAP
7.5 - MINUTE SERIES
CONCORD, NC
DATED 2019
FIGURE 1
SITE TOPOGRAPHIC MAP
SURRETT DRIVE SITE
2176 SURRETT DRIVE
HIGH POINT, GUILFORD COUNTY, NC
ECS PROJECT NO. 49:18909-A

UST Incident #48443
No Remaining Impacts
x
SOURCE:
ECS PHASE I ESA
PROJECT NUMBER 49:18909-A
DATED AUGUST 10, 202
SCALE:
NOT TO SCALE
Thomas Built
Hoses (REC.)
UST Incident #17044
Gravid Central
Express gasoline
station and car
wash (REG)
UST Incident #37028
UST Incident #9220
Crossroads
Grcrery gasoline
station {REO) `
Site Parcel Boundary
Proposed GrourtdwatGr Boring Location
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L? 7 .Rr I Powered byEsn I ER -I .gymrrx.rYfy rk¢a Cai1rlbuaorg. h1C CGIA
ss
FIGURE 2
PROPOSED SAMPLE LOCATIONS MAP
SURRETT DRIVE SITE
2176 SURRETT DRIVE
HIGH POINT, GUILFORD COUNTY, NC
ECS PROJECT NO. 49:18909-A

GROUND
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
-... "`
SURFACE
ESTIMATED
^'20'-25'
FEET
A
NATURAL FORMATION
BACKFILL
GROUNDWATER
1.5-INCH STEEL DIRE
PUSH RISER
2--INCH BORE
HOLE
SLOTTED STEEL S
0.01-INCH SLOT W
SET TO INTERSECT GROI
ESTIMATED 4 FEET IN
V
V
WELL CONTRUCTION DI/
REPRESENTATIVE OF DIRECT
D(IIAIT SAMDI FI
CT
CREEN
IDTHS
JNDWATER
LENGTH
GRAM IS
PUSH SCREEN
NOT TO SCALE
FIGURE 3
PROPOSED MONITORING WELLS
SURRETT DRIVE SITE
2176 SURRETT DRIVE
HIGH POINT, GUILFORD COUNTY, NC
ECS PROJECT NO. 49:18909-A