WM0401429_Monitoring Well Permit Application_20230203

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: January 31, 2023
2. County: Guilford
FOR OFFICE USE ONLY
PERMIT NO. W PAO LJ b IISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring (temporary)
4. Applicant: Greenway Real Estate Asset Traders, LLC (Mr. Chester Brown III)
Applicant's Mailing Address: 1007 Battleground Avenue, 4th floor, Greensboro, NC 27408
Applicant's Email Address (if available): chetbrownbipinc.com
Contact Person (if different than Applicant): Ron Navarro
Contact Person's Mailing Address: 5260 Greens Dairy Rd, Raleigh, NC 27616
Telephone: [phone]
Telephone: [phone]
Contact Person's Email Address (if available): RNavarro(a,,ecslimited.com
6. Property Owner (if different than Applicant): Davenport Energy, Inc. (Mr. Harold E. Thornton Jr) Telephone: [phone]
Property Owner's Mailing Address: PO Box 879, Chatham, VA 24531
Property Owner's Email Address (if available): N/A
7. Property Physical Address (Including PIN Number) 1013 Battleground Avenue
City Greensboro County Guilford Zip Code 27408
8. Reason for Well(s): Phase II Environmental Site 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: Vacant (former gas station and auto garage)
(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: Petroleum hydrocarbons (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): On -site source
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 5. - How will the well(s) be secured? Capped and locked
material: 4
3. Number of wells to be constructed in bedrock: 6. Estimated beginning construction date: February 2023
4. Total Number of wells to be constructed:4 7. Estimated construction completion date: February 2023
(add answers from 2 and 3)
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,
Cherter 6rowb.rfepter 2C) and accepts full responsibility for compliance with these rules
Manager
Signature of Applicant or *Agent Title of Applicant fl
Chester Brown III
Appficant or•'*Agent
* If signing as Agent, attach authorization agreement stating Printed name of
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-Salem Regional Office
450 W. H
Suite 30

Legend
O Proposed Groundwater Sampling
Location
0 Proposed Soil Sampling Location
A Proposed Sub -Slab Soil Gas
Sampling Location
Parcel Boundary
N
SOURCE:
ECS PHASE I (August 2022)
2020 IMAGERY
SCALE SHOWN ABOVE
FIGURE 1
PROPOSED SAMPLE LOCATION MAP
1013 Battleground Avenue
Greensboro, North Carolina 27408
ECS Proposal Number: 49:33815P

ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:33815P
Scope of Work: Proposal for Environmental Assessment Services
Project: Battleground Avenue Site
Location: 1013 Battleground Avenue, Greensboro, North Carolina
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 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): Pc v op fir) l2 Y? f 1/ .1 f C .
Property Owner Telephone (please print): 4113 '7 O - qj IJ
Property Owner Signature.
Date: 2

GEOPROBE° SCREEN POINT 15 GROUNDWATER SAMPLER
STANDARD OPERATOK PROCEDURI
hemicslerRetis Kb. MK.3111
PAFPARM October 995
REVISED: N,.br 20.111
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GEOPRODE4' SCREEN POINT 15 GROUNDWATER SAMPLER