WM0401456_Monitoring Well Permit Application_20230614

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
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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: June 2. 2023
County: Guilford
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring (temporary)
Applicant: City of Burlington (Todd Lambert) Telephone: [phone]
Applicant's Mailing Address: PO Box 1358, Burlington. INC 27216
Applicant's Email Address (if available): tiambert burlin tonnc. ov
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): [e-mail]
Property Owner (if different than Applicant): Rock Creek Investments LLC (Mr. Taylor Williams]
Telephone: [phone]
Property Owner's Mailing Address: 331 High Street, Winston-Salem, NC 27101
Property Owner's Email Address (if available): [e-mail]
Property Physical Address (Including PIN Number) 6509 ZZ Franz Warner Parkway (PIN 8823591546)
City Whitsett County Guilford Zip Code 27377
Reason for Well(s): Phase II Environmental Site Assessment
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
Type of facility or site for which the well(s) is(are) needed: Vacant parcel
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
Are there any current water quality permits or incidents associated with this facility or site? If so, list permit and/or incident no(s).
11. Type of contaminants being monitored or recovered: Petroleum hydrocarbons, chlorinated solvents, and PFAS (ex: organics,
nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many?
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approx. 300 ft
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: 3D Environmental Investigations LLC Certification No.: 3162-A
Well Contractor Address: 2157 Mocksville Hwy, Statesville, NC 28625
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
3. Number of wells to be constructed in bedrock: -_
How will the well(s) be secured? Capped and locked
Estimated beginning construction date: June 16, 2023
4. Total Number of wells to be constructed:4 7, Estimated construction completion date: June 16, 2023
(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 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,
Subchapter 2C) and accepts full responsibility for compliance with these rules
�. City Engineer _
Signature of Applicant or `Agent Title of Applicant or *Agent
City of Burlington
Printed name 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).
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]
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, INC 28405
Phone: [phone]
Fax: (910 35 ZOWr4-r ton•Solr:n
Winston Salem,Rggioiial Offil
450 Vi - Harms- Mill- Rood ,
Fax: [phone] j- J , ` i I —
Raleigh Regional Office 4 F °�'"�I' `
3800 Barrett Drive
Raleigh, NC 27609 w 1 ,. Syron
GW-22M (Rev. 5/11)
GW-22MR Rev. 3-1-2016

ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:38009P
Scope of Work: Proposal for Environmental Assessment
Project: Rock Creek Property
Location: 6594 Judge Adams Road, 6509 ZZ Franz Warner Parkway, and 6900 ZZ Konica
Drive, Whitsett, Guilford County, North Carolina (PINS 8823788628,
8823591546,and 8824605910)
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.
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); (&3C
Property Owner Telephone (please print):
Property Owner E-mail (please print):
Property Owner Mailing Address (please print): 531
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Property Owner Signature: C:4 / Date: Z

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I71ECS Proposal Number: 49:38009P

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Proposed Groundwater Sample Location (VOCs,
SVOCs, and PFAS)
Proposed Groundwater Sample Location
(PFAS only, if requested)
Parcel Boundary
FIGURE 2
Proposed Sample Location Map
Rock Creek Property
6594 Judge Adams Road, 6509 ZZ Franz Warner
Parkway, and 6900 ZZ Konica Drive
Whitsett, Guilford County, NC
ECS Proposal Number: 49:38009P

GROUND MONITORING WELL COVER
NOT TO SCALE
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PROPOSED
MONITORING WELL CONSTRUCTION
6509 ZZ Franz Warner Parkway
Whitsett, Guilford County, NC
ECS Project number: 20189-A