WM0401479_Application_20230906

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: 09/01 /2023
2. County: Stokes
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant: NCDEQ Telephone: [phone]
Applicant's Mailing Address: 1646 Mail Service Center, Raleigh, NC 27699
Applicant's Email Address (if available): scott.ryalsa-ncdenr.gov
5. Contact Person (if different than Applicant): Greg Hans Telephone: [phone]
Contact Person's Mailing Address: 3525 Whitehall Park Drive, Suite 150, Charlotte, NC 28273
Contact Person's Email Address (if available): ghans(a)ces-group. net
6. Property Owner (if different than Applicant): Ghamdan Salim Telephone: [phone]
Property Owner's Mailing Address: 100 E Murphy Street, Madison, NC 27025
Property Owner's Email Address (if available): gsalim2000a_yahoo.com
7. Property Physical Address (Including PIN Number) 1107 N Main Stret PIN 6963444932
City Walnut Cove County Stokes Zip Code 27052
8. Reason for Well(s): 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: USTs
(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 known
11. Type of contaminants being monitored or recovered: petroleum / organics / metals
(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).: N/A
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Presumed Source Area — 0 Feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No known
If yes, give distance(s):
15. Well Contractor: Carolina Soil Investigation Certification No.: Corey Speece #2904 / Daniel
Summers #2579
Well Contractor Address: 132 Gurney Road, Olin, NC 28660
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
material: 3
3. Number of wells to be constructed in bedrock: 0
5. How will the well(s) be secured? 2 x 2 pad, well
covers, locking i-pluq
6. Estimated beginning construction date: 9/18/2023 or
later
4. Total Number of wells to be constructed: 3
(add answers from 2 and 3) 7. Estimated construction completion date: Same day as
install
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. 143-215.1013(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
A��iaAw_
Signature of Applicant or "Agent
Greg Hans
Printed name of Applicant or "Agent
Environmental Division Manager
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
well(s) as outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
(See attached Access Agreement with NCDEQ State Trust Fund)
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 Raleigh Regional Office Wilmington Regional Office
2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension
Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 28405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [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]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
✓-22M/R (Rev. 5-26-2022)

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ANNULUS

ROY COOPER
Governor
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t;a
Waste Management
ENVIRONMENTAL QUALITY
January 9, 2023
Mr. Scott Ryals
Environmental Engineer
DWM UST Section
1637 Mail Service Center
Raleigh, NC 27699-1637
RE: State -Lead Acceptance
Bullins Grocery
1107 N Main St
Walnut Cove, Stokes County, NC
Incident Number 13353
ELIZABETH BISER
Secretary
MICHAEL SCOTT
Director
Dear Mr. Ryals
e are the owners) of a parcel of property, located at or near the incident in question, and
I am/W (Department) or its contractor to enter upon said
hereby permit the Department of Environmental Quality (Dep ) diation of the groundwater and/or soils
property for the purpose of conducting an assessment and/or reme
under the authority of G.S. 143-215.94G.
I am/We/We are granting permission ermission with the understanding that:
investi ation shall be conducted by the UST Section of the Department's Division of Waste
1. The g
Management or its contractor. l be borne by the Department or
The
2. The costs of construction and maintenance ftancetof the cs tesin of the State- lead Pry a aces
its contractor in accordance wit recent damage o the surrounding land- y
Department or its contractor shall protect and p
restored by the Department or its contractor to as close to the pre -work condition as practicably
will be
possible.
ccess to the
Unless otherwise agreed, the Department or its contrDepartment
cent shall have tractor will notilte by the shortest
fy the landowners
3.
feasible route to the nearest public road. The Departm
hours prior to entry and may enter upon the land at reasonable times and have full right of access
48 p
during the period of the investigation.
Tort Claims Against State Departments and
4, Any claims Statutes, T
which may arise against the Department, or itscontractorshall be governed by Article 3
of Chapter 143 of the North Carolina General
Agencies, and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon request and
is a public record, in accordance with G.S. 132-1.
othing Compares_ -_•.._-
State of North Carolina I Environmental Quality 1 Waste Management
1646 Mail Service Center 1 217W9 West
8200 Street ! Raleigh NC 27699-1646
9

6. The activities to be carried out by the De
ts
Department and of the State of North Carolina. enAny t or icontractr are benefits accruing tortthe Prima
rhe ma are inci
ary benefit of the
The Department or its contractor is not and shall not be construed to be an agent, employee orntal.
contractor of the landowner. No representations or warranties, either expressed or implied, have been
made to me/by the Department, the State of North Carolina, or its/their contractor(s) regardin the
results that may be obtained or the quality of work to be performed
g
I/We agree not to interfere with, remove or any ways damage the Department's wel
contractor's Well(s) and equipment during the investigation. ls) or its
Sincerely,
Signature
Type/Print Name of owner or gent
29 C-180 -SO4.0_ Phone Number / E-mail Address
Sa-
Address
N C 2-�162-5"
City/State/Zip Code
Date ~
RE: State -Lead Acceptance
Bullins Grocery
1107 N Main St
Walnut Cove, Stokes County, NC
Incident Number 13353
%'Nothing Compares:-,
State North Carolina
1646 Maill Service 1 Environmental Quality, I Waste Management
ervice Center 217 West Jones Sheet I Raleigh, NC 27699-1646
919 707 8200 T