WM0401498_Monitoring permit application_20231220

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.
FOR OFFICE USE ONLY
1. Date: 12/18/23
2. County: Forsyth PERMIT NO. ISSUED DATE
3. What type of well are you applying for?(monitoring or recovery): Monitoring
4. Applicant: SEA Development Group, LLC(Mr. Lukas Stauffer) Telephone: [phone]
Applicant's Mailing Address: Polar Park, 100 Madison Street,Worcester, Massachusetts 01608
Applicant's Email Address (if available): Istauffer(a�seadevelopmentgroup.com
5. Contact Person (if different than Applicant): Scott Young Telephone: [phone]
Contact Person's Mailing Address: 1812 Center Park Drive, Suite D, Charlotte North Carolina 28217
Contact Person's Email Address(if available): syoung1(cDecslimited.com
6. Property Owner(if different than Applicant): Brookstown Development Partners, LLCTelephone: 336-331-4012
Property Owner's Mailing Address: 101 N Cherry Street, Suite 501,Winston Salem, North Carolina 27101
Property Owner's Email Address(if available):
7. Property Physical Address(Including PIN Number) 930 West First Street
City Winston Salem County Forsyth Zip Code 27101
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: UST/Automotive Fueling Station
(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).
None
11. Type of contaminants being monitored or recovered: Petroleum
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Unknown
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s)to nearest known waste or pollution source (in feet): —50 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Unknown
If yes, give distance(s):
15. Well Contractor: TBD Certification No.: TBD
Well Contractor Address: TBD
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? Groundwater
material: 6 samples will be collected through Geoprobe rods and will not
require securing.
3. Number of wells to be constructed in bedrock: 0
6. Estimated beginning construction date: TBD
4. Total Number of wells to be constructed: 6
(add answers from 2 and 3) 7. Estimated construction completion date: TBD
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 Ap nt assum, total responsibility for ensuring that the well(s)will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Senior Environmental Project Manager
Signature of App' ant or*A ent Title of Applicant or*Agent
Scott Young *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
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 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 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 Washington Regional Office Winston-Salem Regional Office
225 Green Street, Suite 714 943 Washington Square Mall 450 W. Hanes Mill Road
Fayetteville, NC 28301-5094 Washington, NC 27889 Suite 300
Phone: [phone] Phone: [phone] Winston-Salem, NC 27105
Fax: [phone] Fax: [phone] Phone: [phone]
Fax: [phone]
Mooresville Regional Office Win to Sale
610 East Center Avenue
Mooresville, NC 28115 PLC r d
Phone: [phone]
Fax: [phone] 1 t
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F 'Ile
Wei ngton
GW-22M/R(Rev. 5-26-2022)

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LEGEND
APPROXIMATE SITE BOUNDARY "
• APPROXIMATE PROPOSED GROUNDWATER BORING LOCATION
s
FIGURE 2
SOURCE: PROPOSED SAMPLE LOCATION MAP
FORSYTH COUNTY GIS WEBSITE
ACCESSED DECEMBER 14, 2023 PROPSOED WINSTON-SALEM MIXED USE
DEVELOPMENT
SCALE(feet): 930 W. FIRST ST. &929 BALLAPRK WAY
AS SHOWN WINSTON SALEM, NORTH CAROLINA
ECS PROJECT NO.49:21706-A

GROUND TOP OF ROD ABOVE THE LAND
SURFACE SURFACE
ESTIMATED
-25FEET
1-INCH STEEL ROD
OPEN BOREHOLE
-2-INCH BORE
HOLE
GROUNDWATER
SLOTTED STEEL SCREEN
0.01-INCH SLOT WIDTHS
SET TO INTERSECT GROUNDWATER
ESTIMATED 4 FEET IN LENGTH
WELL CONTRUCTION DIAGRAM IS
REPRESENTATIVE OF INSITU GROUNDWATER
SAMPLING POINT
FIGURE 3
PROPOSED SAMPLE POINT DIAGRAM
PROPSOED WINSTON-SALEM MIXED USE
NOT TO SCALE � �� DEVELOPMENT
930 W. FIRST ST. &929 BALLAPRK WAY
WINSTON SALEM, NORTH CAROLINA
ECS PROJECT NO.49:21706-A
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SEA Development G • • ECS Southeast, LLC
LLC 49:41124P
NORTH CAROLINA WELL PERMIT AUTHORIZATION FORM
ECS Southeast, LLC
Proposal No.: 49:41124P
Project Name: Proposed Winston-Salem Mixed Use Development
Location: 930 West First Street and 929 Ballpark Way,
Winston-Salem, Forsyth County, North Carolina 27101
ECS Southeast, LLP (ECS) has been requested to conduct subsurface groundwater sampling at the
site.The groundwater sampling at the site 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 groundwater sampling. By signing below, the property owner authorizes ECS
to conduct the aforementioned groundwater sampling at the site.
Property Owner(Please Print) B rt r Brookstown Development Partners, LLC
Property Owner Signature
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