WM0401513_WM0401513 permit application part 1_Winston Weaver_20240223

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: 2/20/24
2. County: Forsyth PERMIT NO. ISSUED DATE
3. What type of well are you applying for?(monitoring or recovery): Monitoring
4. Applicant: Mike Spence Telephone: [phone]
Applicant's Mailing Address: 9174 Hickory Hill Road,Ashland,VA 23005
Applicant's Email Address(if available): mspence(a)mfifert.com
5. Contact Person (if different than Applicant): Craig Petko Telephone: [phone]
Contact Person's Mailing Address: 1140 Valley forge Road, Phoenixville, PA 19460
Contact Person's Email Address(if available): cpetko(a).montrose-env.com
6. Property Owner(if different than Applicant): Douglas Wiggins Telephone: [phone]
Property Owner's Mailing Address: 8080 North Point Boulevard,Winston-Salem, NC 27106
Property Owner's Email Address(if available): douglas.wiggins(cDwestrock.com
7. Property Physical Address(Including PIN Number) 8080 North Point Boulevard (PIN 6827-55-8478.000)
City Winston-Salem County Forsyth Zip Code 27106
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: Non-discharge Facility
(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).
NPDES Permit No. NCS000555
11. Type of contaminants being monitored or recovered: Heavy Metals, Organics, Nutrients
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes, 12 MWs
Existing Monitoring or Recovery Well Construction Permit No(s).: NA—On Property Owned by Well Owner
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): NA
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Geologic Exploration Certification No.: 2580-A
Well Contractor Address: 176 Commerce Blvd, 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 5. How will the well(s)be secured? Lockable Flush
material: 5 Mount well pad
3. Number of wells to be constructed in bedrock: 2 6. Estimated beginning construction date: 2/26/24
4. Total Number of wells to be constructed: 7 7. Estimated construction completion date: 3/1/24
(add answers from 2 and 3)
ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C.0105(0(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.
Project Geologist
Signature of Applicant or*Agent Title of Applicant or*Agent
Craig E.Petko '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 ownep by someone other than the Applicant,the property owner hereby consents to allow the Applicant to construct
re, s)as outlined finis eII onstruction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensur That e w I §) ill be located,constructed,maintained,and abandoned in accordance with 15A NCAC 02C.
Douglas Wiggins
i�n�f, opertj Ow r(if 67! r than Applicant) Printed name of Property Owner(if different than Applicant)
1 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: (919)791 A200 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
610 East Center Avenue win ton Solo Z�
Mooresville,NC 28115 of 9
Phone: [phone] '�y� o in oo
Fax: [phone] �3��.J
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Wil ngton
GW-221WR(Rev.5-26-2022)

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BEDROCK BOREHOLE OF 10 FEET INTO BEDROCK
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ESTIMATED TO BE 100 FEET
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LEGEND
SITE BOUNDARY (4440 N CHERRY ST)
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