WM0401536_Monitoring well permit application WM0401536_20240531

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: 05/29/24
2. County: Forsyth PERMIT NO. ISSUED DATE
3. What type of well are you applying for?(monitoring or recovery): Monitoring
4, Applicant: Infill Delicate Telephone: [phone]
Applicant's Mailing Address: P.O. Box 21674, Winston-Salem, NC 27120
Applicant's Email Address (if available): brice(cDinfilldelicate.com
5. Contact Person (if different than Applicant): Randy H. Cavallier Telephone: 1'336) 362-5692
Contact Person's Mailing Address: 4811 Koper Blvd, Greensboro, NC 27407
Contact Person's Email Address (if available): rcavallier(a)ecslimited.com
5. Property Owner(if different than Applicant): Moaath Saadeldin Eide Telephone:
Property Owner's Mailing Address: 3023 Kernersville Road. Winston-Salem, NC 27103
Property Owner's Email Address(if available): aiQihomes7726047 ahoo.com
7. Property Physical Address (Including PIN Number) 3023 Kernersville Road (PIN)6854-19-9250
City Winston-Salem County Forsyth Zip Code 27107
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: Commercial
(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: organics (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) Unknown
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: 3D Environmental Investigations LLC _ Certification No.: 3162-A
Well Contractor Address: 2157 Mocksville Highway 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 i. Grout horizons
r 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 5. How will the well(s) be secured? Abandon after sample
3 Number of wells to be constructed in bedrock: 0 6 Estimated beginning construction date: 6/6/24
4 Total Number of wells to be constructed: 3 7. Estimated construction completion date: _ 6H24
(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
ly' Project Manager
Sig o Applicant or gent Title of Applicant or*Agent
Randy H. Cavallier as Agent *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
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).
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 3800 Barrett Drive Wilmington, NC 28405
2090 U.S. Highway 70 Raleigh, NC 27609 Phone: [phone]
Swannanoa, NC 28778 Phone: [phone] Fax: [phone]
Phone: [phone] Fax: [phone]
Fax: [phone] Winston-Salem Regional Office
Washington Regional Office 450 W. Hanes Mill Road
Fayetteville Regional Office 943 Washington Square Mall Suite 300
225 Green Street, Suite 714 Washington, NC 27889 Winston-Salem, NC 27105
Fayetteville, NC 28301-5094 Phone: [phone] Phone: [phone]
Phone: [phone] Fax: [phone] Fax: [phone]
Fax: [phone]
Mooresville Regional Office I
610 East Center Avenue win �'
Mooresville, NC 28115 �r
Phone: [phone] `
Fax: [phone]
f'WI nglon
GW-22MR Rev.3-1-2016
Wilmington Regional Office GW-22M(Rev.5/11)
Raleigh Regional Office 127 Cardinal Drive Extension

dotloop signature verification:dtlp.us/LsHv-fjoq-Gb04
Infill Delicate • • ECS Southeast, LLC
•-
NORTH CAROLINA WELL PERMIT AUTHORIZATION FORM
ECS Southeast, LLC
Proposal No.: 49:44279P
Project Name: Former Auto Sales Lot
Location: 3023 Kernersville Road
Winston-Salem, Forsyth County, North Carolina 27107
ECS Southeast, LLC (ECS) has been requested by the purchaser 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 and obtain the required NCDEQ
permit.
Property Owner(Please Print) oaath Eide
docoo e3 05/28/2024Property Owner Signature O/2p4 1 QQFQ-CQ7E-VWSV-NMUA
Page 8

Randy H. Cavallier
From: Brice Shearburn <[e-mail]>
Sent: Wednesday, May 29, 2024 11:17 AM
To: Randy H. Cavallier
Cc: Scott Young, P.G.; Myranda Durham; Brice Shearburn
Subject: [EXTERNAL] RE: Well Permit Application 3023 Kernersville Road Site
Randy
Good day and thanks
authorize you and ECS to sign as Agent
Let me know if you need anything else—don't see any permit application requirements.
Best
Brice
E. Brice Shearburn
Infill Delicate LLC
PO Box 21674
Winston Salem, North Carolina
27120
Mobile: [phone]
E Mail: [e-mail]
From: Randy H. Cavallier<[e-mail]>
Sent: Wednesday, May 29, 2024 11:10 AM
To: Brice Shearburn <[e-mail]>
Cc: Scott Young, P.G. <[e-mail]>
Subject:Well Permit Application 3023 Kernersville Road Site
Brice,
To expedite the well permit application, please respond to this email authorizing me as Agent to sign as the Applicant for the well permit
(see permit application requirement below).
Thanks
Randy
Randy H. Cavallier as Agent
If signing as Agent, attach authorization agreement stating that you have the authority to act as the Agent.
1

RANDY H. CAVALLIER I [e-mail]
Assistant Staff Project Manager
T 336.856.7150 D 336.748.1612 C 336.362.5692
E� I ECS SOUTHEAST, LLC
COAST COAST 4811 Koger Boulevard, Greensboro, NC 27407
IM C3 10
Confidential/proprietary message/attachments.Delete message/attachments if not intended recipient.
2

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6854-19T8338.000
6854-19-8335.000
M� �.
6.8_'5t-1'9-8332.000 -
6854-19-8239.000
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United Health Center
'Proposed Locatio
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A.
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RSVILLE RD
0 0.01 0.01 0.03 mi
0 0.01 0.02 0.04 km
LEGEND
APPROXIMATE SITE BOUNDARY
• w—E ,
APPROXIMATE GROUNDWATER SAMPLE LOCATION
u
FIGURE 2
SOURCE: PROPOSED SAMPLE LOCATION
FORSYTH COUNTY GIS WEBSITE
ACCESSED MAY 14, 2024 FORMER AUTO SALES LOT
3023 KERNERSVILLE ROAD
SCALE: WINSTON-SALEM, NORTH CAROLINA
AS SHOWN
Tm ECS PROPOSAL NO.49:44279P, Rev 1.0

3023 Kernersville Road, Win X Q
— Sc
Jay'S s for 3023 Ke. . . p
Accel Incident #
Discount Tire 447454 Jay's Mart
Incident # f Incident #
44612 ❑ S' `' 44612
ar Gen.
W ndy'
anvil
-_� R stau ant
Wn gt le aes r -
Five Points -tti }gyp
Walgree Texaco
Incident #
-~ 44657
500 ft
Radius
Former Auto f
Sales Lot
r
L-:±L500ft t_
. :0 Degrees
-Q ..- ^ -nunity Maps Contribui
N
SOURCE: � £ POTENTIAL SOURCE MAP
s FORMER AUTO SALES
NCDEQ Site Locator Tool 3023 KERNERSVILLE ROAD
WINSTON SALEM, FORSYTH COUNTY, NC
ECS PROJECT NO. 49-22975-A
TM

TEMPORARY MONITORING WELL CONSTRUCTION DIAGRAM
Locking cap Project Former Auto Sales Lot
1 ft.Casing Above Ground Owner
Well No. TW
GROUND SURFACE Location Winston Salem
MD Coordinators
State Permit No.
3 inch diameter Topography Setting
drilled hole Ground Elevation
Drilled By 3D Environmental Investigation
Well casing, Proposed Start 6/7/2024
1 inch diameter, Proposed End 6/8/2024
Method of Drilling Direct Push
Type of Rig Geoprobe
Open
MONITORING WELL DATA
21 ft
Bentonite Well No. TW
Hole Diameter 3 inches
23 ft Hole Depth Estimated 40.5 feet
Casing Diameter 1 inch
Casing Length 25 feet
Screen Diameter 1 inch
Screen Slot 0.01
25 ft Screen Type
Surface Elevation
Screen Top El.
Well Screen, Screen Bottom El.
1 inch diamter Well Status
0.01 slot
o Sand Pack REMARKS
40 ft.
40.5 ft.
All Measuring Points are from the Ground
Surface Unless Otherwise Noted.
Temporary Monitoring Well Diagram 3D 1 in 40 WS