WM0401546_Application_20240815

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.
1. Date: _ Aug 8,2024
FOR OFFICE USE ONLY
2. County: Forsyth PERMIT NO. ISSUED DATE
3. What type of well are you applying for?(monitoring or recovery): Monitoring
4. Applicant: FN Prestige Worldwide LLC Telephone: [phone]
Applicant's Mailing Address:-iq@@ Beeir9afarttye-6feeesbei e' Ne RF282 p r)8 3tg ;Z86
Applicant's Email Address(if available): tiefever/,Wmissionmobilemed.com
5. Contact Person(if different than Applicant): Tom Taylor, P.G. Telephone: [phone]
Contact Person's Mailing Address: P.O Box 97607 Raleigh NC 27624
Contact Person's Email Address(if available): ttaylor(a-elmsitesolutions.com
6. Property Owner(if different than Applicant): Forsyth Technical Community.College Telephone: [phone]
Property Owner's Mailing Address: 2100 Silas Creek Pkwy,Winston-Salem NC 27103
Property Owner's Email Address(if available): Scott Booth:dbooth0forsythtech edu
7. Property Physical Address(including PIN Number) 1108 Swisher Center Road(6886-90-1142)
C!ty Kernersville CountyForsvth Zip Code 27284
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: Former manufacturing 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).
IHSB No. NONCDO002765
11, Type of contaminants being monitored or recovered: VOCs and metals
(ex: organics, nutrients, heavy metals,etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 4
Existing Monitoring or Recovery Well Construction Permit No(s).: None. all 4 wells are on the owner's property
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): Approx.250 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): N/A
15. Well Contractor: Geologic Exploration Inc Certification No.: NCWC 4121-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? Flush-mount with
material: 2 locking cap
3. Number of wells to be constructed in bedrock: 0 _
4. Total Number of wells to be constructed' 2 6. Estimated beginning construction date. 9-3-24
(add answers from 2 and 3) 7. Estimated construction completion date: 9-6-24
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. 143-215.106(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.
Member/Manager
Sign*reef ppiicant or*Agent Title of Applicant or*Agent
Travis LeFever *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.
08/09/24 Kizzy Lea—Chief Operating Officer
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 - R
610 East Center Avenue Winston-solem
Mooresville, NC 28115 Rc1e;9h
Phone: [phone]
Fax: [phone]
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GW-22M/R(Rev. 5-26-2022)

Drilling Permit - Dudley Products_2024-08-0
Final Audit Report 2024-08-09
Created: 2024-08-09
By: Jeffrey Jordan([e-mail])
Status: Signed
Transaction ID: CBJCHBCAABAAe2bidttYVabwLN-CpL4xrjwNagcOlzXn
"Drilling Permit - Dudley Products_2024-08-08" History
°" Document created by Jeffrey Jordan ([e-mail])
2024-08-09-4:16:12 PM GMT-IP address:72.11.36.133
Document emailed to [e-mail] for signature
2024-08-09-4:16:1 B PM GMT
IF` Email viewed by [e-mail]
2024-08-09-4:49:03 PM GMT-IP address: 104.47.73.254
Signer [e-mail] entered name at signing as Kizzy Lea
2024-08-09-4:50:25 PM GMT-IP address:198.86.118.18
Document e-signed by Kizzy Lea ([e-mail])
Signature Date:2024-08-09-4:50:27 PM GMT-Time Source:server-IP address:198.86.118.18
Agreement completed.
2024-08-09-4:50:27 PM GMT
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