WM0701334_Application_20241015

Docusign Envelope ID:7A9A6625-05_FA-4918 8F4F-F62875E9FC9D —A 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: 10/4/2024
2. County: Lenoir PERMIT NO. WM0701334 ISSUED DATE 10/25/2024
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: ._ C4 CStore Holdings V, LLC—Mr. Nick Carroll Telephone: [phone]
Applicant's Mailing Address: _ 801 East Boulevard, Charlotte, NC 28203
Applicant's Email Address (if available): ncarroliacsere.com
5. Contact Person (if different than Applicant): Jonathan Garrick Telephone: [phone]
Contact Person's Mailing Address: _1812.Center Park Drive, Suite D Charlotte, NC 28217
Contact Person's Email Address (if available): arrick ecslimited.com
6. Property Owner(if different than Applicant): Austin. Betty, and Zachary_Apperson Telephone: Not Available
Property Owner's Mailing Address: PO Box 625, La Grange, NC 28551
Property Owner's Email Address(if available); Not Available
7. Property Physical Address(Including PIN Number): 3141 Willie Measley Road, La Grange, Lenoir County, NC(PINs 17288,
17289,and 14986)
8. Reason for Well(s): Environmental Assessment
9. Type of facility or site for which the well(s)is(are)needed: former clothing manufacturer and fueling station
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).
Not Applicable
11. Type of contaminants being monitored or recovered: VOCs. SVOCs, EPH,VPH, PFAS (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).: Not Applicable
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): Northwest portion of property(10 ft)(UST
Incident 5354)
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes,give distance(s): Not Applicable
15. Well Contractor: Quantex Certification No.: 3106
Well Contractor Address; 280 W Haywood Street,Wendell, NC 27591
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
a Screen intervals g. Well head completion details
d. Sand/gravel pack intervals
Continued on Reverse

Docusign Envelope ID:7A9A6625-05FA-4918-8F4F-F62875E9FC9D
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s)be secured? Expandable lockable
material: 6 caps for temporary wells
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: October 2024
4. Total Number of wells to be constructed: 6 7. Estimated construction completion date: October
(add answers from 2 and 3) 2024
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,
Sub apter 2C)and accepts full responsibility fo compliance with these rules
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Sign a re of Applicant or*Agent Title of Applicant or*Agent
f / r
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
e41{s' rr,61 form to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
�.ac� Q t,v'saln,
Signa uPHNPP8� 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 - °\
610 East Center Avenue ,�y Win ton Sale
Mooresville, NC 28115 /t al 9
Phone: [phone]
Fax: [phone]
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�'Wei ngron GW-22MR Rev.3-1-2016