WM0701334_Revised Application_20241023

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: 10/23/2024
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 III, LLC—Mr. Nick Carroll Telephone: [phone]
Applicant's Mailing Address: 801 East Boulevard, Charlotte, NC 28203
Applicant's Email Address(if available): ncarroll(a-)csere.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): 6garrick(cecslimited.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): [e-mail]
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)? Yes
If yes, give distance(s): Approximately 400 feet
DWR-WaRO Received 10/23/2024
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
C. Screen intervals g. Well head completion details
d. Sand/gravel pack intervals
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