WM0100449_Application_20190227

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: 212212019
2. County; Hen I o
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (moridaring or recovery): Mgnitorin � _,_ r,
4. Applicant 6questa B nk Telephone: [phone]
Applicant's Mailing Address; 484 fl i mson Road, Mooresville,NC jkjjj
Applicant's Email Address (if available): Sean MoUgak [e-mail]
5. Contact Person (if ditferent than Applicant), James. 2307 8
, S_
Contact Parton's Mailing Address: 1900 l gdersonville Raad,_Suite 10 Ashovilie NC 2$$Q _
Contact Person's Email Address (f available): 'bever ecslimited m
B. Property Owner (f different than Applicant): David Pea ce Telephone; 8287582-1 b7 7
Property Owner's Mailing Address: li i A H nde t C S
Property Owners Email Address (if available): hound malixom
7. Property Physical Address {Including PITS Number) shev'11$ w IN 1-63-015
City HendersonvilleCounty p Cade 28791
a. reason for well($): gssessm nt of sus a cunt min I n of the roundwa er
(ex; non -discharge permit requirements, suspected contamination, assessment, groundwater Contamination, remediation, etc.)
9, Type of facility or site for which the well(s) is(are) needed: fg[mer landfill 4 current scrER metal Wd
(ex: non -discharge facility, waste disposal site, landfill, UST, atc.)
10, Are there any current water quality permits or incidents associated with this facility or site? If to, list permit andfor incident no(s).
11, Type of contaminants being monitored or recovered: _ PCBs, solv4tnT .metals
(ex. organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with The proposed wsll(s)? If yes, how many? No
Existing Monitoring or Recovery Well Construction Permit No(s).: N
13, Distance from proposed well(e) to nearest known waste or pollution source (in feet): 0-50
14, Are tttera any water supply wells located less than 500 feet from the proposed well($)? Yes
If yes, give distance(s): Qn the pro peRv repo edly atsandbned currently uses murij I I water
15, Well Contractor MpuntMln Envi nmental SeNices Certification No.: 4179-B
Well Contractor Address: 1 0 Pisgah, rive Canton NO
FEB 2 7 2019
QuaRy
Wateer Regional ope►alloM
ar .... ,_
ge
Vf FX e$.l'7�M
INZ

PROPOSED WELL CONSTRUCTION INFORMATION
As required by 15A NCAC 02C .0109(f)(7), attach a well construction diagram of each well showing the following:
Borehole and well diameter
Estimated well depth
Screen intervals
Send/gravel pack intervals
Type of casing Material and thickness
Grout horizons
Well head completion details
PROPOSED WELL CONSTRUCTION INFORMATION iContinuedj
Number of wells to be constructed in unconsolidated 5. Mow will the well(R) be secured? Locking
materiel: 5 expansion cap, grq_mnt aband9nrnent
Number of wells to be constructed in bedrock: D
4. Total Number of wells to be constructed' S
(add answers from 2 and 3)
6. Estimated beginning construction date: TBD
Estimated Construction completion date: TBD
(within 96 hours of installation)
ADDITIONAL INFORMATION
As required by I SA NCAC 020 0105(%5), attach a scaled map of the site showing the locatlons of tree 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 600 feet of the proposed well or well system-
b. All existing wells, identified by type of use, within 500 Not of the proposed well or well system,
C. The proposed well or well system.
posed well or well system.
d. Any test borings within 600 feet of pro
C. 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 wall(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 20) and accepts full responsibility for compliance with these rules
Signature of Appli t or *Agent
L9 P] 4r-,J1,
Printed name of Appli or *Agent
SKJ /9 4'C 04 -7
"Title of Applicant or *Agefit
* if signing as Agent, attach authorization agreement stating
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 d shall be the responsibility of the applicant to ensure that the
s} con to tha Well Con inn Standards (Title 15A of the North Carolina Administrative Code, Su�bchapier 2C).
17 1./
Signature of Property Owner (f different than Applicant) Printed name of Property Owner (if different than Applicant)