WM0401183_Monitoring Well Permit_20190715

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
Ms. Allyson Sonntag
First Citizens Bank
4300 Six Forks Road
Raleigh, North Carolina 27699
NORTH CAROLINA
Environmental Quality
July 15, 2019
SUBJECT: MONITORING WELL CONSTRUCTION
PERMIT NO.
COUNTY:
FILE NAME:
Dear Ms. Sonntag:
WM0401183
Forsyth
Dominos 4890 Country Club Road
In accordance with your application received on July 15, 2019, we are forwarding herewith:
Monitoring Well Construction Permit No. WM0401183 for the construction of three (3)
temporary monitoring wells at 4890 Country Club Road in Winston-Salem in Forsyth
County.
Henceforth, correspondence and data relating to this well shall be designated as specified in the
subject heading above. This Permit will be effective from the date of issuance and shall be
subject to the conditions and limitations as specified therein. If you have any questions regarding
this permit, please contact me or Jim Gonsiewski at [phone].
Sincerely,
I/I DocuSiTgned<by:
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Lon . nlder
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
cc: WQROS — Groundwater Protection Unit, 1636 Mail Service Center, Raleigh, NC 27699
Graham T. Mullikin — Coffee Investments, LLC
Scott Werley - ECS
WSRO Files
D North Carolina Department of Environmental Quality I Division of Water Resources
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Winston-Salem Regional Office 1 450 West Hanes Mill Road, Suite 300 I Winston-Salem, North Carolina 27105
NORTH CAROLINA �
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES — WATER QUALITY REGIONAL OPERATIONS
SECTION
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and
other applicable Laws, Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
First Citizens Bank
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of three (3)
temporary monitoring wells owned by First Citizens Bank. The wells will be located at 4890
Country Club Road in Winston-Salem, North Carolina, in Forsyth County. This Permit is issued
in accordance with the application received on July 15, 2019, in conformity with specifications
and supporting data, all of which are filed with the Department of Environmental Quality and are
considered integral parts of this Permit.
This Permit is for well construction only, and does not waive any provision or requirement of
any other applicable law or regulation. Construction of any well under this Permit shall be in
strict compliance with the North Carolina Well Construction Regulations and Standards (15A
NCAC 02C .0100), and other State and Local Laws and regulations pertaining to well
construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to
an adjudicatory hearing upon written request within 30 days of receipt of this Permit. The
request must be in the form of a written petition conforming to Chapter 150B of the North
Carolina General Statutes and filed with the Office of Administrative Hearings, 6714 Mail
Service Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit
is final and binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to
other specified conditions, limitations, or exceptions as follows:

1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these
wells are being installed as part of an investigation for contamination from an
underground storage tank or dry cleaner incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement
issued by another agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as
part of the Permit application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A
NCAC 02C .0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of
Water Resources' Information Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with
15A NCAC 02C .0113 and a well abandonment record (GW-30) shall be submitted to the
Division of Water Resources' Information Processing Unit within 30 days of the well
abandonment.
7. The County Health Department may require a county monitoring well construction
permit. Please contact the health department for their requirements.
Permit issued the 15th day of July, 2019
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
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Docu Siiggned by:
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Lon T. Snider, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
By Authority of the Environmental Management Commission
Permit No. # WM0401183