WM0701230_Signed Application Form_20200702

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: 6/ 19/2020
2. County: Craven
FOR OFFICE USE ONLY
PERMIT NO. _ ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): _ ___Monitoring; _
4. Applicant: McDonald's Corporation
PP Telephone: [phone]
Applicant's Mailing Address: 110 N. Carpenter Street. Chicago. IL 60607
Applicant's Email Address (if available): _ leo.vanbuurengE us.mcd.com Contact: Leo VanBuuren
5. Contact Person (if different than Applicant): Amy DeSaix Telephone: [phone]
Contact Person's Mailing Address: 6714 Netherlands Drive. Wilmington- NC 28405
Contact Person's Email Address (if available): ADeSaixCa ecslimited.com
6. Property Owner (if different than Applicant), .iasher Investments. LLC Telephone:
Property Owner's Mailing Address: 702 New Bridge Street. Jacksonville, NC 28540
Property Owner's Email Address (if available): Dopkinbeagmail.com
7. Property Physical Address (Including PIN Number) 710 Dgjraffenreid Road — PINS 8-023-004-8 and 8-023-0_.89
City New Bern County Craven Zip Code 28560
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 Industrial/Commercial
(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).
11. Type of contaminants being monitored or recovered: VOCs & SVOCs
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Unknown
Existing Monitoring or Recovery Well Construction Permit No(s).: _ Unknown
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): N/A
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: TBD Certification No.: TBD
Well Contractor Address: TBD
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? Temporary
material: 3 Sampling Point —Abandoned same dam
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: TBD
4. Total Number of wells to be constructed: 3 7. Estimated construction completion date: TBD
(add answers from 2 and 3)
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.
-- - L ---- 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,
Subchapter 2C) and accepts full responsibility for compliance with these rules
Signat6re of Applicant or *Agent Title of Applicant or *Agent
:3- fit', „ tie l�ltar?�ti 4 * if signing as Agent attach authorization agreement stating
Printed name of Applicant or *Agent �e,?O�a l llbs } 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
wel he Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
Signa re o rty ti 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
3800 Barrett Drive
Wilmington, NC 28405
2090 U.S. Highway 70
Raleigh, NC 27609
Phone: [phone]
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Winston-Salem Regional Office
Washington Regional Office
450 W. Hanes Mill Road
Fayetteville Regional Office
943 Washington Square Mall
Suite 300
225 Green Street, Suite 714
Washington, NC 27889
Winston-Salem, NC 27105
Fayetteville, NC 28301-5094
Phone: [phone]
Phone: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
AR Rev. 3�-1-2016
Raleigh Regional Office
GW-22M (Rev. &11)