WM0401261_Monitoring Well Permit Application_20201109

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: 11/6/2020
2. County: Alamance
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Temporary Monitoring Well
4. Applicant: Clachan Properties —Ms. Lindsay A. Lewis Telephone: [phone]
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Applicant's Mailing Address: 110 South 151h Street, Suite A, Richmond, Virginia 23219
Applicant's Email Address (if available): Iindsay(@clachanproperties.com
Contact Person (if different than Applicant): ECS Southeast, LLP — Mr. Colby Jones Telephone: [phone]
Contact Person's Mailing Address: 9001 Glenwood Avenue, Raleigh, North Carolina 27617
Contact Person's Email Address (if available): ciones6(a)ecslimited.com
Property Owner (if different than Applicant): Pickett Hosiery Mill, Inc. Telephone: [phone]
Property Owner's Mailing Address: PO Box 877, Burlington, North Carolina 27216
Property Owner's Email Address (if available): [e-mail]
Property Physical Address (Including PIN Number) 741 East Webb Avenue — PIN 887500783
City Burlington County Alamance Zip Code 27217
Reason for Well(s): Assessment
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
Type of facility or site for which the well(s) is(are) needed: Former UST, On/Off-Site Groundwater Impacts
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
Are there any current water quality permits or incidents associated with this facility or site? If so, list permit and/or incident no(s).
Unknown
Type of contaminants being monitored or recovered: VOCs, SVOCs, and RCRA-8 Metals
(ex: organics, nutrients, heavy metals, etc.)
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).: N/A
Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 100 feet Southeast
Are there any water supply wells located less than 500 feet from the proposed well(s)? Unknown
If yes, give distance(s):
15. Well Contractor: Quantex Drilling Certification No.: 3106-A
Well Contractor Address: PO Box 1388, Wendell, NC 27591
PROPOSED WELL CONSTRUCTION INFORMATION
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
material: 6
3. Number of wells to be constructed in bedrock: Zero 0
5. How will the well(s) be secured? Not applicable —
temporary wells to be abandoned upon completion
6. Estimated beginning construction date: 9/20/20
4. Total Number of wells to be constructed: 6 7. Estimated construction completion date: 9/20/20
(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.
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
Signature f Applicant or *Agent
Lindsay A. Lewis
Printed name of Applicant or *Agent
Director of Operations
Title of Applicant or *Agent
* 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 it shall be the responsibility of the applicant to ensure that the
well(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
SEE ATTACHED J. Nimrod Harris
Signature of Property 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
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
AR Rev. 3-1-2016

PROPERTY OWNER ACCESS AUTHORIZATION
ECS SOUTHEAST, LLP
Project Name: Pickett Hosiery Mill — Environmental Assessment Services
Location: 741 East Webb Avenue, Burlington, Alamance County, North Carolina
ECS Southeast, LLP (ECS) has been requested to conduct subsurface groundwater sampling at the site. The
groundwater sampling at the site requires that ECS procure a permit from the North Carolina Department
of Environmental Quality (NCDEQ).
ECS respectfully requests that the owner of the property grant permission to ECS to access the property
to conduct the groundwater sampling. By signing below, property owner authorizes ECS to conduct the
aforementioned groundwater sampling at the site and to obtain the above -referenced permit on behalf
of the owner.
Property Owner (please print): p�o/i r'r'r -owe
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Property Owner Signature _ Date:
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FIGURE 1
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SOURCE: TOPOGRAPHIC LOCATION MAP
USGS TOPOGRAPHIC MAPS
BURLINGTON QUADRANGLE 2013 741 East Webb Avenue
Burlington, Alamance County, North Carolina
SCALE SHOWN ABOVE
ECS Proposal Number: 49-21026
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LEGEND
SITE PARCEL BOUNDARY
PROPOSED GROUNDWATER SAMPLING POINTS -
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SOURCE: wF PROPOSED TEMPORARY MONITORING WELL
GOGGLE EARTH 17 LOCATION MAP
IMAGERY DATED 2020 s
N 741 East Webb Avenue
APPROXIMATE SCALE: Burlington, Alamance County, North Carolina
150 FT. ECS Proposal Number: 49-21026
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LEGEND
Inactive Hazardous Sites • UST Active Facilities
DryCleaning Land Use Restriction and/or Notices
0 City Directory Notice
UST Incidents Notice and Restriction
SOURCE:
NCDEQ-DWM SITE LOCATION TOOL
2020
APPROXIMATE SCALE:
270 FT.
Parcels (Polygons) - Parcels
County Boundary
FIGURE 3
CONTAMINATION SOURCE LOCATION MAP
741 East Webb Avenue
Burlington, Alamance County, North Carolina
ECS Proposal Number: 49-21026
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PROPOSED TEMPORARY SCREEN POINT SAMPLER
/I^,1 741 East Webb Avenue
1, I I I Burlington, Alamance County, North Carolina
ECS Proposal Number: 49-21026
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