WM0401275_Monitoring Well Permit Application_20210129

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCIA 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: 1/19/2020
2. County: Alamance
PERMIT NO.
FOR OFFICE USE ONLY
ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery)
1
4. Applicant: Clachan Properties — Ms. Lindsay A. Lewis Telephone: [phone]
Temporary Monitoring Well
Applicant's Mailing Address: 110 South 151" Street, Suite A Richmond, Virginia 23219
Applicant's Email Address (if available): lindsav onclachanproperties.com
5. Contact Person (if different than Applicant): ECS Southeast LLP — Mr. Colby Jones Telephone: [phone]
Contact Person's Mailing Address: 5260 Greens Dairy Road. Raleigh, North Carolina 27617
Contact Person's Email Address (if available): ciones6(a�ecslimited.com
6. Property Owner (if different than Applicant): Pickett Hosiery Mill Inc. Telephone:
Property Owner's Mailing Address: PO Box 877. Burlington, North Carolina 27216
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 741 East Webb Avenue — PIN 887500783
City Burlington County Alamance Zip Code 27217
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 UST On/Off-Site Groundwater Impacts
(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).
Unknown
11. Type of contaminants being monitored or recovered: Cr-VI and Total Chromium
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes (1)
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401261
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 100 feet Southeast
14. 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: 3D Environmental Investigations Certification No.: 3162-A
Well Contractor Address: 2157 Mocksville Hwy, Statesville. NC
PROPOSED WELL CONSTRUCTION INFORMATION
1. As required by 15A NCAC 02C .0105(0(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 R. 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: 2
5. How will the well(s) be secured? Not Applicable —
temporary monitoring wells to be abandoned upon completion
3. Number of wells to be constructed in bedrock: Zero (0) 6. Estimated beginning construction date: 2/1/21
4. Total Number of wells to be constructed: 2 7. Estimated construction completion date: 2/1/21
(add answers from 2 and 3)
1.
ADDITIONAL INFORMATION
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. 143-215.1OB(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant hereby agrees It proposed well(s) will be constructed in accordance with approved specifications and conditions of
this Well Construct* Per regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
7.� Subchapter 2C) and accepts full responsibility for compliance with rules
Signature of Applicants o g t Title of Applicant or `Agent
If signing as Agent, attach authorization agreement stating
Printed name of Applicant or *Agent 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
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [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]
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
yet, villa
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

1,;(11iIlfl:/1.`;I, I.II'
PROPERTY OWNER ACCESS AUTHORIZATION
ECS SOUTHEAST, LLP
Project Name: Pick. tt Hosiery Mill — Environmental Assessment Services
Location: 741 ast Webb Avenue, Burlington, Alamance County, North Carolina
ECS Southeast, LLP ('CS) has been requested to conduct subsurface groundwater sampling at t le site. The
groundwater sampli g at the site requires that ECS procure a permit from the North Carolina Iepartment
of Environmental Qr ality (NCDEQ).
ECS respectfully req ests that the owner of the property grant permission to ECS to access ti e property
to conduct the grou )dwater sampling. By signing below, property owner authorizes ECS to conduct the
aforementioned gro rndwater sampling at the site and to obtain the above -referenced perm t on behalf
of the owner.
Property Owner (please print):
Property Owner Sig attire:
ECS Proposal Number /19:21838
Page 1 9
//Ze-it 5(04-zei
Date:
oai

SOURCE:
USGS TOPOGRAPHIC MAPS
BURLINGTON QUADRANGLE 2013
SCALE SHOWN ABOVE
FIGURE 1
TOPOGRAPHIC LOCATION MAP
741 East Webb Avenue
Burlington, Alamance County, North Carolina
ECS Project Number: 49-12466-B
TM

PROPOSED GROUNDWATER SAMPLING POINT
SOURCE:
GOOGLE EARTH
IMAGERY DATED 2019
FIGURE 2
PROPOSED TEMPORARY MONITORING WELL
LOCATION MAP
741 East Webb Avenue
Burlington, Alamance County, North Carolina

LEGEND
— Inactive Hazardous Sites • UST Active Facilities I Parcels (Polygons) - Parcels
DryCleaning Land Use Restriction andfor Notices County Boundary
City Directory Notice
9 Notice and Restriction
UST Incidents
SOURCE:
NCDEQ-DWM SITE LOCATION TOOL
IMAGERY DATED 2020
APPROXIMATE SCALE:
4-0 270 FT.
FIGURE 3
CONTAMINATION SOURCE LOCATION MAP
741 East Webb Avenue
Burlington, Alamance County, North Carolina
ECS Project Number: 49-12466-B

GROUND
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
.,... . ".`
SURFACE
25 FEET
n
NATURAL FORMATION
BACKFILL
GROUNDWATER
1.5-INCH STEEL DIRE
PUSH RISER
2--INCH BORE
HOLE
SLOTTED STEEL S
0.01-INCH SLOT W
SET TO INTERSECT GROI
ESTIMATED 10 FEET IP
V
WELL CONSTRUCTION DIAGRAM IS R
OF DIRECT PUSH SCREEN POINT S
TEMPORARY 2-INCH P\
CT
CREEN
IDTHS
JNDWATER
LENGTH
EPRESENTATIVE
AMPLER OR
/C
NOT TO SCALE
FIGURE 4
PROPOSED TEMPORARY SCREEN POINT SAMPLER
741 East Webb Avenue
Burlington, Alamance County, North Carolina
ECS Project Number: 49-12466-B
TM