WM0100489_WM0100489 Monitoring Well Construction Application_20210422

FOR OFFICE USE ONLY

PERMIT NO. ISSUED DATE
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: April 21, 2021

2. County: Madison

3. What type of well are you applying for? (monitoring or recovery): temporary monitoring

4. Applicant: Bunnell-Lammons Engineering Telephone: [phone]

Applicant’s Mailing Address: 6004 Ponders Ct., Greenville, SC 29607

Applicant’s Email Address (if available): [e-mail]

5. Contact Person (if different than Applicant): Same Telephone: Same

Contact Person’s Mailing Address: Same

Contact Person’s Email Address (if available): Same

6. Property Owner (if different than Applicant): ROBINSON, KIM & SHERRY MAMA'S KITCHEN Telephone:

Property Owner’s Mailing Address: 7529 HWY 25-70, MARSHALL NC 28753

Property Owner’s Email Address (if available):

7. Property Physical Address (Including PIN Number) 7607 U.S. 25, Marshall, NC 2875, PIN 9707231350
City Marshall County Madison Zip Code 28645
8. Reason for Well(s): Assessment (Real estate due diligence)
(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: Undeveloped
(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).

None known

11. Type of contaminants being monitored or recovered: Benzene, toluene, ethylbenzene, xylenes (BTEX) naphthalene and MTBE
via Environmental Protection Agency (EPA) Method 8260__ex: organics, nutrients, heavy metals, etc.)

12. Are there any existing wells associated with the proposed well(s)? If yes, how many? N/A

Existing Monitoring or Recovery Well Construction Permit No(s).: N/A

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)? None known

If yes, give distance(s):

15. Well Contractor: VERCO Certification No.: 3379

Well Contractor Address: 2047 Industrial Blvd, Lexington, SC 29072

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
material: 4
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed:
(add answers from 2 and 3)
4
5. How will the well(s) be secured? 0
6. Estimated beginning construction date: 5/6/2021
7. Estimated construction completion date: 5/6/2021
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. 143-215.10B(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 of Applicant or *Agent
Robert T. Hawkins
Printed name of Applicant or *Agent
Manager, Environmental Services
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) f rm to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
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Kir► koson Rota ns
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Signature of Property Owner (if di erent 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]
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

DRAWN:
TES
DATE:
4/26/2021
6004 Ponders Court, Greenville, SC 29615
Phone: [phone]

Boring Location Plan

7529 HWY 25-70, MARSHALL NC
28753
Figure
2
CHECKED:
RTH
JOB No:
J20-16157-02
APPROVED:

Proposed
Boring
location for
Temporary
Monitioring
Well

JOB NO.:
1-INCH WELL DIAGRAM
GROUND SURFACE—\
NATIVE SOIL
1—INCH O.D. PVC RISER
1—INCH O.D. PVC SCREEN
2 TO 5 FEET LONG
(SLOT SIZE 0.010—INCH)
NA
NO CAP (TEMPORARY WELL)
BOREHOLE DIAMETER 2 TO 3 INCHES
DATE:
04-13-20
SCALE:
NOT TO SCALE
'I' IM LAMMONSL
AMMON
ENGINEERING
6004 Ponders Court, Greenville, SC 29615
Phone: [phone] Fax: [phone]
OPEN BOREHOLE
SAND TO APPROXIMATELY 2 FEET ABOVE SCREEN
NOTE:
WELLL IS RETRACTED AFTER SAMPLING
AND BORING ABANDONED WITH
BENTONITE GROUT.
TYPICAL 1—INCH WELL
DIAGRAM
FIGURE
1