WM0501435_Application_20210419

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 there to,
application is hereby made for a permit to construct monitoring or recovery wells.
1.Date:5/16/2021
2.County: Wake
3.What type of well are you applying for? (monitoring or recovery):Temporary Monitoring Well
4.Applicant: Almmaz 2021, LLC – Ammar Almaraisi Telephone: [phone]
Applicant’s Mailing Address: 5517 Overdale Lane, Raleigh, North Carolina 27603
Applicant’s Email Address (if available): [e-mail] cc:[e-mail]
5.Contact Person (if different than Applicant):ECS Southeast, LLP – Samantha Szakasits Telephone: [phone]
Contact Person’s Mailing Address: 5260 Greens Diary Road, Raleigh, North Carolina 27616
Contact Person’s Email Address (if available): [e-mail]
6.Property Owner (if different than Applicant): Wilborn B. Coward, III Telephone: [phone]
Property Owner’s Mailing Address: 2800 Hazelwood Drive, Raleigh, Wake County, North Carolina 27608
Property Owner’s Email Address (if available):
7.Property Physical Address (Including PIN Number)3417 Hillsborough Street. – PIN 0794337632
City Raleigh County Wake Zip Code 27607
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:Off-site UST Incident
(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 in cident no(s).
Unknown
11.Type of contaminants being monitored or recovered:VOCs and SVOCs
(ex: organics, nutrients, heavy metals, etc.)
12.Are there any existing wells associated with the proposed well(s)? If yes, how many?No
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):Approximately 50 feet Northwest
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: Quantex Drilling Certification No.: 3106-A
Well Contractor Address:PO Box 1388, Wendell, NC 27591
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








  


WM0501435
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)

2. Number of wells to be constructed in unconsolidated
material: 3

3. Number of wells to be constructed in bedrock: Zero (0)

4. Total Number of wells to be constructed: 3
(add answers from 2 and 3)
5. How will the well(s) be secured? Not Applicable –
temporary monitoring wells to be abandoned upon completion.

6. Estimated beginning construction date: TBD

7. Estimated construction completion date: TBD

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 speci fications 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 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 en sure that the
well(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).

SEE ATTACHED Wilborn B. Coward, III
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]

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








  


 
 


SOURCE:
USGS TOPOGRAPHIC MAPS
RALEIGH WEST QUADRANGLE 2013
SCALE SHOWN ABOVE
FIGURE 1
TOPOGRAPHIC LOCATION MAP
New Automotive Development
973 N. Wesleyan Blvd.
Rocky Mount, Nash County, North Carolina
ECS Proposal Number: 49:12416-D
SITE
SOURCE:
ECS PHASE I (APRIL 2020)
2020 IMAGERY
SCALE SHOWN ABOVE
FIGURE 1
PROPOSED SAMPLE LOCATION MAP
Restaurant Property –Phase II
3417 Hillsborough Street
Raleigh, Wake County, North Carolina
ECS Proposal Number: 49:13607-A
LEGEND
SITE PARCEL BOUNDARY
PROPOSED TEMPORARY MONITORING WELL LOCATION
EXISTING MONITORING WELL LOCATION
FIGURE 3
CONTAMINATION SOURCE LOCATION MAP
Restaurant Property –Phase II
3417 Hillsborough Street
Raleigh, Wake County, North Carolina
ECS Proposal Number: 49:13607-A
SOURCE:
NCDEQ-DWM SITE LOCATION TOOL
2020
APPROXIMATE SCALE:
LEGEND
500 feet
200 FT.
SITE
Active UST Facilities Parcels (Polygons) -Parcels
UST Incidents City Directory (Drycleaning)
Notice and Restrictions Proposed Groundwater Sampling Point
WELL CONTRUCTION DIAGRAM IS
REPRESENTATIVE OF DIRECT PUSH SCREEN
POINT SAMPLER
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
SURFACE
NOT TO SCALE
2--INCH BORE
HOLE
1.5-INCH STEEL DIRECT
PUSH RISER
GROUND
SURFACE
GROUNDWATER SLOTTED STEEL SCREEN
0.01-INCH SLOT WIDTHS
SET TO INTERSECT GROUNDWATER
ESTIMATED 5 FEET IN LENGTH
NATURAL FORMATION
BACKFILL
35 FEET
FIGURE 4
PROPOSED TEMPORARY SCREEN POINT
SAMPLER
Restaurant Property –Phase II
3417 Hillsborough Street
Raleigh, Wake County, North Carolina
ECS Proposal Number: 49:13607-A