WM0401294_Monitoring Well Permit Application_20210510 (2)

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: 05/07/21
2. County: Forsyth
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant: R&M Development Services, LLC (Michael LaRue)
Applicant's Mailing Address: 940 Aquaview Drive, Kernersville, NC 27284
Applicant's Email Address (if available): [e-mail]
Monitoring
Telephone: [phone]
5. Contact Person (if different than Applicant): Scott Young Telephone: [phone]
Contact Person's Mailing Address: 1812 Center Park Drive, Suite D, Charlotte, NC 28217
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Goodwill Industries of NW North Carolina Telephone: [phone]
Property Owner's Mailing Address: PO Box 4299, Winston Salem, NC 27115
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 536 Waughtown Street — PIN-6834-67-6296
City Winston-Salem County Forsyth Zip Code 27115
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: USTs
(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: 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:
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?
material: 4 Sample will be collected through Geoprobe Sampling
Point
6. Estimated beginning construction date: TBD
4. Total Number of wells to be constructed: 4
(add answers from 2 and 3) 7. Estimated construction completion date: TBD
3. Number of wells to be constructed in bedrock: 0
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
,Sotf
Environmental Project Manager
Signature of Aplicaht or *Agent Title of Applicant or *Agent
Scott Young * 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 signed Access Agreement
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]
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, 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
Raleigh Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension
GW-22M (Rev. 5/11)

May 4, 2021
Proposal No:
Scope of Work:
:
Project:
Location:
ECS SOUTHEAST, 0
ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
49:24256P
Proposal for Environmental Assessment Services
Waughtown Street Property
536 Waughtown Street, Winston-Salem, Forsyth County, North Carolina
As part of the proposed read estate transaction, ECS Southeast, LLP (ECS) has been requested by the
purchaser to conduct subsurface soil, groundwater, and surface water sampling at the site. The
groundwater sampling requires that ECS procure a permit from the North Carolina Department of
EnvironrnentiI Quality (NCDEQ).
ECS respectfully requests that the owner of the property grant permission to ECS to access the property
to conduct the soil, groundwater, and surface water sampling. By signing blow, the property owner
authorizes ECS to conduct the aforementioned sampling at the site.
Property Owner (please print): B 11 Hay Or
Property Owner Telephone please print): 336-408-0731
DocuSigned by:
Property Owner Signature: t54, iftirtiVt
ECS Proposal No. 49:24256P
Page I 7
Date:
5/7/2021
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SOURCE:
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SCALE:
AS SHOWN
FIGURE 1
USGS TOPOGRAPHIC MAP
WAUGHTOWN STREET PROPERTY
536 WAUGHTOWN STREET
WINSTON-SALEM, NORTH CAROLINA
ECS PROJECT NO. 49:13459-A
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LEGEND
O APPROXIMATE GROUNDWATER BORING LOCATION
SOURCE:
FORSYTH COUNTY GIS WEBSITE
ACCESSED MAY 4, 2021
SCALE:
AS SHOWN
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FIGURE 2
PROPOSED SAMPLE LOCATIONS MAP
WAUGHTOWN STREET PROPERTY
536 WAUGHTOWN STREET
WINSTON-SALEM, NORTH CAROLINA
ECS PROJECT NO. 49:13459-A
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IDTHS
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FIGURE 3
PROPOSED TEMPORARY SCREEN
POINT SAMPLER
WAUGHTOWN STREET PROPERTY
536 WAUGHTOWN STREET
WINSTON-SALEM, NORTH CAROLINA
ECS PROJECT NO. 49:13459-A
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