WM0501443_Application_20210606

/vv lib/2 C
cn.Ack:
DocuSign Envelope ID: A617BOCB-EOAC-4ISC-A37D-29FAAEBE661E
�rvn n vnnv�mr� ucr, r mcir i yr csrvirwrIMENTAL 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: 6/29/2021
2. County: Johnston
3.
4.
PERMIT NO.
FOR OFFICE USE ONLY
ISSUED DATE
What type of well are you applying for? (monitoring or recovery):
Applicant: Aubrey Linville — Twin City Capital
Monitoring
Telephone: Not Applicable
Applicant's Mailing Address: 206 West Fourth Street, Winston-Salem, North Carolina 27101
Applicant's Email Address (if available): aubrey(o.ltpcommercial.com
5. Contact Person (if different than Applicant): Travis O'Quinn Telephone: [phone]
Contact Person's Mailing Address: 1812 Center Park Drive. Suite D Charlotte, NC 28217
Contact Person's Email Address (if available): tloguinnfdrecslimited.com
6. Property Owner (if different than Applicant): Timothy and Lynn Matthews Telephone. [phone]
Property Owner's Mailing Address: 11133 Highway 70 West, Clanton. North Carolina 27520
Property Owner's Email Address (if available): Not Applicable
7. Property Physical Address (Including PIN Number): 1687 South Briahtleaf Boulevard PIN 163400-02-6460
City: Smithfield County: Johnston Zip Code: 27577
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: Commercial (Auto Service & Maintenance Shoo)
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
10. Are there any current water quality pennits or incidents associated with this facility or site? If so, list permit and/or incident no(s).
Not Applicable
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).: Not Applicable
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approx. 320 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Unknown
If yes, give distance(s): Not Applicable
15. Well Contractor: Quantex, Inc. Certification No.: 3106
Well Contractor Address: [e-mail]
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

DocuSign Envelope ID: A617BOCB-E0AC-415C-A37D-29FAAEBE661 E
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
DocuSigned by:
Signature EE93537E4C484C2...
Aubrey Linville
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Groundwater
material: 3 Semolina Probe
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 7/7/2021
4. Total Number of wells to be constructed: 3
(add answers from 2 and 3)
7. Estimated construction completion date: 7/7/2021
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,
e-6-6-49r 2C) and accepts full responsibility for compliance with these rules
Printed name of Applicant or *Agent
Manager
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).
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 Mali
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 MAP
7.5 — MINUTE SERIES
FOUR OAKS NE, NC
DATED 2019
SCALE: 1 : 24,000
CONTOUR INTERVAL= 10'
FIGURE 1
SITE TOPOGRAPHIC MAP
Central Lube --Smithfield, NC
1687 South Brightleaf Blvd
Smithfield, Johnston County, NC
ECS Project No. 49:14200-A

SOURCE:
GOOGLE EARTH
IMAGERY DATED 2018
APPROXIMATE SCALE:
50 ft
Central Lube
Facility
FIGURE 2
SAMPLE LOCATION MAP
Central Lube —Smithfield, NC
1687 South Brightleaf Blvd
Smithfield, Johnston County, NC
ECS Project No. 49:14200-A

GROUND
SURFACE
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
SURFACE
ESTIMATED
-15'-20'
FEET
NATURAL FORMATION
BACKFILL
GROUNDWATER
NOT TO SCALE
1.1
1.5-INCH STEEL DIRECT
PUSH RISER
2--INCH BORE
HOLE
SLOTTED STEEL SCREEN
0.01-INCH SLOT WIDTHS
SET TO INTERSECT GROUNDWATER
ESTIMATED 4 FEET IN LENGTH
WELL CONSTRUCTION DIAGRAM IS
REPRESENTATIVE OF DIRECT PUSH SCREEN
POINT SAMPLER
FIGURE 3
PROPOSED TEMP SCREEN POINT SAMPLER
Central Lube--Smithfield, NC
1687 South Brightleaf Blvd
Smithfield, Johnston County, NC
ECS Project No. 49:14200-A

DocuSign Envelope ID A4441 F08-21 BE-4658-8918-C7296CDF2526
111111MMILECS SOl3THEAS ,
ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:25121P
Scope of Work: Proposal for Environmental Assessment Services
Project: Central Luke —Smithfield, NC
Location: 806 South Fayetteville Street; Clayton,, Johnston County, North Carolina
As part of the proposed real estate transaction, ECS Southeast, LLP (ECS) has been requested by the
purchaser to conduct subsurface soil and groundwater quality sampling at the site. The groundwater
sampling 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 soil and groundwater sampling: ay signing below, the property owner authorizes ECS to
conduct the aforementioned sampling at the site.
Property Owner (please print): T ins yroi gcorr
AArt MfriiiNos
Property Owner Telephone (please print :Ole
Property Owner Signature:d'itifti;t6a/Dater
EC5 Proposal No. 49:2$121P
Page 8