WM0701253_Application_20210915

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: September 3, 2021
2. County: Pitt County
3.
4. Applicant: Lampe Management Company
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery):
Monitoring (temporary)
Telephone: [phone]
Applicant's Mailing Address: 225 Peedin Road, Smithfield, NC 27577
Applicant's Email Address (if available): quyl(a).lampemanagement.com
5. Contact Person (if different than Applicant): Erin Warren
Telephone: [phone]
Contact Person's Mailing Address: ECS Southeast LLP 6714 Netherlands Drive, Wilmington NC 28405
Contact Person's Email Address (if available): ewarren(c�ecslimited.com
6. Property Owner (if different than Applicant): Nesa Page Worthington Telephone: [phone]
Property Owner's Mailing Address: 3811 Ballards Crossroads Road, Greenville, NC 27834
Property Owner's Email Address (if available): Uknown
7. Property Physical Address (Including PIN Number) 3103 Williams Road — PIN 25864
City Greenville County Pitt County Zip Code 27834
8. Reason for Well(s): Assessment
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
9. Type of facility for which the well(s) is(are) needed: Residence
10. Are there any current water quality permits or incidents associated with this facility or site? no
11. Type of contaminants being monitored or recovered: VOCs and SVOCs
12. Are there any existing wells associated with the proposed well(s)? no
Existing Monitoring or Recovery Well Construction Permit No(s).: NA
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 100 feet from a historic fuel
station
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? None Observed
If yes, give distance(s):
15. Well Contractor: Mid -Atlantic Drilling, Inc. (MAD) Certification No.: 2540-A
Well Contractor Address: istewarta(�midatlanticdrillinq.com 426 Landmark Drive Wilmington, NC 28412
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: 3
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 3
(add answers from 2 and 3)
5. How will the well(s) be secured? Same day
abandonment
6. Estimated beginning construction date: September
2021
7. Estimated construction completion date: September
2021
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 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
,D Lac
Printed name of Applicant or *Agent
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).
See attached see attached
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
GW-22M (Rev. 5/11)

ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:26253P
Scope of Work: Proposal for Environmental Assessment Services
Project: Single Family Residence Property
Location: 3103 Williams Road, Greenville, Pitt 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 sampling at the site. This 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. By signed below, the property owner authorizes ECS to
conduct the aforementioned sampling at the site.
Property Owner (please print):46---gg a 19; i`j 1 ' b :l t r} 3 71-0 VI
Property Owner Telephone (please print): f-� �' 75-2 3 g 1 jam - e- r"i-
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Property Owner Signature:

Approximate location
of the apparent
historic pump Inland
i •
FIGURE 1
• ROPOSED GROUNDWATER SAMPLE LOCATIONS C
3103 Williams Road
Greenville, North Carolina
Pitt County
ECS Project No. 49-14509-A

GROUND
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
'v"' "`'`
SURFACE
A
15 FEET
NATURAL FORMATION
BACKFILL
GROUNDWATER
_
1.5-INCH STEEL DIRECT
PUSH RISER
2--INCH BORE
HOLE
SLOTTED STEEL SCREEN
0.01-INCH SLOT WIDTHS
SET TO INTERSECTGROUNDWAI
ESTIMATED 10 FEET IN LENGTF
` /
\ /
`/
WELL CONTRUCTION DIAGRAM
REPRESENTATIVE OF DIRECT PUSH ;
PC)INT SAMPI FP
-
ER
IS
CREEN
NOT TO SCALE
FIGURE 2
PROPOSED TEMPORARY SCREEN
POINT SAMPLER