WM0501454_Application_20211004

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: 9/27/2021

2. County: Nash

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

4. Applicant: Starlight Homes of North Carolina, LLC – Christina Malone Telephone: [phone]

Applicant’s Mailing Address: 3820 Mansell Road, Suite 400, Alpharetta, Georgia 30022

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

5. Contact Person (if different than Applicant): ECS Southeast, LLP – Samantha Szakasits Telephone: [phone]

Contact Person’s Mailing Address: 5260 Greens Dairy Road, Raleigh, NC 27616

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

6. Property Owner (if different than Applicant): Clifton Price Harper, Jr. Telephone:

Property Owner’s Mailing Address: 8904 Columbine Drive, Raleigh, NC 27613

Property Owner’s Email Address (if available):

7. Property Physical Address (Including PIN Number) 4575 Sunset Avenue (PIN 382008972953)
City Rocky Mount County Nash Zip Code 27804
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 – off-site source
(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).

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. 200 feet

14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No

If yes, give distance(s): Not Applicable

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

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? 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 Clifton Price Harper, Jr.
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



 
 




 


ECS Proposal No. 49-26775
Page | 8

ECS SOUTHEAST, LLP September 20, 2021
ECS SOUTHEAST, LLP

PROPERTY OWNER ACCESS AUTHORIZATION

Project Name: Sunset Avenue Site
Location: Sunset Venue, Rocky Mount, Nash 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 Departme nt 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 and submit the results to NCDEQ.

Property Owner (please print):____________________________________________________________

Property Owner Telephone (please print):___________________________________________________

Property Owner Signature:___________________________________________ Date:_______________




 


  




 

FIGURE 1
SITE TOPOGRAPHIC MAP
Sunset Avenue Site
Sunset Avenue
Rocky Mount, Nash County, North Carolina
ECS Proposal Number: 49-26775
SOURCE:
USGS TOPOGRAPHIC MAP
7.5 –MINUTE SERIES
NASHVILLE, NC
DATED 2016
SCALE: 1 : 24,000
CONTOUR INTERVAL = 10’
SITE
SOURCE:
GOOGLE EARTH
2020 IMAGERY
APPROXIMATE SCALE:
FIGURE 2
PROPOSED SAMPLE LOCATION MAP
Sunset Avenue Site
Sunset Avenue
Rocky Mount, Nash County, North Carolina
ECS Proposal Number: 49-26775
Sunset Express Mart
(REC)
LEGEND
APPROXIMATE SITE PARCEL BOUNDARY
PROPOSED GROUNDWATER SAMPLE LOCATIONS
= 100 Feet
FIGURE 3
POTENTIAL SOURCES MAP
Sunset Avenue Site
Sunset Avenue
Rocky Mount, Nash County, North Carolina
ECS Proposal Number: 49-26775
SOURCE:
NCDEQ
DWM SITE LOCATOR TOOL
APPROXIMATE SCALE:
SITE PARCEL
BOUNDARY
APPROX.
500 FOOT
RADIUS UST Incident
#15186
NO WATER SUPPLY WELLS OR POTENTIAL SOURCES
OF CONTAMINATION ARE KNOWN TO EXIST OTHER
THAN ILLUSTRATED ABOVE.
= 300 Feet
WELL CONSTRUCTION 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 4 FEET IN LENGTH
NATURAL FORMATION
BACKFILL
ESTIMATED
~15’-20’
FEET
FIGURE 4
PROPOSED TEMP SCREEN POINT SAMPLER
Sunset Avenue Site
Sunset Avenue
Rocky Mount, Nash County, North Carolina
ECS Proposal Number: 49-26775