WM0401322_Monitoring Well Permit Application_20211018

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
L
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: 1046721
2. County: Guilford
PERMIT NO.
FOR OFFICE USE ONLY
ISSUED DATE
3. What type of welt ate you applying for? (monitoring or recovery):
Monitoring
4. Applicant: N3 Property Advisors, LLC Telephone: _(66 1651-9327
Applicant's Mailing Address: 1240 Kimball Ave.. Southlake. TX. 76092
Applicant's Email Address (if available): cthelenPen3realestate.com
Contact Person (if different than Applicant): Randy H. CavaSlier
Contact Person's Mailing Address: 4811 Koger Blvd, Greensboro, NC 27407
Contact Person's Email Address (if available) rcavQI,ieriecslimteel..com
6 Property Owner (if different than Applicant): Sam's Commercial Properties, LLC
7938 Council Placer Suite 200, Matthews, NC 28105
Telephone: [phone]
Property Owners Mailing Address. -
Telephone: [phone]
Property Owner's Email Address (if available):
7 Property Physical Address (including PIN Number) 3223 igattlearound Avenue, (PIN) 7856t 2478
City, Greensboro County, Guilford Zip Code 27408 .�
8 Reason for Well(s): Assessm91j.
(ex: non discharge permit re4uirernents, suspected contamination, assessment, groundwater contamination. remedIaton, etc.)
9 Type of facility or site for which the well(s) is(are) needed:__Commercial «.
(ex: non -discharge facility, waste disposal site, Landfill, UST, etc.)
10. Are there any current water quality permits of incidents associated with this facility or slte? If so, list permit and/or incident no(s).
Yes NCQEQ Incident # 44894.
11. Type of contaminants being monitored or recovered: organics (ex: organics. nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? NO Abandoned
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed wellis) to nearest known waste or pollution source (in feet): c0
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: 3D Environmental Investigations, 11.0 Certification No.: 3162-A
Well Contractor Address: 2]pr7-itecksyitle Hiehwgv, Stateavill; 1' C 28625
a� . .mom.-.. .�.,
PROPOSED WELL CONSTRUCTION. IN.I=ORMATION
t 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 r Grout horizons
c. Screen intervals g. Well heed completion details
d. Sand/gravel pack intervals
Continued on Reverse

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2 N umber of wells to be const~ucted in unconsolidated
material: 2
t. Number of wells to be constructed in bedrock: g
4, Total Number of wells to be constructed: 2
(add answers from 2 and 3)
1.
b. How will the well(s) be secured? Abandon after sample
i', 1Q
6, Estimated beginning construction date: 10115-6 1
22. re file
7. Estimated construction completion date: 'Q(4121
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, anima feedlots as defined in G.S. 143-215.10E1(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant hereby agrees that he 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,
Subcf aper 2C) and accepts full responsibility for compliance with these rules
Signatu jam• pplicant or *Agent
Brenna A Wadleigh
Printed name of Applicant or'Agert
President
Title of Applicant or "Agent
ff 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 Corstruction Permit application and that It shall be the responsibility of the applicant to ensure that the
vjell(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C),
---- — /7dc'iarlr n a'i1rr 1c'Y' . c c 11fir] t<ii .
Signature of Property er (if different than Applicant) Printed name o roperty Owner (If different than Applicant) r
A wito-
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]

• APPROXIMATE WELL LOCATION
SOURCE:
GOOGLE EARTH
Can yd)tspensers
Tword
FIGURE 1
WELL LOCATION MAP
3223 Battleground Avenue
Greensboro, Guilford County, North Carolina
ECS Project No. 49-14467-A

GROUND
SURFACE
ESTI MATED
20' FEET
NATURAL FORMATION
BACKFILL
GROUNDWATER
NOT TO SCALE
TOP ROD ABOVE THE LAND
SURFACE
1-INCH Steel Geoprobe
Rods
2--INCH BORE
HOLE
SLOTTED PVC SCREEN
0.01-INCH SLOT WIDTHS
SET TO INTERSECT GROUNDWATER
4 FEET IN LENGTH
WELL. CONTRUCTION DIAGRAM IS
REPRESENTATIVE OF TEMPORARY MONITORING
W ELL
FIGURE 3
PROPOSED TEMPORARY SCREEN
POINT SAMPLER
3223 BATTLEGROUND AVENUE
GREENSBORO, NORTH CAROLINA
ECS PROJECT NO. 49:14467-A