WM0701260_Application_20211029

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT,A MONITORING OR RECOVERY WELL SYSTEM
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In accordance with the provisions
of Article 7,Chapter 87,General Statutes of North Carolina and regulati�s pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery wells.
PLEASE TYPE OR PRINT CLEARLY
1. Date: October 13, 2021
2. County: Pitt
3. What type of well are you applying for? (monitoring or recovery): Monitoring — Temporary Well Points
4. Applicant: Jamie Ziemba
Telephone: [phone]
Applicant's Mailing Address: 3550 W Market Street, Suite 200, Akron, OH 44333
Applicant's Email Address (if available): Jamie.ziemba(u�nv5.com
5. Contact Person (if different than Applicant): Abigail Akinosho
Telephone: [phone]
Contact Person's Mailing Address: United Consulting
Contact Person's Email Address (if available): aakinosho(a)unitedconsulting.com
6. Property Owner (if different than Applicant): MCG Greenville Owner, LLC Telephone:
Property Owner's Mailing Address: 1170 Kane Concourse, Ste 200, Bay Harbor Islands, FL 33154
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 3600 S Memorial Drive (ID# 34293)
City Greenville
County Pitt
Zip Code 27834
8. Reason for Well(s): Environmental Site 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 building
(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).
No
11. Type of contaminants being monitored or recovered: VOCs, SVOCs, and lead (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).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 1000 feet
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: Bridger Drilling Certification No.: 2393A
Well Contractor Address: 4837 Carolina Beach Road, Suite 207, Wilmington, NC 28415
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: 2
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 2
(add answers from 2 and 3)
5. How will the well(s) be secured? Temporary
Well points to be removed after sampling
6. Estimated beginning construction date: Early Nov 2021
7. Estimated construction completion date: Early Nov 2021
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 aminimum 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 theproposedwell 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,
hapter 2C) and accepts full responsibility for compliance with these rules
Signature o -Ap icant or *Agent
Jamie Ziemba
Applicant
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 isownedbysomeone other than the applicant, the property owner hereby consents to allow the applicant to construct
wells as outlined' this Well Construction Permit application and that it shall be the responsibility of the applicant to ensure that the
well(s) con to iell Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
I fff,�f! l Joe F. Teague, MCG Greenville Owner,-LLC
Printed name of Property Owner (if different than Applicant)
Signature of Property 0
er (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)

Figure Scale
UNITED N 0 250 500
CONSULTING A
1 inch = 400 feet
Prepared: BWS
Checked:
Title: Project Site Location Map (Street Map)
Project: 3600 S. Memorial Drive
Project No. 21-NC-05785-01
Date: 10/12/21 Client: —
FIG. 1

Figure Scale
N 0 250 500
A1 inch = 400 feet
Prepared:
Checked:
Date:
BWS
10/12/21
Title:
Project:
Project No.
Client:
Project Site Location Map (Aerial)
3600 S. Memorial Drive
21-NC-05785-01
FIG. 2

Former Dears Automotive
(Oil/Water Separator)
!References: ESRI.(2021)''
�.,
Map Index
Legend
Project Site Boundary
h Proposed Temporary
Y Monitoring Well
Note:
Original version of this drawing is provided in fug -
osier, black -and -white reproductions may not
accurately depict certain information.
UNITED
CONSULTING
625 Hdcan,&Mge Rove. Naaos, Oxeye 30071
720-209-0029 Fax [phone] wsmun4ehmcufine com
Project:
3600 S. Memorial Dr WO
Client:
Sheet Proposed Temporary
rue: Monitoring Wells
Scale N 0 37.5 75 150
A 1 inch = 150 feet
Prepared:
Checked:
Date:
Project No.
B. Sharp
Oct 12,2021
21-NC-05785-01
Figure 3

UNITED PROPOSED ID: WELLID:
WELL/PIEZOMETER LOG .. EB-z
CONSULTING" '
CLIENT: .
N/A "
SITE LOCATION:
Greenville, -NC
CONSTR. START: •
TBD -
PROJECT NAME:
3600 S: Memorial Drive
DRILLING METHOD:
'Direct Push . ",
CONSTR.-COMP:
TBD
PROJECT NUMBER:
• 21-NC-05785-01 -
DRILLING CONTRACTOR AND EQUIP: -
. TBD
DEVELOPMENT DATE:
TBD .
LOGGED BY:
SAMPLING METHOD: : • .
Direct Push Drilling/Low-Flow Sampling
STATIC GROUNDWATER DEPTH:
•Approximately 15'feet bgs :
Depth (feet)
USCG
Graphic .
• Log '
.LITHOLOGY ." " .
... .. .. - • -
. SAMPLES
SKETCH
.. ... - ..
NOTES
...
% REC
'Sample ID - '
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NOTES
. BGS,.below round .surface'
9.
' -
- :
•: Time 9f. fling. .
Groundwater Level
Surface Elev:: -
NIA .
Surface Completion: •
Flush " '
Filter Pack Type::
i20 Weil Slot Sand '
Screen•Length; • •
10 Feet
TOC, Elev.:
. N/A
Riser Height (Surface):
N/A
Well Diameter.
1 Inch '•
Screen Slot Size: '
0.001 In •
- .,
.. 24-Hour ' '
..Grounderater Level
NorthinglLat:
' WA
Annular Fill Type:
Fill Soils '
Borehole Diameter::
,
3.25 Inches
Bottom of 'Screen:: '
20 Feet
Q
Development
Croundvrater Level
EastinglLong.: •
WA ' - -
Annular Sealant Type: '
Bentonite Seal .
Top of Screen:
10 Feet '
. Bottom of Well:'
• 20 Feet"