WM0701264_Application_20211116

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT & NATURAL, RESOURCES
DIVISION OF WATER QUALITY — AQUIFER PROTECTION SECTION
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 fora permit to construct monitoring or recovery wells.
1. Date: 1 O118/21
2. County: Pitt
FOR OFFICE USE ONLY
PERMIT NO......._.......... ---
ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Country Mart Telephone: [phone]
Applicant's Mailing Address: 4787 NC-11 Bethel 27812
Applicant's Email Address (if available):
5. Contact Person (if different than Applicant):.T,2U-e- LU C & S Telephone: 7b 1--3 i - 7 C13 9
Contact Persons Mailing Address: P. 0 . & 61( / 3 7 9 / f iu e r5 /k, /U ,2�'D 7o
Contact Person's Email Address of available): ST-L-'e e /191L'fI� eu5� f ":Pc- t coy, Cum
6. Property Owner (if different than Applicant): Weyerhaaeuser Telephone: [phone]
Property Owner's Mailing Address: 2087 Pulp Mill Road, Jamesville NC 27846
1
Property Owner's Email Address (if available): •� , m /trier e w y. IA ewe 14se , Cc II-%
7. Property Physical Address (including zip code) and PIN Number Sai ntsville Road Ge n u i NC 2,93f
8. Reason for Well(s): Samples ground water
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
9. Type of fadlity or site for which the well(s) is(are) needed: Logging propery
(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.perrnit and/or incident no(s).
no
11. Type of contaminants being monitored or recovered: Off road diesel fuel
(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): n/a
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? no
If yes, give distance(s): 1
15. Well Contractor. GRI %,JGi s /in P-"-c f Certification No.: 7 0
Well Contractor Address: 35'6 01 daye5 /L A / /M ra-e- NG s%/-0
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: 2inch PVC
5. How will the well(s) be secured? Grount and bentonite
locking cap, bolt down, manwaywith concrete monument
3. Number of wells to be constructed In bedrock: 6. Estimated beginning construction date: / /' . —''2 f
4. Total Number of wells to be, constructed: 1 7. Estimated construction completion date: / i <-2 - /
(add answers from 2 and 3)
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,
Subchapter 2C) and accepts full responsibility for compliance with these rules
Signature of Applicant or 'Agent
64..et bQt1 i?, I-JCc,J'
Printed name of Applicant or 'Agent
C, jac,e- ///>9 X c uu
Title of Applican 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 outlinedin•this Well Co. rGction Permit application and that it shall be the responsibility of the applicant to ensure that the
well(s) conform too'' the 61 onstruction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
—:'�"fJbfvi %i
Signature of Property7wner (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 Quality's Aquifer Protection Section 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
585 Waughtown Street
Winston-Salem, NC 27107
Phone: [phone]
Fax: [phone]
GW-22MR (Rev. 7/11)

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Figure 1
Country Mart Diesel Fuel Spill
Weyerhaeuser Timberland, Greenville, North Carolina
Grindte
PPcosin
Monitor Well Location
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261
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