WM0401333_Monitoring Well Permit Application_20211215

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: 12/8/2021
2. County: Forsyth County
3.
4. Applicant: Family Services of Forsyth
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery):
Monitoring
Telephone: [phone] x 1004
Applicant's Mailing Address: 1200 Broad Steet, Winston-Salem, NC 27101
Applicant's Email Address (if available): Robert (Bob) J. Feikema [e-mail]
5. Contact Person (if different than Applicant): Don R. Marlor, P.G., ECS Southeast, LLP Telephone: [phone]
Contact Person's Mailing Address: 1900 Hendersonville Road, Suite 10, Asheville, NC 28803
Contact Person's Email Address (if available): dmarlor©ecslimited.com
6. Property Owner (if different than Applicant): Infill Delicate, LLC Telephone: NA
Property Owner's Mailing Address: PO BOX 21674, Winston-Salem, NC 27120
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 1504 Felicity Lane (6846-83-6045)
City Winston-Salem County Forsyth Zip Code 27101
8. Reason for Well(s): assessment of potential off -site groundwater impacts
(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: potential UST site
(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: Petroleum
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? No, not for proposed well
Existing Monitoring or Recovery Well Construction Permit No(s).: No
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 350 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: To be determined Certification No.:
Well Contractor Address:

PROPOSED WELL CONSTRUCTION INFORMATION
As required by 15A NCAC 02C .0105(0(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
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Expansion cap
material: 2 temporary
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: Unknown
Total Number of wells to be constructed: 2 7. Estimated construction completion date: Unknown
(add answers from 2 and 3) (within 96 hours of installation)
ADDITIONAL INFORMATION
As required by 15A NCAC 02C .0105(0(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 �. g2fe f✓I1.Qot 1., //60
Signat of App i •- nt or *Agent
Title of Applicant or *Agent
* If signing as Agent, attach authorization agreement stating
Printed name oiAppiicant 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 ensure that the
well(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
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 SOUTHEAST, LLP
ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49-28000P
Scope of Work: Groundwater Assessment
Project: The Commons
Location: 1504 Felicity Lane, Winston-Salem, North Carolina
As part of the proposed real estate transaction, ECS Southeast, LLP (ECS) has been requested by the
purchaser to conduct subsurface groundwater sampling at the site. The groundwater sampling at the
site 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 install temporary monitoring wells and conduct the groundwater sampling. By signing below,
property owner authorizes ECS to conduct the aforementioned groundwater sampling at the site and to
obtain the above -referenced permit on behalf of the owner.
Property Owner (please print): ,` 1,K u-t "EZ,ZY°r-tt L,L
Property Owner Signature:
ei.LL ti
ECS Proposal No. 49:28000P
Page I 1
Date: (?(Z(2

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SOURCE:
USGS TOPOGRAPHIC MAP
WINSTON-SALEM EAST AND WALKERTOWN,
NORTH CAROLINA QUADRANGLE DATED 2019
SCALE: 1:24,000
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FIGURE 1
SITE LOCATION MAP
THE COMMONS
1504 FELICITY LANE
WINSTON-SALEM, NORTH CAROLINA
ECS PROJECT NO. 49:12672-A

101.
•
•
Former
Filling
Station
•
•
•
♦
APPROXIMATE SITE BOUNDARY
• APPROXIMATE GROUNDWATER SAMPLE LOCATION
LEGEND
NOTE: NO OTHER EXISTING WELLS OR POTENTIAL
SOURCES OF CONTAMINATION, OTHER THAN
ILLUSTRATED ABOVE, ARE KNOWN TO EXIST.
W---?OE SOURCE:
GOOGLE EARTH
ACCESSED DECEMBER 7, 2021
APPROXIMATE SCALE:
FIGURE
PROPOSED SAMPLE LOCATIONS MAP
THE COMMONS
1504 FELICITY LANE
WINSTON-SALEM, NORTH CAROLINA
6 6=100feet
TM
ECS PROJECT NO. 49:12672-A

GROUND
SURFACE
BOLTED VAULT
COVER
30 FEET
EXPANSION CAP
WITH LOCK
GROUT
MINIMUM 3 FEET
BENTONITE PLUG
MINIMUM 2 FEET
SAND SCREEN
MINIMUM 1 FOOT ABOVE
THE SLOTTED PVC SCREEN
GROUNDWATER
VAULT
1-INCH PVC CASING
SCHEDULE 40
6-INCH
BORE HOLE
SLOTTED PVC SCREEN
0.01-INCH SLOT WIDTHS
SET TO INTERSECT GROUNDWATER
ESTIMATED 10 FEET IN LENGTH
WELL CONTRUCTION DIAGRAM IS
REPRESENTATIVE OF ALL PROPOSED
MONITORING WELLS
NOT TO SCALE
FIGURE 3
PROPOSED WELL CONSTRUCTION
DIAGRAM
THE COMMONS
1504 FELICITY LANE
WINSTON-SALEM, NORTH CAROLINA
TM
ECS PROJECT NO. 49:12672-A