WM0401336_Monitoring Well Permit Application_20211221

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: 12/17/2021
2. County: Forsyth
3.
4.
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (Monitoring or Recovery): Monitoring
Applicant: C.F. Smith Property Group Telephone: [phone]
Applicant's Mailing Address: 1227 Rockingham Road, Rockingham, NC 28379
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Emery Lovekamp Telephone: [phone]
Contact Person's Mailing Address: 5260 Greens Dairy Rd, Raleigh, NC 27616
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Stan Forester
Property Owner's Mailing Address: 5911 Immanuel Road, Clemmons, NC 27012
Property Owner's Email Address (if available): N/A
7. Property Physical Address (Including PIN Number): 5911 Immanuel Road — PIN — 5884-98-0345
City: Clemmons County: Forsyth Zip Code: 27012
8. Reason for Well(s): Environmental 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: Residential gas station adjacent to the south
(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).
Unknown
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): Unknown
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 500 feet north of UST
Incident No's 45042 and 23735
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): N/A
15. Well Contractor: 3D Environmental Investigations ([e-mail]) Certification No.: 3162-A
Well Contractor Address: 2157 Mocksville Hwy, Statesville, NC 28265
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: Two (2)
3. Number of wells to be constructed in bedrock: Zero (0)
4. Total Number of wells to be constructed: Two (2)
(add answers from 2 and 3)
5. How will the well(s) be secured? Not applicable — temp
wells to be abandoned upon completion
6. Estimated beginning construction date: 12/28/21
7. Estimated construction completion date: 12/28/21
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
DQy� &el& Director of Construction and Property
Signature of Applicant or *AgeI f
Dennis Holloway
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 ensure that the
well(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
See Attached Access Agreement
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]
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
,44F•ir
loorfon
Abk4
qek
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]
01/4
4414
I ngtan
GW-22MR Rev. 3-1-2016
Raleigh Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension
GW-22M (Rev. 5/11)

DocuSign Envelope ID: 3BB8810E-0056-4248-86E8-928CCCE3C79E
ECS SOUTHEAST, LLP
ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.:
Scope of Work:
Project:
Location:
49-27909
Soil and Groundwater Assessment
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 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):
Stan Forester
,-Docuslgned by:
SfatA, %Ovt,Sft r
Property Owner Signature: `—FCF2F2e5022649D..
ECS Proposal No. 49:27909-P
Page I 1
Date:
12/16/2021

SOURCE:
USGS TOPOGRAPHIC MAP
7.5 — MINUTE SERIES
CLEMMONS, NC
DATED 2019
SCALE: 1 : 24,000
CONTOUR INTERVAL = 10'
FIGURE 1
SITE TOPOGRAPHIC MAP
Immanuel Road Site
5911 Immanuel Road
Clemmons, Forsyth County, NC
ECS Project No: Pending

NO WATER SUPPLY WELLS OR POTENTIAL SOURCES
OF CONTAMINATION ARE KNOWN TO EXIST OTHER
THAN ILLUSTRATED ABOVE.
SOURCE:
NCDEQ
DWM SITE LOCATOR TOOL
APPROXIMATE SCALE:
250 ft.
N
FIGURE 2
L POTENTIAL SOURCES MAP
Immanuel Road Site
5911 Immanuel Road
Clemmons, Forsyth County, NC
ECS Project No: Pending

GROUND
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
�.,... "`
SURFACE
ESTIMATED
—25'-30'
FEET
A
NATURAL FORMATION
BACKFILL
GROUNDWATER
1.5-INCH STEEL DIRE
PUSH RISER
2--INCH BORE
HOLE
SLOTTED STEEL S
0.01-INCH SLOT W
SET TO INTERSECT GROI
ESTIMATED 4 FEET IN
V
WELL CONSTRUCTION DI
REPRESENTATIVE OF DIRECT
Df1IAIT CAMDI GI
CT
CREEN
IDTHS
JNDWATER
LENGTH
AGRAM IS
PUSH SCREEN
NOT TO SCALE
I
FIGURE 3
PROPOSED GROUNDWATER SAMPLER
Immanuel Road Site
5911 Immanuel Road
Clemmons, Forsyth County, NC
ECS Project No: Pending