WM0501466_Application_20220124

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NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL. QUALITY - DIVISION OF WATER RE OUR S
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
fay 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: 2_. y oi+.r1 Za ZZ
2. County: ._ 1 1L
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant .-'y =Ytrtan Telephone: (4" -737 -20t9
Applicant's Mailing Address: 34174 Cora( ✓&Atli~ !?I4, 1144 Sip S21, EC,u / 4r6,4.w (e 1 .4/L 7 913,r 8
Applicant's Email Address (if available): -IvcfS p i-. j $ * _ tc.0 . eau'.7
5. Contact Person (if different than Applicant): Ymitt . r Tree Telephone: Ci1C1- 9kkke 30-?•N
Contact Person's Mailing Address: Ori `i , 1 a a., c e_ ,t-m ZA 4-413 . C 0_0 ,N] C 2151
Contact Person's Email Address (if available): Oi- _\ \.5-` oJi 1Y110-1 \ . CM rY-1
B. Property Owner (if different than Applicant): Chris�jo•-rr Telephone: Riot -`I.24 -S9I.��
Property Owner's Mailing Address: a1D5k V t re rr 13 N NC ta"is v 1
Property Owner's Email Address (if available): ein r i shckrr AR e Tro. . C-e,r-Y %
7. Property Physical Address (Including PIN Number) 2Z 17- jk 1. , 'Pr- (PIIO 07fir 2,153.8-)
City_P .I al + L, County lnroik1 Zip Code 27601
8. Reason for Well(s): 60-11%•••44....-_!5—rww-4 o le Lee rl'a- 5/54,.. crlarrriac.t t tic ECG)
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
9. Type of facility or site for which the wells) is(are) needed: nilz 111u r c .:1; {,( / Ma►411-1401,- f t44.4at 5
(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).
_'o
11. Type of contaminants being monitored or recovered: M.4-it-wit
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? N0
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 0 fit ; 0e44 fie olfIlin&US
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Na .s.04,
If yes, give dlstance(s): _
15. Well Contractor. Certification No.:
Well Contractor Address:
PROPOSED WELL CONSTRUCTION INFORMATION
1 As required by 15A NCAC 02C .0105(1)(7), attach a well construction diagram of each well showing the following:
a. Borehole and wel diameter e. Type of casing material and thiclaress
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)
pplicant or *Agent
�V vGeisen
Printed n me o Applicant or *Agent
2. Number of wells to be construcpd in ungonsolidated 5. How will the well s) be secured? f wheat be l.,
material: (,-!0 i ere 'Ar Ay „r ti .ti �...1 ae._.rsof t.(
vu re-
3. Number of wells to be constructed in bedrock: , 0 6. Estimated beginning construction date: lititaliaL Z 2.
4. Total Number of wells to be constructed: 6 - /0 7. Estimated construction completion date: "Tok.:, 21/ b Z2
(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.
b.
c.
d.
e.
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.
All existing welts, idenflfled by type of use, within 500 feet of the proposed well or well system.
The proposed well or well system.
Any test borings within 500 feet of proposed well or well system.
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 (Tide 15A of the North Carolina Administrative Code,
Subchapter 2C) and accepts full responsibility for compliance with these rules
Tit plicant 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 outlined in this Well Constrution 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 caner (if .' rent than Applicant) Printed name of Property Ownev(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
Swannenoa, 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
810 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

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• Proposed Well Location
Property Boundary
Proposed Well Buffer (500 ft)
Property Buffer (500 ft)
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- Stream
• Drinking Well
Garage & Race Track
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Simpkins Road
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Meters
300
1 i 1 I
Feet
0 1,000 2,000
Known & Suspected Septic Tank
0
600
Figure 2. Site map showing proposed well scheme (approximately 6 —10 wells total) to
monitor surficial aquifer concentrations of nutrients downgradient from septic systems.
Additional known or potential groundwater contaminants are also mapped within 500 ft
of the entire property.