WM0701270_Application_20220211

NORTH CAROUNA 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; February 7 2022
2. County: Wayne
3.
4. Applicant:. NC Goldsboro Hwy 70. LLC
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery):
Monitoring Well
Telephone: [phone]
Applicant's Mailing Address: 201 Riverolace Suite 400. Greenville. South Carolina 29601
Applicant's Email Address (it available): [e-mail]
5. Contact Person (if different than Applicant): Dan Matz
Telephone: [phone]
Contact Person's Mailing Address: 6004 Ponders Court. Greenville. South Carolina 29615
Contact Person's Email Address (if available): dan.matztU)blecoro.com
6. Property Owner (if different than Applicant): HWB of North Carolina. LLC Telephone: NA
Property Owner's Mailing Address: PO Box 189. Kinston North Carolina 28502
Rope' tyOwne?sEmail Address (if available): NA
7. Property Physical Address (Including PIN Number) 2773. 2783. and 2803 US Highway 70 West Goldsboro. Wayne County
North Carolina - Wayne County Taxi() 2671818723) and a portion of a Wayne County Tax ID 2671804967
City Goldsboro County Wayne Zip Code 27530
8. Reason for Well(s): Groundwater Assessment. suspected contamination
(et 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: Former electricai/highwire installation business - Stackhouse. Inc.
(ex: non-dischargefacility,..wastedisposal site, landfill, UST,. etc.)
10. Are there any current water quality permits or incidents associated with this facility or site? If so, list permit andlor incident no(s).
Yes - Incident Number 19336. UST ID 00-0-0000005425. Incident Number 88369
11. Type of contaminants being monitored or recovered: Organics - Petroleum and solvents
(ex: organics, nutrients, heavy meta, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? None known at this time
Existing Monitoring or Recovery Well Construction Permit No(s).: Not Applicable
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): <10-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: Environmental Hydrogeologicai Consultants. Inc: Certification -No:: ThomasAmtrrous 2035A
Well Contractor Address: 207 West Fourth Avenue. Red Springs. North Carolina 28377
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 5. How will the well(s) be secured?
material: Four (4) Temporary Well
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 2-16-22
4. Total Number of wells to be constructed: Four (4)) 7. Estimated construction completion date: 2-16-22
(add answers from 2 and 3)
ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C .0105(1)(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,
7/
$�bthalpter 2C) and accepts full responsibility for compliance with these rules
GGG�i�f Manager
r ' gent Title of Applicant or `Agent
NC G
Signature of Appli
Philip J. Wilson
* 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
well outlined in this Well Construction Permit application and that it shall be the responsibility of the applicant to ensure that the
) conform to the astruction Standards (Title 15A of the North C lina Administrative Code, Subchapter 2C).
1 1 V // wAku er a J i W 1
Signature of Property (if different than Applicant) ' Printed name of Property Owner (if different than Applicant)
t �tF)'ofTo.�`

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]
Wllmington 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: (336) T76-9800
Fax: [phone]
GIN-22M (Rev. 5111)
GW-22MR (6/11)

R
t i Hl itnt ilt i 111
III
i i i i i i1 i i Y i i iY
Ii
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3 i i i i ■i i i i i i! f 1 1!•■ {

GEOPROBE BORING
GROUND SURFACE
1.5-INCH STEEL PI
EXISTING
FORMATION
STAINLESS STEEL
SCREEN
(4 FEET LONG)
(SLOT SIZE 0.010-INCH)
STAINLESS STEEL
PONT
Estimated Well Depth - 20-feet below
ground surface.
No sand/gravel pack
Stainless steel casing
No Grout
No well head
NUE
"FOOL IS REIRACIED AF1ER SWUNG
AND BORING ABANDONED MTh
BENTONITE GROUT.
Alb NU
JI1-7432-01
041D
00-16-11
NOT 10 SCALE
1111.111.
NOMaur MINS IND.
aOL tm4 Itrel-44SI
TYPICAL GEOPRORE
BORING DIAGRAM
APPENDIX
A

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�— 20
<p' L
Q-i
-104
NF
_Aoww_i i8E MW-2
<PQL WNF
/
<PQL
W-4
QL
WNF
\
-202
\
ug/1. (— \
VMW--201 \
I <PQL
101
-6
<PQL
vMW-7
<p
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Co
/
MW-9
<PQL
/
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\
vMW./
-4'QL.
MOMITORING
WELL
TOP OF WELL
CASING
ELEVATION
DEPTH TO
GROUNDWATER
GROUNDWATER
ELEVATION
MW-1
98.14'
6.46'
91.68'
MW-2
---
---
---
MW-3
- - -
- - -
---
MW-4
99.64'
8.15
91.49'
MW5
- --
- - -
- - -
MW-6
98.71'
7.19'
91.52'
MW-7
100.71'
10.35'
90.36'
MW-8
96.66'
6.71'
89.95'
MW-9
97.94'
8.33'
89.61.
MW-10
- - -
- - -
.... -
MW-101
96.36'
6.58'
89.78'
MV1L102
92.74'
4.35'
8&39'
MW-103
---
---
---
MW-104
---
---
---
MW-201
94.58'
5.06'
89.52'
MW-202
95.76'
6.29'
89.4r
MW-203
95.34'
5.79'
89.55'
MW-# -MONITORING WELL
is( WNF - WELL NOT FOUND
<PQL - LESS THAN P QUANTITY LIMIT
ISOCONCENTRATION CONTOURS FOR
TRICHLOROETHENE
FEBRUARY 11, 2009
GROUNDWATER STANDARD = 2.8 ug/I
SCALE: 1" = 100'
VD
ro
BRYANK
'`.:04 / JONES CONSULTING ENGINEERS, P.A. STACKHOUSE PROPERTY
Carolina Commerce Center
�y 2815 North William Street, Suite E
evqGoldsboro, North Carolina 27530
919-221-5222
WELL MONITORING
WEIL ENTERPRISES
�x 1 m.,le6b[17.
BKJ 08065
SEE PLAN
6/10/2009 1 of 1