WM0801188_Application_20220414

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: 4/14/22
2. County: New Hanover
3.
4.
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): monitoring(temporary)
Applicant: Tribute Investment & Development, Inc.
Telephone: [phone]
Applicant's Mailing Address: 332 Military Cutoff Rd, Wilmington, NC 28405
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Ron Navarro 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): Lee Van Ormer Telephone: [phone]
Property Owner's Mailing Address:
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 1602 Burnett Blvd, PIN #R05417-016-002-000
City Wilmington County North Carolina Zip Code 28401
8. Reason for Well(s): Phase II Environmental Site 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
(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: VOCs (ex: organics, nutrients, heavy
metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many?
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Adjoining property
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? none observed
If yes, give distance(s):
15. Well Contractor: Regional Probing Certification No.: 3322A Lawrence Opper
Well Contractor Address: Po Box 1161, Wake Forest, North Carolina 27588
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: 2
3. Number of wells to be constructed in bedrock:
4. Total Number of wells to be constructed: 2
(add answers from 2 and 3)
5. How will the well(s) be secured? Capped and locked
6. Estimated beginning construction date: April 2022
7. Estimated construction completion date: April 2022
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
Staff Environmental Project Manager
Signature of Applicant or *Agent Title of Applicant or *Agent
Ron Navarro
Printed name of Applicant 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 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 sttached
Lee van Ormer
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 Cardin
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
`i GW-22M (Rev. 5/11)
GW-22MR Rev. 3-1-2016

SOURCE:
ECS PHASE I (APRIL 2022)
2020 IMAGERY
SCALE SHOWN ABOVE
LEGEND
SITE PARCEL BOUNDARY
PROPOSED GROUNDWATER SAMPLE LOCATION
FIGURE 1
PROPOSED SAMPLE LOCATION MAP
Burnett Boulevard Site
1602 Burnett Boulevard
Wilmington, North Carolina 28401
ECS Proposal Number: 49:30632

ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:30632
Scope of Work: Proposal for Phase II ESA
Project: Burnett Boulevard Site
Location: 1602 Burnett Blvd, Wilmington, New Hanover County, North Carolina
As part of the proposed real estate transaction, ECS Southeast, LLP (ECS) has been requested by the
purchaser to conduct due diligence tasks including groundwater sampling at the site. The groundwater
sampling 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 above referenced tasks. By signed below, the property owner authorizes ECS to conduct
the aforementioned sampling at the site.
Property Owner (please print):
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Property Owner Telephone (please print): J 7` 23 -7,33
Property Owner Signature: , Date:/ /3