WM0501484_Application_20220524

DocuSign Envelope ID: 6AAC3162-4DAB-46C8-BB13-F8A13i i 2
JMENTAL QUALITY - DIVISION OF WATER RESOURCES
IYVR 1 1-1l VFIRV LIIYPI L/rF1R I IYICIY 1 .jr CIY vIRVI
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: 5/18/2022
2. County: Wake
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Temporary Monitoring Wells to be Abandoned After Sampling
4. Applicant: Geosyntec Consultants of NC P.C. as agent of The Halle Companies Telephone: [phone]
Applicant's Mailing Address: 2501 Blue Ridge Road, Suite 430, Raleigh, NC 27607
Applicant's Email Address (if available):
5. Contact Person (if different than Applicant): Ryan Gabelman
Telephone: [phone]
Contact Person's Mailing Address: 2501 Blue Ridge Road, Suite 430, Raleigh, NC 27607
Contact Person's Email Address (if available): rabelman©geosyntec.com
6. Property Owner (if different than Applicant): Wal-Mart Real Estate Business Trust Telephone:
Property Owner's Mailing Address: PO Box 8050 Bentonville, AR, 72716-8050
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 4401 Poole Rd, Raleigh, NC 27610, PIN 1733047524
City Raleigh County NC Zip Code 27610
8. Reason for Well(s): 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: Undeveloped Property
(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
(ex: organics, nutrients, heavy metals, etc.): Wells will be sampled to evaluate potential presence of Volatile Organic
Compounds (VOCs)
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).: WM0501468
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Possible LUST — 254 feet south of the Site
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: AmeriProbe, LLC — John Allen (Driller Certification No.: 4196-B
Well Contractor Address: PO Box 135, Huntersville, NC 28070
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

DocuSign Envelope ID: 6AAC3162-4DAB-46C8-BB13-F8A1302DB072 cued on Reverse
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated
5. How will the well(s) be secured? Locking
material: 5 expansion plug
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 5
(add answers from 2 and 3)
6. Estimated beginning construction date: 6/6/2022
7. Estimated construction completion date: 6/8/2022
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,
Digitally signetl by Ericp' { phapter 2C) and accepts full responsibility for compliance with these rules
D N'. cnEric Riflcin, cU
Eric Rifkin Halle Companies, ou=Assistant Vice
emeaitleni
mail=eriFkin©hallecom panies.com
Date'. 2022. 05.23 14'.51'. 50-04'00'
Signature of Applicant or *Agent
Eric Rifkin
Printed name of Applicant or *Agent
Assistant Vice President
Title 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
DDOM`L- nform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
�lInG1 ktArt1Llgl, Walmart Real Estate
Gina Meredith
SignatureSignaturr glIsTiglty 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]
�L It�l
e."441
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]
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GW-22M GW-22M (Rev. 5/11)

DocuSign Envelope ID: 6AAC3162-4DAB-46C8-BB13-F8A1302DB072
Legend
•
Former Surface Water Sampling
Leaking Underground Storage Tank
Surface Water Direction
Stream
Surface Water Feature
Proposed Temporary Monitoring Well Location
Culvert
Wetlands (unclassified)
United States Wetland Inventory (wetland type)
Freshwater Forested/Shrub Wetland
Freshwater Pond
Riverine
Approximate Parcel Boundary
Parcel Boundary
Upgradiant'
Notes:
1. Leeking underground storage tanks based on ERIS Figure.
2. Stream, culvert, and wetlands (unclassified) locations based on Figure 1 Surface Water Sample Location, S&ME
dated 21 January 2020.
3. Surface water creek based on field observations December 2021.
4. United States (U.S.) wetland inventory data layer obtained from U.S. Fish and Wildlife Service Wetlands Mapper
website (last modified 1 December 2021, North Carolina geodatabase).
5. Parcel boundaries obtained from Wake County North Carolina Open data site (5 January
2022, https://data.wakegov.com/).
6. 2020 World Imagery Source: Esri, Maxar, GeoEye, Earthstar Geographics, CNES/Airbus DS,
USDA, USGS, AeroGRID, IGN, and the GIS User Community.
0 200
Feet
Trademark,Drive
Proposed Temporary
Monitoring Well Location
Poole Road Multifamily Development
Raleigh, North Carolina
Geosyntec°
consultants
Geosyntec Consultants of NC, P.C.
NG License No.: C-3500 and (', 295
Raleigh, NC
May 2022
Figure
1
Path: (Titusville-01\DATA) T:\OGIS\GN8486_PooleRd\MXDs\SiteVicinity_wetlands.mxd 10 January 2022. Last Edited by: mhensley

DocuSign Envelope ID: 6AAC3162-4DAB-46C8-BB13-F8A1302DB072
GROUND SURFACE
1" SCH 40 PVC RISER
u-
7' BGS
9' BGS
10 FT. 1" SCH 40 PVC
SCREEN (0.01" SLOT
SIZE)
n•
END CAP
TD=20' BGS
LOCKING COMPRESSION CAP
7' GROUT TO SURFACE
2' BENTONITE SEAL
11' 20/30 SAND FILTER PACK
NOTE: Total depth may be modified based on
field conditions.
BGS - below ground surface
Grout will only be used if converted to a
permanent monitoring well
NOT TO SCALE
MONITORING WELL CONSTRUCTION DETAILS
Geosyntec Figure
consultants
Geosyntec Consultants of NC, P.C. 2
GN8486 May 2022