WM0100513_Groundwater Monitoring Well Construction Application_20220602

FOR OFFICE USE ONLY

PERMIT NO. ISSUED DATE
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: 6/2/2022

2. County: Henderson

3. What type of well are you applying for? (monitoring or recovery): Monitoring

4. Applicant: Housing Assistance Corporation Telephone: [phone] x 105

Applicant’s Mailing Address: 602 Kanuga Road, Hendersonville, NC 28739

Applicant’s Email Address (if available): Sean Rose [e-mail]

5. Contact Person (if different than Applicant): James C. Bevers, P.E., ECS Southeast, LLP Telephone: [phone]

Contact Person’s Mailing Address: 1900 Hendersonville Road, Suite 10, Asheville, NC 28803

Contact Person’s Email Address (if available): [e-mail]

6. Property Owner (if different than Applicant): CD-MATT LLC Telephone: [phone]

Property Owner’s Mailing Address: 847 Tracy Grove Rd. Flat Rock, NC 28731

Property Owner’s Email Address (if available): [e-mail]

7. Property Physical Address (Including PIN Number) 524 E Prince Road PIN 9579740966
City Hendersonville County Henderson Zip Code 28792
8. Reason for Well(s): assessment of suspected contamination of the groundwater
(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: paint business
(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 in cident no(s).

No

11. Type of contaminants being monitored or recovered: volatiles and semi-volatiles
(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).: No

13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 250

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: JG Drilling, LLC Certification No.: 4328-B

Well Contractor Address: 132 Gurney Road, Olin, NC

DocuSign Envelope ID: 7774EEC0-66E5-49F1-AAD9-29BA3D21F7C9

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

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)

2. Number of wells to be constructed in unconsolidated
material: 3

3. Number of wells to be constructed in bedrock: 0

4. Total Number of wells to be constructed: 3
(add answers from 2 and 3)
5. How will the well(s) be secured? Locking
expansion cap

6. Estimated beginning construction date: 6/8/2022

7. Estimated construction completion date: 6/8/2022
(within 96 hours of installation)

ADDITIONAL INFORMATION

1. 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 speci fications 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

Signature of Applicant or *Agent 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 en sure that the
well(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).

Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant)

DocuSign Envelope ID: 7774EEC0-66E5-49F1-AAD9-29BA3D21F7C9
Ashlynn McCoy
Executive Director
Dennis Dorn
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 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
DocuSign Envelope ID: 7774EEC0-66E5-49F1-AAD9-29BA3D21F7C9
FIGURE 1
PROPOSED SAMPLE LOCATION MAP
SUGARLOAF ROAD PROPERTY
HENDERSONVILLE, HENDERSON COUNTY,
NORTH CAROLINA
ECS PROPOSAL NO. 49-15281-A
SOURCE:
GOOGLE EARTH, DATED 2019
SCALE:
PROPOSED SOIL & GROUNDWATER SAMPLE LOCATION
APPROXIMATE SITE BOUNDARY
= 250 FEET
LEGEND
FIGURE 2
PROPOSED WELL CONSTRUCTION
DIAGRAM
SUGARLOAF ROAD PROPERTY
HENDERSONVILLE, HENDERSON COUNTY,
NORTH CAROLINA
ECS PROPOSAL NO. 49-15281-A
NOT TO SCALE
EXPANSION CAP
WITH LOCK
2-INCH BORE
HOLE
1-INCH PVC CASING
SCHEDULE 40
GROUND
SURFACE
GROUNDWATER SLOTTED PVC SCREEN
0.01-INCH SLOT WIDTHS
SET TO INTERSECT GROUNDWATER
ESTIMATED 10 FEET IN LENGTH
SAND SCREEN
MINIMUM 1 FOOT ABOVE THE
SLOTTED PVC SCREEN
BENTONITE PLUG
MINIMUM 2 FEET
25 FEET
WELLS ARE INTENDED TO BE INSTALLED USING DIRECT
PUSH DRILLING OR AIR ROTARY, GROUNDWATER
SAMPLED, & ABANDONED ON THE SAME DAY.
Certificate Of Completion
Envelope Id: 7774EEC066E549F1AAD929BA3D21F7C9 Status: Completed
Subject: Please DocuSign: GW-22MR Monitoring or Recovery Well APPLICATION Sugarloaf (003).pdf
Source Envelope:
Document Pages: 3 Signatures: 2 Envelope Originator:
Certificate Pages: 5 Initials: 0 Gregory Sachs
AutoNav: Enabled
EnvelopeId Stamping: Enabled
Time Zone: (UTC-08:00) Pacific Time (US & Canada)
PO Box 2057
Hendersonville, NC 28793
[e-mail]
IP Address: 24.246.154.73
Record Tracking
Status: Original
6/3/2022 6:32:32 AM
Holder: Gregory Sachs
[e-mail]
Location: DocuSign
Signer Events Signature Timestamp
Ashlynn McCoy
[e-mail]
Executive Director
Security Level: Email, Account Authentication
(None)Signature Adoption: Pre-selected Style
Signed by link sent to
[e-mail]
Using IP Address: 24.246.154.73
Signed using mobile
Sent: 6/3/2022 6:38:26 AM
Viewed: 6/3/2022 8:39:51 AM
Signed: 6/3/2022 8:40:55 AM
Electronic Record and Signature Disclosure:
Accepted: 6/3/2022 8:39:51 AM
ID: 3a66e4b1-2201-48cb-9d23-39d634400f8d
Dennis Dorn
[e-mail]
Security Level: Email, Account Authentication
(None)
Signature Adoption: Pre-selected Style
Signed by link sent to [e-mail]
Using IP Address: 173.246.211.189
Sent: 6/3/2022 6:38:27 AM
Viewed: 6/3/2022 6:42:03 AM
Signed: 6/3/2022 6:42:28 AM
Electronic Record and Signature Disclosure:
Accepted: 6/3/2022 6:42:03 AM
ID: d82188d1-1c14-41d1-984a-15d75fc113b4
In Person Signer Events Signature Timestamp
Editor Delivery Events Status Timestamp
Agent Delivery Events Status Timestamp
Intermediary Delivery Events Status Timestamp
Certified Delivery Events Status Timestamp
Carbon Copy Events Status Timestamp
Witness Events Signature Timestamp
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps
Envelope Sent Hashed/Encrypted 6/3/2022 6:38:27 AM
Certified Delivered Security Checked 6/3/2022 6:42:03 AM
Signing Complete Security Checked 6/3/2022 6:42:28 AM
Completed Security Checked 6/3/2022 8:40:55 AM
Payment Events Status Timestamps
Electronic Record and Signature Disclosure
ELECTRONIC RECORD AND SIGNATURE DISCLOSURE
From time to time, The Housing Assistance Corporation (we, us or Company) may be required
by law to provide to you certain written notices or disclosures. Described below are the terms
and conditions for providing to you such notices and disclosures electronically through the
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elect to create a DocuSign account, you may access the documents for a limited period of time
(usually 30 days) after such documents are first sent to you. After such time, if you wish for us to
send you paper copies of any such documents from our office to you, you will be charged a
$0.00 per-page fee. You may request delivery of such paper copies from us by following the
procedure described below.

Withdrawing your consent
If you decide to receive notices and disclosures from us electronically, you may at any time
change your mind and tell us that thereafter you want to receive required notices and disclosures
only in paper format. How you must inform us of your decision to receive future notices and
disclosure in paper format and withdraw your consent to receive notices and disclosures
electronically is described below.

Consequences of changing your mind
If you elect to receive required notices and disclosures only in paper format, it will slow the
speed at which we can complete certain steps in transactions with you and delivering services to
you because we will need first to send the required notices or disclosures to you in paper format,
and then wait until we receive back from you your acknowledgment of your receipt of such
paper notices or disclosures. Further, you will no longer be able to use the DocuSign system to
receive required notices and consents electronically from us or to sign electronically documents
from us.

All notices and disclosures will be sent to you electronically
Electronic Record and Signature Disclosure created on: 2/23/2021 7:47:00 AM
Parties agreed to: Ashlynn McCoy, Dennis Dorn
Unless you tell us otherwise in accordance with the procedures described herein, we will provide
electronically to you through the DocuSign system all required notices, disclosures,
authorizations, acknowledgements, and other documents that are required to be provided or made
available to you during the course of our relationship with you. To reduce the chance of you
inadvertently not receiving any notice or disclosure, we prefer to provide all of the required
notices and disclosures to you by the same method and to the same address that you have given
us. Thus, you can receive all the disclosures and notices electronically or in paper format through
the paper mail delivery system. If you do not agree with this process, please let us know as
described below. Please also see the paragraph immediately above that describes the
consequences of your electing not to receive delivery of the notices and disclosures
electronically from us.

How to contact The Housing Assistance Corporation:
You may contact us to let us know of your changes as to how we may contact you electronically,
to request paper copies of certain information from us, and to withdraw your prior consent to
receive notices and disclosures electronically as follows:
To contact us by email send messages to: [e-mail]

To advise The Housing Assistance Corporation of your new email address
To let us know of a change in your email address where we should send notices and disclosures
electronically to you, you must send an email message to us at christina@housing-
assistance.com and in the body of such request you must state: your previous email address, your
new email address. We do not require any other information from you to change your email
address.
If you created a DocuSign account, you may update it with your new email address through your
account preferences.

To request paper copies from The Housing Assistance Corporation
To request delivery from us of paper copies of the notices and disclosures previously provided
by us to you electronically, you must send us an email to [e-mail] and
in the body of such request you must state your email address, full name, mailing address, and
telephone number. We will bill you for any fees at that time, if any.

To withdraw your consent with The Housing Assistance Corporation
To inform us that you no longer wish to receive future notices and disclosures in electronic
format you may:
i. decline to sign a document from within your signing session, and on the subsequent page,
select the check-box indicating you wish to withdraw your consent, or you may;
ii. send us an email to [e-mail] and in the body of such request you
must state your email, full name, mailing address, and telephone number. We do not need any
other information from you to withdraw consent.. The consequences of your withdrawing
consent for online documents will be that transactions may take a longer time to process..

Required hardware and software
The minimum system requirements for using the DocuSign system may change over time. The
current system requirements are found here: https://support.docusign.com/guides/signer-guide-
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Acknowledging your access and consent to receive and sign documents electronically
To confirm to us that you can access this information electronically, which will be similar to
other electronic notices and disclosures that we will provide to you, please confirm that you have
read this ERSD, and (i) that you are able to print on paper or electronically save this ERSD for
your future reference and access; or (ii) that you are able to email this ERSD to an email address
where you will be able to print on paper or save it for your future reference and access. Further,
if you consent to receiving notices and disclosures exclusively in electronic format as described
herein, then select the check-box next to ‘I agree to use electronic records and signatures’ before
clicking ‘CONTINUE’ within the DocuSign system.
By selecting the check-box next to ‘I agree to use electronic records and signatures’, you confirm
that:
 You can access and read this Electronic Record and Signature Disclosure; and
 You can print on paper this Electronic Record and Signature Disclosure, or save or send
this Electronic Record and Disclosure to a location where you can print it, for future
reference and access; and
 Until or unless you notify The Housing Assistance Corporation as described above, you
consent to receive exclusively through electronic means all notices, disclosures,
authorizations, acknowledgements, and other documents that are required to be provided
or made available to you by The Housing Assistance Corporation during the course of
your relationship with The Housing Assistance Corporation.