WM0401387_Monitoring Well Permit Application_20220819

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
1.
2.
3.
4.
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.
Date: 08/18/22
County: Davidson
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery):
Applicant: C4 CStore Holdings II, LLC (Mr. Jamie Dillen)
Monitoring
Telephone: [phone]
Applicant's Mailing Address: 121 West Trade Street, Suite 2550, Charlotte, NC 28202
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Scott Young
Contact Person's Mailing Address: 1812 Center Park Drive, Suite D, Charlotte, NC 28217
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Piedmont Hardwood Lumber
Property Owner's Mailing Address: PO Box 535, Mt. Pleasant, NC 2812
Property Owner's Email Address (if available):
Property Physical Address (Including PIN Number) 0 Marlin Dr and 0 Hargrave Rd — PIN-6704-04-90-7177 & 6704-04-90-9171
7.
8.
9.
10.
City
Lexington
Reason for Well(s): Assessment
Telephone: [phone]
Telephone: [phone]
County Davidson Zip Code 27292
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
Type of facility or site for which the well(s) is(are) needed: USTs
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
Are there any current water quality permits or incidents associated with this facility or site? If so, list permit and/or incident no(s).
Unknown
11. Type of contaminants being monitored or recovered: VOCs & SVOCs
(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).: N/A
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): —250' NW of LUST Incident #44090
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Unknown
If yes, give distance(s):
15. Well Contractor: 3D Environmental Investigations, LLC Certification No.: 3162-A
Well Contractor Address: 2157 Mocksville Highway, Statesville, NC 28625
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.
b.
c.
d.
Borehole and well diameter
Estimated well depth
Screen intervals
Sand/gravel pack intervals
e.
f.
9.
Type of casing material and thickness
Grout horizons
Well head completion details
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: 1 Sample will be collected through Geoprobe Sampling
Point
6. Estimated beginning construction date: 8/22/22
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3) 7. Estimated construction completion date: 8/22/22
3. Number of wells to be constructed in bedrock: 0
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. 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 Corstruction 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
Environmental Project Management
Signature of Appl ant or Agent Title of Applicant or *Agent
Scott Young
* 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 ensure that the
well(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
See attached signed Access Agreement
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]
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, 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
Raleigh Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension
GW-22M (Rev. 5/11)

DocuSign Envelope ID: 455CE7F1-A38F-4E06-AFFE-AB64ADCDA238
July 25, 2022
ECS SOUTHEAST, LLP
ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:32658P
Scope of Work: Proposal for Baseline Environmental Assessment Services
Project: Proposed 7-Eleven
Location: 288/330/362 Hargrave St., 0/143 Marlin Dr., 0 Hargrave Rd., & 0 Dixon St.,
Lexington, Davidson County, North Carolina
As part of the proposed real estate transaction, ECS Southeast, LLP (ECS) has been requested by the
purchaser to conduct subsurface soil and groundwater sampling at the site. This 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 soil and groundwater sampling. By signed below, the property owner authorizes ECS to
conduct the aforementioned sampling at the site.
Property Owner (please print): Lynn sti rewal t
704-436-9311
Property Owner Telephone (please print):
Property Owner Signature:
ECS Proposal No. 49:32658P
Page
DocuSigned by:
gimmka
�2FBOA43AC10A4A0...
Date: 8/17/2022

0.5
0
SCALE I :24 000
KILOMETERS 1
2
1000
500 0
5
rETERS
2000
1E4D
?ACC
MILES
MCC #4X 50X 600C 70a MCC 5OCC 1000C
FEET
SOURCE:
GOOGLE EARTH
SCALE:
AS SHOWN
TM
FIGURE 1
SITE TOPOGRAPHIC MAP
PROPOSED 7-ELEVEN
288, 330, & 362 HARGRAVE ROAD, 143 MARLIN
DRIVE, 0 HARGRAVE ROAD, 0 DIXON STREET, & 0
MARLIN DRIVE
LEXINGTON, NORTH CAROLINA
ECS PROJECT NO. 49:17109-A

APPROXIMATE SITE BOUNDARY
LEGEND
OAPPROXIMATE PROPOSED GROUNDWATER BORING LOCATION
SOURCE:
DAVIDSON COUNTY GIS WEBSITE
ACCESSED JULY 20, 2020
SCALE:
150 75 0
150
FIGURE 2
PROPOSED SAMPLE LOCATION MAP
PROPOSED 7-ELEVEN
288, 330, & 362 HARGRAVE ROAD, 143 MARLIN
DRIVE, 0 HARGRAVE ROAD, 0 DIXON STREET, & 0
MARLIN DRIVE
LEXINGTON, NORTH CAROLINA
ECS PROJECT NO. 49:17109-A

GROUND
TOP OF DIRECT PUSH STEEL
RODS ABOVE THE LAND
-... "`
SURFACE
ESTIMATED
^'15'-20'
FEET
A
NATURAL FORMATION
BACKFILL
GROUNDWATER
1.5-INCH STEEL DIRE
PUSH RISER
2--INCH BORE
HOLE
SLOTTED STEEL S
0.01-INCH SLOT W
SET TO INTERSECT GROI
ESTIMATED 4 FEET IN
V
V
WELL CONTRUCTION DI/
REPRESENTATIVE OF DIRECT
D(IIAIT SAMDI FI
CT
CREEN
IDTHS
JNDWATER
LENGTH
GRAM IS
PUSH SCREEN
NOT TO SCALE
TM
FIGURE 3
PROPOSED TEMPORARY SCREEN
POINT SAMPLER
PROPOSED 7-ELEVEN
288, 330, & 362 HARGRAVE ROAD, 143 MARLIN
DRIVE, 0 HARGRAVE ROAD, 0 DIXON STREET, & 0
MARLIN DRIVE
LEXINGTON, NORTH CAROLINA
ECS PROJECT NO. 49:17109-A