WM0401400_Monitoring Well Permit Application_20220920

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 welts.
1. Date: 9/16/2022
2. County: Guilford
FOR OFFICE USE ONLY
PERMIT NO. _____ ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant: Koury Corporation — Mr. Alex Crow
Monitoring
Telephone: [phone]
Applicant's Mailing Address: 2275 Vanstory Street, Suite 200, Greensboro, NC 27403
Applicant's Email Address (If available): [e-mail]
5. Contact Person (If different than Applicant): Jonathan Garrick Telephone: [phone]
Contact Person's Mailing Address: 1812 Center Park Drive, Suite D Charlotte. NC 28217
Contact Person's Email Address (If available): Igarrick(a.ecslimited.com
6. Property Owner (If different than Applicant): Q-Dog Properties (PIN 7872389680). John Doutt (PIN 7872487501)
Telephone: Not Available
Property Owner's Mailing Address: 3302 Liberty Road, Greensboro. NC 27406
Property Owner's Email Address (If available): Not Available
3300 Liberty Road and
7. Property Physical Address (Including PIN Number): 3302 Liberty Road, Greensboro, Guilford County, NC 27406 (PiN
7872389660 and 7872487501)
8. Reason for Well(s): Environmental Assessment
9. Type of facility or site for which the well(s) is(are) needed: UST, AST, Paint and Fireproofing office
10. Are there any current water quality permits or incidents associated with this facility or slte? If so, Ilst permit and/or Incident no(s).
Not Applicable
11. Type of contaminants being monitored or recovered: VOCs. S1[OCs. TPH-GRO, TPH-DRO. PFAS (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).: Not Applicable
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): property to the North (1200 ftj
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): Not Applicable
15. Well Contractor: 3D Environmental Investigations Certification No.: 3162-A
Well Contractor Address: 2157 Mocksville Highway. Statesville, NC 26626
PROPOSED WELL CONSTRUCTION INFORMATION
1. As required by 15A NCAC 02C .0105(0(7), attach a well construction diagram of each well showing the following:
a. Borehole and well diameter
b. Estimated well depth
c, Screen Intervals
d. Sand/gravel pack Intervals
e. Type of casing material and thickness
f. Grout horizons
g. Well head completion details
Continued on Reverse

Sure of Property Owner (if different than Applicant)
ohn A. Doutt I
anager o Q-Dog Properties LLC DIRECTIONS
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2, Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Expandable
material: 5 locking well cap forlemp well construction
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 10/3/2022
4. Total Number of wells to be constructed: 5
(add answers from 2 and 3)
7. Estimated construction completion date: 10/3/2022
ADDITIONAL INFORMATION
i. 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
Signature of Applicant or `Agent
't.E-�X Geoff
Printed name of Applicant or `Agent
Title of Applicant or `Agent
!f 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
ell(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
�1r
oI-AJ A. Doutl
Printed name of Property Owner (if different than Applicant)
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. 3.1-2018
GW-22M (Rev. 5/11)

0.5
0
KILOMETERS
--+ • -- �-, I--1 1
1000
500
0.5
0
METERS
0
1000
2
2000
1 000
0 1000 2000
MILES
3000 4000 5000 6000
FEET
7000 8000
9000 10000
SOURCE:
USGS TOPOGRAPHIC MAP
7.5 — MINUTE SERIES
GREENSBORO, NC
DATED 2019
FIGURE 1
r SITE TOPOGRAPHIC MAP
Liberty Road Property
3000, 3302, 3306, 3310, 3312, and 3314
Liberty Road
Greensboro, NC
ECS Project No. 49:17926-C

_Ap
SITE PARCEL
--
BOUNQARY u^ P�
NO WATER SUPPLY WELLS OR POTENTIAL SOURCES OF CONTAMINATION ARE KNOWN TO EXIST OTHER THAN ILLUSTRATED ABOVE.
SOURCE:
GOOGLEEARTH IMAGERY
DATED ZO22&N[DECi
DWM SITE LOCATOR TOOL
APPROXIMATE SCALE:
As Shown
E c
5
FIGURE
~'Ar' POTENTIAL SOURCES MAP
Liberty Road Property
30N\J3OJ,3306,3310'33l2'and 33l4
Liberty Road
Greensboro, NC
ECS Project No.49:17926'C

LEGEND
• APPROXIMATE MONITORING WELL LOCATION
SOURCE:
GOOGLE EARTH
IMAGERY DATED 2022
Not to Scale
FIGURE 3
SAMPLE LOCATION MAP
Liberty Road Property
3000, 3302, 3306, 3310, 3312, and 3314
Liberty Road
Greensboro, NC
ECS Project No. 49:17926-C

ESTIMATED
"20' FEET
GROUND
SURFACE
0.5' — 6' PORTLAND CEMENT
6' — 8' BENTONITE
SAND 8'-10'
GROUNDWATER
MONITORING WELL COVER
2.0-INCH SCH 40 PVC
RISER
8.25 --INCH
BORE HOLE
2.0-INCH SHC 40 PVC SLOTTED SCREEN
0.01-INCH SLOT WIDTHS
SET TO INTERSECT GROUNDWATER
ESTIMATED 10 FEET IN LENGTH
NOT TO SCALE
NM'S
FIGURE 4
PROPOSED MONITORING WELLS
Liberty Road Property
3000, 3302, 3306, 3310, 3312, and 3314
Liberty Road
Greensboro, NC
ECS Project No. 49:17926-C