WM0401403_Monitroing Well Permit Application_20220929

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:
2. County: Forsyth PERMIT NO.
FOR OFFICE USE ONLY
ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: NCDEQ Telephone: [phone]
Applicant's Mailing Address: 1646 Mail Service Center, Raleigh, NC 27699
Applicant's Email Address (if available): scott.rvals(cDncdenr.gov
5. Contact Person (if different than Applicant): Greg Hans Telephone: [phone]
Contact Person's Mailing Address: 3525 Whitehall Park Drive, Suite 150, Charlotte, NC 28273
Contact Person's Email Address (if available): ghans(cces-group.net
6. Property Owner (if different than Applicant): Julian Williams Telephone: [phone]
Property Owner's Mailing Address: 3206 Woods Circle, Detroit, MI 48207
Property Owner's Email Address (if available): juwilliams4(@aol.com
7. Property Physical Address (Including PIN Number) 1401 N Liberty Street PIN 6836-52-4356
City Winston-Salem County Forsyth Zip Code 27105_
8. Reason for Well(s): 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: Unknown (believed to be USTs)
(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).
11
12
13
14
No known
Type of contaminants being monitored or recovered: organics / metals
(ex: organics, nutrients, heavy metals, etc.)
Are there any existing wells associated with the proposed well(s)? If yes, how many? No known
Existing Monitoring or Recovery Well Construction Permit No(s).:
Distance from proposed well(s) to nearest known waste or pollution source (in feet): Unknown (believed to be a source area)
Are there any water supply wells located less than 500 feet from the proposed well(s)? No known
If yes, give distance(s):
15. Well Contractor: Carolina Soil Investigation Certification No.: Corey Speece #2904 /
Daniel Summers #2579
Well Contractor Address: 132 Gurney Road, Olin, NC 28660
PROPOSED WELL CONSTRUCTION INFORMATION
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 5. How will the well(s) be secured? 2 x 2 pad, well
material: One covers, locking -plug
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: One
(add answers from 2 and 3) 7. Estimated construction completion date: 10/3/2022
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.
G. 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 assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
W m
Signature of Applicant or *Agent
Greg Hans
Printed name of Applicant or *Agent
Environmental Division Manager
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
well(s) as outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
(See attached Access Agreement with NCDEQ State Trust Fund)
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 Raleigh Regional Office
Phone: [phone] Barrett Drive
Fax: [phone] Raleigh, NC 27609 Wilmington Regional Office
Phone: [phone] Cardinal Drive Extension
Fayetteville Regional Office Fax: [phone] Wilmington, NC 28405
225 Green Street, Suite 714 Phone: [phone]
Fayetteville, NC 28301-5094 Washington Regional Office Fax: [phone]
Phone: [phone] Washington Square Mall
Fax: [phone] Washington, NC 27889 Winston-Salem Regional Office
Phone: [phone] W. Hanes Mill Road
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
05

9/29/22, 5:26 AM 1401 N Liberty St - Google Maps
GO gle Maps 1401 N Liberty St
Proposed Monitoring Well Location MW-1
74th St N'�
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Imagery ©2022 Maxar Technologies, U.S. Geological Survey, Map data ©2022 Google 20 ft
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ENVIRONMENTAL PROTECTION
� HAZARDOUS SITES RESPONSE PROGRAM
6EOi6U
TYPICAL
FLUSH -MOUNT GROUNDWATER MONITORING WELL
CONSTRUCTION DIAGRAM
BOLTED MANHOLE COVER
CONCRETE PAD
MANHOLE SLEEVE
LOCKING WELL CAP
2" SCHEDULE 40 PVC PIPE
BENTONITE GROUT
BENTONITE SEAL
TYPE
SAND PACK
GRAIN SIZE
2" SLOTTED SCHEDULE
40 PVC SCREEN
BOTTOM CAP
BOTTOM OF BORING
ANNULUS

Waste Management
ENVIRONMENTAL QUALITY
July 13, 2022
Mr. Scott Ryals
Environmental Engineer
DWM UST Section
1637 Mail Service Center
Raleigh, NC 27699-1637
RE: State -Lead Acceptance
Williams Union 76
1401 N Liberty Street
Winston-Salem, Forsyth County, NC
Incident Number 30120
Dear Mr. Ryals
ROY COOPER
Governor
ELIZABETH BISER
Secretary
MICHAEL SCOTT
Director
I am/We are the owner(s) of a parcel of property, located at or near the incident in question, and
hereby permit the Department of Environmental Quality (Department) or its contractor to enter upon said
property for the purpose of conducting an assessment and/or remediation of the groundwater and/or soils
under the authority of G.S. 143-215.94G.
I am/We are granting permission with the understanding that:
The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the Department or
its contractor in accordance with the acceptance of the site into the State -Lead Program. The
Department or its contractor shall protect and prevent damage to the surrounding lands. Any damages
will be restored by the Department or its contractor to as close to the pre -work condition as practicably
possible.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the shortest
feasible route to the nearest public road. The Department or its contractor will notify the landowners
48 hours prior to entry and may enter upon the land at reasonable times and have full right of access
during the period of the investigation.
4. Any claims which may arise against the Department, or its contractor shall be governed by Article 31
of Chapter 143 of the North Carolina General Statutes, Tort Claims Against State Departments and
Agencies, and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon request and
is a public record, in accordance with G.S. 132-1.
Nothing Comparesr. .
State of North Carolina I Environmental Quality I Waste Management
1646 Mail Service Center 1 217 West Jones Street ; Raleigh, NC 27699-1646
919 707 8200 T

6. The activities to be carried out by the Department or its contractor are for the primary benefit of the
Department and of the State of North Carolina. Any benefits accruing to the owner are incidental.
The Department or its contractor is not and shall not be construed to be an agent, employee, or
contractor of the landowner. No representations or warranties, either expressed or implied, have been
made to me/by the Department, the State of North Carolina, or its/their contractor(s) regarding the
results that may be obtained or the quality of work to be performed
I/We agree not to interfere with, remove or any ways damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
Oe Jr
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Signature
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Type/Print Name of Owner or Agent
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Phone Number / b -mail Address
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Address
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City/State Zip Code
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Date
RE: State -Lead Acceptance
Williams Union 76
1401 N Liberty Street
Winston-Salem, Forsyth County, NC
Incident Number 30120
Nothing Compares_-___.._
State of North Carolina I Environmental Quality I Waste Management
1646 Mail Service Center 1 217 West Jones Street I Raleigh, NC 27699-1646
919 707 8200 T