WM0701287_Application_20221007

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: 10/6/2022
2. County: Currituck
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring (temporary)
4. Applicant: Ryan Homes (Mr. Daniel Rojas)
Telephone: [phone]
Applicant's Mailing Address: 4525 South Boulevard, Suite 100, Virginia Beach, VA 23452
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Ron Navarro
Contact Person's Mailing Address: 5260 Greens Dairy Rd, Raleigh, NC 27616
Contact Person's Email Address (if available): [e-mail]
Telephone: [phone]
6. Property Owner (if different than Applicant): Justin Old Telephone: [phone]
Property Owner's Mailing Address: PO Box 88, Maple, NC 27956
Property Owner's Email Address (if available): Not available
7. Property Physical Address (Including PIN Number) Baxter Ln, Parcel ID Number 0009000025A0000
City Moyock County Currituck Zip Code 27958
8. Reason for Well(s): Phase II 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: Agricultural
(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: Petroleum and solvents (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).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Adjoining property, Approx. 200 ft to
southwest
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? none observed
If yes, give distance(s):
15. Well Contractor: Ground Zero Environmental Certification No.: NCWC 30127-A
Well Contractor Address: 11100 Astarita Ave, Partlow, VA 22534
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

Continued on Reverse
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:
4. Total Number of wells to be constructed: 3
6. Estimated beginning construction date: October 14,
2022
7. Estimated construction completion date: October 14,
(add answers from 2 and 3) 2022
5. How will the well(s) be secured? Capped and locked
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 Apphcanl herehy agrees that the proposed well(s) will he constructed in accordance with approved specifications and condition of
ihrs WeEI C a.nstri fonfermit as regulated irfder the Well Cpnslruction Standards (Title 15A of the North Carolina Adminlsiratwe Code.
Subchapter 2C) and accepts ;call nyspDnsihility for compliance with these rules
ure of Applicant or Ageni Ttle Of Applicant or 'Agent
DPnoW\_. -
if signing as A{{rarrt ntta;:tr aarftiorizirtforr ngreorrrcnt strrfir?g Printed name of
Applicant or 'Agent theryoo rlavea tttei arrtfieorgy rtr act ass trig AgW.10.
If the property Is ownot by $O1116010 Other than the applicerit, the property owner hereby rnneenIs to allow the appicani to construct
wells as outlined in this Well Conslnuallon Permit apppGedGn and that it shall Ehe responsibilly of the applicant to endure that the
tiaell(s} conform to the Well Cons/recline Standards (Title 15A of the Noilh Carolina Adr iiiatratiwe Code, Subchapter 2C).
Soo attached Ju91ui Old
Signature of Property OM cr (f dtlorent than App[icanl) Printed name of Property Owner (if different lhan 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]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. H
Suite 30
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GW-22M (Rev. 5/11)
GW-22MR Rev. 3-1-2016