WM0701289_Well_20221108

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: October 26, 2022
2. County: Wayne
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
Monitoring
4. Applicant: Capital Growth Buchalter (Mr. Jeffery Lewin) Telephone: [phone]
Applicant's Mailing Address: 361 Summit Blvd, Suite 110, Birmingham, Alabama 35243
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Travis L. O'Quinn Telephone: [phone]
Contact Person's Mailing Address: 1900 Center Park Drive, Suite A, Charlotte, NC 28217
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Drew Linda Gail Wiggins Telephone: Not Available
Property Owner's Mailing Address: 2302 Wayne Memorial Drive, Goldsboro, NC 27534
Property Owner's Email Address (if available): Not Available
7. Property Physical Address (Including PIN Number) 2608 Medical Office Place PINs: 3610127533 and 3610125496
City Goldsboro County Wayne Zip Code 27534
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: Undeveloped grass lots. Proposed petroleum sales and storage.
(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: VOCs, SVOCs, RCRA 8, EDB & DBCP
(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): No reported pollution sources within 500 ft
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: Quantex, Inc. Certification No.: 3106
Well Contractor Address: [e-mail]
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: 0
4. Total Number of wells to be constructed: 3
(add answers from 2 and 3)
5. How will the well(s) be secured? Flu h mounted
protective covers. expandable lockino well caps. keyed locks,
and well completion teas affixed to the well head
6. Estimated beginning construction date: TBD
7. Estimated construction completion date: TBD
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, identfied 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,
S;sbct,apter 2C) and accepts full responsibility for compliance with these rules
Agent of Capital Growth Buchalter Environmental Project Manager
Signature of Applicant or *Agent Title of Applicant or *Agent
Travis O'Quinn / ECS Southeast, LLP
* 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).
A (A� , i.CE►vNETH f wZ'66z 3R
Signature of Property 0 r (if d ererrt 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]
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
Ptlone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

SOURCE:
USGS TOPOGRAPHIC 7.5' QUADRANGLE
CHARLOTTE EAST NC
SCALE:
AS SHOWN
FIGURE 1
USGS TOPOGRAPHIC MAP
GOLDSBORO PROPOSED WAWA
2608 MEDICAL OFFICE PLACE
GOLDSBORO, NORTH CAROLINA
ECS PROJECT NO. 49:17379-A
TM

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tt f
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0
WAYNE CR•
EMOJAL HOSPITAL
n•.
311.
.fI rRE a1 I
IrCF
•
m
3
m
011.0m14--
M,tATE SITE BOUNDARY
0 £PPROIOMATE SOIL AND GROUNDWATER BORING LOC:.TION
LEGEND
• APPitOXI MATE SOIL GAS BORING LOCATION
SOURCE;
KIMLEY HORN DROP IN PLAN
DATED NOVEMBER 30, 2021
SCALE:
= 100 ft
FIGURE 2
PROPOSED GROUNDWATER SAMPLE
LOCATIONS MAP
GOLDSBORO PROPOSED WAWA
2608 MEDICAL OFFICE PLACE
GOLDSBORO, NORTH CAROLINA
ECS PROJECT NO. 49:17379-A

ESTIMATED
-35 FEET
GROUND
SURFACE
PORTLAND GROUT
BENTONITE SEAL
(-2 FEET)
GROUNDWATER
V
TOP OF RISER ABOVE THE LAND
SURFACE
2-INCH PVC RISER
"'4-INCH BORE
HOLE
FILTER SAND
(-2 FEET ABOVE TOP OF
SCREEN)
SLOTTED PVC SCREEN
0.01-INCH SLOT WIDTHS
SET TO INTERSECT GROUNDWATER
ESTIMATED 10 FEET IN LENGTH
WELL CONTRUCTION DIAGRAM IS
REPRESENTATIVE OF PERMANENT MONITORING
WELL
NOT TO SCALE
TM
FIGURE 3
PROPOSED MONITORING WELL DIAGRAM
GOLDSBORO PROPOSED WAWA
2608 MEDICAL OFFICE PLACE
GOLDSBORO, NORTH CAROLINA
ECS PROJECT NO. 49:17379-A