WM0401372_Monitoring Well Permit Application_20220613

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:06/09/22
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: Crown GHO, LLC
Monitoring Well
Telephone: [phone]
Applicant's Mailing Address: 2905 Premiere Parkway, Suite 300, Duluth, GA 30097
Applicant's Email Address (if available): Brian DePouli; bdepouli a(�asburyauto.com
5. Contact Person (if different than Applicant): Justin Vickery
Telephone: [phone]
Contact Person's Mailing Address: 235 Ponce de Leon Place, Suite M-183, Decatur, GA 30030
Contact Person's Email Address (if available): iustin.vickery(@,trammco.com
6. Property Owner (if different than Applicant): Bob Neil, Inc. of Winston Salem Telephone:
Property Owner's Mailing Address: 691 Jonestown Road, Winston Salem, NC 27103
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 823 Norwalk Street
City Greensboro
County Guilford
Zip Code 27407
8. Reason for Well(s): Environmental 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: Non -Discharge
(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).
NONCD0001569
11. Type of contaminants being monitored or recovered: Volatile Organic Compounds
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 21 Monitoring Wells
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401186
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 300 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: Carolina Soil Investigations
Well Contractor Address: 132 Gurney Road, Olin, NC 28660
Certification No.: 2856-A
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 5. How will the well(s) be secured?
material: 2 Locking stand-up well vault and locking cap
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 06/27/22
4. Total Number of wells to be constructed: 2 7. Estimated construction completion date: 06/29/22
(add answers from 2 and 3)
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 i C©nstruction�ara,it as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
bchapter 2C) and accepts full responsibility for compliance with these rules
Signature of Applicant or * gent
Printed name of Applican
If the property is owned
wells as outlined in this
well(s) conform to
Signa re of Prope
or *Agent
Owne
Title of Applicant or "Agent
• If signing as Agent, attach authorization agreement stating
that you have the authority to act as the Agent.
by someone other than the applicant, the property owner hereby consents to allow the applicant to construct
Well Construction Permit application and that it shall be the responsibility of the applicant to ensure that the
Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
'OcEt ce. G Cem. r QCtfracl
erhnt than Applicant) 'f>=Ae100:5 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
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

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QCrown Honda and Camco
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• Monitoring Well Location
Proposed Monitoring Well
Figure 1
Proposed Monitoring
Well Locationss
trammco,
environmental solutionsder
Crown Honda & Camco
3633 W. Wendover Avenue
Greensboro, NC

Stand -Up Well Vault
with Locking Cover
Note: drawing not to scale
2'x2' Concrete Well Pad
Ground Surface
Portland Cement Grout
2" PVC Well Casing
Depth to Bentonite = 6'
Bentonite Seal
Depth to Sand Pack = 8'
Depth to Top of Screen = 10'
Sand Filter Pack
2" SCH 40 PVC
0.01" Machine Slot Screen
Depth to Bottom of Screen = 20'
Depth to Bottom of Boring = 20'
Figure 2A
Monitoring Well
Construction Diagram
(MW-22)
trammco
environmental solutionsale
Crown Honda & Camco
3633 W. Wendover Avenue
Greensboro, NC

Stand -Up Well Vault
with Locking Cover
Note: drawing not to scale
2'x2' Concrete Well Pad
Ground Surface
Portland Cement Grout
2" PVC Well Casing
Depth to Bentonite = 31'
Bentonite Seal
Depth to Sand Pack = 33'
Depth to Top of Screen = 35'
Sand Filter Pack
2" SCH 40 PVC
0.01" Machine Slot Screen
Depth to Bottom of Screen = 40'
Depth to Bottom of Boring = 40'
Figure 2B
Monitoring Well
Construction Diagram
(MW-23)
trammco
environmental solutionsile
Crown Honda & Camco
3633 W. Wendover Avenue
Greensboro, NC