WM0401420_Monitoring Well Permit Application_20221212 (2)

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: 12/05/22
2. County: Davidson
3.
4.
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring
Applicant: Ohio Star Forge Co. (William Petruzzi) Telephone: [phone]
Applicant's Mailing Address: 4000 Mahoninq Avenue, Warren, Ohio 44483
Applicants Email Address (if available):
5. Contact Person (if different than Applicant): Scott Young Telephone: [phone]
Contact Person's Mailing Address: 1812 Center Park Drive, Suite D, Charlotte, NC 28217
Contact Person's Email Address (if available): syoungl anecslimited.com
6. Property Owner (if different than Applicant): Elizabeth Carbide of NC Telephone: [phone]
Property Owner's Mailing Address: 5801 East US Highway 64, Lexington, NC
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 5801 East US Highway 64 — PIN-0502100000014
City Lexington County Davidson Zip Code
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: Industrial
(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).
Unknown
11. Type of contaminants being monitored or recovered: petroleum
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Unknown
Existing Monitoring or Recovery Well Construction Permit No(s).: Unknown
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): N/A
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: TBD Certification No.: TBD
Well Contractor Address:
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: 2
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 2
(add answers from 2 and 3)
5. How will the well(s) be secured?
The samples will be collected through the Geoprobe rods
and will not require securing
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, 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. 143-215.106(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 Constriction 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 pplic t or *Agent
Scott Young
Printed name of Applicant or *Agent
Senior Environmental Proiect 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
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).
See attached signed Access Agreement
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
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

0.5
0
SCALE 1:24 000
KILOMETE!15 1
2
1000
F.00
0.5
0
NETERS
0
1000
2000
1000
0
1000
2000
3000
MILES
5C00 6000 7000 e000 9000 10000
FEET
SOURCE:
USGS 7.5' TOPOGRAPHIC MAP
LEXINGTON EAST, NC 2022
SCALE:
AS SHOWN
7M
FIGURE 1
USGS TOPOGRAPHIC MAP
ELIZABETH CARBIDE SITE
5801 EAST US HIGHWAY 64
LEXINGTON, NORTH CAROLINA
ECS PROJECT NO. 49:18800-A

•
APPROXIMATE SITE BOUNDARY
APPROXIMATE PROPOSED GROUNDWATER SAMPLE LOCATION
LEGEND
250
SOURCE:
DAVIDSON COUNTY GIS WEBSITE
ACCESSED NOVEMBER 21, 2022
125
SCALE (feet):
0
250
FIGURE 2
PROPOSED SAMPLE LOCATION MAP
ELIZABETH CARBIDE SITE
5801 EAST US HIGHWAY 64
LEXINGTON, NORTH CAROLINA
ECS PROJECT NO. 49:18800-A

GROUND
TOP OF PVC CASING ABOVE THE
LAND SURFACE
ESTIMATED
"'15'-20'
FEET
A
NATURAL FORMATION
BACKFILL
GROUNDWATER
1-INCH PVC RISER
2--INCH BORE
HOLE
SLOTTED PVC SCREEN
0.01-INCH SLOT WIDTHS
SET TO INTERSECT GROUNDWAT
ESTIMATED 5 FEET IN LENGTH
V
WELL CONTRUCTION DIAGRAM
REPRESENTATIVE OF TEMPORARY MO
IAICI I
ER
IS
NITORING
NOT TO SCALE
FIGURE 3
PROPOSED TEMPORARY SCREEN POINT SAMPLER
ELIZABETH CARBIDE SITE
5801 EAST US HIGHWAY 64
LEXINGTON, NORTH CAROLINA
ECS PROJECT NO. 49:18800-A

NORTH CAROLINA WELL PERMITAUTHORIZATION FORM
ECS Southeast, LLP
Proposal No.: 49:34971 P
Project Name: Elizabeth Carbide Site
Location: 5801 East US Highway 64,
Lexington, Davidson County, North Carolina 27292
ECS Southeast, LLP (ECS) has been requested by the purchaser to conduct subsurface soil
and groundwater sampling at the site. The sampling at the site requires that ECS procure a permit
from the North Caroline Department of Environmental Quality (NCDEQ).
ECS respectfully requests that the owner of the property grant permission to ECS to access the
property to conduct the sampling activities, By signing below, the property owner authorizes ECS to
conduct the aforementioned sampling activities at the site.
Property Owner (Please Print)
Property Owner ignature
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