WM0401415_Monitoring Well Permit Application_20221202

Doalsign Envelope ID: 88DD1EOB-4D5E-4646-83F6-5669V78CD0 JMENTAL QUALITY - DIVISION OF WATER RESOURCES
IYVI\ 1 fl I�MRVLIIYN UCr NRI IYICIY 1 Vf CI\YIRVI
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.
Date: 11/29/22
2. County: Stokes
FOROFFICEFFICE USE ONLY
PERMIT NOW M Ot(0 f -1 I . ISSUED DATE
3 What type of well are you applying for? (monitoring or recovery): Monitoring (temporary)
4. Applicant: McDonald's US, LLC (Mr. Leo VanBuuren) Telephone: [phone]
Applicant's Mailing Address: 110 N Carpenter Street Chicago, IL 60607
Applicant's Email Address (if available): leo.vanbuurenna us.mcd.com
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): RNavarro onecslimited.com
6. Property Owner (if different than Applicant): Dimitrios Sialmas
Telephone:[phone]
Telephone: [phone]
Property Owner's Mailing Address: 632 S MAIN ST WALNUT COVE, NC 27052
Property Owner's Email Address (if available): NA
Property Physical Address (Including PIN Number)(t071 and 1075 N Main Street (PIN 6963349406.000)
City Walnut Cove County Stokes Zip Code 27052
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: 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).
no
11. Type of contaminants being monitored or recovered: Petroleum Hydrocarbons (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, Approx. 200 ft to north
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: Quantex Certification No.: 3106
Well Contractor Address: ibarker2(a�nc.rr.gov
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

DocuSign Envelope ID: 88DD1E0B-405E-464B-83F6-56696F678CD0
rrwrvomv rrcLL 1/4.vrvo a RUCTION 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
5. How will the well(s) be secured? Capped and locked
6. Estimated beginning construction date: December 2022
7. Estimated construction completion date: December
(add answers from 2 and 3) 2022
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 Construction Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
LoDocuSigned
by:: ¢¢CSubchapter 2C) and accepts full responsibility for compliance with these rules
Val& -w Area Construction Manager
f9R ifdall4�r *A ent Title of or *
Sig nat g t e Applicant "Agent
Leo VanBuuren * 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).
See attached See attached
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]
GW-22M (Rev. 5/11)
GW-22MR Rev. 3-1-2016
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

• 'Kingswo pierce pr
s IA
r'or
I.
Speydway
First Christian
Church
Walnut Cove
Center
Vacant
Bank
Legend
0 Proposed Groundwater Sampling Location
Off -Site Environmental Concern Location
Parcel Boundary
SOURCE:
2020 IMAGERY
SCALE SHOWN ABOVE
r�r
FIGURE 1
PROPOSED SAMPLE LOCATION MAP
32-1726 McDonald's Walnut Cove
1075 and 1071 North Main Street
Walnut Cove, NC
ECS Proposal Number: 49:34924P

f . Fl= -_I j_
r i is -'}
_ „ k,
J•�i =
1
1
t _ • �
� +- 1y�✓
+�i:1_� 4• _� ,=J
❑ i- - 1
-
Prit-
_ 11. m]
J
4 =�•_1
4.1
-
= xr
k
- a - ti,. L .x r--� I-1- 1- - -

DocuSign Envelope ID: 1FFDC957-02D9-45DA-AFFD-93F92501F5B8
ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:34924
Scope of Work: Proposal for Environmental Assessment
Project: 32-1726 McDonald's Walnut Cove
Location: 1071 and 1075 North Main Street, Walnut Cove, Stokes County, NC (PIN 6963-
34-9406)
As part of the proposed real estate transaction, ECS Southeast, LLP (ECS) has been requested by the
purchaser to conduct due diligence tasks including groundwater sampling at the site. The groundwater
sampling requires that ECS procure a permit from the North Carolina 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 above referenced tasks. By signed below, the property owner authorizes ECS to conduct
the aforementioned sampling at the site.
Dimi trios Sialmas
Property Owner (please print):
Property Owner Telephone (please print): 336-602-2329
Property Owner Signature:
OocuSigned by:
Plw,tfyios S-itilguts
711DFOBBJE524B1..
Date: 11/28/2022

GEOPROBE° SCREEN POINT 15 GROUNDWATER SAMPLER
STANDARD OPERATING PROCEDURE
rtd.niul Rg8rtig NoM$3141
PRFPARR) Octvbq .1995
REVISED- Nor..wber,2607
oOtawkister
GIOPROW ski i'NNr i s GftoUN ODU1f* smote*
WOUT1Rfi