WM0401423_Monitoring Well Permit Application_20230113

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: 1/9/23
2. County: Alamance
FOR OFFICE USE ONLY
PERMIT NO'' MO AV \ a.3 ISSUED DATE%/13'
a3
3. What type of well are you applying for? (monitoring or recovery); Monitoring (temporary)
4, Applicant: Goodwill Industries of Central North Carolina, Inc. (Ms. Celeste MacMurdo) Telephone: [phone]
Applicant's Mailing Address: 1235 South Eugene Street, Greensboro, NC 27406
Applicant's Email Address (if available): cmacmurdo(a�triadgoddwill,org
5. Contact Person (if different than Applicant): Ron Navarro Telephone: [phone]
Contact Person's Mailing Address: 5260 Greens Dairy Rd, Raleigh, NC 27616
Contact Person's Email Address (if available): RNavarroAecslimited.com
6. Property Owner (if different than Applicant): Marie Andrews Irrevocable Trust & ETAL c/o Jeffrey McVey (Heir: H Lea Holt)
Telephone: [phone]
Property Owner's Mailing Address: 1661 Allen Jarrett Dr A, Mebane, NC 27302-9521
Property Owner's Email Address (if available): NA
7. Property Physical Address (Including PIN Number) 1108 South Main Street (PIN 144200)
City Graham County Alamance Zip Code 27253
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 wells) is(are) needed: Vacant
(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): Approx. 100 ft 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: 4
5. How will the well(s) be secured? Capped and locked
3. Number of wells to be constructed in bedrock: 6. Estimated beginning construction date: January 2023
4. Total Number of wells to be constructed:4
(add answers from 2 and 3)
7. Estimated construction completion date: January 2023
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. 143-215.10B(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
thiell Construction Permit-as.ra ulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
S .c, ap r 2C) and accepts full responsibility for m fiance withxthese rules
Sinature of Applicant or*A en(
Applicant or *Agen
ta
Title of Appl ant_or *Agent,
" If signing as Agent, attach authorization agreement stating Printed name of
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
Signature of Property Owner (if different than Applicant)
See attached
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]
GW-22M (Rev. 5/11)
GW-22MR Rev. 3-1-2016

GEOPROEE° SCREEN POINT 15 GROUNDWATER SAMPLER
STANDARD OPERATING PROCEDURE
Technical 8tlietie No WU1t1
PREPARED: Octubtt,19lS
REVISED- Ravtiabar, 20OT
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GEOPROBE6 SCREEN POINT 1 S GROUNDWATER SAMPLER

Bowman Brothers
(SDG)
Graham Quality Plus
Gasoline (REC)
SOURCE:
QUIRE MAPPING TOOL — JANUARY 2023
SCALE SHOWN ABOVE
Legend
Proposed Groundwater Sampling
Location
REC/SDG Location
Parcel Boundary
Leafie:t i Paroered b Esri I ECornmunity Mays Ci nuibutors, NC CGIA
FIGURE 1
PROPOSED SAMPLE LOCATION MAP
1108 South Main Street
Graham, Alamance County, NC
ECS Proposal Number: 49:35511P

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ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:35511P
Scope of Work: Proposal for Environmental Assessment
Project: South Main Street Site
Location: 1108 South Main Street, Graham, Aiamance County, NC (PIN 144200)
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.
Property Owner (please print): FY"_ i " i I (44-1f ry
Property Owner Telephone (please print): gig CY 0 , 0 / Z
Property Owner Signature:
Date:
/7/2V 2.3