WQ0000193_Final Permit_20230125

DocuSign Envelope ID: E5F86C10-7110-4B5D-AFAE-834DDED321CF
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
Mr. Jordan McMillen
122 Young Street
Henderson, NC 27536
NORTH CAROLINA
Environmental Quality
January 24, 2023
Subject: Monitoring Well Construction
Permit # WM0501537
3181 NC Hwy 39N
Henderson, NC 27537 — Vance County
Mr. McMillen:
In accordance with the application received on January 24, 2023, we are forwarding herewith
Monitoring Well Construction Permit No. WM0501537 effective January 25, 2023, issued for the
construction of a monitor well system (installation of two wells). Please be aware that some counties
have well construction programs, and you may be required to obtain a well construction permit
before installation.
This Permit will be effective from the date of its issuance and shall be subject to the conditions and
limitations as specified therein. Please note the addition of stipulation #3 to the permit enclosed. If you have
any questions about this permit, please contact Tyler Clark at [phone].
Enclosure
cc: RRO Files/Laserfiche
NORTH CAROLINA
Department M Environmental Quality
Sincerely,
-DocuSigned by:
llatAA-ssa f. llutAAA. ,) for
"-B2916E6AB32144F...
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11611 Mail Service Center I Raleigh, North Carolina 27699-1611
919.707.9000

DocuSign Envelope ID: E5F86C10-7110-4B5D-AFAE-834DDED321CF
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and other applicable Laws,
Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
Mr. Jordan McMillen — Vance County
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of two monitoring wells owned
by Vance County, 122 Young Street, Henderson, N 27536. The wells will be located at 3181 NC Hwy
39N, Henderson, NC 27537, on property owned by Herman Davis. This Permit is issued in accordance
with the application received on January 23. 2023, in conformity with specifications and supporting
data, all of which are filed with the Department of Environmental Quality and are considered integral
parts of this Permit.
This Permit is for well construction only and does not waive any provision or requirement of any other applicable law or
regulation. Construction of any well under this Permit shall be in strict compliance with the North Carolina Well
Construction Regulations and Standards (15A NCAC 02C .0100), and other State and Local Laws and regulations pertaining
to well construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to an adjudicatory hearing upon
written request within 30 days of receipt of this Permit. The request must be in the form of a written petition conforming
to Chapter 150B of the North Carolina General Statutes and filed with the Office of Administrative Hearings, 6714 Mail
Service Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit is final and binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to other specified conditions,
limitations, or exceptions as follows:
1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these wells are being
installed as part of an investigation for contamination from an underground storage tank or dry cleaner
incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement issued by another
agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as part of the Permit
application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A NCAC 02C .0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of Water Quality's
Information Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with 15A NCAC 02C
.0113 and a well abandonment record (GW-30) shall be submitted to the Division of Water Quality's
Information Processing Unit within 30 days of the well abandonment.
7. If the well penetrates any water -bearing zone that contains contaminated waters, the upper three feet of the
well shall be grouted within one day after the casing is set or the well abandoned.
Permit issued the 25th of January 2023
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
FDocuSigned by:
htiALSSA,f. AILMAlta For
B2916E6AB32144F...
Scott Vinson, Regional Supervisor
Division of Water Resources
By Authority of the Environmental Management Commission
Permit No. WM0501537
£ D_E
NORTH CAROLINA
Departmentof Environmental Duel
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11611 Mail Service Center I Raleigh, North Carolina 27699-1611
919.707.9000

DocuSign Envelope ID: E5F86C10-7110-4B5D-AFAE-834DDED321CF
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 far a permit to construct monitoring or recovery wells.
1. Date: January 18. 2023
2. County: Vance
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitonng or recovery). ..monitor well
4. Applicant: Vance Co. - Mr. Jordan. McMillen, Co. Mgr. Telephone: [phone]
Applicant's Mailing Address: 122 Youna St., Henderson, NC 27536
Applicant's Email Address (;f available): JMcMillen•vancecounty.orq
5. Contact Person (If different than Applicant): Mr. ,lison Falls Telephone: [phone]
Contact Person's Mailing Address: 122 Young 51., Henderson, NC 27536
Contact Person's Email Address (if available): JFalls
b?
vancecounty.org,
6. Property Owner (if different than Applicant): Herman Davis Telephone: [phone]
Property Owner's Mailing Address: 558 Rowland St., Henderson, NC 27536
Property Owner's Email Address (if available): NIA
7. Property Physical Address (Including PIN Number) 3181 NC Hw+r 39N
City Henderson County_ Vance Zip Code 27537
8. Reason for Well(s): __. assessment of groundwater contamination
(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: closed landfill
(ex: non -discharge facil.ty, 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).
Permit WMQ501479
11. Type of contaminants being monitored or recovered: metals and organics
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 14 wells
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0501479
13. Distance from proposed well(s) to nearest known waste or pollut.on source (in feet): < 500 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? yes but abandoned
If yes, give thstance(s): -270 feet
15. Well Contractor: not selected yet Certification No.: NIA
Well Contractor Address: N/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 dsameter e. Type of casing material and thickness
b. Estimated well depth f Grout horizons
c. Screen intervals g. Well head completion details
d. Sandlgravel pack intervals
Continued on Reverse

DocuSign Envelope ID: E5F86C10-7110-4B5D-AFAE-834DDED321CF
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
5_ How will the well(s) be secured? Locking cap and
cover
6. Estimated beginning construction date: TBD
4. Total Number of wells to be constructed: _ 2 7. Estimated construction completion date: TBD
(add answers from 2 and 3)
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 assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
� ?vac
Signatufre of Applicant or *Agent
Mr. Jordan McMillen
Printed name of Applicant or *Agent
Couns . 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
well(s) as outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
Herman A Davis. Jr.
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-22M/R (Rev. 5-26-2022)
GW-22M (Rev. 5/11)

DocuSign Envelope ID: E5F86C10-7110-4B5D-AFAE-834DDED321CF
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DocuSign Envelope ID: E5F86C10-7110-4B5D-AFAE-834DDED321CF
4"x 4" STEEL CASE
WITH HINGED LID
2'x2' CONCRETE COLLAR, NOT
TO EXCEED 1' IN ORDER TO
DIMINISH EFFECTS OF
EROSION AROUND CONCRETE
COLLAR
FILTER PACK SHOULD
EXTEND A MIN. OF 1' ABOVE
THE SCREEN AND NO MORE
THAN 2' ABOVE
SAND FILTER PACK • .
(NC #1, 2 OR 3)
0.01" MACHINE SLOTTED SCREEN. PVC
END CAP, PVC
WELLS TO BE CONSTRUCTED PER 15A NCAC 02C .01 STANDARDS
PVC VENTED CAP, NO LESS
THAN 2' ABOVE GROUND
SURFACE
< 1'
GROUT BACKFILL, NEAT CEMENT
<5% BENTONITE POWDER BY VOLUME
OR BENTONITE GROUT
CASING GROUTED FROM
LAND SURFACE TO TOP OF
BENTONITE SEAL
2" (NOMINAL) SCHEDULE 40 PVC
Note•If groundwater found <=5 ft of land
surface, filter pack and bentonite seal
will be a minimum of 6' thick.
per 15A NCAC 2C .0108(j}
1 FOOT MINIMUM
BENTONITE
CHIPS/PELLETS SEAL
SCREEN INTERVAL
NOT TO EXCEED 15'
MAX 1' FILTER PACK
BELOW SCREEN
MUNICIPAL ENGINEERING, INC.
8 SHIPWABM DRIVE, GARNER, NC 27529 - PHONE: [phone]
P.G. Bo% 349, BORNE, NC 28607 • PHONE: B2B'262.1767
LICENSE NUMBERS: F•0812 & C•586
FIGURE 2
TYPICAL TYPE 11 MONITORING WELL SCHEMATIC
Vance County Closed Landfill
North Carolina
/GALE:
NOT TO SCALE
OATEm
04106122
PROJECT No.I