WM0401428_Monitoring Well Permit Application_20230126

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: 01/23/2023
2. County: Guilford
3.
4. Applicant:
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring
NCDEQ
Telephone: [phone]
Applicant's Mailing Address: 1646 Mail Service Center, Raleigh, NC 27699
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Greg Hans Telephone: [phone]
Contact Person's Mailing Address: 3525 Whitehall Park Drive, Suite 150, Charlotte, NC 28273
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Jacob Darr, High Point Industrial Leasing Telephone: [phone]
Property Owner's Mailing Address: PO Box 7163, High Point, NC 27264
Property Owner's Email Address (if available): [e-mail]
7. Property Physical Address (Including PIN Number) 2213 Shore Street PIN 7709311176
City High Point County Guilford
Zip Code 27264_
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: USTs
(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 known
11. Type of contaminants being monitored or recovered: petroleum/ organics / metals
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? No known
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Presumed Source Area — 0 Feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No known
If yes, give distance(s):
15. Well Contractor: Carolina Soil Investigation Certification No.: Corey Speece #2904 / Daniel
Summers #2579
Well Contractor Address: 132 Gurney Road, Olin, NC 28660
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: One
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: One
(add answers from 2 and 3)
5. How will the well(s) be secured? 2 x 2 pad, well
covers, locking j-plug
6. Estimated beginning construction date: 01/30/2023
7. Estimated construction completion date: 01/30/2023
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.
Signature of Applicant or *Agent
Greg Hans
Printed name of Applicant or *Agent
Environmental Division 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.
(See attached Access Agreement with NCDEQ State Trust Fund)
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: (252
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
C 27105
9800
7

1/13/23, 1:49 PM
2213 Shore St - Google Maps
Go gle Maps 2213 Shore St
Proposed LSA Well Location
Imagery ©2023 Maxar Technologies, U.S. Geological Survey, Map data ©2023 50 ft
https://www.google.com/maps/place/2213+Shore+St,+High+Point,+NC+27263/@35.919721,-80.002615,180m/data=!3m 1 ! 1 e3!4m5!3m4! 1 s0x88530c0f3a292937:0x8667d7974da2a63a!8m2!3d35.9196... 1/1

ENVIRONMENTAL PROTECTION
HAZARDOUS SITES RESPONSE PROGRAM
TYPICAL
FLUSH -MOUNT GROUNDWATER MONITORING WELL
CONSTRUCTION DIAGRAM
(TOP OF MANHOLE
(SPACING DEPENDS
ON WELL DEPTH)
2 FEET
2 FEET
BOLTED MANHOLE COVER
CONCRETE PAD
MANHOLE SLEEVE
LOCKING WELL CAP
2" SCHEDULE 40 PVC PIPE
BENTONITE GROUT
BENTONITE SEAL
TYPE
SAND PACK
GRAIN SIZE
2" SLOTTED SCHEDULE
40 PVC SCREEN
BOTTOM CAP
BOTTOM OF BORING
ANNULUS

I/We agree not to interfere with, remove or any ways damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
Signature
.r'
Type/Print Name of Owner or Agent
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Phone Number / E-mail Address
.0.i3o "7�3
Address
City/State/Zip Code
Nothing Cornpares':-,,. _
State of North Carolina I Envitomnete]l Quality I Waste Management --
1646 Mail Service Center 1217 West Jones Street I Raleigh, NC 27699-1646
919 707 8200 T
RE: State -Lead Acceptance
Custom Finishes Inc
2213 Shore Street
High Point, Guilford County, NC
Incident Number 7868
If possible, please indicate where the old tank was located on this figure.
ELIZABETH BISE'
:.r.Tenn
MICHAEL SCOI-
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