WM0501550_Application_20230510

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
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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: April 25, 2023
County: Johnston
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring (temporary)
Applicant: Zaremba Group (Mr. Mark F. Zawadski) Telephone: [phone]
Applicant's Mailing Address: 14600 Detroit Ave, Suite 1500, Lakewood, OH 44107
Applicant's Email Address (if available): mzawadski(a�zarem bagroup.com
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): RNavarro(a),ecslimited.com
Property Owner (if different than Applicant): Paul Howard Telephone: [phone]
Property Owner's Mailing Address: 1661 NC Hwy. 96 N. Selma, NC 27576
Property Owner's Email Address (if available): N/A
7. Property Physical Address (Including PIN Number) North Pollock Street, Selma, Johnston County, NC 27576 (PINs 14M10087
and a portion of 14011001
City Selma County Johnston Zip Code 27576
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: 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)
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
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: ibarker3 @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
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated
material: 3
3. Number of wells to be constructed in bedrock:
5. How will the well(s) be secured? Capped and locked
6. Estimated beginning construction date: May 2023
4. Total Number of wells to be constructed:3 7. Estimated construction completion date: May 2023
(add answers from 2 and 3)
ADDITIONAL INFORMATION
1. 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,
Subchapter 2C) and accepts full responsibility for compliance with these rules
A6
Senior Development Manager
Signature of Appli n or *Agent L Title of Applicant or *Agent
Mark Zawadski * 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 Raleigh Regional Office Wilmington Regional Office
2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension
Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 28405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [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]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
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 (Rev. 5/11)
GW-22MR Rev. 3-1-2016

ECS SOUTHEAST, LLP
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:37248P
Scope of Work: Proposal for Environmental Assessment
Project: Proposed Dollar General
Location: North Pollock Street, Selma, Johnston County, NC (PINS 14M10087 and a
portion of Parcel Number 14011001)
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.
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):
Property Owner Telephone (please print): q I Q Z �pn
Property Owner E-mail (please print): d Obb-L A Caroy
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Property Owner Signature: Date: Js
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SOURCE: FIGURE 1
USGS TOPOGRAPHIC MAP SITE TOPOGRAPHIC MAP:
7.5 — MINUTE SERIES s
SELMA, NC QUADRANGLE PROPOSED DOLLAR GENERAL
DATED: 2022 NORTH POLLOCK STREET
SELMA, JOHNSON COUNTY, NC
SCALE: 1 : 24,000 ECS PROJECT NO 49:19817-A
CONTOUR INTERVAL = 10' TM

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ProposedProposed Groundwater Sample Location
Parcel Boundary
SOURCE: FIGURE 2
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PROPOSED SAMPLE LOCATION MAP:
GOOGLE EARTH AERIAL
PUBLISHED: 2015 PROPOSED DOLLAR GENERAL
NORTH POLLOCK STREET
SCALE AS SHOWN ABOVE SELMA, JOHNSON COUNTY, NC
TM ECS PROJECT NO 49:19817-A

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WATER SUPPLY WELLS OR POTENTIAL SOURCE
CONTAMINATION ARE KNOWN TO EXIST OTHER
AN ILLUSTRATED ABOVE.
SOURCE:
NCDEQ
DWM SITE LOCATOR TOOL
APPROXIMATE SCALE:
= 430 FEET
FIGURE 3
POTENTIAL SOURSES MAP:
PROPOSED DOLLAR GENERAL
NORTH POLLOCK STREET
SELMA, JOHNSON COUNTY, NC
ECS PROJECT NO 49:19817-A

ESTIMATED
-15' FEET
GROUND
SURFACE
INATU RAL FO tMATION
WKFILL
GROUNDWATER
NOT TO SCALE
TOP OF DIRECT PUSH STEEL
_ - - - - - - - RODS ABOVE THE LAID
SURFACE
1.9-iiICH STEEL DIRECT
----- PUSH RISER
2--iNCH BORE
HOLE
SLOTT ED STEEL SCM EN
0.41 INCH SLfl T 1'41UTH 5
SET Tfl I NT EH.5ECT URUUNOWATE H
ESTIMATE U 4 FEET IN LEh{iTN
WELL -CONSTRUCTION DMR M 13
REPRESE11TATI'VE OF DIRECT PUSH SCREEN
POINT SAMPLER
FIGURE 4
PROPOSED TEMP SCREEN POINT
SAMPLER:
PROPOSED DOLLAR GENERAL
NORTH POLLOCK STREET
SELMA, JOHNSON COUNTY, NC
ECS PROJECT NO 49:19817-A