WM0701304_Application_20230601

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.
FOR OFFICE USE ONLY
1. Date: 05/05/2023
2. County: Jones [PERMIT NO. ISSUED DATE _
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Town of Maysville Telephone: [phone]
Applicant's Mailing Address: 404 Main St Maysville NC 28555
Applicant's Email Address (if available): townmana er townofmaysville org
5. Contact Person (if different than Applicant): Ethan Gartin (TRC) Telephone: [phone]
Contact Person's Mailing Address: 114 Edinburgh S Dr Ste 200 Cary, NC 27511
Contact Person's Email Address (if available): egartin(o),trccompanies com
6. Property Owner (if different than Applicant): Jones County Board of Education Telephone: [phone]
Property Owners Mailing Address: PO Box 187 Trenton NC 28585 _
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) Bynum Ave PIN837 543207663600
City Maysville County Jones Zip Code 28555
8. Reason for Wallis): Sampling for Municipal Production Well
(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: Municipal Public Water System
(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 water quality permits or incidents at the proposed well site
11. Type of contaminants being monitored or recovered: Organics Nutrients Heavy Metals WAS
(ex: organics, nutrients, heavy metals, etc.)
12, Are there any existing wells associated with the proposed well(s)? If yes, how many? 1 sample (this permit) 1 production later
Existing Monitoring or Recovery Well Construction Permit No(s).: N/A
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approx. 1,950 ft to PFAS contaminant
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: TBD Certification No.:
Well Contractor Address:
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 I. 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 5. How will the well(s) be secured? Well enclosure
material: shall be securely locked when not being serviced.
3. Number of wells to be constructed in bedrock: 1 6. Estimated beginning construction date: August 2023
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: Auqust 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 assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
/ Town Manager
Signature of Applicant or *Agent Title of Applicant or *Agent
Schumata Brown * 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
well(s) as outline 'n this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
nsure t the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
Ben Thigpen — Jones County Schoolboard
Signature o erty 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]
GW-22MIR (Rev. 5-26-2022)