WM0401452_Monitoring Well Permit Application_20230511

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: 04/27/23
County: Forsyth
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring
Applicant: Illinois Tool Works, Inc. / Ken Brown, CHMM Telephone: [phone]
Applicant's Mailing Address: 155 Harlem Avenue, Glenview, IL 60025
Applicant's Email Address (if available): kbrown(a-)itw.com
Contact Person (if different than Applicant): WSP / Derick Havdin, PG Telephone: [phone]
Contact Person's Mailing Address: 2801 Yorkmont Road, Ste 100, Charlotte, NC 28208
Contact Person's Email Address (if available): Derick.haydin wsp.com
Property Owner (if different than Applicant): Associated Posters, Inc./ Robert Arnold, President Telephone: [phone]
Property Owner's Mailing Address: 2737 W Mountain St. Kernersville NC 27284
Property Owner's Email Address (if available): robert(a�associatedposters. com
Property Physical Address (Including PIN Number) 2737 W Mountain Street (6856-62-7585)
City Winston Salem County Forsythe Zip Code 27284
Reason for Well(s): Groundwater contamination delineation
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
Type of facility or site for which the well(s) is(are) needed: Former manufacturing building, 2744 West Mountain Street
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
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
Type of contaminants being monitored or recovered: volatile organic compounds (1,4-dioxane, chlorinated solvents
(ex: organics, nutrients, heavy metals, etc.)
Are there any existing wells associated with the proposed well(s)? If yes, how many? 21
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401235
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet):
C
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: Innovative Environmental Technologies Certification No.: 2725-A (Mike Tynan)
Well Contractor Address: 232 Highway 49, Concord, NC 28205
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 5. How will the well(s) be secured? Lockable well
material: 2 cap with flush mount steel manhole
3. Number of wells to be constructed in bedrock:
6. Estimated beginning construction date: 5/22/23
4. Total Number of wells to be constructed: 2 7. Estimated construction completion date: 6/2/23
(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
Digitally signed accordance with 15A NCAC 02C.
Helen
by Helen Corley
Corley Dale:708155-04'000
Signature of Applicant or *Agent
Printed name of Applica t or *Agent
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 th well will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
Robert Arnold, President
Signature of Pr6-perfy 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 127 Cardinal Drive Extension
2090 U.S. Highway 70 3800 Barrett Drive Wilmington, NC 28405
Swannanoa, NC 28778 Raleigh, NC 27609 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
Phone: (704) 6
Fax: (704) 663
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. GW-22M (Rev. 5/11)

PROPOSED MONITORING WELL CONSTRUCTION
JOB NAME ITW Kernersville
JOB NUMBER
WELL NUMBER Performance Wells (MW-C16 & MW-C17)
INSTALLATION DATE
LOCATION (LAT, LONG)
TBD
TOP OF CASING ELEVATION (FT AMSL) TBD
GRANULAR BACKFILL MATERIAL #2 Sand
SLOT SIZE
SCREEN MATERIAL PVC
SCREEN DIAMETER
RISER MATERIAL PVC
RISER DIAMETER
DRILLING TECHNIQUE Hollow Stem Auger
DRILLING CONTRACTOR
BOREHOLE DIAMETER 6 25��
WSP FIELD
REPRESENTATIVE
LOCK BRAND "Dolphin lock" padlock
SIZE/MODEL
KEY CODE/COMBINATION Kev
STEEL MAN H0LE COVER LENGTH OF
SOLID SECTION
45
DEPTH TO TOP OF
BENTONITE SEAL CEMENT
246 BENTONITE
RISER
LENGTH OF
SLOTTED SECTION
15
3160201046
May 22, 2023
0.010 in
2 in
2 in
IET
Derick Haydin
35 mm
GROUND
SURFACE
NOT TO SCALE
TOTALDEPTH
OF VVELL
45
STABILIZED WATER
LEVEL AFTER
DEVELOPMENT
FEET
BELOW TOP OF
INNER CASING
MEASURED ON
xx%% )
WSP Environment & Infrastructure, Inc. 2801
Yorkmont Road, Suite 100
Charlotte, North Carolina Completed By: Derick Haydin Date: 04/27/2023