WM0401461_Monitoring well construction application_20230719

DocuSign Envelope ID: DD31553C-5BC5-4B7A-85D5-8ED0783CC582
IMvICI n VNrcljL_11V ► LJCrmr%I IVICIM 1 yr C19vIrcvI4MENTAL 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: July 17, 2023
2. County: Forsyth PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Reedy Property Group Telephone: [phone]
Applicant's Mailing Address: 1186 Pendleton Street, Greenville SC
Applicant's Email Address(if available):
5. Contact Person (if different than Applicant): Erika Thompson Telephone: [phone]
Contact Person's Mailing Address: 6004 Ponders Court, Greenville, SC
Contact Person's Email Address(if available): [e-mail]
6. Property Owner(if different than Applicant): Gene Lowder Telephone: [phone]
Property Owner's Mailing Address: 10490 N. NC Hwy 150, Clemmons, NC
Property Owner's Email Address(if available):
7. Property Physical Address(Including PIN Number) 10490 N. NC Hwy 150 6811-04-082-9942
City Clemmons County Forsyth Zip Code 27012
8. Reason for Well(s): Limited 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: Multi-use commercial
(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
11. Type of contaminants being monitored or recovered: Organics—petroleum and solvents (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).: Not applicable
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): <10-feet
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: JIG DRILLING Certification No.: Jeff Grant 4328-B
Well Contractor Address: 124 Pisgah Road, Easley SC
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

DocuSign Envelope ID: DD31553C-5BC5-4B7A-85D5-8ED0783CC582
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?
material: 5 Temporary wells
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 7-24-2023
4. Total Number of wells to be constructed: up to 5 7. Estimated construction completion date: 7-24-2023
(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.
r '" Asset Manager
0=;d_1 _
1 Signature of Applicant or*Agent Title of Applicant or*Agent
Danny Hinson *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 omeone other than the Applicant,the property owner hereby consents to allow the Applicant to construct
well(s)as outlined in is ell Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ens that a ells) ill be located,constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
Signature of Pr p rty Owner(if different than Applicant) Printed name of P perty 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 Raleigh Regional Office
Swannanoa, NC 28778 3800 Barrett Drive Wilmington Regional Office
Phone: [phone] Raleigh, NC 27609 127 Cardinal Drive Extension
Fax: [phone] Phone: [phone] Wilmington, NC 28405
Fax: [phone] Phone: [phone]
Fayetteville Regional Office Fax: [phone]
225 Green Street, Suite 714 Washington Regional Office
Fayetteville, NC 28301-5094 943 Washington Square Mail Winston-Salem Regional Office
Phone: [phone] Washington, NC 27889 450 W. Hanes Mill Road
Fax: [phone] Phone: [phone] Suite 300
Fax: [phone] Winston-Salem, NC 27105
Mooresville Regional Office � �� 6-9800
610 East Center Avenue 797
Mooresville, NC 28115
Phone: [phone] r +`
Fax: [phone] y
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DocuSign Envelope ID: DD31553C-5BC5-4B7A-85D5-8ED0783CC582
1. 10490 N NC Hwy 150 -
H & P Business Center
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2. 10492 N NC Hwy 150
SITE 3. 10494 N NC Hwy 150
--,,t F. 4. Suite 1 - Capitol Coffee
5. Suite 2 - Legendary
- Construction
6. Suite 3 - Legendary
A Construction
7. Suite 4 - A Fast Fence
8. Suite 5 - Shared
warehouse storage space
g 2 9. 55-gallon drums
10. Septic tank
Proposed boring location
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6 7
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• • • -
DRAWN: DATE:
GDD 5/25/2023 BUNNELL Aerial Photograph of Site FIGURE
CHECKED: JOB No: IM
� LAMMONS
ELT J23-20108-01 ENGINEERING 10490, 10492, & 10494 N NC Hwy 150
6004 Ponders Court,Greenville,SC 29615 Clemmons, NC 2
APPROVED: Phone:[phone]
ELT