WM0401477_Application_20230816

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: 8/8/2023
2. County: Guilford PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Permanent Monitoring Wells(AMW-106 and AMW-107)
4. Applicant: SUSO 4 Battleground LP(petitioner for DSCA Site ID DC410045) Telephone: Mike Cunningham [phone]
Applicant's Mailing Address: DSCA Program, 1646 Mail Service Center, Raleigh, NC 27699-1646
Applicant's Email Address(if available): mike.cunningham(a).ncdenr.gov
5. Contact Person (if different than Applicant): Savannah Scott, Hart&Hickman, PC Telephone: [phone]
Contact Person's Mailing Address: 3921 Sunset Ridge Rd, Suite 301, Raleigh, NC 27607
Contact Person's Email Address(if available): sscott(charthickman.com
6. Property Owner(if different than Applicant): City of Greensboro Right-of-Way(ROW) Telephone: [phone]
Property Owner's Mailing Address: 401 Patton Avenue, Greensboro, NC 27406
Property Owner's Email Address(if available): Richard.lovett(o-)greensboro-nc.aov
7. Property Physical Address(Including PIN Number) City of Greensboro ROW near 2803 and 2811 Stratford Dr(or adjacent)
City Greensboro County Guilford Zip Code 27408
8. Reason for Well(s): Environmental Assessment for DSCA Program
(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: Dry-cleaner
(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).
NCDEQ DSCA Site ID#DC410045
11. Type of contaminants being monitored or recovered: Chlorinated Solvents
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes, 4
Existing Monitoring or Recovery Well Construction Permit No(s).: Not available
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): Approximately 600-650 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: Brian Ewing of SAEDACCO Certification No.: 4240
Well Contractor Address: 9088 Northfield Dr, Fort Mill, SC 28707
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 5. How will the well(s) be secured? Bolted flush-mount
material: 2 well with lockable well cap and concrete pad
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 08/28/2023
4. Total Number of wells to be constructed: 2 7. Estimated construction completion date: 09/01/2023
(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,
j Subchapter 2C)and accepts full responsibility for compliance with these rules
`,4 ��on behalf of Petitioner for DSCA Site DC410045 Agent for Petitioner for DSCA Site DC410045
Signature of Applicant or*Agent Title of Applicant or*Agent
Savannah Scott *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 property access agreement(Attachment 3) See attached property access agreement(Attachment 3)
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 WI" t
Mooresville, NC 28115
Phone: [phone] �L r d
Fax: [phone] �-/ j ' A
's 'Ile r le
F efttville
nwm
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: [phone]
GW-22MR Rev.3-1-2016
Wilmington Regional Office GW-22M(Rev.5/11)
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]