WM0401496_Permit (Issuance)_20231211

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: December 7,2023
2. County:Alamance PERMIT NO. ISSUED DATE
3. What type of well are you applying for?(monitoring or recovery): Monitoring(temporary)
4. Applicant: Mavis Tire Supply,LLC(Rachael Dickinson) Telephone: [phone]
Applicant's Mailing Address: 200 Summit Lake Drive, Suite 350,Valhalla,New York 10545
Applicant's Email Address(if available): [e-mail]
5. 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(D_ecslimited.com
6. Property Owner(if different than Applicant): CityPlat Burlington, LLC(Jonathan Anderson)
Telephone: [phone]
Property Owner's Mailing Address: PO Box 6356, Raleigh, NC 27628
Property Owner's Email Address(if available): ion(a_lawofficeiwa.com
7. Property Physical Address(Including PIN Number)2135 North Church St(PIN 8885135239)
City Burlington County Alamance Zip Code 27217
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 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: VOCs(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.200 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: Ground Zero Environmental Certification No.: NCWC 30127-A
Well Contractor Address: 11100 Astarita Ave,Partlow,VA 22534
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
material: 3
3. Number of wells to be constructed in bedrock:
4. Total Number of wells to be constructed:3
(add answers from 2 and 3)
5. How will the well(s)be secured? Capped and locked
6. Estimated beginning construction date: December 2023
7. Estimated construction completion date:December 2023
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,
i" Subchapter 2C)and accepts full responsibility for compliance with these rules
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Signature of Applicant or*Agent Title of Applicant or*Ageftt
!�"\a4 �) cy``�J� *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 450 W. Hanes Mill Road
2090 U.S. Highway 70 Raleigh Regional Office Suite 300
Swannanoa, NC 28778 3800 Barrett Drive Winston-Salem, NC 27105
Phone: [phone] Raleigh, NC 27609 Phone: [phone]
Fax: [phone] Phone: [phone] Fax: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714 Washington Regional Office
Fayetteville, NC 28301-5094 943 Washington Square Mall
Phone: [phone] Washington, NC 27889
Fax: [phone] Phone: [phone]
Fax: [phone]
Mooresville Regional Office Wilmington Regional Office • GW-22M(Rev.5111)
610 East Center Avenue 127 Cardinal Drive Cie
Mooresville, NC 28115 Wilmington,X(�2 05 GW-22MR Rev.3-1-2016
Phone: [phone] Phone:"f918
Fax: [phone] `Fa L910 t, 20 _

ECS SOUTHEAST, LLC
PROPERTY OWNER ACCESS AUTHORIZATION
Proposal No.: 49:41152P
Scope of Work: Proposed Mavis#2220
Location: 2135 North Church Street, Burlington,Alamance County, North Carolina 27217
As part of the proposed real estate transaction, ECS Southeast, LLC (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 signing below, the property owner authorizes ECS to conduct
the aforementioned sampling at the site.
Property Owner(please print): CityPlat Burlington, LLC
Property Owner Telephone (please print): 919-578-3075
Property Owner E-mail (please print):[e-mail]
Property Owner Mailing Address (please print): PO Box 6356 Raleigh NC 27628
Property Owner Signature: )Z' Date: 12/06/2023

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SCALE SHOWN ABOVE Burlington, North Carolina 27217
IL ' °" ECS Proposal Number: 49:41152P

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