WM0401504_WM0401504 moniotoring well permit application_20240110

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.
Date: 1 /4/2023
2. County: Forsyth County PERMIT NO.
FOR OFFICE USE ONLY
ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Temporary Monitoring Well
4. Applicant: Terracon Consultants Inc. on Behalf of Carter Acquisitions
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Applicant's Mailing Address: 7327-G West Friendly Ave, Greensboro, NC 27409
Applicant's Email Address (if available):
Telephone: [phone]
Contact Person (if different than Applicant): Chris Driscoll Telephone: [phone]
Contact Person's Mailing Address: 7327-G West Friendly Ave, Greensboro, NC 27409
Contact Person's Email Address (if available): chris.driscoll jcOerracon.com
Property Owner (if different than Applicant): Wake Forest University
Telephone: 336.758.EHAS (3427)
Property Owner's Mailing Address: PO Box 7201, Winston Salem, NC 27109
Property Owner's Email Address (if available): N/A
Property Physical Address (Including PIN Number) 1194 Reynolds BLVD (6826-69-9975), No Address parcel (6826-79-
2428), 1008 Reynolds BLVD (6826-89-5270), 2825 University PKWY (6826-87-4512)
City Winston Salem County Forsyth Zip Code 27105
8. Reason for Well(s): Temporary Monitoring Well for due diligence 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: Two UST locations, one open grassy area, and parking lot for
Coliseum
(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: Analyzing samples for VOCs and SVOCs
(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).: N/A
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): No known associated pollution source
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No known wells
If yes, give distance(s): N/A
15. Well Contractor: Environmental Drilling & Probing Services Certification No.: 3307
Well Contractor Address: 17538 Green Hill Road. Charlotte. NC 28278

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? Sand + bentonite
material: 7 after installation. Will abandon after sampling
3. Number of wells to be constructed in bedrock
6. Estimated beginning construction date: 1/8/2023
4. Total Number of wells to be constructed: 7
(add answers from 2 and 3) 7. Estimated construction completion date: 1/8/2023
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 assumes tota�onsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Agent for Carter Acquistions
Signature of Applicant or *Agent
Chris Driscoll
Printed name of Applicant 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 that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
Stephen W Fisenne for Wake Forest University
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant)

Project Manager: Project75237 FCD 75SITE DIAGRAM Exhibit
Drawn by: FCD ScaIAS SHOWNWN Irerracon
Checked by: FCD File Name: WS Temporary Monitoring Wells
7327 W Friendly Ave Ste G 2825 University Parkway
Approved by: FCD JAN 2024 Date: Greensboro, NC 27410-6253 Winston-Salem, NC

PROPOSED TEMPORARY MONITORING
WELL CONSTRUCTION DIAGRAM
Notes:
*All temporary wells will be installed
in accordance to this diagram.
*Wells are temporary and will be
abandoned by a licensed North Car-
olina well contractor following sam-
pling in accordance with 15A NCAC
02C.
Number 2 Filter Sand
from bottom of screen
to a minimum of two
feet above the screen
ElBentonite
El Sand Filter Media
■ ierracon
Ground Surface
2"Diameter PVC
Schedule 20 Well
Casing
Minimum 2 feet of
hydrated bentonite
2" Diameter PVC
Schedule 20 Screen
Bottom of Well proposed to be
15-35 feet below ground surface
depending on observed ground-
water depth
PROJECT NO.: 75237194
DATE: January 2024
DRAWN BY: FCD