WM0401520_WM0401520 application_20240311

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: 3/6/2024
2. County: Guilford PERMIT NO. ISSUED DATE
3. What type of well are you applying for?(monitoring or recovery): Monitoring
4. Applicant: RHGC Investments, LLC—Mr. Gray Hill Telephone: [phone]
Applicant's Mailing Address: 13500 City View Center, Oviedo, FL 32765
Applicant's Email Address(if available): gravCc-)hillgrayseven.com
5. Contact Person (if different than Applicant): Jonathan Garrick Telephone: [phone]
Contact Person's Mailing Address: 1812 Center Park Drive, Suite D Charlotte, NC 28217
Contact Person's Email Address(if available): 6garrick(@ecslimited.com
6. Property Owner(if different than Applicant): OP Partners(William R. Fonner) Telephone: [phone]
Property Owner's Mailing Address: 2633 Randleman Road, Greensboro, NC 27406
Property Owner's Email Address(if available): Not Available
7. Property Physical Address(Including PIN Number): 2633 Randleman Road, Greensboro, Guilford County, NC 27406 (PIN
7862-39-0907)
8. Reason for Well(s): Environmental Assessment
9. Type of facility or site for which the well(s)is(are)needed: Former Printing Facility
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).
Not Applicable
11. Type of contaminants being monitored or recovered: VOCs, 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).: Not Applicable
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): Property to the Northwest(750 ft)(UST
Incident 129751
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): Not Applicable
15. Well Contractor: 3D Environmental Investigations Certification No.: 3162-A
Well Contractor Address: 2157 Mocksville Highway, Statesville, NC 28625
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? Expandable locking
material: 3 caps for temp wells
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 3/14/24
4. Total Number of wells to be constructed: 3 7. Estimated construction completion date: 3/14/24
(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,
Subchapter 2C)and accepts full responsibility for compliance with these rules
As agent of RHGC Investments, LLC Project Manager
Signature of Applicant or*Agent Title of Applicant or*Agent
Jonathan Garrick *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 access agreement OP Partners(William R. Fonner)
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 Raleigh Regional Office GW-22MR Rev.3-1-2016
Phone: [phone] 3800 Barrett Drive
Fax: [phone] Raleigh, NC 27609 Wilmington Regional Office
Phone: [phone] 127 Cardinal Drive Extension
Fayetteville Regional Office Fax: [phone] Wilmington, NC 28405
225 Green Street, Suite 714 Phone: [phone]
Fayetteville, NC 28301-5094 Washington Regional Office Fax: [phone]
Phone: [phone] 943 Washington Square Mall
Fax: [phone] Washington, NC 27889 Winston-Salem Regional Office
Phone: [phone] 450 W. Hanes Mill Road
Mooresville Regional Office Fax: (252 -
610 East Center Avenue in Sale (ty C 27105
Mooresville, NC 28115 ✓L al gh ne: 7 9800
Phone: [phone] r � F 8 - 7
Fax: [phone]
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