WM0100589_Monitoring Well Construction Application_20240902

FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
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.
1.Date:9/2/2024
2.County:McDowell
3.What type of well are you applying for? (monitoring or recovery):Type II Monitoring
4.Applicant:
Kyle Church / Terracon
Telephone:
[phone]
Applicant’s Mailing Address:
7 Glenn Bridge Rd, Suite A, Arden, NC 28704
Applicant’s Email Address (if available):
[e-mail]
5.Contact Person (if different than Applicant):Telephone:
Contact Person’s Mailing Address:
Contact Person’s Email Address (if available):
6.Property Owner (if different than Applicant):West Marion Community Forum Inc.Telephone:
Property Owner’s Mailing Address: 220 West Grayson Street Marion, NC 28752
Property Owner’s Email Address (if available):
7.Property Physical Address (Including PIN Number)148 E Hudgins Street (PIN 1701-44-5664)
City Marion County McDowell Zip Code 28752
8.Reason for Well(s): groundwater 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:former furniture finishing facility
(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 in cident no(s).
None
11.Type of contaminants being monitored or recovered:Metals, 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?None
Existing Monitoring or Recovery Well Construction Permit No(s).: None
13.Distance from proposed well(s) to nearest known waste or pollution source (in feet):150
14.Are there any water supply wells located less than 500 feet from the proposed well(s)?Unknown
If yes, give distance(s):
15.Well Contractor:Stefan Smith - SAEDACCO Certification No.: 3576
Well Contractor Address: 9088 Northfield Drive, Fort Mill, SC 29707
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
[phone]
[e-mail]

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)

2. Number of wells to be constructed in unconsolidated
material: up to 7

3. Number of wells to be constructed in bedrock: up to 7

4. Total Number of wells to be constructed: 7
(add answers from 2 and 3)
5. How will the well(s) be secured? Bolted manway
and locked well cap

6. Estimated beginning construction date: 09/16/2024

7. Estimated construction completion date: 09/19/2024

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.

Signature of Applicant or *Agent Title of Applicant or *Agent

* 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
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 .

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
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]

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]

Wilmington Regional Office
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]
GW-22M/R (Rev. 5-26-2022)
BRS Project Manager
Jordan Thompson
Paula Swepson Paula Swepson

CONSENT FOR SAMPLING

If you have questions on how to fill out this form or about the activities at this site,
please contact the Brownfields Redevelopment Section Project Manager,
Ms. Jordan Thompson at [e-mail] or [phone].

Please Print

________________________________________________________________________
(Name of Property Owner)

________________________________________________________________________
(Street Number and Street Name of Property)

________________________________________________________________________
(City or Town in Which Property Is Located) / (County in Which Property is Located) / (Zip Code)

I voluntarily consent to the Division of Waste Management (Division) and its independent
contractors (contractors) entering and having continued access to my property for the
following purposes:

(1) taking such soil, groundwater and/or air samples as may be necessary;
(2) collection of soil gas and/or sub-slab vapor samples to assess vapor intrusion risk.
(2) taking other actions related to the investigation of surface or subsurface conditions;
(3) taking response actions necessary to mitigate any threat to human health or the
environment.

Other conditions:

(1) The Division and its contractors shall attempt to perform any activities at the Property
in a manner that minimizes interference with use of the Property.

(2) On conclusion of all activities, the Division and its contractors shall, to the extent
practicable, restore the Property to the original condition it was in prior to any activities
conducted by the Division or its contractors. All sampling points will be properly
abandoned in accordance with applicable laws and regulations, unless other
arrangements are agreed to by the Property Owner.
Brownfields ID
No. or Name:
Ridgewood
Property

(3) The Division or its contractors will make reasonable attempts to notify the Property
Owner at least 48 hours prior to entering the Property for any purpose. In situations
that the Division determines to be of an emergency nature, the Division or its
contractors shall have immediate access to the property.

(4) Property Owner shall not willingly destroy, damage, remove, pave over or cover any
permanent sampling points (including but not limited to monitoring wells, soil vapor
points, etc.) at the site without prior consent of the Division.

Special conditions specific to this consent:

(1) IF NEEDED: The Division's contractor has agreed to provide a Certificate of Insurance
(COI) naming the property owner as additional insured prior to the start of work. Please
initial here if you would like a COI. ____

(2) OTHER SPECIFICS

By signing this consent document, I acknowledge that I am the legal property owner
that has the authority to allow this work on the property and have contacted all
tenants (if there are tenants) occupying the property and all tenants agree to the
conditions of this “Property Access Consent”.

(Signature of Property Owner) (Date)

(Telephone Number for Property Owner for scheduling work/notification)

(Email Address for Property Owner if you prefer to be contacted via email)

Please return form via e-mail or mail to:
Brownfields Redevelopment Section
Attn: Ms. Jordan Thompson
217 West Jones Street
Raleigh, NC 27603
[e-mail]
[phone]
Well ID:MW-01 through MW-07
Project :Ridgewood Furniture Plant KF247038
Site Location:148 E Hudgins St, Marion, NC
Field Personnel: M Maltba
Date:9/16-9/19 2401 Brentwood Road Suite 107
Driller:SEADACCO Raleigh, NC 27604
Drilling Method:Roto-sonic 919.873.2211
Riser Pipe Concrete
Diameter 2"
Material PVC
Length 40'
Bottom of Grout 36-38'
Bottom of Bentonite Seal 38-39'
Sand Pack Top of Screen 40'
Sand Size 20/40
Well Screen
Diameter 2"
Length 10'Bottom of Screen 50'
Slot Size 0.010"Bottom of Tail Pipe 50'
Material PVC Bottom of Borehole 50'
4"Borehole Diameter (inches)
Note: Not to scale
Land Surface
Monitoring Well Construction Diagram
0
Depth Below Land Surface (ft)