WM0501335_Application_20190108

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: 1/8/19 FOR OFFICE USE ONLY /
2. County: Wilson PERMIT NO. IMO5O 13 3 ISSUED DATE l _�
3. What type of well are you applying for?(monitoring or recovery): Monitoring
4. Applicant: GHHD (Terefe Mazengla) Telephone: [phone]
Applicant's Mailing Address: _ 3075 Ureghinrldge 131vd.,Suite 470, Duluth, G-eorgia 30096
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Applicant's Email Address(if available): terefe.mazengla(fthd.com
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5. Contact Person(if different than Applicant): Terefe Mezengla Telephone: [phone] o
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Contact Person's Mailing Address: same
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Contact Person's Email Address(if available): same
6. Property Owner(if different than Applicant): Dick Cozart Telephone: [phone]
Property Owner's Mailing Address: P, .B x 14 7 Wilson,NO 27894
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Property Owner's Email Address(if available): NA Z
7. Property Physical Address(Including PIN Number) Charleston St, SE,Wilson.NC. PIN 3731-00-8548.000
City Wilson County Wilson Zip Code 27894
8. Reason for Well(s): Off-§ite d�Gn§dtio(gEgggdwater contamination)
(ex non-discharge permit requirements,suspected contamination,assessment,groundwater contamination,remedialion,etc.)
9. Type of facility or site for which the well(s)is(are)needed: Manufacturing
(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).
Noneknown
11. Type of contaminants being monitored or recovered: Volatile
(ex: organics,nutrients,heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? NA
Existing Monitoring or Recovery Well Construction Permit No(s).: NA
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): NA
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: GeoLab Ddlina Certification No.: NCWC 4280E
Well Contractor Address: 800 Bill Rutledge Rd.,Winder Georgia 30680
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? Locking well cap and
material: 1 protective cover
3. Number of wells to be constructed in bedrock: 0
6. Estimated beginning construction date: 1/28/19
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3) 7. Estimated construction completion date: 1/30/19
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. 143-215.1013(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 Wel nstruction 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
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Signa ure of Applicant or*Agent Title of Applicant or*Agent
L!t� 111jLZ ;rA *If signing as Agent, attach authorization agreement stating
Printed name of Applicant or*Ag nt 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).
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 Raleigh Regional Office Wilmington Regional Office
2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension
Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 28405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [phone] Fax: [phone]
Fayetteville Regional Office Washington Regional Office Winston-Salem Regional Office
,225 Green Strget, Suite 714 943 Washington Square Mall 450 W. Hanes Mill Road
Fayetteville, NC 28301-5094 Washington, NC 27889 Suite 300
Phone: (910)A33-3300 Phone: [phone] Winston-Salem, NC 27105
Fax: [phone] Fax: [phone] Phone: [phone]
Fax: [phone]
Mooresville Regional Office d
610 East Center Avenue
Mooresville, NC 28115 al ,
Phone: [phone] ;e
Fax: [phone]
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1Ni1 nstan GW-22MR Rev.3-1-2016

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s)be secured? Locking well cap and
material: -___-1_ protective cover
3. Number of wells to be constructed in bedrock: 0 _
6. Estimated beginning construction date: 1/28/19
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3) 7. Estimated construction completion date: 1/30119
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 lank 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 Z
ction 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
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Signa re of Applicant or"Acme t Title of Applicant or*Agent
rtrL:R C *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
wells)Gull n to the W C n Standards(Title 15A of the North Carolina Administrat' a Code,Subchapter 2C).
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f different than Applicant) Prin a name of Property Owner(f different than Applicant)
DIRECTIONS
Please send the completed application to the approprisi a Division of Water Resources'Regional Office:
Asheville Regional Office Raleigh Regional Office Wilmington Regional Office
2090 U.S.Highway 70 3800 BE rrett Drive 127 Cardinal Drive Extension
Swannanoa,NC 28778 Raleigh, NC 27609 Wilmington,NC 28405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [phone] Fax: [phone]
Fayetteville Regional Office Washington Regional Office Winston-Salem Regional Office
225 Green Street,Suite 714 943 Washington Square Mall 450 W.Hanes Mill Road
Fayetteville,NC 28301-5094 Washington, NC 27889 Suite 300
Phone: [phone] Phone: [phone] Winston-Salem,NC 27105
Fax: [phone] Fax: [phone] Phone: [phone]
Fax: [phone]
Mooresville Regional Office °
Win ro Sale
610 East Center Avenue
Mooresville,NC 28115 0l
Phone: [phone]
Fax: [phone]
IIs or to
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Will eton GW-22MR Rev,3-1-2016

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LEGEND 2
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APPROXIMATE PROPERTY BOUNDARY
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PROPOSED WELL LOCATIONS
LINAMAR FORGINGS❑INC
2401 STANTONSBURG ROAD SE
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CAP TYPE:LOCKING,WATER PROOF
PROTECTIVE CASING
STICK UP=3 It
GROUND
SURFACE SEAL TYPE:CONCRETE
WELL CASING
ANNULUS BACKFILL TYPE:
NEAT CEMENT GROUT
TOP OF SEAL AT-5 ft.
SEAL TYPE:HYDRATED BENTONITE
BOTTOM OF SEAL AT-7 ft.
PACK TYPE:SAND
TOP OF SCREEN AT-9 ft.
BOTTOM OF SCREEN AT-19 ft
BOTTOM OF HOLE AT-20 ft. NOTE:
ALL DIMENSIONS ARE BELOW
GROUND SURFACE(BGS)
SCREEN TYPE:CONTINUOUS SLOT
SCREEN MATERIAL: PLASTIC
SCREEN LENGTH:1 Oft SCREEN DIAMETER:2 IN, SCREEN SLOT SIZE:0.010 IN.
WELL CASING MATERIAL:PLASTIC WELL CASING DIAMETER: 2 IN.
HOLE DIAMETER:8 IN.
PROPOSED OVERBURDEN MONITORING WELL CONSTRUCTION DETAILS
STICK-UP
2401 STANTONSBURG ROAD
Wi/son, Noah Carolina