26043 - Carpet Warehouse Brownfields Investigation Work Plan 20230327

BROWNFIELDS SITE ASSESSMENT
WORK PLAN

Carpet Warehouse
923 N. Liberty Street
Winston-Salem, Forsyth County, North Carolina
NCBP #26043-22-034
March 27, 2023
Revision 2.0
Terracon Project No. 75227127

Prepared for:
DPJ Residential Acquisitions, LLC
1539 Tippah Park Court
Charlotte, North Carolina 28205

Prepared by:
Terracon Consultants, Inc.
Greensboro, North Carolina

Terracon Consultants, Inc. 7327-G West Friendly Avenue Greensboro, NC 27410
P [phone] F [phone] terracon.com
March 27, 2023

Mr. Seth Titley
Brownfields Project Manager
Division of Waste Management – Brownfields Program
NC Department of Environmental Quality
1646 Mail Service Center
Raleigh, NC 27699-1646

P: [phone]
E: [e-mail]

Re: Brownfields Site Assessment Work Plan – Revision 2.0
Carpet Warehouse
923 N. Liberty Street
Winston-Salem, Forsyth County, North Carolina
NCBP #26043-22-034
Terracon Project No. 75227127

Dear Mr. Titley:

On behalf of DPJ Residential Acquisitions, LLC, the Prospective Developer (PD), Terracon
Consultants, Inc. (Terracon) is pleased to submit this Brownfields Site Assessment Work Plan for
the above referenced site. Terracon has prepared this work plan based on our Phase I
Environmental Site Assessment for the property which was completed on June 7, 2022. The PD
is seeking your approval of the work plan so that the assessment activities can be completed, an
Environmental Management Plan can be prepared, and a Brownfields Agreement can be
obtained for this site.

Terracon appreciates the opportunity to present this work plan to the North Carolina Brownfields
Program (NCBP). Terracon Consultants, Inc. is licensed to practice geology in North Carolina.
The certification number of the corporation is F-0869. Should you have any questions or require
additional information, please do not hesitate to contact us at [phone].

Sincerely,
Terracon Consultants, Inc.

Laura R. Elliott, P.G. Edmund Woloszyn Jr., R.E.M.
Group Manager, NCLG 2271 Department Manager

Cc: Mr. D. Porter Jones, DPJ Residential Acquisitions, LLC

TABLE OF CONTENTS

ii

1.0 INTRODUCTION ............................................................................................................. 1 1.1 General Site Description ...................................................................................... 1 1.2 On-site and Off-site Concerns .............................................................................. 1 1.3 Site Characteristics .............................................................................................. 3 2.0 SCOPE OF WORK .......................................................................................................... 3 2.1 Brownfields Assessment Work Plan ..................................................................... 4 2.2 Health and Safety Plan ....................................................................................... 4 2.3 Mark Utilities ....................................................................................................... 4 2.4 Advance Soil Borings .......................................................................................... 4 2.5 Convert Selected Soil Borings into Monitoring Wells ............................................ 6
2.6 Convert Selected Soil Borings into Soil Vapor Sampling Probes .......................... 7 2.7 Brownfields Receptor Survey ............................................................................... 8 3.0 SAMPLING METHODS ................................................................................................... 8
3.1 Soil Sampling Procedures .................................................................................... 8 3.2 Groundwater Sampling Procedures ..................................................................... 9 3.3 Soil Vapor Sampling Procedures ......................................................................... 9 4.0 SAMPLE ANALYSES ................................................................................................... 11 5.0 QUALITY ASSURANCE / QUALITY CONTROL .......................................................... 12 6.0 INVESTIGATION DERIVED WASTE MANAGEMENT ................................................. 12 7.0 BROWNFIELDS INVESTIGATION REPORT ................................................................ 13

Exhibits

Exhibit 1 – Topographic Map
Exhibit 2 – Site Plan with Sampling Locations
Exhibit 3 – Proposed Site Use

Table

Table 1 – Proposed Sampling and Analysis Plan

Appendix

Appendix A – NCBP Minimum Requirements Checklist for Site Assessment Work Plans
and Reports
Appendix B - Brownfields Receptor Survey Form

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BROWNFIELDS SITE ASSESSMENT WORK PLAN
Revision 2.0
CARPET WAREHOUSE
923 N. LIBERTY STREET
WINSTON-SALEM, FORSYTH COUNTY, NORTH CAROLINA

NCBP #26043-22-034
Terracon Project No. 75227127
March 27, 2023

1.0 INTRODUCTION

1.1 General Site Description

The site consists of 8 parcels of land located in downtown Winston-Salem, Forsyth County, North
Carolina (Exhibit 1). The parcels consist of:

 Forsyth County Parcel ID No. 6835-39-4439: 951 N. Liberty Street, 0.44 acres
 Forsyth County Parcel ID No. 6835-39-5574: 923 N. Liberty Street, 1.25 acres
 Forsyth County Parcel ID No. 6835-39-7772: 0 N. Liberty Street, 0.83 acres
 Forsyth County Parcel ID No. 6835-39-7523: 331 N. Martin Luther King, Jr. Drive, 0.22
acres
 Forsyth County Parcel ID No. 6835-39-7585: 347 N. Martin Luther King, Jr. Drive, 0.22
acres
 Forsyth County Parcel ID No. 6835-39-8642: 0 Ivy Avenue, 0.17 acres
 Forsyth County Parcel ID No. 6835-39-8567: 916 Ivy Avenue, 0.08 acres
 Forsyth County Parcel ID No. 6835-39-8563: 0 N. Martin Luther King, Jr. Drive, 0.11 acres

The site properties comprise a total of 3.41 acres of land. The parcel at 923 N. Liberty Street is
developed with a commercial office/warehouse building operating as a Carpet Warehouse. The
site is bordered to the north by N. Liberty Street followed by Taylor’s Warehouse and C&T Truck
and Auto Repair, to the south by N. Martin Luther King Jr. Drive followed by the Atrium Health
Downtown Health Plaza, to the east by Ivy Avenue NE followed by Salvage Building Materials
and a vacant commercial building, and to the west by Patterson Avenue followed by Truliant
Federal Credit Union. The site configuration is shown on Exhibit 2.

The site was accepted into the North Carolina Brownfields Program (NCBP) on June 6, 2022.
The NCBP will be the lead regulatory agency for this project.

1.2 On-site and Off-site Concerns

Terracon completed a Phase I Environmental Site Assessment (ESA) for the property and
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March 27, 2023 ■ Terracon Project No. 75227127

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provided our findings, conclusions and recommendations in a report dated June 7, 2022
(Terracon Project No. 75227075). The Phase I ESA identified the following Recognized
Environmental Conditions (RECs) potentially affecting the site:

REC/Site Concern Description
Potentially Up-Gradient
Off-site Concerns
 The former Vine Dry Cleaners facility was inferred to be
approximately 50 feet north and topographically up-
gradient relative to the site, as identified in the
DRYCLEANERS database and EDR’s proprietary
Historical Cleaners database. According to the Historical
Cleaners database, the facility operated from 1970
through 1979. Based on distance and gradient relative to
the site, Terracon considers the former Vine Dry Cleaners
facility to represent a REC to the site.
 The Salvage Building Materials facility was formerly
located approximately 50 feet north and topographically
up-gradient relative to the site and is identified in the State
Hazardous Waste Sites (SHWS) database, and the
Incident Management Database (IMD). (The Salvage
Building Materials business has changed locations and is
currently located to the northeast of the site.) Two
gasoline USTs and one Kerosene UST were closed by
removal, leaving a waste oil UST in the ground. A
groundwater sample from a monitoring well contained the
chlorinated solvent trichloroethylene (TCE) and the
volatile organic compound chloroform at concentrations
exceeding 15A North Carolina Administrative Code
(NCAC) 2L Groundwater Quality Standards (2L
Standards). Based on the lack of documentation
concerning the source or extent of the chlorinated solvent
Terracon considers the former Salvage Materials facility
to represent a REC to the site.
 The 893 North Liberty Street / 747 North Chestnut Street
facility located approximately 70 feet west and
topographically cross-gradient relative to the site is
identified in the U.S. Brownfields database. Other records
or reports for this facility were not identified or made
available. Based on distance and gradient relative to the
site and the lack of information regarding the US
Brownfields listing Terracon consider it to represent a
REC to the site.
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Terracon notes that undiscovered underground storage tanks (USTs) may also be present at the
site. No sampling activities have been completed to date to assess if the aforementioned RECs
have adversely impacted the site’s soil, groundwater or created adverse soil vapor conditions by
hazardous materials (chlorinated hydrocarbons) or petroleum-based constituents (i.e., chemicals
of potential concern or COPCs), which are considered significant data gaps.

Subsequent to the issued Phase I ESA, Terracon reviewed additional historical records and
addresses, and has concluded that it is likely that the Vine Dry Cleaners address listed (905 N.
Liberty Street) corresponds to the on-site parcel 6835-39-4439.

Terracon plans to utilize ground-penetrating radar (GPR) to search for USTs in the eastern portion
of the site near the former dwellings as mapped in the historical Sanborn maps.

1.3 Site Characteristics

The site is located within the Milton Belt of the Piedmont Physiographic Province. Soils underlying
the site consist of clayey silts that were chemically weathered from biotite gneiss and schist
bedrock. Based on Terracon’s recent assessment activities at the nearby Vernon Packaging
Brownfields Site, groundwater was present at depths of 45 to 55 feet below ground surface.
Based on surface topography, it appears likely that N. Liberty Street, located along the northern
site boundary, is located along a topographic ridge such that groundwater south of N. Liberty
Street flows in a southerly direction, while groundwater north of the street flows in a northerly
direction.

2.0 SCOPE OF WORK

It is Terracon’s understanding that the primary concern of the NCBP is how human health could
be affected during and after redevelopment activities at the site. In order to assess the site for
COPCs and associated health-based risks, Terracon proposes to advance soil borings, install
groundwater monitoring wells, install indoor and outdoor soil vapor sampling probes, collect and
analyze soil, soil vapor and groundwater samples, and complete a Brownfields Receptor Survey.
Proposed sample locations are based primarily on areas of potential concern due to site history,
identified data gaps, and discussions with the NCBP. The NCBP Minimum Requirement Checklist
for Site Assessment Work Plans and Reports dated February 2022 (Appendix A) and the most
recent Inactive Hazardous Sites Branch (IHSB) Program Guidelines for Assessment and Cleanup
will be used as a protocol for additional assessment activities. The rationale for selecting specific
sample intervals/locations is discussed below for the different sample media.

The soil, soil vapor and groundwater assessment activities are intended to address historical site
conditions, and nearby and potentially up-gradient off-site environmental conditions that could
affect the site. The assessment will generally consist of the following elements:
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 Prepare draft and final Brownfields Site Assessment Workplan
 Prepare a site-specific Health and Safety Plan
 Mark the locations of underground utilities and screen for orphaned USTs in the eastern
portion of the site using GPR
 Advance nine soil borings across the site to depths of approximately 10 feet below ground
surface (bgs) in an effort to characterize the environmental quality of on-site soils
 Advance one soil boring to a depth of approximately 13 feet bgs in the area of the
rubberized asphalt fill material noted in the Geotechnical Report in the vicinity of proposed
soil boring B-6
 All soil borings (total of nine) will be converted to soil vapor monitoring probes
 Install seven sub-slab vapor sampling points inside of the existing building
 Install five permanent groundwater monitoring wells around the site perimeter to depths
of approximately 60 feet bgs
 Collect two soil samples from each exterior soil vapor probe boring (18 samples), plus one
duplicate soil sample for quality assurance/quality control (QA/QC) purposes (total of 19
samples).
 Collect one round of soil vapor samples and analyze 16 soil vapor samples plus one
duplicate sample (total of 17 samples)
 Collect one round of groundwater samples and one duplicate sample (total of 6 samples)
 Conduct NCDEQ Brownfields Program Receptor Survey
 Prepare draft and final Brownfields Site Assessment report

2.1 Brownfields Assessment Work Plan

Terracon will prepare draft and final Brownfields Site Assessment Workplan in accordance with
NCDEQ Brownfields Program requirements.

2.2 Health and Safety Plan

Terracon will prepare a Health and Safety Plan to address physical and chemical hazards at the
site. The Plan will be prepared in accordance with Occupational Safety and Health (OSHA)
1910.120 requirements. At this time, we anticipate that a U.S. EPA Level D work uniform
consisting of a hard hat, safety vest, safety glasses, protective gloves and steel-toed boots will be
required by all personnel in the work area. It may become necessary to upgrade this level of
protection in the event that petroleum or chemical constituents are present and an increased risk
for personal exposure is encountered in soils or groundwater while sampling activities are being
conducted.

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2.3 Mark Utilities

Following our receipt of your authorization to proceed and at least three days prior to intrusive
activities, Terracon will contact a utility locator (NC 811) to arrange for identifying underground
utilities at the above-referenced site. The locator will attempt to identify all utilities traversing the
site. Terracon will also subcontract with a private utility locator for the purpose of identifying on-
site utilities at our proposed boring locations. Terracon will additionally depend on assistance from
the client and/or site contact for identifying the location of private underground utilities at the site.
At the request of the Brownfields Program, Terracon will perform additional screening for
orphaned USTs in the eastern portion of the site near the former dwellings mapped in historical
Sanborn maps.

2.4 Advance Soil Borings

Terracon proposes to advance 14 soil borings at the site. The soil borings will be positioned to
generally assess soil, soil vapor and/or groundwater quality concerns associated with on-site and
off-site environmental concerns. Eight soil borings will be advanced to depths of approximately
10 feet bgs to assess the quality of on-site soils. One soil boring will be advanced to a depth of
approximately 13 feet bgs in the vicinity of the documented rubberized asphalt documented in the
Geotechnical Report. Nine soil borings will be converted to exterior soil gas sampling points to
assess soil vapor conditions in the area of the proposed on-site apartment building.

Five borings will be advanced to depths of approximately 60 feet bgs around the site boundary
and converted to groundwater monitoring wells. In addition to the soil borings, seven sub-slab
soil vapor samples will be collected beneath the existing on-site building.

The soil borings will be advanced using a track-mounted Geoprobe® direct push technology (DPT)
drill rig using a 2.25-inch diameter Macrocore® soil sampler. The five monitoring well borings will
be advanced with an air-rotary DPT rig advancing eight-inch diameter hollow stem augers. The
proposed boring and sub-slab vapor locations are described in the following table and are shown
in Exhibit 2:

Boring No. Sample Depth Total Depth Other Use
B-1 3 feet, 7 feet 10 feet Soil Boring/Soil Vapor Probe
B-2 3 feet, 7 feet 10 feet Soil Boring/Soil Vapor Probe
B-3 3 feet, 7 feet 10 feet Soil Boring/Soil Vapor Probe
B-4 3 feet, 7 feet 10 feet Soil Boring/Soil Vapor Probe
B-5 3 feet, 7 feet 10 feet Soil Boring/Soil Vapor Probe
B-6 3 feet, 10 feet 13 feet Soil Boring/Soil Vapor Probe
B-7 3 feet, 5 feet 10 feet Soil Boring/Soil Vapor Probe
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Boring No. Sample Depth Total Depth Other Use
B-8 3 feet, 5 feet 10 feet Soil Boring/Soil Vapor Probe
B-9 3 feet, 7 feet 10 feet Soil Boring/Soil Vapor Probe
SVP-1 (Refer to B-1) 10 feet Soil Boring/Soil Vapor Probe
SVP-2 (Refer to B-2) 10 feet Soil Boring/Soil Vapor Probe
SVP-3 (Refer to B-3) 10 feet Soil Boring/Soil Vapor Probe
SVP-4 (Refer to B-4) 10 feet Soil Boring/Soil Vapor Probe
SVP-5 (Refer to B-5) 10 feet Soil Boring/Soil Vapor Probe
SVP-6 (Refer to B-6) 13 feet Soil Boring/Soil Vapor Probe
SVP-7 (Refer to B-7) 10 feet Soil Boring/Soil Vapor Probe
SVP-8 (Refer to B-8) 10 feet Soil Boring/Soil Vapor Probe
SVP-9 (Refer to B-9) 10 feet Soil Boring/Soil Vapor Probe
SSVP-10 n/a 0.5 feet Sub-Slab Vapor Probe
SSVP-11 n/a 0.5 feet Sub-Slab Vapor Probe
SSVP-12 n/a 0.5 feet Sub-Slab Vapor Probe
SSVP-13 n/a 0.5 feet Sub-Slab Vapor Probe
SSVP-14 n/a 0.5 feet Sub-Slab Vapor Probe
SSVP-15 n/a 0.5 feet Sub-Slab Vapor Probe
SSVP-16 n/a 0.5 feet Sub-Slab Vapor Probe
MW-1 n/a 60 feet Permanent Well
MW-2 n/a 60 feet Permanent Well
MW-3 n/a 60 feet Permanent Well
MW-4 n/a 60 feet Permanent Well
MW-5 n/a 60 feet Permanent Well

Please refer to the attached Table 1 for the proposed number of samples per area of concern.
The proposed boring locations may be modified in the field to account for utility clearance, access
limitations, and/or site conditions. The client will be notified of any significant modifications to the
sampling locations. Terracon will prepare boring logs for each boring.

Drilling equipment will be cleaned using a high-pressure washer prior to beginning the project and
before each boring. Non-dedicated sampling equipment will be cleaned using an Alconox®
detergent wash and potable water rinse prior to commencement of the project and after collection
of each sample. The sample locations (horizontal control only) will be documented by a North
Carolina licensed surveyor.

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2.5 Convert Selected Soil Borings into Monitoring Wells

Five soil borings will be converted to permanent groundwater monitoring wells in accordance with
the USEPA Region 4 Science and Ecosystem Support Division (SESD) Guidance for the Design
and Installation of Monitoring Wells (SESD Guidance Document) dated January 2018 and in
accordance with North Carolina’s well construction standards as promulgated in 15A NCAC 2C:

 Advance soil borings to depths of approximately 60 feet bgs;
 Install a 10-foot section of two-inch diameter, 0.010-inch machine slotted PVC well screen;
 Install a 2-inch diameter, threaded, flush-joint PVC riser pipe to the ground surface;
 Install a sand pack around and 2 feet above the well screen;
 Install a 2-foot-thick bentonite seal over the sand pack, followed by grout to within
approximately 1 foot of the ground surface; and
 Install a flush-mounted, traffic-rated well vault set in a concrete pad.

The groundwater monitoring well locations (both horizontal and vertical control) will be
documented by a North Carolina licensed surveyor.

2.6 Convert Selected Soil Borings into Soil Vapor Sampling Probes

Seven sub-slab vapor points will be installed inside the on-site building, and nine soil borings will
be installed as permanent exterior soil gas sampling points in accordance with the following
procedures:

Sub-Slab Soil Vapor Probes

 Advance 3/8-inch diameter hole through the existing slab foundation with a hand drill and
approximately 6 inches into the underlying soils/gravel.
 Install vapor sampling pin into drilled hold, install cap.

Exterior Soil Gas Sampling Points

 Advance soil boring to 10 feet bgs.
 Install a 1/4-inch diameter TeflonTM tube to approximately 6 inches from the bottom of the
boring and extending two feet above ground surface. Bottom end of tube is equipped with
a GeoprobeTM implant anchor/drive point and top end of tube is crimped;
 Install a coarse sand pack around and approximately two feet above the bottom of the
tubing;
 Install a 2-foot thick bentonite seal over the sand pack, followed by grout to the ground
surface;
 Install a flush-mounted, traffic-rated well vault set in a concrete pad.

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The sub-slab soil vapor points and the exterior soil gas sampling points (horizontal control only)
will be documented by a North Carolina licensed surveyor.

2.7 Brownfields Receptor Survey

A Brownfields Receptor Survey will be completed as part of the additional assessment for the
site. The “Brownfields Property Receptor Survey” form will be used to conduct the field and office-
based portions of the receptor survey. The completed form and a summary of findings will be
included in the Brownfields Assessment Report. A copy of the Brownfields Property Receptor
Survey form is attached in Appendix B.

3.0 SAMPLING METHODS

3.1 Soil Sampling Procedures

Soil sampling techniques outlined in this work plan are in general accordance with the North
Carolina Department of Environmental Quality (NCDEQ), Inactive Hazardous Sites Branch
(IHSB) Guidelines for Assessment and Cleanup of Contaminated Sites dated July 2021. All soil
samples will be collected via Direct-Push Technologies from new, disposable macrocore liners to
document lithology, color, and relative moisture content. Soil type, relative moisture content, and
other lithologic characteristics will be documented in boring logs prepared in the field. Terracon
will screen the soils continuously for visual staining and odors, at a minimum of five-foot intervals
in the field using a photo-ionization detector (PID) that screens for volatile vapors.

Soil samples (including one duplicate sample for every 20 samples collected) will be collected at
the depth intervals described in the Sampling and Analysis Plan (Table 1). The soil samples will
generally be collected in the 3-foot to 4-foot and 7-foot to 8-foot depth intervals, but may vary
based on the results of PID screening activities.

Terracon notes that the sampling depths will be determined in the field based on the actual
thickness of soils. In the event that soil samples from a boring exhibit elevated PID readings, the
sample collected in soils with the highest PID reading will be submitted for laboratory analyses.
The default soil sampling depths shown above were selected based on the anticipated depth of
base of foundation excavation based on previously advanced geotechnical soil borings. Soil
samples will not be collected from the seven sub-slab sampling locations (SSVP-10 through
SSVP-16), or from the five monitoring well locations.

The soil samples will be placed into laboratory-supplied glass containers with appropriate
preservative, labeled with pertinent sample information with a permanent marker, and stored in
an ice-packed cooler pending submittal to Pace Analytical Laboratories in Mt. Juliet, Tennessee,
a North Carolina-certified laboratory. Samples should be received by the lab within 48 hours of
collection. Chain of custody documentation will accompany the samples to the laboratory.
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Terracon notes that additional soil samples, beyond those described in Table 1, may also be
collected on the basis of the PID readings.

Soil sample results will be compared to the IHSB’s Preliminary Soil Remediation Goals (PSRGs)
for unrestricted use and residential use. In addition, constituent concentrations in the soils will be
evaluated using the NC Brownfields Program’s Risk Calculator under Residential and Non-
Residential exposure scenarios.

3.2 Groundwater Sampling Procedures

After allowing at least 24 hours for equilibration of groundwater in the wells, depth to groundwater
and total depth measurements will be obtained from each well using an electronic water level
meter. The depth to groundwater measurements will be compared to the monitoring well location
and elevation information to construct a groundwater gradient map for the site. The samples will
be collected with a submersible pump and associated controller. Disposable bailers will be used
if the collection of groundwater is not feasible with the use of either a peristaltic pump or
submersible pump. The wells will be purged of at least three well volumes of groundwater prior
to sampling.

Using a peristaltic pump, the groundwater samples will be collected from the monitoring wells
using low flow sampling rates (<200 milliliters per minute). The following parameters: pH,
temperature, oxidation reduction potential (ORP), dissolved oxygen (DO), conductivity and
turbidity will be measured during purging. The groundwater samples will be collected after the
field-measured water quality parameters have stabilized within 10 percent and turbidity values
have decreased to less than 10 nephelometric turbidity units (NTUs). In the event that
groundwater conditions do not allow for the use of low-flow sampling, the groundwater samples
will be collected using disposable bailers, and the parameters will be measured following removal
of each well volume of water. The groundwater samples will be placed into laboratory-supplied
bottles, stored on ice in an insulated container, and shipped along with chain-of-custody
documentation to the state-certified Pace Analytical Laboratories in Mt. Juliet, Tennessee for
analysis.

Groundwater analytical results will be compared to the 15A NCAC Subchapter 2L Groundwater
Quality Standards. Additionally, constituent concentrations in groundwater will be evaluated using
the IHSB’s Residential and Non-Residential Groundwater Screening Levels for Vapor Intrusion
and the NC Brownfields Program’s Vapor Intrusion Risk Calculator under Residential and Non-
Residential exposure scenarios.

3.3 Soil Vapor Sampling Procedures

The exterior soil vapor probes will be allowed to equilibrate for a minimum of 24 hours after
installation. The sub-slab sampling points will be allowed to equilibrate for a minimum of 20
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minutes after installation. A helium tracer gas leak test will be conducted prior to sampling. The
tracer gas serves as a QA/QC method to verify the integrity of the soil vapor probe seal.
Approximately three volumes of the vapor implant annulus and attached Teflon® lined tubing will
be purged. Purge samples will be screened for helium to assess for leaks in the shroud seal and
with a PID detector to assess for VOCs. Sample collection will begin if the tracer testing indicates
helium concentrations in the vapor implant are less than or equal to 10 percent of the helium
concentration in the shroud, indicating a sufficiently sealed vapor implant annulus. Soil vapor
samples will be collected using an inline purge/sampling train consisting of a batch-certified 1-liter
Summa canister for sample collection (sample canister) connected to a critical orifice flow
restrictor (flow controller). The sample will be collected over a 15-minute time interval.

Samples will be collected with 1.0-liter Summa® canisters equipped with flow controllers.
Investigation and sample collection procedures will be conducted in accordance with local
industry standard practices.

Shut-In Test
At each soil vapor implant, prior to connection of the sampling train to the implant, a shut-in (dead-
head) test will be conducted to check for leaks in the above-ground purge/sampling manifold. The
sample canister will be connected to the sampling train. The sampling train influent will be capped,
the sampling canister will remain closed, and a handheld vacuum gauge will be connected to
create a negative pressure reading on the sampling train pressure gauge. The sacrificial canister
valve will then be closed. If there is an observable loss of vacuum, the fittings will be adjusted
until the vacuum in the sample train does not noticeably dissipate. This test will be conducted in
accordance with the NCDEQ DWM Vapor Intrusion Guidance Document, dated March 2018.

Helium Tracer Test
For each soil vapor implant sample, following the shut-in test, the purge/sampling train will be
connected to the soil vapor sampling implant and a Helium tracer gas leak test will be conducted.
The tracer gas serves as a QA/QC method to verify the integrity of the seal of sampling train to
the sample implant. An MGD-2002 (or equivalent) helium detector will be used to verify the
presence and concentration of tracer gas.

The protocol for using a tracer gas is to enclose the sampling train within a shroud and enrich the
shroud atmosphere to at least 10 percent helium. The purging device (i.e. syringe or peristaltic
pump) will be situated inside the shroud and connected to the sampling train by Teflon® lined
tubing running through the shroud. A minimum of three volumes of the vapor implant annulus and
attached Teflon® lined tubing will be purged. Purged soil gas will be directed to a TedlarTM bag
at the end of each purge volume. Purged soil gas in the TedlarTM bag will then be screened for
helium to assess for leaks in the sampling implant seal and with a photo-ionization detector (PID
RAE 3000 or equivalent) to assess for VOCs. The shroud helium concentration and the helium
concentration in the purged soil vapor will be documented after each volume purged.

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Sample collection will begin if the tracer testing indicates helium concentrations in the vapor
implant are less than or equal to 10 percent of the helium concentration in the shroud, indicating
a sufficiently sealed vapor implant annulus. A photograph of the shroud and sampling set-up at
each sample location will be included in the report.

Sample Collection
After completion of the helium tracer test, the valve of the purge device will be closed, and the
sample canister valve will be opened to collect soil vapor for laboratory analysis. The sample will
be collected in a laboratory-supplied, batch-certified 1-liter Summa canister connected to sample
tubing using Swagelok® fittings at the soil vapor implant. The sample canister will be filled using
a dedicated flow controller and set to a sample rate of less than or equal to 200 milliliters per
minute. An in-line vacuum gauge will be installed to the sample controller to verify initial vacuum
levels within the canister and as an indicator that final equalization has been reached (i.e.
sampling is complete). The sample canister valve will be closed when the gauge measures 6-7
inches of mercury (in Hg) vacuum (i.e. sampling is complete). The final vacuum will not be allowed
to reach 0 in Hg vacuum. A minimum of 5 in Hg vacuum should be maintained, following sample
collection.

Each initial container volume, post-sampling volume, and as-received by the laboratory container
volumes will be recorded and documented on the Chain of Custody. New batch-certified canisters
that have lost 10% or greater vacuum between shipment from the lab to receipt for use in the field
should not be used for sampling. Containers received by the lab post-sampling without a residual
vacuum will not be considered valid for analysis.

Sample Point Abandonment
Following sample collection, the sub-slab sampling points will be removed, if possible, and the
resulting hole in the building slab will be patched with neat cement. If a sampling point cannot be
easily removed, it will be pounded into the drill hole to the extent practicable and patched with
neat cement. The soil vapor probes will extend into soil only, and therefore the vapor tubing and
surface vaults can be removed with a backhoe or similar equipment.

4.0 SAMPLE ANALYSES

A total of 19 soil samples will be analyzed by Pace Analytical laboratory located in Mount Juliet,
Tennessee (NC Laboratory Accreditation No. Env375). The soil samples will be analyzed for
volatile organic compounds (VOCs) using USEPA Method 8260, semi-volatile organic
compounds (SVOCs) using USEPA Method 8270, eight Resource and Recovery Act (RCRA)
metals using USEPA Method 6020/7471, and hexavalent chromium using USEPA Method 7199.
The laboratory Reporting Limits (RLs) and Method Detection Limits (MDLs) will meet applicable
screening criteria (to the extent feasible) and will include the reporting of “J-Flags.” The laboratory
will provide Level II Quality Assurance / Quality Control data packages for all analyses.

Brownfields Site Assessment Work Plan – Revision 2.0
Carpet Warehouse ■ Winston-Salem, NC
March 27, 2023 ■ Terracon Project No. 75227127

Responsive ■ Resourceful ■ Reliable 12
A total of 16 soil vapor samples will be analyzed for VOCs only using USEPA Method TO-15,
including naphthalene.

A total of five groundwater samples will be analyzed for VOCs, SVOCs, and RCRA metals using
the analytical methods described above.

5.0 QUALITY ASSURANCE / QUALITY CONTROL

Laboratory samples will be analyzed in conjunction with standard laboratory QA/QC procedures
including appropriate blanks, duplicates, continuing calibration standards, surrogate standards,
and matrix spiking standards in accordance with approved methodologies to monitor both
instrument and analyst performance. The laboratory will include estimated concentrations for
compounds that are detected at levels above the laboratory detection but below the laboratory
reporting limit (J flags). Laboratory results not meeting reporting limits with be identified within
the QA/QC discussion of the report. Based on the sample collection containers provided by the
laboratory, the laboratory will be provided sufficient sample volume for MS/MSD analyses. Chain
of custody documentation will accompany the samples to the laboratory.

Blind duplicate samples will be collected as part of this investigation for QA/QC purposes.
Specifically, one duplicate sample will be collected for every 20 samples per sample media (soil,
groundwater, and soil vapor) for a total of one duplicate soil sample, one duplicate soil vapor
sample, and one duplicate groundwater sample. The duplicate samples will be submitted for
laboratory analysis of VOCs, SVOCs, RCRA metals and hexavalent chrome using the analytical
methods described above. In addition to the duplicate samples, one trip blank will be submitted
with the groundwater samples for analysis of VOCs using EPA Method 8260.

A level II QA/QC data package will be requested from the analytical laboratory for the soil,
groundwater and soil vapor samples. Terracon will require that laboratory RLs and MDLs be
below applicable standards and screening levels, to the extent feasible. Terracon will also request
“J-Flag” values to be included in the laboratory analytical reports.

6.0 INVESTIGATION DERIVED WASTE MANAGEMENT

Following the completion of sampling activities, each soil boring will be properly abandoned in
general accordance with applicable USEPA Region 4 SESD Guidance Document dated January
2018. The borings will be abandoned by backfilling the borehole with bentonite pellets. The
pellets will be hydrated, and the boring will be grouted to the surface. Soil cuttings generated
during the assessment activities that exhibit PID readings in excess of 50 parts per million
(referenced to an isobutylene standard) will be containerized in 55-gallon drums onsite pending
analysis.

Brownfields Site Assessment Work Plan – Revision 2.0
Carpet Warehouse ■ Winston-Salem, NC
March 27, 2023 ■ Terracon Project No. 75227127

Responsive ■ Resourceful ■ Reliable 13

7.0 BROWNFIELDS INVESTIGATION REPORT

Upon completion of the assessment activities and receipt of the laboratory analytical results, a
Brownfields Investigation Report will be prepared that will include the following items:

 Documentation of field activities including field notes;
 Site plan showing pertinent site features;
 Soil boring logs and groundwater sampling logs;
 Development of a groundwater potentiometric map showing the groundwater flow
direction based on field measurements and well surveying activities;
 Receptor survey form and results;
 Analytical laboratory results;
 Data evaluation and presentation of findings including comparison of data to applicable
regulatory standards; and
 Recommendations concerning further assessment, if necessary.

The report will be completed in a format suitable for submittal to the North Carolina Brownfields
Program. Work associated with this scope of services will be performed under the direction of a
Licensed Geologist registered in the State of North Carolina. The final report will be signed and
sealed by a Licensed Geologist registered in the State of North Carolina.

EXHIBITS

TOPOGRAPHIC MAP
Carpet Warehouse
923 N. Liberty Street Winston-Salem, NC
TOPOGRAPHIC MAP IMAGE COURTESY OF THE U.S. GEOLOGICAL SURVEY QUADRANGLES INCLUDE: RURAL HALL, NC (1/1/1994), WALKERTOWN, NC (1/1/1997), WINSTON-SALEM WEST, NC (1/1/1997) and WINSTON-SALEM EAST, NC (1/1/1997).
7327 W Friendly Ave Ste G
Greensboro, NC 27410-6253
75227127 Project Manager:
Drawn by:
Checked by:
Approved by:
LRE
MIM
EW
1”=2,000’

02/23/23
Project No.
Scale:
File Name:
Date: 1
Exhibit LRE
APPROXIMATE
SITE BOUNDARY

SITE DIAGRAM
Carpet Warehouse
923 N. Liberty Street Winston-Salem, NC
7327 W Friendly Ave Ste G
Greensboro, NC 27410-6253
DIAGRAM IS FOR GENERAL LOCATION ONLY, AND IS NOT INTENDED FOR CONSTRUCTION PURPOSES
75227127
AERIAL PHOTOGRAPHY PROVIDED BY MICROSOFT BING MAPS
LRE
MIM
EW
AS SHOWN

02/23/23
Scale:
2
Exhibit Project Manager:
Drawn by:
Checked by:
Approved by:
Project No.
File Name:
Date:
LRE
APPROXIMATE
SITE BOUNDARY
LEGEND

MONITORING WELL

SOIL BORING

SOIL VAPOR POINT

PROPOSED SITE USE
7327 W Friendly Ave Ste G
Greensboro, NC 27410-6253
75227127 AERIAL PHOTOGRAPHY PROVIDED BY
MICROSOFT BING MAPS
Carpet Warehouse
923 N. Liberty Street Winston-Salem, NC DIAGRAM IS FOR GENERAL LOCATION ONLY, AND IS NOT INTENDED FOR CONSTRUCTION PURPOSES
Project Manager:
Drawn by:
Checked by:
Approved by:
FCD
LRE
EW
LRE
CW
Feb 2023
Scale:
Project No.
File Name:
Date:
AS SHOWN 3
Exhibit N. PATTERSON AVENUE

TABLE

BROWNFIELDS INVESTIGATION WORK PLAN
Carpet Warehouse ■ Winston-Salem, NC
March 14, 2023 ■ Terracon Project No. 75227127
Table 1 – Sampling and Analytical Program
Carpet Warehouse
923 N Liberty Street Winston-Salem, NC
Terracon Project No. 75227127

Type and Designation1 Advancement Method Estimated Boring Depth2 (ft)
Estimated Sampling Depth (ft)
No. of Soil Analytical Samples3
Soil Analytical4 Groundwater Sampling Method
Groundwater Analytical4 Soil Gas Analytical4 QC Samples5

B-1 Direct Push 10

3 and 7 2
VOCs
SVOCs RCRA 8 Metals
Hexavalent Cr
N/A

N/A

N/A
B-2

Direct Push 10

3 and 7 2
VOCs
SVOCs RCRA 8 Metals
Hexavalent Cr

N/A

N/A

N/A
B-3

Direct Push 10

3 and 7 2
VOCs
SVOCs RCRA 8 Metals
Hexavalent Cr

N/A

N/A

N/A
B-4

Direct Push 10

3 and 7 2
VOCs
SVOCs RCRA 8 Metals
Hexavalent Cr

N/A

N/A

N/A
B-5

Direct Push 10

3 and 7 2
VOCs
SVOCs RCRA 8 Metals
Hexavalent Cr

N/A

N/A

N/A
B-6

Direct Push 13
3 and 10;
Targeted rubberized asphalt – between 8 and 13 feet bgs
2
VOCs
SVOCs RCRA 8 Metals
Hexavalent Cr

N/A

N/A

N/A
1 Duplicate Soil
B-7

Direct Push 10

3 and 7 2
VOCs
SVOCs RCRA 8 Metals
Hexavalent Cr

N/A

N/A

N/A
B-8

Direct Push 10

3 and 7 2
VOCs
SVOCs RCRA 8 Metals
Hexavalent Cr

N/A

N/A

N/A
BROWNFIELDS INVESTIGATION WORK PLAN
Carpet Warehouse ■ Winston-Salem, NC
March 14, 2023 ■ Terracon Project No. 75227127
B-9

Direct Push

10

3 and 7
2

VOCs
SVOCs RCRA 8 Metals
Hexavalent Cr

N/A

N/A

N/A
SVP-1 Direct Push & Hollow-stem auger
10 10 N/A N/A N/A N/A VOCs
SVP-2 Direct Push & Hollow-stem auger
10 10 N/A N/A N/A N/A VOCs
SVP-3 Direct Push & Hollow-stem auger
10 10 N/A N/A N/A N/A VOCs
SVP-4 Direct Push & Hollow-stem auger
10 10 N/A N/A N/A N/A VOCs
SVP-5 Direct Push & Hollow-stem auger
10 10 N/A N/A N/A N/A VOCs
SVP-6 Direct Push & Hollow-stem auger
10 10 N/A N/A N/A N/A VOCs
SVP-7 Direct Push & Hollow-stem auger
10 10 N/A N/A N/A N/A VOCs
SVP-8 Direct Push & Hollow-stem auger
10 10 N/A N/A N/A N/A VOCs
SVP-9 Direct Push & Hollow-stem auger
10 10 N/A N/A N/A N/A VOCs
SSVP-10 Hammer Drill and Vapor Pin 0.5 0.5 N/A N/A N/A N/A VOCs
SSVP-11 Hammer Drill and Vapor Pin 0.5 0.5 N/A N/A N/A N/A VOCs 1 Duplicate Soil Gas
SSVP-12 Hammer Drill and Vapor Pin 0.5 0.5 N/A N/A N/A N/A VOCs
SSVP-13 Hammer Drill and Vapor Pin 0.5 0.5 N/A N/A N/A N/A VOCs
SSVP-14 Hammer Drill and Vapor Pin 0.5 0.5 N/A N/A N/A N/A VOCs
SSVP-15 Hammer Drill and Vapor Pin 0.5 0.5 N/A N/A N/A N/A VOCs
SSVP-16 Hammer Drill and Vapor Pin 0.5 0.5 N/A N/A N/A N/A VOCs

BROWNFIELDS INVESTIGATION WORK PLAN
Carpet Warehouse ■ Winston-Salem, NC
March 14, 2023 ■ Terracon Project No. 75227127
MW-1

Hollow-stem auger / air rotary

50

N/A

N/A

N/A
Submersible Pump or Dedicated Bailer

VOCs
SVOCs RCRA 8 Metals
Hexavalent Cr

N/A

MW-2

Hollow-stem auger / air rotary
50

N/A

N/A

N/A Submersible Pump or Dedicated Bailer
VOCs
SVOCs RCRA 8 Metals
Hexavalent Cr

N/A
MW-3

Hollow-stem auger / air rotary
50

N/A

N/A

N/A Submersible Pump or Dedicated Bailer
VOCs
SVOCs RCRA 8 Metals
Hexavalent Cr

N/A
MW-4

Hollow-stem auger / air rotary
50

N/A

N/A

N/A Submersible Pump or Dedicated Bailer
VOCs
SVOCs RCRA 8 Metals
Hexavalent Cr

N/A
MW-5

Hollow-stem auger / air rotary
50

N/A

N/A

N/A Submersible Pump or Dedicated Bailer
VOCs
SVOCs RCRA 8 Metals
Hexavalent Cr

N/A 1 Duplicate Groundwater

Notes:
1 Type and Designation: B = Soil Boring; MW = Permanent Monitoring Well; TMW = Temporary Monitoring Well; TSP = Temporary Groundwater Sampling Point; SVP = Soil Vapor Probe; SSVP = Sub-slab Soil Vapor Probe; IAS = Indoor Air
Sample
2 Proposed maximum depth based on current knowledge of subsurface conditions and depth to groundwater in area. Depths may be modified based on the actual depth to groundwater or refusal on bedrock. If boring advancement beyond above
depths is necessary, client will be notified to discuss options and associated costs.
3 Number of unsaturated zone soil samples to be submitted for analytical testing. Samples will be assigned based on photoionization detector (PID) readings and/or professional judgement considering the type of chemical, nature and depth of
source, and chemical fate and transport characteristics.
4 Analytical Methods:
VOCs = volatile organic compounds by EPA 8260 (EPA TO-15 including naphthalene for soil gas)
SVOCs = semi-volatile organic compounds by EPA 8270
RCRA Metals = Resource Conservation and Recovery Act Metals by EPA 6010/7470/7471
Hexavalent Chromium by EPA 7196A

APPENDIX A
Minimum Requirement Checklist for
Site Assessment Work Plan and Reports

Work Plan and Report Checklist
Version 2 February 2022

Minimum Requirements Checklist for Site Assessment Work Plans and Reports
NCDEQ Brownfields Program – February 2022
Instructional Page
All references to Prospective Developers includes follow-on owners who may be conducting work in accordance with the Brownfields Property Management Unit.
To increase predictability and most efficiently assess Brownfields Properties and the redevelopment
timing requirements of Prospective Developers or follow-on owners, the Brownfields Program has standardized the format for Site Assessments. This format has been generated in the form of a checklist to allow for ease in submission by the prospective developer’s consultant and for the Brownfields Program’s completeness review. This checklist outlines the minimum requirements and
submittal format under the Brownfields Program for Assessment Requirements and Reporting. All
Assessment Work Plans and Reporting submissions to the Brownfields Program must include this
completed checklist in the outlined format.
These requirements allow DEQ to reduce review time for the Assessment Work Plan and Report and increase process predictability for prospective developers. This checklist will also provide
reliable data for risk-based decisions and further expedite the project timeline. Any divergence from
these requirements will lengthen the process of assessing risks on the site, may necessitate reprioritization of a project manager’s queue towards projects that meet these requirements. Therefore, delaying production of the brownfields agreement and/or environmental management plan. Any alterations to the checklist on a site- specific basis must be reviewed and approved by the
Program prior to implementation. However, in order to respect the schedule of all projects in house
and keep the program’s entire project pipeline moving, we strongly recommend against seeking changes to the checklist.
Based on a review of environmental and risk data from our project inventory, please note there are some new points of emphasis that are included herein:
1. For ALL residential reuses; sub-slab vapor assessment (full list EPA TO-15) is required,
regardless if existing structures will be removed. If no structures or slabs exist on the
Brownfields Property, exterior soil gas assessment is required within all proposed structure footprints.
2. ALL properties require groundwater data (VOCs, SVOCs and RCRA Metals) from a minimum of three sample locations, depth to groundwater and a resulting potentiometric map.
3. Soil shall be assessed based on areas of concern and redevelopment plans and across the
depth interval of the cut/grading.

Work Plan and Report Checklist
Version 2 February 2022

Environmental Site Assessment Work Plan Checklist Reviewed and checked by (Name ): ____________________________________ Title Page
The title page should include the following information. Letter style reports are acceptable, as long as this
information is somewhere on the first page.
p.1 Title of Work Plan
p.1 Brownfields Project Name (not the development name)
p.1 Brownfields Project Number
p.1 Date (updated with each revision)
p.1 Revision Number
p.2 Firm PE/PG License Number
p.2 Individual PE/PG seal & signature
p.1-2 Contact information for Developer, Consultant, and Project Manager
Section 1 – Introduction
p.4 Provide the site location, address, and acreage. p.4-6 Provide a BRIEF summary of the history of the property and its history in the program. For example: reiterate RECs from a Phase I ESA, indicate if the scope of work was negotiated during a Data Gap Meeting, etc. p.4-6 Briefly list and describe the data gaps the assessment is attempting to fill NA Indicate if the assessment data is for the use of any other DEQ programs in addition to the Brownfields Program (i.e. the site is a regulated UST, IHSB, etc. property)
Section 2 – Scope of Work
p.3-4 Provide a general description of proposed scope of work covered in this plan (i.e. 2 new monitoring wells, six groundwater samples, 5 exterior soil gas sampling points and 6 soil borings) p.4-7 Discuss samples to be collected by media and source area/location. Generally, the reasoning for the sample locations selected. p.5-6 Describe depths of samples to be collected (Reference Table 1) or how that decision will be made in the field, if needed. p.11 State for what each sample will be analyzed (briefly). Reference Table 1.
- For all residential reuses, sub slab vapor is required, if no slabs exist, exterior soil gas is required within all proposed footprints.
Section 3 – Sampling Methodology
p.3 Reference the guidance documents you intend to use. IHSB, EPA SESD, VI Guidance, Well Construction Rules (NCAC 2C). Note deviations or methodology planned that is not covered by such guidance (e.g., multi-increment sampling, passive air samplers, mobile labs, Hapsite, simultaneous indoor/outdoor radon, high-volume subslab vapor testing, PFAS sampling). p.3-7 Describe what will be installed (soil boring, temporary well, permanent well, sub slab vapor, exterior soil gas, etc.). Include construction details. p.3-7 Discuss installation methodology (Hand Auger, DPT, etc.) p.8-11 Discuss sample collection procedures. Include the following, at a minimum:
• Equipment to be used
• Purging methods and volumes
Work Plan and Report Checklist
Version 2 February 2022

• Stabilization parameters for groundwater sampling
• Field screening methods
• Leak check procedures for sub-slab vapor and exterior soil gas samples (Note this is
required)
• Discuss how and when vacuum readings will be collected (for summa cans) p.14 Discuss sample point abandonment
Section 4 – Laboratory Analyses
p.14 Discuss the proposed analyses (include method number, preparation method, if there are concerns with short hold times, etc).
p.14-15 Discuss any proposed limitations on the contaminants of concern, if any, and the reason for such limitation (sufficient previous data, indoor air interferences, etc). p.14 Discuss laboratory certifications. Please note, NC does not certify labs for air samples. Please specify what certification the proposed air lab holds. p.14-15 Indicate that the Reporting Limits/Method Detection Limits will meet applicable screening
criteria (to the extent feasible). Include Reporting of J-Flags to meet criteria. p.15 Indicate what Level QA/QC will be reported by the laboratory. Level II QA/QC is typically acceptable.

Section 5 – QA/QC
p.14-15 Specify the duplicate sample frequency. Minimum requirement: 1 duplicate per 20 samples, per media, per method. p.15 Discuss Trip Blank. 1 Trip Blank per cooler/shipment of groundwater VOC analyses is required. p.14 Discuss how the lab will have sufficient sample volume for MS/MSD analyses. p.14 Discuss chain of custody and shipping.
Section 6 – Investigation Derived Waste (IDW) Management
p.15 Discuss what IDW will be generated and how it is proposed to be managed. Management
recommendations should be in accordance with 15A NCAC 02T.1503 and 15A NCAC 02H. 0106.
Generally, if the Brownfields Property has not previously been assessed, then all IDW must be
containerized and characterized prior to management. Previous assessment data that indicate no
Hazardous Waste (listed or characteristic) is likely to be encountered in the area of proposed
assessment will be required before thin spreading of IDW on-site is permitted.
Section 7 – Reporting
This section should discuss the components of the assessment report which will be prepared as a result of
the above sample collection. At a minimum, the report shall include:
p.15 Reporting/summary of site work conducted for all sections outlined above in this checklist; p.15 Summary of findings and possible recommendations; p.15 All applicable tables and figures outlined below with the addition of: Tables for tabulated analytical data per media sampled and analyzed, compared against applicable screening levels, sample depths and depth to groundwater;
Figure depicting actual sample locations collected, with each media depicted in the legend, graphic scale and north arrow; and Groundwater potentiometric map, with graphic scale and north arrow. - Boring logs for all soil borings, newly constructed monitoring wells, and exterior soil gas locations - Well construction and abandonment records, if applicable
Work Plan and Report Checklist
Version 2 February 2022

p.2 Firm PE/PG License Number p.2 Individual PE/PG seal & signature
Work Plan and Report Checklist
Version 2 February 2022

Attachments
p.22 Table 1 – Proposed Sample Locations and Analyses on a Summary Table that includes:
x Sample ID x Sample Objective x Proposed Depth(s) x Analytical Method(s) x QA/QC Samples n/a Background Samples

p.18 Figure 1 – Site Location Map
x Site location on a topographic map base
x Graphic scale and north arrow

p.19 Figure 2 – Site Map should include the following
x Buildings n/a Historical sample locations n/a RECs or other areas of concern
x Proposed sample locations x Sample identification labels n/a Background samples n/a QA/QC samples x Graphic scale and north arrow
x High quality aerial suggested as the base map

APPENDIX B
Brownfields Receptor Survey Form

North Carolina Department of Environmental Quality
Division of Waste Management
Brownfields Program
Site:
Address:
City:
County:
Brownfields Project Number:
Date
Property and Building Characteristics
a. Provide occupancy and use information.
c. Describe the foundation construction. Include details on type, floor construction, and depth below grade.
e. Are any subslab ventilation systems or moisture barriers in place? If so, please provide details.
NASize of Property (acres)
% of property that is wooded/brush
d. Describe the HVAC system in the building. Include available details on type, equipment location, source of air
return, and design considerations (e.g. positive pressure?).
BROWNFIELDS PROPERTY RECEPTOR SURVEY
This form was created to clarify and simplify preparing a receptor survey for a brownfield site. Please provide the
information requested below. Distances are measured from the site property boundary unless otherwise indicated
by the DEQ Brownfield’s Project Manager (PM).
Current Usage Proposed UsageSurface Conditions
% of property that is grassed areas
% of property that is agricultural crops
% of property that is paved
If an existing building is on-site, please respond to the following. Information can be provided on additional sheets
as needed. If numerous buildings are on-site, consult with your PM as only information on specific buildings may
be needed.
b. Describe the construction of the builidng including materials (e.g. wood frame, block), type and size of openings
(e.g. windows, bay doors), and height (number of stories).
% of property that is covered by buildings
Rev. 09/2015 Page 1 of 3
North Carolina Department of Environmental Quality
Division of Waste Management
Brownfields Program
Surrounding Property Land Use
North
South
East
West
Utilities
Is there a septic system on-site? (Y or N) _________
Please provide the utility providers for the subject property
a. Natural Gas ___________________________
b. Sewer ___________________________
c. Electricity ___________________________
d. Other __________________________
For surrounding properties, please complete the following table with available information.
Zoning/Land Use Proposed Usage Current Use/Occupant
DirectionDistance
(ft)Address
Please provide information on the following land uses in the vicinity of the subject site, including a map of the
surrounding areas. If specific receptors are present, please provide addresses of the facilities.
For the subject property, please provide a map of known buried utilites. If available, include depth to top,
construction material, and diameter of the utilities. In addition, please provide the following information on utilty
providers. If additional assessment is required, the public utility locators should be contacted. This information
can then be added to a site map.
Y/N *
Is a school or daycare center within 1,000 ft of the
Specific Land Uses of Interest Y/N *
* If numerous facilities of interest are present, their locations can be placed on a map in lieu of providing specific
addresses.
Distance
(ft)
* If yes, please provide a map or detailed information (distance, direction, depth) of the utility in correlation with
the subject property.
Is a water line main within 100 ft of Property boundary?
Is a natural gas line main within 100 ft of the Property boundary?
Is a buried telephone/ cable main within 100 ft of the Property boundary?
Is a septic system leach field within 500 ft of the Property boundary?
Direction
Is there a basement within 1,000 ft of the Property
Is there a residence within 1,000 ft of the Property?
Utility/Potential Receptor
Is a buried electrical cable main within 100 ft of Property boundary?
Is a storm water pipe within 100 ft of the Property boundary?
Is a sanitary sewer within 100 ft of the Property boundary?
Rev. 09/2015 Page 2 of 3
North Carolina Department of Environmental Quality
Division of Waste Management
Brownfields Program
Water Supply
What is the potable water supply for the property? Public ______ Private ______
Surface Water & Wetlands
Are there surface water features on the
property? (If yes, please complete a. to d.)
Provide Information regarding Surface Water
and Wetlands
Distance
(ft)Direction Address
a. Is the water body naturally developed or
man-made?
Y/NWater Supply Wells
Please provide the following information regarding water supply wells in the vicinity of the Property. At a
minimum, a windshield survey within 1,500 ft of the property boundaries should be completed to determine if
water supply or irrigation wells may be present. Information from applicable databases can and should be
utilized; however, should not be utilized in lieu of the windshield survey. If multiple wells are present within the
requested radius, please provide a map of the well locations. If needed, please attach a separate table to list all
wells. Please note, the PM may opt for a more extensive water supply well survey if needed.
If Private, please provide details of the water supply source (i.e. well location, well construction, etc). If public,
please include the water providers name.
The purpose of this section is to provide information on the water supply for the site and surrounding areas.
Is a public water supply well within 1 mile of the Property boundary?
Is a private water supply well within 1,500 ft of the Property
b d?Is an irrigation well within 1,500 ft of the Property boundary?
Response/Comments
The purpose of this section is to provide information on the presence of surface waters and/or wetlands on, or in
the vicinity of the Property.
b. List the uses of the water body.
c. What is the source of the water for the
water body?
d. What is the nature of the bottom of the
water body (e.g., rocky or concrete bottom,
drainage ways or impoundments)
If no on-site surface water features, what is the
nearest surface water body?
Are there any wetlands present on the
property? If no wetlands on-site, are wetlands
suspected on adjoining properties?
Rev. 09/2015 Page 3 of 3