WM0401212_Application_20200114

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SIItL01NSU021, • MATERAU TESTIIIB
January 10, 2020
Mr. Jim Gonsiewski
North Carolina Department of Environmental Quality
Winston-Salem Regional Office
450 W. Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
Re: Permit to Construct Monitoring Wells
White Swan Rentals — DSCA Site 4DC860002
204 East Market Street
Elkin, Surry County, North Carolina 28621
DSCA Site No. DC860002
Dear Mr. Jim Gonsiewski:
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax:[phone]
www, atcassociates. com
N.C. Engineering License No. C-1598
Enclosed please find two applications for permits to construct two monitoring wells (MW-4 and
MW-5). The monitoring wells will be located at 110 Gwyn Avenue (PIN#: 495114438464) and
222 Main Street (PIN# 495114428977), Elkin, North Carolina. The permit applications, site map
with the proposed locations of the monitoring wells, well construction details and other relevant
information are enclosed as attachments. Please review this package and return the approved
permit to this office.
If you have any questions or require additional information, please contact our office at (919)
871-0999.
Sincerely,
ATC Associates of North Carolina, P.C.
Robert Broda, P.G.
Project Geologist

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made fc
1.� Date: 1-10-2020
2. County:
,r a permit to construct monitoring or recovery wells.
FOR OFFICE USE ONLY
PERMIT N0 W rA 0`, O kQ(
ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Kenneth Haney (Petitioner for DSCA site #DC860002) Telephone: [phone]
Applicant's Mailing Address: DSCA Program Mail Service Center 1646 Raleigh NC 27699-1646
Applicant's Email Address (if available): Jay Kingericdenr gov
5. Contact Person (if different than Applicant): Robert Broda ATC Telephone: [phone]
Contact.Person's Mailing Address: 2725 E Millbrook Rd Suite 121', Raleigh NC 27604
Contact Person's Email Address. (if available): RobertBfoda(d)ATCGS com
6. Property Owner (if different than Applicant): First Baptist Church Of Elkin Telephone: [phone]
Property Owner's Mailing Address: 110 Gwyn Avenue Elkin North Carolina 28621
Property Owner's Email Address (if available): ineed2retire((Dyahoo com
7. Property Physical Address (Including PIN Number) 110 Gwyn Avenue (PIN#� 495114438464)
City Elkin CountySurry _ Zip Code 28621
8. Reason for Well(s): - Groundwater contamination
(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 Dry-cleaner (DSCA)
(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).
DSCA Site DC860002
11. Type of contaminants being monitored or recovered: Chlorinated Solvents
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposedwell(s)? If yes, how many? Yes One existing well
Existing Monitoring or Recovery Well Construction Permit No(s).: Not Available
13.. Distance from proposed well(s) to nearest known waste or pollution source (in feet):
14. Are there any water supply wells located less than 500 feet fromtheproposed well(s)T Unknown
If yes, give distance(s):
15. Well Contractor: Geologic Exploration Certification No.: NCA4305
Well Contractor Address: 176 Commerce Blvd Statesville NC 28625
PROPOSED WELL CONSTRUCTION INFORMATION
As required by 15A NCAC 02C .0105(f)(7), attach a well construction diagram of each well showing the following:
Borehole and well diameter e. Type of casing material and thickness
Estimated well depth f. Grout horizons
Screen intervals g. Well head completion details
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.
material: 1 Flush -mount steel Protective casing
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 2/18/20
4. Total Number of wells to be constructed: 1 - 7. Estimated construction completion date: 2/19120
(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 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.
G. 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
" � Agent for DSCA Site DC860002 (will include power of attorney.
Signature of Applicant or *Agent Title of Applicant or *Agent upon request)
Robert Broda * 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 See attached access agreement
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
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East CenterAvenue
Mooresville, NC 28115
Phone: .[phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC27889
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
AR Rev. 3-1-2016

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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) tatting sock soil, groundwater and/or, air samples as maybe neeessary;
(2) tatting other actions related to the investigation ofambsce or subsurface conditions;
(3) taking response actions necessary to mitig to any threat to human health or the environment,
Lather conditions;
(1) The Division and its contractors shall attempt to perform any activities at the Prop" in a'
manner that minimizes interference with use of the Property.

(2)
and roplations, unless other arrangements are
(3)
ttentpraeticable,
:onducted by the
accordance With
by the Propert}!
(4) Pm}terty, Owner, shalt. not wit ,destroy, 4*P. ge, moue, pave over or cover anyy
mco to;4'.)?vclls at the site without prior consent 6(the Divisko,
Please return form to:
Robert Broda, P.G.
ATC Associates of North Carolina, P.C.
2125 East Mlllbrook Road, Suite 121
Raleigh, NC 27604
Or via email to: Rob.. "Brodaifatcas.cot
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2725 E. Millbrook Road, Suite 121
Raleigh; NC 27604
eurnerirucuTe7 . uiiur�iunf6ei [phone]
PROJECT NO: DC860002
DATE: 10/10/2020 1 REVIEWED BY: AW
Well finished at surface with locking
well cap and 8" diameter flush -
mounted manhole cover with 2' by 2'
concrete pad.
Cement Grout Extending From Ground Surface
To Top of Bentonite Seal (0-10 feet)
2" Diameter Schedule 40 PVC Casing Extending
From Ground Surface to Top of Screen (0-15 feet)
3-Foot Bentonite Seal (10-13 feet)
15 Feet of 2" Schedule 40 Well Screen (0.010id Slot)
(15-30 feet)
Groundwater Table
#2 Filter Sand Pack Extending 2 Feet Above Screen
(13-30 feet)
MONITORING WELL
CONSTRUCTION DETAIL
White Swan Rentals
204 East Market Street
Elkin, Surry County, North Carolina
28621
DSCA ID: DC860002

913331 913731

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made
1. Date:
2. County:
for a permit to construct monitoring or recovery wells.
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: KennethHaney (Petitioner for DSCA site #DC860002) Telephone: [phone]
Applicant's Mailing Address: DSCA Program Mail Service Center 1646 Raleigh NC 27699-1646
Applicant's Email Address (if available): Jay. King(o).ncdenr gov
5. Contact Person (if different than Applicant): Robert Broda, ATCC Telephone: [phone]
Contact Person's Mailing Address: 2725 E Millbrook Rd Suite 121 Raleigh NC 27604
Contact Person's Email Address (if available): RobertBroda(a),ATCGS com
6. Property Owner (if different than Applicant): McCulloch Enterprises LLC Telephone: [phone]
Property Owner's Mailing Address: 636 West Main Street Elkin North Carolina 28621-3226
Property Owner's Email Address (if available): cicely(LDlibertydowntown com
7. Property Physical Address (Including PIN Number) 222 Main Street (PIN# 495114428977)
City Elkin County Surry Zip Code 28621
8: Reason. forWell(s):- Groundwater contamination
(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 Dry-cleaner (DSCA)
(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).
DSCA Site DC860002 -
11. Type of contaminants being monitored or recovered: Chlorinated Solvents
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes One existing well.
Existing Monitoring or Recovery Well Construction Permit No(s).: Not Available
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 95
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Unknown
If yes, give distance(s): N/A
15. Well Contractor: Geologic Exploration Certification No.: NCA4305
Well Contractor Address: 176 Commerce Blvd 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? Locking well cap.
material: 1 Flush -mount steel protective casing
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3)
6. Estimated beginning construction date: 2/18/20
Estimated construction completion date: 2/19/20
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
r
_ZG_ "" - Agent for DSCA Site DC860002 (will include power of attorney
Signature of Applicant or *Agent Title of Applicant or *Agent - upon request)
Robert Broda * 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 See attached access agreement
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, INC 28405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [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]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
OR Rev. 3-1-2016

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Well finished at surface with locking
well cap and 8" diameter flush -
mounted manhole cover with 2' by 2'
concrete pad.
Cement Grout Extending From Ground Surface
To Top of Bentonite Seal (0-3 feet)
12" Diameter Schedule 40 PVC Casing Extending
From Ground Surface to Top of Screen (0-5 feet)
P1 no 1-Foot Bentonite Seal (3-4 feet)
MW-5
2725 E. Millbrook Road, Suite 121
Raleigh, NC 27604
[phone]
PROJECTNO: DC860002
DATE: 10/10/2020 I REVIEWED BY: AW
15 Feet of 2" Schedule 40 Well Screen (0.010" Slot)
(5-20 feet)
Groundwater Table
#2 Filter Sand Pack Extending 1 Foot Above Screen
(4-20 feet)
MONITORING WELL
CONSTRUCTION DETAIL
White Swan Rentals
204 East Market Street
Elkin, Surry County, North Carolina
28621
DSCA ID: DC860002