WM0401218_Permit (Issuance)_20200124

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
Mr. Al Chapman
NCDEQ — DSCA Program
1646 Mail Service Center
Raleigh, North Carolina 27699
NORTH CAROLINA
Environmental Quality
January 24, 2020
SUBJECT: MONITORING WELL CONSTRUCTION
PERMIT NO. WM0401218
COUNTY: Surry
FILE NAME: Ray's Cleaners — DSCA Site DC860004
Dear Mr. Chapman:
In accordance with your application received on January 22, 2020, we are forwarding herewith:
1. Monitoring Well Construction Permit No. WM0401218 for the construction of one (1)
monitoring well at 1535 North Bridge Street and one (1) monitoring well at 1617 North
Bridge Street in Elkin in Surry County.
Henceforth, correspondence and data relating to this well shall be designated as specified in the
subject heading above. This Permit will be effective from the date of issuance and shall be
subject to the conditions and limitations as specified therein. If you have any questions regarding
this permit, please contact me or Jim Gonsiewski at [phone].
Sincerely,
usaned 9y.
CEO
49E..c94FA...
Lon T. Snider
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
cc: James L. Lowe (Electronic Copy)
Matt Wilmont - W & C Properties of NC, LLC (Electronic Copy)
Shane Sisco — Hart & Hickman, PC (Electronic Copy)
D _E-� North Carolina Department of Environmental Quality I Division of Water Resources
N as as > Q� Winston-Salem Regional Office1450West Hanes Mill Road. Suite 3001Winston-Salem. North Carolina27105
/'� 336.776.9800

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES — WATER QUALITY REGIONAL OPERATIONS
SECTION
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and
other applicable Laws, Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
NCDEQ — DSCA Program
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of two (2)
monitoring wells owned by the NCDEQ DSCA Program. The wells will be located at 1535
North Bridge Street and 1617 North Bridge Street in Elkin, North Carolina, in Surry County.
This Permit is issued in accordance with the application received on January 22, 2020, in
conformity with specifications and supporting data, all of which are filed with the Department of
Environmental Quality and are considered integral parts of this Permit.
This Permit is for well construction only, and does not waive any provision or requirement of
any other applicable law or regulation. Construction of any well under this Permit shall be in
strict compliance with the North Carolina Well Construction Regulations and Standards (15A
NCAC 02C .0100), and other State and Local Laws and regulations pertaining to well
construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to
an adjudicatory hearing upon written request within 30 days of receipt of this Permit. The
request must be in the form of a written petition conforming to Chapter 150B of the North
Carolina General Statutes and filed with the Office of Administrative Hearings, 6714 Mail
Service Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit
is final and binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to
other specified conditions, limitations, or exceptions as follows:

1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these
wells are being installed as part of an investigation for contamination from an
underground storage tank or dry cleaner incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement
issued by another agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as
part of the Permit application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A
NCAC 02C .0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of
Water Resources' Information Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with
15A NCAC 02C .0113 and a well abandonment record (GW-30) shall be submitted to the
Division of Water Resources' Information Processing Unit within 30 days of the well
abandonment.
7. The County Health Department may require a county monitoring well construction
permit. Please contact the health department for their requirements.
Permit issued the 24th day of January, 2020
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
Uxu8i0naU by:
E
4 T LIM
145ME225CREA...
Lon T. Snider, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
By Authority of the Environmental Management Commission
Permit No. # WM0401218

hart ► hickman
SMARTER ENVIRONMENTAL SOLUTIONS
Via E-mail
January 22, 2020
NCDEQ Division of Water Resources
Winston-Salem Regional Office
450 W. Hanes Mill Road
Winston-Salem, NC 27105
Attn: Mr. Jim Gonsiewski
Re: Application for Permit to Install Permanent Monitoring Wells
DSCA Site ID: DC860004, Ray's Cleaners
Elkin, North Carolina
H&H Project No. DSO-149B
Dear Mr. Gonsiewski:
Hart & Hickman, PC (H&H) has prepared this application for a permit to install permanent
monitoring wells to assess groundwater impacts associated with the North Carolina Dry-cleaning
Solvent Cleanup Act (DSCA) Program Site DC860004, Ray's Cleaners, located at 1526 N.
Bridge Road in Elkin, Surry County, North Carolina. If you have any questions, please do not
hesitate to call at 704-586-0007.
Sincerely,
Hart & Hickman, PC
Shane Sisco, PG
Project Hydrogeologist
Attachments
2923 South Tryon Street, Suite 100 3921 Sunset Ridge Rd, Suite 301
Charlotte, NC 28203 Raleigh, NC 27607 www.liarthickman.com
704.586.0007 main j 919.847.4241 main

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 R
1. Date: 1/22/2020
2. County: Burry
it a permit to construct monitoring or recovery wells.
FOR OFFICE USE ONLY
PERMIT NO. Mai �� ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): _ Monitoring
4. Applicant: Elkin Village, LLC (Petitioner for DSCA Site #DC860004) Telephone: [phone]
Applicant's Mailing Address: DSCA Proaram (Contact: At Chapman) 1649 Mail Service Center, Raleigh NC 27699
Applicant's Email Address (if available): _ al.chapmangbncdenr.nov
5. Contact Person (if different than Applicant): Shane Sisco / Hart & Hickman Telephone: [phone]
Contact Person's Mailing Address: 2923 South Tryon Street, Charlotte, NC 28203
Contact Person's Email Address (if available): ssiscoLMharthickman.com
6. Property Owner (if different than Applicant): James L. Lowe Telephone: [phone]
Property Owner's Mailing Address: 117.Knollwood Drive, Elkin, NC 28261
Property Owner's Email Address (if available): iamesllowe(Mroadrunner.comP-amail.com
7. Property Physical Address (Including PIN Number) 1535 N. Bridge Street (PIN# 495214332122)
City Elkin County Surry Zip Code 28621
8. Reason for Well(s): Environmental 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: Dry-cleaner
(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 #DC860004
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? No
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 160 ft
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: Geologic Exploration Certification No.: 2401
Well Contractor Address: 176 Commerce Boulevard, 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? Well will be
material: 1 completed as a flush mount (locked expansion plug and
bolted steel manhole cover) monitoring well
3. Number of wells to be constructed in bedrock: 0
6. Estimated beginning construction date: 1129120
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3) 7. Estimated construction completion date: 1/31120
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
uv
Agent for Petitioner for DSCA Site #DC860004
Signature of Applicant or *Agent Title of Applicant or *Agent
Shane Sisco. PG * 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 Property Owner 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
3800 Barrett Drive
Wilmington, NC 28405
2090 U.S. Highway 70
Raleigh, NC 27609
Phone: [phone]
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Winston-Salem Regional Office
Washington Regional Office
450 W. Hanes Mill Road
Fayetteville Regional Office
943 Washington Square Mall
Suite 300
225 Green Street, Suite 714
Washington, NC 27889
Winston-Salem, NC 27105
Fayetteville, NC 28301-5094
Phone: [phone]
Phone:. [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension
4R Rev. 3-1-2016
GW-22M (Rev. 5/11)

ROY COOPER NORTH CAROLINA
Governor Environmental Quality
MICHAEL S. PEGAN
secretary
MICHAELSCOTT
Director
PROPERTY ACCESS CONSENT
For DSCA Use Only
This document may not he modified without the Program's approval. DSCA ID No.
Ifyou have questions on how to fill out this form or about the activities DC860004
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program's contractor for this project Shane Sisco with Hart & Hickman, P.C. at
[e-mail] com or [phone]. Ifyou still have questions after"contacting Mr.
Sisco with H&H, please contact the DSCA Program Project Manager, Mr. Al Chapman at
al.cha [e-mail] or 919-707-8368.
Please Print
James L Lowe Sr & Lorene S Lowe (1 Revocable Trust)
(Name of Property Owner or Tenant in Residence)
1535 N. Bridge Street (Parcel ID: 495214332122)
(Street Number
Elkin
(City or To
Fropeny IS Located) / (County
28621
(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) 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.
Q
North Carolina Departnrnt o(rnvlronmrntal Quality I nirlslon or waste Management
217 went Jonesstreet 1 I64{, Mall Service Center l Rateigh, North Cardma 2769916,16
919.7078200

(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 monitoring wells will be properly abandoned in accordance
with applicable laws and regulations, unless other arrangements are agreed to by the Property
Owner.
(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
monitoring wells at the site without prior consent of the Division.
By signing this consent document, I acknowledge that I am the legal property owner or tenant
in residence that has the authority to allow this work on the property.
101
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Shane Sisco
Hart & Hickman, PC
2923 S. Tryon Street, Suite 100
Charlotte, NC 28203
Or via email to: ssisco harthickman.com
Q6�w'�"n:ult '�x«mwxnawn
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NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
)LICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
ii
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto
application is hereby made ft
1. Date: 1/16/2020
2. County: Surry
rr a permit to construct monitoring or recovery wells.
``A
FOR OFFICE USE ONLY
PERMIT NOW V1 (014ID � aA ISSUED DATE 3 a
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Elkin Village. LLC (Petitioner for DSCA Site #DC860004) Telephone: [phone]
Applicant's Mailing Address: DSCA Program (Contact: Al Chapman), 1649 Mail Service Center Raleiah NC 27699
Applicant's Email Address (if available): al chapmandlincdenr gov
5. Contact Person (if different than Applicant): Shane Sisco / Hart & Hickman Telephone: [phone]
Contact Person's Mailing Address: 2923 South Tryon Street, Charlotte NC 28203
Contact Person's Email Address (if available): ssisco0harthickman.com
6. Property Owner (if different than Applicant): W& C Properties of NC. LLC Telephone: [phone]
Property Owner's Mailing Address: 796 Stanley Mill Road, Elkin NC 28261
Property Owner's Email Address (if available): Registered Agent/Owner Matt Wilmont (mwilmont0hvac cas com)
7. Property Physical Address (Including PIN Number) 1617 N. Bridge Street (PIN# 496214332767)
City Elkin County_ Surry Zip Code 28621
8. Reason for Well(s): Environmental 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: Dry-cleaner
(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 #DC860004
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?
Existing Monitoring or Recovery Well Construction Permit Nola).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 250 ft
14.
Are there any water supply wells located less than 500 feet from the proposed well(s)?
If yes, give distance(s):
15. Well Contractor: _ Geologic Exploration Certification No.: 2401
Well Contractor Address: 176 Commerce Boulevard 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:
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

(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 monitoring wells will be properly abandoned in accordance
with applicable laws and regulations, unless other arrangements are agreed to by the Property
Owner.
(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
monitoring wells at the site without prior consent of the Division.
By signing this consent document, I acknowledge that I am the legal property owner or tenant
in residence that has the authority to allow this work on the property.
(Signature of Property Owner or Tenant in Residence) (Date)
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Shane Sisco
Hart & Hickman, PC
2923 S. Tryon Street, Suite 100
Charlotte, NC 29203
Or via email to: [e-mail]
North Carolina beftixtment of 6nvlronmental Quality I DlvIshul of Waste Management
2I7 West Jones Street i 1646ldail Service critic, i Raleigh. North Car.Ana 2769916-16
919.707.8200

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Well will be
material: 1 completed as a flush mount (locked expansion plus and
bolted steel manhole cover) monitoring well
3. Number of wells to be constructed in bedrock: 0
6. Estimated beginning construction date: 1/29120
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3) 7. Estimated construction completion date: 1/31120
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 wells) 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,
(7, p Subchapter 2C) and accepts full responsibility for compliance with these rules
Agent for Petitioner for DSCA Site #DC860004
Signature of Applicant or *Agent Title of Applicant or *Agent
Shane Sisco. PG * 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 Property Owner 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
3800 Barrett Drive
Wilmington, NC 28405
2090 U.S. Highway 70
Raleigh, NC 27609
Phone: [phone]
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Winston-Salem Regional Office
Washington Regional Office
450 W. Hanes Mill Road
Fayetteville Regional Office
943 Washington Square Mall
Suite 300
225 Green Street, Suite 714
Washington, NC 27889
Winston-Salem, NC 27105
Fayetteville, NC 28301-5094
Phone: [phone]
Phone: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension
IR Rev. 3-1-2016
GW-22M (Rev. 5111)

ROY COOPER NORTH CAROLINA
Covernor Environmental Quality
MICHAEL S. REGAN
Secretary
MICHAELSCOTT
Director
PROPERTY ACCESS CONSENT
For DSCA Use Only
This document may not he modified without the Program's approval. DSCA ID No.
If you have questions on how to fill out this form or about the activities DC860004
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program's contractor for this project Shane Sisco with Hart & Hickman, P.C. at
[e-mail] or [phone]. If you still have questions after contacting Mr.
Sisco with H&H, please contact the DSCA Program Project Manager, Mr. Al Chapman at
[e-mail] or 919-707-8368.
Please Print
W & C Properties of NC, LLC (Contact: Matt
(Name of Property Owner or Tenant in
1617 N Bridge St
(Street Number and Sheet Name
ID:49521
Elkin Surry 28621
(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) 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.
D Q�
North Carolina Department of Cnvirmrmenial Quality I Dlvlsiwr of Wrier Narugement
21TWrst lours Slrert I Wit, Stall Service Center ! R.1<Igh,Nordr f:arr�'Ina 17h99 ih-0b
n19.70M.00

(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 monitoring wells will be properly abandoned in accordance
with applicable laws and regulations, unless other arrangements are agreed to by the Property
Owner.
(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
monitoring wells at the site without prior consent of the Division.
By signing this consent document, I acknowledge that I am the legal property owner or tenant
in residence 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".
/` Z e-/-ZD 20
or Tenant in Residence) (Date)
Z7 -r 71e£r9
Number for Property Owner or Tenant in
f4.to h Lo'kvhc- c4s."OO,—
(Email Address for Property Owner or
email)
Please return form to:
Shane Sisco
Hart & Hickman, PC
2923 S. Tryon Street, Suite 100
Charlotte, NC 28203
Or via email to: [e-mail]
if you prefer to be contacted via
NorthCar*WntpmVwntofWWWMw�t
2n Westlaxs 5lrert C 1"6M00UTVkeCftW 1 Rak69.NarthCM%WZ7699.1646
919.707d200

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L1 =
L2 =
L3 =
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MSS
CROSS SECTIONAL VIEW
CAP
DIAMETER OF
BOREHOLE
4.25 in
CONCRETE PAD
FLUSH METAL WELL COVER
CONCRETE PAD
BACKFILL AROUND CASING
MATERIAL
LENGTH
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
BACKFILL AROUND CASING
MATERIAL
LENGTH
TYPE OF SEAL
THICKNESS
FILTER PACK
TYPE OF FILTER
THICKNESS
WELL SCREEN
SCREEN MATERIAL
DIAMETER
LENGTH
SLOT SIZE
DEPTH TO BOTTOM OF
MONITORING WELL
Cement grout
3ft(0 to 3ft)
Schedule 40 PVC
2 inches
Flush threaded
20 ft
Bentonite/grout
13 ft(3 ft to 16 ft)
Bentonite
2 feet(16 ft to 18 ft)
No. 2 Sand
17 ft(18 ft to 35 ft)
Schedule 40 PVC
2 inches
15 feet
0.010 inches
35 feet
Hart & Hickman, PC
2923 South Tryon St., Suite 100
Charlotte, North Carolina 28203
1/12/2020
ID#

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(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 monitoring wells will be properly abandoned in accordance
with applicable laws and regulations, unless other arrangements are agreed to by the Property
Owner.
(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
monitoring wells at the site without prior consent of the Division.
By signing this consent document, I acknowledge that I am the legal property owner or tenant
in residence 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".
of Property Owner or Tenant in Residence) (Date)
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Shane Sisco
Hart & Hickman, PC
2923 S. Tryon Street, Suite 100
Charlotte, NC 28203
Or via email to: [e-mail]
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North Carolltw neparintent of Etwirmmental Quality 101s'Ision of Waste Management
217 West Joaes Street I Ibib Stail $erWce Center i Raleigh. North Carolina 2;6"-1646
919.707.8200