WM0701226_Application_20200604

FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
PLEASE TYPE OR PRINT CLEARLY
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery wells.
1.Date:6/3/20
2.County: Pitt
3.What type of well are you applying for? (monitoring or recovery):Permanent Monitoring Well
4.Applicant: Adoria Beauty Center, Inc. (petitioner for DSCA Site #DC740014) Telephone: Jay King [phone]
Applicant’s Mailing Address: DSCA Program, 1646 Mail Service Center, Raleigh, NC 27699-1646
Applicant’s Email Address (if available): [e-mail]
5.Contact Person (if different than Applicant): Greg Kanellis, Hart & Hickman, PC Telephone:[phone]
_______
6.[phone]
Contact Person’s Mailing Address: 3921 Sunset Ridge Road, Ste. 301, Raleigh, NC 27607
Contact Person’s Email Address (if available): [e-mail] Property
Owner (if different than Applicant): PGP Arlington, LLC Telephone:
Property Owner’s Mailing Address: PO Box 17119 Chapel Hill, NC 27516
Property Owner’s Email Address (if available): [e-mail]
7.Property Physical Address (Including PIN Number)1600 W. Arlington Blvd (PIN# 4677555051)
City Greenville County Pitt Zip Code 27834
8.Reason for Well(s): Environmental Assessment for DSCA Program
(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
(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).
NCDEQ DSCA Site ID #DC740014
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, 9
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0701184, WM0701190, WM0701198
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 1,600 feet
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: IET Certification No.: 2725-A
Well Contractor Address: 232 Hwy 49 South Concord, NC 28025_______
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
material: 1
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)
5.How will the well(s) be secured? Bolted flush-mount
well with lockable well cap
6.Estimated beginning construction date: June 2020
7.Estimated construction completion date: June 2020
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
on behalf of Petitioner for DSCA Site DC740014 Agent for Petitioner for DSCA Site DC740014
Signature of Applicant or *Agent Title of Applicant or *Agent
Greg Kanellis *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 access agreement (Attachment 3) See attached property access agreement (Attachment 3)
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water Resources’ Regional Office:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016
Attachment 1
TYPE II MONITORING WELL CONSTRUCTION DETAILS
CROSS SECTIONAL VIEW
LOCKABLE WELL CAP CONCRETE PAD
FLUSH METAL WELL COVER
CONCRETE PAD
BACKFILL AROUND CASING
MATERIAL cement grout
LENGTH 2 ft (0 to 2 ft)
WELL CASING
MATERIAL schedule 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threaded
LENGTH 4 feet
L1
BACKFILL AROUND CASING
L3 MATERIAL bentonite/grout
LENGTH 0 feet
SEAL
TYPE OF SEAL bentonite
THICKNESS 1 foot (2 ft to 3 ft)
FILTER PACK
TYPE OF FILTER No. 2 Sand
THICKNESS 11 feet (3 ft to 14 ft)
WELL SCREEN
SCREEN MATERIAL schedule 40 PVC
L2 DIAMETER 2 inches
LENGTH 10 feet
SLOT SIZE 0.010 inches
DEPTH TO BOTTOM OF
L1 =4 FT.MONITORING WELL 14 feet
L2 =10 FT.DIAMETER OF
L3 =14 FT.BOREHOLE
4.25 in
TITLE Monitoring Well Diagram
MW-9 Hart & Hickman, PC
2923 South Tryon St., Suite 100
Charlotte, North Carolina 28203
FILE PREP. BY REV. BY DATE
GK GK
PROJECT NO.
6/3/2020 DS0-108 (DSCA ID# DC740014)
Attachment 2

NC 11SW.ARLINGTON B
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MERIDIAN DRIVESUNSET AVENUEHARVEY DRIVEARLINGTON CIRCLEASPHALT
MW-3
MW-2
MW-6
MW-7
DW-1
MW-4
MW-5
MW-8
MW-3
DW-1
ADORIA BEAUTY
SUPPLY
STORAGE UNITSRJ'S FAMOUS
CHICKEN, BBQ, & RIBS
PIT ROOM
(FORMER FABRIC CARE CENTER)
STORAGE ROOM
(FORMER SUITE)
MW-1
REVISION NO. 0
JOB NO. DS0-108
DATE: 1-21-20
ATTACHMENT NO. 3
FABRIC CARE CENTER
DSCA ID: DC740014
2512 S. MEMORIAL DRIVE
GREENVILLE, PITT COUNTY
SITE MAP
LEGEND
SOURCE PROPERTY BOUNDARY
NON-SOURCE PROPERTY BOUNDARY
SHALLOW MONITORING WELL
DEEP MONITORING WELL
STREAM
2923 South Tryon Street-Suite 100
Charlotte, North Carolina 28203
704-586-0007(p) 704-586-0373(f)
License # C-1269 / #C-245 Geology
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(proposed)
Attachment 3
ROY COOPER NORTH CAROLINA
Governor Environmental Quality
MICHAEL S. REGAN
Secretary
MICHAEL SCOTT
Director
PROPERTY ACCESS CONSENT
For DSCA Use Only
Thu document may not be modified without the Program's approval DSCA ID No.
If you have questions on how to fill out this form or about the activities DC830001
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program's contractor for this project Christie Zawtocki with Hart & Hickman, P.C. at
czawtocki dbarthicknian.com or [phone]. If you still have questions after contacting Ms.
Zawtocki with H&H, please contact the DSCA Program Project Manager, Mr. Jay King at
Jay. King_La ncdenr.gov or (919)-707-8367
Please Print
(Name of Property Owner or Tenant in Residence)
(ow w . het ,_T_L)m W�
(Street Number and Street Name of Property)
>-JR.c'�JV ku'u 'r-? M--
(City or Town in Whichroperty 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.
DEQ��
North Carolina Department of environmental Quality I Division of waste %tanage ent
117 West lore% Street I Ibdb 1,1ai1 Set vice Center 1 Raleigh, North Carolina 27699-1b1b
919 707 5200

(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".
It&S '�, 3 / � 12-D
(Signature of Property Owner or Tenant in Residence) (Date)
'CVOAA S ftvw 5e . vV-4fA lra 9—
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
R-%-Weez) "ewe fx-4s tatfer-t ILSO � . c
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Christie Zawtocki
Hart & Hickman, PC
2923 S. Tryon Street, Suite 100
Charlotte, NC 28203
Or via email to: [e-mail]
%.x th Carolina Department of Emironmental Quahty 0nnion of Waste Management
I; He.t J�wxt Street i iblb M.rl SCI-We Center I Raltigh North Cirohru 2ib99 lblb
919 707 8200