WM0401307_Monitoring Well Permit Application_20210720

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: July 16, 2021
2. County: Forsyth
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring (Temporary)
4. Applicant: Christopher T. Edwards (Petitioner for DSCA Site DC340041) Telephone: [phone]
Applicant's Mailing Address: 2019 Eastchester Drive, High Point, NC 27265
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Sam Martin - Hart & Hickman, PC Telephone: [phone]
Contact Person's Mailing Address: 2923 S. Tryon Street, Suite 100, Charlotte, NC 28203
6. Contact Person's Email Address (if available): [e-mail]
7. Property Owner (if different than Applicant): Ray & Sallie Edwards Investments LLC Property Telephone: [phone]
Owner's Mailing Address: 209 Eastchester Drive, High Point, NC 27265
Property Owner's Email Address (if available): [e-mail]
Property Physical Address (Including PIN Number) 3775 Peters Creek Parkway (6822-78-3202)
City Winston-Salem County Forsyth Zip Code 27127
8. Reason for Well(s): Environmental assessment for DSCA Program (DSCA Site DC340041)
(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-cleaning facility
(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).
No
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):
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, Inc. Certification No.: 4163-A
Well Contractor Address: 176 Commerce Boulevard, Statesville, NC 28652
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: 3
5. How will the well(s) be secured: Temporary DPT
screen -point sample borings will be abandoned upon
completion of groundwater sample collection
3. Number of wells to be constructed in bedrock: 0
6. Estimated beginning construction date: 8/4/2021
4. Total Number of wells to be constructed: 3
(add answers from 2 and 3) 7. Estimated construction completion date: 8/5/2021
ADDITIONAL INFORMATION
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 DC340041 Agent for Petitioner for DSCA Site DC340041
Signature of Applicant or *Agent Title of Applicant or *Agent
Sam Martin. Hart & Hickman. PC
Printed name of Applicant or *Agent
* If signing as Agent, attach authorization agreement stating
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
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
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]
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AGREEMENT FOR ASSESSMENT AND REMEDIATION PURSUANT TO DSCA
ATTACHMENT 1
LIMITED POWER OF ATTORNEY
1, 4 no a,,,siBpke / ' ., y/ torts. ("Petitioner"), do hereby
grant a limited power of attorney to the Division and to the Division's independent contractors,
as follows.
The Division and the Division's independent contractors shall have the limited power of attorney
for the preparation, signing, filing and delivery of any permit application, hazardous waste
manifest, non-ha7lydous waste manifest, National Pollution Discharge Elimination System
(NPDES) permit, for complying with any reporting requirements and for any administrative
activities that may be necessary in the course of assessment and remediation conducted pursuant
to the Agreement into which this Attachment 1 is incorporated.
This limited power of attorney shall terminate upon termination of the Agreement.
Dated ^n i447 e , 2 z r
(Seal)
Signature of Petitioner
STATE OF -not-fit) Caho.lA:1 COUNTY OF s uisL4.0hoL-
On this F#'`' day of a od 1 , personally appeared before me, the said named
Chh,uo vpkh. 7 E ,QJ,dy to me known and known to me to be the person described
in and who executed the foregoing limited power of attorney and he (or she) acknowledged that
he (or she) executed the same and being duly sworn by me, made oath that the statements in the
foregoing limited power of attorney are true.
My Commission Expires / J - / 4 - AO Al
g/'7]gv_c„ 0 6.,-iayu(Signature of Notary Public)
Notary Public (Official�GA C.U�,��.
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Attachment 1

ROY COOPER
Govern ur
DIONNE DELLI-GATTI
Secretory
MICHAEL SCOTT
Director
NORTH CAROLINA
Environmental Quality
PROPERTY ACCESS CONSENT
This document may not be modified without the Program's approval.
If you have questions on how to fill out this form or about the activities
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program's contractor for this project Sam Martin with Hart & Hickman, P.C. at
smartinr r harthickman.com or [phone]. Ifyou still have questions after contacting Mr.
Martin with H&H, please contact the DSCA Program Project Manager, Mr. Billy Meyer at
billy _mever ZLncdenr.gov or 919-707-8359.
For DSCA Use Only
DSCA ID No.
DC340041
Please Print
Ray & Sallie Edwards Investments LLC
(Name of Property Owner or Tenant in Residence)
3775 Peters Creek Pkwy
(Street Number and Street Name of Property)
Winston-Salem Forsyth County 27127
(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
mariner that minimizes interference with use of the Property.
(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
-DECO
North Cooks) Department of f: nrirormnereat Qualsty Divnan of W.tste Msnagrmrnt
211 West Jones Street I 1646 Mali Service Center Raleigh. North Carotnw dtueSt • lb -lb
914.T01.8200

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".
(Signature of/Property Owner or Tenant in Residence)
•
11///b/
(Date)
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
/1 1
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Sam Martin
Hart & Hickman, PC
2923 S. Tryon Street, Suite 100
Charlotte, NC 28203
Or via email to: [e-mail]
North Carolina Department of Environmental Quality I Division of Waste Management
217 West }ones Street 1161b Mail Service Centre 1 A#IHgh. North Carolina 216n 1b46
919.707.8200

Proposed Off -Source DPT
Screen Point Sample Location
3735Peters Creek Parkway
(Active Dry Cleaner Facility)

- PA Assessment\Geoprobe Sample Diagram.dwg, Model,
g Logs, WCRs, Well Permits\July
WATER TABLE
UNCASED DIRECT -PUSH
BORING
APPROXIMATELY
25 FT
0
LEGEND
0 WATER TABLE
NOTES:
4 FT
DPT SCREEN POINT SAMPLING INTERVAL
1. GROUNDWATER SAMPLES WILL BE COLLECTED WITH
4-FT SCREEN -POINT SAMPLER AT APPROXIMATELY
25 FT BELOW GROUND SUFACE.
2. BORING WILL BE PROPERLY ABANDONED AFTER
COMPLETION OF SAMPLING.
GROUND SURFACE
APPROXIMATELY
20 FT
V WATER TABLE
TTLTYPICAL TEMPORARY DPT SCREENING POINT
WELL DIAGRAM
PROJECT
A CLEANER WORLD #150
DSCA SITE ID: DC340041
3735 PETERS CREEK PARKWAY
WINSTON-SALEM. NORTH CAROLINA
hart hickman
SMARTER ENVIRONMENTAL SOLUTIONS
2923 South Tryon Street -Suite 100
Charlotte. North Carolina 28203
704-586-0007(p) 704-586-0373(f)
License # C-1269 / #C-245 Geology
DATE: 7-9-21
JOB NO. DSO-167
REVISION NO. 0
ATTACHMENT NO. 1