WM0401318_Monitoring Well Permit Application_20211008

ATC
ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcassociates.com
N.C. Engineering License No. C-1598
October 5, 2021
Mr. Jim Gonsiewski
North Carolina Department of Environmental Quality
Winston-Salem Regional Office
Division of Water Resources
450 W. Hanes Mill Rd, Suite 300
Winston-Salem, North Carolina 27105
Re: Permits to Construct Monitoring Wells
Pro Clean
2406 North Main Street
High Point, Guilford County, North Carolina
DSCA Site No. DC410016
Dear Mr. Jim Gonsiewski:
Enclosed please find one permit application to construct four offsite permanent monitoring
wells.at 2411 North Main Street in High Point, Guilford County, North Carolina. The permit
application, 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 permits 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.
;CA -
Timothy Grant, P.G.
Project Manager

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: 10/5/2021
2. County: Guilford
3.
4.
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery):
Monitoring
Applicant: R.L. Kennedy Properties LLC (Petitioner for DSCA site #DC410016) Telephone: [phone]
Applicant's Mailing Address: DSCA Program, Mail Service Center 1646, Raleigh, NC 27699-1646
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Tim Grant, ATC Telephone: [phone]
Contact Person's Mailing Address: 2725 E. Millbrook Road, Suite 121, Raleigh, NC 27604
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Welborne Real Estate LLC Telephone: [phone]
Property Owner's Mailing Address: 5402 Westfield Dr. Greensboro, NC 27410
Property Owner's Email Address (if available): [e-mail]
7. Property Physical Address (Including PIN Number) 2411 N Main Street (PIN: 6891652862)
City High Point County Guilford Zip Code 27265
8. Reason for Well(s): Suspected 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: 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 # DC410016
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).: WM0401157
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approx. 20 feet
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: Innovative Environmental Technologies, Inc. Certification No.: 3287-B
Well Contractor Address: 232 Highway 49 S, 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)
4. Total Number of wells to be constructed: 4
(add answers from 2 and 3)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Sampled through
material: 4 geoprobe and abandoned following sample collection.
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 10/20/2021
7. Estimated construction completion date: TBD
1.
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
-7—,e04 L 6-law
Signature of Applicant or *Agent
Tim Grant (Agent for Petitioner for DSCA Site #410016)
Printed name of Applicant or *Agent
Agent for DSCA Site DC410016 (will include power of attorney
Title of Applicant or *Agent upon request)
* 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 access agreement
Signature of Property Owner (if different than Applicant)
See attached access agreement
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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GW-22MR Rev. 3-1-2016

ROY COOPER NORTH CAROLINA
Governor Environmental Quality
MICHAEL S. REGAN
Secretary
MICHAEL SCOTT
Director
PROPERTY ACCESS CONSENT
This document may not be modified without the Program's approval.
Ifyou 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, Andrew McMillan with ATC
Associates of North Carolina, P.C. at andrew.mcrnillan(i ate.gs.com or
[phone]. Ifyou still have questions after contacting Mr. McMillan with
ATC, please contact the DSCA project manager, Mike Cunningham at
mike.cunninghamic.ncdenr.eov or 919-707-8361.
For DSCA Use Only
DSCA ID No.
DC410016
Please Print
( bGn e 16, b6 6e47Orn ¢ (i.ejjar )r e.
(Name of Property Owner or Tenant in Residence)
2411 N Main Street
(Street Number and Street Name of Property)
High Point Guilford 27262
(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_EQi
North Gxohna Dep vrment of Eenironmereal Qua'3ty ! D:siston of Waste Manayrmetx
2t7 weir( tones snort 1 15461:SaH Senior Center ; Raleigh. north Carolina 27041646
919-70711700

Property Access Consent for 2411 N. Main St.
Pro Clean
DSCA Site #: DC410016
Page 2 of 2
November 16, 2018
(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 contra+±tors 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 1 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".
I-7/i7l/ff
(Signature of Property Owner or Tenant in Residence) (Date)
`62C3- ;o - tftp tC�
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
chfsUJ Llacerne @ -vA 1, Cc`rn
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Andrew L. McMillan
ATC Associates of North Carolina, P.C.
2725 East Miilbrook Road, Suite 121
Raleigh, NC 27604
Or via email to: [e-mail]
.1:1ECO
Korth Carolina Dep.vwent of Environmental ¢duty ; Division of Waste Management
217 West Jones Street 1646 Mail Service Center RakNgh North Caeothu 7769V•1¢4b
919.7078200

ROY COOPER
Governor
MICHAEL S. REGAN
secretary
MICHAEL SCOTT
Director
A
NORTH CAROLfNA
Environmental Quality
URGENT MATTER — PROMPT REPLY REQUESTED
November 26, 2018 •
Welbome Real Estate, LLC
2351 Ferndale Ct.
Landis, NC 28088
Re: Subsurface Contamination Investigation Associated with Dry -Cleaning Facility Located at
Pro Clean, 2406 North Main Street, High Point (Guilford County)
DSCA Site ID: DC410016
To Whom It May Concern:
The North Carolina Division of Waste Management (Division) is investigating the release of
hazardous substances, pollutants or contaminants at the facility listed above. After careful review
of all the information provided, it is possible that the subsurface contamination extends beyond
the facility's property.
The Division has a program to address these types of releases, called the Dry -Cleaning Solvent
Cleanup Act (DSCA) Program. The DSCA Program uses independent contractors hired by the
Division to investigate and remediate any contamination related to the dry-cleaning facility. The
DSCA Program's contractor for this project is ATC Associates of North Carolina, P.C. (ATC). To
assist in this investigation, the Division is requesting that you grant access to your property to
allow the Division's independent contractor, ATC, to conduct additional assessment activities.
Please find an attached Off -Site Property Access Consent for your signature.
Since additional site activities cannot be performed without completion of this form, the Division
would appreciate your prompt return of the form to:
Andrew L. McMillan
ATC Associates of North Carolina, P.C.
2725 East Millbrook Road, Suite 121
Raleigh, NC 27604
E
North Carolina Depmstnernt of Ensironmental Quality ! Division of Waste Management
217 test logy, Street ; 1646 Malt Service Center 1 Raleigh. North Carolina 27699.1646
90,707.8200

Property Access Consent for 2411 N. Main St.
Pro Clean
DSCA Site #: DC410016
Page 2 of 2
November 16, 2018
If you have any questions regarding the status of site activities or the Off -Site Property Access
Consent, please do not hesitate to contact the DSCA Program's approved contractor for this
project, Andrew McMillan with ATC, at andrew.mcmillan(a7,atcgs.com or [phone]. If you
still have questions after contacting Mr. McMillan with ATC, please contact the DSCA Program
Project Manager, Mr_ Mike Cunningham at mike.cunningham(a�ncdenr.gov or 919-707-8361.
Thank you for your cooperation.
J
North Carolina Department of Environmental Qtt3:Mty ( Division of Waste Management
217 West Jones Street i 1b46 Mail Service Center 1 Raleigh. North Carolina 27699.164o
919,707.8200

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MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
(NOT TO SCALE)
LOCKABLE WELL CAP
L4
L2
L3
L1 = 0 FT.
;ter
1
4
PROTECTIVE CASING AND CONCRETE PAD
CASING MATERIAL
CASING DIAMETER
CASING LENGTH
PAD DIMENSIONS
HEIGHT ABOVE GROUND
sch 40 PVC
8 inches
12 inches
2 feet x 2 feet
flush mounted
WELL CASING
MATERIAL sch 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threaded
LENGTH 20 feet
BACKFILL AROUND CASING
MATERIAL cement grout
THICKNESS 17 feet
SEAL
TYPE OF SEAL bentonite
THICKNESS 2 feet
FILTER PACK
TYPE OF FILTER #2 silica sand
DISTANCE ABOVE SCREEN 1 feet
WELL SCREEN
SCREEN MATERIAL sch 40 PVC
DIAMETER 2 inches
LENGTH 10 feet
SLOT SIZE 0.010 inches
DEPTH TO BOTTOM OF
MONITORING WELL
DEPTH TO BOTTOM OF
BOREHOLE
30 feet
30 feet
L2 = 20 FT. DIAMETER OF BOREHOLE 8 inches
L3 = 10 FT.
L4 = 30 FT.
TITLE Monitoring Well
ProClean
2411 North Main Street
High Point, Guilford County
North Carolina
ETC
ENVIRONMENTAL • CEOTECHNICAL
NOILOINE SGIENGES • MATERIALS TESTING
2725 East Millbrook Road
Suite 121
Raleigh, North Carolina 27604
FILE
PREP. BY
JR
REV. BY
TG
DATE
10/5/2021
PROJECT NO.
DC410016