HomeMy WebLinkAboutWM0401340_Monitoring Well Permit Application_20220119NORTH 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: 1/18/2022
2. County: Forsyth
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Petitioner for DSCA Site # 340039
Telephone: 919-707-8361
Applicant's Mailing Address: DSCA Program, 1646 Mail Service Center, Raleigh, NC 27699-1646
Applicant's Email Address (if available): mike.cunningham@ncdenr.gov
5. Contact Person (if different than Applicant): Tim Grant, ATC Telephone: 919-871-0999
Contact Person's Mailing Address: 2725 E. Millbrook Road, Suite 121, Raleigh, NC 27604
Contact Person's Email Address (if available): tim.grant@oneatlas.com
6. Property Owner (if different than Applicant): BACCO LLC Telephone: 919-632-4806
Property Owner's Mailing Address: PO Box 1307, Morrisville, NC 27560
Property Owner's Email Address (if available): chrisbaird718@yahoo.com
7. Property Physical Address (Including PIN Number)2330 Cragmore Street (PIN 6844-86-8934)
City Winston-Salem County Forsyth Zip Code 27107
8. Reason for Well(s): Suspected 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 Site # DC340039
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 - Five
Existing Monitoring or Recovery Well Construction Permit No(s).: N/A
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 410
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): n/a
15. Well Contractor: SAEDACCO, Inc. Certification No.: TBD
Well Contractor Address: 9088 Northfield Drive, Fort Mill, SC 29707
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, 8"
material: 0 flush mount manhole cover
3. Number of wells to be constructed in bedrock: 1
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3)
6. Estimated beginning construction date: 1/24/2022
7. Estimated construction completion date: 1/26/2022
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
Agent for DSCA Site #340039 (POA available on request)
Signature of Applicant or *Agent Title of Applicant or *Agent
Tim Grant (Agent for DSCA Site # 340039) * 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
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: (828) 296-4500
Fax: (828) 299-7043
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: (910) 433-3300
Fax: (910) 486-0707
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: (704) 663-1699
Fax: (704) 663-6040
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: (919) 791-4200
Fax: (919) 571-4718
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: (252) 946-6481
Fax: (252) 975-3716
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Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: (910) 796-7215
Fax: (910) 350-2004
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
6-9800
797
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GW-22MR Rev. 3-1-2016
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
MICHAEL SCOTT
Director
NORTH CAROL..INA
Environmental Quality
PROPERTY ACCESS CONSENT
This document may not be modified without the Program's
approval. lfyou 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, Tim Grant
with ATC Associates of North Carolina, P.C. at tim.grant@atcgs.com
or(919) 740-0172. Ifyou still have questions after contacting Mr. Grant with
ATC, please contact the DSCA project manager, Mike Cunningham at
mike.cunningharn@ncdenr.gov or (919) 707-8361.
For DSCA Use Only
DSCA Site ID
DC340039
Please Print
BACCO LLC
(Name of Property Owner or Tenant in Residence)
2330 Cragmore Street (PIN #6844-86-8934)
(Street Number and Street Name of Property)
Winston-Salem Forsyth 27107
(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 pertorn) any activities at the Property in
a manner that minimizes interference with use of the Property.
North Carolina Department of Environmental Quality I Division of Waste Management
217 West Jones Street 11646 Mull Service Center I Raleigh, North Carolina 27699-I646
919.707.8200
(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".
(Signature o
pistdp c, R;f4,VS 1V
roperty Owner or Tenant in Residence) (Date)
.°1
(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 he contacted via
email)
Please return form to:
Tim Grant
ATC Associates of North Carolina, P.C.
2725 East Millbrook Road, Suite 121
Raleigh, NC 27604
Or via email to: tim.grant@atcgs.com
LEGEND:
MW-5 MONITORING WELL
49.598 Well Identification
PCE Concentration (mg/L)
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PARCEL LINE
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— 0.07— PCE CONCENTRATION
(DASHED WHERE INFERRED)
NOTE: ALL LOCATIONS ARE APPROXIMATE
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FORMER N.S.
FARRINGTON
0.0007
100 0 25 50 75 100
SCALE: 1" = 100'
AS
Attachmen
L11
MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
(NOT TO SCALE)
LOCKABLE WELL CAP
L4
L2
L3
L1 = 0 FT.
L2 = 20 FT.
L3 = 10 FT.
L4 = 30 FT.
•
4
•
PROTECTIVE CASING AND CONCRETE PAD
CASING MATERIAL
CASING DIAMETER
CASING LENGTH
PAD DIMENSIONS
HEIGHT ABOVE GROUND
Ductile Iron/Steel
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 15 feet
SEAL
TYPE OF SEAL bentonite
THICKNESS 3 feet
FILTER PACK
TYPE OF FILTER #2 silica sand
DISTANCE ABOVE SCREEN 2 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
DIAMETER OF BOREHOLE 7.25 inches
TITLE Monitoring Well
N.S. Farrington
2355 Farrington Point Drive
Winston-Salem, Forsyth County
North Carolina
ATC 2725 East Millbrook Road
Suite 121
ENVIRONMENTAL• GEOTECHNICAL
BUILDING SCIENCES• MATERIALS TESTING Raleigh, North Carolina 27604
FILE
PREP. BY
AS
REV. BY
TG
DATE
1/3/2022
PROJECT NO.
DC340039