WM0401337_Monitoring Well Permit Application_20220118

ATC
ENVIRONMENTAL • GEOTECIINICAI
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
January 11, 2022
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
N.S. Farrington
2355 Farrington Point Drive
Winston-Salem, Forsyth County, North Carolina
DSCA Site No. DC340039
Dear Mr. Jim Gonsiewski:
Enclosed please find four permit applications to construct four offsite permanent monitoring wells at 2410
Farrington Point Drive (PIN 6844-86-0998), 2367 Farrington Point Drive (PIN 6844-86-3863), 2367
Farrington Point Drive (PIN 6844-86-7813), and 2326 Cragmore Street (PIN 6844-87-9060) in Winston-
Salem, Forsyth County, North Carolina. The permit applications, 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 [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
rem=
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: 1/13/2022
2. County: Forsyth
PERMIT NO.
FOR OFFICE USE ONLY
ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Petitioner for DSCA Site # 340039
Telephone: [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): 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): tim.orantCaioneatlas.com
6. Property Owner (if different than Applicant): Dunn Well Holdings, LLC Telephone: [phone]
Property Owner's Mailing Address: 2410 Farrington Point Drive
Property Owner's Email Address (if available): kdifoods(a)aol.com
7. Property Physical Address (Including PIN Number)2410 Farrington Point Drive, Winston-Salem, NC 27107 (PIN 6844-86-0998)
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): 540
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 6. Estimated beginning construction date: 1/24/2022
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 1/26/2022
(add answers from 2 and 3)
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
t, . 6iag*
Signature of Applicant or *Agent
Tim Grant (Agent for DSCA Site # 340039)
Printed name of Applicant or *Agent
Agent for DSCA Site #340039 (POA available on request)
Title 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 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
ki' 6-9800
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GW-22MR Rev. 3-1-2016

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PROPERTY ACCESS CONSENT
This document may nor he ttrndljied without the Pri rcun'.s approval,
if you have clue.stiu,t.c cur hair r„ lilt tat this farm or about the at1iriries
at this site. pl('ctac• call the thy.Cleaning Solvent C7eattup A I !C)S('A)
Pr okra„ t 's cu,rtraetur fur 11ri % pn„ je c 1. Tint Grunt with AT(:' Am:whites
of North Carolina, P,C' (It :.,, . i.,,rt r• ,Gc i • . • 141 r,r (9/9) 7,10-1)172, If
you still have questions after contacting AM Grant with ATC• please contact the
1).SC'it project ra ingisrr, iIiike Ciutuin,r;luun ut iittke: ton riig,1)(tt)1«",tiAt.,.+tr ,lor
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USC•A Site It)
1)C340039
Please Print
[)unit Wc1I Holdings. LLC
(Vaok al' Property Owner or Tenant in Residence
2410 Farrington Point Drive (PIN 116844•86-091)8)
(Street Number and Sheet Nunn. of Property)
Winston Salmi Forsyth 27107
(City or Town of Which Property Is 1.0uated) / (County in Which Property is L(watcd) t 1%i1r ('ode)
voluntarily consent to the I)ivision at Waste Management (Division) and its independent
contractor% (contractors) entering and having continued access to my property for the I'ollowing
pu rposcs:
11) taking such soil, gromnlvvater andlnr air samples as may he necessary:
(21 taking other actions related to the investigation of swine', 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 otinintiles interference with use ol'the Property.
(.21 On t•uttcluslun of all activities, the Division ,ind its contractors shall, to the extent prac•tieiihle,
restore the Properly to the original condition it was in prior to any activities conducted by the
1>ivision or its contractors, All monitoring wells will he properly abandoned in accordance
2

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s►ith applicable laws and regulations. toile—, 411l1: art: agreed to by the Property
Owner,
(3) The Division or its contractors will stake reasonable attempts ti► nobly the Property Owner at
leasi 48 hours prior to entering the Pitmeny lin• any purpose. In situations that the Division
determines to he of an emergency nature. the Division or its contractors shall have immediate
accc'S 10 the property.
(•I) Property Owner shall not willingly destroy. Mintage, remove. pave uVcr ur rover unv
monitoring uellc at the site without prior consent of the Division.
13y signing this consent document. I acknowledge that 1 an► 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
ol'this "Property Access Consent".
(Sig mute of Property Owner or Tenant in Residence)
3.7 - r �-7 CST
c'I'rl� �rlunu yuinbur fur Property (wrier or Tenant in Residence I'ur scheduling wurk/notiftcation)
/101,610
(Entail Address for Property Owner or "Tenant in Residence if you prefer to be 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 emall to: tim.(;rant®atcgs.com
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MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
(NOT TO SCALE)
LOCKABLE WELL CAP
L1
L4
L2
L3
L1 = 0 FT.
L2 = 20 FT.
L3 = 10 FT.
L4 = 30 FT.
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
4 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
AI27��� �5 t Millbrook RoadSuite 121
EN VINBNMENIAL• 6EBIECHNICAI
BUIIOINS SCIENCES • MATERIALS TERNS Raleigh, North Carolina 27604
FILE
PREP. BY
AS
REV. BY
TG
DATE
1/3/2022
PROJECT NO.
DC340039