WM0401413_Monitoring Well Permit Application_20221128

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: 11/21/22 FOR OFFICE USE ONLY
2. County: Forsyth PERMIT NOW (V\O'A ISSUED DATE I 130
3. What type of well are you applying for? (monitoring or recovery): Permanent Monitorino Wells
4. Applicant: Michael and Kristine Tozer (petitioner for DSCA Site #DC340022) Telephone: Scott Stupak [phone]
Applicant's Mailing Address: DSCA Prooram. 1646 Mail Service Center Raleigh NC 27699-1646
Applicant's Email Address (if available): scott.stuoak aencdenr.aov
5. Contact Person (if different than Applicant): Jeffrey 011ison. Hart & Hickman. PC Telephone: [phone]
Contact Person's Mailing Address: 3921 Sunset Ridge Road Suite 301, Raleigh NC 27607
Contact Person's Email Address (if available): jollison(ccaharthickman.com
6. Property Owner (if different than Applicant): Town of Kernersville Telephone: [phone]
Property Owner's Mailing Address: Attention Bill Metzinoer, PO Box 728 Kernersville NC 27285
Property Owner's Email Address (if available): BMetzinoer0.ToKNC.com
7. Property Physical Address (Including PIN Number) Right -of -Way for Railroad St.. Alley west of 101 N. Main St, 130E Mountain St (PIN # 6886-33-
1986 000) 137 W. Mountain St (PIN # 6886-24-5287 000) 133 S. Main St (PIN # 6886-23-8867 000)' 134E Mountain t (PIN # 6886-33-2628 000)
City Kernersville CountyForsyth Zip Code 27284
8. Reason for Wallis): 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 #DC340022
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): known waste in oroundwater at proposed location
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes - two
If yes, give distance(s): MW-8 located approximately 415 ft from WSW-1 and 420 ft from WSW-8
15. Well Contractor: Innovative Environmental Technologies Inc. -Certification No.: 2725-A
Well Contractor Address: 4185 Barrier Road, Concord. NC 28025
PROPOSED WELL CONSTRUCTION INFORMATION
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 wells) be secured? Bolted nush-mount
material: 7 to 12 fadditional nested wells maybe well cover with lockable cap
constructed at locations MW-2 through MW-5 and MW-8.
based on depth to bedrock observed in field). 6. Estimated beginning construction date: Dec. 2022
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 710 12
(add answers from 2 and 3)
Estimated construction completion date: Dec. 2022
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.tOB(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 wells) will be constructed in accordance with approved specifications and conditions of
this Well Construction,Peiinit 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 DC340022 Agent for Petitioner for DSCA Site DC340022
-��t4grfaTure of Applicant or *Agent Title of Applicant or *Agent
Jeffrey 011ison .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 access agreement (Attachment 31
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 Raleigh Regional Office Wilmington Regional Office
2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension
Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 28405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [phone] Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 283015094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
100
OR Rev. 3-1-2016

Attachment 1

LOCKABLE WELL CAP
UKING WILL GUNSTKUC
CROSS SECTIONAL VIEW
CONCRETE PAD
FLUSH METAL WELL COVER
CONCRETE PAD
BACKFILL AROUND CASING
MATERIAL cement grout
LENGTH 3 ft (0 to 3 ft)
WELL CASING
MATERIAL schedule 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threaded
LENGTH 30 feet
L1
BACKFILL AROUND CASING
L3
MATERIAL bentonite/grout
LENGTH 23 feet (3 ft to 26 ft)
L2
L1 = 30 FT.
L2 = 10 FT.
L3 = 40 FT.
DIAMETER OF
BOREHOLE
4.25 in
MW-2, MW-3, MW-4, MW-5,
MW-6, MW-7, MW-8
9=2
CCC
TYPE OF SEAL
THICKNESS
FILTER PACK
TYPE OF FILTER
THICKNESS
WELL SCREEN
SCREEN MATERIAL
DIAMETER
LENGTH
SLOT SIZE
DEPTH TO BOTTOM OF
MONITORING WELL
bentonite
2 feet (26 ft to 28 ft)
No. 2 Sand
12 feet (28 ft to 40 ft)
schedule 40 PVC
2 inches
10 feet
0.010 inches
40 feet
Hart & Hickman, PC
3921 Sunset Ridge Rd., Suite 301
Raleigh, North Carolina 27607
JAO 1 11/21/20221 DSO-163 (DSCA ID#

MONITORING WELL CONSTRUCTION DETAILS (NESTED OPTII
CROSS SECTIONAL VIEW
LOCKABLE WELL CAPS FLUSH METAL WELL COVER
CONCRETE PAD
L4
L3
L6
L2
-1 = 30 FT
-2=10FT
.3 = 40 FT
L5
L4 = 55 FT
L5 = 5 FT
L6 = 60 FT
Monitoring Well Diagram (Nested
MW-2, MW-3, MW4, MW-5, MW-S
BY
DIAMETER OF
BOREHOLE
4.25 in
BACKFILL AROUND CASING
MATERIAL
LENGTH
BACKFILL AROUND CASING
MATERIAL
LENGTH
TYPE OF SEAL
THICKNESS
FILTER PACK
TYPE OF FILTER
THICKNESS
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
WELL SCREEN
SCREEN MATERIAL
DIAMETER
LENGTH
SLOT SIZE
DEPTH TO BOTTOM OF
MONITORING WELLS
oe,nenlgrout
3fi to 3ft)
Eentonitelgrout
23 ft (3 to 26 ft)
2 ft(upper, 2&2&ft) &13a0p r;40-53 a)
No.2 sand
12 ft (upper, 2&40 ft) & 7 a 6omr; 53-50 a)
schedule 40 PVC
l inch
flush threaded
30 feet (Shallov4 & 55 feet (Deep),
schedule 40 PVC
1 inch
10 feet (ShalloM & 5last (Deep)
0010 inches
40 feet (Shallm) & 60 %at (Deep)
Hart & Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, North Carolina 27607

Attachment 2

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SOURCE PROPERTY BOUNDARY
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— — — SURFACE WATER FEATURE
NOTES.. —�
1 INDICATEDATACOLLECTED FROM
O NODERN
THE MOSTNANT
THE RECENT SAMPLING EVENT EACH
NT AT EACH LOCATION.WELLS
CYITORIRE)
(MODERN CLEANERS)
ME .DSAM THROUGH OPTS DWE
CLEAN WC-1
THROUGH MW-T,OEASOCIATE
MAT6,MUITNROUGHMN
iHflOVGX WC -SERE ASSOCIATED MATE PREVIOUS MODERN CLEANERS
02009-2016 TEMPORARY MONITORING
ASSESSMENT ACT VVES. MCI THROUGH MG4 WERE SAMPLED IN FEBRUARY
WELL LOCATION
2009.WC- I THROUGH WC4 WERE SAMPLED IN MARCH 2009. MW.S, MWE,ANO
WCS WERE SAMPLED IN MARCH 2O14. MW 1 THROUGH MI AND MW ] WERE
82o20TEMPORARY MONITORING WELL
SAMPLED IN DECEMBER 2014. DPT.I THROUGH OPTS WERE SAMPLED IN
LOCATION
FEBRUARY 2016.7MW-1 THROUGH TMWAS WERE SAMPLED IN JANUARY 202D.
WV-1 THROUGH SW , AND WSW.1 WERE SAMPLED IN SEPTEMBER 2020.
IS WATER SUPPLY WELL
2. DATA IS NOT SHOWN FO R TEMPORARY WELLS MC -I THROUGH MCA SINCE
PERMANENT MONITORING WELLS MI THROUGH MW 4 PROVIDE MORE
(12.8) PCE CONCENTRATION(mA)
RECENT AND RELIABLE DATA AT THESE LOCATIONS.
3. GROUNDWATER FLOW DIRECTION SHOWN BASED ON HISTORICAL DATA
PCE CO NTOUR(TME)(DASHED
COLLECTED FROM MODERN CLEANERS PERMANENT MONITORING WELLS.
—Q'QD%— WHERE INFERRED)
4. E BASED ON DATA FOR SHALLOW MONITORING WELLS.
EACONTOURSAR
DATA FOR WSW 1, WHICH IS ASSUMED TO BE A BEDROCK WELL, ARE NOT
INFERRED GROUNDWATER FLOW
USED IN CONTOURING.
DIRECTION
5. '- SURFACE WATERSAMPLING DATA CONSIDERED IN CONTOURING.
o
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SyCRTSTRF
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PCE ISOCONCENTRATION MAP
WARREN CLEANERS
DSCA SITE ID: DC340022
127 CHURCH LANE
KERNERSVILLE, NORTH CAROLINA
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WARREN CLEANERS
LEGEND DSCA SITE ID: DC340022
zo 201s TEMPORARY MONITORING WELL 127 CHURCH LANE
souacE PaoPEatt ROuuoaRv 0 LOCATION KERNERSVILLE, NORTH CAROLINA
PARCEL ROUNOARY a 2020 TEMPORARY MONITORING WELL LOCATION ii / k ±9$)[..uJ� Ill—),�.r,-.w,r iW
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GATE: 11-10-22 REVISION NO.0
NOTE
t. LOCATIONS SHOWN FOR WSW2ANO WSIUI ARE APPROXIMATE. J06 N0. 050.15] pTfgCHMENi N0. 20

Attachment 3

ROY COOPER NORTH CAROLINA
Cmemor Environmental Quality
MICHAEL S. REGAN
secretary
MICHAEL SCOTT
Director
PROPERTY ACCESS CONSENT
For DSCA Use Only
This document may not be mod yled without the Program's approval. DSCA ID No.
Ifyou have questions on how to fill out this form or about the activities DC340022
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program's contractor for this project Jeffrey 011ison with Hart & Hickman, P.C. at
iollison rf harlhickntan.com or [phone]. Ifyou still have questions ajler contacting Mr.
011ison with H&H, please contact the DSCA Program Project Manager, Mr. Scott Stupak at
scoll.stunak na ncdenr.gov or [phone].
Please Print
Town of Kernersville
(Name of Property Owner or Tenant in Residence)
Right-of-way for Railroad Street
(Street Number and Street Name of Property)
Kemersville Forsyth 27284
(City or Town in Which Pronerty Is Located) / (County in Which Property is Located) / Mo 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.
Noah Carollw Depanmem of Em4mm,etaal QuaMy I DNlfiond wale Mar"tm
mwestlm WW 11646Mao&rYkeGmer I Rafetph North Cwc4m27699•I6e6
919.70IA200

Page 2 of 2
DSCA Site ID No.
DC340022
(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".
Owner or Tenant in Residence) (Date)
�3b yob 5 , T93
(Telephone Number for Property Owner or Tenant in
Address for Property Owner or Tenant in Residence if you prefer to be contacted
email)
Please return form to:
Jeffrey 011ison
Hart & Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, NC 27607
Or via email to: [e-mail]

.w SNir o
u raw
ROY COOPER NORTH CAROLINA
Go nor Envlro tal Quaary
MICHAEL S. REGAN
Se t-y
MICHAEL SCOTT
Director
PROPERTY ACCESS CONSENT
For DSCA Use Only
This 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 DC340022
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program's contractor for this project Jeffrey 011ison with Hart & Hickman, P.C. at
iollison rt harthickman.com or [phone]. Ifyou still have questions afer contacting Mr.
011ison with H&H, please contact the DSCA Program Project Manager, Mr. Scott Stupak at
scoti.stuoaknncdencv_ov or [phone].
Please Print
Town of Kernersville
(Name of Property Owner or Tenant in Residence)
137 W Mountain Street, 133 S Main Street, Alley west of 101 N Main Street
(Street Number and Street Name of Property)
Kernersville Forsyth 27284
(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.
NonhCmahw DeWmml of Erwlr ml Qualm I Waonorwaste Marogemem
2I7 wnt lopes smel I I"6 MA servkeCemv I ackgh NonhCwoaro ZM99 I"6
vrororsxoo

Page 2 of 2
DSCA Site ID No.
DC340022
(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".
//-&-zZ
(Date)
v736 g010 sg93
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
Zme.-t-z.(Ag,er Cd, To KNc. cOV-4-
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Jeffrey 011ison
Hart & Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, NC 27607
Or via email to: [e-mail]

�fYa ��ro
r1' rr
. W.x
hY Qw+N� e�1
�.iafe:t"
ROY COOPER NORTH CAROLINA
Gavrmar fnviranmenrat Quality
MICHAEL S. RECAN
S"wary
MICHAELSCOTT
Dimaor
PROPERTY ACCESS CONSENT
For DSCA I Only
This Ilocamenl mi r not be modii led mithow the Programs appraraL DSC,k 11) Nil.
l )011 have questions on hour to fill out, this faro, or about the uc•tiviticx DC340022
at this site. IdeaSC call Ihr Ur'I'-('Ic<ain,G Solvent Cleanup; Ic!
111wgra0,'e ruurra:tor fin'this pet jcn.lei ei j' 011isa,nrith liart, el'• llickman, P.C. at
iollison(aharthickman.comor19/9)S4'7-4241./j)ou.crillhuvrgnrviartsafi•rcoruarring.1/r.
llllisan with HAH, plu,se couluct dh• QSC.d Program 1'ru%rc•r 1 /unu•�er, .1 /r. Scour Sntpak nt
scott.sutpaF Oncdenr.gov or r919/70'-8359.
Please Print
[,own of Kernersville
(Nance of Property Owner or Tenant in Residence)
134 I", Mountain Street
(Stec! Number and Street Name of Property)
Kernersville Form ill 27294
Cite or Io%%a in lthich Property Is Located) / (County in Which Propeny is
I voluntarily consent to the Division of Waste Management (Division) and its independent
contractors (contractors) entering and having continued access to n7y property for the Iollowing
purposes:
( I ) taking such soil, groundwater andror air samples as may be necessary:
(2) takine other actions related to the invesligalion of surface or subsurface conditions;
(31 taking response actions necessary to mitigate any threat to human health or the environment.
Other conditions:
( I ) The Division and its contractors shall attempt to perform tiny activities at the Property in it
manner that minimizes interl'crence with use of the Property.
North Carding Depatment of rmlrorunemgi Quaiq I Dmom or w.ntr Management
717w•nl loon Sltett I ibrbhWSentee Ctmtr I Raleigh North Cardw77699 Ibtb
919.707.6700

Page 2 of 2
DSCA Site ID No.
DC340022
(2) On conclusion of all activities, the Division and its contractors shall, to the extent practicable,
restore (lie 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 Imes 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 properly 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 properly and all tenants agree to the conditions
of this "Properly Access Consent".
336- 56y- 16z-1
Tenant in
nTi
�; MCrzi mU&x C TKNc . eo t.�
(Email Address for Property Owner or Tenant in Residence if you prefer to he contacted via
email)
Please return form to:
Jeffrey 011ison
Hart & Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, NC 27607
Or via email to: [e-mail]

d sTArFo
J Wn
ROY COOPER
Covanw
ELIZABETH S. BISER
Seaemry
MICHAEL SCOTT
NORTH CAROLINA
DIm10r
fnrbonm ud Quatiry
PROPERTY ACCESS CONSENT
For DSCA Use Only
This document may not be modified without the Program's approvaL DSCA ID No.
Ifyou have questions on how to fill out this form or about the activities DC340022
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program's contractor for this project Jeffrey 011ison with Hart & Hickman, P.C. at
iollison a harthickman.com or [phone]. Ifyou still have questions after contacting Mr.
011ison with H&H, please contact the DSCA Program Project Manager, Mr. Scott Stupak at
scott.stupak a ncdenr.eov or [phone].
Please Print
Town of Kemeisville
(Name of Property Owner or Tenant
130 E Mountain Street
(Street Number and Street Name of Property)
Kemersville
27284
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.
(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
Northcmolbn Depart lo/Emlr m QLAMV I Dhklanot waste MUMV<
217YR417onn5treet 11646MW$Mi eCents I Rdelgh North C=UMZ76941646
%9.707AM

Page 2 of 2
DSCA Site ID No.
DC340022
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".
1211( ojo—T-L%w r // - Z 9 - ZZ
Property
336 -LleJ6 - 5393
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
(Email Address
email)
Please return form to:
7 -To k K3C , cot-
Owner or Tenant in Residence if you prefer to
Jeffrey 011ison
Hart & Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, NC 27607
Or via email to: [e-mail]