WM0100558_Monitoring Well Construction Application_20231004

FOR OFFICE USE ONLY 
PERMIT NO.    ISSUED DATE   
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: October 4, 2023
2.County:Buncombe
3.What type of well are you applying for? (monitoring or recovery): Monitoring (MW-1, Alternate if needed)
4.Applicant: Janice G. Starnes (Petitioner for DSCA Site #110012) Telephone: [phone]
Applicant’s Mailing Address: DWM DSCA Program, Attn: Mike Cunningham,1646 Mail Service Center, Raleigh, NC 27669-1646
Applicant’s Em ail Add res (if s avai lable): [e-mail]
5.Contact Person (if different than Applicant): Al Quarles, ATC Associates of North Carolina, P.C. Telephone:
704-529-3200 Contact Person’s Mailing Address: 7606 Whitehall Executive Center Drive, Suite 800, Charlotte NC 28273
Contact Person’s Email Address (if available): [e-mail]
6.Property Owner (if different than Applicant): Janice G. Starnes Telephone: [phone]
Property Owner’s Mailing Address: 231 Tipton Hill Road, Leicester, NC 28748
Property Owner’s Email Address (if available): [e-mail]
7.Property Physical Address (Including PIN Number) 740 Haywood Road (PIN: 963814748900000)
City Asheville County Buncombe Zip Code 28806
8.Reason for Well(s): Assessment
(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: DSCA Program Site
(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 ID DC110012
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): 10 feet
14.Are there any water supply wells located less than 500 feet from the proposed well(s)?None Identified
If yes, give distance(s):
15.Well Contractor: John Eisenman, SAEDACCO Certification No.: 4439
Well Contractor Address: 9088 Northfield Drive, Fort Mill, SC 29707 (email c/o: [e-mail])
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
WM0100558 10/6/2023

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)

2. Number of wells to be constructed in unconsolidated
material: 1

3. Number of wells to be constructed in bedrock: 0

4. Total Number of wells to be constructed: 1
(add answers from 2 and 3)
5. How will the well(s) be secured?
Bolt-down 8” manhole, encased in a 2x2 concrete pad.

6. Estimated beginning construction date: 10/30/2023

7. Estimated construction completion date: 11/2/2023

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. 143-215.10B(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 DSCA Petitioner for Site DC110012 Agent for Petitioner for DSCA Site DC110012
Signature of Applicant or *Agent Title of Applicant or *Agent

Al Quarles * 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 consent see attached access consent
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]
GW-22MR Rev. 3-1-2016
Proposed Monitoring Well
Power Pole
Overhead Utility
Source Property
DC110012, Mayflower Cleaners, Monitoring Well Locations
MW-1
MW-2
MW-3
MW-4
MW-5 Properties requiring
well permits
12 Brevard Rd
PIN 963814920900000
718 Haywood Rd
PIN 963824029000000
(no #) Dundell Ave
PIN 963824065300000
Optional for alternative MW-1 location
740 Haywood Rd
PIN 963814748900000
Alternate
MW-1
750 Hawood Rd
PIN 963814644400000
TYPICAL TYPE II MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
NOT TO SCALE
LOCKABLE WELL CAP
PROTECTIVE CASING AND CONCRETE PAD
L1 CASING MATERIAL steel
CASING DIAMETER 8 inches
CASING LENGTH 12 inches
PAD DIMENSIONS 2 feet x 2 feet
HEIGHT ABOVE GROUND flush mounted
WELL CASING
MATERIAL sch 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threaded
LENGTH 35 feet
L2 BACKFILL AROUND CASING
MATERIAL cement-sand grout
THICKNESS 31 feet
SEAL
TYPE OF SEAL bentonite
L4 THICKNESS 2 feet
FILTER PACK
TYPE OF FILTER #2 silica sand
DISTANCE ABOVE SCREEN 2 feet
WELL SCREEN
L3 SCREEN MATERIAL Sch 40 PVC
DIAMETER 2 inches
LENGTH 15 feet
SLOT SIZE 0.010 inches
DEPTH TO BOTTOM OF
MONITORING WELL 50.0 feet
DEPTH TO BOTTOM OF
BOREHOLE 50.0 feet
L1 =0.5 FT.
L2 =35 FT.DIAMETER OF BOREHOLE 8.25 inches
L3 =15 FT.
L4 =50 FT.
TITLE Permanent Monitoring Well Diagram
FILE PREP. BY REV. BY DATE SITE ID NO.
BM 9/19/2023 DC110012
7606 Whitehall Executive Center Drive
Charlotte, North Carolina 28273
Mayflower Cleaners
732 Haywood Road
Asheville, NC
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
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 Al Quarles with ATC Associates of North Carolina, P.C.
(ATC) at [e-mail] or [phone]. If you still have questions after
contacting Mr. Quarles with ATC, please contact the DSCA Program Project Manager, Mr.
Mike Cunningham at mike.cunningham c_f deq.nc.gov or [phone].
For DSCA Use Only
DSCA ID No.
DC110012
Please Print
Janice Starnes
(Name of Property Owner or Tenant in Residence)
740 Haywood Road
(Street Number and Street Name of Property)
Asheville
Buncombe 28806
(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, surface water, 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
WD_E ra/
North Carolina Department of Environmental Quality I Division of Waste Management
217 West Jones Street 11646 Mall Service Center I Raleigh, North Carolina 27699-1646
919.707.8200

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".
(Siattire of Property Owner or Tenant in Residence)
7 /sd-.A°
(Date)
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
a 11- s5-ftx(nes D off: ►' +
mail Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Al Quarles
ATC Associates of North Carolina, P.C.
7606 Whitehall Executive Center Drive, Suite 800
Charlotte, NC 28273
Or via email to: [e-mail]
ODE
OMrY_I.I t waarnw.tal Quat�
North Carolina Department of Environmental Quality I Division of Waste Management
217 West Jones Street 11646 Mail Service Center I Raleigh. North Carolina 27699-1646
919.707.8200