WM0401524_WM0401524 permit application_20240326

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
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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.
Date: 3/22/2024
County: Forsyth
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring
Applicant: Dutch Defense, LLC (Petitioner for DSCA Site ID: DC340046) Telephone: Ariana Rivera [phone]
Applicant's Mailing Address: DSCA Program, 1646 Mail Service Center, Raleigh, NC 27699-1646
Applicant's Email Address (if available): ariana.rivera(a�deq.nc.gov
Contact Person (if different than Applicant): Colin Carraway, 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): ccarrawayaharthickman.com
Property Owner (if different than Applicant): Ridge Top Real Estate Investments, LLC Telephone: [phone]
Property Owner's Mailing Address: 25639 Elk Lick Road, Chantilly, VA 20152
Property Owner's Email Address (if available): gfineyer01agmail.com
Property Physical Address (Including PIN Number) 334 Waughtown Street (PIN # 6834-58-6181)
City Winston-Salem County Forsyth Zip Code 27127
Reason for Well(s): Environmental assessment for DSCA Program
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
Type of facility or site for which the well(s) is(are) needed: Former dry-cleaning solvent distribution facility
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
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 # DC340046
Type of contaminants being monitored or recovered: Chlorinated solvents
(ex: organics, nutrients, heavy metals, etc.)
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).: N/A
Distance from proposed well(s) to nearest known waste or pollution source (in feet): approx. 100 ft
Are there any water supply wells located less than 500 feet from the proposed well(s)? Unknown
If yes, give distance(s): Unknown
Well Contractor: Geologic Exploration, Inc. Certification No.: 2580-A
Well Contractor Address: 176 Commerce Boulevard, Statesville, NC 28625
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
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? Completed as flush
mount (locked expansion plug and bolted steel manhole cover)
with a concrete pad
6. Estimated beginning construction date: 4/1/2024
Estimated construction completion date: 4/5/2024
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 assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
C1 Agent for Petitioner for DSCA Site DC340046 Agent for Petitioner for DSCA Site DC340046
Signature of Applicant or *Agent Title of Applicant or *Agent
Colin Carraway . 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
well(s) as outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
See attached property access agreement (Attachment 3) See attached property access agreement (Attachment 3)
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 28301-5094
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]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22M/R (Rev. 5-26-2022)

Attachment 1

LOCKABI � 1-1 ' —A —
"ORING WELL CONSTRUC
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 35 feet
L1
4 BACKFILL AROUND CASING
L3
MATERIAL bentonite/grout
LENGTH 28 feet (3 ft to 31 ft)
SEAL
TYPE OF SEAL bentonite
THICKNESS 2 feet (31 ft to 33 ft)
FILTER PACK
TYPE OF FILTER No. 2 Sand
THICKNESS 12 feet (33 ft to 45 ft)
WELL SCREEN
SCREEN MATERIAL schedule 40 PVC
L2 DIAMETER 2 inches
LENGTH 10 feet
SLOT SIZE 0.010 inches
DEPTH TO BOTTOM OF
L1 = 35 FT. MONITORING WELL 45 feet
L2 = 10 FT. DIAMETER OF
L3 = 45 FT. BOREHOLE
4.25 in
(TITLE Monitoring Well Diagram
M W-6
Hart & Hickman, PC
3921 Sunset Ridge Rd., Suite 301
Raleigh, North Carolina 27607
II CFILE PREP. BY CC (REV. BY JAO (DATE 3/15/2024 1 DSO-185 ECDSCA ID# DC340046)

Attachment 2

Attachment 3

ROY COOPER
ca,rrnnr
ELIZABETH S. BISER
se -"on,
MICHAEL SCOTT
Di+wtor
NORTH CAROLINA
EnyMmmental Quatitr
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 DC340046
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program's contractor for this project Colin Carraway with Hart & Hickman, PC at
cearraway(a),harthickman.com or 919-723-2509. Ifyou still have questions after contacting Mr.
Carraway with Hart & Hickman, PC, please contact the DSCA Program Project Manager, Ms.
Arian Rivera at ariana.rivera(&deq.nc.gov or 919-707-8352.
Please Print
Ridge Top Real Estate Investments, LLC
(Name of Property Owner or Tenant in Residence)
334 Waughtown Street
(Street Number and Street Name of Property)
Winston-Salem Forsyth County 27127
(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
North Carolna Depammnt of EmArotrnmal Quality I Division of Waste Management
217 West Jones Street 11646 Mal Service Center I Raleigh, North Carolina 27699.1646
919.707A200

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.
(5) The Division and its contractors will abandon any monitoring wells, if requested by the Property
Owner, to facilitate sale or redevelopment of the property.
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 ail
tenants (if there are tenants) occupying the property and all tenants agree to the conditions
of this "Property Access Consent".
0312-1/9-
(Signature of Property Owner or Tenant in Residence)
33�I e37- 7s
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
Address for roperty Owner or TenajjjA Residence if you prefer to be contacted via
email)
Please return form to:
Colin Carraway
Hart & Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, NC 27607
Or via email to: ccarrawayCcDharthickman.com
North Carolina Department of EnvWonmentai Quality I Division of Waste Managcrosrt
217 west Jones Street 1 1646 Mall Service Center i Raleigh, North Carolina 27699-1646
919.707.8200