WM0401545_Application_20240801

AECOM AECOM Technical Services of North Carolina, Inc. [phone] tel
6000 Fairview Road,Suite 200
Charlotte, NC 28210
July 30,2024
Mr. Lon Snider
Winston-Salem Regional Office
Division of Water Resources
Water Quality Regional Operations Section
Re: Monitoring Well Permit Application—MW-7
NCDEQ—DSCA Program,DSCA Site DC340045
3021 Waughtown Street
Winston-Salem,Forsyth County,North Carolina
Dear Mr. Snider:
On behalf of the NCDEQ Dry-Cleaning Solvent Cleanup Act Program, AECOM Technical Services of
North Carolina,Inc.(AECOM)has prepared the attached permit application in accordance with 15A NCAC
2C .0105. Proposed activities include installation of one monitoring well on the adjacent property located
at 0 Waughtown Street,Forsyth County,NC(MW-7).
Included herein are the Application for Permit to Construct a Monitoring or Recovery Well System packets
for the aforementioned property. The packet includes Form GW-22MR, a map of the proposed well
location, a general well construction diagram, and a signed access agreement.
Upon approval, please forward the monitoring well construction permit(s) to me at
madalyn.stonegaecom.com. If you have any questions or require additional information, please do not
hesitate to call me at 704-661-4061.
Sincerely,
AECOM TECHNICAL SERVICES OF NORTH CAROLINA,INC.
q 41,
Madalyn P. Stone,PG
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.
FOR OFFICE USE ONLY
1. Date: July 30, 2024
2. County: Forsyth PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring Well (MW-7)
4. Applicant: Southeast Plaza LLC-Petitioner for DSCA Site ID DC340045(Quality Dry Cleaners) Telephone: [phone]
Applicant's Mailing Address: DWM DSCA Program, Attn: Ariana Rivera, 1646 Mail Service Center, Raleigh, NC 27699-1646
Applicant's Email Address(if available): ariana.rivera aC deg.nc.gov
5. Contact Person (if different than Applicant): Madalyn Stone(AECOM) Telephone: [phone]
Contact Person's Mailing Address: 6000 Fairview Road,Suite 200, Charlotte, NC 28210
Contact Person's Email Address(if available): madalyn.stone a.aecom.com
6. Property Owner(if different than Applicant): Parkview Shopping Center Condominium Association(Amith J Arrita:Agent of Owner)
Telephone: [phone]
Property Owner's Mailing Address: 3025 Waughtown Street, Suite G,Winston-Salem, NC, 27107
Property Owner's Email Address(if available): amith ajtmcap.com
7. Property Physical Address(Including PIN Number)0 Waughtown Street(PIN: 6854-19-6444)
City Winston Salem County Forsyth Zip Code 27107
8. Reason for Well(s): Environmental assessment, groundwater 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-cleaning facility
(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).
None
11. Type of contaminants being monitored or recovered: Volatile organic compounds(specifically chlorinated solvents)
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 5
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): Approximately 120 ft
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Unknown
If yes,give distance(s): N/A
15. Well Contractor: Geologic Exploration Certification No.: Varies by individual driller
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 5. How will the well(s) be secured? Locking cap
material: 1
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 09/11/24
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 09/12/24
(add answers from 2 and 3)
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 Petitioner for DSCA Site DC340045 Agent for Petitioner for DSCA Site DC340045
Signature of Applicant or*Agent Title of Applicant or*Agent
Madalvn Pierce Stone *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 signed 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 Raleigh Regional Office GW-22MR Rev. 3-1-2016
Phone: [phone] 3800 Barrett Drive
Fax: [phone] Raleigh, NC 27609 Wilmington Regional Office
Phone: [phone] 127 Cardinal Drive Extension
Fayetteville Regional Office Fax: [phone] Wilmington, NC 28405
225 Green Street, Suite 714 Phone: [phone]
Fayetteville, NC 28301-5094 Washington Regional Office Fax: [phone]
Phone: [phone] 943 Washington Square Mall
Fax: [phone] Washington, NC 27889 Winston-Salem Regional Office
Phone: [phone] 450 W. Hanes Mill Road
Mooresville Regional Office Fax: (252 -
610 East Center Avenue Iffit sale �N' , C 27105
Mooresville, NC 28115 ✓L al ph ne: 7 -9800
Phone: [phone] r F - 7
Fax: [phone]
F eft�ville @ � �
Will ng►on

LEGEND MW-4(03/27/24)* 00 MW-3(03/27/24)* 00
Petitioned Property Boundary BDL BDL U
_7
Parcel Line MW-4(03/28/24)**00 MW-3(03/28/24)**00
Approximate Location of Former Quality Cleaners BDL BDL
Temporary Monitoring Well Location(Partner,2023) �O
Monitoring Well Location * M
MW-2(03/27/24)* 00 ?? s� U
® Proposed Monitoring Well Location / PCE-90.4 µg/L
HSA Refusal-DRY TCE-46.4 µg/L �' O Q
672.68 Relative Groundwater Elevation(ft),March 28,2024 / cis-1,2-DCE-20.1 µg/L �(� �" y
_ / PARCEL ID: 6854-19-6444 trans-1,2-DCE-0.5 µg/L 3
Potentiometric Surface Contour(ft)and Inferred .C�
Groundwater Flow Direction,March 28,2024 i�A / MW-2(03/28/241** N N z U
PCE-76 µg/L
\ Estimated extent of PCE in groundwater exceeding // t~
TCE-39.3 µg/L M O Q
the 2L Standard of 0.7 µg/L
J Estimate Value cis-1,2-DCE-17.9 µg/L
trans-1,2-DCE-0.45 µg/L
µg/L micrograms per liter -
BDL Below Laboratory Detection Limits � �
B2GW(06/01/23) 00
PCE-Tetrachloroethylene / PCE-0.53 J µg L
TCE-Trichloroethylene /
cis-1,2-DCE-cis-1,2-Dichloroethylene / cn
trans-1,2-DCE-cis-1,2-Dichloroethylene W
B3GW(06/01/23) N H
** Sampled using Hydrasleeve - PCE-0.82 J µg/L a
Sampled using Low Flow 3
Groundwater analytical results do not exceed calculated vapor a N
N intrusion risk for residential or non-residential exposure-
DSCA Indoor Air/Soil Gas Risk Calculator I / - z o
N Groundwater analytical results exceed calculated vapor 78 16 - - _� / U H
intrusion risk for residential and non-residential exposure - / 01F
DSCA Indoor Air/Soil GasRisk Calculator 01
100-0 / \ p O w
Note:Historical data optained from the Phase II Subsurface / U w o W
Investigation Report prepared by Partner Engineeing and Science, ' / Q O U H
Inc.,dated June 21,2023(Partner,2023). /
�/
$off, . ol
/
/ \
l /
/ I /. \ 11
MW-5(03/27/24)* 00 O
/Acetone-47.6 µg/L
Toluene-0.3 J µg/L (4 O / / w■
MW-5(03/28/24)**4PO o o ��' /
Acetone-31.8 ug L - _ __
66��
3021 Waughtown Street 64.97 60.
i- io
rim N N N
r � .. rr► o 0
N N
�_ ' _ N
MW-1(03/27/241* N B1CW(06/01/23) 00
Acetone-12.7 J µg/L BDL
MW-1(03/28/24)**N o
t. w BDL 0 60 A a
PARCEL ID: 6854-19-6444 SHEET.
- APPROX.SCALE,ft. Figure 1

Client: Quality Dry Cleaners DC340045(MW-7)
WELL ID: Proposed Type II Well
_ Pro ect Number: 60722553
COMSite Location: 3021 Wau hto"Street, Winston Salem,NC Date Installed: Estimated September 2024
Well Location: Coords: Inspector: AECOMStaff
Method: 4.25"ID HSA Contractor: Geologic Exploration
PROPOSED MONITORING WELL CONSTRUCTION DETAIL
Depth from G.S.(feet) Elevation(feet)
Datum
8-inch diameter flush-mount steel vault to be set in 2'x2'x0.5'concrete pad
Top of Riser Pipe 0.0
Ground Surface(G.S.) 0.0
Riser Pipe:
Length 15
Diameter(ID) 2"
Type of Material PVC
Thickness Sch 40
Grout:
Type neat cement
Thickness 10'
Top of Bentonite 10
Bentonite Seal Thickness 3'
To of Sand 13
Top of Screen 15
Screen:
Length 15
Diameter(ID) 2"
Slot Size 0.010"
Type of Material PVC
Thickness Sch 40
Type/Size of Sand #2
Sand Pack Thickness 17
Bottom of Screen 30
Bottom of Tail Pipe: 30
Bottom of Borehole 30
Borehole Diameter 4.25"ID HSA
Describe Measuring Point:
Signature Date
Note: Depths area ropmate and will be adjusted based on field conditions. Not to scale.

STArE
ROY COOPER
GovernorELIZABETH S. BISER '^4.,^•. a .
Secretary
MICHAEL SCOTT NORTH CAROLINA
Direc ror Environmental Quality
PROPERTY ACCESS CONSENT
For DSCA Use Only
This document may not be modified without the Program's approval If you DSCA ID No.
have questions on how to fill out this form or about the activities at this site, DC340045
please call the Dry-Cleaning Solvent Cleanup Act (DSCA) Program's
contractor for this project,Ms. Madalyn Stone with AECOM at [e-mail] or(704) 522-
0330. If you still have questions after contacting Ms. Stone with AECOM, please contact the DSCA
Program Project Manager, Ms. Ariana Rivera at ariana.rivera(a-ded.nc.��ov [phone].
Please Print
Amith J Arrieta
(Name of Property Owner or Tenant in Residence)
0 Waughtown Street (Pin ID: 6854-19-6444)
(Street Number and Street Name of Property)
Winston Salem, Forsyth County,NC 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, 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
4�2 R E Qr,ANorth Carolina Department of Environmental Quality I Division of Waste Management
217 West Jones Street 1 1646 Mall Service Center I Raleigh,North Carolina 27699-1646
m.ar� / 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".
07/17/2024
(Signature of Property Owner or Tenant in Residence) (Date)
336 462 0499
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
[e-mail]
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Madalyn Stone
AECOM
6000 Fairview Road
Suite 200
Charlotte,NC 28210
Or via email to: [e-mail]
North Carolina Department of Environmental Quality I Division of Waste Management
217 West Jones Street 1 1646 Mail Service Center I Raleigh.North Carolina 27699-1646
TM� / 919.707.8200