WM0801136_Application_20190708

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
DIVISION OF WATER RESOURCES — AQUIFER PROTECTION SECTION
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:
2. County:
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant:
Applicant's Mailing Address:
Applicant's Email Address (if available):
5. Contact Person (if different than Applicant):
7.
8.
9.
10
11
12
13
14
Contact Person's Mailing Address:
Contact Person's Email Address (if available):
Property Owner (if different than Applicant): _
Telephone:
Telephone:
Telephone:
Property Owner's Mailing Address:
Property Owner's Email Address (if available):
Property Physical Address (including zip code) and PIN Number
Reason for Well(s):
(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:
(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).
Type of contaminants being monitored or recovered:
(ex: organics, nutrients, heavy metals, etc.)
Are there any existing wells associated with the proposed well(s)? If yes, how many?
Existing Monitoring or Recovery Well Construction Permit No(s).:
Distance from proposed well(s) to nearest known waste or pollution source (in feet): _
Are there any water supply wells located less than 500 feet from the proposed well(s)?
If yes, give distance(s):
15. Well Contractor: Certification No.:
Well Contractor Address:
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
5. How will the well(s) be secured? 8" flush mounted bolt -
down manhole set in 2' x 2' x 4" thick concrete pad, locking
6. Estimated beginning construction date: 7/1/2019
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3) 7. Estimated construction completion date: 7/2/2019
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
Signature of Applicant or *Agent
Larry George
Printed name of Applicant or *Agent
Agent for DSCA site DC650014
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 See Attached 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] Barrett Drive
Fax: [phone] Raleigh, NC 27609 Wilmington Regional Office
Phone: [phone] 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] Washington Square Mall
Fax: [phone] Washington, NC 27889 Winston-Salem Regional Office
Phone: [phone] W. Hanes Mill Road
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
05

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© 2014 Microsoft Cor;oratio"2014 Nokia ©AND
Map Location Site Location Map N Attachment 1
KY VA Williams Cleaners A COM
DSCA Site ID# 065-0014 /'�i�
TN 1402 South College Road AECOM
NC Wilmington, New Hanover County, NC 701 Corporate Center Drive, Suite 475
0 80 160 240 320 Raleigh, NC 27607
tel: [phone]
GA SC Feet fax:[phone]
August 2014 1 inch = 150 feet 60314717 www.AECOM.com

■1111155!
L1
L2
L3
MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
(NOT TO SCALE)
LOCKABLE WELL CAP
PROTECTIVE CASING AND CONCRETE PAD
CASING MATERIAL
sch 40 PVC
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
5 feet
BACKFILL AROUND CASING
MATERIAL cement grout
THICKNESS 3 feet
SEAL
TYPE OF SEAL bentonite
THICKNESS 1 feet
FILTER PACK
TYPE OF FILTER #2 silica sand
DISTANCE ABOVE SCREEN 11 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 15 feet
DEPTH TO BOTTOM OF
BOREHOLE 15 feet
L1 = 0 FT.
L2 = 5 FT. DIAMETER OF BOREHOLE 6 inches
L3 = 10 FT.
L4 = 15 FT.
TITLE Monitoring Well -
Williams Cleaners AwAkT
1402 South College Road Awr C
Wilmington, New Hanover County 2725 East Millbrook Road, Suite 121
North Carolina Raleigh, North Carolina 27604
FILE PREP. R REV. BY DATE PROJECT NO.
JR LG 1/23/2018 DC650014

ICU
Waste Management
"WROMMMUL QUALITY
URGENT MATTER — PROMPT REPLY REQUESTED
5-26-2017
Wesley Memorial United Methodist Church
1401 S College Rd
Wilmington, NC 29403
ROY COOPER
aowr
MICHAEL S. REGAN
9 _ftq
MICHAELSCOTT
Re: Subsurface Contamination Investigation Associated with Dry -Cleaning Facility Located at
Williams Cleaners, 1402 S. College Road, Wilmington (New Hanover County)
DSCA Site # 65-0014
Dear Wesley Memorial United Methodist Church:
The North Carolina Division of Waste Management (Division) is investigating the release of hazardous
substances, pollutants or contaminants at the facility listed above. After careful review of all the
information provided, it is possible that the subsurface contamination extends beyond the facility's
property.
The Division has a program to address these types of releases, called the Dry -Cleaning Solvent Cleanup
Act (DSCA) Program. The DSCA Program uses independent contractors hired by the Division to
investigate and remediate any contamination related to the dry-cleaning facility. To assist in this
investigation, the Division is requesting that you grant access to your property to allow the Division's
independent contractor to conduct additional assessment activities. Please find an attached Off -Site
Property Access Consent for your signature.
Since additional site activities cannot be performed without completion of this form, the Division would
appreciate your prompt return of the form to:
Mr. Patrick Watters
Division of Waste Management, DSCA Program
1646 Mail Service Center
Raleigh, NC 27699-1646
If you have any questions regarding the status of site activities or the Off -Site Property Access Consent,
please do not hesitate to contact the DSCA Project Manager, Mr. Patrick Watters at 919-707-8363.
Thank you for your cooperation.
SW, ofNwh Cwoh.I H M.a u W Qmkiy I W.m. Mm.Ve
1646 M.0 Service Cem.1217 WW mutes So- I R.Idsh, NC 176994646
919707 RM UWI, ne

Waste Management
ENVIRONMENTAL QUALITY
PROPERTY ACCESS CONSENT
This document may not be modifred 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 Program at
[phone].
Please Print
Memorial United Methodist Church
UWher m -tenant 1n Kesldence) ( (Date Property Purchased,
1401 S College Rd
(Street Number and Strcct Name of Property)
ROY COOPER
aa.
MICHAEL S. REGAN
&--MY
MICHAEL SCOTT
Dh07on Direem
For DSCA Use Only
DSCA ID No.
DC650014
New Hanover 28403
Property Is Located) / (County in Which Property is Located) / (Zip Code)
Property Owner or Tenant)
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 he necessary;
(2) taking other actions related to the investigation of surface or subsurface conditions;
(3) tatting 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 with applicable laws and regulations, unless other
arrangements are agreed to by the Property Owner,
%MM of Nan. (Wolmn I Fmi.m.tM Q Wily I �Yasla MannganeN
1646 Mad Service CMner 1217 West rolls Street I Mleig., NC 2769961646
919707 82W TeleFlmne

(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 have contacted all tenants (if
there are tenants) occupying the property and all tenants agree to the conditions of
this "Property Access Consent".
Please return form to:
Division of Waste Management
DSCA Program — DC650014
1646 Mail Service Center
Raleigh, NC 27699.1646
Or via email to: [e-mail]