WM0100460_Application_20191002

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: 10/2/2019
2. County: Haywood
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: 44 Church Street, LLC Telephone: [phone]
Applicant's Mailing Address: 165 Montgomery Street, Waynesville, NC 28786
Applicant's Email Address (if available):
5. Contact Person (if different than Applicant): Brett Lawrence Telephone: [phone]
Contact Person's Mailing Address: 2923 S. Tryon Street, Ste. 100, Charlotte, NC 28203
Contact Person's Email Address (if available): blawrence(charthickman.com
6. Property Owner (if different than Applicant): Town of Waynesville ROW Telephone: [phone]
Property Owner's Mailing Address: 16 S. Main Street, P.O. Box 100, Waynesville, NC 28786
Property Owner's Email Address (if available): rhites(a)waynesvillenc.gov (Rob Hites; Town Manager)
7. Property Physical Address (Including PIN Number) ROW along N. Haywood Street, Montgomery Street, and Miller Street
City: Waynesville County Haywood Zip Code 28786
8. Reason for Well(s): Assessment for the NCDEQ 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-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).
NCDEQ — DSCA Site #DC440001
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): Adjacent to 450 ft
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Unknown
If yes, give distance(s):
15. Well Contractor: Geologic Exploration, Inc. Certification No.: 2401
Well Contractor Address: 176 Commerce Blvd., Statesville, NC 28625
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
material: 5 Type II monitoring wells
3. Number of wells to be constructed in bedrock: 0
5. How will the well(s) be secured? Lockable
expansion plug: steel manhole set in concrete pad
6. Estimated beginning construction date: 10/21/2019
4. Total Number of wells to be constructed: 5 7. Estimated construction completion date: 10/24/2019
(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 DC440001 Agent for Petitioner for DSCA Site DC440001
Signature of Applicant or *Agent Title of Applicant or *Agent
Brett Lawrence (Hart & Hickman, PC) * 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 owner 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 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]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
>00
MR Rev. 3-1-2016

STATE OF NORTH CAROLINA
COUNTY OF HAYWOOD
ENCROACHMENT AGREEMENT
100 Blocks of Church, Haywood, Miller
and Montgomery Streets,
DSCA Monitoring Well
THIS ENCROACHMENT AGREEMENT made and entered into this :36 day of
1 , 2018, by and between the Town of Waynesville, a municipal
corporation existing under the laws of the State of North Carolina (herein "Town"), AND
Hart Hickman Corporation. (Herein "Company").
WITNESSETH;
WHEREAS, the rights -of -way adjacent to the 100 blocks of Church, Haywood,
Miller and Montgomery Streets are property belonging to and under the authority and
control of the Town; and
WHEREAS, Company is under the contract and authority to install monitoring
wells; and
WHEREAS the Company has requested the Town enter into an encroachment
agreement to allow the placement a monitoring well, coving an area of approximately 2
square feet; and
WHEREAS, the Company has submitted plans (Exhibit 1) to the Town showing
the location of the monitoring wells and.
WHEREAS, the location of the monitoring wells have been investigated by
appropriate Town staff and it is the opinion of the Public Works Director and his staff
that the monitoring wells will create no undesirable or hazardous condition or interfere
with the -use and movement along that portion of the right-of-way adjacent to the rights
of way In question.
NOW, THEREFORE, in consideration of the foregoing premises and other good
and valuable considerations, the receipt of which is hereby acknowledged, the Town
hereby grants unto the Company the right to encroach upon the right-of-way adjacent
to the above stated locations in , Waynesville, North Carolina, for the purpose of
allowing monitoring wells at the locations shown on the plans submitted to the Town
along with the application as reviewed by the Town, both of which are incorporated
herein in "Exhibit 1", Said encroachment is granted subject to the following conditions;
1. The Company shall be responsible for proper maintenance, repair and
renovation of the monitoring wells and the portion of the property where the
encroachment is located.

Z The Company shall be responsible for removal or relocation of the monitoring
wells and any connections thereto.
3, This Agreement shall continue only so long as the Company uses the monitoring
weil, provided however, that the Town may terminate this Agreement or any
other privileges granted under this Agreement by providing the Company with 30
days written notice.
4. Upon termination of this Agreement, both at the option of the Company or at the
request of the Town, the Company shall remove the monitoring well and any
connections located within the property and replace any areas disturbed by the
removal to the reasonable requirements of the Town. Should the Company fail
to do so, the Town shall make such repairs to the disturbed areas and bill the
Company the costs of such remedlation,
5. The Company shall maintain a minimum amount of liability insurance equal to
one (1) million dollars for damage resulting from the Company's activities at he
sites. The Town shall be shown as an additional insured on the Policy,
6. The Owner shall hold harmless and indemnify the City for any and all injury
resulting or arising from the location or placement of the encroachment to the
proportionate extent Caused by the negligence or intentional misconduct of the
Owner.
IN WITNESS WHEREOF each party has caused this Agreement to be duly
executed on the day and year first above written and if corporate, by their duly
authorized representative.

Hart Hickman Corporation
Company
By: � f (sign)
STATE OF NORTH CAROLINA
COUNTY OF MECKLENBURG
I, Notary Public of the County and State aforesaid certify that Aaron Council
personally appeared before me this day and acknowledged the due execution of the
foregoing instrument as the business owner of Hart Hickman Corporation.
Witness my hand and notarial seal this day of v , 2018.
\APHN (Sign)
��`~ y , Notary Public
�Q Print or type name Q-6,V \Ok rilvinYi
s
J Notary Public
Mecklenburgcounty zE My Commission Expires: 3ti�� -n
7,lesion Expires r7

TOWN OF WAYNESVII-LE
k
By:(Sign)
Davi ster, Dire r of Public Facilities
STATE OF NORTH CAROLINA
COUNTY OF HAYWOOD
I, Notary Public of the County and State aforesaid certify that David Foster
personally came before me this day and acknowledged that she Is the Director of Public
Facilities of the Town of Waynesville, a municipal corporation, and that by authority duly
given and as the act of the corporation the foregro�innglinstrument was signed in its name.
Witness my hand and notarial seal this Cc !' day of , 2018.
NotqrV Public
Prin r type name:
My Commission Expires;

L3
TYPE II MONITORING WELL CONSTRUCTION DETAILS
CROSS SECTIONAL VIEW
LOCKABLE WELL CAP CONCRETE PAD
FLUSH METAL WELL COVER
CONCRETE PAD
L1
L2
L1 = 20 FT.
L2 = 15 FT.
L3 = 35 FT.
ng
DIAMETER OF
BOREHOLE
4.25 in
ram
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
20 ft
BACKFILL AROUND CASING
MATERIAL
bentonite/grout
LENGTH
13 ft (3 ft to 16 ft)
SEAL
TYPE OF SEAL
bentonite
THICKNESS
2 feet (16 ft to 18 ft)
FILTER PACK
TYPE OF FILTER
No. 2 Sand
THICKNESS
17 ft (18 ft to 35 ft)
WELL SCREEN
SCREEN MATERIAL
schedule 40 PVC
DIAMETER
2 inches
LENGTH
15 feet
SLOT SIZE
0.010 inches
DEPTH TO BOTTOM OF
MONITORING WELL
35 feet
Hart & Hickman, PC
2923 South Tryon St., Suite 100
Charlotte, North Carolina 28203
FILE PREP. BY REV. BY DATE PROJECT NO.
CBL 10/2/2019 DSO-101 / DSCA #: DC440001

! ' '- \ �- ? LEGEND
. _ ��
9 ♦� pp pp o ?or 11 vi
SOURCE PROPERTY BOUNDARY
R TEMPORARY MONITORING WELL (AMEC; 2013)
i yy • ` II HH o ` GROUNDWATER GRAB SAMPLE (AMEC; 2013)
(0.98) 9
- 0 GROUNDWATER GRAB SAMPLE (H&H; 2018)
l % o ow 10I
�� �� p i� �� • (0.980) PCE CONCENTRATION (mg/L)
HHGW-2S/D
I�
—0.07— PCE ISOCONCENTRATION CONTOUR (mg/L)
vt
f
, f � � •;_ � +� ' ` t i� �� PROPOSED TYPE II MONITORING WELL
{ / F a. {►
HHGW-4S/D • r _ may,
♦ ,� ' HHGW-3S/D /• #y 'ti f I
- � HHGW-6.
IL i• HHGW-SS
Ah
lee
-
HHG W-7S/D
NOTES:
# r
f r s'P i
. k * GW-9 {} { ' 1. BOLD CONCENTRATIONS INDICATE AN EXCEEDANCE OF
i NC 2L GROUNDWATER QUALITY STANDARD
y � �� _ � �r_ - � ..'• `�j � * ' ;� 2. PCE = TETRACHLOROETHENE
r GW-10
*•; J� • +;3. BQL =BELOW LABORATORY QUANTITATION LIMIT
' f J
• f ti s+'y 4. SAMPLES HHGW-1 THROUGH HHGW-7 WERE COLLECTED
' IN MAY 2018. TMW-1 THROUGH TMW-3 WERE
,
«�. r • * COLLECTED IN SEPTEMBER 2011. REMAINING SAMPLES
WERE COLLECTED IN JUNE 2013.
/ GW-6 l
k.
,w •i �y� t .�+ TMW-6 + �.
yGW-2 ? -
, •A
♦ TMW-7 � / • - R•�
a (BQL) i
APPROXIMATE
GW-5 ;f TMW-4 �1 f
0 150 300
(BQL) f SCALE IN FEET
s 0GW-4
04 SHALLOW PCE GROUNDWATER
( TMW-2
(0.0033) (B �' `' `� ISOCONCENTRATION MAP
TMW-5 TMW-3 r * PROJECT CENTRAL CLEANERS
ft�
GW-1 I' F „' DSCA ID: DC440001
77
*; �L - �•.. .' '� 44 CHURCH STREET
"s fr • TMW-1 _ WAYNESVILLE, HAYWOOD COUNTY
o 2923 South Tryon Street -Suite 100
• hart '1s• hickman Charlotte, North Carolina28203
•- } { a y # t' , • 704-586-0007(p) 704-586-0373(f)
o +ti -$TMW-8 `�*'' - ` f SMARTER ENVIRONMENTAL SOLUTIONS License # C-1269 / #C-245 Geology
r
DATE: 5-29-18 REVISION NO. 0
'` dr BMW JOB NO. DSO-101 ATTACHMENT NO. 71B