WM0401213_Permit (Issuance)_20200123

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
Mr. Scott Stupak
NCDEQ — DSCA Program
1646 Mail Service Center
Raleigh, North Carolina 27699
NORTH CAROLINA
Environmental Quality
January 22, 2020
SUBJECT: MONITORING WELL CONSTRUCTION
PERMIT NO. WM0401213
COUNTY: Forsyth
FILE NAME: Modern Cleaners — DSCA Site DC340022
Dear Mr. Stupak:
In accordance with your application received on January 17, 2020, we are forwarding herewith:
1. Monitoring Well Construction Permit No. WM0401213 for the construction of two (2)
temporary monitoring wells at 125 Allen Street in Kemersville in Forsyth County.
Henceforth, correspondence and data relating to this well shall be designated as specified in the
subject heading above. This Permit will be effective from the date of issuance and shall be
subject to the conditions and limitations as specified therein. If you have any questions regarding
this permit, please contact me or Jim Gonsiewski at [phone].
Sincerely,
E
euegmtl by:
T5mgw
B4BEV'c"`7..
Lon T. Snider
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
cc: Clarence & Imogene Lambe (Electronic Copy)
Jeffrey 011ison — Hart & Hickman, PC (Electronic Copy)
DEQ�� North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1450 West Hanes Mlll Road, Suite 3001 Winston-Salem, North Carolina 27105
NOPIH CPPpLINq ` _'
omammmmun,m�uw""•'\ � 336.776.9800

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES — WATER QUALITY REGIONAL OPERATIONS
SECTION
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and
other applicable Laws, Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
NCDEQ — DSCA Program
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of two (2)
temporary monitoring wells owned by the NCDEQ DSCA Program. The wells will be located at
125 Allen Street in Kemersville, North Carolina, in Forsyth County. This Permit is issued in
accordance with the application received on January 17, 2020, in conformity with specifications
and supporting data, all of which are filed with the Department of Environmental Quality and are
considered integral parts of this Permit.
This Permit is for well construction only, and does not waive any provision or requirement of
any other applicable law or regulation. Construction of any well under this Permit shall be in
strict compliance with the North Carolina Well Construction Regulations and Standards (15A
NCAC 02C .0100), and other State and Local Laws and regulations pertaining to well
construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to
an adjudicatory hearing upon written request within 30 days of receipt of this Permit. The
request must be in the form of a written petition conforming to Chapter 150B of the North
Carolina General Statutes and filed with the Office of Administrative Hearings, 6714 Mail
Service Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit
is final and binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to
other specified conditions, limitations, or exceptions as follows:

1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these
wells are being installed as part of an investigation for contamination from an
underground storage tank or dry cleaner incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement
issued by another agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as
part of the Permit application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A
NCAC 02C .0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of
Water Resources' Information Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with
15A NCAC 02C .0113 and a well abandonment record (GW-30) shall be submitted to the
Division of Water Resources' Information Processing Unit within 30 days of the well
abandonment.
7. The County Health Department may require a county monitoring well construction
permit. Please contact the health department for their requirements.
Permit issued the 22nd day of January, 2020
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
uoeuftned by. CLO 6.2w
145E49E225C94EA...
Lon T. Snider, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
By Authority of the Environmental Management Commission
Permit No. # WM0401213

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 h
1. Date:
2. County:
rr a permit to construct monitoring or recovery wells.
FOR OFFICE USE ONLY
PERMIT N0. b is 4 3 ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Temporary Monitoring Wells
4. Applicant: Michael and Kristine Tozer (petitioner for DSCA Site #DC340022) Telephone: ScottStupak [phone]
Applicant's Mailing Address: DSCA Prooram 1646 Mail Service Center Raleigh NC 27699-1646
Applicant's Email Address (if available): scott.stuvak0nodenr.gov
5. Contact Person (if different than Applicant): Jeffrey 011ison. 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): iollison(a)harthickman cam
6. Property Owner (if different than Applicant): Clarence & Imogene Lambe Telephone: [phone]
Property Owner's Mailing Address: PO Box 1785, Kernersville, NC 27285
Property Owner's Email Address (if available): clarencelambesr(oivahoo.com
7. Property Physical Address (Including PIN Number) 125 Allen Street (PIN# 6886335444)
City Kernersville County Forsyth Zip Code 27284
8. Reason for Well(s): Environmental Assessment for DSCA Proaram
(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 Cleaner
(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 ID #DC340022
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).: Not available
13. Distance from proposed well(a) to nearest known waste or pollution source (in feet): Approximately 790 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, givedistance(s):
15. Well Contractor: Innovative Environmental Technologies Inc Certification No.: 2725-A
Well Contractor Address: 4185 Barrier Road, Concord NC 28025
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? Temporary monitoring
materiel: 2 wells —will he abandoned following sampling
3.. Number of wells to be constructed In bedrock: 0 6. Estimated beginning construction dale: January 2020
4. Total Number of wells to be constructed: 2 7. Estimated construction completion dale: January 2020
(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 mods,
Intersections„ streams, or lakes within 500 feet of the proposed well or wall system.
b. All existing wells, identiied 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.
a. 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 Conviction Permit as regulated under the Well ConsWction Standards (Title 16A of the North Carolina Administrative Code,
����''''jjjj
- Subchapter 2C) and accepts full responsibility for compliance with these rules
Q�on behalf of Petitioner for DSCA Site DC340022 Agent for Petitioner for DSCA Site DC340022
Signature of Applicant or 'Agent Title of Applicant or *Agent
Jeffrey 011ison ' ff 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 properly owner hereby consents to allow the applicant to construct
walls as outlined In this Well Conviction 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 16A of the North Carolina Administrative Code, Subchapter 2C).
—See attached crooenv access agreement (Attachment 31 ...See attached property access agreement (Attachment 31
Signature of Property Owner (if different than Applicant) Printed name of Properly Owner (If different than AppllcanQ
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 28116
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-22MR Rev. 3.1.2016

Attachment 1

L3
L1
L2
L1 =
35
FT
L2=
10
FT
L3 =
45
FT
CROSS SECTIONAL VIEW
DIAMETER OF
BOREHOLE
4.25 in
Diagram
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
NELL SCREEN
'CREEN MATERIAL
)IAMETER
.ENGTH
'LOT SIZE
DEPTH TO BOTTOM OF
MONITORING WELL
schedule 40 PVC
1 inch
lush threaded
35 feel
schedule 40 PVC
1 inch
10 feet
0.010 inches
45 feet
TMW-2 & TMW-3 Hart & Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, North Carolina 27607
FILE PREP. BY REV. BY DATE PROJECT NO.
JAO GKO 1/17/2020 DSO-163 (DSCA ID# DC340022)

Attachment 2

Attachment 3

ROY COOPER NORTH CAROLINA
Governor EaHronmenrdQuality
MICHAEL S. REGAN
Sec etary
MICHAELSCOTT
Dlnrrtor
PROPERTY ACCESS CONSENT
For DSCA Use Only
This document may not be modified without the Program Is approval. DSCA to No.
Jf you have questions on how to fill out this form or about the activities DC340022
at this site, please call the Diy-Cleaning Solvent Cleanup Act (DSCA)
Program's contractor -for this project Jeffrey 011ison with Hart & Hickman, P.C. at
iotlisontriliiarthic rl�,ga q,ggm or [phone]. Jfyou still hate questions after contacting Mr.
011ison with H&H, please contact the DSCA Program Project Manager, Mr. Scott Stnpak at
scott.stuoak0.ncdencgov or [phone].
Please Print
Clarence & Imogene Lambe
(Name of Property Owner or Tenant in Residence)
125 Allen Street
(Street Number and Street Name of Property)
Kemersville Forsyth 27284
ItY or Town In Which PronertV IS Located) I (County in Which Pmnemr is i nratedl 1 21n C•ndel
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 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.
D
NanhCmaRm Department o(DwIrenmrnWlQuSny: DMsbn W Mste.LLltugernm
21TWest1we Street ! 16"hW5nNee Gentee i Wt1gttNw1h Cam0w2ra99 1tre6
911.7076200

Page 2 of 2
DSCA Site ID No.
DC340022
(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.
(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 pnor 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".
or Tenant in Residence for
Property Owner or
email)
Please return form to:
Jeffrey 011ison
Hart & Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, NC 27607
Or via email to: [e-mail]
be contacted

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
Mr. Scott Stupak
NCDEQ — DSCA Program
1646 Mail Service Center
Raleigh, North Carolina 27699
NORTH CAROLINA
Environmental Quality
January 22, 2020
SUBJECT: MONITORING WELL CONSTRUCTION
PERMIT NO. WM0401214
COUNTY: Forsyth
FILE NAME: Modern Cleaners — DSCA Site DC340022
Dear Mr. Stupak:
In accordance with your application received on January 17, 2020, we are forwarding herewith:
1. Monitoring Well Construction Permit No. WM0401214 for the construction of six (6)
temporary monitoring wells at 134 East Mountain Street in Kemersville in Forsyth
County.
Henceforth, correspondence and data relating to this well shall be designated as specified in the
subject heading above. This Permit will be effective from the date of issuance and shall be
subject to the conditions and limitations as specified therein. If you have any questions regarding
this permit, please contact me or Jim Gonsiewski at [phone].
Sincerely,
Co uslan.d by:
TL O 5.aw
onmdera Lt
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
cc: Bill Metzinger — Town of Kemersville (Electronic Copy)
Jeffrey 011ison — Hart & Hickman, PC (Electronic Copy)
4�01INDEQ�
w,.mme.iaumm..wowi� /�
I
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 West Hanes Mill Road, Suite 3001 Winston-Salem. North Carolina 27105
336.776.9800

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES — WATER QUALITY REGIONAL OPERATIONS
SECTION
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and
other applicable Laws, Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
NCDEQ — DSCA Program
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of six (6)
temporary monitoring wells owned by the NCDEQ DSCA Program. The wells will be located at
134 East Mountain Street in Kemersville, North Carolina, in Forsyth County. This Permit is
issued in accordance with the application received on January 17, 2020, in conformity with
specifications and supporting data, all of which are filed with the Department of Environmental
Quality and are considered integral parts of this Permit.
This Permit is for well construction only, and does not waive any provision or requirement of
any other applicable law or regulation. Construction of any well under this Permit shall be in
strict compliance with the North Carolina Well Construction Regulations and Standards (15A
NCAC 02C .0100), and other State and Local Laws and regulations pertaining to well
construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to
an adjudicatory hearing upon written request within 30 days of receipt of this Permit. The
request must be in the form of a written petition conforming to Chapter 150B of the North
Carolina General Statutes and filed with the Office of Administrative Hearings, 6714 Mail
Service Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit
is final and binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to
other specified conditions, limitations, or exceptions as follows:

1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these
wells are being installed as part of an investigation for contamination from an
underground storage tank or dry cleaner incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement
issued by another agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as
part of the Permit application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A
NCAC 02C .0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of
Water Resources' Information Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with
15A NCAC 02C .0113 and a well abandonment record (GW-30) shall be submitted to the
Division of Water Resources' Information Processing Unit within 30 days of the well
abandonment.
The County Health Department may require a county monitoring well construction
permit. Please contact the health department for their requirements.
Permit issued the 22nd day of January, 2020
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
E
sTa�.acev:y l5.1W
495225MFA...
Lon T. Snider, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
By Authority of the Environmental Management Commission
Permit No. # WM0401214

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
2.
3.
4.
5.
6.
7.
8.
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and reanlatlnne „..r.. ..m *H.—+.
application is hereby made fi
Date: 1/17/20
County: _Forsyth
r a permit to construct monitoring or recovery wells.
FOR OFFICE USE ONLY
PERMIT NO. N M o ()I al � ISSUED DATE I a
What type of well are you applying for? (monitoring or recovery): Temoorary Monitoring Wells
Applicant: Michael and Kristine Tozer (petitioner for DSCA Site #DC340022) Telephone: ScottStuoak [phone]
Applicant's Mailing Address: _ DSCA Program 1646 Mail Service Center Raleigh NC 27699 1646
Applicant's Email Address (if available): scoff stupakOncdenr gov
Contact Person (if different than Applicant): Jeffrey 011ison 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): iollison(cDharthickman com
Property Owner (if different than Applicant): Town of Kemersville Telephone: [phone]
Property Owner's Mailing Address: Attention Bill Metzinger, PO Box 728 Kernersville NC 27285
Property Owner's Email Address (if available): BMetzingerGDToKNC com
Property Physical Address (Including PIN Number)_ 134 E Mountain Street (PIN# 6888332626)
City Kernersville County_ Forsyth Zip Code 27284
Reason for Well(s): Environmental Assessment for DSCA Prooiram
(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 Cleaner
(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 ID #DC340022
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?
Existing Monitoring or Recovery Well Construction Permit No(s).: Not available
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): _ Approximately 490 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Innovative Environmental Technologies Inc Certification No.: 2725-A
Well Contractor Address: 4185 Barrier Road Concord NC 28025
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 5. How will the walks) be secured? Temporary monitoring
material' 6 well —will be abandoned following samolina
3. Number of wells to be constructed in bedrock: _0 6. Estimated beginning construction date: January 2020
4. Total Number of wells to be constructed: 6 7. Estimated construction completion dale: January 2020
(add answers from 2 and 3)
ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C .0105(t)(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 lest borings within 600 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 600 feel
of the proposed wag or well system.
The Applicant hereby agrees that the proposed walls) wig be constructed in accordance with approved specifications and conditions of
this Well Construction Permit as regulated under the Well Construction Standards (Tide 15A of the North Carolina Administrative Code,
Subchapter 2C) and accepts full responsibility for compliance with these rules
or
Jeffrey 011ison
Printed name of Applicant or 'Agent
Anent for Petitioner for DSCA Site DC340022
Tide of Applicant or'Agent
If signing as Agent, aflach authorization agreement slating
that you have the authority to act as the Agent.
If the property is owned by someone other than the applicant, the properly 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
wells) conform to the Well Construction Standards (Tide 1 SA of the North Carolina Administrative Code, Subchapter 2C).
See attached orooerty access agreement (Attachment 31 See lidimbed property access agreement (Attachment 31
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
Swannanos, NC 28778
Raleigh, NC 27609
Wilmington, NC 28405
Phone: [phone]
Phone: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Fax: [phone]
Fayetteville Regional Office
226 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-22MR Rev. 3-1-2016

Attachment 1

L3
CROSS SECTIONAL VIEW
L7
L2
L1 = 35 FT.
L2= 10 FT. DIAMETER OF
L3= 45 FT. BOREHOLE
4.25 in
Monitoring Well Diagram
Till TMW-5, TMW-6, TMW-7, TMW-8,
& TMW-9
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
WELL SCREEN
SCREEN MATERIAL
DIAMETER
LENGTH
SLOT SIZE
DEPTH TO BOTTOM OF
MONITORING WELL
schedule 40 PVC
1 inch
flush threaded
35 feet
schedule 40 PVC
1 inch
10 feet
0.010 inches
45 feet
Hart &, Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, North Carolina 27607
(FILE (PREP. BY By
IREV. BY GKO (DATE (PROJECT NO. I
1/17/2020 DSO-153 (DSCA ID# DC340022)

Attachment 2

Attachment 3

� �� •tA SrrVF O�•1pr
fF> d w
✓ V F
ROY COOPER .NORTH CAROLINA
Govemor EnvironmmralQuality
MICHAEL S. REGAN
Sermfury
MICHAEL SCOTT
Director
PROPERTY ACCESS CONSENT
For DSCA Use Only
This i1neument map tort be utotliyietl without the Program's npproral. DSCA ID Nm
if you have gtrestioxs on hot- to fill our this farm or abotil the activities DC340022
at ihis site, please call the DrwCYeanlug Solvent Cleanup Ac•i (DS('A)
Prf tgram s Cowraclor .lit' Iliic prnjecr JeJJi ev 011isar triih flciri e$ Nic•knuni, P.C. at
jollison/ harthickman.com of l91918a--d 2d1. Ifyou still have questions cfie cataciing alr.
011ison with H&H, please ce mlaci the DSCA Program Prgjeci Aburager, Ali. Scott Stupnk at
seott.stnnak r2ncdenr.¢(v or r919)?07' 83?9.
Please Print
Down of Kernersville
(Natne of Property Owner or Tenant in Residence)
1 +a E Mountain Street
(Street Number and Street'
Kernersville
(CityorTown 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 havine continued access to my property for the following
Purposes: .
(1) taking such soil. groundwater and/or air samples as may be necessary;
(2) taking other actions related to the investigation of surface or subsurt:ace conditions:
(3) taking response actions necessary to mitigate anv threat to human health or the environment.
Other conditions:
I I ) 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.
�E
North Camt,w Deparl"m of EmlrnnmentatQuaLty Ipbr4on or$V fe 6ramgtmenr
217 w'Httones Street I IW6Atan5an1ea Center I Ratelgh\onh Caretrm27699.1E 16
919.7078200

Page 2 of 2
DSCA Site ID No.
DC340022
(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.
(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".
Tenant
336- shy- rbzi
Property Owner or Tenant in Residence
15 WETr- 1 m (6 &-X
(Email Address for Propetyt
email)
Please return form to:
Jeffrey Oilison
Hart & Hickman, PC
3921 Sunset Ridge Road, suite 301
Raleigh, NC 27607
Or via email to: [e-mail]
to
(Date)

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
Mr. Scott Stupak
NCDEQ — DSCA Program
1646 Mail Service Center
Raleigh, North Carolina 27699
NORTH CAROLINA
Environmental Quality
January 22, 2020
SUBJECT: MONITORING WELL CONSTRUCTION
PERMIT NO. WM0401215
COUNTY: Forsyth
FILE NAME: Modern Cleaners — DSCA Site DC340022
Dear Mr. Stupak:
In accordance with your application received on January 17, 2020, we are forwarding herewith:
Monitoring Well Construction Permit No. WM0401215 for the construction of one (1)
temporary monitoring well at 230 East Mountain Street in Kernersville in Forsyth
County.
Henceforth, correspondence and data relating to this well shall be designated as specified in the
subject heading above. This Permit will be effective from the date of issuance and shall be
subject to the conditions and limitations as specified therein. If you have any questions regarding
this permit, please contact me or Jim Gonsiewski at [phone].
Sincerely,
E
�IgEn=114EA
ee by:
n6
2w..
Lon T. Snider
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
cc: Edwin Walker— Walker Brothers Properties, LLC (Electronic Copy)
Jeffrey 011ison — Hart & Hickman, PC (Electronic Copy)
North Carolina Department of Environmental Quality l Division of Water Resources
Winston-Salem Regional Office 1450 West Hanes Mill Road. Suite 3001 Winston-Salem. North Carolina 27105
onw A iu
336.776.9800

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES — WATER QUALITY REGIONAL OPERATIONS
SECTION
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and
other applicable Laws, Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
NCDEQ — DSCA Program
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of one (1)
temporary monitoring well owned by the NCDEQ DSCA Program. The well will be located at
230 East Mountain Street in Kernersville, North Carolina, in Forsyth County. This Permit is
issued in accordance with the application received on January 17, 2020, in conformity with
specifications and supporting data, all of which are filed with the Department of Environmental
Quality and are considered integral parts of this Permit.
This Permit is for well construction only, and does not waive any provision or requirement of
any other applicable law or regulation. Construction of any well under this Permit shall be in
strict compliance with the North Carolina Well Construction Regulations and Standards (15A
NCAC 02C .0100), and other State and Local Laws and regulations pertaining to well
construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to
an adjudicatory hearing upon written request within 30 days of receipt of this Permit. The
request must be in the form of a written petition conforming to Chapter 150B of the North
Carolina General Statutes and filed with the Office of Administrative Hearings, 6714 Mail
Service Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit
is final and binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to
other specified conditions, limitations, or exceptions as follows:

1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these
wells are being installed as part of an investigation for contamination from an
underground storage tank or dry cleaner incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement
issued by another agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as
part of the Permit application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A
NCAC 02C .0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of
Water Resources' Information Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with
15A NCAC 02C .0113 and a well abandonment record (GW-30) shall be submitted to the
Division of Water Resources' Information Processing Unit within 30 days of the well
abandonment.
7. The County Health Department may require a county monitoring well construction
permit. Please contact the health department for their requirements.
Permit issued the 22nd day of January, 2020
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
ooeuSig d by:
L T SMiler
1469/9EY25 EA..
Lon T. Snider, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
By Authority of the Environmental Management Commission
Permit No. # WM0401215

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 f
1. Date: 1/17/20
2. County:. Forsyth
)r a permit to construct monitoring or recovery wells.
FOR OFFICE USE ONLY
PERMIT NOWMLya1 a j_� ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Temporary Monitoring Wells
4. Applicant: Michael and Kristine Tozer (petitioner for DSCA Site #DC340022) Telephone: ScottStupak [phone]
Applicant's Mailing Address: DSCA Program, 1646 Mail Service Center, Raleigh NC 27699-1646
Applicant's Email Address (if available): scott.stuoak()ncdenr goy
5. Contact Person (if different than Applicant): Jeffrey 011ison. 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): iollison(rDharthickman com
6. Property Owner (if different than Applicant): Walker Brothers Progenies LLC Telephone: [phone]
Property Owner's Mailing Address: Attention Edwin C. Walker, 202 S Cherry Street Kernersville NC 27284
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 230 E Mountain Street (PIN# 6886337658)
City Kernersville CountyForsyth Zip Code 27284
8. Reason for Well(s): Environmental Assessment for DSCA Prooram
(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 Cleaner
(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 ID #DC340022
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).: Not available
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 690 feet
14.. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Innovative Environmental Technologies Inc Certification No.: 2725-A
Well Contractor Address: 4185 Barrier Road, Concord, NC 28025
PROPOSED WELL CONSTRUCTION INFORMATION
1. As required by 15A NCAC 02C .0105(%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 wells) be secured? Temporary monitoring
material: 1 well — will be abandoned following samolirw
3. Number of wells to be constructed in bedrock: _ 0 6. Estimated beginning construction date: January 2020
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: January 2020
(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 takes within 500 feet of the proposed well or well system.
b. All existing wells, identified by type of use, within 5110 feet of the proposed well or well system.
C. The pmposed wall or well system.
d. Any lest 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.143-215.108(5), landfills, or other waste disposal areas) within 500 feel
of the proposed weti 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 DC340022 Agent for Petitioner for DSCA Site OC34W22
Signature of Applicant or *Agent Title of Applicant or *Agent
Jeffrev 011ison ' If signing as Agent, attach authorization agreement slating
Printed name of Applicant or *Agent that you have the ardhonly 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 access aareement (Attachment ) See attached properly access agreement tAoaehment 31
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 27509
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: (910) 48"707
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-22MR Rev. 3-1-2016

Attachment 1

L3
L1 = :ib h I
1.2 = 10 FT
L3 = 45 FT
Monitoring
TMW-1
CROSS SECTIONAL VIEW
DIAMETER OF
BOREHOLE
4.25 in
Well Diagram
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
iNELL SCREEN
SCREEN MATERIAL
31AMETER
_ENGTH
SLOT SIZE
JEPTH TO BOTTOM OF
MONITORING WELL
schedule 40 PVC
1 inch
flush threaded
35 feet
schedule 40 PVC
i inch
10 feet.
0.010 inches
45 feet
Hart & Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, North Carolina 27607
JAO I GKO 1 1/17/20201 DSO-153

Attachment 2

Attachment 3

r'
ROY COOPER NORTH CAROLINA
Qoreroar Ene7ronmenrol Quality
MICHAEL S. REGAN
Se wary
MICHAELSCOTT
0lreaor
PROPERTY ACCESS CONSENT
For DSCA Use Only
This document may not he nrodifred without the Program's approval. DSCA ID No.
If you have questions on how to Jill out this form or about the activities DC340022
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program's contractor for this project Jeffrey 011)son with Hart & Hickman. P.C. at
jollison a harthickman.com or [phone]. Ifyou still have questions Oer contacting Mr.
olltson with H&H, please contact the DSCA Program Project Manager, Mr. Scott Sntpak at
scottstupak ancdenr.aov or (919)7074359.
Please Print
Walker Brothers Properties LLC
230 E Mountain Street
Kernetsville Forsyth 27284
(City or Town in Which Property Is Located) I (County in Which Property is Located) I (Zip Code)
1 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 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 Properly.
Nonh CuoUm Departmmt of EmirmunouAQuaty I envWonof Waste WnWtnem
217Weselon Sown 116e6MOSerNeeComer i ItaMgh.North CuoUns2ft" 1646
919107n200

Page 2 of 2
DSCA Site ID No.
DC340022
(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.
(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 them are tenants) occupying the property and all tenants agree to the conditions
of this "Property Access Consent".
c. P c. io-io-
(Signature of Property O er or Tenant in Residence) (Date)
�pA`�
(Telephone Number for Property Owner o enant in Residence or scheduling work/notification)
Cole
(Email AddrAss1for Property Owner o enan to estdence 'f you prefer to be contacted via
email)
Please return form to:
Jeffrey 0111son
Hart & Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, NC 27607
Or via email to: )[e-mail]
-as 33 -t a "wzj
-Zl&tJ1644m

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
Mr. Scott Stupak
NCDEQ — DSCA Program
1646 Mail Service Center
Raleigh, North Carolina 27699
NORTH CAROLINA
Environmental Quality
January 22, 2020
SUBJECT: MONITORING WELL CONSTRUCTION
PERMIT NO. WM0401216
COUNTY: Forsyth
FILE NAME: Modern Cleaners— DSCA Site DC340022
Dear Mr. Stupak:
In accordance with your application received on January 17, 2020, we are forwarding herewith:
1. Monitoring Well Construction Permit No. WM0401216 for the construction of two (2)
temporary monitoring wells on the East Mountain Street Right -of -Way in Kemersville in
Forsyth County.
Henceforth, correspondence and data relating to this well shall be designated as specified in the
subject heading above. This Permit will be effective from the date of issuance and shall be
subject to the conditions and limitations as specified therein. If you have any questions regarding
this permit, please contact me or Jim Gonsiewski at [phone].
Sincerely,
CDaauSigmd by:
"� 5m2w
t4s 490250a4EA...
Lon T. Snider
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
cc: Jeremy Guy - NCDOT (Electronic Copy)
Jeffrey 011ison — Hart & Hickman, PC (Electronic Copy)
DEQ� North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1450 West Hanes Mill Road, Suite 3001 Winston-Salem, North Carolina 27105
N[)HMC O W4

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES - WATER QUALITY REGIONAL OPERATIONS
SECTION
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and
other applicable Laws, Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
NCDEQ - DSCA Program
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of two (2)
temporary monitoring wells owned by the NCDEQ DSCA Program. The wells will be located
on the East Mountain Street Right -of -Way in Kernersville, North Carolina, in Forsyth County.
This Permit is issued in accordance with the application received on January 17, 2020, in
conformity with specifications and supporting data, all of which are filed with the Department of
Environmental Quality and are considered integral parts of this Permit.
This Permit is for well construction only, and does not waive any provision or requirement of
any other applicable law or regulation. Construction of any well under this Permit shall be in
strict compliance with the North Carolina Well Construction Regulations and Standards (15A
NCAC 02C .0100), and other State and Local Laws and regulations pertaining to well
construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to
an adjudicatory hearing upon written request within 30 days of receipt of this Permit. The
request must be in the form of a written petition conforming to Chapter 150B of the North
Carolina General Statutes and filed with the Office of Administrative Hearings, 6714 Mail
Service Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit
is final and binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to
other specified conditions, limitations, or exceptions as follows:

1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these
wells are being installed as part of an investigation for contamination from an
underground storage tank or dry cleaner incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement
issued by another agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as
part of the Permit application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A
NCAC 02C .0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of
Water Resources' Information Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with
15A NCAC 02C .0113 and a well abandonment record (GW-30) shall be submitted to the
Division of Water Resources' Information Processing Unit within 30 days of the well
abandonment.
7. The County Health Department may require a county monitoring well construction
permit. Please contact the health department for their requirements.
Permit issued the 22nd day of January, 2020
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
CDouuffl�d by:
L Ow -r 6.jw
10.5B4B�-
Lon T. Snider, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
By Authority of the Environmental Management Commission
Permit No. # WM0401216

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
r
o 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: Forsyth
FOR OFFICE USE ONLY
PERMIT Na M i) qD (D, YJ ISSUED DATE ! ��
3. What type of well are you applying for? (monitoring or recovery): Temporary Monitoring Wells
4. Applicant: Michael and Kristine Tozer (petitioner for DSCA Site #DC340022) Telephone: Scott Stupak [phone]
Applicant's Mailing Address: DSCA Program, 1646 Mail Service Center, Raleigh NC 27699-1646
Applicant's Email Address (if available): scott.stupakidncdenr.00v
5. Contact Person (if different than Applicant): Jeffrey 011ison. Hart & Hickman. PC Telephone: [phone]
Contact Person's Mailing Address: 3921 Sunset Ridae Road Suite 301, Raleigh NC 27607
Contact Person's Email Address (if available): iollison(a)harthickman.com
6. Property Owner (if different than Applicant): NC Department of Transpiration Telephone: [phone]
Property Owner's Mailing Address: Attention Jeremy Guy, 375 Silas Creek Parkway Winston- Salem NC
27127 Property Owner's Email Address (if available): imguvCcancdot.gov
7. Property Physical Address (Including PIN Number) Right -of -Way for E. Mountain Street
City Kernersville County Forsyth Zip Code 27284
8. Reason for Well(s): _ Environmental Assessment for 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: Dry Cleaner
(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 ID #DC340022
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).: Not available
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 260 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Innovative Environmental Technologies Inc Certification No.: 2725-A
Well Contractor Address: 4185 Barrier Road, Concord, NC 28025
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? Temograry monitoring
material: 2 well —will be abandoned following sampling
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: January 2020
4. Total Number of wells to be constructed: 2 7. Estimated construction completion date: January 2020
(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 800 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 600 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. 143-21 5.10B(5), landfills, or other waste disposal areas) within 500 feet
of the proposed wall or well system.
SIGNATURES
The Applicant hereby agrees that the proposed wall(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 or the North Carolina Administrative Code,
Subchapter 2C) and accepts full responsibility for compliance with these rules
AOon behalf of Petitioner for DSCA Site DC340022 Agent for Petitioner for OSCA Site DC340022
Signature of Appllcont or •Agent This of Applicant or *Agent
Jeffrey 011ison • 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 access agreement (Attachment 3) _See attached property access aareemenl (Attachment 31
Signature of Property Owner (it 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 Once
Raleigh Regional Office
Wilmington Regional Office
2090 U.S. Highway 70
3800 Barrett Drive
127 Cardinal Drive Extension
Swannenoa, NC 28778
Raleigh, NC 27609
Wilmington, NC 28405
Phone: [phone]D
Phone: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Fax: [phone]
Fayatinville 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-22MR Rev. 3-1-2016

Attachment 1

L3
L2
L1 = 35 FT
L2= 10 FT
1.3 = 45 FT
Monitoring Well Di
TMW-15 & TMW-16
JAO
CROSS SECTIONAL VIEW
DIAMETER OF
BOREHOLE
4.25 in
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
WELLSCREEN
SCREEN MATERIAL
DIAMETER
LENGTH
SLOT SIZE
DEPTH TO BOTTOM OF
MONITORING WELL
schedule 40 PVC
1 inch
flush threaded
35 feet
schedule 40 PVC
1 inch
10 feet
0.010 inches
45 feel
Hart & Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, North Carolina 27607
DSO-153 (DSCA ID#

Attachment 2

Attachment 3

MICHAEL F. EASLEY
GOVERNOR
December 28, 2006
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
UILRALI S-VURUJUNAINVINUT4X1 LYNDOTIPPETr
1555MALssavKEcauER,RALmmNC27699-1555 SHCRErARv
Mr. John Powers
Head, Special Remediation Branch
NCDENR - Division of Waste Management
401 Oberlin Road, Suite 150
1646 Mail Service Center
Raleigh, North Carolina 27699-1646
Min L�N L 2007
51 h'i IND SECTION
Subject: NCDOT Encroachment Agreements for Groundwater Monitoring Wells for the
NCDENR Division of Waste Management Dry Cleaning Solvent Cleanup Program
Dear Mr. Powers:
NCDOT has prepared the attached Guidelines for Processing Groundwater Monitoring Well
Encroachments and Special Provisions for accommodating ground water monitoring wells
associated with the Dry Cleaning Solvent Cleanup Act (DSCA). NCDOT reserves the right to
further limit, restrict or suspend operations associated with this program if safety or traffic
conditions warrant such action. Please distribute this information to the companies contracted by
NCDENR for their use in preparing encroachment submittals. If companies not included in the
list provided by NCDENR of June 23, 2006 are contracted for this program, please notify David
West in writing at the address above.
All encroachments for groundwater monitoring wells should be submitted to the appropriate
NCDOT District Engineer's Office on the enclosed FORM R/W 16.IA, RIGHT OF WAY
ENCROACHMENT AGREEMENT FOR NON -UTILrI Y ENCROACHMENTS ON PRIMARY
AND SECONDARY HIGHWAYS. The applicant should submit one original and three copies
of the completed agreement along with four sets of the plans or drawings which include the
information described in the Guidelines and in the Instructions section of the FORM R/W I6.IA.
Also enclosed is FORM R/W 16B for Continuing Indemnity Bond. NCDOT is requiring a
Continuing Indemnity Bond in the amount of $100,000.00 from each of the companies installing
groundwater monitoring wells within the NCDOT right of way. The Form R/W 16D should be
completed by the surety company and executed by authorized personnel of the applicant and
returned with Power of Attorney from the surety company to the attention of David West at the
address above. NCDOT reserves the right to increase the amount of bond required if, in the
opinion of NCDOT, conditions warrant such action. No encroachment agreements shall be
approved until the applijant's Continuing Indemnity Bond is posted with NCDOT.
MAILING ADDR688:
NC DEPARTMENr OF TRANSPORTATION
UTILITIES COORDINATION UNR
16M MAIL SERVICE CENTER
RALEIGH NC 27690.1655
TELEPHONE: [phone]
Fez; 919-733-4440
WROSITE: WWW.DON.DOT.STATE.NC.US
LOCATION:
TRANSPORTATION BUILDING
1 Soum WILMNGTON STREET
RALEIGH NO

NCDENR (DSCA)
Page 2
Additional Encroachment Forms and Bond Forms are available on-line at wwwaicdot.ori? under
Business Resources, Electronic Forms or by contacting David West at [phone] x 363.
Do not hesitate to contact us with any questions.
Sincerely,
..,---Rub amory
State Utility Agent
7RM/DW
Enclosures
cc; Steve Varnedoe, PE, NCDOT Chief Engineer
Tommy Cozart, PE, NCDOT Project Services

STATE OF OF NORTH CAROLINA
DEPARTMENT OP TRANSPORTATION
MICHAELF. EASLEY . UTILITIESC00RDINATI0NUNIT LYNDOTippt;TT
GOVERNOR 1555MAILSERVLTCINInt,RALMHNC27699-1555
SerRSTnav
Guidelines for Processing Goundwater Monitoring Well Encroachments requested under
the North Carolina Da Cleaning Solvent Cleanup Act.
Encroachment request should.be submitted to the NCDOT District Office on FORM R/W 16.IA
for Non -Utility Encroachments.
Encroachment request for monitoring wells under the North Carolina Dry Cleaning Solvent
Cleanup Act (DSCA) should only be accepted from firms contracted with NCDENR DSCA
Program. (List of contracted firms attached)
All encroachment submittals under the NCDENR DSCA Program shall include a letter to the
NCDOT District Engineer from the NCDENR DSCA Program Project Manager identifying the
Contracting firm, the DSCA Site name, DSCA-Site ID number and Site address. (Sample letter
attached)
Any encroachment submittal for a monitoring well within the NCDOT right of way but outside
of the property limits of the subject DCSA Site must include the written permission of the
underlying property owner of the proposed well site.
A Continuing Indemnity Bond of One Hundred Thousand dollars will be required of all
contracted firms prior to working within the NCDOT right of way.
The encroachment submittals should include the following details: location map, plan sheet with
the proposed well (a) clearly marked and referenced by dimensions, existing roadway and right
of way widths, existing edge of pavement, curb and gutter and diteblines, existing utilities which
may conflict with the proposed installation, distance to the nearest intersection, name slid
telephone number of a contact person representing the contracting firm and all other applicable
information required in the instruction section of the encroachment agreement form.
In most cases, encroachment agreements for groundwater monitoring wells submitted under the
NCDENR/ DSCA Program are to be processed at the Division Level. When the proposed wells
are within the limits of an Active Transportation Improvement Project, Controlled Access Right
of Way, or require the technical assistance of the Project Services Unit, they are to be forwarded
to Raleigh for processing.
Monitoring wells shall not be allowed in pavement, medians or traffic islands.
MAILING ADDRESS:
NO DEPARTMENT OF TRANSPORTATION
UTRITIES COORDINATION UNIT
1553 MAIL SERVICE CENTER
RALEIGH NC 27699-1555
TELEPHONE: [phone]
Fax: 919.733A440
WESSITE: WWW.DOHGOTSTATE.NC.US
LOCATION:
TRANSPORTATION SURDING
1 SOUTH WILMINGTON STREET
RALEIGH NO

Guidelines
Page 2
Requests for soil sampling or test drilling alone, without the installation of an actual monitoring
well or other installation within the NCDOT right of way do not require an encroachment
agreement but must be authorized in writing by the District Engineer.
Rev. 12/04/2006

SPECIAL PROVISIONS
Special Provisions for groundwater monitoring wells being Installed under the
North Carolina Department of Environment and Natural Resources (NCDENR) Dry
Cleaning Solvent Cleanup Act (DSCA) Program should include as applicable, but not be
limited to the following Special Provisions.
1. The encroaching party shall notify the NCDOT District Engineer's Office at telephone
(000 ) 000-000 prior to beginning construction and after construction is complete.
2. An executed copy of this encroachment agreement shall be present at the. construction
site at all times during construction. If safety or traffic conditions warrant such an action,
NCDOT reserves the right to further limit, restrict or suspend operations within the right of way.
3. A letter provided by the NCDENR/DSCA Program Project Manager, identifying the encroaching
party as an authorized contractor for the specific site shall be present at the installation site at
all times during installation and subsequent monitoring.
4. A Continuing Indemnity Bond shall be on file with the NCDOT Utility Coordination Unit prior to
beginning any installation within the NCDOT right of way.
5. NCDOT does not guarantee the right of way on this road, nor will it be responsible for any
claim for damages brought about by any property owner by reason of this installation.
6. The encroaching party is required to contact the appropriate Utility Companies involved and make
satisfactory arrangements to adjust the utilities in conflict with the proposed work prior to beginning
construction. No cost to adjust, relocate or repair utilities shall be borne by NCDOT.
7. Excavation, including boring or drilling, within 500 feet of a signalized intersection will require
notification by the.party of the second part to the Division Traffic Engineer at telephone number
[phone]. All traffic signal or detection cables must be located prior to excavation.
8. The encroaching party shall comply with all applicable Federal, State and local environmental
regulations and shall obtain all necessary Federal, State and local environmental permits, including
but not limited to, those related to sediment control, stormwater, wetland, streams, endangered
species and historical sites.
9. The contractor shall not begin the construction until after the traffic control and erosion control
devices have been installed to the satisfaction of the District Engineer.
10. Trenching, bore pits and/or other excavations shall not be left open or unsafe overnight. The
Contractor shall comply with all OSHA requirements and provide a competent person on site to
supervise excavation at all times.
11. All fill areas/backfill shall be compacted to 95% density in accordance with AASHTO T99 as
modified by the NCDOT.
12. Vegetative cover shall be established on all disturbed areas in accordance with the recommendations
of the Division Roadside Environmental Engineer.

Special Provisions (Cont.)
Page 2
13. Proper temporary and permanent measures shall be used to control erosion and. sedimentation in
accordance with all local, State and Federal regulations.
14. No wells shall be installed that may interfere with the proper drainage or maintenance of any
drainage structure. Any drainage structure disturbed or damaged shall be restored to its original
condition as directed by the District Engineer.
15. Any disturbed guardrail shall be reset according to the applicable standard or as directed by the
District Engineer.
16. All driveways altered during construction shall be returned to a state comparable with the condition
of the driveways prior to construction.
17. Right of Way monuments and property corners disturbed during construction shall be referenced by
a registered Land Surveyor and reset after construction,
18. Proper traffic control devices, signs, etc. shall be installed to ensure public safety in accordance with
the latest edition of the Manual on Uniform Traffic Control Devices and any supplements thereto and
NCDOT Roadway Standard Drawings.
19. All lanes of traffic are:to be open during the hours of 6:00 A.M. to 9:00 A.M. and from 4:00 P.M. to
6:00 P.M. Traffic will be maintained at all times.
20. Ingress and egress shall be maintained to all businesses and dwellings affected by the project.
Special attention shall be paid to police and fire stations, fire hydrants and hospitals.
21. Any work requiring equipment or personnel within 5' of the edge of any travel lane of an undivided
facility and within 10' of the edge of any travel lane of a divided facility shall.require a lane closure
with appropriate tapers.
22. No parking or material storage shall be allowed along NCDOT maintained roadways.
23. During non -working hours, equipment'shall be parked as close to the right of way line as possible
and be properly barricaded in order not to have any equipment obstruction within the Clear Recovery
Area.
24. All roadway signs that are removed due to construction shall be reinstalled as soon as possible
25. Excavation material or spoils from drilling shall not be placed on the pavement. Drainage structures
shall not be blocked with excavation materials.
26. Only the well (s) shown on the attached plan is approved by this agreement. Additional wells at the
site will require a revision to this agreement or a separate encroachment agreement.
27. Any and all costs for adjustments to the proposed wells due to NCDOT construction shall be the
responsibility of the encroaching party.

Special Provisions (Cont.)
Page 3
28. NCDOT or its contractors shall not be held responsible for damage to monitoring wells due to
roadway construction or maintenance activities.
29. Ground water monitoring wells shall not be allowed in pavement, medians, or traffic islands.
30. Well caps shall be flush mounted with the ground surface with the frames and covers of a NCDOT
approved design for HS 20 loading when installed within clear recovery area or within routine
mowing boundaries.
31. Wells proposed outside of the clear recovery area and outside of the boundaries of routine mowing
.shall be flush mounted but are not required to be designed for HS 20 loading.
32. Any conversion of a monitoring well to an extraction or remediation system will require a separate
encroachment agreement requiring review by NCDOT's Project Services Unit.
33. Spoils from the well installation shall be disposed of outside NCDOT right of way at an approved
site. Any contaminated soils encountered in construction as spoil from the well installation shall be
removed from the NCDOT right of way immediately upon discovery and properly disposed of in
accordance with the appropriate governing regulations.
34. A copy of all test results from the well (s) within the NCDOT right of way shall be made available
to the NCDOT District Engineer's Office.
35. After the monitoring well (a) has served its intended purpose, the well (s) shall be filled in a manner
approved by NCDENR. and NCDOT. Any flush mounted or above ground obstructions shall be
removed from the right of way and the site shall be returned to a condition satisfactory to the District
Engineer.
Rev. 12/04/2006

From: Guy. Jeremy M
To: Jeffrey 011ison
Subject: RE: [External] DOT Right -of -Way Access Kernerwille
Date: Tuesday, December 17, 2019 7:39:35 AM
Attachments: imaae005.ona
J effe ry,
I am ok with this, however I ask that the work take place between Sam —4 pm Monday through
Friday and not during the week of Christmas.
Thanks,
Jeremy M. Guy, PE
District Engineer
Division 9
District 2 Office
336 747 7900 office
0mauy(a)ncdot aov
375 Silas Creek Parkway
Winston-Salem, NC 27127
yl',I
v
p"
t
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Jeffrey 011ison <[e-mail]>
Sent: Thursday, December 12, 2019 10:12 AM
To: Guy, Jeremy M <[e-mail]>
Subject: [External] DOT Right -of -Way Access Kernersville
Hello Mr. Guy
I am contacting you on behalf of the NC Department of Environmental Quality (DEQ) in regards to
Right -of- Way Access in the area of 101 E Mountain Street and 237 E Mountain Street Kernersville,
Forsyth County. Hart & Hickman has been contracted by the NCDEQ Dry-cleaning Solvent Cleanup
Act Program to complete two small 2-inch in diameter temporary boring to collect groundwater
samples along the sidewalk. The work will take no more than 2 days, one to install the boring and
temporary sample points, and one day to collect the sample and properly abandon the borings.

During abandonment the borings will be filled with bentonite and patched to match surrounding
surface conditions at the completion of our activities.
I've attached maps with the two locations and the letter between NCDOT and NCDEQ regarding
right-of-way encroachment. Please see page 4 of the attached Access agreement with DOT and the
DSCA program- in which it states we only need written authorization from the District Engineer to
proceed with this type of work. Authorization from you in the form of an email response is only
needed for us to proceed with our activities.
Please feel free to contact me with any questions.
Best Regards
Jeffrey Cillison, Assistant Project Environmental Scientist
Hart & Hickman, PC
3921 Sunset Ridge Rd., Ste. 301 • Raleigh, NC 27607
Direct: 919-723-2513 • Mobile: [phone]
t..rmun,r -r •r
f ',T'° i n
We've launched a new websitel Follow the link above to see what's changed.
APlease consider the environment before printing this e-mail
Email correspondence to and from this sender is subject to the N.C. Public Records Law and may be disclosed to third parties.

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
Mr. Scott Stupak
NCDEQ — DSCA Program
1646 Mail Service Center
Raleigh, North Carolina 27699
NORTH CAROLINA
Environmental Quality
January 22, 2020
SUBJECT: MONITORING WELL CONSTRUCTION
PERMIT NO. WM0401217
COUNTY: Forsyth
FILE NAME: Modern Cleaners — DSCA Site DC340022
Dear Mr. Stupak:
In accordance with your application received on January 17, 2020, we are forwarding herewith:
Monitoring Well Construction Permit No. WM0401217 for the construction of five (5)
temporary monitoring wells on the Church Lane, Short Street, and Harmon Lane Rights -
of -Way in Kemersville in Forsyth County.
Henceforth, correspondence and data relating to this well shall be designated as specified in the
subject heading above. This Permit will be effective from the date of issuance and shall be
subject to the conditions and limitations as specified therein. If you have any questions regarding
this permit, please contact me or Jim Gonsiewski at [phone].
Sincerely,
CLoti T SMXea-
146a49maeR4Ek..
Lon T. Snider
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
cc: Bill Metzinger — Town of Kernersville (Electronic Copy)
Jeffrey 011ison — Hart & Hickman, PC (Electronic Copy)
D_E Q North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 West Hanes Mill Road, Suite 3001 Winston-Salem. North Carolina 27105
uo Hcnxaiiun
336.776.9800

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES — WATER QUALITY REGIONAL OPERATIONS
SECTION
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and
other applicable Laws, Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
NCDEQ — DSCA Program
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of five (5)
temporary monitoring wells owned by the NCDEQ DSCA Program. The wells will be located
on the Church Lane, Short Street, and Harmon Lane Rights -of -Way in Kernersville, North
Carolina, in Forsyth County. This Permit is issued in accordance with the application received
on January 17, 2020, in conformity with specifications and supporting data, all of which are filed
with the Department of Environmental Quality and are considered integral parts of this Permit.
This Permit is for well construction only, and does not waive any provision or requirement of
any other applicable law or regulation. Construction of any well under this Permit shall be in
strict compliance with the North Carolina Well Construction Regulations and Standards (15A
NCAC 02C .0100), and other State and Local Laws and regulations pertaining to well
construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to
an adjudicatory hearing upon written request within 30 days of receipt of this Permit. The
request must be in the form of a written petition conforming to Chapter 150B of the North
Carolina General Statutes and filed with the Office of Administrative Hearings, 6714 Mail
Service Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit
is final and binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to
other specified conditions, limitations, or exceptions as follows:

1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these
wells are being installed as part of an investigation for contamination from an
underground storage tank or dry cleaner incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement
issued by another agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as
part of the Permit application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A
NCAC 02C .0108(o).
5. Well construction records (GW-I) for each well shall be submitted to the Division of
Water Resources' Information Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with
15A NCAC 02C .0113 and a well abandonment record (GW-30) shall be submitted to the
Division of Water Resources' Information Processing Unit within 30 days of the well
abandonment.
7. The County Health Department may require a county monitoring well construction
permit. Please contact the health department for their requirements.
Permit issued the 22nd day of January, 2020
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
EDoeusgnaU by:
ow i5.2w
14584OM5C94EA...
Lon T. Snider, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
By Authority of the Environmental Management Commission
Permit No. # WM0401217

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 f
1. Date:
2. County:
x a permit to construct monitoring or recovery wells.
FOR OFFICE USE ONLY
PERMIT NOVL7 ® LLA' ,17SSUED DATE I a a �
3. What type of well are you applying for? (monitoring or recovery): Temporary Monitoring Wells
4. Applicant: Michael and Kristine Tozer (petitioner for DSCA Site #DC340022) Telephone: Scott Stupak [phone]
Applicant's Mailing Address: _ DSCA Program 1646 Mail Service Center Raleigh, NC 27699-1646
Applicant's Email Address (if available): scott.stupak(dncdenr oov
5. Contact Person (if different than Applicant): Jeffrey 011ison. 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): iollison gnharthickman com
6. Property Owner (if different than Applicant): Town of Kernersville Telephone: [phone]
Property Owner's Mailing Address: Attention Bill Metzinaer, PO Box 728 Kernersville NC 27285
Property Owner's Email Address (if available): BMetzingen;:DToKNC.com
7. Property Physical Address (Including PIN Number) Right -of -Way for Church Lane Short Street and Harmon Lane
City Kernersville County Forsyth Zip Code 27284
8. Reason for Well(s): Environmental Assessment for 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: Dry Cleaner
(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 ID #DC340022
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).: Not available
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 260 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Innovative Environmental Technologies Inc Certification No.: 2725-A
Well Contractor Address: 4185 Barrier Road, Concord, NC 28025
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? Temporary monitoring
material: 5 well will be abandoned following semolina
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction dale: January 2020
4. Total Number of wells to be constructed: 5 7. Estimated construction completion date: January 2020
(add answers from 2 and 3)
ADDITIONAL INFORMATION'
1. As required by 15A NCAC 02C .0105(fx5), 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 5W feet of the proposed well or well system.
c. The proposed well or well system.
d. Any test borings within 500 feel 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. 143-21 5.10B(5), landfills, or other waste disposal areas) within SW 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 condfllons of
this Wag Construction Permit as regulated under the Well Construction Standards (TiUe 15A of the North Carolina Administrative Code,
Subchapter 2C) and accepts full responsibility for compliance with these rules
r
on behaff of Petitioner for DSCA Site OC340022 Agent for Petitioner for DSCA Site DC340022
Signature of Applicant or *Agent Title of Applicant or *Agent
Jeffrey 011ison • 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
wall(s) conform to the Well Construction Standards (Title 1SA of the North Carolina Administrative Code, Subchapter 2C).
See attached orooerty 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: (828) 296-MO
Phone: [phone]W
Phone: [phone]
Fax: [phone]
Fax: [phone]
Fax: [phone]W4
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
843 Washington Square Mall
Washington, NC 27889
Phone: [phone]Ml
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes MITI Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
AR Rev. 3-1-2p16

Attachment 1

L3
CROSS SECTIONAL VIEW
WELL CASING
MATERIAL schedule 40 PVC
DIAMETER 1 inch
JOINT TYPE flush threaded
LENGTH 35 feet
L1
WELLSCREEN
SCREEN MATERIAL schedule 40 PVC
L2 DIAMETER 1 inch
LENGTH 10 feet
SLOT SIZE 0.010 inches
11 = 35 FT
L2= 10 FT
L3 = 45 FT
DIAMETER OF
BOREHOLE
4.25 in
TMW-10, TMW-11, TMW-12, TMW-13,
& TMW-14
GKO
DEPTH TO BOTTOM OF
MONITORING WELL
45 feet
Hart & Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, North Carolina 27607
ID#

Attachment 2

Attachment 3

•I. 1
yr ��
J
�In:mna:�a"`a
ROY COOPER
NORTH CAROLINA
Covrrnor
EnvlronmentalQuality
MICHAEL S. REGAN
Secretary
MICHAELSCOTT
Director
PROPERTY ACCESS CONSENT
Yet DSCA t'se titlly
This tlocumeut nu(r not he moil led without lire Progratn's approval. US(':% II) Nn.
('von have gocctiortc on hmv to jilt out leis form or neonl the activities DC3.10022
at this site, lileace call the Der-Cleunhrg Solveni 0eanigl Aet ID.S'C At
h-ograin's contractor jar this projee1.le(/i•er 011ison with Hari it. HicLvtnat, P.('. ctl
iollisonfa luirlhiekman.com or (919)84--4241. it' you still have eprestiortc ujier conruethki,,, 31r.
011ison a ith t1fi11, please contact the DSC9 Pragrwn Projec! ,llunager, 11r. Scott S'lulluk at
scotCstunak(&ncdcnr.gov nr (919)170--8339.
Please Print
Town of Kernersville
(Name ol'Property Owner or Teaant in Residence)
liar Church Lane, Short Street. and Harmon Lane
and Street Nai
2723-I
(City or Tov%a in Which Propene Is Located) 1 (County in
I voluntarily consent to- the Division of Waste Management (Division) and its independent
contractors (contractor) entering and having continued access to my property for the following
purposes:
(1) taking such soil. gruund\Nater and!or air samples as may hrnecessary:
12) taking other actions related to the investigation 01'surlace or suhsurluce condition.;
(3) taking respunse actions necessary to mitigate any ducat ro human health or the environment.
Other conditions:
( I ) The Division and its contractors shall attempt to perform any activities at the Property in it
manner that minimizes interference ailh use of the Property.
ne#Ih C.11QWw Dtprl"m¢frnvirom entai Qua7ayI Dublaa of%vaete Alalvgamenl
TI7lv<d lont55deet t614MAJSruvlcr Center I Fa!ttgh North Cardona 27899 lot,
919.7078700

Page 2 of 2
DSCA Site ID No.
DC340022
(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.
(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 Ibis consent document, I acknowledge that l 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 "Properly Access Consent".
336-56V-/62-f
(Email Address for Properly
email)
Please return form to:
Jeffrey 011ison
Hart & Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, NC 27607
or Tenant
A.C.
or Tenant in Residence if you prefer to be contacted via
Or via email to: [e-mail]

V. R S v,4
TOWN OF KERN ERSVILLE
�e��� ENCROACHMENT PERMIT
f1C Sr
PERMIT NO: E-353
PERMIT DATE:
12/02/2019
ISSUED TO:
NCD W M
CONTACT NAME/NUMBER:
Jeffrey 011ison [phone]
LOCATION OF WORK:
Church Lane, Short Street, and Harmon Lane
ESTIMATED START DATE:
12/02/2019
ESTIMATED COMPLETION DATE: 03/31/2020
Special Instructions/Conditions:
1. Construction drawings must be submitted to Permit Issuer
Permit General Requirements:
1. Contractor must call Public Services prior to start of work. [phone]
2. Installation of utilities,in the Public Right -of -Way (ROW), shall be performed in such manner to insure the
safety of those who use said ROW and not to obstruct or interfere with the proper maintenance thereof.
3. If at any time the Town of Kernersville (Town) shall require the removal of or changes in the location or
time of work on said facilities that the Applicant binds himself, his successors and assigns, to promptly
remove or alter the said facilities and work, in order to conform to the said requirement, without any cost
to the Town.
4. That in the case of noncompliance with the terms of this agreement by the applicant, the Town reserves
the right to stop all work until the facility has been brought into compliance or removed from the ROW at
no cost to the Town..
5. That it is agreed by both parties that this agreement shall become void if actual construction of the work
proposed herein is not begun within six (6) months from the date of this permit, unless a written waiver is
secured from the Public Services Director.
6. In the event that the Applicant does not make the required repairs in the time stipulated, or does not
maintain the area prior to or after repairs in an acceptable manner, then the Town will make the
necessary repairs to bring ROW back into its previous state and invoice the Applicant for the actual costs
plus 50%.

Construction Requirements:
1. Applicant will provide during construction and any subsequent maintenance proper signs, signal lights,
Ragmen, and other warning devices for the protection of traffic. This shall be done in conformance with
the most current edition of the Manual for Uniform Traffic Control Devices. Applicant shall also abide by
all other Federal, State and local laws, regulations and guidelines which govern the type work being
performed.
2. The roadway structural integrity must be protected at all times. Therefore, the Applicant shall abide by
the following rules:
a. All pavements, if authorized, shall be removed by cutting on a straight line with vertical
edges. Repair to this cut shall be in accordance with the attached drawing (No. 328A).
b. All areas of construction shall be backrilled and compacted to achieve a density of at least
98%.
c. Drainage shall not be impeded at any time.
d. All driveways shall be bored when possible or replaced to a quality equal to that prior to
construction.
e. All roadway, driveway and sidewalk cuts, if authorized, shall be replaced within three (3)
calendar days after completion of work.
3. When any installation or maintenance operation disturbs the existing ground surface and or landscaping,
Applicant shall reestablish said area to its pre -construction state.
Applicant agrees that the electronic submittal of the original application for encroachment constitutes a signature
and acceptance of the above terms and the following:
Applicant hereby agrees to Indemnify and save harmless the Town from all damages and claims for that
may arise by reason of the installation and maintenance of this utility; and all damages to this utility and
claims for such damages that may occur while the Town or Its contractors are maintaining and installing
streets and/or utilities owned by the Town.
The Public Services Director, through his/her authorized agent, shall have the authority to inspect at any
time to determine compliance with this Permit
The Town does not guarantee the ROW, norwill it be responsible for any claim brought by any property
owner by reason of working in said ROW.
This permit has been Issued by: Town of Kernersviile
Public Services Director