WM0401260_Monitoring Well Permit Application_20201029

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SO�I�,�OVS
.rr
West Chester, PA 19380
TO: North Carolina Dept. of Envir. Quality
Division of Water Resources
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
[phone]
WE ARE SENDING YOU:
Letter of Transmittal
Date: October 19, 2020 Job No.: 11621.043.011
RE: Nokia -Lucent Cotton Mill Square Site,
Greensboro NC — Replacement Well Install
Permit Application
X❑ Attached ❑ Under Separate Cover
Drawings
Manuals
Report
Affidavit of Compliance Sample(s)
Schedule Change Order
Other (Work Scope)
X
Transmitta
Copies
Date
Description
I No.
Submittal
No.
1
1
10/19/20
Application for Permit to Construct Monitoring Well, Nokia -
Lucent Cotton Mill Square Site, Greensboro NC
WE ARE TRANSMITTING as checked below:
X
For Approval
As Requested
For Your Use
Returned After Loan to Us
Copies for Approval
Copies for Distribution

T •�
Letter of Transmittal
West Chester, PA 19380
X I For Review and Comment I I Other (explain)
REMARKS:
Corrected Prints
Signed: i Date 10/19/2020
Weston Solutions, Inc.
Please find attached an application for monitoring well installation in Greensboro NC associated with
Lucent -Nokia Cotton Mill Site. A separate well permit request has also been forwarded to the Guilford
County Dept. of Environmental Health.
Please do not hesitate to contact me with any questions you may have. Best Regards,
Best Regards -David Kane- [phone] [e-mail]
COPY TO:
Gene Mao —Guilford County Dept. of Health

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
PLEASE TYPE OR PRINT CLEARLY
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery wells.
FOR OFFICE USE ONLY
1. Date:
2. County: Guilford I PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: David Kane Telephone: [phone]
Applicant's Mailing Address: 1400 Weston Way, West Chester PA 19380
Applicant's Email Address (if available): David KaneCa)westonsolutions com
5. Contact Person (if different than Applicant): N/A Telephone: N/A
Contact Person's Mailing Address: N/A
Contact Person's Email Address (if available): N/A
S. Property Owner (if different than Applicant): City of Greensboro Telephone: [phone]_
Property Owner's Mailing Address: Right -of -Way Management 300 W. Washington St PO Box3136 Greensboro NC 27402-
3136
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) Well is located in City of Greensboro ROW (See attached figure)
City Greensboro County Guilford Zip Code 27407
8. Reason for Well(s): Replacement monitoring well for groundwater quality/plume delineation
(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 Manufacturing 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).
Non -discharge Permit # W00036621
11. Type of contaminants being monitored or recovered: volatile organic compounds
(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 Nola).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): -2,000 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)?
If yes, give distance(s):
15. Well Contractor: _Geologic Exploration Certification No.: 2580
Well Contractor Address: 176 Commerce Blvd., Statesville NC 28625
PROPOSED WELL CONSTRUCTION INFORMATION
As required by 15A NCAC 02C .0105(0(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? Flush mount pad
material: 0 bolted with locking expansion cap
3. Number of wells to be constructed in bedrock: 1 6. Estimated beginning construction date: 11/2/2020
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 11/13/2020
(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 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
Senior Project Manager
Signature of Applicant or *Agent Title of Applicant or *Agent
David Kane. P.G. * 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).
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water Resources' Regional Office:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [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]
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: (2521rft5=37-16, . .
Wilmington Raninnai Offinp
127 Cardina GW-22MR Rev. 3-1-2016
Wilmington,
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
27105

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Greensboro, NC

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NORTH CAROLINA
Pc/ GLOBAL ENCROACHMENT AGREEMENT
GUILFORD COUNTY P/L$ tjN ,J �. .s-%lkkey
THIS AGREEMENT, made and entered into this ±) day of /° t A-fC6 N 2016, by and
between the CITY OF GREENSBORO, (hereinafter the City); and Weston Solutions, Inc
(hereinafter Weston) party of the second part.
WHEREAS, the City of Greensboro owns certain street rights of way located in Greensboro,
North Carolina, and Weston has requested permission, as agent for Alcatel -Lucent Technologies
to encroach into. the City street rights of way at the described locations shown in Exhibit A, said
encroachments to be in the nature of monitoring soil, water, and air. Future locations will also
require approval under this agreement.
NOW THEREFORE, the parties agree as follows:
(I) The City grants and conveys to Weston a temporary encroachment as follows:
(A) Taking such soil, water and air samples as may be necessary;
(B) Installation of monitoring wells;
(C) Taking other actions related to the investigation of surface or subsurface
conditions; and
(D) Attached to this Agreement as Exhibit A is the location of the encroachment,
(2) Weston shall attempt to perform any activities at the property in a manner that minimizes
interference with use of the Property and that of adjoining private owners. Weston will
provide 72 hour's written notice to the City's Engineering and Inspections Department,
Utility Coordination, P.O. Box 3136, Greensboro, North Carolina (Tel. [phone])
(Fax. [phone]).
(3) Weston agrees that use of the Property is not intended for any use apart from the business
of Weston.
(4) On conclusion of all activities, Weston, to the extent practicable, shall restore the
Property to the original condition it was in prior to any activities conducted by Weston 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.
(5) Weston or its contractors shall provide the City and adjoining private owners where
applicable, notice prior to entering the Property for any purpose. In situations that
Weston determines to be of an emergency nature Weston or its contractors shall have

immediate access to the Property and shall inform the City and private owners within 72
hours of entering the Property.
(6) The City shall not willingly destroy, damage, remove, pave over or cover any monitoring
wells at the site without providing prior notice to Weston, or its contractor.
(7) Weston guarantees that the encroachment will neither cause a public nuisance nor
unreasonably interfere with the use of the streets and sidewalks by the public or public
utilities.
(8) Weston agrees to maintain the encroached upon area in a safe condition and restore the
area to it's original condition upon completion of the activities granted in this agreement.
(9) Weston is responsible for locating any and all utilities (Public and Private) and structures
in the encroachment area and to prevent damage to the same.
(10) Weston shall be responsible for all necessary permits and fees, both annual and job
specific, and all permits shall be in the name of Weston.
(11) Termination for Convenience: The City, in its sole discretion, may terminate this
Agreement in whole or in part whenever the City determines that said termination is in its
best interest. Any such termination shall be effected by the delivery to the Client of a
written notice of termination thirty (30) days before the effective date of the termination.
(12) Indemnification: Weston does hereby agree to indemnify and save harmless the City of
Greensboro, its officers, agents and employees against all claims, actions, lawsuits and
demands, including reasonable attorney fees, made by anyone for any damages, loss or
injury of any kind, including environmental, which may arise in connection with or as a
result of, work pursuant to the Agreement.
(13) Payment of Taxes and Insurance: Weston assumes full responsibility for the payment of
all assessments, payroll taxes, or contributions, whether State or Federal, as to all
employees engaged in the performancepf work under this Agreement.
(14) Non -Discrimination Requirements: In hiring, contracting, and all other acts, Weston
shall abide by all local, State and federal laws and regulations relevant to
Minority/Women's Business Enterprises and shall not discriminate on the basis of sex,
age, race, creed, color, religion, national origin, or disability.
(15) Weston shall obtain the following:
(A) Worker's Compensation: Coverage to apply for all employees for statutory limits in
compliance with the applicable state and federal laws. The policy must include
employer's liability with a limit of $100,000 for each accident, $100,000 bodily
injury by disease each employee and $500,000 bodily injury by disease policy limit.

(B) Comprehensive General Liability: Shall have minimum limits of $1,000,000 per
occurrence combined single limit for bodily injury liability and property damage
liability. This shall include premises and/or operations, independent contractors,
products and/or completed operations, broad form property damage and explosion,
collapse and underground damage coverage, sudden and accidental pollution losses,
and a contractual liability endorsement.
(C)Business Auto Policy: Shall have minimum limits of $1,000,000 per occurrence
combined single limit for bodily injury liability and property damage liability. This
shall include: owned vehicles, hired and non -owned vehicles and employee non -
ownership,
(D)Special Requirements: The City of Greensboro is to be named as an additional
insured on the Comprehensive General Liability policy.
(E) Current, valid insurance policies meeting the above requirements shall be maintained
for the duration of the project. Renewed policies shall be sent to the City of
Greensboro thirty (30) days prior to any expiration date. There shall also be a 30 day
notification to the City in the event of cancellation or modification of any stipulated
insurance coverage. Policies of Insurance on an Accord 25 (8/84) or similar form
meeting the required insurance provisions shall be forwarded to the City of
Greensboro. Wording on the Policy of Insurance which states that no liability shall be
imposed upon the company for failure to provide such notice is not acceptable.
Original policies or certified copies of policies may be required by the City at any
time.
(F) It shall be the responsibility of Weston to insure that all subcontractors comply with
the insurance requirements specified above.
(16) Hold Harmless: Weston agrees to indemnify and hold harmless the City of Greensboro
from all loss, liability, claims or expense (including reasonable attorneys' fees) arising
from bodily injury, including death or property damage to any person or persons caused
in whole or in part by the negligence or willful misconduct of Weston except to the extent
same are caused by the negligence or misconduct of the City.
(17) Scope of Agreement: This Agreement is intended by the parties hereto to be the final
expression of their Agreement and it constitutes the full and entire understanding between
the parties with respect to the subject hereof, notwithstanding any representations,
statements, or agreements to the contrary heretofore made.
(18) Governing Law: This agreement shall be construed and interpreted in accordance with
the laws of the State of North Carolina, which parties agree shall be the sole and
exclusive jurisdiction for any suit or cause of action based upon or arising out of this
Agreement. The parties further agree that the venue for any suit or cause of action based
upon or arising out of the Agreement shall be Guilford County, North Carolina.

U
(19) Severability: If, after the date hereof, any provision of this Agreement is held by a court
of competent jurisdiction to be illegal, invalid, or unenforceable under present or future
law, the remaining provisions of this Agreement shall be fully enforceable.
(20) E-VERIFY- The Client certifies that it currently complies with the requirements of
Article 2 of Chapter 64 of the North Carolina General Statutes, and that at all times
during the term of this Agreement, it will continue to comply with these requirements.
The Contractor also certifies that it will require that all of its subcontractors that perform
any work pursuant to this Agreement to comply with the requirements of Article 2 of
Chapter 64 of the North Carolina General Statutes. The terms "Contractor", "Sub -
Contractor" and "comply" shall have the same meanings intended by Chapter 160A
Section 20.1(b) of the North Carolina General Statues. Violation of this section shall be
deemed a material breach of this Agreement.
(21) Weston shall also forward to the following named City Official all abandonment
records, preliminary and final environmental reports, closure reports, and Notices and
reports from DENR.
Mail to:
Manager Environmental Services Support
City of Greensboro
P.O. Box 3136
Greensboro, NC 27402-3136
� 'TO/�tF WITNESS WHEREOF, each of the parties to this agreement has caused the same to
S�,• ]ic�a�u`vi duplicate originals the day and year first above written.
At
Weston Solutions, Inc.
tt`•i! �1y41` //VW"' By:V'r`.-!L.
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ATTE TED BY: CITY OF GREENSBORO
By: 4 01 j3X:
((Cii'ty Jerk_
F.,J A g,E 3 b� City Manager
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Recommend�li�

B-
gineerin irector
Approved as to Form: (This instrument has been pre -audited In the manner
required by the Local Government Budget and Fiscal Control
Act.)
By: c c By: fi�(} ar
A ist ity Attorney Finance Officer

Method : HSA / Air Rotary
EK
Spring
Boring Diameter 8.25"
LOG OF BORING MW-50(i)
®
Sample Type(s) : Grab - Culengs
North Coord.
(Page 1 of 1)
Well Elevation 833,37'
Lucent CMS
Dale / Time Started : 4114103 / 16:35
Cotton Mill Square, Greensboro, NC
Ground Elevation : 833e2'
Date / Time Complete : 4114103 / 18:35
Project Number, 04364-103-420
Depth of Boring : 27'
Weather : Sunny 80 F
Screened Interval : 17.27'
Water level :12.96'
Logged By : RAW
Survey By
E
n
5
8
n
Well:
MW-50(i)
Depth
Surf.
v
2
,n
d
Elev.:
833.37'
Well Construction
to
Elev.
Nj
DESCRIPTION
E
Information
Feet
=
N
0
WELL CONSTRUCTION
To )soil
_
Red -brown slightly sitty day, dry
1
Date Compl. : 4114/03
Hole Diameter : 6.26 in.
2
Drill. Method :HSA/Air Rotary
Drilling
3
Contractor : SAEDACCO
4
WELL CASING
Material : PVC
5
CL
Diameter : 2 in.
Joints :threaded
6
WELL SCREEN
7
Material : Stainless Steel
Diameter : 2 in.
81
IvJoints
:threaded
11
openi9
Fiat End Cap
Sand Pack : #2
10
Annulus Seat : bentonite cups
Medium brown day, moist
11
12
12
NOTES
13
Switched from HSA to Air
..
14
rotary at 2211.
14
CL
15
tipper 5 R. of hart) rock has
few fractures, does not appear
16
wet.
17
17
18
Medium brown to yellow brown day, very wet
19
20
CIL
21
1-27
•d_.'d_'.'
Dense saprolite / partially weathered rock dark
23greenish-gray
o :.0.�
o.---
24
• •
Hard rock; dark green with plagioclase and black
25
ferro-mag minerals; dry
26
27
Boring terminated at 27.0 ft.
28
29
30