WM0100325_Application_20130621

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
DIVISION OF WATER QUALITY—AQUIFER PROTECTION SECTION
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
PLEASE TYPE OR PRINT CLEARLY
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery wells.
FOR OFFICE USE ONLY
1. Date: 06/21/2013
2. County: Transylvania PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: James Mcintosh (petitioner for DSCA Site#88-0001) Telephone: [phone]
Applicant's Mailing Address: DSCA Program 1646 Mail Service Center, Raleigh, NC 27699-1646
Applicant's Email Address(if available):
5. Contact Person (if different than Applicant): David Graham- Hart&Hickman Telephone: [phone]
Contact Person's Mailing Address: 2923 S. Tryon St., Suite 100, Charlotte, NC 28203
Contact Person's Email Address (if available): dgraham harthickman.com
6. Property Owner(if different than Applicant): Brenda Smith Telephone: [phone]
Property Owner's Mailing Address: 101 Killarney Way, Easley, SC 29642
Property Owner's Email Address (if available):
7. Property Physical Address (including zip code)and PIN Number 180 N. Caldwell St, Brevard, NC 28712 PIN: 8586-51-4789
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: Former 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).
NCDENR-DSCA Site ID#88-0001
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? yes, 12 monitoring wells
Existing Monitoring or Recovery Well Construction Permit No(s).: N/A
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): approx. 300
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: Geologic Exploration Certification No.: 2401
Well Contractor Address: 176 Commerce Boulevard, Statesville, NC 28625
PRnPOSFn WFI I CONSTRUCTION INEDRMATION
1. As required by 15A NCAC 02C .0105(f)(7), attach a well construction diagram of each well showing the following:
a. Borehole and well diameter e. Type of casing material and thickness
b. Estimated well depth f. Grout horizons
C. Screen intervals g. Well head completion details
d. Sand/gravel pack intervals
Continued on Reverse

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s)be secured? locking cap at TOC;
material: 1 manhole set in concrete
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 7/11/13
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 7/12/13
(add answers from 2 and 3)
ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C.0105(f)(5), attach a scaled map of the site showing the locations of the following:
a. All property boundaries,at least one of which is referenced to a minimum of two landmarks such as identified roads,
intersections,streams, or lakes within 500 feet of the proposed well or well system.
b. All existing wells, identified by type of use,within 500 feet of the proposed well or well system.
C. The proposed well or well system.
d. Any test borings within 500 feet of proposed well or well system.
e. All sources of known or potential groundwater contamination (such as septic tank systems,pesticide,chemical or fuel
storage areas, animal feedlots as defined in G.S. 143-215.10B(5), landfills, or other waste disposal areas)within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant hereby agrees that the proposed well(s)will be constructed in accordance with approved specifications and conditions of
this Well Construction Permit as regulated under the Well Construction Standards(Title 15A of the North Carolina Administrative Code,
Subchapter 2C)and accepts full responsibility for compliance with these rules
on behalf ,of petitioner for DSCA site '88-0001 Agent for Petitioner for DSCA Site 88-0001
Signature of Applicant or*Agent Title of Applicant or*Agent
David Graham
*If signing as Agent, attach authorization agreement stating
Printed name of Applicant or*Agent that you have the authority to act as the Agent.
If the property is owned by someone other than the applicant,the property owner hereby consents to allow the applicant to construct
wells as outlined in this Well Construction Permit application and that it shall be the responsibility of the applicant to ensure that the
well(s)conform to the Well Construction Standards(Title 15A of the North Carolina Administrative Code,Subchapter 2C).
See attached property owner access agreement
Signature of Property Owner(if different than Applicant) Printed name of Property Owner(if different than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water Quality's Aquifer Protection Section 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 Washington Regional Office Winston-Salem Regional Office
225 Green Street, Suite 714 943 Washington Square Mall 585 Waughtown Street
Fayetteville, NC 28301-5094 Washington, NC 27889 Winston-Salem, NC 27107
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [phone] Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone] _ .
Fax: [phone] t a
n9ton
GW-22MR(Rev.7/11)

NCDENR .
- Mf f r r.
1R.
OFF-SITE PROPERTY ACCESS CONSENT
If you have questions on how to fill out 1hisforn2 or about the activities DSCA Site ID No,
at this site,please call. the Dry-Cleaning Solvent Cleanup Program at
9191508-8400. 88-0001
Please P1.1111
Smith 864-222-8 114
(Name of Property Owner) (Telephone Number of Property Owner)
North Caldwell Street (Parcel ID No. 8586-5 t-4789-000)
(Street Number and S tree t Maine of Property)
Brevard Tr insylvania 23712
(City or Town in WhiGh Property Is Located) / (County in Which Property is Located) f (Zip Code of Property)
I volwitarily consent to the Division of Waste Management (Division) and its independent
contractors (contractors) entering and having continued access to illy property for the following
purposes:
(1) taking such soil, water and 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's contractors shall attempt to perform any activities at the Propet-ty
in a manner that ininimizes interference with use of the Property.
(2) On conclusion of all activities, the Division and its contractors shall, to the extent
practicable, restore the Property to the original condition it was in prior to any
activities conducted by the Division or its contractors. All monitoring wells will
be properly abandoned in accordance with applicable laws and regulations, unless
other arrangements are agreed to by the Property Owner.
I ryisi Cis,i r. 0 aluitlj'i,NcAh Di-c!r1ta 2'1"K9-I 1,i
A, 91�i 5,it3c-{i 1 iii terir ort:

(3) The Division's contractors will makc reasonable attempts to notify the Property
Owner at least 48 hours prior- to entering the Property for any purpose. In
situations that the Division determines to be of an emergency nature, the Division
or its contractors shall have immediate access to the property.
(4) Property Owner shall not willingly destroy, damage, remove, pave over or cover
any monitoring wells at the site without prior consent of the Division.
By signing this consent document, I acknowledge that .I have contacted all tenants
occupying the property, and all tenants agree to the conditions of this "Off-site Property
Access Consent".
(S i iature of Property Owner) (Date)
S -'Y
61-eldco
c f
(Printed Name of Property Owner)
Please return to:
Division of Waste Management
DSC:A Program
401 Oberlin Rd., Spite 150
Raleigh, NC 27605-1350
(v3,July 3,2007) Pagc 2

TYPE 11 TOP OF ROCK MONITORING WELL CONSTRUCTION DETAILS
CROSS SECTIONAL VIEW
LOCKABLE WELL CAP CONCRETE PAD
FLUSH METAL WELL COVER
CONCRETE PAD
BACKFILL AROUND CASING
MATERIAL cement grout
LENGTH 3 ft(0 to 3 ft)
WELL CASING
MATERIAL schedule 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threaded
LENGTH 45 ft
Ll
4 BACKFILL AROUND CASING
L3 MATERIAL bentonite/grout
LENGTH 38 ft(3 ft to 41 ft)
SEAL
TYPE OF SEAL bentonite
THICKNESS 2 feet(41 ft to 43 ft)
FILTER PACK
TYPE OF FILTER No.2 Sand
THICKNESS 7 ft(43 ft to 50 ft)
WELL SCREEN
SCREEN MATERIAL schedule 40 PVC
L2 DIAMETER 2 inches
LENGTH 5 feet
SLOT SIZE 0.010 inches
DEPTH TO BOTTOM OF
Ll = 45 FT. MONITORING WELL 50 feet
L2= 5 FT. DIAMETER OF
L3= 50 FT. BOREHOLE
4.25 in
TITLE Monitoring Well Diagram
Hart & Hickman, PC
2923 South Tryon St., Suite 100
Charlotte, North Carolina 28203
FILE I PREP. BY REV. BY DATE 1 PROJECT NO.
TCD DG 6/20/2013
DSO-1 8

LEGEND
-- PROPERTY BOUNDARY
PARCEL LINE
FORMER DRY CLEANER BUILDING
BUILDING
CHARLIE'S TIRE&AUTO
SERVICES CENTER MONITORING WELL
FRENCH BROADeCE TEMPORARY WELL
CHARLIE'S TIRE&AUTO (CONDOS-96&TAURANTS,AND
\` SERVICES CENTER / / RETAIL SHOP PCE CONCENTRATION (mg/L)
PCE ISOCONTOUR LINE IN mg/L
\ �S (DASHING INDICATES INFERRED)
TW-1+
Q
LIGHTLY
WOODED MW-8+ 9<< NOTES:
TW 2
PACE'S AUTO
� 1.MONITORING WELLS SAMPLED ON 6/5/12-
6/6/12.
GW-27 GW-34
LOADING DOCK GW-22
LAUNDROMAT MW-3 2.PCE ISOCONTOUR LINES BASED ON
MW-10 G W-32 G W-35 CURRENT MONITORING WELL DATA.
\
HISTORICAL TEMPORARY WELL DATA FROM
11/09/09-11/10/09(NOT SHOWN)WAS
/ MW4S/D� CONSIDERED IN CONTOURING.
�lGW-25 GW-26
/ �MW-7
m.m..b.b_- GW-30+ Q
ORAGE MW-1 4j� Oy�O
' MW-5 AREA MW-2 C2 GW-28 QJ� /
L ` VACANT
\GW-31
DI CT / GW-29
TV QQO
k MW-11
a *MW-6 MW-PLAZA INV.
22 AREA 22 Q
a RS GUITARS \ -� G+7 �� / \�O O�
�
11-
CO Q�`Q� / �O O APPROXIMATE
u QO � 0 60 120
P�Q + GW 18 QQO SCALE IN FEET
+ GW-33
3 /
Q GW-19
TITLE
�o GW-23 SHALLOW GROUNDWATER
GRASS
/ PCE ISOCONCENTRATION MAP
/ PROJECT RAINBOW CLEANERS
3 GW-24 / DSCA ID: 88-0001
o
249 N. CALDWELL STREET
GW-36 / BREVARD, TRANSYLVANIA COUNTY
o / 2923 South Tryon Street-Suite 100
hart hickman Charlotte,
North Carolina0 - 23733
60 0
(P) (l)
p SMARTER ENVIRONMENTAL SOLLMONS License#C-1269/#C-245 Geology
0
DATE: 6-27-12 REVISION NO. 0
JOB NO: DSO-18 ATTACHMENT NO. 5