WM0501423_Application_20210118

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— 4 -Fmit to cons monitoring or recovery wells.
1. Date: January 18.2021
2. County: Halifax
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring —
4. Applicant: Roanoke Realty (Petitioner for DSCA Site #42-0001) Telephone: [phone]
Applicant's Mailing Address: DSCA Program MSC 1646 Raleigh NC 27699
Applicant's Email Address (if available):
5. Contact Person (if different than Applicant): Bethany Donovan Telephone: [phone]
Contact Person's Mailing Address: 1600 Perimeter Park Drive Suite 400 Morrisville NC 27560
Contact Person's Email Address (f available): Bethany donovan aNaecom com
6. Property Owner (if different than Applicant): ASJC Realty IL PLC Telephone: [phone]
Property Owner's Mailing Address: 4121 Meadowdale Blvd Suite B. North Chesterfield VA 23234
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 1110J 190 Julian R Allsbrook Mwv (PIN 3998-20-90-2848i
City Roanoke Rapids County Halifax Zip Code 27870
8. Reason for Well(s): Assessment
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remed(alion, etc.)
9. Type of facility or site for which the well(s) is(are) needed: DSCA
(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).
None known
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? Yes. 14
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 260'
14. Are there any water supply wells located less than 5W feet from the proposed well(s)? None Known
It yes, give distance(s):
15. Well Contractor: Geologic Exploration Certification No.: Specific Driller TBD
Well Contractor Address: 176 Commerce Blvd Statesville NC 28625
PROPOSED WELL CONSTRUCTION INFORMATION
1. As required by 15A NCAC 02C .0105(f)(7), attach a well construction diagram of each well showing the following:
a. Borehole and well diameter e. Type of casing material and thickness
b. Estimated well depth f. Grout horizons
C. Screen intervals g. Well head completion details
d. Sand/gravel pack intervals
Continued on Reverse

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated
material: 2
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 2
(add answers from 2 and 3)
5. How will the well(s) be secured? Will be
abandoned following immediate sampling (Temporary wellsl
Estimated beginning construction date 2/3/21
Estimated construction completion date. 2/3/21
ADDITIONAL INFORMATION
As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:
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.
All existing wells, identified by type of use, within 500 feet of the proposed well or well system
The proposed well or well system.
Any test borings within 500 feet of proposed well or well system.
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. 143-215.1013(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 Constriction 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
'f-
Signature of Applicant or *Agent Title of Applicant or *A
Bethany Donovan on behalf of DSCA Petitioner
* 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 Signed Access Agreement approving installation of monitoring wells]
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 C
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: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
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

Site Name:
Oakland Cleaners (DC420001) DPT-100/01PT-101
AECOM Project number
Monitoring Well Location
60622984
ASJC Realty II, LLC Property, 1110- 1190 Julian Allsbrook Highway, Roanoke Rapids, NC
Drilling company
Ground elevation (approximate)
Date
Geologic Explorations
154 ft amsl
January 11, 2021
A = Top of Steel Cover (N/A) K DEPTHS
B = Ground Surface E (n below
ground not to
C = Top of Riser Y scale)
D = Top of Bentonite Seal B 0.00 GROUND SURFACE—
E = Top of Sand Pack IIIltlilil illllllll
C 0.50
F = Top of Screen
G = Bottom of Screen
H = Bottom of Borehole
RISER PIPES:
1-inch Schedule 40 PVC
D 14.0
BENTONITE SEAL:
E 17.0 Hydrated Bentonite Chips
SAND/GRAVEL PACK:
F 20.0 #2 Fitter Pack Sand
SCREEN:
1-inch Schedule 40 PVC, 0.020 slot
G 30
H 31
DIAMETER OF
BOREHOLE: 2.25"
REMARKS
Temporary monitoring wells will be sampled then immediately abandoned following installation.
PROPOSED TEMPORARY WELL CONSTRUCTION
ASJC REALTY, LLC PROPERTY
DSCA
ROANOKE RAPIDS, NC
PROJECT NO: 606229840M
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DATE: 1 /11 /2021

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ROY COOPER NORTH CAROLINA
Governor Environmentat Quattty
MICHAEL S. RECAN
Secretary
MICHAEL SCOTT
Dfredor
PROPERTY ACCESS CONSENT
This document may not be modified without the Program Is approval: For DSCA Use Only
If you have questions on how to fill out this form or about the activities D-SCA ID NQ
at this site, please contact the DSCA project manager, Al Chapman at
aLchapil7cinta>ncdcnr.>~tw or919-707--8368.
Please Print
ASJC Realty II LLC
(Name of Property Owner or Tenant in Residence)
Oakland Shopping Center, 1110-1190 Julian R Allsbrook Hwy.
(Street Number and Street Name of Property)
Roanoke Rapids, NC/ Halifax
(City or Town 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 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.
(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
D_E ,
North CaroW►a Department of Envirwimcntal (bmWy I Dlsr &W of Waste Mang9eme+u
217 West im" Simi 11646 Mail Se►vlce Center I Raleigh. North CaroBna 21694-lb4b
919,707.6200

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".
1 111141, �
(Signature of Property Owner or Tenant in Residence) (Date)
804-928-5594
("Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
[e-mail]
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Al Chapman
NCDEQ DSCA Program
217 West Jones St.
1646 Mall Service Center
Raleigh, NC 27699-1646
Or via email to: al.chapman@ncdenrgov
1EQ;
North Carn!rna ckpan mertt Of &WjMt 'W" Quality I DfVWM of waste Management
217 West )Ono $meet 11646 Mai a C"4er t Raleigh. North Crrk4inn 21699,1646

A=COM 1600 Perimeter Park Drive, Suite 400 919.461.1100 tel
Morrisville, NC 27560 919.461.1415 fax
January 18, 2021
Attn: Scott Vinson
North Carolina DENR-DWR
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Subject: Monitoring Well Permit Application
Roanoke Realty/Oakland Cleaners (Petitioner for DSCA Site DC420001)
Dear Mr. Vinson:
AECOM Technical Services of North Carolina (AECOM), on behalf of Roanoke Realty/Oakland
Cleaners (Petitioner for DSCA Site DC420001), has prepared the attached permit application for the
construction of two temporary monitoring wells in Roanoke Rapids, Halifax County, North Carolina.
This application is being submitted in accordance with 15A NCAC 2C .0105. Proposed activities
include installation of two temporary monitoring wells on one offsite property. Upon approval,
please forward a copy of the monitoring well construction permit to AECOM at the address below.
If you have any questions or require additional information please do not hesitate to call either
Beth Donovan at 919-461-1560 or Rob MacWilliams at 704-522-0330.
Sincerely,
AECOM TECHNICAL SERVICES OF NORTH CAROLINA
Bethany Donovan, PG
Staff Geologist
Enclosures
cc: Project File (hard copy)
Robert H. MacWilliams, PG
Program Manager