WM0501423_Permit (Issuance)_20210122

ROY COOPER
Governor
MICHAEL S. REGAN
secretory
S. DANIEL SMITH
DUector
NORTH CAROLINA
Env omse ttalQuality
January 22, 2021
Roanoke Realty (Petitioner for DSCA Site #42-0001)
N.C. DWM DSCA Program
MSC 1646
Raleigh, NC 27699
Subject: Monitoring Well Construction
Permit # WM0501423
Oakland Cleaners
1190 Julian Allsbrook Highway
Roanoke Rapids, NC -Halifax County
To Whom It May Concern;
In accordance with the application received on January 18, 2021 we are forwarding herewith
Monitoring Well Construction Permit No. WM0501423 dated January 22, 2021 issued for the construction
of a monitor well system (installation of two temporary wells) at the subject prouerty. Please he Awurn
that emm- ........a:. - L--._ ___IT
This Permit will be effective from the date of its issuance and shall be subject to the conditions and
limitations as specified therein. Please note the addition of stipulation #3 to the permit enclosed. If you have
any questions about this permit, please contact Eric Rice at [phone].
Sincerely,
SDocuSigned by:
ettUA44t,
BCDA9D825D4A46D...
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
Enclosure
cc: RRO Files
Halifax County Health De artment
Email: Bethan.donovan
NC aecom.com AECOM 1600 Perimeter Parkway, Suite 400, Morrisville,
North Carolina Department of Environmental Quality I Division of Water Resources
Raleigh Regional Office 13800 Barrett Drive I Raleigh, North Carolina 27609
919.791,4200

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
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
Roanoke Realty (Petitioner for DSCA #42-0001)
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM (Oakland Cleaners consisting of two tam ovary
monitoring wells owned by Roanoke Realty (Petitioner for DSCA #42-0001)) at mailing address MSC 1646 in Raleig NC
27699. The wells will be located on the property owned by ASJC Realty R, LLC located at 1110-1Igo Julian Al, sbrook
Highway in Roanoke Rapids, NC- Halifax County. This Permit is issued in accordance with the application received on
January 18, 2021, in conformity with s ecifications and supporting data, all of which are filed with the Department of
Environment and Natural Resources andareconsidered 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 .0I 08(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of Water Quality's
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 Quality's
Information Processing Unit within 30 days of the well abandonment.
7. If the well penetrates any water -bearing zone that contains contaminated waters, the upper three feet of the
well shall be grouted within one day after the casing is set or the well abandoned.
8. Temporary wells must be permanently abandoned or converted to a permanent well within seven days (168
hours) of the completion of drilling of the borehole
Permit issued the 22°d of January 2021
FOR THE NORTH CAROLINA ENVY}MENTAL MANAGEMENT COMMISSION
Scott Vinson, Regional Supervisor
Division of Water Resources
By Authority of the Environmental Management Commission
Permit No. WM0501423

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 fr+r a ruermit to ennstruct monitorina or recovery wells.
1. Date: January 18 2021
2. County: Halifax
FOR OFFICE USE ONLY
PERMIT NO.:Jy*f) OS-0 (`{'23 ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Roanoke Reap{► (Petitioner for DSCA Site #42-0001) Telephone: [phone]
Applicant's Mailing Address: DSCA Program MSC 1646 Raleigh NCt27699
Applicant's Email Address (if available):
5. Contact Person (d 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 aecom com
6. Property Owner (if different than Applicant): ASJC Realty 11, LLC 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) 1110-1190 Julian R MOM* Hwy RN 399s-20-90-2MI
City Roanoke Rapids County Halifax Zip Code 27870
8. Reason for Well(s): Assessment -
(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: 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 500 feet from the proposed well(s)? None Known
If 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
As required by 15A NCAC 02C .0105(fx7), 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
matenal: 2
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 2
(add answers ffom 2 and 3)
5. How will the well(s) be secured? Will be
abandoned following immediate sampling_(Temoorary wells)
Estimated beginning construction date: 2/3121
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. 143-215.10B(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 (Tale 15A of the North Carolina Administrative Code,
Subchapter 2C) and accepts full responsibility for compliance with these rules
on k5et�t a Pe.h tw rtiet 7j C3 12S qN S t`
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 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. [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
W riston-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 (NIA) K DEPTHS
B = Ground Surface E (ft 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 s! : iiiiiiiil
C 0.50
F =Top of Screen
G = Bottom of Screen
N = 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 Filter 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
Att.
low
DATE: /11/ 0260622984
■

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*
Legend
A. �I
Proposed Monitoring Wells
Monitoring Wells
Inferred PCE 2L Exceedance
Former Oakland Cleaners
1 inch • feet Site Parcel
.,,
500' Buffer
Feet
e o u n i��fAx �;c 3po
LJWDfl Mau �� ParcelsTax u

ROY COOPER NORTH CAROUNA
Governor Environmental Quality
MICHAEL S. REGAN
secretary
MICHAEL SCOTT
Director
PROPERTY ACCESS CONSENT
This document may not be modified without the Programs approval For DSCA Use Only
If you have questions on how to fill out this form or about the activities DSCA tD No.
at this site, please contact the DSCA project manager, Al Chapman at
al.dial nrinwincdenr. ov or 919-707 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 County/27870
(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
North CarOW Deparimmi of Envirornnrmal Qu.*y 1 DIVMw or WaateMansgem m
217 West Jones Strert I Ib4b MW 5ervktCemtr 1 Raleigh North CaroMna 21894-lb4b
916.707$200

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".
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 Mail Service Center
Raleigh, NC 27699-1646
Or via email to: [e-mail]
North Cxo!"u DeWmmt of Erwirrntmwrttal Qut4tty I tNvisW of wave MmM ewm
711 V*St jorteg Street 11646 MM Servkee C*Mer S Raktgh. North C.ir.Miim 27699.1646
919.7014M