WM0401276_Monitoring Well Permit Application_20210212

ATC
ENVIRONMENTAL• GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcassociates.com
N.C. Engineering License No. C-1598
February 9, 2021
Mr. Jim Gonsiewski
North Carolina Department of Environmental Quality
Winston-Salem Regional Office
450 W. Hanes Mill Road Suite 300
Winston-Salem, NC 27105
Re: Permit to Construct Monitoring Wells
Daniel's Cleaners — DSCA Site DC410059
660 N. Main Street
High Point, Guilford County, North Carolina
DSCA Site No. DC410059
Dear Mr. Gonsiewski:
Enclosed please find permit applications to construct four temporary monitoring wells. The
monitoring wells will be located at 441 N. Wrenn Street 501 (PIN 7800163883), 650 N. Main
Street (PIN 7800163721), 658 N. Main Street (PIN 7800163704), and 662 N. Main Street (PIN
7800163813) in High Point, North Carolina. The permit applications, site map with the proposed
locations of the monitoring wells, well construction details and other relevant information are
enclosed as attachments. Please review this package and return the approved permit to this
office.
If you have any questions or require additional information, please contact our office at (919)
871-0999.
Sincerely,
ATC Associates of North Carolina, P.C.
Emily Fuller
Staff Scientist

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.
1. Date: 02-09-2021
2. County: Guilford
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
Monitoring
4. Applicant: Peters Development III, LLC (Petitioner for DSCA site #DC410059) Telephone: [phone]
Applicant's Mailing Address: DSCA Program, Mail Service Center 1646, Raleigh, NC 27699-1646
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Emily Fuller, ATC
Telephone: [phone]
Contact Person's Mailing Address: 2725 E Millbrook Rd Suite 121, Raleigh NC, 27604
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): See above Telephone: See above
Property Owner's Mailing Address: 507 N. Lindsay Street, High Point, North Carolina 27262
Property Owner's Email Address (if available): [e-mail]
7. Property Physical Address (Including PIN Number) 441 N. Wrenn Street (PIN 7800163883)
City High Point
County Guilford
Zip Code 27262
8. Reason for Well(s): Groundwater contamination
(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 (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).
DSCA Site DC410059
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 Applicable
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 0
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): N/A
15. Well Contractor: Innovative Environmental Technologies, Inc.
Well Contractor Address: 232 Highway 49 South, Concord, NC 28025
Certification No.: 3287-B
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? Not Applicable -
material: 1 Will be abandoned shortly after construction.
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 2/22/21
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 2/22/21
(add answers from 2 and 3)
ADDITIONAL INFORMATION
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
Signature of Applicant or *Agent
Emily Fuller
Agent for DSCA Site DC410059 (will include power of attorney
Title of Applicant or *Agent upon request)
* 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 access agreement
Signature of Property Owner (if different than Applicant)
See attached access agreement
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
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

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.
1. Date: 02-09-2021
2. County: Guilford
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
Monitoring
4. Applicant: Peters Development III, LLC (Petitioner for DSCA site #DC410059) Telephone: [phone]
Applicant's Mailing Address: DSCA Program, Mail Service Center 1646, Raleigh, NC 27699-1646
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Emily Fuller, ATC
Telephone: [phone]
Contact Person's Mailing Address: 2725 E Millbrook Rd Suite 121, Raleigh NC, 27604
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): See above Telephone: See above
Property Owner's Mailing Address: 507 N. Lindsay Street, High Point, North Carolina 27262
Property Owner's Email Address (if available): [e-mail]
7. Property Physical Address (Including PIN Number) 650 N. Main Street (PIN 7800163721)
City High Point
County Guilford
Zip Code 27262
8. Reason for Well(s): Groundwater contamination
(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 (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).
DSCA Site DC410059
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 Applicable
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 0
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): N/A
15. Well Contractor: Innovative Environmental Technologies, Inc.
Well Contractor Address: 232 Highway 49 South, Concord, NC 28025
Certification No.: 3287-B
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? Not Applicable -
material: 1 Will be abandoned shortly after construction.
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 2/22/21
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 2/22/21
(add answers from 2 and 3)
ADDITIONAL INFORMATION
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
Signature of Applicant or *Agent
Emily Fuller
Agent for DSCA Site DC410059 (will include power of attorney
Title of Applicant or *Agent upon request)
* 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 access agreement
Signature of Property Owner (if different than Applicant)
See attached access agreement
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
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

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.
1. Date: 02-09-2021
2. County: Guilford
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
Monitoring
4. Applicant: Peters Development III, LLC (Petitioner for DSCA site #DC410059) Telephone: [phone]
Applicant's Mailing Address: DSCA Program, Mail Service Center 1646, Raleigh, NC 27699-1646
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Emily Fuller, ATC
Telephone: [phone]
Contact Person's Mailing Address: 2725 E Millbrook Rd Suite 121, Raleigh NC, 27604
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): See above Telephone: See above
Property Owner's Mailing Address: 507 N. Lindsay Street, High Point, North Carolina 27262
Property Owner's Email Address (if available): [e-mail]
7. Property Physical Address (Including PIN Number) 658 N. Main Street (PIN 7800163704)
City High Point
County Guilford
Zip Code 27262
8. Reason for Well(s): Groundwater contamination
(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 (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).
DSCA Site DC410059
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 Applicable
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 0
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): N/A
15. Well Contractor: Innovative Environmental Technologies, Inc.
Well Contractor Address: 232 Highway 49 South, Concord, NC 28025
Certification No.: 3287-B
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? Not Applicable -
material: 1 Will be abandoned shortly after construction.
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 2/22/21
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 2/22/21
(add answers from 2 and 3)
ADDITIONAL INFORMATION
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
Signature of Applicant or *Agent
Emily Fuller
Agent for DSCA Site DC410059 (will include power of attorney
Title of Applicant or *Agent upon request)
* 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 access agreement
Signature of Property Owner (if different than Applicant)
See attached access agreement
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
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

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.
1. Date: 02-09-2021
2. County: Guilford
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
Monitoring
4. Applicant: Peters Development III, LLC (Petitioner for DSCA site #DC410059) Telephone: [phone]
Applicant's Mailing Address: DSCA Program, Mail Service Center 1646, Raleigh, NC 27699-1646
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Emily Fuller, ATC
Telephone: [phone]
Contact Person's Mailing Address: 2725 E Millbrook Rd Suite 121, Raleigh NC, 27604
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): See above Telephone: See above
Property Owner's Mailing Address: 507 N. Lindsay Street, High Point, North Carolina 27262
Property Owner's Email Address (if available): [e-mail]
7. Property Physical Address (Including PIN Number) 662 N. Main Street (PIN 7800163813)
City High Point
County Guilford
Zip Code 27262
8. Reason for Well(s): Groundwater contamination
(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 (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).
DSCA Site DC410059
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 Applicable
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 0
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): N/A
15. Well Contractor: Innovative Environmental Technologies, Inc.
Well Contractor Address: 232 Highway 49 South, Concord, NC 28025
Certification No.: 3287-B
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? Not Applicable -
material: 1 Will be abandoned shortly after construction.
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 2/22/21
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 2/22/21
(add answers from 2 and 3)
ADDITIONAL INFORMATION
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
Signature of Applicant or *Agent
Emily Fuller
Agent for DSCA Site DC410059 (will include power of attorney
Title of Applicant or *Agent upon request)
* 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 access agreement
Signature of Property Owner (if different than Applicant)
See attached access agreement
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
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
MICHAEL SCOTT
Director
NORTH CAROLINA
Environmental Quality
PROPERTY ACCESS CONSENT
This document may not be modified without the Prograrn's approval.
If you have questions on how to fill out this form or about the activities
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program's contractor for this project, Emily Fuller with ATC
Associates of North Carolina, P.C. at emily. fuller(alatcgs.com or
[phone]. If you still have questions after contacting Ms. Fuller with
please contact the DSCA project manager, David Kwiatkowski at
David_Kwiatkowski a,ncdenr.gov or [phone].
For DSCA Use Only
DSCA ID No.
DC410059
Please Print
Peters Development III, LLC
ATC,
(Name of Property Owner or Tenant in Residence)
435 & 441 N. Wrenn Street and 650, 658, & 662 N. Main Street
(Street Number and Street Name of Property)
High Point Guilford 27262
(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.
North Carolina Department of Environmental Quality I Division of Waste hitanagerntm
217 West Jones Street 11b16 t<fail Setvlce Center I Raleigh North Carolina 27699 ttvt6
919.707.8200

(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".
/Zv
(Signature of Property Owner or Tenant in Residence)
(Date)
(77
)242-5-z-9-3 °5
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
Clan Of ifitho$ ettAiZl09rot 71lC. ftJ''✓)
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Emily Fuller
ATC Associates of North Carolina, P.C.
2725 East Millbrook Road, Suite 121
Raleigh, NC 27604
Or via email to: [e-mail]
ttarlhCaraMa
T17 w!e#1 Janes Stitet t ttwf6

1" Diameter Schedule 40 PVC Casing Extending
From Ground Surface to Top of Screen (0-5 feet)
4/ Groundwater Table
15 Feet of 1" Schedule 40 Well Screen (0.010" Slot)
(5-20 feet)
ATC
ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 E. Millbrook Road, Suite 121
Raleigh, NC 27604
[phone]
PROJECT NO: DC410059
DATE: 02/08/2021 REVIEWED BY: AW
MONITORING WELL
CONSTRUCTION DETAIL
Daniel's Cleaners
660 N. Main Street
High Point, Guilford County, NC 27262
DSCA ID: DC410059

Former
Daniel's
Cleaners
Source: Guilford County GIS
Note:
All properties owned by Petitioner
(Peters Development III, LLC).
No water supply wells are located within
500 feet of the site.
• Proposed Temporary Monitoring Well Location
Ref. No./
Map No.
Physical Address of
Property
1
PIN: 7800163813
662 N. Main Street
High Point, NC 27262
2
PIN: 7800163883
441 N. Wrenn Street
High Point, NC 27262
3
PIN: 7800163721
650 N. Main Street
High Point, NC 27262
4
PIN: 7800163704
658 N. Main Street
High Point, NC 27262
ATC
ASSOCIATES OF NORTH CAROLINA. P.C.
2725 E. Millbrook Road, Suite 121
Raleigh, NC 27604
[phone]
PROJECT NO: DC410059
SCALE: Not to Scale
DATE: 02/08/2021
Proposed Monitoring Well Locations
Daniel's Cleaners
660 N. Main Street
High Point, Guilford County, NC
DSCA Site #DC410059