WM0100484_Monitoring Well Construction Application_20210216

FOR OFFICE USE ONLY

PERMIT NO. ISSUED DATE
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: February 16, 2021

2. County: Buncombe

3. What type of well are you applying for? (monitoring or recovery): Monitoring

4. Applicant: Bon Ton Cleaners & Laundry (Petitioner for DSCA Site #110011) Telephone: [phone]

Applicant’s Mailing Address: DSCA Program, Mail Service Center 1646, Raleigh, NC 27669-1646

Applicant’s Email Address (if available): [e-mail]

5. Contact Person (if different than Applicant): Al Quarles Telephone: [phone]

Contact Person’s Mailing Address: 7606 Whitehall Executive Center Drive, Suite 800, Charlotte NC 28273

Contact Person’s Email Address (if available): [e-mail]

6. Property Owner (if different than Applicant): Ingles Markets, Inc., c/o: Preston Kendall Telephone: [phone]

Property Owner’s Mailing Address: 669 Haywood Rd, Asheville, NC 28806
Property Owner’s Email Address (if available): [e-mail]

7. Property Physical Address (Including PIN Number) 669 Haywood Road (PIN: 963824478700000)
City Asheville County Buncombe Zip Code 28806

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: Drycleaner
(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 ID DC110011

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, 5

Existing Monitoring or Recovery Well Construction Permit No(s).: NC WM9199439, WM0100431

13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 140 feet

14. Are there any water supply wells located less than 500 feet from the proposed well(s)? None Identified

If yes, give distance(s):

15. Well Contractor: Geologic Exploration Certification No.: 2580

Well Contractor Address: 176 Commerce Boulevard, 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: 1

3. Number of wells to be constructed in bedrock: None

4. Total Number of wells to be constructed: 1
(add answers from 2 and 3)
5. How will the well(s) be secured?
Bolt-down 8” manhole, encased in a 2x2 concrete pad.

6. Estimated beginning construction date: 4/1/2021

7. Estimated construction completion date: 4/3/2021

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

Project Manager (ATC Associates of North Carolina, P.C.)
Signature of Applicant or *Agent Title of Applicant or *Agent

Al Quarles, on behalf of DSCA Petitioner for Site DC110011 * 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 Property Access Consent signed 3/6/2020 Ingles Markets, Inc. (Preston Kendall)
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
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW -22MR Rev. 3-1-2016
GW -22M (Rev. 5/11)
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Feb rua ry 16, 2021
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1:2,257

TYPICAL TYPE II MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
NOT TO SCALE
LOCKABLE WELL CAP
PROTECTIVE CASING AND CONCRETE PAD
L1 CASING MATERIAL steel
CASING DIAMETER 8 inches
CASING LENGTH 12 inches
PAD DIMENSIONS 2 feet x 2 feet
HEIGHT ABOVE GROUND flush mounted
WELL CASING
MATERIAL sch 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threaded
LENGTH 31 feet
L2 BACKFILL AROUND CASING
MATERIAL cement-sand grout
THICKNESS 27 feet
SEAL
TYPE OF SEAL bentonite
L4 THICKNESS 2 feet
FILTER PACK
TYPE OF FILTER #2 silica sand
DISTANCE ABOVE SCREEN 2 feet
WELL SCREEN
L3 SCREEN MATERIAL Sch 40 PVC
DIAMETER 2 inches
LENGTH 15 feet
SLOT SIZE 0.010 inches
DEPTH TO BOTTOM OF
MONITORING WELL 46.0 feet
DEPTH TO BOTTOM OF
BOREHOLE 46.0 feet
L1 =0.5 FT.
L2 =31 FT.DIAMETER OF BOREHOLE 8.25 inches
L3 =15 FT.
L4 =46 FT.
TITLE Permanent Monitoring Well Diagram
FILE PREP. BY REV. BY DATE PROJECT NO.
SS 2/5/2021 DC11001101
7606 Whitehall Executive Center Drive
Charlotte, North Carolina 28273
Bon Ton Cleaners and Laundry
650 Haywood Road
Asheville, NC
Waste Management
ENVIRONMENTAL QUALITY
PROPERTY ACCESS CONSENT
This document may not be modified without the Program'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 Program's
contractor for this project, Al Quarles with ATC Associates of North
Carolina, P.C. at al.quarlesatcgs.com or [phone]. If you still
have questions after contacting Mr. Quarles with ATC, please contact
the DSCA Program Project Manager, Mr. Mike Cunningham at
mike.cunningham.meyer ancdenr.gov or 919-707-8361.
Please Print
Ingles Markets Inc
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
MICHAEL SCOTT
Division Director
For DSCA Use Only
DSCA ID No.
DC110011
(Name of Property Owner or Tenant in Residence)
669 Haywood Road
(Street Number and Street Name of Property)
Asheville Buncombe 28806
(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
State of North Carolina I Environmental Quality j Waste Management
1646 Mail Service Center 1217 West Jones Street i Raleigh, NC 27699-1646
919 707 8200 Telephone

DSCA Site ID No.
Page 2 of 2
DC110011
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".
ature of Property Owner or Tenant in Residence)
15)-g" 76S- 3512_
3-G-,2d
(Date)
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
KENV loA 1 (. :LNG-1- — ! A e15 c 4Y''t-
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via email)
Please return form to the DSCA Program's contractor for this site:
Al Quarles, L.G.
ATC Associates of North Carolina, P.C.
7606 Whitehall Executive Center Drive, Suite 800
Charlotte, NC 28273
Or via email to: [e-mail]