WM0401296_Monitoring Well Permit Application_20210525

Via E-mail
May 20, 2021
NCDEQ Division of Water Resources
Winston-Salem Regional Office
450 W. Hanes Mill Road
Winston-Salem, NC 27105
Attn: Mr. Jim Gonsiewski
hart a hickman
SMARTER ENVIRONMFN 11O 1 Ri t of
Environmental Quality
, Received
Re: Application for Permit to Install Permanent Monitoring Wells
DSCA Site ID: DC860004, Ray's Cleaners
Elkin, North Carolina
H&H Project No. DSO-149C
Dear Mr. Gonsiewski:
MAY 21 2021
Winston-Salem
Regional Office
Hart & Hickman, PC (H&H) has prepared two applications for permits to install permanent
monitoring wells to assess groundwater impacts associated with the North Carolina Dry-cleaning
Solvent Cleanup Act (DSCA) Program Site DC860004, Ray's Cleaners, located at 1526 N.
Bridge Road in Elkin, Surry County, North Carolina. If you have any questions, please do not
hesitate to call at 704-586-0007.
Sincerely,
Hart & Hickman, PC
COk-QX—
Ayla Horner, PG
Assistant Project Geologist
Attachments
2923 South Tryon Street, Suite 100
Charlotte, NC 28203
704.586.0007 main
3921 Sunset Ridge Rd , Suite 301
Raleigh, NC 27607
919.847.4241 main
www.harthickman.com

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: 5-20-2021
2. County: Surry
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant: Elkin Village, LLC (Petitioner for DSCA Site #DC860004)
Monitoring
Telephone: [phone]
Applicant's Mailing Address: DSCA Program (Contact: Al Chapman), 1649 Mail Service Center, Raleigh, NC 27699
Applicant's Email Address (if available): al.chapman aAncdenr.gov
5. Contact Person (if different than Applicant): Ayla Homer / Hart & Hickman
Contact Person's Mailing Address: 2923 South Tryon Street, Charlotte, NC 28203
Contact Person's Email Address (if available): ahomerharthickman.com
Telephone: [phone]
6. Property Owner (if different than Applicant): Betty D. Cockerham Telephone: [phone]
Property Owner's Mailing Address: 308 Country Club Road, State Road, NC, 28676
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 1521 N Bridge Street (PIN# 495214323799)
City Elkin County Surry Zip Code 28621
8. Reason for Well(s): Environmental 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: 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).
DSCA Site #DC860004
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, Five
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401218
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 350 ft
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
Well Contractor Address: 176 Commerce Boulevard, Statesville, NC 28625
Certification No.: 2401
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: 0
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3)
5. How will the well(s) be secured? Well will be
completed as a flush mount (locked expansion plug and
bolted steel manhole cover) monitoring well
6. Estimated beginning construction date: 6-2-2021
7. Estimated construction completion date: 6-3-2021
1.
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
Ayla Homer, PG
Printed name of Applicant or *Agent
Agent for Petitioner for DSCA Site #DC860004
Title of Applicant or *Agent
* If signing as Agent, attach authorization agreement stating
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 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] ,/L.
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]
GW-22MR Rev. 3-1-2016
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]

ROY COOPER
Governor
DIONNE DELLI-GATTI,uq.
Secretary
MICHAEL SCOTT NORTH CAROLINA
Director 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 Act (DSCA)
Program's contractor for this project Ayla Homer with Hart & Hickman, PC at
[e-mail] or [phone]. If you still have questions after contacting Ms.
Homer with H&H, please contact the DSCA Program Project Manager, Mr. Al Chapman at
[e-mail] or 919-707-8368.
For DSCA Use Only
DSCA ID No.
DC860004
Please Print
Betty D Cockerham
(Name of Property Owner or Tenant in Residence)
1521 North Bridge Street (Parcel ID: 4952-14-32-3799)
(Street Number and Street Name of Property)
Elkin Surry 28621
(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
North Carolina Department of Environmental Quality I Division of Waste Management
217 West Jones Street 11646 Mail Service Center I Raleigh. North Carolina 27699-1646
919.707.8200

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".
(Signature of Pperty Owner or Tenant in Residence) (Date)
Cis 95:-J',/rfl
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Ayla Homer
Hart & Hickman, PC
2923 S. Tryon Street, Suite 100
Charlotte, NC 28203
Or via email to: [e-mail]
r.tl D_E
C)1),
MDfaepor`not a[esmvmtta OW
North Carolina Department of Environmental Quality 1 Division of Waste Management
217 West Jones Street 1 1646 Mall Service Center 1 Raleigh, North Carolina 27699-1646
919.707.8200

TYPE II MONITORING WELL CONSTRUCTION DETAILS
CROSS SECTIONAL VIEW
LOCKABLE WELL CAP
A
L3
L1
L2
L1 = 30 FT.
L2 = 15 FT.
L3 = 45 FT.
DIAMETER OF
BOREHOLE
8.25 in
CONCRETE PAD
FLUSH METAL WELL COVER
CONCRETE PAD
BACKFILL AROUND CASING
MATERIAL
LENGTH
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
BACKFILL AROUND CASING
MATERIAL
LENGTH
SEAL
TYPE OF SEAL
THICKNESS
- FILTER PACK
TYPE OF FILTER
THICKNESS
WELL SCREEN
SCREEN MATERIAL
DIAMETER
LENGTH
SLOT SIZE
Cement grout
3 ft (0 to 3 ft)
Schedule 40 PVC
2 inches
Flush threaded
30 ft
Bentonite/grout
23 ft (3 to 26 ft)
Bentonite
2 feet (26 to 28 ft)
No. 2 Sand
17 ft (28 to 45)
Schedule 40 PVC
2 inches
15 feet
0.010inches
DEPTH TO BOTTOM OF
MONITORING WELL 45 feet
TITLE Monitoring Well Diagram
Hart & Hickman, PC
2923 South Tryon St., Suite 100
Charlotte, North Carolina 28203
FILE
PREP. BY
AH
REV. BY
CZ
DATE
15/20/2021
PROJECT NO.
DSO-149 (DSCA ID# 860004)

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.
Date: 5-20-2021
2. County: Surry
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Elkin Village, LLC (Petitioner for DSCA Site #DC860004)
Telephone: [phone]
Applicant's Mailing Address: DSCA Program (Contact: Al Chapman), 1649 Mail Service Center, Raleigh, NC 27699
Applicant's Email Address (if available): al.chapmanAncdenr.gov
5. Contact Person (if different than Applicant): Ayla Homer / Hart & Hickman Telephone: [phone]
Contact Person's Mailing Address: 2923 South Tryon Street, Charlotte, NC 28203
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): W& C Properties of NC, LLC Telephone: [phone]
Property Owner's Mailing Address: 796 Stanley Mill Road, Elkin, NC 28621
Property Owner's Email Address (if available): Registered Agent/Owner Matt Wilmoth (mwilmothtahvac.cas.com)
7. Property Physical Address (Including PIN Number) 1617 N. Bridge Street (PIN# 495214332757)
City Elkin County Surry Zip Code 28621
8. Reason for WeII(s): Environmental 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: 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).
DSCA Site #DC860004
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, Five
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401218
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 350 ft
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
Well Contractor Address: 176 Commerce Boulevard, Statesville, NC 28625
Certification No.: 2401
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: 0
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3)
5. How will the well(s) be secured? Well will be
completed as a flush mount (locked expansion plug and
bolted steel manhole cover) monitoring well
6. Estimated beginning construction date: 6-2-2021
7. Estimated construction completion date: 6-3-2021
1.
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. 143-215.106(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
Avla Homer, PG
Agent for Petitioner for DSCA Site #DC860004
Title of Applicant or *Agent
* 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 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] f L
Fax: [phone]

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 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 Act (DSCA)
Program's contractor for this project Shane Sisco with Hart & Hickman, P.C. at
ssisco@ harthickman.com or [phone]. If you still have questions after contacting Mr.
Sisco with H&H, please contact the DSCA Program Project Manager, Mr. Al Chapman at
[e-mail] or 919-707-8368.
For DSCA Use Only
DSCA ID No.
DC860004
Please Print
W & C Properties of NC, LLC (Contact: Matt Wilmoth)
(Name of Property Owner or Tenant in Residence)
1617 N Bridge St (Parcel ID: 495214332757)
(Street Number and Street Name of Property)
Elkin Surry 28621
(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.
�V'c.hlf 1 � E
YMM�ti G.Ay� 7
North Carol!na Department of Environmental Quality i Division of Waste Management
217 West Jones Street ; 1646 Mai Service Center I Ralcuih, North Carotsna 27699 WIt>
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".
/- 2 6/--2-v 20
(Signature of Property Owner or Tenant in Residence) (Date)
316-zyy7G7
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
44/.. 641. CA s ,
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Shane Sisco
Hart & Hickman, PC
2923 S. Tryon Street, Suite 100
Charlotte, NC 28203
Or via email to: [e-mail]
North Carolina Department of Environmental Quality I Division of Waste Management
717 West jaws Street ! 1644 Mal Service Center I R tigh, North Cara'.ina 27699.1641S
gig 707,4200

TYPE II MONITORING WELL CONSTRUCTION DETAILS
CROSS SECTIONAL VIEW
LOCKABLE WELL CAP
L3
/\
L1
L2
V
L1 = 30 FT.
L2 = 15 FT.
L3 = 45 FT.
DIAMETER OF
BOREHOLE
8.25 in
CONCRETE PAD
FLUSH METAL WELL COVER
CONCRETE PAD
BACKFILL AROUND CASING
MATERIAL
LENGTH
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
BACKFILL AROUND CASING
MATERIAL
LENGTH
SEAL
TYPE OF SEAL
THICKNESS
FILTER PACK
TYPE OF FILTER
THICKNESS
WELL SCREEN
SCREEN MATERIAL
DIAMETER
LENGTH
SLOT SIZE
— DEPTH TO BOTTOM OF
MONITORING WELL
Cement grout
3 ft (0 to 3 ft)
Schedule 40 PVC
2 inches
Flush threaded
30 ft
Bentonite/grout
23 ft (3 to 26 ft)
Bentonite
2 feet (26 to 28 ft)
No. 2 Sand
17 ft (28 to 45)
Schedule 40 PVC
2 inches
15 feet
0.010 inches
45 feet
TITLE Monitoring Well Diagram
Hart & Hickman, PC
2923 South Tryon St., Suite 100
Charlotte, North Carolina 28203
FILE
PREP. BY
AH
REV. BY
CZ
DATE
15/20/2021
PROJECT NO.
DSO-149 (DSCA ID# 860004)

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