HomeMy WebLinkAboutWM0501464_Application_202112132725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: 919-871-0999
Fax: 919-871-0335
www.atcgroupservices.com
N.C. Engineering License No. C-1598
December 13, 2021
Mr. Brion N. Byers, P.G.
Hydrogeologist
North Carolina Department of Environmental Quality
Raleigh Regional Office
Division of Water Quality, Aquifer Protection Section
3800 Barrett Drive
Raleigh, North Carolina 27609
Re: Permit to Construct Monitoring Wells
D W Dry Cleaners
314 South Driver Street
Durham, Durham County, North Carolina
DSCA Site ID DC320032
Dear Mr. Byers:
Enclosed please find two applications for permits to construct two permanent Type II
groundwater monitoring wells. One groundwater monitoring well will be installed on each of the
following two properties; 2019 Angier Avenue and 2021 Angier Avenue in Durham, Durham
County, North Carolina. The permit applications, site maps 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 or via email
to Robert.Broda@oneatlas.com.
If you have any questions or require additional information, please contact our office at (919)
871-0999 or my cellular telephone at (919) 624-1183.
Sincerely,
ATC Associates of North Carolina, P.C.
Robert Broda, P.G.
Project Geologist
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: 12/13/2021
2. County: Durham
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Charmin Holdings, LLC (Petitioner for DSCA Site ID DC320032) Telephone: (919) 437-4181
Applicant’s Mailing Address: DSCA Program, Mail Service Center 1646, Raleigh, NC 27699-1646
Applicant’s Email Address (if available): Jay.King@ncdenr.gov
5. Contact Person (if different than Applicant): Robert Broda, ATC Associates of NC, PC (ATC) Telephone: (919) 871-0999
Contact Person’s Mailing Address: 2725 E. Millbrook Road, Suite 121, Raleigh, NC 27604
Contact Person’s Email Address (if available): Robert.broda@oneatlas.com
6. Property Owner (if different than Applicant): Ashleys Corner LLC Telephone: (919) 621-1487
Property Owner’s Mailing Address: 203 Bathgate Lane, Cary, North Carolina 27513
Property Owner’s Email Address (if available): rogers286@aol.com
7. Property Physical Address (Including PIN Number) 2019 Angier Avenue (PIN # 0831-15-62-0524)
City Durham County Durham Zip Code 27703
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 DC320032
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, 3
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): ~60 Feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? ATC identified 2 structures that are
possibly water supply wells within 500 feet of the proposed wells.
If yes, give distance(s): ~400 & 450 Feet
15. Well Contractor: Innovative Environmental Technologies, Inc. Certification No.: 3287-B
Well Contractor Address: 232 Highway 49 South, Concord, NC 28025
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? Locking well cap,
Flush-mount steel protective casing
6. Estimated beginning construction date: 01/17/2022
7. Estimated construction completion date: 01/18/2022
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
Agent for DSCA Site DC320032 (will include power of attorney
Signature of Applicant or *Agent Title of Applicant or *Agent upon request)
Robert Broda, P.G. (Agent for NCDEQ DWM) * 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 See attached 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: (828) 296-4500
Fax: (828) 299-7043
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: (910) 433-3300
Fax: (910) 486-0707
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: (704) 663-1699
Fax: (704) 663-6040
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: (919) 791-4200
Fax: (919) 571-4718
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: (252) 946-6481
Fax: (252) 975-3716
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: (910) 796-7215
Fax: (910) 350-2004
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: (336) 776-9800
Fax: (336) 776-9797
GW-22MR Rev. 3-1-2016
1
H:\2019\OTHER OFFICES\NORTH CAROLINA\NCDEQ-DWM-DSCA PROGRAM\32-0032 NO NAME\DC3232SL01 - SITE.DWG, FIG1
316 DRIVER STREET
FORMER DRY
CLEANERS
FORMER LOCATION
OF CHEMICAL
STORAGE TRAILER /
/
2104 ANGIER AVENUE
FORMER LAUNDROMAT AND
COMMERCIAL PRINTER
T /
MW-2/ /
\\\ T W — 2 /
2725 E. Millbrook Road, Suite 121
Raleigh, NC 27604
(919) 871-0999
PROJECT NO: DC3232SL02
MONITORING WELL
CONSTRUCTION DETAIL
D W Dry Cleaners
314 South Driver Street
Durham, Durham County, North
Carolina
DSCA Site ID DC320032REVIEWED BY: AWDATE: 12/13/2021
2” Diameter Schedule 40 PVC Casing Extending
From Ground Surface to Top of Screen (0-10 feet)
Grout Extending From Ground Surface
To Top of Bentonite (0-5 feet)
#2 Filter Sand Pack Extending 2 Foot Above Screen
(8-20 feet)
15 Feet of 2” Schedule 40 Well Screen (0.010” Slot)
(10-20 feet)
Well finished at surface with a locking
well cap and flush-mount steel
protective casing
Groundwater Table
Type II Groundwater Monitoring Well
Installed in Unconsolidated Material
3-Foot of Bentonite Seal (5-8)
SITELEGEND:SOURCE PROPERTY LINENOTE: ALL LOCATIONS ARE APPROXIMATEWSW-1POSSIBLE WATER SUPPLY WELL -ACTIVE MUNICIPAL WATER ACCOUNTWell IdentificationPARCEL LINE1,500 FT.RADIUS0.5 MILERADIUS1907 CARDENS LANE2006 ANGIER AVENUE2405 OWEN STREET501 BINGHAM STREET2402 HARVARD AVENUE2612 SATER STREET208 NORTH GUTHRIE AVENUE304 CHERRY GROVE STREET206 NORTH MAPLE STREET600400200600SCALE: 1" = 600'0NAttachment:Drawing File:
Project Number:
Ckd. By:
Drn. By:
App'd By:
Ckd. Date:Scale:Date:H:\2021\OTHER OFFICES\NORTH CAROLINA\NCDEQ-DWM-DSCA PROGRAM\32-0032 D W DRY CLEANERS\DC3232SL02-WSW.DWG, ATT20
POSSIBLE WATER SUPPLY WELLS12/02/2021SEE LOWER LEFTD W DRY CLEANERS
314 SOUTH DRIVER STREET
DURHAM, DURHAM COUNTY, NORTH CAROLINA
DC3232SL02AS SHOWNDH
RB20NOTES:
1.Features shown are not an authoritative location, nor are they presented
to a stated accuracy.
COORDINATE SYSTEM:
NAD 1983 NORTH CAROLINA STATE PLANE FIPS 3200, US SURVEY FEET
DSCA Site ID:
DC320032
ROY COOPER
Governor
ELIZABETH S. BISER
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, Robert Broda with ATC
Associates of North Carolina, P.C. (ATC) at
Robert.Broda@oncatlas.com or (919) 624-1183. If you still have questions after
contacting Mr. Broda with ATC, please contact the DSCA project manager, Al
Chapman at A1.Chapman( ncdenr.gov or (919) 707-8368.
For DSCA Use Only
DSCA Site ID
DC320032
Please Print
Ashleys Corner LLC
(Name of Property Owner or Tenant in Residence)
2019 Angier Avenue
(Street Number and Street Name of Property)
Durham Durham 27703
(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 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
North Carolina Department of Environmental Quality I Division of Waste Management
217 West Jones Street 11646 Mall Service Center I Raleigh, North Carolina 27699-1646
919.707.8200
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".
(Signat e ro pe rty Owner or Tenant in Residence)
o
/o/)
(f
( ate
-t 0-1 e_› c( 2 1 —
(Telephone Number for Property Ow r or Tenant in Residence for scheduling work/notification)
V 0 cof t-S 2 0 w no( . c,60,1
(Email Address fo Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Robert Broda, P.G.
ATC Associates of North Carolina, P.C.
2725 East Millbrook Road, Suite 121
Raleigh, NC 27604
Or via email to: Robert.Broda@oneatlas.com
DEQ1
P r
North Carolina Department of Environmental Quality I Division of Waste Management
217 West Jones Street 11646 Mall Service Center I Raleigh. North Carolina 27699-1646
919.707.8200
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: 12/13/2021
2. County: Durham
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Charmin Holdings, LLC (Petitioner for DSCA Site ID DC320032) Telephone: (919) 437-4181
Applicant’s Mailing Address: DSCA Program, Mail Service Center 1646, Raleigh, NC 27699-1646
Applicant’s Email Address (if available): Jay.King@ncdenr.gov
5. Contact Person (if different than Applicant): Robert Broda, ATC Associates of NC, PC Telephone: (919) 871-0999
Contact Person’s Mailing Address: 2725 E. Millbrook Road, Suite 121, Raleigh, NC 27604
Contact Person’s Email Address (if available): Robert.broda@oneatlas.com
6. Property Owner (if different than Applicant): SHVF East Durham 1 LLC Telephone: (919) 956-4622
Property Owner’s Mailing Address: PO Box 3619, Durham, North Carolina 27702
Property Owner’s Email Address (if available): john.craddock@self-help.org
7. Property Physical Address (Including PIN Number) 2101 Angier Avenue (PIN # 0831-19-62-3540)
City Durham County Durham Zip Code 27703
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 DC320032
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, 3
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): ~135 Feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? ATC identified 2 structures that are
possibly water supply wells within 500 feet of the proposed wells.
If yes, give distance(s): ~400 & 450 Feet
15. Well Contractor: Innovative Environmental Technologies, Inc. Certification No.: 3287-B
Well Contractor Address: 232 Highway 49 South, Concord, NC 28025
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? Locking well cap,
Flush-mount steel protective casing
6. Estimated beginning construction date: 01/17/2022
7. Estimated construction completion date: 01/18/2022
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
Agent for DSCA Site DC320032 (will include power of attorney
Signature of Applicant or *Agent Title of Applicant or *Agent upon request)
Robert Broda, P.G. (Agent for NCDEQ DWM) * 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 See attached 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: (828) 296-4500
Fax: (828) 299-7043
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: (910) 433-3300
Fax: (910) 486-0707
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: (704) 663-1699
Fax: (704) 663-6040
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: (919) 791-4200
Fax: (919) 571-4718
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: (252) 946-6481
Fax: (252) 975-3716
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: (910) 796-7215
Fax: (910) 350-2004
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: (336) 776-9800
Fax: (336) 776-9797
GW-22MR Rev. 3-1-2016
1
H:\2019\OTHER OFFICES\NORTH CAROLINA\NCDEQ-DWM-DSCA PROGRAM\32-0032 NO NAME\DC3232SL01 - SITE.DWG, FIG1
316 DRIVER STREET
FORMER DRY
CLEANERS
FORMER LOCATION
OF CHEMICAL
STORAGE TRAILER /
/
2104 ANGIER AVENUE
FORMER LAUNDROMAT AND
COMMERCIAL PRINTER
T /
MW-2/ /
\\\ T W — 2 /
2725 E. Millbrook Road, Suite 121
Raleigh, NC 27604
(919) 871-0999
PROJECT NO: DC3232SL02
MONITORING WELL
CONSTRUCTION DETAIL
D W Dry Cleaners
314 South Driver Street
Durham, Durham County, North
Carolina
DSCA Site ID DC320032REVIEWED BY: AWDATE: 12/13/2021
2” Diameter Schedule 40 PVC Casing Extending
From Ground Surface to Top of Screen (0-10 feet)
Grout Extending From Ground Surface
To Top of Bentonite (0-5 feet)
#2 Filter Sand Pack Extending 2 Foot Above Screen
(8-20 feet)
15 Feet of 2” Schedule 40 Well Screen (0.010” Slot)
(10-20 feet)
Well finished at surface with a locking
well cap and flush-mount steel
protective casing
Groundwater Table
Type II Groundwater Monitoring Well
Installed in Unconsolidated Material
3-Foot of Bentonite Seal (5-8)
SITELEGEND:SOURCE PROPERTY LINENOTE: ALL LOCATIONS ARE APPROXIMATEWSW-1POSSIBLE WATER SUPPLY WELL -ACTIVE MUNICIPAL WATER ACCOUNTWell IdentificationPARCEL LINE1,500 FT.RADIUS0.5 MILERADIUS1907 CARDENS LANE2006 ANGIER AVENUE2405 OWEN STREET501 BINGHAM STREET2402 HARVARD AVENUE2612 SATER STREET208 NORTH GUTHRIE AVENUE304 CHERRY GROVE STREET206 NORTH MAPLE STREET600400200600SCALE: 1" = 600'0NAttachment:Drawing File:
Project Number:
Ckd. By:
Drn. By:
App'd By:
Ckd. Date:Scale:Date:H:\2021\OTHER OFFICES\NORTH CAROLINA\NCDEQ-DWM-DSCA PROGRAM\32-0032 D W DRY CLEANERS\DC3232SL02-WSW.DWG, ATT20
POSSIBLE WATER SUPPLY WELLS12/02/2021SEE LOWER LEFTD W DRY CLEANERS
314 SOUTH DRIVER STREET
DURHAM, DURHAM COUNTY, NORTH CAROLINA
DC3232SL02AS SHOWNDH
RB20NOTES:
1.Features shown are not an authoritative location, nor are they presented
to a stated accuracy.
COORDINATE SYSTEM:
NAD 1983 NORTH CAROLINA STATE PLANE FIPS 3200, US SURVEY FEET
DSCA Site ID:
DC320032
ROY COOPER
Governor
ELIZABETH S. BISER
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, Robert Broda with ATC
Associates of North Carolina, P.C. (ATC) at
Rahert.Broda@oneatlas.com or (919) 624-1183. If you still have questions after
contacting Mr. Broda with ATC, please contact the DSCA project manager, Al
Chapman at A1.Chapman(aincdenr.gov or (919) 707-8368.
For DSCA Use Only
DSCA Site ID
DC320032
Please Print
SHVF East Durham 1 LLC
(Name of Property Owner or Tenant in Residence)
2101 Angier Avenue
(Street Number and Street Name of Property)
Durham Durham 27703
(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 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
eQtE 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
11/3/2021
john.craddock@self-help.org
919-956-4622