WM0501464_Permit (Issuance)_20211215

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental Quality
December 15, 2021
Charmin Holdings, LLC (Petitioner for DSCA Site DC320032)
N.C. Department of Environmental Quality, DWM, DSCA Program
1646 Mail Service Center
Raleigh, NC 27699-1646
Subject: Monitoring Well Construction
Permit # WM0501464
D W Dry Cleaners
314 South Driver Street
Durham, NC -Durham County
To Whom It May Concern:
In accordance with the application received on December 13, 2021, we are forwarding herewith
Monitoring Well Construction Permit No. WM0501464 dated December 15, 2021, issued for the
construction of a monitor well system (installation of two wells) at the subject properties (2019 & 2101
Angier Avenue). Please be aware that some counties have well construction programs, and you may
be required to obtain a well construction permit before installation.
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,
�DocuSigned by:
Sc &kz ,
.'-BCDA9D825D4A46D...
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
Enclosure
cc: RRO Files/Laserfiche
Durham County Health Department
Email: robert.brcdaIa.oneatlas.com, Robert Broda, ATC, 2725 E. Millbrook, Suite 121, Raleigh,
NC
North Carolina Department of Environmental Quality I Division of Water Resources
Raleigh Regional Office : 3800 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
Charmin Holdings, LLC (Petitioner for DSCA Site DC320032)
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM (D W Dry Cleaners) consisting of two monitoring
wells owned by Charmin Holdings, LLC (Petitioner for DSCA Site DC320032) at mailing address 1646 MSC in Raleigh,
NC. The wells will be located on the property owned by Ashleys Corner, LLC and SHVF East Durham 1 LLC at 2019
and 2101 Angier Avenue respectively in Durham, N.C.-Durham County. This Permit is issued in accordance with the
application received on December 13, 2021, in conformity with specifications and supporting data, all of which are filed
with the Department of Environment and Natural Resources and are considered 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 .0108(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.
Permit issued the 15' of December 2021
FOR THE NORTH CAROLINA EN-V1 NMENTAL MANAGEMENT COMMISSION
Scott "-VnsoDnd ial ..
Supervisor
Division oater Resources By Authority of the Environmental Management Commission
Permit No. WM0501464
North Carolina Department of Environmental Quality I Division of Water Resources
Raleigh Regional Office 3800 Barrett Drive I Raleigh, North Carolina 27609
939.791.4200

Per-, i 2-A 5/2-1
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
1.
2.
3.
4.
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:
12/13/2021
County:
Durham
FOR OFFICE USE ONLY
PERMIT NO.CJ/ %OSSO /+ ? ' ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring
Applicant: Charmin Holdings. LLC (Petitioner for DSCA Site ID DC320032) Telephone: [phone]
Applicant's Mailing Address: DSCA Proaram, Mail Service Center 1646. Raleiah. NC 27699-1646
Applicant's Email Address (if available): Jay.Kingl5).ncdenr.aov
5. Contact Person (if different than Applicant): Robert Broda. ATC Associates of NC. PC (ATC) Telephone: f919) 871-0999
Contact Person's Mailing Address: 2725 E. Millbrook Road. Suite 121, Raleigh. NC 27604
Contact Person's Email Address (if available): Robert.brodat oneatlas.com
6. Property Owner (if different than Applicant): Ashlevs Corner LLC
Property Owner's Mailing Address: 203 Bathgate Lane. Cary, North Carolina 27513
Property Owner's Email Address (if available): roaers2860,aol.com
7. Property Physical Address (Including PIN Number) 2019 Angier Avenue (PIN # 0831-15-62-0524)
8.
9.
10.
Telephone: [phone]
City Durham County Durham Zip Code 27703
Reason for Well(s): Groundwater contamination
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
Type of facility or site for which the well(s) is(are) needed: Drv-cleaner (DSCA)
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
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.
Well Contractor Address: 232 Hiahwav 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.
b.
c.
d.
Borehole and well diameter
Estimated well depth
Screen intervals
Sand/gravel pack intervals
e.
f.
9.
Type of casing material and thickness
Grout horizons
Well head completion details
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
1.
ADDITIONAL INFORMATION
As required by 15A NCAC 02C .0105(0(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 feel 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 MCA Site DC320032 (will include power of attorney
Title of Applicant or *Agent upon request)
* If signing as Agent, attach authorization agreement stating
that you have the authority to act as the Agent.
Signature of Applicant or *Agent
Robert Broda. P.G. (Agent for NCDEQ DWM)
Printed name of Applicant or *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]
W€nston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW 22MR Rev. 3-1-2016

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Well finished at surface with a locking
well cap and flush -mount steel
protective casing
Grout Extending From Ground Surface
To Top of Bentonite (0-5 feet)
2" Diameter Schedule 40 PVC Casing Extending
From Ground Surface to Top of Screen (0-10 feet)
3-Foot of Bentonite Seal (5-8)
15 Feet of 2" Schedule 40 Well Screen (0.010" Slot)
(10-20 feet)
Groundwater Table
2 Filter Sand Pack Extending 2 Foot Above Screen
(8-20 feet)
Type II Groundwater Monitoring Well
Installed in Unconsolidated Material
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ENVIRONMENTAL• BEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 E. Millbrook Road, Suite 121
Raleigh, NC 27604
[phone]
PROJECT NO: DC3232SL02
DATE: 12/13/2021 REVIEWED BY: AW
MONITORING WELL
CONSTRUCTION DETAIL
D W Dry Cleaners
314 South Driver Street
Durham, Durham County, North
Carolina
DSCA Site ID DC320032

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
MICHAEL SCOTT
Director
NORTH CAROLINA
Envlranmentat Quality
PROPERTY ACCESS CONSENT
This document may not be modified without the Program's approval.
Ifyou 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
Rcb l.l3rodn@[e-mail] or [phone]. Ifyou still have questions afer
contacting Mr. Broda with ATC, please contact the DSCA project manager, Al
Chapman at A1.Chapman ti ncdenr.gov or [phone].
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:
(I) 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 Depart ment of Environmental Quality Division of Waste Management
2l7 West Jones Street 11646 Mall Service Center ' Raleigh, North Carolina 27b99 1646
N9.707.8200

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 arc tenants) occupying the property and all tenants agree to the conditions
of this "Property Access Consent".
(Signatp. of roperty Owner or Tenant in Residence)
O : ti
( ate)
(Telephone Number for Property Ow or Tenant in Residence for scheduling work/notification)
acer.�S2�w coo+•
Address
Please return form to:
Robert Broda, P.G.
ATC Associates of North Carolina, P.C.
2725 East Milibrook Road, Suite 121
Raleigh, NC 27604
Or via email to: Robert.Bruda nneatlas.cvm
North Carolina Department or Environmental Quality Division or Waste Management
217 West Jones Street 1646 Mall Service Center I Raleigh, North Carolina 27699 1646
919.707.8200

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
FOR OFFICE USE ONLY
PERMIT NO. (J V' OSv ItC't ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
Monitorina
4. Applicant: Charmin Holdings. LLC (Petitioner for DSCA Site ID DC320032) Telephone: [phone]
Applicants Mailing Address: DSCA Program. Mail Service Center 1646. Raleigh. NC 27699-1646
Applicant's Email Address (if available): Jay.Kinct ncdenr.gov
5. Contact Person (if different than Applicant): Robert Broda, ATC Associates of NC. PC Telephone: [phone]
Contact Person's Mailing Address: 2725 E. Millbrook Road. Suite 121, Raleigh. NC 27604
Contact Person's Email Address (if available): Robert.brodatia?oneatlas.com
6. Property Owner (if different than Applicant): SHVF East Durham 1 LLC Telephone: i919) 956-4622
Property Owner's Mailing Address: PO Box 3619. Durham, North Carolina 27702
Property Owner's Email Address (if available): john.craddocktfi�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 weil(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.
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
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 casino
6. Estimated beginning construction date: 01/17/2022
7. Estimated construction completion date: 01/18/2022
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
2" Agent for DSCA Site DC320032 (will include cower of attorney
Title of Applicant or *Agent upon reauest)
* If signing as Agent, attach authorization agreement stating
that you have the authority to act as the Agent.
Signature of Applicant or *Agent
Robert Broda. P.G. (Agent for NCDEQ DWMJ
Printed name of Applicant or *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]
*91411111diF
npton
GW-22MR Rev. 3-1-2016

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Well finished at surface with a locking
well cap and flush -mount steel
protective casing
Grout Extending From Ground Surface
To Top of Bentonite (0-5 feet)
2" Diameter Schedule 40 PVC Casing Extending
From Ground Surface to Top of Screen (0-10 feet)
3-Foot of Bentonite Seal (5-8)
15 Feet of 2" Schedule 40 Well Screen (0.010" Slot)
(10-20 feet)
Groundwater Table
#2 Filter Sand Pack Extending 2 Foot Above Screen
(8-20 feet)
Type II Groundwater Monitoring Well
Installed in Unconsolidated Material
A
ENVIRONMENTAL • SEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 E. Millbrook Road, Suite 121
Raleigh, NC 27604
[phone]
PROJECT NO: DC3232SL02
DATE: 12/13/2021 REVIEWED BY: AW
MONITORING WELL
CONSTRUCTION DETAIL
D W Dry Cleaners
314 South Driver Street
Durham, Durham County, North
Carolina
DSCA Site ID DC320032

GOY COOPER
GovernorELIZABE ELIZABETH S. BISER�r
4ww
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Se<l�Qry nnawu���
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, Robert Broda with ATC
Associates of North Carolina, P.C. (ATC) at
Rohert.Broda(riloneatlas.com or [phone]. If you still have questions after
contacting Mr. Broda with ATC, please contact the DSCA project manager, Al
Chapman at Al.Chapman(aincdenr.gov or [phone].
For DSCA Use Only
PSCA 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
North Carolina Department of Emiro mental Quality I Division of waste Management
217 west Jones Street 11646 Mail 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".
.366, la'
(Signature of Property Owner or Tenant in Residence)
919-956-4622
11/3/2021
(Date)
(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:
Robert Broda, P.G.
ATC Associates of North Carolina, P.C.
2725 East Milibrook Road, Suite 121
Raleigh, NC 27604
Or via email to: [e-mail]
.D..9")4
.4.,......„....,
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

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