WM0401411_Monitoring Well Permit Application_20221128

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 fr
1. Date:
2. County: Forsyth
rr a permit to construct monitoring or recovery wells.
FOR OFFICE USE ONLY
[PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Permanent Monitoring Well
4. Applicant: Michael and Kristine Tozer (oetitioner for DSCA Site #DC340022) Telephone: Scott Stupak [phone]
Applicant's Mailing Address: DSCA Program, 1646 Mail Service Center, Raleiah. NC 27699-1646
Applicant's Email Address (if available): scott.stupak(Dncdenr.aov
5. Contact Person (if different than Applicant): Jeffrey 011ison. Hart & Hickman. PC Telephone: [phone]
Contact Person's Mailing Address: 3921 Sunset Ridae Road Suite 301. Raleigh, NC 27607
Contact Person's Email Address (if available): iollisonO-harthickman.com
6. Property Owner (if different than Applicant): Main Street Baptist Church Telephone: [phone]
Property Owner's Mailing Address: 126 N. Main Street, Kernersville, NC 27284
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 126 N. Main Street (PIN# 6886-34-3473.000)
City Kernersville CountyForsyth Zip Code 27284
8. Reason for Well(s): Environmental Assessment for DSCA Program
(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: Former 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).
NCDEQ DSCA Site ID #DC340022
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?
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): know waste in groundwater at proposed location
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. Certification No.: 2725-A
Well Contractor Address: 4185 Barrier Road, Concord, NC 28025
PROPOSED WELL CONSTRUCTION INFORMATION
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 rasing material and thickness
b. Estimated well depth I. Grout horizons
C. Screen intervals g. Well head completion details
d. Sand/gravel pack intervals
Continued on Reverse

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
Number of wells to be constructed in unconsolidated (add answers from 2 and 3)
material: 1 to 2 (an additional nested well may be 5. How will the well(s) be secured? Bolted flush -mount
constructed based on depth to bedrock observed in Heidh well cover with lockable cap
Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 1 to 2
6. Estimated beginning construction date: Dec.2022
7. Estimated construction completion date: Dec. 2022
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 orwell 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 rmil as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
r / Subchapter 2C) and accepts full responsibility for compliance with these rules
on behalf of Petitioner for DSCA Site DC340022 Agent for Petitioner for DSCA Site DC340022
ZT—nature of Applicant or *Agent Title of Applicant or *Agent
Jeffrey 011ison ' 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
wells) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
See attached property access agreement (Attachment 3) See attached property access agreement (Attachment 3)
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 Raleigh Regional Office Wilmington Regional Office
2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension
Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 28405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [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: (7G4)663-1699
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
IR Rev. 3G-2016

Attachment 1

LOCKAB
-ORING WELL CONSTRUC
CROSS SECTIONAL VIEW
CONCRETE PAD
FLUSH METAL WELL COVER
CONCRETE PAD
0 BACKFILL AROUND CASING
MATERIAL cement grout
LENGTH 3 ft (0 to 3 ft)
WELL CASING
MATERIAL schedule 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threaded
LENGTH 30 feet
Li
4 BACKFILL AROUND CASING
L3
MATERIAL bentonite/grout
LENGTH 23 feet (3 ft to 26 ft)
SEAL
TYPE OF SEAL bentonite
THICKNESS 2 feet (26 ft to 28 ft)
FILTER PACK
TYPE OF FILTER No.2 Sand
THICKNESS 12 feet(28 ft to 40 ft)
WELL SCREEN
SCREEN MATERIAL schedule 40 PVC
L2
DIAMETER 2 inches
LENGTH 10 feet
SLOT SIZE 0.010 inches
30 FT.
DEPTH TO BOTTOM OF
MONITORING WELL 40 feet
L1 =
L2=
10 FT.
DIAMETER
OF
L3=
40 FT.
BOREHOLE
4.25
in
TITLE Monitoring Well Diagram
MW-1
Hart & Hickman, PC
3921 Sunset Ridge Rd., Suite 301
Raleigh, North Carolina 27607
FILE
PREP. BY
REV. BY
DATE
PROJECT N0.
CCC
JAO
11/21/2022
DSO-153 (DSCA ID# DC340022)

L3
L1 = 30 FT
L2 = 10 FT
L3 = 40 FT
Monitoring
MW-1
L4
L8
L4 = 55 FT.
L5 = 5 FT.
L6 = 60 FT.
Diagram (Nest
Y V,YJ, RVYr, V,Y VC,WL{
CROSS SECTIONAL VIEW
FLUSH METAL WELL COVER
CONCRETE PAD
BACKFILL AROUND CASING
MATERIAL
LENGTH
BACKFILL AROUND CASING
MATERIAL
LENGTH
SEAL
t�TYPE OF SEAL
THICKNESS
FILTER PACK
TYPE OF FILTER
THICKNESS
DIAMETER OF
BOREHOLE
4,26 in
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
WELL SCREEN
SCREEN MATERIAL
DIAMETER
LENGTH
SLOT SIZE
DEPTH TO BOTTOM OF
MONITORING WELLS
bentonite/gmut
23 R(3 to 26 ft)
bentonite
2 ft (upper; 26-28 ft) & 13 ft (laser; 40-53 th
No. 2 send
12 ft (uppeq 2840 ft) & 7 ft (buret; 5&60 th
schedule 40 PVC
t indn
flush threaded
30 feet (Sh slloy4j & 55 feet (Deep)
schedule 40 PVC
1 Inch
10 feet (Shallov4 & 5 feet (Deep)
40 feet (shallm) & 80 feet (deep)
Hart & Hickman, PC
3921 Sunset Ridge Road, Suite 301
Raleigh, North Carolina 27607

Attachment 2

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LEGEND
SOURCE PROPERTY 801NDAR1
�1(2)..
- PPACEL BOUNDARY
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- - SURFACE WATER FEATURE
NOTES
L CONTAMINANT CONCENTRATIONS SHOWN INDICATE DATA COLLECTED FROM
SCALE M FEET
Q TYPEIIMOMTCHINGmU-
IMODERN OEPNERSI
THE MOST RECENT SAMPLING OWNTAT EACH LOCATIONWELLS MW-I
THROUGH MW7,DPT-1 THROUGH OPTd, MCI THROUGH MC{ANOWC-1 PCE
ISOCONCENTRATION MAP
THROUGH WCb ARE ASSOCIATED WTH PREVIOUS MODERN CLEANERS
O NW3818 TEMPOFARY MONITORING
ASSESSMENTACTINTIEB.MC-I THROUGH MC<WERESAMPLED IN FEBRUMY "
WARREN I'.LEANERS
WELL LOCATION
IN MARCH 20N PAIRS. MW-6, AND
WCCS WERE SAMPEDI MAARCH 2014WERE MMW0I THROUGH MWA AND MAJ WERE
DSCA SITE ID: DC300022
4 ]030TEMPORARYMONITORINGWELL
SAMPLED IN DECEMBER 3D11, DPTA THROUGH CRT 8 WERE SAMPLED IN
127 CHURCH LANE
LOCATION
FEBRIIARY 2018.TMW-1 THROUGH TMWIS WERE BAMPEO IN JANUARY 2020,
SWI THROUGH SWB. AND WOW I WERE SAMPLED IN SEPTEMBER MO. KERNERSVILLE, NORTH CAROLINA
® WATER SUPPLY WELL
2, DATA IB NOT SHOWN FOR TEMPORARY WELLS MC-1 THROUGH MISINCE .
02.8) PCECONCEMRATIONNA)
PER MANENT MONITORING WELLS MWI THROWN MWA PRONOE MORE .y •
RECENT AND RELIABLE DATA AT THESE LOCATIONS. hart
3921Swih Tryon Srx,Si
hICkmaII cuWnw,None [.Mw1
IS CONTOUR(.p CASHED
]. GROUNDWATER FLOWDIRECTION SHOWN BASEO ON HISTORICAL DATA t0i5B60]" ISIL,MO
COLLECTED FROM MODERN CLEANERS PERMANENT MONITORING WELLS. 91FAIw vrvF.cxL11MeL1mllwe Iv'n'e%W2w/M 24
—0.007—MERE INFERRED)
<_ •. OONTOURBARE BASED ON DATA FOR SHALLOW MONITORING WELLS.
DATA FOR WSW -I, WHICH IS ASSUMED TO BE A BEDROCK WELL. ARE NOT DATE: 4-5,21
REVISION N0.0
INFERRED GRWNOWATER FLOW
DIRECTION
USEDIN CONTOURING .
S. —= SURFACE WATER SAMPLING DATA CONSIDERED IN CONTOURING. JOB NO. DSDA 53 ATTADHMENTNOI

Attachment 3

NCDENR I FEs 1'°0°
North Carolina Department of Environment and Natur EResoyrpps
Dexlor R. Williams, Director Division of Wasto Managoinont Michael .,t'05"y; T, or
William G. Ross Jr., Secretary
OFF -SITE PROPERTY ACCESS CONSENT
This document may not he modified without the Progrant's approval' pSCA Site ID No.
Ifyou have questions on how to fill out this form or about the activities
at this site, please call the Dty-Cleaning Solvent Cleanup Program at 34-0021
9191508-8400.
Please Print
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, water and 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's 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.
164G Mnil Seiviso Cent(,,r, Raloigh, North Caiolina 27699-16,16
Phono 919.733-499GIPN( 919-715-360541tornel hllplfwastenotic.org
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(3) The Division's contractors will make rcasonable attempts to notify the Property
Owner at least 48 hours prior to entering the Property for any purpose, In
situations that the Division detennines to be of tin 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 docuntcnl, 1 acknowledge that 1 have contacted all tenants
ocenpying the property and all teunnis agree to the conditions of this "Off -site Property
Access Consent".
f � 0V'V so
( ratUM of rrnpcXVM%rAWr (llntc)
--- 1/,23,22
gram �O-e- It�(o.�
(PhnfedNameoFP0pertyQwncq
Please return to:
Division of Waste Management
DSCA Program
401 Oberlin Rd., Suite 150
Raleigh, NC 27605-1350
Timothy no longer works
for church - Kim Eubanks
(contact as of 1120/20)
(v4, September 10, 2007) Page 2