WM0401436_Monitoring Well Permit Application_20230220

INA,
®r
ENVIRONMENTAL • GEOTECNNICAL
BUILDING SCIENCES - MATERIALS TESTING
February 13, 2023
Mr. Jim Gonsiewski
North Carolina Department of Environmental Quality
Winston-Salem Regional Office
450 W. Hanes Mill Road Suite 300
Winston-Salem, NC 27105
Re: Permit to Construct Monitoring Wells
The Cleaners
200 Jonestown Road
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax:[phone]
www.atcassociates.com
N.C. Engineering License No. C-1598
Winston-Salem, Forsyth County, North Carolina 27104-4619
DSCA Site ID DC340040
Dear Mr. Jim Gonsiewski:
Enclosed please find applications for permits to construct five permanent groundwater
monitoring wells (MW-5 through MW-9) in Winston-Salem, Forsyth County, North Carolina.
Monitoring well MW-5 will be located at 4718 Randall Street (PIN# 6805-40-8048), MW-6 will
be located at 4711 Randall Street (PIN# 6805-50-0390), MW-7 will be located at 116 Jonestown
Road (PIN# 6805-50-3222), MW-8 will be located at 125 Jonestown Road (PIN# 6804-59-
6901), and MW-9 will be located at 204 Jonestown Road (PIN# 6805-50-3010). The permit
applications, site maps with the proposed location 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. Brodagoneatlas.com.
If you have any questions or require additional information, please contact our office at (919)
871-0999.
Sincerely,
ATC Associates of North Carolina, P.C.
Robert Broda, P.G.
Project Manager

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: 02-13-2023
2. County: Forsyth
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring (permanent)
4. Applicant: ATC Associates of NC. PC on Behalf of NCDEQ DWM DSCA Telephone: [phone]
Applicant's Mailing Address: 2725 E Millbrook Road Suite 121 Raleigh NC 27604 / DSCA Program Mail Service Center 1646,
Raleigh, NC 27699-1646
Applicant's Email Address (if available): David. Kwiatkowski(a-)ncdenr.gov
5. Contact Person (if different than Applicant): Robert Broda, ATC Telephone: [phone]
Contact Person's Mailing Address: 2725 E Millbrook Rd Suite 121 Raleigh NC 27604
Contact Person's Email Address (if available): Robert. Broda gaoneatlas.com
6. Property Owner (if different than Applicant): Lockbridge, LLC Telephone: [phone]
Property Owner's Mailing Address: 4711 Randall Street Winston-Salem, NC 27104
Property Owner's Email Address (if available): tlockhart(a-)financialquide.com
7. Property Physical Address (Including PIN Number) 4711 Randall Street (PIN#: 6805-50-0390)
City Winston-Salem County Forsyth Zip Code 27104
8. Reason for Well(s): Suspected 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 DC340040
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 4 wells on the source property
Existing Monitoring or Recovery Well Construction Permit No(s).: N/A
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 34
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): approximately 125 135 250 300 and 325 feet
15. Well Contractor: South Atlantic Environmental Drilling and Construction Co. Inc. Certification No.: 2675
Well Contractor Address: 9088 Northfield Drive, Fort Mill, SC 29707
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 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? Flush -mount steel
protective casing and locking well cap.
6. Estimated beginning construction date: 3/20/23
Estimated construction completion date: 3/24/23
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. 143-215.1013(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,
Y111-9
Subchapter 2C) and accepts full responsibility for compliance with these rules
`� �� Agent for NCDEQ DWM (will include power of attorney upon
Signature of Applicant or *Agent Title of Applicant or *Agent 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 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: [phone]
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]
OR Rev. 3-1-2016

2725 E Millbrook Road, Suite 121 Proposed Groundwater Monitoring Well Map
jkTc Raleigh, NC 27604 The Cleaners
j [phone] 200 Jonestown Road
Winston Salem, North Carolina
1 inch = 100 feet Date: 9/23/2022 Reviewed By: MG DSCA ID DC340040
Document Path: S:\GIS_GPS\Project_Folders\DSCA_34-0040\Access Maps 2021\4711 Randall Street2022.mxd
Coordinate System: NAD 1983 StatePlane North Carolina FIPS 3200 Feet

Well finished at surface with locking well
cap and flush -mounted protective casing.
Grout extending from ground surface to
45' top of bentonite (0-25 feet).
2" Schedule 40 PVC riser
extending from ground surface to top of screen
(0-30 feet)
ArAkT 2725 E. Millbrook Road, Suite 121
N C Raleigh, NC 27604
ENVIRONMENTAL • GEDTECHNICAL [phone]
niHr Sf.IFtjr.FS • MATFRIALS TESTING
PROJECT NO: DC340040
DATE: 02/13/2023 1 REVIEWED BY: RB
Bentonite seal (25-28 feet).
#2 Filter sand pack extending 2 feet above screen
(28-45 feet)
Groundwater Table
10 Feet of 2" Schedule 40 PVC screen (0.010" slot)
(30-45 feet)
TEMPORARY MONITORING
WELL CONSTRUCTION
DIAGRAM
The Cleaners
200 Jonestown Road
Winston-Salem, Forsyth County, NC 27104
DSCA ID: DC340040

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. For Dsea Use Only
If you have questions on how to fill out this form or about the activities DSCA Site ID
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program 's contractor for this project, .Robert Broda with ATC DC340040
Associates of North Carolina, P.C. (ATC) at.
[e-mail] or [phone]. Ifyou still have questions after contacting Mr.
Broda with ATC, please contact the DSCA project manager, Mr. David Kwiatkowski at
David.Kiviatkowski a,nedenr•.gov or [phone].
Please Print
Lockbridge LLC
(Name of Property Owner or Tenant in Residence)
4711 Randall Street
(Street Number and Street Name of Property)
Winston Salena Forsyth 27104
(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
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North Carolina Department of Environmental Quality i Division of Waste Management
217 West Jones Street 1 1646 Mail Service Center I Raleigh, North Carolina 27699-1646
919.707.6200

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".
i
_�______ _��iglaal�lre_of • . ei-ty_Ovuner.or'F�ff
P 97/-SPO,3 / -I
(Telephone Number for Property Owner or Tenant in Reside
(Email Address for Property Owner or Tenant in Residence
email)
Please return form to:
Robert Broda, P.G.
ATC Associates of North Carolina, P.C.
2725 East M'illbrook Road, Suite 121
Raleigh, NC 27604
Or via email to: [e-mail]
teVvIzz-
-,71ZVI
for scheduling work/notification)
to be coil
n North Carolina Department of Environmental Quality I Division of Waste Management
E 217 Vilest }ones Street 11646 Mail Service Center I Raleigh, North Carolina 27699-1646
NORM CAK00111
nee. .mcierffi—mwaa+atr� /fir 919,707.8200