WM0401438_Monitoring Well Permit Application_20230220

ENVIRONMENTAL • GEOTECHNICAL
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
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax:[phone]
www.atcassociates.com
N.C. Engineering License No. C-1598
200 Jonestown Road
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. [e-mail].
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(&oneatlas.com
6. Property Owner (if different than Applicant): SCG Summit Station LLC Telephone: [phone]
Property Owner's Mailing Address: 23B Shelter Cove Ln Suite 202 Hilton Head Island, SC 29928
Property Owner's Email Address (if available): tbonnstetterCo)southcoastcenters.com tluskQsouthcoastcenters.com, and
am i ntz(a)southcoastcenters.com
7. Property Physical Address (Including PIN Number) 125 Jonestown Road (PIN#: 6804-59-6901)
City Winston-Salem County Forsvth 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).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet):
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): approximately 440 and 480 feet
15. Well Contractor: South Atlantic Environmental Drilling and Construction Co. Inc. Certification No.:
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 5. How will the well(s) be secured? Flush -mount steel
material: 1 protective casing and locking well cap.
3. Number of wells to be constructed in bedrock: 0
6. Estimated beginning construction date: 3/20/23
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3) 7. Estimated construction completion date: 3/24/23
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 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
2090 U.S. Highway 70
Raleigh Regional Office
Swannanoa, NC 28778
3800 Barrett Drive
Wilmington Regional Office
Phone: [phone]
Raleigh, NC 27609
127 Cardinal Drive Extension
Fax: [phone]
Phone: [phone]
Wilmington, NC 28405
Fax: [phone]
Phone: [phone]
Fayetteville Regional Office
Fax: [phone]
225 Green Street, Suite 714
Washington Regional Office
Fayetteville, NC 28301-5094
943 Washington Square Mall
Winston-Salem Regional Office
Phone: [phone]
Washington, NC 27889
450 W. Hanes Mill Road
Fax: [phone]
Phone: [phone]
Suite 300
Fax: [phone]
Winston-Salem, NC 27105
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

'VT 2725 E Millbrook Road, Suite 121 Proposed Groundwater Monitoring Well Map
AWCRaleigh, NC 27604 The Cleaners
[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\125 Jonestown2022.mxd
Coordinate System: NAD 1983 StatePlane North Carolina FIPS 3200 Feet

45'
At
svr
ENVIRONMENTAL • GEOTECHNICAL
IIING SCIFNCFS . MATMAIS
TFS
Well finished at surface with locking well
cap and flush -mounted protective casing.
2725 E. Millbrook Road, Suite 121
Raleigh, NC 27604
[phone]
PROJECT NO: DC340040
DATE: 02/13/2023 1 REVIEWED BY: RB
Grout extending from ground surface to
top of bentonite (0-25 feet).
2" Schedule 40 PVC riser
extending from ground surface to top of screen
(0-30 feet)
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 docuntent may not be modified without the Program's approval. For DSCA Use only
If you have questions on how to fill out this farm or about the activities DSCA site ty
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. (ATQ at
Robert.Broda t ooneatlas.coni or [phone]. Ifyou still have questions after contact€ngA4r.
Broda with ATC, please contact the DSCA project manager, Mr. David Kwiatkowski at
David.KwiatkovyskiCd),etcdenr.goy or [phone],
Please Print
SM-Summit Station, LLC (the "Property Owner")
(Name of Property Owner or Tenant in Residence)
125 Jonestown Road
(Street Number and Street Name of Property)
Winston Salem
27104
(City or Town in Which Property Is Located) / (County in Which Property is Located) / (Zip Code)
Subject to the teams and conditions set forth herein, the Property Owner voluntarily consents to the
Division of Waste Management (the "Division") and its independent contractors (contractors)
entering and having continued access to its property for the following purposes;
(1) installing and utilizing one (1_) monitoring well, which monitoring well shall be in the location
identified on the Proposed Groundwater Monitoring Well Map attached hereto and
incorporated herein as the "Proposed Groundwater Monitoring Well", or in such other location
as approved by the Property Owner in writing in its sole discretion;
(2) taking such soil, groundwater and/or air samples as may be necessary for the remediation
and/or continued monitoring of any actionable levels of chlorinated solvents and/orother
regulated chemicals found in, on or under the subject Property and originating from The
Drycleaners located at 200 Jonestown Road, Winston Salem, Forsyth County, North Carolina
(DSCA Site ID DC 340040); and
(3) taking other actions which are related to the investigation of surface or subsurface conditions
resulting from the presence of any actionable levels of chlorinated solvents and/or other
regulated chemicals found in, on or under the subject Property and originating from The
Drycleaners located at 200 Jonestown Road, Winston Salem, Forsyth County, North Carolina
,ME
aowanem of [mk.erim �tr
North Carolina Department of Environmental Quality I Division of Waste Management
217 West Jones Street i 1646 Mail Service Center I Raleigh, North Carolina 27699-1646
919.707.8200

(DSCA Site ID DC 340040) and reasonably necessary to mitigate any threat to human health
or the environment caused by same.
Other conditions:
(1) The Division and its contractors shall coordinate all activities and work pursuant to this Consent
(collectively, the "Activities") with the Property Owner in advance and shall perform such
Activities so as to occasion the least practical inconvenience and interruption to the tenants
operating at the Property.
(2) All Activities shall be at the Division's sole cost and expense. The Division shall pay, prior to
delinquency, all costs in connection with the Activities, and in no event shall the Division create
or pen -nit to be created or remain as a result of the Activities, any lien, encumbrance or charge
levied upon the Property.
(3) The results of all sampling, testing and investigation performed by the Division and its
contractors in connection with the Activities shall be promptly delivered to the Property Owner.
(4) Promptly after the 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 of the
Activities conducted by the Division or its contractors. The Division and its contractors shall
properly abandon the monitoring well in accordance with applicable laws and regulations,
unless other arrangements are agreed to in writing by the Property Owner.
(5) 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.
(6) The Property Owner shall not willfully destroy, damage, remove, pave over or cover the
monitoring well at the Property without prior consent of the Division.
(7) The rights of the Division and its contractors as set forth herein shall run from the date on which
the Property Owner signs this Consent to the conclusion of all Activities and the restoration
and well abandonment obligations set forth above. The Division or its contractors will give
written notice when all such obligations are completed. All of the Division's and its contractors'
obligations set forth herein shall survive the termination of same.
(8)
By signing this consent document, I acknowledge that I am a duly authorized representative
of the Property Owner 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".
By: 6Joh''n Mo
(Signature of Property Owner or Tenant in Residence)
Name: John F. Morgan, Jr.,
Feb. 2, 2023
(Date)
Title: Member of South Coast Management, LLC, the Manager of Property Owner
AID North Carolina Department of Environmental Quality I Division of Waste Management
_ 217 West Jones Street 1 1646 Mall Service Center I Raleigh. North Carolina 27699-1646
919.707.8200

404) 460-4511 Attn: Teresa Bonnstetter or Arnie Mintz
(Telephone Number for Property Owner or Tenant in Residence for scheduling
[e-mail], with copy to [e-mail]
and [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 Millbrook Road, Suite 121
Raleigh, NC 27604
Or via email to: Robert. [e-mail]
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
om.. .... wu.nr 919,707.8200