WM0401467_Permit application_20230726

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ASSOCIATES OF NORTH CAROLINA, P.C.
July 25, 2023
Mr. Jim Gonsiewski
North Carolina Department of Environmental Quality
Winston-Salem Regional Office
450 West Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
Re: Permit to Construct Monitoring Well
Quality Cleaners
501 West English Road
High Point, Guilford County, North Carolina
DSCA ID No. DC410057
Dear Mr. Gonsiewski:
2725 East Millbrook Road, Suite 121
Raleigh, NC 27604
Tel: [phone]
www.oneatlas.com
N.C. Engineering License No. C-1598
Enclosed please find four applications for permits to construct four permanent groundwater
monitoring wells. The permanent groundwater monitoring wells will be located at 209 Appling
Way (PIN 7800056086), 401 West English Road (PIN 7800141814), 516 West English Road
(PIN 7800047832), and 418 Martin Luther King Jr Boulevard (PIN 7800141501) in High Point,
North Carolina. The permit applications, site map 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
j eremy.robbins(a�oneatlas.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.
Jeremy J. Robbins, 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.
Date: 7/25/2023
2. County: Guilford
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant:
5
6
II
8.
9.
10.
11.
12.
13.
14.
501 ENG. LLC (Petitioner for DSCA Site ID DC41005
Telephone: [phone]
Applicant's Mailing Address: DSCA Program, Mail Service Center 1646, Raleigh, NC 27699-1646
Applicant's Email Address (if available): 0ay.king aadeg.nc.gov
Contact Person (if different than Applicant): Jeremy Robbins, ATC Associates of NC, P.C. Telephone: [phone]
Contact Person's Mailing Address: 2725 E. Millbrook, Suite 121, Raleigh, NC 27604
Contact Person's Email Address (if available): Jeremy. Robbins6a oneatlas.com
Property Owner (if different than Applicant): City of High Point (Deputy City Manager: Greg Ferguson) Telephone: [phone]
Property Owner's Mailing Address: PO Box 230, High Point, NC 27262
Property Owner's Email Address (if available): greg.ferguson6a highpointnc.gov
Property Physical Address (Including PIN Number) 209 Appling Way (PIN 7800056086)
City High Point County Guilford Zip Code 27262
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: Dry-cleaner
(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 ID DC410057
Type of contaminants being monitored or recovered: Chlorinated Solvents
(ex: organics, nutrients, heavy metals, etc.)
Are there any existing wells associated with the proposed well(s)? If yes, how many? 5
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401188, WM0401189, and WM0401190
Distance from proposed well(s) to nearest known waste or pollution source (in feet): —120 feet
Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Geologic Exploration, Inc. Certification No.: 4459-A
Well Contractor Address: 176 Commerce Boulevard. Statesville. NC 28625
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? Locking well cap,
material: 1 flush -mount steel protective casing
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 9/11/2023
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 9/15/2023
(add answers from 2 and 3)
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. 143-215.1013(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Agent for DSCA Site ID DC410057 (Will include power of
on behalf of DSCA Petitioner Attorney upon request)
Signature of Applicant or *Agent Title of Applicant or *Agent
Jeremy Robbins, on behalf of DSCA Petitioner * 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
well(s) as outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
See attached access consent See attached access consent
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]
GW-22M/R (Rev. 5-26-2022)

ROY COOPER
Governor
ELIZABETH S. B1SER
Secretary
MICHAEL SCOTT
Director
NORTH CAROLINA
,Environmental Quality
PROPERTY ACCESS CONSENT
For DSCA Use Only
This document may not be modified without the Prograni's approval DSCA. ID No.
If yore have questions on how to fill out this form or about fire activities DC410057
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Progranr's contractor for this project Jeremy Robbins with ATC Associates of North Carolina,
P.G at [e-mail] or [phone]. Ifyou still have questions after
contacting Mr. Robbins with ATC, please contact the DSCA Program Project Manager, M•. Jay
King at jay.kin a,deq.nc.gov or [phone].
Please Print
City of High Point
(Name of Property Owner or Tenant in Residence)
209 Appling Way
(Street Number and Street Name of Property)
High Point Guilford County 27262
(City or Town in Which Property Is Located) 1 (County in Which Property is Located) I (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, surface water, 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 Properly 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
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
oepunwi a rc.`e�ernro++w�
919.707.8200

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
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".
(Signature of Priperty OwiWr or Tenant in
�G• 99'? - 95-/ S
or ??G • psir- � q
7 (Dar__ ............. /Z x
e_r)
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
its e(�rqt;, sb-- & % •�
(Email Addze'9s for Property Owner or
email)
Please return form to:
Jeremy J. Robbins, P.G.
ATC Associates of North Carolina, P.C.
2725 Past Millbrook Road, Suite 121
Raleigh, NC 27604
Or via email to: [e-mail]
I Darn'~ Ile .
Resid 1 ce t e if you
aV
to be contacted via
D Qq
.,- Worth Carolina Department of Environmental Quality I DIv€sion of Waste Management
��l}� 217 West Jones Street 1 1646 Mall Servlce Center I Ralelgh, North Caro€ina 27699-1646
i;�SRi GVY%4'1
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.
Date: 7/25/2023
2. County: Guilford
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: 501 ENG, LLC (Petitioner for DSCA Site ID DC410057) Telephone: [phone]
Applicant's Mailing Address: DSCA Program, Mail Service Center 1646, Raleigh, NC 27699-1646
Applicant's Email Address (if available): 0ay.king aadeg.nc.gov
5. Contact Person (if different than Applicant): Jeremy Robbins, ATC Associates of NC, P.C. Telephone: [phone]
Contact Person's Mailing Address: 2725 E. Millbrook, Suite 121, Raleigh, NC 27604
Contact Person's Email Address (if available): Jeremy. Robbins(�oneatlas.com
6. Property Owner (if different than Applicant): 401 English LLC Telephone: [phone]
Property Owner's Mailing Address: PO Box 6635, High Point, NC 27262
Property Owner's Email Address (if available): megan(�congdonfoundation.org
7. Property Physical Address (Including PIN Number) 401 W English Road (PIN 7800141814)
City High Point County Guilford Zip Code 27262
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
(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 ID DC410057
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? 5
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401188, WM0401189, and WM0401190
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): —95 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Geologic Exploration, Inc. Certification No.: 4459-A
Well Contractor Address: 176 Commerce Boulevard, Statesville, NC 28625
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? Locking well cap,
material: 1 flush -mount steel protective casing
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 9/11/2023
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 9/15/2023
(add answers from 2 and 3)
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. 143-215.1013(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
' accordance with 15A NCAC 02C.
/- #�- _ Agent for DSCA Site ID DC410057 (Will include power of
on behalf of DSCA Petitioner Attorney upon request)
Signature of Applicant or *Agent Title of Applicant or *Agent
Jeremy Robbins, on behalf of DSCA Petitioner * 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
well(s) as outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
See attached access consent
See attached access consent
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
3800 Barrett Drive
Wilmington, NC 28405
2090 U.S. Highway 70
Raleigh, NC 27609
Phone: [phone]
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Winston-Salem Regional Office
Washington Regional Office
450 W. Hanes Mill Road
Fayetteville Regional Office
943 Washington Square Mall
Suite 300
225 Green Street, Suite 714
Washington, NC 27889
Winston-Salem, NC 27105
Fayetteville, NC 28301-5094
Phone: [phone]
Phone: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
bvv-zzivi/K (Kev. o-zu-zuzL)
Raleigh Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension
GW-22M (Rev. 5/11)

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 DSCA Use Only
If you have questions on how to fill out this form or about the activities DSCA ID No.
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program's contractor for this project, Emily Fuller with ATC DC410057
Associates of North Carolina, P.C. at emily. fullerkoneatlas. com or
[phone]. If you still have questions after contacting Ms. Fuller with ATC
please contact the DSCA project manager, Jay King atday.Kingkncdenr.gov or
919-707-8367.
Please Print
401 English LLC
(Name of Property Owner or Tenant in Residence)
401 W English Road
(Street Number and Street Name of Property)
High Point
Guilford 27262
(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
North Carolina DeparImem of Environmental Quality I Dtvtslon of Waste Management
217 West jours Street 1 1646 MMI SeMce Center I RA49K North Carolina 27699.1646
919.707=0

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
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".
4/6/22
(Signature ofProperty Owner or Tenant in Residence) (Date)
Megan Oglesby 336-880-6293
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
megan @congdonfoundation. org
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Emily Fuller, P.G.
ATC Associates of North Carolina, P.C.
2725 East Millbrook Road, Suite 121
Raleigh, NC 27604
Or via email to: [e-mail]
North Carolina Department of Envlronmentat Quality I DMMon of Waste Management
217 West Jones Street i t646 MM SeMce Center I Rj"K North Carohru 27699-IW6
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.
Date: 7/25/2023
2. County: Guilford
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: 501 ENG, LLC (Petitioner for DSCA Site ID DC41005
5
6
II
8.
9.
10.
11.
12.
13.
14.
Telephone: [phone]
Applicant's Mailing Address: DSCA Program, Mail Service Center 1646, Raleigh, NC 27699-1646
Applicant's Email Address (if available): 0ay.king aadeg.nc.gov
Contact Person (if different than Applicant): Jeremy Robbins, ATC Associates of NC, P.C. Telephone: [phone]
Contact Person's Mailing Address: 2725 E. Millbrook, Suite 121, Raleigh, NC 27604
Contact Person's Email Address (if available): Jeremy. Robbins6a oneatlas.com
Property Owner (if different than Applicant): City of High Point (Deputy City Manager: Greg Ferguson) Telephone: [phone]
Property Owner's Mailing Address: PO Box 230, High Point, NC 27262
Property Owner's Email Address (if available): greg.ferguson6a highpointnc.gov
Property Physical Address (Including PIN Number) 516 West English Road (PIN 7800047832)
City High Point County Guilford Zip Code 27626
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: Dry-cleaner
(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 ID DC410057
Type of contaminants being monitored or recovered: Chlorinated Solvents
(ex: organics, nutrients, heavy metals, etc.)
Are there any existing wells associated with the proposed well(s)? If yes, how many? 5
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401188, WM0401189, and WM0401190
Distance from proposed well(s) to nearest known waste or pollution source (in feet): —90 feet
Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Geologic Exploration, Inc. Certification No.: 4459-A
Well Contractor Address: 176 Commerce Boulevard. Statesville. NC 28625
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? Locking well cap,
material: 1 flush -mount steel protective casing
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 9/11/2023
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 9/15/2023
(add answers from 2 and 3)
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. 143-215.1013(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Agent for DSCA Site ID DC410057 (Will include power of
on behalf of DSCA Petitioner Attorney upon request)
Signature of Applicant or *Agent Title of Applicant or *Agent
Jeremy Robbins, on behalf of DSCA Petitioner * 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
well(s) as outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
See attached access consent See attached access consent
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]
GW-22M/R (Rev. 5-26-2022)

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
MICHAEL SCOTT
Director
NORTH CAROLINA
Environmental Quality
PROPERTY ACCESS CONSENT
For DSCA Use Only
This document may not be modified without the Program's approval. DSCA ID No.
Ifyou have questions on how to fill out this forin or about the activities DC4410057
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program's contractor for this project Jeremy Robbins with A TC Associates of North Carolina,
P.C. at [e-mail] or (919) 573-I197. Ifyou still have questions after
contacting Mr. Robbins tvith ATC, please contact the DSCA Prograin Project Manager, Mr Jay
King at iay.king a,deq.nc.goy or [phone].
Please Print
City of High Point
(Name of Property Owner or Tenant in Residence)
516 W English Road
(Street Number and Street Name of Property)
High Point Guilford County 27262
(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, surface water, 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
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

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
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 ani 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".
C1,1y 11,7a r, 0 %/ I1 /z-ip
(Signature of Property 0Kvncr or Ten tin Residence)
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
r e 1, -4
(Email Address for ropert
email)
Please return form to.
r or Tenant in Residence if you I
Jeremy J. Robbins, P.G.
ATC Associates of North Carolina, P.C.
2725 East Millbrook Road, Suite 121
Raleigh, NC 27604
Or via email to. [e-mail]
6e
to be contacted via
D North Carolina Department of Environmental Quality I Division of Waste Management
217 West )ones Street 11646 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.
Date:
2. County:
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: 501 ENG, LLC (Petitioner for DSCA Site ID DC41005
Telephone: [phone]
Applicant's Mailing Address: DSCA Program, Mail Service Center 1646, Raleigh, NC 27699-1646
Applicant's Email Address (if available): 0ay.king aadeg.nc.gov
5. Contact Person (if different than Applicant): Jeremy Robbins, ATC Associates of NC, P.C. Telephone: [phone]
Contact Person's Mailing Address: 2725 E. Millbrook, Suite 121, Raleigh, NC 27604
Contact Person's Email Address (if available): Jeremy. Robbins6a oneatlas.com
6. Property Owner (if different than Applicant): New Man Holdings, LLC (Chad Newman) Telephone: [phone]
Property Owner's Mailing Address: 418 W Martin Luther King Jr. Drive
Property Owner's Email Address (if available): ChadNewman6a circaloft.com
7. Property Physical Address (Including PIN Number) 418 W Martin Luther King Jr. Drive (PIN 7800141501)
City High Point County Guilford Zip Code 27262
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
(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 ID DC410057
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? 5
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401188, WM0401189, and WM0401190
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): —80 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Geologic Exploration, Inc. Certification No.: 4459-A
Well Contractor Address: 176 Commerce Boulevard. Statesville. NC 28625
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? Locking well cap,
material: 1 flush -mount steel protective casing
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 9/11/2023
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 9/15/2023
(add answers from 2 and 3)
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. 143-215.1013(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Agent for DSCA Site ID DC410057 (Will include power of
on behalf of DSCA Petitioner Attorney upon request)
Signature of Applicant or *Agent Title of Applicant or *Agent
Jeremy Robbins, on behalf of DSCA Petitioner * 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
well(s) as outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
See attached access consent See attached access consent
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]
GW-22M/R (Rev. 5-26-2022)

r
,,
52
32
ROY COOPER
G'%V ml
ELIZABETH S. BISER
Sec-Awly
MICHAEL SCOTT
Director
r. STAT�-a
Ids
NORTH CAROLINA
Environmental Quality
PROPERTY ACCESS CONSENT
For DSCA Use Only
This document »car not be modified without the Program's approval. DSCA ID No.
#),ou have questions on how ro fill out this form or about the activities DC410057
at this site. please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program 's contractor_ for this project Jeremy Robbins with ATC Associates of North Carolina,
P.C. arJurr_n� .r�ihhins:�nea(I�isor [phone]. If you still have questions after
contacting Afr. Robbins with ATC please contact the DSCA Program Project Manager, Mr, Jay
King arla-N L, � or [phone].
Please Print
Nevi• Man Holdings, LLC
('Name of Property Owner or Tenant in Residence)
418 W Martin Luther King Jr Drive
(Street Number and Street Name of Property)
High Point Guilford County 27262
(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, surface water, 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
oarunmml a [nvnonmenm puHiry�
North Carolina Department of Environmental Quality I Clivislon of Waste Management
217 West Jones Street €646 Mail Service Center I RaWg#t, North Carolina 27699-1646
9€9.707.8200

with applicable laws and regulations, unless other arrangements are agreed to by the properly
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
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.
f
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 "Properth Access Consent".
a� �
(Signature of Property 4w ner ur Tenant in Residence)
t
(Date)
�oakl
-(Telephone !`umber for Property Owner or Tenant in Residence for scheduling work/notification)
c
; -4 6 � rt -ems
00 C i►'eo-P. cc)VV1 C ac�/l�e,�a.�q�, ���cq Ld`��, co,
'! •ad Ne w r4 a n
,9lv _gzR
(Email Address for Property Owner or Tenant in Residence if you prefer to be contacted via
email)
Please return form to:
Jeremy J. Robbins, P.G.
ATC Associates of North Carolina, P.C.
2725 East Millbrook Road, Suite 121
Raleigh, NC 27604
Or via email to: [e-mail]
Q
�� North Carolina Department or Environmental Qudilty 1 Division of Waste Management
217 West Jones Street I 1646 Mail Service Center I Raleigh. North Carolina 27699-1f,46
�'� 919.707.8200

L4
TYPICAL TYPE II MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
NOT TO SCALE
LOCKABLE WELL CAP
L1
L2
PROTECTIVE CASING AND CONCRETE PAD
CASING MATERIAL
Steel
CASING DIAMETER
8 inches
CASING LENGTH
12 inches
PAD DIMENSIONS
2 feet x 2 feet
HEIGHT ABOVE GROUND
flush mounted
Iliyl:IISq_F'1Ikiln
MATERIAL sch 40 PVC
DIAMETER 1 inches
JOINT TYPE flush threaded
LENGTH 10 feet
BACKFILL AROUND CASING
MATERIAL cement -sand grout
THICKNESS 6 feet
SEAL
TYPE OF SEAL bentonite
THICKNESS 3 feet
J 10 111 :1:»_Tel:/
TYPE OF FILTER
#2 silica sand
DISTANCE ABOVE SCREEN
1 feet
TOTAL FILTER PACK LENGTH
11 feet
WELL SCREEN
L3
SCREEN MATERIAL
sch 40 PVC
DIAMETER
1 inches
LENGTH
10 feet
SLOT SIZE
0.010 inches
L1 =
0
FT.
L2 =
10
FT.
L3 =
10
FT.
L4 =
20
FT.
DEPTH TO BOTTOM OF
MONITORING WELL 20 feet
DEPTH TO BOTTOM OF
BOREHOLE 20 feet
DIAMETER OF BOREHOLE 8.25 inches
TITLE Permanent Monitoring Well Diagram
(Example of typical MW installation displayed above) lim,
Quality Cleaners 2725 East Millbrook Road, Suite 121
501 West English Road Raleigh, North Carolina 27604
High Point, Guilford County, NC
FILE PREP. BY REV. BY DATE PROJECT NO.
JR I AO 7/25/2023 DC4157SL03

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