WM0401469_Monitoring well construction permit application_20230802

AECOM AECOM Technical Services of North Carolina, Inc. [phone] tel
6000 Fairview Road,Suite 200
Charlotte,NC 28210
July 26, 2023
Mr. Jim Gonsiewski
Winston-Salem Regional Office
Division of Water Resources
Water Quality Regional Operations Section
Re: Monitoring Well Permit Application—MW-3,MW-4, and MW-5
NCDEQ—DSCA Program,DSCA Site DC410063
A Cleaner World#188 Dry Cleaner
2527 Eastchester Drive
High Point, Guilford County,NC
Dear Mr. Gonsiewski:
On behalf of the NCDEQ Dry-Cleaning Solvent Cleanup Act Program, AECOM Technical Services of
North Carolina,Inc.(AECOM)has prepared the attached permit application in accordance with 15A NCAC
2C .0105. Proposed activities include installation of three monitoring wells on the adjacent property to the
subject property located at 2525 Eastchester Drive (MW-3, MW-4,and MW-5).
Included herein are the Application for Permit to Construct a Monitoring or Recovery Well System packets
for the aforementioned property. The packet includes the Application for Installation of Monitoring Well,
a map of the proposed well location, a general well construction diagram, and a signed access agreement.
Upon approval, please forward the monitoring well construction permit(s) to me at
jeff.hvozdikkaecom.com. If you have any questions or require additional information, please do not
hesitate to call me at 704-522-0330.
Sincerely,
AECOM TECHNICAL SERVICES OF NORTH CAROLINA,INC.
, A 7—� �
Jeffrey T. Hvozdik,PG
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.
FOR OFFICE USE ONLY
1. Date: July 26, 2023
2. County: Guilford PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Petitioner—ACW Management Corp. Telephone:
Applicant's Mailing Address: 2019 Eastchester Dr, High Point, NC 27265
Applicant's Email Address(if available): chrisedw6a�aol.com
5. Contact Person (if different than Applicant): Jeff Hvozdik(AECOM) Telephone: [phone]
Contact Person's Mailing Address: 6000 Fairview Road, Suite 200, Charlotte, NC 28210
Contact Person's Email Address(if available): ieff.hvozdikCa�aecom.com
6. Property Owner(if different than Applicant): Telephone: [phone]
Property Owner's Mailing Address: 2525 Eastchester Drive, High Point, NC 27265
Property Owner's Email Address(if available): phunt(cDtriad.rr.com
7. Property Physical Address(Including PIN Number): 2525 Eastchester Dr(PARCEL ID 7813300895)
City: High Point County: Guilford Zip Code:27265
8. Reason for Well(s): Environmental assessment, 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-cleaning facility
(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 DC410063
11. Type of contaminants being monitored or recovered: Volatile organic compounds
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? No
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): 250
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 Certification No.:
Well Contractor Address: 176 Commerce Boulevard Statesville, NC 28677
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 5. How will the well(s) be secured? Locking cap
material: 3
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: August 2023
4. Total Number of wells to be constructed: 3 7. Estimated construction completion date: August 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. 143-215.10B(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
Project Manager/Geologist
i nature of Applicant or*Agent Title of Applicant or*Agent
Jeffrey T. Hvozdik of AECOM/Agent for DSCA Program
and on behalf of the Petitioner for DSCA Site DC410063 *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 signed 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 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 win sale r \\l\
Mooresville, NC 28115 ✓L r `I gh i
Phone: [phone]
Fax: [phone] J '
lie r le
F eft 'Ile
Will'ngtcn GW-22MR Rev.3-1-2016
Wilmington Regional Office I GW-22M(Rev.5/11)
Raleigh Regional Office 127 Cardinal Drive Extension

� . LEGEND
2
w Q Petitioned Property Boundary
A Cleaner World#188,DC410063
o
j ! Approximate Location of Dry-Cleaning y
• ` Machine&Waste Storage* p 0-100
0
Approximate Footprint of Former a Q U
_ .';, • Dry-Cleaning Machine* i y Q
Approximate Location of Boiler Room
�_ •.t w Approximate Location of Dumpster o U
t ��� � Parcel Lines o U"a
® N
` Proposed Monitoring Well Locations Q N �
_ _ Q
>; ..� • '�+ ' - Temporary Monitoring Well Location(PSI,2022) x
r `�` � � •�, ug/1 micrograms per liter p
\ Red highlighted text indicates concentrations above 2L
: n
• �+ a ` ' Standards.
c
!�' .. ��� \.. • �: �� BDL-Below Detection Limit oN
_ "'J ► '. ,A - PCE-Tetrachloroethylene .WU. U
TCE-Trichloroethylene
cis-1,2-DCE-cis-1,2-Dichloroethylenern
Of "O
a
• 00 Analytical results do not exceed calculated vapor � o N
o N O
a,
intrusion risk for residential or non-residential exposure zz z o
Z —DSCA Indoor Air Risk Calculator W v H rj
t
y ® N Analytical results do not exceed calculated vapor a O
intrusion risk for non-residential exposure but do 0 z o :a
exceed for residential exposure—DSCA Indoor Air p 8
1 Risk Calculator
00 Analytical results exceed calculated vapor intrusion
risk for residential and non-residential exposure —
MW-5 �' °`- , DSCA Indoor Air Risk Calculator
a i *Locations are based on a site walk performed on March 29,2023
• ' �"' � AECOM base layers from ArcMap Version 10.8.1 World Imagery
' '► ")t Base Map layer.
z+'%' AECOM obtained historical soil,groundwater,and vapor quality data 1
from the Phase II Environmental Site Assessment prepared by
6 t Professional Service Industries,Inc.(PSI)and dated October 11,
2022.
4� MW_q % w
•,� �e '�� "`fit, '� �'* �''� •--- � /�
MW-3 — It
rq
` S1(09/23/22) 00 r1
PCE-294 ug/L - �. o o
TCE-15.4 ug/L44
a
j > ' cis-1,2-DCE-13.9 ug/L
x` j ►s IQQ
Toluene-1.17 ug/L /
SHEET:
.41 ,� ,� APPROX.SCALE,ft. Figure 5

MW-3, MW-4 and MW-5
Ground Surface
0
Legend Title
Bentonite seal
Cap
5 2" Diameter SCH 40 PVC Riser ❑
Concrete
Filter pack
10 ® Outside grout
Screen
Solid riser
15 end cap
1z
r) 20
c�
25
E
x
0
a
Q 30
35
2" Diameter SCH 40 PVC
40 0.010" Machine Slot Screen
45
AECOMMONITORING WELL CONSTRUCTION DIAGRAM
A CLEANER WORLD#107
DC410063
QE�,�

z�,��:J�•...03'��is
ROYCOOPERs�'
Gat-ernor ,, -
�J
ELIZABETH S.BISER
Secretory
MICHAEL SCOTT NORTH CAROLINA
Director Environmental Quality
PROPERTY ACCESS CONSENT
For DSCA Use Only
DSCA ID No.
DC410063
This document may not be modified without the Program's approval.if you have questions on
horn 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 Mr.Jeffrey Hvozdik with AECOM at
jefj:l vo,,zdiknaeconacom or 704-522-0330. Ifyou still have questions after contacting Mt:
11vozdik with AECOM,please contact the DSCA Program Project Manager Mr.Eric
Rice at eric.rice(a)ncdenr:gnv or(919) 707-8373.
Please Print
--1 —
r 1Q.J C.q MrntA)t t4L4 1,. a P4 IS 1. C�1�k
(Name of Property Owner or Tenant in Residence)
r r t
5 C� C9 si-CA.-le�Ce-r U r
(Street Number and Street Name of Property)
c� ocn` rIVC� a7�(� 5
(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 leaving 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 with applicable laws and regulations,unless other arrangements arc
agreed to by the Property Owner.

(3) The Division or its contractors will make reasonable attempts to notify the Properly
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 Property Owner or Tenant in Residence) (Date)
/-?Dj 3
(Telephone Number for Property Owner or Tenant in Residence for scheduling worldnotification)
3� 6 � 6 og 5
(Email Address for ProDerty Owner or.T ant in Residence if you prefer to be contacted via
email) P k r I
Please return form to:
Jeffrey IIvozdik
AECOM
60M Fairview Road,Suite 200
Charlotte,NC 28210
Or via email to jeff' .hvozdik®aceom.cotn