WM0401486_Monitoring well permit issuance_20231025

North Carolina Department of Environmental Quality | Division of Water Resources
Winston-Salem Regional Office | 450 W. Hanes Mill Rd, Suite 300 | Winston-Salem, North Carolina 27105
336.776.9800

October 25, 2023

DWM DSCA Program
Attn: David Kwiatkowski
1646 Mail Service Center
Raleigh, NC 27699-1646

SUBJECT: MONITORING WELL CONSTRUCTION
PERMIT NO. WM0401486
COUNTY: Forsyth
FILE NAME: South Fork Cleaners – DSCA Site DC34-0037

Dear Mr. Kwiatkowski:

In accordance with your application received on October 23, 2023, we are forwarding herewith:

1. Monitoring Well Construction Permit No. WM0401486 for the construction of two (2)
performance monitoring wells at 118 Tucker Avenue in Winston-Salem, North Carolian in
Forsyth County.

Henceforth, correspondence and data relating to this well shall be designated as specified in the
subject heading above. This Permit will be effective from the date of issuance and shall be subject
to the conditions and limitations as specified therein. If you have any questions regarding this
permit, please contact me or Shuying Wang at [phone].

Sincerely,

Lon T. Snider
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ – WSRO

cc: Sam Martin – Hart & Hickman, PC. (Electronic Copy)
Connie Steinburg (Electronic Copy)
WSRO eFiles

North Carolina Department of Environmental Quality | Division of Water Resources
Winston-Salem Regional Office | 450 W. Hanes Mill Rd, Suite 300 | Winston-Salem, North Carolina 27105
336.776.9800

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES – WATER QUALITY REGIONAL OPERATIONS
SECTION

PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL

In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and
other applicable Laws, Rules and Regulations.

PERMISSION IS HEREBY GRANTED TO

John Clore (Petitioner for DSCA Site DC340037)

FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of two (2)
performance monitoring wells owned by John Clore (Petitioner for DSCA Site DC340037). The
wells will be located at 118 Tucker Avenue in Winston-Salem, North Carolina, in Forsyth County.
This Permit is issued in accordance with the application received on October 23, 2023 in
conformity with specifications and supporting data, all of which are filed with the Department of
Environmental Quality and are considered integral parts of this Permit.

This Permit is for well construction only and does not waive any provision or requirement of any
other applicable law or regulation. Construction of any well under this Permit shall be in strict
compliance with the North Carolina Well Construction Regulations and Standards (15A NCAC
02C .0100), and other State and Local Laws and regulations pertaining to well construction.

If any requirements or limitations specified in this Permit are unacceptable, you have a right to an
adjudicatory hearing upon written request within 30 days of receipt of this Permit. The request
must be in the form of a written petition conforming to Chapter 150B of the North Carolina General
Statutes and filed with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh,
North Carolina 27699-6714. Unless such a demand is made, this Permit is final and binding.

This Permit will be effective for one year from the date of its issuance and shall be subject to other
specified conditions, limitations, or exceptions as follows:

1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these
wells are being installed as part of an investigation for contamination from an underground
storage tank or dry cleaner incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement
issued by another agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as part
of the Permit application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A NCAC
02C .0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of Water
Resources’ Information Processing Unit within 30 days of the well completion.

North Carolina Department of Environmental Quality | Division of Water Resources
Winston-Salem Regional Office | 450 W. Hanes Mill Rd, Suite 300 | Winston-Salem, North Carolina 27105
336.776.9800

6. When the well is discontinued or abandoned, it shall be abandoned in accordance with 15A
NCAC 02C .0113 and a well abandonment record (GW-30) shall be submitted to the
Division of Water Resources’ Information Processing Unit within 30 days of the well
abandonment.
7. The County Health Department may require a county monitoring well construction permit.
Please contact the health department for their requirements.

Permit issued the 25th day of October 2023

FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION

_______________________________________________
Lon T. Snider, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO

By Authority of the Environmental Management Commission

Permit No. # WM0401486