WM0401486_Monitoring well permit application_20231025

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: 10/17/2023
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 nested pair)
4. Applicant: John Clore (Petitioner for DSCA Site DC340037) Telephone: [phone]
Applicant's Mailing Address: DWM DSCA Program, Attn: David Kwiatkowski,1646 Mail Service Center, Raleigh, NC 27699-1646
Applicant's Email Address (if available): david.kwiatkowski(cDdeg.nc.gov
5. Contact Person (if different than Applicant): Sam Martin — Hart & Hickman, PC Telephone: [phone]
Contact Person's Mailing Address: 2923 S. Tryon St., Ste. 100 Charlotte, NC 28203
Contact Person's Email Address (if available): smartin(cDharthickman.com
6. Property Owner (if different than Applicant): Connie Steinburg Telephone: [phone]
Property Owner's Mailing Address: 118 Tucker Avenue, Winston-Salem, NC 27104
Property Owner's Email Address (if available): leocusp1(cD*uno.com
7. Property Physical Address (Including PIN Number) 118 Tucker Avenue (PIN: 6815-03-9870)
City Winston-Salem County Forsyth Zip Code 27104
8. Reason for Well(s): Environmental assessment for DSCA Program (DSCA Site DC340037)
(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).
NCDEQ DSCA Site DC340037
11. Type of contaminants being monitored or recovered: VOCs (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
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401034 through WM0401040
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): approx. 265 ft
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): See Attached Water Supply Well Location Map
15. Well Contractor: Geologic Exploration Certification No.: 4121
Well Contractor Address: 176 Commerce Blvd, 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
material: 2 (one nested well pair)
5. How will the well(s) be secured? Metal vault with
locking expansion plug
3. Number of wells to be constructed in bedrock: 0
6. Estimated beginning construction date: 10/25/23
4. Total Number of wells to be constructed: 2 7. Estimated construction completion date: 10/27/23
(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 assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
On behalf of petitioner for DSCA Site DC340037 Agent for petitioner for DSCA Stie DC 340037
Signature of Applicant or *Agent Title of Applicant or *Agent
Sam Martin — Hart & Hickman, PC * 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 property owner Access Agreement See attached property owner 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 Avenu
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]

AGREEMENT FOR ASSESSMENT AND REMEDIATION PURSUANT TO DSCA
ATTACHMENT 1
LIMITED POWER OF ATTORNEY
1, JU � o r Ip l c ("Petitioner"), do hereby
grant a limited power of attorney to the Division and to the Division's independent contractors, as
follows.
The Division and the Division's independent contractors shall have the limited power of attorney
for the preparation, signing, filing and delivery of any permit application, hazardous waste
manifest, non -hazardous waste manifest, National Pollution Discharge Elimination System
(NPDES) permit, for complying with any reporting requirements and for any administrative
activities that may be necessary in the course of assessment and remediation conducted pursuant
to the Agreement into which this Attachment 1 is incorporated.
This limited power of attorney shall terminate upon termination of the Agreement.
Dated ,
(Seal)
Signature of Petitioner 44 l�
STATE OF �qq COUNTY OF
On this / day of 4 P,L— , ; � 1.5' , personally appeared before me, the said named
La
dle" 42 .- (�4� to me known and known to me to be the person described
in and who executed the foregoing limited power of attorney and he (or she) acknowledged that
he (or she) executed the same and being duly sworn by me, made oath that the statements in the
foregoing limited power of attorney are true.
My Commission Expires lj !q _-,4&- _Za/7
(Signature of Notary Public)
Notary Public (Official Seal
I' rJhi BIdIALL—A!
Notary h uUic - Norli Carolina
x t County of Davie
@ Lind. M. Moore / 7
y_Corn n s rn 4rx Tres —
DSCA ARAv0705 Attachment 1

ROY COOPER,
Governor
'
t�
ELIZABETH S. BISER
•
Secretary
(4lY 1vµN
MICHAEL SCOTT
NORTH CAROLINA
Director
EnWronmentn/ Quality
PROPERTY ACCESS CONSENT
For DSCA Use Only
This document may not be modified without the Program's approval. DSCA ID No.
If you have questions on how to fill out this form or about the activities DC340037
at this site, please call the Dry -Cleaning Solvent Cleanup Act (DSCA)
Program 's contractor for this project Sam Martin with Hart & Hickman, PC, at
smartingharthickman. com or 704-586-0007. If you still have questions after contacting Mr.
Martin, please contact the DSCA Program Project Manager, Mr. David Kwiatkowski at
[e-mail] or [phone].
Please Print
Connie Steinb
(Name of Property Owner or Tenant in Residence)
118 Tucker Avenue
(Street Number and Street Name of Property)
Winston-Salem Forsyth County 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, 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 Mail Service Center I Raleigh, North Carolina 27699-1646
err r' 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".
Nr to ® L
(Signature of Property Owner o Tenant it eside (Date)
2LI - 79 9
lephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
(Email Address for Prbperty Owner or
email)
Please return form to:
Sam Martin
Hart & Hickman, PC
2923 S. Tryon Street, Charlotte, NC 28203
Or via email to: [e-mail]
in Residence if you prefer to be contacted via
r North Carolina Department of Environmental Quality I Division of Waste Management
_EQI% 217 West Jones Street 1 1646 Mail Service Center I Raleigh, North Carolina 27699-1646
919.707.8200

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— — — — SOURCE PROPERTY BOUNDARY
PARCEL
SOURCE PROPERTY BUILDINGS
OFF -SOURCE PROPERTY BUILDINGS
INTERMITTENT TRIBUTARY OF SILAS CREEK
TYPE II MONITORING WELL
4 TYPE III MONITORING WELL
I
N
APPROXIMATE
180 360
SCALE IN FEET
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0
NOTE:
MONITORING WELLS MW-1' THROUGH MW-10` ARE ASSOCIATED WITH DSCA SITE #DC340029 (ONE HOUR
MARTINIZING), MW-1^ & MW-2A ARE ASSOCIATED WITH DSCA SITE DC340037 (SOUTH FORK CLEANERS).
REMAINING WELLS ARE ASSOCIATED WITH DSCA SITE #DC340018 ($2.09 CLEANERS).

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SOURCE PROPERTY BOUNDARY
PARCEL LINE
m® SURFACE WATER
(N3 ® WATER SUPPLY WELL
(USE UNKNOWN)
QO= (4 INACTIVE WATER SUPPLY WELL
mm
® WATER SUPPLY WELL
❑ O Q�❑❑�Py��❑a1��❑ (NON -POTABLE USE)
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QGOEID 00 �Q O QQ SEPTIC SYSTEM
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�Y NOTES:
Cn 1. WATER SUPPLY WELL LOCATIONS ARE APPROXIMATE
AND BASED ON A WINDSHIELD SURVEY AND PUBLIC
MAILING CONDUCTED BY H&H.
ERS n
;p 2. TWO SUPPLY WELLS ARE LOCATED AT WSW-2
m (BOTH INACTIVE).
m
m 3. WSW-5 & WSW-6 WERE PREVIOUSLY IDENTIFIED AS
7D0 POTENTIAL WATER SUPPLY WELLS, BUT WERE
CONFIRMED TO BE SEPTIC SUMPS.
®WSW-47 D 4. WSWA9 THROUGH WSW-22 AND WSW-25 THROUGH
"< WSW-33 ARE LOCATED >1 MILE FROM THE SOURCE
® PROPERTIES AND ARE NOT DEPICTED ON THE
FIGURE.
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APPROXIMATE
0 600 1,200
mE SCALE IN FEET
WATER SUPPLY WELL LOCATION MAP
F;
U.S. $2.09 CLEANERS, ONE HOUR MARTINIZING,
SOUTH FORK CLEANERS
DSCA SITE ID: DC340018, DC340029, DC340037
3915, 4001, 3900 COUNTRY CLUB ROAD
WINSTON-SALEM, FORSYTH COUNTY
2923 South Tryon Street -Suite 100
hart h i c k m a n Charlotte, North Carolina 28203
704-586-0007(p)704-586-0373(�
SMARTER ENVIRONMENTAL SOLUTIONS License # C-1269 / #C-245 Geology
DATE: 7-12-23 REVISION NO. 0
JOB NO. DSO-03/DSO-63 ATTACHMENT NO. 5

NESTED MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE COVER
CROSS SECTIONAL VIEW
LOCKABLE WELL CAPo CONCRETE PAD
PAD DIMENSIONS ufeet xufeet
HEIGHT ABOVE GROUND Flush
BACKF|LLAROUND CASING
MATERIAL oomom ut/bomo uo grout
LENGTH o-3o/3-2sftfrom surface
WELL CASING
MATERIAL schedule 40pvo
DIAMETER 1mo»
JOINT TYPE flush threaded
LENGTH ao&aofeet
Ll
SEAL uonmn/te
WELL SCREEN (15f)
TYPE OFSEAL ufeet minimum
FILTER K
THICKNESS
FILTER PACK
TYPE OFFILTER No. uSand
DISTANCE ABOVE SCREEN ufeet
WELL SCREEN
WELL EN (5ft)
SCREEN MATERIAL schedule 4nPVC
DIAMETER 1mo»
LENGTH 1s&ofeet
FILTER K
SLOT SIZE 0.010mo»oo
DEPTH TOBOTTOM OF
Ll ~ 65 FT.
MONITORING WELL 4s&ss�ot
Le~ 45 FT �
DIAMETER
\
\
BOREHOLE
`—OEPTHTOBOTTOMOF
ueo/no»ou
_____
BOREHOLE efeot
TITLE Monitoring Well Diagram MW-3S/D
(Two nested one -inch diameter monitoring wells) Hart & Hickman, PC
2923 South Tryon St., Suite 100
Charlotte, North Carolina 28203
FILE PREP. BY SQM REV. BY CEZ DATE 10/17/2023� PROJECT NO. DSO-98