WM0100566_Monitoring Well Construction Application_20240103

FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
uijNORTH 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:January 3, 2024
2.County: Rutherford
3.What type of well are you applying for? (monitoring or recovery): Monitoring
4.Applicant: Doug Barrick, Rutherfordton Town Manager (Petitioner for DSCA Site ID DC810002) Telephone: [phone]
Applicant’s Mailing Address: DSCA Program, Attn: Ariana Riviera, 1646 Mail Service Center, Raleigh, NC 27699-1646
Applicant’s Email Address (if available): [e-mail]
5.Contact Person (if different than Applicant): Natalie McCarthy - Hart & Hickman, PC Telephone: [phone]
Contact Person’s Mailing Address: 2923 S. Tryon Street, Suite 100, Charlotte, NC 28203
Contact Person’s Email Address (if available): [e-mail]
6.Property Owner (if different than Applicant): Oriel Hospitality, LLC dba The Firehouse Inn Telephone: [phone]
Property Owner’s Mailing Address: 134 N Washington Street, Rutherfordton, NC
Property Owner’s Email Address (if available): N/A
7.Property Physical Address (Including PIN Number) 134 N Washington Street
City Rutherfordton County Rutherford Zip Code 28139
8.Reason for Well(s): Environmental assessment for DSCA Program (DSCA Site DC810002)
(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 ID DC810002
11.Type of contaminants being monitored or recovered: Stoddard Varsol (petroleum solvents)
(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):~ 15 ft
14.Are there any water supply wells located less than 500 feet from the proposed well(s)?No
j
If yes, give distance(s):
15.Well Contractor: Innovative Engineering Technologies, LLC. Certification No.: 3287-A or 2725-A
Well Contractor Address: 232 Highway 49 S, Concord, NC 28025
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
WM0100566 01/08/2024

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)

2. Number of wells to be constructed in unconsolidated
material: 1

3. Number of wells to be constructed in bedrock: 0

4. Total Number of wells to be constructed: 1
(add answers from 2 and 3)
5. How will the well(s) be secured? Bolted manhole and
locking expansion plug.

6. Estimated beginning construction date: 1/16/2024

7. Estimated construction completion date: 1/18/2024

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

On behalf of petitioner for DSCA Site DC810002 Agent for Petitioner for DSCA Site DC810002
Signature of Applicant or *Agent Title of Applicant or *Agent

Natalie McCarthy, Agent for the 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
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 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
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [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]

Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]

Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]

Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]

Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

PROPERTY ACCESS CONSENT
This document may not be modified without the Program’s approval.
If you have questions on how 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 Natalie McCarthy with Hart & Hickman, P.C. at
[e-mail] or [phone]. If you still have questions after contacting
Ms. McCarthy with H&H, please contact the DSCA Program Project Manager, Ms. Ariana
Rivera at [e-mail] or [phone].
Please Print
(Name of Property Owner or Tenant in Residence)
134 Washington Street
(Street Number and Street Name of Property)
Rutherfordton Rutherfordton 28139
(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
Division or its contractors. All monitoring wells will be properly abandoned in accordance
For DSCA Use Only
DSCA ID No.
DC810002
Oriel Hospitality, LLC dba The Firehouse Inn
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 Property Owner or Tenant in Residence) (Date)
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
(Email Address for Property Owner or Tenant in Residence)
Please return form to:
Natalie McCarthy
Hart & Hickman, PC
2923 S Tryon Street, Suite 100
Charlotte, NC 28203
Or via email to: [e-mail]
12/18/23
828-755-4073
REVISION NO. 0
JOB NO. PPA-072
DATE: 8-7-23
FIGURE NO. 2
COMMERCIAL PROPERTY
115 W. FIRST STREET
RUTHERFORDTON, NORTH CAROLINA
SITE AND SAMPLE LOCATION MAP
NOTES:
1. AERIAL IMAGERY OBTAINED FROM NC ONEMAP, 2019.
2. BASE DATA OBTAINED FROM RUTHERFORD COUNTY GIS,
2022.
2923 South Tryon Street-Suite 100
Charlotte, North Carolina 28203
704-586-0007(p) 704-586-0373(f)
License # C-1269 / #C-245 Geology
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FLYBOY PIZZA
(151 CENTRAL STREET)
VACANT
FIREHOUSE INN
(134 N. WASHINGTON STREET)
VACANT
VACANT
VACANT
NEW CREATION TATTOO
(112 W. FIRST STREET)
FORMER OFFICE AREAS
FORMER BOILER ROOM
AND CHIMNEY
SB-5
SB-4 SB-3
SB-2
SB-1
FALLEN TREE
BATHROOM
FORMER DRY
CLEANING AREA
SUSPECTED HEATING OIL UST
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LEGEND
SITE PROPERTY BOUNDARY
PARCEL LINE
UNDERGROUND STORAGE TANK (UST)
FORMER DRY-CLEANING MACHINE FLOOR
DRAIN
SOIL BORING
EXTERIOR DOORWAY
APPROXIMATE EXTENT OF STAINING
PROPOSED MONITORING WELL
TYPE II PERMANENT MONITORING WELL CONSTRUCTION DETAILS
CROSS SECTIONAL VIEW
LOCKABLE WELL CAP
bentonite/cement grout
15 ft (1 to 16 ft)
schedule 40 PVC
2 inches
flush threaded
20 ft
L1
L3
bentonite
2ft (16 ft to 18 ft)
No. 2 Sand
17ft (18 ft to 35 ft)
schedule 40 PVC
L2 2 inches
15 feet
0.010 inches
L1 =20 FT.
CONCRETE PAD
FLUSH METAL WELL COVER
CONCRETE PAD
BACKFILL AROUND CASING
MATERIAL
LENGTH
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
SEAL
TYPE OF SEAL THICKNESS
FILTER PACK
TYPE OF FILTER THICKNESS
WELL SCREEN
SCREEN MATERIAL
DIAMETER
LENGTH
SLOT SIZE
DEPTH TO BOTTOM OF
MONITORING WELL
35 feet
L2 =15 FT.DIAMETER OF
L3 =35 FT.BOREHOLE
6.25 in
TITLE Monitoring Well Diagram
Hart & Hickman, PC
2923 South Tryon St., Suite 100
Charlotte, North Carolina 28203
FILE PREP. BY REV. BY DATE PROJECT NO.NSM DS0-183A1/2/2024
REVISION NO. 0
JOB NO. PPA-072
DATE: 8-7-23
FIGURE NO. 2
COMMERCIAL PROPERTY
115 W. FIRST STREET
RUTHERFORDTON, NORTH CAROLINA
SITE AND SAMPLE LOCATION MAP
NOTES:
1. AERIAL IMAGERY OBTAINED FROM NC ONEMAP, 2019.
2. BASE DATA OBTAINED FROM RUTHERFORD COUNTY GIS,
2022.
2923 South Tryon Street-Suite 100
Charlotte, North Carolina 28203
704-586-0007(p) 704-586-0373(f)
License # C-1269 / #C-245 Geology
W. FIR
S
T

S
T
R
E
E
T
FLYBOY PIZZA
(151 CENTRAL STREET)
VACANT
FIREHOUSE INN
(134 N. WASHINGTON STREET)
VACANT
VACANT
VACANT
NEW CREATION TATTOO
(112 W. FIRST STREET)
FORMER OFFICE AREAS
FORMER BOILER ROOM
AND CHIMNEY
SB-5
SB-4 SB-3
SB-2
SB-1
FALLEN TREE
BATHROOM
FORMER DRY
CLEANING AREA
SUSPECTED HEATING OIL UST
S:
\
A
A
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P
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LEGEND
SITE PROPERTY BOUNDARY
PARCEL LINE
UNDERGROUND STORAGE TANK (UST)
FORMER DRY-CLEANING MACHINE FLOOR
DRAIN
SOIL BORING
EXTERIOR DOORWAY
APPROXIMATE EXTENT OF STAINING
PROPOSED MONITORING WELL