WR0800815_Application_20230602

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
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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: June 2, 2023
County: Onslow
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Recovery Wells
Applicant: Petitioner for DSCA Site ID DC670006 (Al Cleaners) Telephone: [phone]
Applicant's Mailing Address: NCDEQ DWM, DSCA Program, Scott Stupak 1949 Mail Service Center, Raleigh, NC 27699
Applicant's Email Address (if available): scott.stupak6d�ncdenr.gov
Contact Person (if different than Applicant): Nick Shore (AECOM) Telephone: [phone]
Contact Person's Mailing Address: 5438 Wade Park Boulevard, Suite 200, Raleigh, NC 27607
Contact Person's Email Address (if available): nick.shore(a).aecom.com
Property Owner (if different than Applicant): Wednesday L. Cowan Telephone: [phone]
Property Owner's Mailing Address: 501 Beacham Ln., Jacksonville, NC 28540
Property Owner's Email Address (if available): carol ina35raised(o).gmail.com
Property Physical Address (Including PIN Number) 501 Beacham Ln (PIN 437714337067)
City Jacksonville County Onslow Zip Code 28540
Reason for Well(s): LNAPL Removal
(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:
(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).
none
11. Type of contaminants being monitored or recovered: chlorinated solvents and metals
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes, 12
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0801080, WM080801078, WM080101079
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet):
0 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 Certification No.: 2580A
Well Contractor Address: 176 Commerce Boulevard, Statesville, NC 28626
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? Flush Mount Vaults,
material: 3 with locking well caps
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: June 21, 2023
4. Total Number of wells to be constructed: 3 7. Estimated construction completion date: June 23, 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
Signature of Applicant or `Agent
Env. Project Manager
Title of Applicant or *Agent
Nick Shore on behalf of DSCA Petitioner for DSCA Site ID DC670006
* 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 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 Cen
Mooresville, �
Phone: (704)
Fax: (704) 6E
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]
-ax: [phone]
GW-22MR Rev. 3-1-2016

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ROY COOPER
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Governor
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JOHN NICHOLSON
Interim Secretary
NORTH CAROLINA
MICHAEL SCOTT
Environmental Quallry
Director
PROPERTY ACCESS CONSENT
This document may not be modified without the Program's For DSCA Use Only
approval. Ifyou have questions on how to fill out this form or about DSCA ID No
the activities at this site, please call the Dry-cleaning Solvent
Cleanup Program's contractor for this project, Nick Shore with DC670006
AECOM Technical Services of North Carolina (AECOM) at
nick.shorePaecom.com or [phone]. Ifyou still have questions after
contacting Mr. Shore with AECOM, please contact the DSCA Program Project
Manager, Mr. Scott Stupak at [e-mail] or 919-707-8359.
Please Print
Wednesday L Cowan
(Name of Property Owner or Tenant in Residence)
501 Beacham Lane (437714337067)
(Street Number and Street Name of Property)
Jacksonville, Onslow County, NC 28540
(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.
— o -, o nC^�;: �,.
North Carolina Department of Environmental Quality I Division of Waste Management
99-1646

f r.
(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 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 Propertywner or Tenant in Residence) (Darr-)
910,5s�) lN6
(Telephone Number for Property Owner or Tenant in Residence for scheduling
work/notification)
(Email Address for Property Owner or �Tenan Residence if you prefer to be contacted via
email)
Please return form to:
Nick Shore,
AECOM
5438 Wade Park Boulevard, Suite 200
Raleigh, NC 27607
[e-mail]
Phone [phone]
Or via email to: [e-mail]
North Carolina Department of Environmental Quality Division of Waste Manayeme-nt
217 West Jones Street 1 1646 Mail Service Center I Raleigh, North Carolina 27699 Ih4f;
wow 919,707.8200

Client: AI Cleaners (DC670006)
Project Number: 60706410
WELL ID: Proposed Temp Wells
A_
:COM Site Location: 327 Henderson Dr, Jacksonville, NC Date Installed: 21-Jun-23
Well Location: Coords: Inspector:
Method: 2.5"ID DPT Contractor: Geologic Exploration
PROPOSED MONITORING WELL CONSTRUCTION DETAIL
Depth from G.S. (feet) Elevation (feet)
Datum
12-inch diameter flush -mount steel vault to be set in 2'x2'x0.5' concrete pad
Top of Riser Pipe 0.0
Ground Surface (G.S.) 0.0
Benton
Describe Measuring Point:
Note: Depths are
Riser P
ipe:
Length
Diameter (ID)
Type of Material
Thickness
Grout:
Type
Thickness
Top of Bentonite
3
2"
PVC
Sch 40
neat cement
0
ite Seal Thickness
0
Top of Sand
Top of Screen
Screen:
Len gth
5
Dia meter (ID)
1"
Slot Size
10 slot
Type of Material
PVC
Thickness
Sch 40
Type/Size of Sand
#2
Sand Pack Thickness
6
Bottom of Screen
Bottom of Tail Pipe:
Bottom of Borehole
Borehole Diameter 4.25" ID HAS
Signature
and will be adjusted based on field conditions. Not to scale.
0
0
0
8
8
8
Date