WM0501332_Application_20181220

AECOM AECOM Technical Services of North Carolina, Inc. 919.461.1100 tel
1600 Perimeter Park Drive, Suite 400 919.461.1415 fax
Morrisville, NC 27560
December 4, 2018 NC Dept of Environmental Quality
Aquifer Protection Section IFC 11 2018
North Carolina DEQ-DWR
Raleigh Regional Office Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Subject: Monitoring Well Permit Application
Petitioner for DSCA Site DC640008 (One Hour Koretizing)
NCDEQ — DSCA Program
To Whom It May Concern:
AECOM Technical Services of North Carolina, Inc. (AECOM), on behalf of NCDEQ — DSCA
Program, has attached the permit applications for the construction of a total of three (3)
monitoring wells on three (3) offsite properties (i.e., 173 NE Main Street, NE Main Street, and
the City of Rocky Mount Right -of Way near 231 Falls Road) in Rocky Mount, Nash and
Edgecombe Counties, North Carolina. These applications are being submitted in accordance
with 15A NCAC 2C .0105. Proposed activities include installation of three monitoring wells on
three offsite properties associated with additional assessment of DSCA Site DC640008, One
Hour Koretizing, 202 Falls Road, Rocky Mount, NC.
Upon approval, please forward (or fax) a copy of the monitoring well construction permits to
AECOM at the address listed. If you have any questions or require additional information,
please do not hesitate to call Carlin Slusher at 919-461-1341.
Sincerely,
AECOM Technical Services of North Carolina, Inc.
i
Carlin Slusher
Project Manager
Enclosures
Robert H. MacWilliams, PG
Program 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.
1. Date: December 4. 2018
2. County: Nash
FOR OFFICE USE ONLY
PERMIT NO. M06Vj ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitorinq
4. Applicant: Mary Wells (Petitioner for DSCA Site DC640008) Telephone: [phone]
Applicant's Mailing Address: DSCA Program (Attn. Sue Murphy) Mail Service Center 1646 Raleigh NC 27699-1646
Applicant's Email Address (if available): sue. murphyCcDncdenr.gov
5. Contact Person (if different than Applicant): Carlin Slusher — AECOM Technical Services Telephone: [phone]
Contact Person's Mailing Address: 1600 Perimeter Park Drive Suite 400, Morrisville, NC 27560
Contact Person's Email Address (if available): carlin.slusher(@aecom.com
6. Property Owner (if different than Applicant): City of Rocky Mount — Brad Kerr Telephone: [phone]
Property Owner's Mailing Address: 331 South Franklin Street, Post Office Box 1180, Rocky Mount NC 27802-1180
Property Owner's Email Address (if available): brad. kerr rock mountnc. gov
7. Property Physical Address (Including PIN Number) City Right-of-way across from 231 Falls Road (see figures attached)
City Rocky Mount County Nash Zip Code 27804
8. Reason for Well(s): Environmental Assessment
(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).
11. Type of contaminants being monitored or recovered: volatile organics
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes (4)
Existing Monitoring or Recovery Well Construction Permit No(s).. WM0501262
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): —300
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: SAEDACCO Certification No.: TBD (specific driller TBD)
Well Contractor Address: 9088 Northfield Dr. Fort Mill, SC 29707
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)
Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Locking well cap
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)
Estimated beginning construction date: Jan. 8. 2019
Estimated construction completion date: Jan. 10, 2019
ADDITIONAL INFORMATION
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
Carlin Slusher on Behalf of Petitioner for DSCA Site DC640008
Printed name of Applicant or *Agent
Project Manager
Title of Applicant or *Agent
* If signing as Agent, attach authorization agreement stating
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 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
GW-22MR Rev 3-1-2016

ROY COOPER
NORTH CAROLINA
Governor
Envkwunentat Quattty
L S. BEGAN
Se`retar)
For DSCA Use Only
MICHAEL SCOTT
DSCA ID No.
Director
DC640008
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 contractorfor this
project, Carlin Slusher with AECOM, at carlin.slusher a,aeconl.com or (919) 461-
1341. If you still have questions after contacting Ms. Slusher, please contact the
DSCA project manager, Sue Murphy at sue.mu►phv a.ncdenr.gov or 919-707-
8354.
Please Print
City of Rocky Mount
(Name of Property Owner or Tenant in Residence)
Falls Road right-of-way (see attached
(Street Number and Street Name of Property)
City of Rocky Mount, Edgecc
(City or Town in Which Property Is
27804
(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
Nortkst 5tr 6 6 MaAE" Q IvAy I Dhigon of Waste Management
Raleigh. North Carotlm 27699.16"
919.7 1&*0Q

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".
of Pro ertfOwner or Tenant in Residence) ((Date)
SZ - ,97Z • ) / z a
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
(Email Address for Property Owner
email)
Please return form to:
Carlin Slusher
AECOM
1600 Perimeter Park Drive, Suite 400
Morrisville, NC 27560
cnant in Residence if you prefer to be contacted via
Or via email to: [e-mail]
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AECOM WELL CONSTRUCTION LOG
PROJECT NO: 60550568 BORING NO: PROJECT NAME: One Hour Koretizing
DATE BEGAN: DATE FINISHED: FIELD ENGINEER:
DRILLER: NORTH: EAST:
DRILLING METHOD: Hollow Stem Auger (HSA) DRILL EQUIP: CHECKED BY:
CONTRACTOR: SAEDACCO
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NUMBER
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7
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16
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-20.0 -20
IESCRIPTION
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Rocky Mount, North CarolinaSHEET:
DSCA Site ID DC640008

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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: December 6. 2018
2. County: Edgecombe
FOR OFFICE USE ONLY
PERMIT NO. VA.0501337_ ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Mary Wells (Petitioner for DSCA Site DC640008) Telephone: [phone]
Applicant's Mailing Address: DSCA Program (Attn. Sue Murphy) Mail Service Center 1646 Raleigh NC 27699-1646
Applicant's Email Address (if available): sue. murphyOncdenr.gov
5. Contact Person (if different than Applicant): Carlin Slusher — AECOM Technical Services Telephone: [phone]
Contact Person's Mailing Address: 1600 Perimeter Park Drive Suite 400, Morrisville, NC 27560
Contact Person's Email Address (if available): carlin.slusher0aecom.com
6. Property Owner (if different than Applicant): City of Rocky Mount — Brad Kerr Telephone: [phone]
Property Owner's Mailing Address: 331 South Franklin Street, Post Office Box 1180, Rocky Mount, NC 27802-1180
Property Owner's Email Address (if available): brad. kerr rock mountnc. ov
7. Property Physical Address (Including PIN Number) 173 NE Main Street. PIN # 3850-60-8554
City Rocky Mount County Edgecombe Zip Code 27804
8. Reason for Well(s): Environmental Assessment
(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)
11. Type of contaminants being monitored or recovered: volatile organics
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes (4)
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0501262
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): —300
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: SAEDACCO Certification No.: TBD (specific driller TBD)
Well Contractor Address: 9088 Northfield Dr. Fort Mill, SC 29707
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 well cap
material: 1
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: Jan. 8. 2019
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: Jan. 10, 2019
(add answers from 2 and 3)
ADDITIONAL INFORMATION
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
Carlin Slusher on Behalf of Petitioner for DSCA Site DC640008
Printed name of Applicant or *Agent
Proiect Manager
Title of Applicant or *Agent
* If signing as Agent, attach authorization agreement stating
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 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
GW-22MR Rev. 3-1-2016

ROY COOPER
NORTH CAROLINA
Covemor
Envhvnmental Quality
MICHAEL S. REGAN
Secretary
For DSCA Use Only
MICHAEL SCOTT
DSCA ID No.
Director
DC640008
PROPERTY ACCESS CONSENT
This document may not be modified without the Program's approvab If you have
questions on how to f ll 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, Carlin Slusher with AECOM, at carlin.slusher @.aecom.com or (919) 461-
1341. Ifyou still have questions after contacting Ms. Slusher, please contact the
DSCA project manager, Sue Murphy at stte.murphv Ancdenr.gov or 919-707-
8354.
Please Print
City of Rocky Mount
(Name of Property Owner or Tenant in Residence)
173 NE Main Street, PIN # 3850-60-8554
(Street Number and Street Name of Property)
City of Rocky Mount, Edgecombe, 27804
(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
:Offf
4-5- -1
INM - --
,.19
Noah Car cUm Depanmew of EmMortmental Quakty I DMOm of waste Management
217 west Tones Street 1 Ib46 MaA 5mRe Center I RaW4% North C&m4w 27699.1616
919.707AM

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
detennines 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
er or Tenant in Residence)
jZ 7'7Z.
' fii
(Date)
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notilication)
bc—
(Email Address for Property Owner or T
email)
Please return form to:
Carlin Slusher
AECOM
1600 Perimeter Park Drive, Suite 400
Morrisville, NC 27560
Or via email to: [e-mail]
c . 5 v v
in Residence if you prefer to be contacted via
North Can�l:na Department of Cm irbnmtntal Quality DivWon cif lvj-.Te %tanagement
?17 %%'e%t )one-, Strcet lodb %fall Sen ice Ccntcr Ralrigh..North Carollru 27G99 lb4b
919 701 n700

AECOM WELL CONSTRUCTION LOG
PROJECT NO: 60550568
BORING NO:
PROJECT NAME: One Hour Koretizing
DATE BEGAN:
DATE FINISHED:
FIELD ENGINEER:
DRILLER:
NORTH:
EAST:
DRILLING METHOD: Hollow Stem Auger (HSA)
DRILL EQUIP:
CHECKED BY:
CONTRACTOR: SAEDACCO
w
DEPTH �DRILLING SAMPLE REC
(FT.) METHOD TYPE / (%) O DESCRIPTION
SAMPLE Ix
NUMBER a-
0.0 0
-1
2
-3
4
-5.0 -5
6
-7
-8
9
-10.0 -10
-11
-12
13
14
-15.0 -15
-16
17
18
-19
-20.0 -20
HA
HSA
0 a
u a Well Construction
� o
d
Al
Concrete Pad
- Cement Grout
Bentonite Seal
2" Schedule 40
PVC Riser and
Screen
#2 Filter Sand Pack
0.010" Screen
Proposed Monitoring Well Construction m 20
W�W�
4=mCOM------
IDSCA C^WXB One HOUf KOfetlZing 3 W m ' Lo
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O U ci a CO
Rocky Mount, North Carolina HEET:
Site ID DC640008

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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: December 6. 2018
2. County: Edaecombe
FOR OFFICE USE ONLY
PERMIT NO. ItIN�050/3 ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Mary Wells (Petitioner for DSCA Site DC640008) Telephone: [phone]
Applicant's Mailing Address: DSCA Program (Attn. Sue Murphy) Mail Service Center 1646 Raleigh NC 27699-1646
Applicant's Email Address (if available): sue. murphyO-ncdenr.gov
5. Contact Person (if different than Applicant): Carlin Slusher — AECOM Technical Services Telephone: [phone]
Contact Person's Mailing Address: 1600 Perimeter Park Drive Suite 400, Morrisville NC 27560
Contact Person's Email Address (if available): carlin.slusherCa-Daecom.com
6. Property Owner (if different than Applicant): City of Rocky Mount — Brad Kerr Telephone: [phone]
Property Owner's Mailing Address: 331 South Franklin Street, Post Office Box 1180 Rocky Mount NC 27802-1180
Property Owner's Email Address (if available): _ brad. kerra;rockymountnc.gov
7. Property Physical Address (Including PIN Number) NE Main Street. PIN # 3850-71-2009
City Rocky Mount County Edaecombe Zip Code 27804
8. Reason for Well(s): Environmental Assessment
(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).
11. Type of contaminants being monitored or recovered: volatile organics
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes (4)
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0501262
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): —300
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: SAEDACCO Certification No.: TBD (specific driller TBD)
Well Contractor Address: 9088 Northfield Dr. Fort Mill, SC 29707
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? Lockinq well cap
material: 1
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: Jan. 8. 2019
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: Jan. 10, 2019
(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
Carlin Slusher on Behalf of Petitioner for DSCA Site DC640008
Printed name of Applicant or *Agent
Project Manager
Title of Applicant or *Agent
* If signing as Agent, attach authorization agreement stating
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 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
GW-22MR Rev. 3-1-2016

ROY COOPER
NORTH CAROLINA
Gamnor
Envhvnmental Quality
MICHAEL S. REGAN
Secrnmry
For DSCA Use Only
MICHAEL SCOTT
DSCA ID No.
Drrertor
DC640008
PROPERTY ACCESS CONSENT
This document may not be modified without the Program Is 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, Carlin Slusher with AECOM, at carlin.slusherAgecom.com or (919) 461-
1341. If you still have questions after contacting Ms. Slusher, please contact the
DSCA project manager, Sue Murphy at site. tnurphv a,ncdenr.gov or 919-707-
8354.
Please Print
City of Rocky Mount
(Name of Property Owner or Tenant in Residence)
NE Main Street, PIN # 3850-71-2009
(Street Number and Street Name
City of Rocky Mount, Edgecombe, 27804
(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
North Carolina l tW'nntt of ErmrorutmMQuaWy I tlMamot Waste Management
21711 W Jones Street I IW 6 StA Service Center 1 Rdel9k North carobw 27699d646
919.MY.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 I'or any purpose. In situations that the Division
detennines to be of an emergency nature, the Division or its contractors shall have immediate
access to the property.
(4) Property Owncr 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".
�r
of Pro . crt Owner or Tenant in Residence) (Date)
�5 Z 77-z- - //zb
(Telephone Number for Property Owner or Tenant in Residence for scheduling work/notification)
(Email Address for Property Owner or Tc
email)
Please return form to:
Carlin Slusher
AECOM
1600 Perimeter Park Drive, Suite 400
Morrisville, NC 27560
Or via email to: [e-mail]
in Residence if you prefer to be contacted via
North Carolina Depatment of Crnlronmental Qua!d" Dl-.hlon of \Paste k1anagemcnt
117 We,t tone-. Street ttAb l Wl Sm ice Center Ralcigh Ntx th c4roUno 27u99 Itrtb
919 707IV00

AECOM WELL CONSTRUCTION LOG
PROJECT NO: 60550568 BORING NO: PROJECT NAME: One Hour Koretizing
DATE BEGAN: DATE FINISHED: FIELD ENGINEER:
DRILLER: NORTH: EAST:
DRILLING METHOD: Hollow Stem Auger (HSA) DRILL EQUIP: CHECKED BY:
CONTRACTOR: SAEDACCO
W
DEPTH
DRILLING
SAMPLE
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Sentonite Seal
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#2 Filter Sand Pack
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T Proposed Monitoring Well Construction m zto
One Hour Koretizing 3 W W 0
202 Falls Road w = w o
o�uUacfl
Rocky Mount, North CarolinaSHEET:
DSCA Site ID DC640008

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