WS-10085_45241_G_NORR_20230517

May 17, 2023

Michael Dowd
1201 John Green Road
Winston-Salem, North Carolina 27101

Re: Notice of Regulatory Requirements
NCGS 143B-279.9 and 143B-279.11
Notice of Residual Petroleum Session
Law 2015-241 Section 14.16B

Watson Property, Dana J.
207 Julian Avenue
High Point, Randolph County
Incident Number: 45241
Risk Classification: Low

Dear Mr. Dowd:

Information received by the UST Section, Division of Waste Management, Winston-Salem Regional Office
on June 10, 2019, has been reviewed.

Pursuant to Session Law 2015-241 Section 14.16B Incident Number 45241 has been ranked Low since
water supply wells are greater than 150 feet from the source area of the release. North Carolina
General Statute (NCGS) 143B-279.9 and 143B-279.11 require a Notice of Residual Petroleum (Notice) to
be filed with the Register of Deeds in Randolph County, where the release is located, when a release from
an underground storage tank has not been remediated to below “unrestricted use standards”. The Notice is
required either prior to conveyance of a contaminated property or prior to receiving a Notice of No Further
Action. “Unrestricted use standards” for groundwater are the groundwater quality standards and interim
standards contained in Title 15A NCAC 2L .0202, and “unrestricted use standards” for soil are the
residential maximum soil contaminant concentrations (MSCCs) established in Title 15A NCAC 2L .0411.
The Notice must be filed for both soil and groundwater.

The Notice must be prepared in accordance with the attached instructions and format. It must contain a
legal description of the property containing the source of contamination and legal descriptions of any other
properties which you own (or control) which are contaminated by the release. The Notice must also include
appropriate land use restrictions for these properties. In addition, the Notice must identify all other
properties (adjacent, adjoining, downgradient, etc.) on which contamination is known to exist at the time
the Notice is prepared.

The Notice must be sent to this regional office of the UST Section within 30 days of the date of this letter
for approval and notarization. The approved and notarized Notice must then be filed by you with the
Register of Deeds, and a certified copy of the filed Notice must be submitted to this office within 30 days
of its return to you.

Page 2 of 2
45241
May 17, 2023

Failure to comply with this letter is a violation of North Carolina law and may result in the assessment of
civil penalties and/or the use of other enforcement mechanisms available to the state. If you have any
questions regarding this letter, please contact Aaron Williamson at the address and telephone number listed
below, or via email at [e-mail].

Sincerely,

Aaron R. Williamson, L.G.
Hydrogeologist
Winston-Salem Regional Office
UST Section, Division of Waste Management, NCDEQ

Attachment: Instructions for Preparing Alternate Notice of Residual Petroleum

cc: Kimberly Kennedy, KB Realty (email)

Revised February 7, 2019
1
INSTRUCTIONS FOR PREPARING A 'NOTICE OF RESIDUAL PETROLEUM' REFERENCING
ALTERNATE LAND USE RESTRICTIONS (FOR EXISTING RESIDENCES ONLY) FOR FILING

The following is a list of instructions to assist in the preparation and filing of a Notice of Residual
Petroleum'.

1. The Notice shall be prepared in accordance with the format provided in these instructions and shall
include reference to the appropriate alternate land use restrictions. (REWORDING OF THE NOTICE IS
NOT RECOMMENDED AND WILL SUBSTANTIALLY DELAY APPROVAL.)

2. The Notice shall include a description that would be sufficient as a description in an instrument of
conveyance of the (i) real property on which the source of contamination is located and (ii) any real
property on which contamination is located at the time the remedial action plan is approved and that was
owned or controlled by any owner or operator of the underground storage tank or other responsible party
at the time the discharge or release of petroleum is discovered or reported or at any time thereafter.

3. The Notice shall also identify the location (legal description) of any residual petroleum on other real
property on which contamination is known to exist at the time the Notice is prepared and that is a result of
the release.

4. The Notice shall reference any restrictions on the current or future use of the real property that are
imposed by the Secretary to protect public health, the environment, or users of the property.

5. (IF REQUIRED BY DEPARTMENT OF ENVIRONMENTAL QUALITY.) If the contamination is
located on more than one parcel or tract of land, the Department may require that the owner, operator, or
other person responsible for the discharge or release prepare a composite map or plat that shows all
parcels or tracts.
If the contamination is located on one parcel or tract of land, the owner, operator, or other person
responsible for the discharge or release may prepare a map or plat that delineates the contamination but is
not required to do so.
When the Department has approved a map or plat, it shall be recorded in the office of the register of
deeds and shall be incorporated into the Notice by reference.
Any map or plat shall be prepared and certified by a professional land surveyor, shall meet the
requirements of G.S. 47-30 and any requirements of the county Register of Deeds, and shall be submitted
to the Department for approval. The plat shall include: (ALL CONTENTS OF THE PLAT MUST BE
DRAWN IN INDELIBLE INK.)

a. Property lines, north arrow, scale, bearings and distances as appearing on the deed;

b. With respect to permanently surveyed benchmarks, location and dimensions of areas of the
property where contamination is known to exist in
 groundwater at a concentration exceeding the standard or interim standard established in 15A
NCAC 2L .0202 and/or
 soil at a concentration exceeding the residential maximum soil contaminant concentration
established in 15A NCAC 2L .0411.

c. The printed name(s) and title(s) and properly notarized signature(s) of individual(s) with authority
to legally bind the responsible party(ies) (i.e., responsible party(ies), an individual with power of
attorney for the responsible party(ies), officer of a corporation, etc.) (PRINTED TEXT,
SIGNATURES, AND NOTARY SEALS, AS WITH ALL MARKINGS ON THE PLAT, MUST
BE MADE IN INDELIBLE INK);

Revised February 7, 2019
2
d. The following language: "The areas of contamination depicted upon the map are approximations
derived from the best available information at the time of filing.";

e. The following language, for use by the Department, positioned in the upper left corner of the plat:

"Approved for the purposes of N.C.G.S. 143B-279.9 and 143B-279.11
_____________________
(signature of Regional Supervisor)
_____________________, Regional Supervisor
(printed name of Regional Supervisor)
_____________ Regional Office
UST Section
Division of Waste Management
Department of Environmental Quality

NORTH CAROLINA
_____________________COUNTY

I certify that the following person(s) personally appeared before me this day, each
acknowledging to me that he or she signed the foregoing document: ____________(printed full
name of Regional Supervisor)

Date: __________________ ______________________________ (signature of Notary Public)
(Official Seal) ______________________________ (printed or typed name of Notary Public)
Notary Public

My commission expires: ___________

f. Surveyor's certification and seal (using a permanent ink stamp).

6. The signed and notarized Notice (with all indicated attachments) shall be sent to the appropriate UST
Section Regional Office.

7. After the Department approves, notarizes and returns the Notice, the responsible party shall, within
thirty (30) days of its return:

a. File approved Notice in the County Register of Deeds' office of the county or counties in which
the site is located; and

b. Send to the appropriate UST Section Regional Office, a certified copy of the Notice affixed with
the seal of the Register of Deeds and reflecting the book(s) and page number(s) where recorded
and a copy of the page(s) in the grantor index where the Notice is referenced.

Revised February 7, 2019
1
NOTICE OF RESIDUAL PETROLEUM

____________________________________, _______________County, North Carolina
(site name)

The property that is the subject of this Notice (hereinafter referred to as the “Site”)
contains residual petroleum and is an Underground Storage Tank (UST) incident under North
Carolina’s Statutes and Regulations, which consist of N.C.G.S. 143-215.94 and regulations adopted
thereunder. This Notice is part of a remedial action for the Site that has been approved by the
Secretary (or his/her delegate) of the North Carolina Department of Environmental Quality (or its
successor in function), as authorized by N.C.G.S. Section 143B-279.9 and 143B-279.11. The North
Carolina Department of Environmental Quality shall hereinafter be referred to as “DEQ”.

NOTICE

Petroleum product was released and/or discharged at the Site. Petroleum constituents remain
on the site, but are not a danger to public health and the environment, provided that the
restrictions described herein, and any other measures required by DEQ pursuant to N.C.G.S.
Sections 143B-279.9 and 143B-279.11, are strictly complied with. This "Notice of Residual
Petroleum" is composed of a description of the property, the location of the residual petroleum, and the
land use restrictions on the Site. The Notice has been approved and notarized by DEQ pursuant to
N.C.G.S. Sections 143B-279.9 and 143B-279.11 and has/shall be recorded at the
________________ Register of Deeds’ office Book ____, Page ____.
(name of county)

Any map or plat required by DEQ has been/shall be recorded at the ______________ Register of (name of county)
Deeds’ office Book ____, Page ____, and has been/shall be incorporated into the Notice by this reference.

Source Property

____________________________ of ____________________________ is the owner in fee
(owner’s name) (city & state of homeowner)
simple of all or a portion of the Site, which is located in the County of _______________, State of North
Carolina, and is known and legally described as:

Revised February 7, 2019
2
(Insert Real Property Description Here for Source Property)

Additional Affected Property Also Subject to Restrictions

______________________ of _________________________ is the owner in fee simple of a portion of
(owner’s name) (city & state of owner)
the Site, which is located in the County of ______________, State of North Carolina. Petroleum
contamination is located on this property at the time this Notice is approved. This property was also
owned or controlled by the underground storage tank owner or operator or another party responsible for
the petroleum discharge or release at the time the discharge or release was discovered or reported, or at
any time thereafter. This property is known and legally described as:

(Insert Real Property Description Here for Additional Properties Owned or Controlled by Any Owner or
Operator of the Underground Storage Tank or Other Responsible Party, if Applicable)

Additional Affected Property Not Subject to Restrictions

Additionally residual petroleum is also located on the following property. The following
property is not subject to land use restrictions pursuant to N.C.G.S. Section 143B-279.9(b). The
following property is known and legally described as:

(Insert Legal Description of Other Real Property Affected by Residual Petroleum Not Owned or
Controlled by Any Owner or Operator of the Underground Storage Tank or Other Responsible Party, if
Applicable)

For protection of public health and the environment, the following land use restrictions required
by N.C.G.S. Section 143B-279.9(b) shall apply to all of the above-described real property. These
restrictions shall continue in effect as long as residual petroleum remains on the site in excess of
unrestricted use standards and cannot be amended or cancelled unless and until the ________County
Register of Deed receives and records the written concurrence of the Secretary (or his/her delegate) of

Revised February 7, 2019
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DEQ (or its successor in function).

PERPETUAL LAND USE RESTRICTIONS

[Restrictions apply to activities on, over, or under the land. Choose one or more of the following as
appropriate.]

Soil: Alternate 1) Soil containing residual petroleum, above applicable regulatory
standard(s), remains on the site at/within/etc. (Description of specific location on
the site of remaining petroleum contaminated soil). No soil shall be excavated or
disturbed, within ___ feet of (Description of specific location on the site of remaining
petroleum contaminated soil), except to remediate the soil in accordance with all
applicable state and federal statutes, regulations and guidelines.

Alternate 2) Soil containing residual petroleum above applicable regulatory
standard(s) remains on the site in the area identified in Figure 1, Attachment A
(Refer to extent of contamination as diagrammed in an existing report and attach
copy of that figure(s)). No soil shall be excavated or disturbed within 3 feet of the
area identified in Figure 1, Attachment A except to remediate the soil in accordance
with all applicable state and federal statutes, regulations and guidelines.

Groundwater: Groundwater from the site is prohibited from use as a water supply. Water supply wells
of any kind shall not be installed or operated on the site.

ENFORCEMENT

The above land use restriction(s) shall be enforced by any owner, operator, or other party
responsible for the Site. The above land use restriction(s) may also be enforced by DEQ through any of
the remedies provided by law or by means of a civil action, and may also be enforced by any unit of local
government having jurisdiction over any part of the Site. Any attempt to cancel this Notice without the
approval of DEQ (or its successor in function) shall be subject to enforcement by DEQ to the full extent
of the law. Failure by any party required or authorized to enforce any of the above restriction(s) shall in
no event be deemed a waiver of the right to do so thereafter as to the same violation or as to one occurring
prior or subsequent thereto.

IN WITNESS WHEREOF, ________________ has caused this Notice to be executed pursuant to
N.C.G.S. Sections 143B-279.9 and 143B-279.11, this _____ day of ___________, 20___.

______________________________________________
(name of responsible party if agent is signing)
By: ___________________________________________
(signature of responsible party, attorney or other agent if there is one)
___________________________________________
(title of agent for responsible party if there is one)
Signatory’s name typed or printed: ___________________________________

(Note to be deleted on final document: Preparer of document must assure that the correct
acknowledgement is used and complies with changes effective October 1, 2006)

Choice One: Instrument signed by one person

Revised February 7, 2019
4
NORTH CAROLINA
_____________________COUNTY
(Name of county in which acknowledgment was taken)

I certify that the following person(s) personally appeared before me this day, each acknowledging to me
that he or she signed the foregoing document: ______________________________________________

Date: ________________________
________________________________
(Official Seal) (signature of Notary Public)
________________________________
(printed or typed name of Notary Public)
Notary Public

My commission
expires:_____________

Choice Two: Acknowledge by attorney in fact

NORTH CAROLINA
_____________________COUNTY
(Name of county in which acknowledgment was taken)

I, , a Notary Public for said County and State, do hereby certify that
, attorney in fact for , personally appeared before me this day, and being by
me duly sworn, says that he executed the foregoing and annexed instrument for and in behalf of the said
, and that his authority to execute and acknowledge said instrument is contained in an instrument duly
executed, acknowledged, and recorded in the office of in the County of
, State of , on the day of , 20 _ and
that this instrument was executed under and by virtue of the authority given by said instrument granting
him power of attorney.
I do further certify that the said acknowledged the due execution of the
foregoing and annexed instrument for the purposes therein expressed for and in behalf of the said
.

WITNESS my hand and official seal, this the ______ day of _______________, 20___.

________________________________
(Official Seal) (signature of Notary Public)
________________________________
(printed or typed name of Notary Public)
Notary Public

My commission
expires:_____________

Choice Three: Conveying security interest in personal property of a corporation

NORTH CAROLINA
_____________________COUNTY
(Name of county in which acknowledgment was taken)

Revised February 7, 2019
5
I, , a Notary Public for said County and State, do hereby certify that
personally came before me this day and acknowledged that he is
of and acknowledged, on behalf of , the grantor
the due execution of the foregoing instrument.

WITNESS my hand and official seal, this the ______ day of _______________, 20___.

________________________________
(Official Seal) (signature of Notary Public)
________________________________
(printed or typed name of Notary Public)
Notary Public

My commission
expires:_____________

Approved for the purposes of N.C.G.S. 143B-279.11

_____________________________
(signature of Regional Supervisor)
_____________________________, Regional Supervisor
(printed name of Regional Supervisor)
_____________ Regional Office

UST Section
Division of Waste Management
Department of Environmental Quality

NORTH CAROLINA
_____________________COUNTY
(Name of county in which acknowledgment was taken)

I certify that the following person(s) personally appeared before me this day, each acknowledging to me
that he or she signed the foregoing document: ______________________ (full printed name of Regional Supervisor)

Date: ________________________
________________________________
(Official Seal) (signature of Notary Public)
________________________________
(printed or typed name of Notary Public)
Notary Public

My commission
expires:_____________