WI0400517_DEEMED FILES_20190306

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400517
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Timothy Terrell
Location Address
600 Liberty Rd
High Point
Owner
Owner Name
Ncdeq Ust Section
Dates/Events
NC
Orig Issue
3/5/2019
App Received
2/20/2019
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27263
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
3/6/2019
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Sharon Ghiold
1637 Mail Service Ctr
Raleigh
County
Guilford
NC
Issue
3/5/2019
Effective
3/5/2019
27699
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
North Carolina Department of Environmental Quality -Division of Water Resources
NOTIFICATION OF INTENT (NOi) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are ''permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C .0200. This form shall be submitted at least 2 WEEKS prior to iniection.
AQUIFER TEST WELLS (1 5A NCAC 02C .0220 )
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A C:\C 02c .0225 1 or TRACER WELLS Cl SA NCAC 02C .0229 ):
1) Passive Injection S y stems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods.
2) Small-Scale Injection Operations -Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation. and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: Februarv 12 , 20_19_ PERMIT NO. V'\/ J.,t) Lf-0 0'511"" (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1)
(2)
(3)
(4)
(5)
(6)
--~Air Injection Well ...................................... Complete sections B through F, K, N
___ .Aquifer Test Well ....................................... Complete sections B through F, K, N
=X,__.Passive Injection System ............................... Complete sections B through F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B through N
--~Pilot Test. ......................................... -~ei>i:WB~ B through N
___ Tracer Injection Well.. ................................. Complete sections B through N
FEB 18 2tl19
B. STATUS OF WELL OWNER: State Government
C. WELL OWNER(S) -State name of Business/Agency, and ~e'~imd Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): ------"-N"""'C=D=E=O"'---'U=-=S=T=--=S=ec=ti=·o=n'----'S=h=ar=o=n"'-=G=h=io=ld=-------------
Mailing Address: 1646 Mail Service Center
City: Raleigh State: NC Zip Code: 27699 County: __ W_ak_e __ _
Day Tele No.: 919-707-8166 Cell No.: _________ _
EMAIL Address: Sharon.Qhioldr ncdenr.,wv Fax No.:
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 1
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: Timothv & Linda Terrell
Company Name _________________________ _
Mailing Address: ___ lO_l_0_Sh_am_r_o_ck_C_t ___________________ _
City: -------'H=1a..·!:!""'h"""P'""'o=in=t'------State: NC Zip Code: 27265 County: Guilford
Day Tele No.: _____ _ Cell No.: __________ _
EMAIL Address: __________ _ Fax No.: ___________ _
E. PROJECT CONT ACT (Typically Environmental Engineering Firm)
Name and Title: Ashlev Barham
Company Name ___ E=C=S~S~o=u=th=e=as~t~. L=L=P'---------------------
Mailing Address: -----~4~8~1~1~K=o'--"'0..Ce~r =B~o=u=le~v~ar~d'--------------------
City: Greensboro State: NC Zip Code: 27407 County: Guilford
Day Tele No.: 336-856-7150 Cell No.: 336-687-7094
EMAIL Address: abarham1a' ecslimited.com Fax No.: ------------
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: ____ T=im=o~t=h --=T~err=el=l _________________ _
600 Libe m Road
City: ___ A_r_ch_d_a_le ______ County: Guilford Zip Code: --~27~2~6~3 _
(2) Geographic Coordinates: Latitude**: 35.917953 °
Longitude**: 79.960154°
Reference Datum: ________ .Accuracy: _______ _
Method of Collection: Gomde Earth
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH
PROPERTYBOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume:_l_0_0 _____ square feet
Land surface area ofinj. well network: __ 1""'0'""'0'--____ square feet(~ 10,000 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated: <1 % (must be~ 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page 2
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
Installim1. one ORC Sox in one on-site monitoring well to assist with the biode!!radation of the
h ydrocarbons in the !ll'oundwater
J. APPROVED INJECT ANTS -Provide a MSDS for each injectant. Attach additional sheets if necessary.
NOTE: Only iryectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at http ://deq.nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/eround-water-protection/ground-water-a pp roved-iniectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program/or more info (919-
807-6496).
lnjectant: ______ O~R~C_S~o~x _______________________ _
Volume of injectant: 113in3
Concentration at point of injection: ___ IO~O~o/c_o ___________________ _
Percent ifin a mixture with other injectants: -----~N"---'-'---'/Ac=_ _____________ _
lnjectant:
Volume of injectant: _____________________________ _
Concentration at point of injection:
Percent if in a mixture with other injectants : ____________________ _
Injectant:
Volume of injectant:
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants:
K. WELL CONSTRUCTION DATA
(1)
(2)
Number of injection wells: --~l ___ Proposed __ ---=O __ ~Existing (provide GW-1s)
For Proposed wells or Existing wells not having GW-ls, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as-built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page 3
Well already constructed. Will take 1 daF to install ORC sox
M. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in subchapter 02! . result from the injection activity.
The monitoring wells are sampled even, six monthsand will be sampled six months aftet
installation of the ORC sox to determine effectiveness.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certin), under penalty of law, that I am familiar with the information submitted in this
docwunent and all attachments thereto and that, based on my inquiry of those individuals immediately responsible
for obtaining said information, I believe that the information is true, accurate and complete. I am aware that
there are significant penalties, including the possibility of fines and imprisonment, for submitting false
information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all j cited appt Antes in accordance with the 1 5A NC .4(02C 020(1 Rules." 4Cf
Ash iRi th ry, — n
Print or Type Full Name and Title
gnature n
PROPERTY OWNER Of the propert► is not owned by the permit applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(15A NCAC' 02C .0 00t "
"Owner» means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing_
Signature'' of
rty Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement b,
een the applicant and property owner may be submitted in lieu of a signature on this firm.
Submit the completed notification package to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted OW Remediatirm NOt Rev. 3-1-2016
Page 4

TiimootthNy Terrell Property, 600 Liberty Road, High Point, NC, Guilford Co. �' * iiigi
LOCATION MAP: I srART DATE & TIME 11-6-2008 @ 9:00
rir paw° COMP.OATERTTME: 11-6-2008 aQ 11:30 (TERRAINS
LOGGED BY: Leif Hazlewaod, Terrain
Environmental Cansultin.
DRILLER: Danny Summers, Geologic Exploration
Former Sarvrce island
DRILLING METHOD: GeoproherS 6620OPT with 4.25" HsA
► IMO
■ Fort▪ ner Orphaned
UST Basin TunothyTema Property
MSL
COMPLETION
DIAGRAM
OREHOLE DIAMETER:4 lie ID
0 1 2 S 4 5 5 7 8
l 2-in l
Lod, rig
Cap
J
a
3
ELEV (USW: J T.D. (MSLl: 20 feet
BORING# SB-1 IPa i
WELL# MW-% Jof T
Standard Boring Log
COMMENTS:
Soil boring SB-1
collected from 5,
converted to monitoring well MW-1 on November 6, 2008_ Soil samples were
10, and 15 feet bag and submitted for laboratory analysis
SAMPLES
PENETRATION DEPTH
RATE THAE
Poritend
Cement
Grout
2" PVC
Castag
Bentonite
Seal
is tat
1r2 Flier 11A0
5'•• Sand —Wit 5
r PVC
scram
:I (10�1aI)
20
End Plug
80
40
—r-
GRAPHIC
UTHOLOGY
OVD
2,000
p,%m
6.000
PPrn
z
DesCRIPT1ON
(Color, Texture. Structure etc.)
— 0 ASPHALT
BROWN TO BLUE -BROWN CLAY,
WITH TRACES SAND, SILT, AND
- CONCRETE (PETROLEUM ODOR)
cs :82608
.5,000 CS
pPm
VPH
ORANGE -YELLOW CLAYEY SILT, WITH
WHITE BANDING (PETROLEUM ODOR)
8264B_ 10 YELLOW-ORANG E SILTY CLAY, WITH SAND,
VPIA
WEATHERED ROCK, AND BLACK AND WHITE
BANDING (PETROLEUM ODOR)
8250
vPH
MOIST
WET
80
40
Boring terminated at 20 feet

NON ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina TCpart mGd-of Es:trfrmtment and Natural Resources- Division of Water (Nary.
WELL CONTRACTOR CERTIFICATION It 25579
1.1NELL CONTRACTOR:
DANNY SUMMERS
Welt Conanctor {Indh i& ai) Name
GEOLOGIC EXPLORATION. INC.
Weil Contractor Co rgrany Name
STREET ACCRE & 176 COMMERCE SLVCI
STATESVILLE NC
20625
City er TOO State Zip C.'xlo
[ 704 )_ 072.7688
Area 403e- Phone number
2 WELL INFORMATION:
SITE WELL 13/(7apptrcabley ree0-1R
STATE WELL PER MIT1r{a applicable)
O W Q a O 1 HEI/ PER 'air air )
WELL USE (Check Appllcabte S Elping E, MuriIriP3IPLIMIC d
IndusDIalrCortiatierri5i i7 Agricuaura J Recur© InleclferL
Irrigaborp der C fU9t use]
DATE DRILLED 11l08106
T1ME COMPLE I'£D AM 0 PM (
3. WELL LOCATION;
Cfiv. HIGFI POINT
800 LI0ERTv RL1AD 27212
COUNTY GUILFORD
{Strict Name, Nombgr4, Cornrows . Subdi:5sion. La Na„ Parcel, Zip Co40
TOPOGRAPi 6C / LAN O SE771NG-
D Sklge ❑ Valley G Flat ORrdgo n Other
rent.* oaprpbnale tool
LATITUX
LONG1iuDE
Mav ix in degas,
rniislt smooth or
-in a dnrirroi %7lE
L l tada1ongitode source: DGPS CjTopographic map
Fix&von oiweff must be shown area +JSGS top3 mime and
attached lofts Harm lnot using MPS)
4. FACILITY. s R1p unw or ePt arni eda chat era %cu It ioesimd
FACILITY ID 81.1s apiiImatile)
IMAMS- OF FAGILITi T1M0thY TERRELL RESIDENCE
STREET ADDRESS &00 LIBERTY ROAD
HIGH POINT NC
27'263
Girl or Taal State
CONTACT PERSON NCOErR
alp Cede
MAI,Lfh13 ADDRESS 1637 HAIL SERVICE CENTER
RAL6lcb-I Tit 27800.
City or Tan Sea! Zip Cods
Area code - Phone member
5. WELL DETAILS.
a. TOTAL DE H: 20.0 FEET
Lk DOES WELL REPLACE EXISTING WELL? YES L3
NO a
c. HATERtEyEk Below Top v1 Casing.: 11.0 Fr.
(Use -42' iI Above? Top or (.asIng)
d TOP OF CASING IS 0.0 FT_ Above Lane assure'
'Top or casing terminated War below land 31rtere miry require
whines in accordance vdth 15A NCAC 2C .0118.
e. YIELD Warr N/A MET}IOC OF TEST NfA
1. DISINFECTION: Type MIA Amount
iF WATER ZONES (depth):
From To From To
Fran To From To
From To tram To
6. CASING; 'Ihicknessi
Fran 0-0 To 14.b Ft. 29 1 1"3 4112LP112
Depth
NIA
FtOW To
Fran To F►
7. °ROUT; Depth Materfai Method
Frpm 0.0 Tq 6.0 FL Paeminnrenmrda SLURRY
To # t.
Fran To Ft,
L SCREE)d Depth DLL Slat SLze Materiel
Fran 15.0 To 20.0 2.0 ,010 in.I}dC
Fran To__ Ft. in. 11r.
praTo FL In. ir1.
a. SANm D RARVEL PACK:Dealt+ SaeiAltrrrLai
Fare t0 Tar 20.0 FI20.40 Floe Silica Sand
Frain TO Ft
From To F��
18. DRUM DRAM
From rarmabon I5ariptiorl
RA 0.0
1
41. REMARKS
aaralonke coal from 6.0 to 8,0 Foot
10GHER YG£A7FFYIWAT7H16
15A hrAC 2C. WEL1 CONSTRt xT1
rootto+0,6e.. PPODTfl-
WELL CONTRACTOR DATE
DANINY SUM ERS
PRINTED NAME OF PERSON CONSTRUCYING THE WELL
&1lbrutT the original to the Division of Water Quality within 30 days. ATM: Worm:tiort Mgt,
1117 Mai 'Smoke Center - Raleigh, NC 27G99-1S1T Prone No. E919) 733-701S ext 668.
Form O1AI-.lb
Rev. 7105

120' 120'
MW-1R
100' --100'
-
Clayey Silt
80' --80'
60' ~ -60'
40' ~ -40'
20' I I I I 20'
I + CROSS SECTION
SCALE
ia l~~ Timothy Terrell
Horizontal Scale: =40' iiiiiii,,I 600 Liberty Road
--Archdale, Guilford County, NC
Vertical Scale: = 20' ECS Project No. 49-1275C .
" -,
Former
Orphaned
UST Basi
d
��boki �o�
Former
Dispenser Excavation
Island Area E-2
•
.
•
■
•
■
t• ■
n; -�t • ��
i1 • _• ��. �.� G1
\ • : -' -.� 1 ' ARW-3R
MW-11 " 88.39
■ \.,.' � 89.10
+ \. \ ► �� t
• •
1L �' tt
4 i
• t
•
•
-' �, Former State
•
•
■
•
Excavation
Area E-1
�` • MW-2 ■
X90.06
,___.----":),,,,,--\
residence
I
■
•
•
•
•
•
•
•
•
t
•
•
■
•
•
90
\ Residence
■
•
•
•
•
•
•
•
89 ■
■
— • — APPROXIMATE SITE BOUNDARY
ED MONITORING WELL LOCQTFON
-90 GROUNDWATER ELEVATION
GROUNDWATER FLOW DINECTION
SOURCE:
GUILFORD COUNTY GIS DEPARTMENT
AERIAL PHOTOGRAPH, DATED 2014
SCALE 1"- 25'
FIGURE 3
GROUNDWATER FLOW DIRECTION MAP
TIMOTHY TERRELL PROPERTY
600 LIBERTY ROAD
ARCHDALE, NORTH CAROLINA
NCDEQ INCIDENT #11101
ECS PROJECT NO. 49-1275B

_ FFormer
Dispenser
Island
Former
Orphaned
UST Basin
f
Excavation
Area E-1
■
Excavation
Area E-2
•
■
■
•
■
•
■
■
■
■
r
(3,100) CONCENTRAION IN ppb
ISOCONCENTRATION LINE "
— • — APPROXIMATE SITE BOUNDARY%
ED MONITORING WELL LOCATION
SOURCE:
GUILFORD COUNTY GIS DEPARTMENT
AERIAL PHOTOGRAPH, DATED 2014
SCALE 1 n- 25'
FIGURE 4
BENZENE ISOCONCENTRATION MAP
TIMOTHY TERRELL PROPERTY
600 LIBERTY ROAD
ARCHDALE, NORTH CAROLINA
NCDEQ INCIDENT #11101
ECS PROJECT NO. 49-1275B

Former
Orphaned
UST Basin
Excavation
Area E-1
f e� woad
Former Lib
Dispenser
Island
• MW-2
► (BRL)
►
/
►
►
Shed
•
■
iji3\
_ MW3R
(O. 61
Former Store
X.
/
►
Excavation
Area E-2
/
►
/
•
(19) CONCENTRAION IN ppb ►
Q ISOCONCENTRATION LINE '
— APPROXIMATE SITE BOUNDA'RY
ED MONITORING WELL LOCATION
SOURCE:
GUILFORD COUNTY GIS DEPARTMENT
AERIAL PHOTOGRAPH, DATED 2014
SCALE 1"- 25'
FIGURE 4A
TOLUENE ISOCONCENTRATION MAP
TIMOTHY TERRELL PROPERTY
600 LIBERTY ROAD
ARCHDALE, NORTH CAROLINA
NCDEQ INCIDENT #11101
ECS PROJECT NO. 49-1275B

mer
Dispenser
Island
Former
Orphaned
UST Basin
Excavation
Area E-1
• MW-2 1
► (BRL)
/
Residence
•
■
•
►
Former Store
N.
•
Excavation
Area E-2
■
■
►
(4.5) CONCENTRAION IN ppb 1
ISOCONCENTRATION LINE •
— - — APPROXIMATE SITE BOUNDAY
® MONITORING WELL LOCATION
SOURCE:
GUILFORD COUNTY GIS DEPARTMENT
AERIAL PHOTOGRAPH, DATED 2014
SCALE 1"- 25'
FIGURE 48
ETHYLBENZENE ISOCONCENTRATION MAP
TIMOTHY TERRELL PROPERTY
600 LIBERTY ROAD
ARCHDALE, NORTH CAROLINA
NCDEQ INCIDENT #11101
1
ECS PROJECT NO. 49-1275B

Former
Orphaned
UST Basin
Excavation
Area E-1
Residence
ad
O
_ ormer \Pe y
Dispenser
Island
>1
/ ED
• MW-2'.
r {BRLO
■
Shed
Former Store
Excavation
Area E-2
Residence
1
w
•
{17,000) CONCENTRAION IN ppb r
ISOCONCENTRATION LINE '
APPROXIMATE SITE BOUNDAY
ED MONITORING WELL LOCATION
SOURCE:
GUILFORD COUNTY GIS DEPARTMENT
AERIAL PHOTOGRAPH, DATED 2014
SCALE 1"- 25'
FIGURE 4C
TOTAL XYLENES ISOCONCENTRATION MAP
TIMOTHY TERRELL PROPERTY
600 LIBERTY ROAD
ARCHDALE, NORTH CAROLINA
NCDEQ INCIDENT #11101
ECS PROJECT NO. 49-12758

_ rrner
Dispenser
Island
>1
Former
Orphaned
UST Basin
Excavation
Area E-1•
MW-2
/ (BRL)
■
■
Shed
•
Excavation
Area E-2
■
■
r
.
'■ (1,200) CONCENTRAION IN ppb■
ISOCONCENTRATION LINE
■ — • — APPROXIMATE SITE BOUNDARY
W MONITORING WELL LOCATION
SOURCE:
GUILFORD COUNTY GIS DEPARTMENT
AERIAL PHOTOGRAPH, DATED 2014
SCALE 1"- 25'
FIGURE 4D
NAPTHALENE ISOCONCENTRATION MAP
TIMOTHY TERRELL PROPERTY
800 LIBERTY ROAD
ARCHDALE, NORTH CAROLINA
NCDEQ INCIDENT #11101
ECS PROJECT NO. 49-1275B

Sharon Ghiold
DWM UST Section
1637 Mail Service Ctr
Raleigh, NC 27699-1637
RE: Site Access Agreement
Timothy Terrell Property
600 Liberty Road
High Point, Guilford CoWity, NC (WSRO)
Incident Number 11101
Dear Mrs. Ghiold:
I am/We are the owner(s) of a parcel of property, located at or near the incident in question,
and hereby permit the Department of Environment and Natural Resources (Department) or its
contractor to enter upon said property for the purpose of conducting an investigation of the
groundwaters under the authority of G.S . 143-215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the
Department or its contractor. The Department or its contractor shall protect and prevent damage
to the surrounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the
shortest feasible route to the nearest public road. The Department or its contractor may enter
upon the land at reasonable times and have full right of access during the period of the
investigation.
4 . Any claims which may arise against the Department or its contractor shall be governed by Article
31 of Chapter 143 of the North Carolina General Statutes, Tort Claims Against State
Departments and Agencies, and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon
request and is a public record, in accordance with G. S. 13 2-1.
6. The activities to be carried out by the Department or its contractor are for the primary benefit
of the Department and of the State of North Carolina. Any benefits accruing to the owner are
incidental. The Department or its contractor is not and shall not be construed to be an agent,
employee, or contractor of the land owner.
Timothy Terrell Property
600 Liberty Road
High Point, Guilford County, NC (WSRO)
Incident Number 11437
I/We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
c).
Signature
Type/Print Name of Owner or Agent
G`- 25 6
Phone Number
. po'./ioeJti
7
Address 2f]e2C.3 /
City/State/Zip Code cajd 63 i ien
Date