WM0401304_Monitoring Well Permit Application_20210707

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: 6/24/2021
2. County: Randolph
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant: NCDEQ (Scott Ryals)
Monitoring
Telephone: [phone]
Applicant's Mailing Address: 1646 Mail Service Center, Raleigh, NC 27699
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Ethan Dinwiddie - Terracon Consultants Telephone: [phone]
Contact Person's Mailing Address: 2401 Brentwood Road, Suite 107, Raleigh, NC 27604
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): NCDOT Division 8 Telephone: [phone]
Property Owner's Mailing Address: 902 N. Sandhills Blvd, Aberdeen, NC 28315
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) DOT ROW — SE of intersection of Beckerdite Road and US Highway 311
City Sophia County Randolph Zip Code 27350
8. Reason for Well(s): Groundwater contamination
(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: Former gas station
(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).
UST Incident #6946
11. Type of contaminants being monitored or recovered: petroleum
(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): Approximately 5 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): Between 240 to 460 feet
15. Well Contractor: James Barker, Quantex Certification No.: 3106
Well Contractor Address: 280 Lake Glad Rd, Wendell, NC 27591
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? Metal flush -mount
material: 0 well cover and locking expansion cap
3. Number of wells to be constructed in bedrock: 1
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3)
6. Estimated beginning construction date: July 29, 2021
7. Estimated construction completion date: July 29, 2021
1.
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 bonngs 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
Consultant
Signature of Applicant or *Agent Title of Applicant or *Agent
Ethan Dinwiddie on behalf of NCDEQ * If signing as Agent, attach authorization agreement Printed Printed
name of Applicant or *Agent 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).
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]
Wk
�JJ 1"7
GW-22MR Rev. 3-1-2016
GW-22M (Rev. 5/11)
GW-22MR (6/11)

Proposed Monitoring Well
Former 500-gallon diesel UST
Former 500-gallon kerosene UST
Former 2,000-gallon gasoline UST
MI Former 5,000-gallon gasoline UST
ME Former 6,300-gallon gasoline UST
JSite Diagram
Norfolk Southern Railroad
PM:
KFC
Project No.
70207501
Drawn By:
CEW
Scale:
1 in=100ft
Checked By:
ECD
File Path:
Site Diagram
Approved By:
KFC
lrerracon
Proposed Monitoring Well
Figure
Tony Farlow Oil (UST Incident #6946)
Highway 311 S.
Sophia, Randolph County, NC
1
Date:
6/23/2021
2401 Brentwood Road, Suite 107
Raleigh, NC 27604
Phone: [phone] Fax: [phone]
Path: N:\G'S\2020\70207501_TonyFarlowOil\Maps \70207501_Proposed Montoring Well.mxd

Legend
• Proposed Monitoring Well
▪ Water Supply Well (Suspected Active)
Former 500-gallon diesel UST
Former 500-gallon kerosene UST
Former 2,000-gallon gasoline UST
▪ Former 5,000-gallon gasoline UST
▪ Former 6,300-gallon gasoline UST
JSite Diagram
Norfolk Southern Railroad
Randolph County Parcel Boundary
PM:
KFC
Project No.
70207501
Drawn By:
CEW
Scale:
1 in=125ft
Checked By:
ECD
File Path:
Site Diagram
Approved By:
KFC
lrerracon
Proposed Monitoring Well
Figure
Tony Farlow Oil (UST Incident #6946)
Highway 311 S.
Sophia, Randolph County, NC
1
Date:
6/25/2021
Path: N:\GIS\2020\70207501
2401 Brentwood Road, Suite 107
Raleigh, NC 27604
Phone: [phone]
Fax: [phone]
_TonyFarlowOil\Maps \70207501_Proposed Montoring Well.mxd

Well ID: MW-1
Project No.: 70207501
Site Location:
US Highway 311 S, Sophia, NC
Field Personnel: ECD
Date: 6/24/2021
Location: SE of intersection of Beckerdite Rd and US Highway 311
Drilling Method:
Driller:
Hollow stem auger/Air rotary
Quantex; James Barker
lrerracon
2401 Brentwood Road Suite 107
Raleigh, NC 27604
919.873.2211
Land Surface
Riser Pipe
Diameter
Material
Proposed Monitoring Well Construction Diagram
2-inch
PVC
Length 40 ft
Sand Pack
Sand Size
Well Screen
No. 2
Diameter 2-inch
Length 10 ft
Slot Size 0.010-inch
Material PVC
Note: Not to scale
>i
Concrete
Depth Below Land Surface (ft)
1 ft
Bottom of Grout 36 ft
Bottom of Bentonite Seal 38 ft
Top of Screen 40 ft
Bottom of Screen
Bottom of Tail Pipe
Bottom of Borehole
50 ft
50 ft
50 ft
6 Borehole Diameter (inches)

STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
ROY COOPER
GOVERNOR
June 29, 2021
Terracon Consultants, Inc.
7327 Friendly Ave.
Greensboro, NC 27410
SUBJECT: ENCROACHMENT AGREEMENT (E081-076-21-00143)
Installing 2-inch Monitoring Well
US-311 / SR-1009
Randolph County
J. ERIC BOYETTE
SECRETARY
Attached is a properly executed copy of a Right of Way Encroachment Agreement which covers
the following:
Installation of permanent 2-inch monitoring well at SR-1009 and US-311 in Randolph County,
and any associated pre -construction work. This permit is for NCDOT right of way only at
mentioned location.
This agreement is approved subject to the Special Provisions and plans which are attached to and
made a part of the Encroachment Agreement. Any work associated with the subject project
permitted under an NCDOT approved Driveway Permit shall be completed in accordance with
this Encroachment Agreement.
Sincerely,
Patrick A. Norman, P.E.
Division Engineer
DocuSigned by:
F1 A9CCB031 DF4C3...
By: R. J. Monroe
District Supervisor
Attachments
cc: Aaron Saunders, Randolph County Maintenance Engineer
Mailing Address: Telephone: [phone] Location:
NC DEPARTMENT OF TRANSPORTATION Fax: [phone] DOT DRIVE
DISTRICT OFFICE Customer Service: 1-877-368-4968 ASHEBORO, NC 27205
300 DOT DRIVE
ASHEBORO, NC 27205 Website: www.ncdot.gov

E081-076-21-00143 ENCROACHMENT SPECIAL PROVISONS
Randolph County Terracon Consultants, Inc.
Pre -Construction
Contact Offices & Outside Agency issues/contacts/info
Page 1 of 14
1. Approval may be rescinded upon failure to follow any of the provisions in this permit and may be
considered a violation of the encroachment agreement.
2. The Encroaching party or their contractor shall provide the following notices prior to construction
activity within the NCDOT Right of Way:
a. Three (3) business days advance phone call at telephone [phone] or email to
Umccaskill(a,ncdot.gov to the District Engineer's office
b. If the construction falls within the limits of an NCDOT managed construction project, five (5)
business days advance phone call to the Resident Engineer, [phone].
Failure to provide these notifications prior to beginning construction is subject to the Division
Engineer's discretion to cease construction activity for this encroachment. NCDOT reserves the right
to cease any construction or maintenance work associated with this installation by the encroaching
party until the construction or maintenance meets the satisfaction of the Division Engineer or their
representative.
3. Prior to beginning work, it is the requirement of the Encroaching Party to contact the appropriate
Utility Companies involved and make arrangements to adjust or relocate any utilities that conflict
with the proposed work.
4. It shall be the responsibility of the encroaching party to determine the location of utilities within the
encroachment area. NCGS § 87-115 through § 87-130 of the Underground Utility Safety and
Damage Prevention Act requires underground utilities to be located by calling 811 prior to
construction. The encroaching party shall be responsible for notifying other utility owners and
providing protection and safeguards to prevent damage or interruption to existing facilities and
maintain access to them.
5. The encroaching party shall notify the appropriate municipal office prior to beginning any work
within the municipality's limits of jurisdiction.
6. Excavation within 1000 feet of a signalized intersection will require notification by the encroaching
party to the Division Traffic Engineer at telephone number [phone] no less than one week
prior to beginning work. All traffic signal or detection cables must be located prior to excavation.
Cost to replace or repair NCDOT signs, signals, pavement markings or associated equipment and
facilities shall be the responsibility of the encroaching party.
7. This agreement does not authorize installations within nor encroachment onto railroad rights of way.
Permits for installations within railroad right of way must be obtained from the railroad and are the
responsibility of the encroaching party.
8. At the option of the District Engineer, a preconstruction meeting including representatives of
NCDOT, the encroaching party, contractors and municipality, if applicable, shall be required.
A pre -construction conference held between a municipality (or other facility owner) and a contractor
without the presence of NCDOT personnel with subsequent construction commencing may be subject

E081-076-21-00143 ENCROACHMENT SPECIAL PROVISONS
Randolph County Terracon Consultants, Inc. Page 2 of 14
to NCDOT personnel ceasing any work on NCDOT right-of-way related to this encroachment until
such meeting is held. Contact the District office to schedule.
9. At the discretion of the District Engineer, a NOTIFICATION FOR UTILITY / NON -UTILITY
ENCROACHMENT WITHIN NCDOT R/W form (See corresponding attachment) with the
scheduled pre -construction meeting and associated construction schedule details must be completed
and submitted to the District Engineer's office a minimum of one week prior to construction.
10. At the discretion of the District Engineer, the encroaching party (not the utility contractor) shall make
arrangements to have a qualified inspector, under the supervision of a Professional Engineer
registered in North Carolina, on site at all times during construction. The registered Professional
Engineer shall be required to submit a signed and PE sealed certification that the utility was installed
in accordance with the encroachment agreement.
Legal & Right -of -Way Issues
11. This approval and associated plans and supporting documents shall not be interpreted to allow any
design change or change in the intent of the design by the Owner, Design Engineer, or any of their
representatives. Any revisions or changes to these approved plans or intent for construction must be
obtained in writing from the Division Engineer's office or their representative prior to construction or
during construction, if an issue arises during construction to warrant changes.
12. NCDOT does not guarantee the right of way on this road, nor will it be responsible for any claim for
damages brought about by any property owner by reason of this installation. It is the responsibility of
the encroaching party to verify the right of way.
13. Encroaching party shall be responsible for obtaining all necessary permanent and/or temporary
construction, drainage, utility and/or sight distance easements.
14. All Right of Way and easements necessary for construction and maintenance shall be dedicated to
NCDOT with proof of dedication furnished to the District Engineer prior to beginning work.
15. No commercial advertising shall be allowed within NCDOT Right of Way.
16. The encroaching party shall obtain proper approval from all affected pole owners prior to attachment
to any pole.
Work Zone Traffic
17. WORK ZONE TRAFFIC CONTROL QUALIFICATIONS AND TRAINING PROGRAM
All personnel performing any activity inside the highway right of way are required to be familiar with
the NCDOT Maintenance / Utility Traffic Control Guidelines (MUTCG). No specific training course
or test is required for qualification in the Maintenance /Utility Traffic Control Guidelines (MUTCG).
All flagging, spotting, or operating Automated Flagger Assist Devices (AFAD) inside the highway
right of way requires qualified and trained Work Zone Flaggers. Training for this certification is
provided by NCDOT approved training resources and by private entities that have been pre -approved
to train themselves.

E081-076-21-00143 ENCROACHMENT SPECIAL PROVISONS
Randolph County Terracon Consultants, Inc. Page 3 of 14
All personnel involved with the installation of Work Zone Traffic Control devices inside the highway
right of way are required to be qualified and trained Work Zone Installers. Training for this
certification is provided by NCDOT approved training resources and by private entities that have
been pre -approved to train themselves.
All personnel in charge of overseeing work zone Temporary Traffic Control operations and
installations inside the highway right of way are required to be qualified and trained Work Zone
Supervisors. Training for this certification is provided by NCDOT approved training resources and
by private entities that have been pre -approved to train themselves.
For questions and/or additional information regarding this training program please refer to
https://connect.ncdot.gov/projects/WZTC/Pages/Training.aspx or call the NCDOT Work Zone Traffic
Control Section [phone].
18. The party of the second part shall employ traffic control measures that are in accordance with the
prevailing federal, state, local, and NCDOT policies, standards, and procedures. These policies,
standards, and procedures include, but are not limited to the following:
a. Manual on Uniform Traffic Control Devices (MUTCD) — North Carolina has adopted the
MUTCD to provide basic principles and guidelines for traffic control device design,
application, installation, and maintenance. North Carolina uses the MUTCD as a minimum
requirement where higher supplemental standards specific to North Carolina are not
established. Use fundamental principles and best practices of MUTCD (Part 6, Temporary
Traffic Control).
b. NCDOT Maintenance / Utility Traffic Control Guidelines — This document enhances the
fundamental principles and best practices established in MUTCD Part 6, Temporary Traffic
Control, incorporating NCDOT-specific standards and details. It also covers important safety
knowledge for a wide range of work zone job responsibilities.
19. If the Traffic Control Supervisor determines that portable concrete barrier (PCB) is required to shield
a hazard within the clear zone, then PCB shall be designed and sealed by a licensed North Carolina
Professional Engineer. PCB plans and design calculations shall be submitted to the District Engineer
for review and approval prior to installation.
20. Ingress and egress shall be maintained to all businesses and dwellings affected by the project. Special
attention shall be paid to police, EMS and fire stations, fire hydrants, secondary schools, and
hospitals.
21. Traffic shall be maintained at all times. All lanes of traffic are to be open during the hours of xxxx
A.M. to xxxx A.M. and from xxxx P.M. to xxxx P.M. Monday through Friday, during any time of
inclement weather, or as directed by the District Engineer. Any violation of these hours will result
in ceasing any further construction by the Encroaching Party or their contractor.
22. Nighttime and weekend operations will NOT be allowed unless written approval is received from the
District Engineer. If nighttime or weekend work is allowed or required, all signs must be retro-
reflective, and a work zone lighting plan must be submitted for approval prior to construction.
23. Two-way traffic shall be maintained at all times unless designated by the District Engineer. Traffic
shall not be rerouted or detoured without the prior written approval from the District Engineer. No
utility work will be allowed on state holidays from 7:00 PM the night before through 9:00 AM the
day prior to, following or during local events without prior approval from the District Engineer. If the
construction is within 1000 feet of a school location or on a designated bus route, the construction
shall be coordinated with the school start and end times to avoid traffic delays.

E081-076-21-00143 ENCROACHMENT SPECIAL PROVISONS
Randolph County Terracon Consultants, Inc. Page 4 of 14
24. Work requiring lane or shoulder closures shall not be performed on both sides of the road
simultaneously within the same area.
25. Any work requiring equipment or personnel within 5 feet of the edge of any travel lane of an
undivided facility and within 10 feet of the edge of any travel lane of a divided facility shall require a
lane closure with appropriate tapers per current NCDOT Roadway Standard Drawings or MANUAL
ON UNIFORM TRAFFIC CONTROL DEVICES.
26. At the discretion of the District Engineer, a traffic control plan shall be developed and submitted
under the seal and signature of a Licensed North Carolina Professional Engineer prior to construction.
The plan shall be specific to the site and adequately detailed. Issues such as the close proximity to
intersections shall be addressed.
27. Temporary and final pavement markings are the responsibility of the encroaching party. Final
pavement markings and sign plans shall be submitted with the encroachment request to the Division
Traffic Engineer prior to construction. Final pavement markings shall be thermoplastic unless
otherwise directed by the Division Traffic Engineer or District Engineer.
28. Any pavement markings that are damaged or obliterated shall be restored by the encroaching party at
no expense to NCDOT.
29. Sidewalk closures shall be installed as necessary. Pedestrian traffic shall be detoured around these
closures and shall be signed appropriately and in accordance with The American with Disabilities Act
Accessibility Guidelines. The encroaching party must adhere to the guidelines for accommodating
pedestrians in encroachment work zones as described in the NCDOT Pedestrian Work Zone
Accommodations Training found at
https://www.youtube.com/watch?v=AOuYa5IW3dg&feature=youtu.be
Roadside Environmental
30. The encroaching party shall comply with all applicable Federal, State and local environmental
regulations and shall obtain all necessary Federal, State and local environmental permits, including
but not limited to, those related to sediment control, stormwater, wetland, streams, endangered
species and historical sites. Additional information can be obtained by contacting the NCDOT
Roadside Environmental Engineer regarding the North Carolina Natural Heritage Program or the
United States Fish and Wildlife Services. Contact the Division Roadside Environmental Engineer's
Office at [phone]
31. When surface area in excess of one acre will be disturbed, the Encroacher shall submit a Sediment
and Erosion Control Plan which has been approved by the appropriate regulatory agency or authority
prior to beginning any work on the Right of Way. Failure to provide this information shall be
grounds for suspension of operations. Proper temporary and permanent measures shall be used to
control erosion and sedimentation in accordance with the approved sediment and erosion control plan.
32. The Verification of Compliance with Environmental Regulations (VCER-1) form is required for all
non -utility encroachment agreements or any utility encroachments when land disturbance within
NCDOT right of way exceeds 1 acre. The VCER-1 form must be PE sealed by a NC registered
professional engineer who has verified that all appropriate environmental permits (if applicable) have
been obtained and all applicable environmental regulations have been followed.
33. All erosion control devices and measures shall be constructed, installed, maintained, and removed by
the Encroacher in accordance with all applicable Federal, State, and Local laws, regulations,

E081-076-21-00143 ENCROACHMENT SPECIAL PROVISONS
Randolph County Terracon Consultants, Inc. Page 5 of 14
ordinances, and policies. Permanent vegetation shall be established on all disturbed areas in
accordance with the recommendations of the Division Roadside Environmental Engineer. All areas
disturbed (shoulders, ditches, removed accesses, etc.) shall be graded and seeded in accordance with
the latest NCDOT Standards Specifications for Roads and Structures and within 15 calendar days
with an approved NCDOT seed mixture (all lawn type areas shall be maintained and reseeded as
such). Seeding rates per acre shall be applied according to the Division Roadside Environmental
Engineer. Any plant or vegetation in the NCDOT planted sites that is destroyed or damaged as a
result of this encroachment shall be replaced with plants of like kind or similar shape.
34. No trees within NCDOT shall be cut without authorization from the Division Roadside
Environmental Engineer. An inventory of trees measuring greater than 4 caliper inches (measured 6"
above the ground) is required when trees within C/A right of way will be impacted by the
encroachment installation. Mitigation is required and will be determined by the Division Roadside
Environmental Engineer's Office.
35. Prior to installation, the Encroaching Party shall contact the District Engineer to discuss any
environmental issues associated with the installation to address concerns related to the root system of
trees impacted by boring or non -utility construction of sidewalk, roadway widening, etc.
36. The applicant is responsible for identifying project impacts to waters of the United States (wetlands,
intermittent streams, perennial streams and ponds) located within the NCDOT right-of-way. The
discharge of dredged or fill material into waters of the United States requires authorization from the
United States Army Corps of Engineers (USACE) and certification from the North Carolina Division
of Water Quality (NCDWQ). The applicant is required to obtain pertinent permits or certification
from these regulatory agencies if construction of the project impacts waters of the United States
within the NCDOT right-of-way. The applicant is responsible for complying with any river or stream
Riparian Buffer Rule as regulated by the NCDWQ. The Rule regulates activity within a 50-foot
buffer along perennial streams, intermittent streams and ponds. Additional information can be
obtained by contacting the NCDWQ or the USACE.
37. The contractor shall not begin the construction until after the traffic control and erosion control
devices have been installed to the satisfaction of the Division Engineer or their agent.
38. The contractor shall perform all monitoring and record keeping and any required maintenance of
erosion and sediment control measures to maintain compliance with stormwater regulations.
Construction
General
39. An executed copy of the encroachment agreement, provisions and approved plans shall be present at
the construction site at all times. If safety or traffic conditions warrant such an action, NCDOT
reserves the right to further limit, restrict or suspend operations within the right of way.
40. The Encroaching Party and/or their Contractor shall comply with all OSHA requirements. If OSHA
visits the work area associated with this encroachment, the District Office shall be notified by the
encroaching party immediately if any violations are cited.

E081-076-21-00143 ENCROACHMENT SPECIAL PROVISONS
Randolph County Terracon Consultants, Inc. Page 6 of 14
41. Any REVISIONS marked in RED on the attached non -PE sealed plans shall be incorporated into and
made part of the approved encroachment agreement.
42. All disturbed areas are to be fully restored to current NCDOT minimum roadway standards or as
directed by the Division Engineer or their representative. Disturbed areas within NCDOT Right -of -
Way include, but not limited to, any excavation areas, pavement removal, drainage or other features.
43. The encroaching party shall notify the Division Engineer or their representative immediately in the
event any drainage structure is blocked, disturbed or damaged. All drainage structures disturbed,
damaged or blocked shall be restored to its original condition as directed by the Division Engineer or
their representative.
44. A minimum of 5 feet clearance is required for utility installations beneath or near drainage pipes,
headwalls, and a minimum of two -foot clearance below the flowline of streams. If directional
drilling, a minimum ten -foot clearance distance is required from drainage structures and a minimum
of 5 feet below flowline of streams.
45. At points where the utility is placed under existing storm drainage, the trench will be backfilled with
excavatable flowable fill up to the outside diameter of the existing pipe.
46. Unless specified otherwise, during non -working hours, equipment shall be located away from the job
site or parked as close to the right of way line as possible and be properly barricaded in order not to
have any equipment obstruction within the Clear Recovery Area. Also, during non -working hours, no
parking or material storage shall be allowed along the shoulders of any state -maintained roadway.
47. No access to the job site, parking or material storage shall be allowed along or from the Control of
Access Roadway.
48. Guardrail removed or damaged during construction shall be replaced or repaired to its original
condition, meeting current NCDOT standards or as directed by the Division Engineer or their
representative.
49. Right of Way monuments disturbed during construction shall be referenced by a registered Land
Surveyor and reset after construction.
50. All Traffic signs moved during construction shall be reinstalled as soon as possible to the satisfaction
of the Division Engineer or their representative.
51. Any utility markers, cabinets, pedestals, meter bases and services for meter reading required shall be
as close to the Right of Way line as possible. If it is not feasible to install at or near Right of Way
line, then written approval shall be obtained from NCDOT prior to installation.
52. Detection tape, where required by NCGS § 87-115 through § 87-130 of the Underground Utility
Safety and Damage Prevention Act, shall be buried in the trench approximately 1 foot above the
installed facility. Where conduit is installed in the right of way and is not of ferrous material, locating
tape or detection wire shall be installed with the conduit.
53. All driveways disturbed during construction shall be returned to a state comparable with the condition
of the driveways prior to construction.
54. Conformance with driveway permit review should be required in conjunction with this encroachment
agreement. In the event there is a conflict between the driveway permit and the encroachment
agreement, the District Engineer should resolve the conflict and notify the parties involved.

E081-076-21-00143 ENCROACHMENT SPECIAL PROVISONS
Randolph County Terracon Consultants, Inc. Page 7 of 14
55. If the approved method of construction is unsuccessful and other means are required, prior approval
must be obtained through the District Engineer before construction may continue.
Engineering
56. All traffic control, asphalt mixes, structures, construction, workmanship and construction methods,
and materials shall be in compliance with the most -recent versions of the following resources: ASTM
Standards, Manual on Uniform Traffic Control Devices, NCDOT Utilities Accommodations Manual,
NCDOT Standard Specifications for Roads and Structures, NCDOT Roadway Standard Drawings,
NCDOT Asphalt Quality Management System manual, and the approved plans.
57. Prior approval for any blasting must be obtained from the Division Engineer or their representative.
58. Regulator stations, metering stations, cathodic test stations, and anode beds are not permitted within
NCDOT right of way. Header wires are permitted.
59. Non -Utility Communication and Data Transmission installations (ground mounted type or Small Cell
pole -mounted type) must adhere to guidelines in the Utilities Accommodations Manual and, when
located within municipal jurisdictions, are subject to review and approval by municipal ordinances
and any additional municipal approval for proximity to historic districts and landmarks. All wiring
and related telecommunications work shall conform to the latest regulations by the Federal
Communications Commission.
60. All wiring and related electrical work shall conform to the latest edition of the National Electrical
Safety Code.
Location within R/W
61. All utility access points, such as manholes, vaults, handholes, splice boxes and junction boxes shall
be located as close to the right of way line as possible and shall not be placed in the ditch line, side
slopes of the ditches or in the pavement. All manholes, handholes, splice boxes, junction boxes and
vaults and covers shall be flush with the ground when located within the vehicle clear zone. Slack
loops for telecommunications in industry standard housing units shall be buried a minimum of 18
inches when buried or meet minimum NCDOT vertical and horizontal clearances when installed
aerially.
62. Fire Hydrants shall be of the breakaway type. Hydrants shall be placed near the right of way line. In
curb and gutter sections with written approval from the District, the hydrants may be placed at 6'
behind the back of the curb or minimum 2' back of sidewalk.
63. Luminaire and/or utility poles and guy wires shall be set as close to the Right of Way line as practical
and outside the Clear Zone in accordance with the latest version of the AASHTO Roadside Design
Guide (See corresponding attachment) or made breakaway in accordance with the requirements of
NCHRP Report 350. Any relocation of the utility poles from the original design due to Clear Zone
requirements shall require a re -submittal for the utility design.
64. Luminaire and/or utility poles shall be set a minimum of 5'-6" behind face of any guardrail or
otherwise sufficiently protected. However, standard placement may be reduced to 3'-6" behind face
of guardrail when posts are spaced 3'-1 1/2", or where speed limit is less than 55 MPH.

E081-076-21-00143 ENCROACHMENT SPECIAL PROVISONS
Randolph County Terracon Consultants, Inc. Page 8 of 14
65. Hot box (aka ASSE 1060) or Safe-T-Cover type enclosures covering utility main pipe joints,
backflow preventers, valves, vent pipes, cross connections, pumps, grinders, irrigation assemblies,
transformers, generators, and other similar large appurtenances shall be located outside sight distance
triangles and off of the NCDOT Right -of -Way.
66. Sprinkler heads shall be located a minimum of 10 feet from the edge of pavement, edge of shoulder,
or back of curb whichever is greater and shall be directed so that water does not spray or drain on the
roadway surface, sidewalk, or passing vehicles at any time. Upon completion of the installation and
prior to activation of the system, the Encroacher shall contact the District Engineer to schedule a test
of the system to verify the spray pattern. Sprinkler systems shall not be operated during periods of
high wind or freezing weather, or to the extent that the subgrade adjacent to the pavement structure
becomes saturated. NCDOT reserves the right to require immediate termination and removal of any
sprinkler system which in its judgement and opinion adversely affects safety, maintenance, or
operation of the roadway.
Excavation
67. Excavation material shall not be placed on pavement.
68. It is the responsibility of the encroaching party or their contractor to prevent any mud/dirt from
tracking onto the roadway. Any dirt which may collect on the roadway pavement from equipment
and/or truck traffic on site shall be immediately removed to avoid any unsafe traffic conditions.
69. The utility shall be installed within 5 feet of the right of way line and outside the 5-foot minimum
from travel lane plus theoretical 2:1 slope from the edge of pavement to the bottom of the nearest
excavation wall for temporary shoring. If the 2:1 slope plus 5 feet requirement above is met for
traffic, then temporary shoring is typically only necessary to protect roadways from damage
when a theoretical 1:1 slope from the edge of pavement intersects the nearest excavation
wall. This rule of thumb should be used with caution and does not apply to all subsurface
conditions, surcharge loadings and excavation geometries. Situations where this 1:1 slope is
not recommended include groundwater depth is above bottom of excavation or excavation is
deeper than 10 feet or in Type B or C soils as defined by OSHA Technical Manual.
Temporary shoring may be avoided by locating trenches, bore pits, and other excavations far
enough away from the open travel lane, edge of pavement and any existing structure,
support, utility, property, etc. to be protected. Temporary shoring is required when a
theoretical 2:1 slope from the bottom of excavation will intersect the existing ground line less
than 5 feet from the outside edge of an open travel lane as shown in the figure below or when
a theoretical 2:1 slope from the bottom of excavation will intersect any existing structure,
support, utility, property, etc. to be protected.
Open Travel
14 Lane A 5 ft Existing Ground
PI min Line
Theoretical
2:1 (H:V)
Slope
Edge of
/.....**••••• Pavement Bottom of
V
H •. Excavation

E081-076-21-00143 ENCROACHMENT SPECIAL PROVISONS
Randolph County Terracon Consultants, Inc. Page 9 of 14
Temporary shoring shall be designed and constructed in accordance with current NCDOT
Standard Temporary Shoring provisions (refer to
https ://connect.ncdot. gov/resources/Specifications/Pages/2018-Specifications-and-
Special-Provisions.aspx and see SP11 R002).
a. Temporary excavation shoring, such as sheet piling, shall be installed. The design of the
shoring shall include the effects of traffic loads. The shoring system shall be designed and
sealed by a licensed North Carolina Professional Engineer. Shoring plans and design
calculations shall be submitted to the Division Engineer for review and approval prior to
construction. (See NCDOT Utilities Accommodations Manual for more information on
requirements for shoring plans and design calculations.) Trench boxes shall not be accepted
as temporary shoring and will not be approved for use in instances where shoring is
required to protect the highway, drainage structure, and/or supporting pavement or
structure foundation.
b. All trench excavation inside the limits of the theoretical one-to-one slope, as defined by the
policy, shall be completely backfilled and compacted at the end of each construction day. No
portion of the trench shall be left open overnight. Any excavation that is not backfilled by the
end of the workday must address any safety and traveling public concerns including
accommodations for bicycles, pedestrians and persons with disabilities.
c. The trench backfill material shall meet the Statewide Borrow Criteria. The trench shall be
backfilled in accordance with Section 300-7 of the latest NCDOT Standard Specifications for
Roads and Structures, which basically requires the backfill material to be placed in layers not
to exceed 6 inches loose and compacted to at least 95% of the density obtained by
compacting a sample in accordance with AASHTO T99 as modified by DOT.
d. At the discretion of the Division Engineer, a qualified NCDOT inspector shall be on the site
at all times during construction. The encroaching party shall reimburse NCDOT for the cost
of providing the inspector. If NCDOT cannot supply an inspector, the encroaching party (not
the utility contractor) should make arrangements to have a qualified inspector, under the
supervision of a licensed North Carolina Professional Engineer, on the site at all times. The
Professional Registered Engineer shall certify that the utility was installed in accordance with
the encroachment agreement and that the backfill material meets the Statewide Borrow
Criteria.
e. The length of parallel excavation shall be limited to the length necessary to install and
backfill one joint of pipe at a time, not to exceed twenty-five (25) feet.
70. All material to a depth of 8 inches below the finished surface of the subgrade shall be compacted to a
density equal to at least 100% of that obtained by compacting a sample of the material in accordance
with AASHTO T99 as modified by the Department. The subgrade shall be compacted at a moisture
content which is approximately that required to produce the maximum density indicated by the above
test method. The contractor shall dry or add moisture to the subgrade when required to provide a
uniformly compacted and acceptable subgrade. The option to backfill any trenches with dirt or either
#57 stone or #78 stone with consolidation with a plate tamp and without a conventional density test
may be pursued with the written consent of the District Engineer. If this option is exercised, then
roadway ABC stone and asphalt repair as required will also be specified by the District Engineer.
Directional bore
71. Boring equipment will be provided of a type and size to facilitate boring in the local geologic
conditions and shall be able to facilitate the encroachment work.
72. When Horizontal Directional Drilling (HDD) is used, the following stipulations apply:
a. Use drilling fluids as appropriate for the type soils but use of water alone is prohibited. Pump
drilling fluids only while drilling or reaming. Directional boring using jetting with a
Bentonite (or equivalent material) slurry is recommended. Monitor flow rates to match the

E081-076-21-00143 ENCROACHMENT SPECIAL PROVISONS
Randolph County Terracon Consultants, Inc.
Page 10 of 14
amount leaving the bore hole and do not increase pressure or flow to free stuck drill heads,
reamers or piping. Open cutting to retrieve stuck drill heads is not allowed without prior
permission from the District Engineer.
b. The minimum depth shall adhere to the table below for transverse (under non -controlled
access, partial controlled access, or limited controlled access roadway) installations and refers
to maximum diameter of hole drilled and not the dimension of the carrier or encasement pipe.
Diameter of Drilled Hole
(Backream)
2" to 6"
Minimum Depth of Cover
5 feet
>6" to 15" 12 times hole diameter (e.g. 6-inch hole means 6 feet
minimum depth)
>15" to 36" 15 feet or greater
c. Under fully controlled access roadway installations, the minimum depth for transverse
crossings shall be 15 feet under any pavement (ramps or thru lanes)
d. An overbore (backream diameter) shall not be more than 1.5 times the outside diameter of the
pipe or encasement under any highway for pipes 12 inches in diameter or less. For pipes with
outer diameter larger than 12 inches, the overbore may be no larger than outer diameter of
pipe plus 6 inches. An overbore exceeding 1.5 times greater than the outside diameter of the
pipe or encasement may be considered if the encroachment agreement includes a statement
signed and sealed by a licensed North Carolina Professional Engineer indicating that an
overbore in excess of 1.5 times the outside diameter of the pipe or encasement will
appropriately arch and no damage will be done to the pavement or sub -grade.
e. Directional boring is allowed beneath embankment material in naturally occurring soil.
f. Any parallel installation utilizing the directional boring method shall be made at a minimum
depth of three (3') feet (cover) below the ground surface and outside the theoretical 1:1 slope
from the existing edge of pavement except where the parallel installation crosses a paved
roadway.
g. All directional bores shall maintain ten (10) feet minimum (clear) distance from the nearest
part of any structure, including but not limited to bridges, footings, pipe culverts or box
culverts. Directional bores are not allowed beneath bridge footings, culvert wingwall
footings, slope protection or retaining walls.
h. The tip of the drill string shall have a cutter head.
i. Detection wire shall be installed with non-ferrous material.
j. HDPE pipe installed by directional boring shall not be connected to existing pipe or fittings
for one (1) week from the time of installation to allow tensional stresses to relax.
Aerial clearances
73. Vertical clearance of overhead power and communication lines shall meet the National Electrical
Safety Code requirements except the minimum vertical clearance shall be 18' for crossings over
NCDOT roadways (24' over Fully Controlled Access roadways) and 16' for parallel installations.
74. In relation to the bridge, the utility line shall be located with minimum clearances as indicated on the
attachment for NCDOT Required Clearances for Aerial Installations by Encroachment Near
Bridge Structures.

E081-076-21-00143 ENCROACHMENT SPECIAL PROVISONS
Randolph County Terracon Consultants, Inc.
Pavement Detail and Repair
Page 11 of 14
75. The paving of this roadway shall be in accordance with the latest version of NCDOT Standard
Specifications, Sections 610, 1012 and 1020. The Contractor shall follow all procedures of the
Quality Management System (QMS) for asphalt pavement - Maintenance Version (see
https://connect.ncdot. gov/resources/Materials/MaterialsResources/2018%20QMS%20Asphal
t%20Manual.pdf). The Contractor must adhere to all testing requirements and quality control
requirements specified.
76. When paving beyond utility installation is involved, a Roadway certification report sealed by a
Professional Engineer shall be submitted to the District Engineer's office indicating the following:
• Pavement thickness by type
• Pavement density, core and/or test locations
• Base thickness
• Base density
• Subgrade density
Test frequency and method shall be in conformance with the NCDOT Materials and Tests Manual.
Test must be performed by a Certified Technician including name and Certification number on report.
77. The minimum pavement design for pavement repair shall be according to NCDOT Standard Drawing
654.01
(https://connect.ncdot.gov/resources/Specifications/2018 StandardRdwyDrawings/Division%2006%2
0Asphalt%20Bases%20and%20Pavements.pdf) and shall include a mechanical overlay extent to be a
minimum of 25 feet each side of the pavement repair area OR as directed by the District Engineer.
78. Pavement cuts shall be repaired the same day the cuts are made unless an asphalt patch cannot be
accomplished the same day due to material availability or time restrictions. When the asphalt patch is
not feasible, the following apply:
a. The pavement cut shall be filled to the surface with ABC stone or Flowable Fill per
NCDOT's Standards and Specifications.
b. Once the cut is filled, a minimum 3/4-inch steel plate shall be placed and pinned to prevent
moving. Plates shall be designed large enough to span a minimum of 1-foot on all sides on
the pavement cut.
c. When flowable fill is used, it shall cure for 24 hours prior to any asphalt material placement.
Flowable fill bleed water shall not be present during paving operations. Paving shall not
cause damage (shoving, distortion, pumping, etc.) to the flowable fill.
d. Install and leave "BUMP" signs according to MUTCD until the steel plate has been removed.
Once the flowable fill has cured, remove the steel plate, and mill/fill according to the
directions of the District Engineer.
e. All pavement cuts must be sealed with NCDOT approved sealant to prevent future pavement
separation or cracking.
79. Any pavement damaged because of settlement of the pavement or damaged by equipment used to
perform encroachment work, shall be re -surfaced to the satisfaction of the District Engineer. This
may include the removal of pavement and a 50' mechanical overlay. All pavement work and
pavement markings (temporary and final) are the responsibility of the Encroaching Party.

E081-076-21-00143 ENCROACHMENT SPECIAL PROVISONS
Randolph County Terracon Consultants, Inc.
Post Construction
Close out/ Inspection
Page 12 of 14
80. The Encroaching party shall notify the District Engineer's office within 2 business days after
construction is complete. The District Engineer may perform a construction inspection. Any
deficiencies may be noted and reported to the encroaching party to make immediate repairs or resolve
any issues to restore the right-of-way to a similar condition prior to construction, including pavement,
signage, traffic signals, pavement markings, drainage, structures/pipes, or other highway design
features.
81. At the discretion of the District Engineer, a final inspection report may be provided to the
encroaching party upon satisfactory completion of the work.
82. A written acknowledgement of the completed work by the District Engineer's office begins the one-
year warranty period associated with the performance bond.
83. If the actual construction differs from the approved plans associated with this encroachment, a copy
of "as -built" plans shall be submitted to the District Engineer's office in a PDF format and in a
current ESRI GIS format within 4 weeks of construction.

E081-076-21-00143 ENCROACHMENT SPECIAL PROVISONS
Randolph County Terracon Consultants, Inc.
Roadside Design (rwde
Attachment for Clear Zone Guidelines from AASHTO
Clear - Zone Tc Ia1e
TABLE 3.t (Cdnt'd)
J.S. Custom ary Units
Page 13 of 14
DESIGN
SPEED
DESIGN
ALIT
-- FQRE LOPES
EACKSLOPES - -
1V:6H
or (latter
IV:511TV
1 V:41-1
1V;341
1V:311
1V5HTO
1V:4H
IV:611
or flitter
40 iiipli
UNDER 750
7 - 10
7- 10
}* I
7 - ID
7 - 10
7 - 10
or
750-1500
10-12
12-14
**
10-12
10-12
10-12
Icss
1500-6000
12-14
14-16
f•
12-14
12-14
12 14
OVER6000
14- 16 .
16•-18
*• I
14--16
14-16
14- 16
___45-50
UNDER 750
10-12
12-14
**
8-l0
8-10
TO-1x
mph
750-1500
14-16
16-20
*•
10-12
12-14
14- 16
1 500 - 6000
116 - Ili
20 - 26
* •
12 -14
14- 16
16--18
OVER6000
20• •22
24-28
**
14-16
18-20
20-22
55mph
UNDER750
12- 14
14-18
**
8-10
10-12
10-12
750-1504
1h-18
20-24
*•
10-12
14-16
16--18
1500-6000
20-22
24-30
is
14-16
16-18
20-22.
OVER 6000
22-24
26--32•
vs
16-18
20-22
22-24
60mphh
UNDER.7S0
16-I8
20-24
**
10-12
12-14
14-16
750--1500
20-24
26-32*
**
12--14
16-18
20-22
1500-6000
26--30
32-404
+s
14-18
18--22
24-26
OVER6000
30-32*
36-44*
**
24--22
24-26
26-2K
65-70
UNDER 750
18-20
20-26
•s
10-12
14-16
14-16
mph
750 - 1500
24 - 26
28 - 36'
*s
12-16
18 - 20
20 - 22
1500-6000
28-32 •
34-42*
a*
16-20
22-24
26-2g
OVElt6000
30-34•
38--46•
•*
22-24
26-30
28-30
* Where a site specific investigation indicates a high probability of continuing crashes, or such occurrences are indicated by crab
history, the designer ally provide clear -zone distances greater than the clear-wvm shown in Table 3.1. Clear zones may be limited to
30 fl for practicality an4 10 provide 4 consistent ruadwiy template if previous experience with similar projects or designs indicates
satisfactory performance.
** Since recovery is Tess likely on lire unshielded, traversable I v:3H slopes, fixed objects should not be present in the vicinity of the toe
of these slopes. Recovery of high-speed ...Aides That encroach beyond the edge or the sboufder may be expected to occur beyond the
toe of slope. Determination or the width of the recovery area at the toe of slope should take into consideration right-of-way
availability, environmental concerns, economic Motors, safety needs, and crash histories, Also, the distance between the edge of the
through traveled lane and the beginning of the 1V:31-1 slope should influence the recovery vita provided at the toe of slope. While the
application may be limited by several factors, the fores]ope parameters which may cntcr into determining a maximum desirable
recovery area are illustrated in Figure 3.2.

E081-076-21-00143 ENCROACHMENT SPECIAL PROVISONS
Randolph County Terracon Consultants, Inc.
Page 14 of 14
NCDOT Required Clearances for Aerial Installations Near Bridge Structures
NOT
TO
SCALF,
Any variation to this detail must be
approved by the Division Engineer
and/or State Utilities Manager.
Published by NCDOT Utilities Unit
June 2020
**Minimum
sag clearance
height (See
Note 2)
Bridge Rail
(design varies)
Horizontal
Clearance to
wire nearest
bridge***
1 ►
Minimum =
8 Feet + Table 'A'
for power OR
telecommunications.
Any exception must
be coordinated with
Division Bridge
personnel prior to
Bridge Deck
Utility Pole (Typical -Power
and/or Telecommunications)
Varies
**See
Note
2
Table A — Minimum Horizontal Clearance Distances to POWER Lines
(from OSHA)
VOLTAGE
(nominal, kV, alternating
current)
MINIMUM CLEARANCE
(feet)
Upto5D
10
Over 50 to 200
15
Over 200 to 350
20
Over 350 to 500
25
Over 500 to 750
35
Over750 to 1000
45
Over 1000
As established by the utility
owner/operator or registered
professional engineer who is a qualified'
person with respect to electrical power
transmission and distribution
♦
Imo
Energized Phase
Conductor
Power Lines (Typical)*
Neutral Conductor
(Varies in location attached to
pole)*
Telecommunications line(s)
mounted below any power line OR
on dedicated telecommunication
poles without power lines*
*Note 1: Aerial lines extending to
next pole with lowest elevation at sag
point. Aerial lines drawn as 3-D
effect to represent typical minimum
parallel installation to bridge.
Top of bridge deck extended
A
•
Distance varies
to ground
where pole is
installed
**Note 2- MINIMUN SAG CLEARANCE
HEIGHT is 25 feet (applies to
telecommunications AND power).
***Note 3: HORIZONTAL CLEARANCE EXCEPTION. If vertical sag clearance height for power above bridge deck is >_
45 feet AND voltage is <_ 350kV, then Minimum Horizontal Clearance may be reduced to 3 feet. Any telecommunications
attachment to power pole allowed in this exception must have a minimum 25 feet sag clearance height above bridge deck.

ROUTE US311/SR1009
STATE OF NORTH CAROLINA
PROJECT Tony Farlow Oil COUNTY OF Randolph
DEPARTMENT OF TRANSPORTATION
-AND-
Terracon Consultants, Inc. on behalf of
North Carolina Department of Environmental Quality
RIGHT OF WAY ENCROACHMENT AGREEMENT
FOR NON -UTILITY ENCROACHMENTS ON
PRIMARY AND SECONDARY HIGHWAYS
Permit for NCDOT right of way only.
THIS AGREEMENT, made and entered into this the 29 day of ,sane 20 21
of Transportation, party of the first part; and Terracon Consultants, Inc. on behalf of
, by and between the Department
North Carolina Department of Environmental Quality party of the second part,
WITNESSETH
THAT WHEREAS, the party of the second part desires to encroach on the right of way of the public road designated as
Route(s) US311/SR1009 , located approximately 50 feet southeast of the intersection
of Beckerdite Rd and US311/SR1009
with the construction and/or erection of: one permanent 2-inch diameter monitoring well
WHEREAS, it is to the material advantage of the party of the second part to effect this encroachment, and the
party of the first part in the exercise of authority conferred upon it by statute, is willing to permit the encroachment
within the limits of the right of way as indicated, subject to the conditions of this agreement;
NOW, THEREFORE, IT IS AGREED that the party of the first part hereby grants to the party of the second
part the right and privilege to make this encroachment as shown on attached plan sheet(s), specifications and
special provisions which are made a part hereof upon the following conditions, to wit:
That the said party of the second part binds and obligates himself to install and maintain the encroaching facility in such safe
and proper condition that it will not interfere with or endanger travel upon said highway, nor obstruct nor interfere with the proper
maintenance thereof, to reimburse the party of the first part for the cost incurred for any repairs or maintenance to its roadways
and structures necessary due to the installation and existence of the facilities of the party of the second part, and if at any time the
party of the first part shall require the removal of or changes in the location of the said facilities, that the said party of the second
part binds himself, his successors and assigns, to promptly remove or alter the said facilities, in order to conform to the said
requirement, without any cost to the party of the first part.
That the party of the second part agrees to provide during construction and any subsequent maintenance proper signs, signal
lights, flagmen and other warning devices for the protection of traffic in conformance with the latest Manual on Uniform Traffic
Control Devices for Streets and Highways and Amendments or Supplements thereto. Information as to the above rules and
regulations may be obtained from the Division Engineer of the party of the first part.
That the party of the second part hereby agrees to indemnify and save harmless the party of the first part from all damages
and claims for damage that may arise by reason of the installation and maintenance of this encroachment.
It is clearly understood by the party of the second part that the party of the first part will assume no responsibility for any
damage that may be caused to such facilities, within the highway rights of way limits, in carrying out its construction and
maintenance operations.
That the party of the second part agrees to restore all areas disturbed during installation and maintenance to the satisfaction of
the Division Engineer of the party of the first part. The party of the second part agrees to exercise every reasonable precaution
during construction and maintenance to prevent eroding of soil; silting or pollution of rivers, streams, lakes, reservoirs, other water
impoundments, ground surfaces or other property; or pollution of the air. There shall be compliance with applicable rules and
regulations of the North Carolina Division of Environmental Management, North Carolina Sedimentation Control Commission, and
with ordinances and regulations of various counties, municipalities and other official agencies relating to pollution prevention and
control. When any installation or maintenance operation disturbs the ground surface and existing ground cover, the party of the
second part agrees to remove and replace the sod or otherwise reestablish the grass cover to meet the satisfaction of the Division
Engineer of the party of the first part.
That the party of the second part agrees to assume the actual cost of any inspection of the work considered to be necessary
by the Division Engineer of the party of the first part.
That the party of the second part agrees to have available at the encroaching site, at all times during construction, a copy of
this agreement showing evidence of approval by the party of the first part. The party of the first part reserves the right to stop all
work unless evidence of approval can be shown.
Provided the work contained in this agreement is being performed on a completed highway open to traffic; the party of the
second part agrees to give written notice to the Division Engineer of the party of the first part when all work contained herein has
been completed. Unless specifically requested by the party of the first part, written notice of completion of work on highway
projects under construction will not be required.
That in the case of noncompliance with the terms of this agreement by the party of the second part, the party of the first part
reserves the right to stop all work until the facility has been brought into compliance or removed from the right of way at no cost to
the party of the first part.
That it is agreed by both parties that this agreement shall become void if actual construction of the work contemplated herei n
is not begun within one (1) year from the date of authorization by the party of the first part unless written waiver is secured by the
party of the second part from the party of the first part.
FORM R/W 16.1A (Revised February 2021)

R/W (161A) : Party of the Second Part certifies that this agreement is true and accurate copy of the form
R/W (161A) incorporating all revisions to date.
IN WITNESS WHEREOF, each of the parties to this agreement has caused the same to be executed the day and
year first above written.
ATTEST OR WITNESS:
EEthan C. Dinwiddie
DEPARTMENT OF TRANSPORTATION
By: ^
DocuSigned by:
BY: Patrick A. Norman, PE te• i. Al.bin.V'Ot,
DIVISION ENGINEER '-F1A9CCB031DF4C3..
Dist. Supervisor
JListn L. Fabriziani
6/25/2021 6/25/2021
Second Party
INSTRUCTIONS
When the applicant is a corporation or a municipality, this agreement must have the corporate seal and
be attested by the corporation secretary or by the empowered city official, unless a waiver of corporate
seal and attestation by the secretary or by the empowered City official is on file in the Raleigh office of the
State Utilities Manager. In the space provided in this agreement for execution, the name of the
corporation or municipality shall be typed above the name, and title of all persons signing the agreement
should be typed directly below their signature.
When the applicant is not a corporation, then his signature must be witnessed by one person. The
address should be included in this agreement and the names of all persons signing the agreement
should be typed directly below their signature.
This agreement must be accompanied, in the form of an attachment, by plans or drawings showing the
following applicable information:
1. All roadways and ramps.
2. Right of way lines and where applicable, the control of access lines.
3. Location of the proposed encroachment.
4. Length and type of encroachment.
5. Location by highway survey station number. If station number cannot be obtained, location
should be shown by distance from some identifiable point, such as a bridge, road,
intersection, etc. (To assist in preparation of the encroachment plan, the Department's
roadway plans may be seen at the various Highway Division Offices, or at the Raleigh
office.)
6. Drainage structures or bridges if affected by encroachment.
7. Typical section indicating the pavement design and width, and the slopes, widths and
details for either a curb and gutter or a shoulder and ditch section, whichever is applicable.
8. Horizontal alignment indicating general curve data, where applicable.
9. Vertical alignment indicated by percent grade, P.I. station and vertical curve length, where
applicable.
10. Amount of material to be removed and/or placed on NCDOT right of way, if applicable.
11. Cross -sections of all grading operations, indicating slope ratio and reference by station
where applicable.
12. All pertinent drainage structures proposed. Include all hydraulic data, pipe sizes, structure
details and other related information.
13. Erosion and sediment control.
14. Any special provisions or specifications as to the performance of the work or the method of
construction that may be required by the Department must be shown on a separate sheet
attached to encroachment agreement provided that such information cannot be shown on
plans or drawings.
15. The Department's Division Engineer should be given notice by the applicant prior to actual
starting of installation included in this agreement.
16. Method of handling traffic during construction where applicable.
17. Scale of plans, north arrow, etc.

Workforce Safety Plan: COVID-19
NCDOT Encroachment ID#: E081-076-21-00143
WORKFORCE SAFETY PLAN
FOR ENCROACHMENT ACTIVITIES: COVID-19
EFFORTS THE N.C. TRANSPORTATION INDUSTRY IS TAKING TO STOP THE SPREAD OF COVID-19
The North Carolina Department of Transportation (NCDOT) and their partners expect all parties involved in
the delivery of transportation projects to abide by the guidelines issued from the Centers for Disease
Control and Prevention (CDC) and the North Carolina Department of Health and Human Services (NCDHHS).
Response to COVID-19 is rapidly evolving; new information and guidelines may be issued from the CDC,
NCDHHS, or other state or federal agencies. NCDOT and their partners should review the current CDC and
NCDHHS guidance, including the resources listed at the end of this document, for up-to-date information
on how to respond to COVID-19. Additional guidelines may be issued by state or federal agencies that
should be followed in addition to the guidance included in this document.
Though certain Americans with Disabilities Act (ADA) requirements have been relaxed in response to the
pandemic, employers must still maintain all information about employee illness as a confidential medical
record in compliance with the ADA. If an employee is suspected of having or tests positive for COVID-19, it
is essential that management keep the identity of the employee and details related to the employee's
health confidential.
Below are precautions required by NCDOT and from encroaching parties and their contractors performing
construction within NCDOT Rights of Way. The term employee refers to any person on a job site within
NCDOT right of way for the purpose of constructing or inspecting the work related to construction of a
facility under an approved encroachment agreement and where that employee may or may not be under
employment by or under contract to NCDOT.
EMPLOYEE WELLNESS
• If an employee has not yet reported to work and develops any COVID-19 symptoms (i.e. fever,
coughing, or shortness of breath) — STAY HOME and immediately:
o Call a health care provider
o Self -Isolate
o Communicate with your supervisor
o Remain calm and follow all instructions from your health care provider
• Employees who appear to have acute respiratory illness symptoms (i.e. cough, shortness of breath)
upon arrival to work, or become sick during the day, should be separated from others and sent
home immediately. The potentially affected employees should immediately follow the steps
outlined above, which includes immediately contacting a health care provider.
• Should an employee show symptoms of acute respiratory illness or be diagnosed with COVID-19, all
other employees who have worked in close proximity to the affected employee during the last 14
Updated: 4/11/2020 Page 1

Workforce Safety Plan: COVID-19 NCDOT Encroachment ID#: E081-076-21-00143
days and all encroachment points of contact indicated at the end of this plan should be notified of
potential exposure to the disease without identifying the affected employee.
• Consideration should be given to employees at "High Risk" of severe illness from COVID-19, who,
per NCDHHS, include employees:
o Over 65 years of age, OR
o With underlying health conditions including heart disease, lung disease, or diabetes, OR
o With weakened immune system
• "High Risk" Employees should be given the opportunity to discuss alternate work
arrangements/duties with their employer or take leave according to their company policies.
• For guidance on confirmed positive tests for COVID-19, refer to the most recent version of the
"COVID-19 Guidance for Employees on Encroachment Job Sites within NCDOT Right of Way"
located on last page of this plan.
PERSONAL HYGIENE
• Clean hands often by washing with soap and water for 20 seconds. If soap and water are not
available and hands are not visibly dirty, an alcohol -based hand sanitizer that contains 60%-95%
alcohol may be used.
• Avoid touching your eyes, nose, mouth, or other parts of your face.
• Do not breathe, cough, or sneeze on another person or into the open air. Employees should cover
their noses and mouth with a tissue when coughing or sneezing (or an elbow or shoulder if no
tissue is available).
• A facemask for covering nose and mouth is encouraged on the job site.
• Appropriate gloves are encouraged while performing functions of the job.
CLEANING/DISINFECTING
• Wash stations and/or hand sanitizer are encouraged on each project site.
• Appropriate cleaning staff should clean frequently touched surfaces and objects with disinfectants
at a minimum of once per day.
o Office/buildings: door knobs, light switches, phones, computers/keyboards, copy machines,
elevator buttons, toilets, faucets, sinks, countertops, paper towel dispensers, desktops,
handrails, folders, vending machines, counters, tables, cabinets/knobs, etc.
o Shop Yard/Jobsite: vehicle/equipment door handles, keys, gear shifts, steering
wheel/operator controls and levers, fuel pump dispensers, touch points on machinery, etc.
o Electronic equipment: cell phones, computers, keyboards, etc.
• Appropriate cleaning staff should sanitize/disinfect facilities and work areas after persons
suspected/confirmed to have COVID-19 have been in the facility or work area.
Updated: 4/11/2020 Page 2

Workforce Safety Plan: COVID-19
NCDOT Encroachment ID#: E081-076-21-00143
o It is recommended to close off access to areas used by the ill persons and wait as long as
practical, 24 hours if possible, before beginning cleaning and disinfection to minimize
potential for exposure to respiratory droplets. Open outside doors and windows to increase
air circulation in the area if possible.
o Appropriate cleaning staff should clean and disinfect all areas used by the ill persons,
focusing especially on frequently touched surfaces.
GENERAL
• Increase communication measures between all parties regarding schedule, daily activities, etc. to
reduce/minimize worker exposure in accordance with but not limited to the requirements below.
• Minimize on -site personnel such as subcontractors, work crews, QC personnel, and inspection staff
to those required for that day's activities. If work is postponed or cancelled, immediately notify
appropriate parties.
• Practice "Social Distancing" whenever feasible. Social Distancing is designed to limit the spread of a
disease by reducing the opportunities for close contact between people. All personnel have the
responsibility to remind each other to stay 6 feet or more apart. Examples of Social Distancing
include:
o Reducing face-to-face exposure by using conference calls and video conferencing
■ If an in -person meeting is absolutely required and cannot be rescheduled or
attended remotely, the meeting is limited to a maximum of 10 people while
maintaining Social Distancing of 6 feet or more.
o Avoiding unnecessary travel
• Do not congregate at lunch or breaks. Bringing your lunch is encouraged.
• No communal coolers or drink stations are allowed. Supervisors should confirm with employees
prior to beginning work for appropriate hydration and nutrition availability to employees for the
duration of the employee's shift and without direct contact with others on the job site.
• First line of communication should be by phone, rather than in -person.
• Do not shake hands.
• Do not share iPads, tablets, pens, or clipboards for signing or any other purpose. Take pictures as
proof of attendance at meetings.
• Sharing of Personal Protective Equipment (PPE) is strictly prohibited.
• Vehicles, equipment, and tools
o Limit the number of people riding in a vehicle together.
o Wipe down and disinfect vehicles after each trip.
o As much as possible, do not share tools or equipment. If a tool or piece of equipment must
be shared, the parts of it that are touched should be sanitized between uses.
Updated: 4/11/2020 Page 3

Workforce Safety Plan: COVID-19
NCDOT Encroachment ID#: E081-076-21-00143
RETURN TO WORK
• The following criteria must be followed for an employee who is tested for Covid-19, or asked to
self -quarantine by health officials, or has contact with another employee with a positive test result
to return to work:
o at least a 14-day quarantine; OR
o release by a health care provider.
• In accordance with CDC guidance, the following criteria must be followed for an employee with a
positive test result to return to work:
o at least 14 days from positive test notification; AND
o at least 3 days (72 hours) have passed since recovery defined as resolution of fever without
the use of fever -reducing medications and improvement in respiratory symptoms (e.g.,
cough, shortness of breath); AND
o at least 7 days have passed since symptoms first appeared.
NCDOT may require certification of fitness to work from a health care provider.
ADDITIONAL RESOURCES
NCDOT and their partners should review the CDC and NCDHHS resources listed below for up-to-date
information on how to respond to COVID-19. Additional guidelines may be issued by state or federal
agencies that should be followed in addition to the guidelines included in this document.
• NCDHHS COVID-19 Resources:
o https://www.ncdhhs.gov/divisions/public-health/coronavirus-disease-2019-covid-19-
response-north-carolina
• NCOSHR Communicable Disease Emergency Policy
o https://oshr.nc.gov/policies-forms/workplace-wellness/communicable-disease-emergency
• OSHA Guidance on Preparing Workplaces for COVID-19
o https://www.osha.gov/Publications/OSHA3990.pdf
• CDC COVID-19 Resources:
o https://www.cdc.gov/coronavirus/2019-ncov/index.html
AGREEMENT
The encroaching party shall adhere to the requirements of this plan in order to continue work under their
approved encroachment agreement. Violations to this plan could result in the violating entity not being
allowed to continue work or all work ceasing as determined by the NCDOT District Engineer or Resident
Engineer.
PROJECT POINTS OF CONTACT
Updated: 4/11/2020 Page 4

Workforce Safety Plan: COVID-19
NCDOT Encroachment ID#: E081-076-21-00143
NCDOT
DocuSigned by:
Name: ALDIitra-
F1 A9CCB031 DF4C3...
Dist. Supervisor
Phone #: [phone]
Name:
Encroaching Party (Primary Contact)
Name: Scott Ryals
Phone #: [phone]
Primary Contractor to Encroaching Party
(Point of Contact)
Ethan Dinwiddie
Phone #:
828-550-5502
Updated: 4/11/2020 Page 5

Updated: April 11, 2020
COVID-19 Guidance for Employees on Encroachment Job sites within NCDOT Right of Way
Relationship to
Confirmed
POSITIVE Test
CONTACT GROUP
What YOU Should Do
What your CREW Should Do
Exposure within 6' and longer than 10 minutes
What PROJECT SITE Personnel
Should Do
No exposure within 6' and longer than 10 minutes
Employee
You
+
AIL
II
/ - ,
I-H
Notify your supervisor
Self -quarantine for 14 days
Advise of POSITIVE test without identifying
the affected employee*
Directly exposed crew self -quarantine for 14
days
Continue hygiene & disinfecting measures
Advise of POSITIVE test without identifying the
affected employee*
Site personnel without direct contact may
continue onsite work or follow their company
policy
Continue hygiene & disinfecting measures
Direct Contact
Interaction with an
infected person
within 6' and longer
than 10 minutes
+ You
I W
t-T-t I-T-4
Self -quarantine for 14 days
Advise of POSITIVE test without identifying
the affected employee*
Crew may continue onsite work or follow
their company policy
Continue hygiene & disinfecting measures
Advise of POSITIVE test
Continue hygiene & disinfecting measures
Secondary
Contact
+ You
ilk AIL ilk
MI I. MI
1-1-t I-T-t I-1-t
You may continue onsite work or follow
your company policy
Continue hygiene & disinfecting measures
I Continue hygiene & disinfecting measures
Continue hygiene & disinfecting measures
Two or more
Persons
Removed from
Contact
+ You
Ak AILAk
II III gl, III
Continue hygiene & disinfecting measures
Continue hygiene & disinfecting measures
Continue hygiene & disinfecting measures
*Notification
Protocol
(Comply with HIPAA
& ADA
confidentiality
requirements)
NCDOT employee / agent tests
POSITIVE
NCDOT District Engineer/Resident Engineer notifies Encroaching Party's primary point of contact and Contractor Point of
Contact, CDC and, if Resident Engineer has oversight for the job site, FHWA any Consultant Firms working for NCDOT
Encroaching party representative notifies other Contractors, Sub -Contractors and Suppliers with exposed Employees
Encroaching Party or Contract crew
member on job site tests POSITIVE
Encroaching party representative or Contractor point of contact notifies appropriate NCDOT District Engineer or Resident
Engineer and all other Contractors, Sub -Contractors and Suppliers with exposed Employees
NCDOT notifies CDC, and as appropriate, FHWA and any Consultant Firms working for NCDOT
Joint Workforce Safety Plan: COVID-19
Page 6

ATTACHMENT FORM
NOTIFICATION FOR UTILITY / NON -UTILITY ENCROACHMENT WITHIN NCDOT R/W
Instructions for use:
This form must be completed in its entirety and submitted directly to the designated personnel in the District Engineer's
office via email, fax or hand delivery a minimum of one week prior to construction for the encroachment. If the
designated NCDOT personnel names are unknown by the person completing this form, please contact the District
Engineer's office to determine that contact info.
Date: 6/29/2021
Submitted by Name: F. D. Owens
To: District Personnel Name: Mickey Pate
District Personnel Email: mpatel @ncdot.gov
District Fax No.:
This notification is to inform you that we (encroaching party or their contractor) will begin construction
work on the following project in a minimum of one week.
Encroachment number
(assigned by NCDOT) for the project:
Construction start date:
Approximate ending date:
Contact NCDOT inspector a minimum of 72 hrs. in advance to set-up Preconstruction meeting in the
District Engineer's office or other location as directed by the District Engineer
E081-076-21-00143
Preconstruction meeting date & time:
Preconstruction meeting address:
Type of project: Montering Well
[Examples: power, telecommunication, water, sewer, gas, petroleum, other (describe)]
Contact Info for this project:
Contractor Company Name:
Contractor Contact Name:
Contractor Phone Number:
Contractor Email:
NCDOT Utility Inspector Name:
Danny Craven
NCDOT Utility Inspector Phone:
336-318-4050
NCDOT Utility Inspector Email:
[e-mail]
NCDOT Utility Project Manager Name:
Jared McCaskill
NCDOT Utility Project Manager Phone:
336-318-4050
NCDOT Utility Project Manager Email:
[e-mail]