WI0400586_Notification of Intent (NOI) – GW Remediation_20220713

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 (NOTE: This form must be received at least 14 DAYS prior to injection)
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C .0229):
1) Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
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: July 8 , 20_22 PERMIT NO.
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
C.
(to be filled in by DWR)
(1) X Air Injection Well ....Complete sections B through F, K, N
(2) Aquifer Test Well Complete sections B through F, K, N
(3) Passive Injection System Complete sections B through F, H-N
(4) Small -Scale Injection Operation Complete sections B through N
(5) Pilot Test Complete sections B through N
(6) Tracer Injection Well Complete sections B through N
STATUS OF WELL OWNER: State Government
WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): NCDEQ-DWM, UST Section, Federal & State Lead Program (TF#17045); Attn: Sharon Ghiold
Mailing Address: 1646 Mail Service Center
City: Raleigh
State: NC Zip Code: 27699-1646 County: Wake
Day Tele No.: 919-707-8166
EMAIL Address:
[e-mail]
Cell No.: NA
Fax No.: 919-571-4718
Deemed Permitted GW Remediation NOI Rev. 1-06-2021
Page 1

D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title:
Company Name
Mailing Address:
Justin Weisser
English Market Associates LLC
20155 NE 38t Court, Ste 201
City: Aventura State: FL Zip Code: 33180 County: Miami -Dade
Day Tele No.: 305-690-9110 Cell No.:
EMAIL Address: Fax No.:
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: Elizabeth A. Allyn, P.G., Environmental Project Geologist II
Company Name WithersRavenel, Inc.
Mailing Address: 115 MacKenan Drive
City: Cary State: NC Zip Code:27511 County: Wake
Day Tele No.: 919-469-3340 Cell No.: 919-418-0279
EMAIL Address: [e-mail] Fax No.: 919-467-6008
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: English Market Shopping Center; 2318 E. Market St., NCDEQ Incident
#17045
City: Greensboro County: Guilford Zip Code: 27420
(2) Geographic Coordinates: Latitude**: 35° 076210
Longitude**: -79° 757473
Reference Datum: Google Earth Accuracy: +/- 5m
Method of Collection: Google Earth
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: square feet
Land surface area of inj. well network: square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (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. 1-06-2021 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.
J. APPROVED INJECTANTS — Provide a MSDS for each injectant (attach additional sheets if necessary).
NOTE: Only injectants 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/ground-water-protection/ground-water-approved-inj ectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Inj ectant:
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:
Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: 0 Proposed 1 Existing (provide GW-1s)
(2) 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):
Deemed Permitted GW Remediation NOI Rev. 1-06-2021 Page 3

L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
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 02L result from the injection activity.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "7 hereby certify, under penalty of law, that I am familiar with the information
submitted in this document 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 related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
42'47+
Signature of Applicant
Elizabeth A. Allyn, PG, Environmental Project Geologist II, WithersRavenel
On behalf on NCDEQ-DWM, UST Section for Incident #17045
Print or Type Full Name and Title
Property Owner (if the property is not owned by the Well Owner/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 .0200)."
"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.
SEE ATTACHED NCDEQ STATE -LEAD ACCESS AGREEMENT FOR PROPERTY
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send 1 (one) hard color copy of this NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 1-06-2021 Page 4

FIGURES
English Market Shopping Center - NCDEQ Incident #17045 WR Project # 02172214.79
Notice of Intent - UIC July 2022

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E BRAGG ST
DOUGLASST
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STEVENS ST
111110 Engineers I Planners I Surveyors
115 MacKenan Drive I Cary, NC 27511 I t: 919.469.3340 I license #: F-1479
www.with ersrave n el.com
220
421
WithersRavenel
PEAR ST
RA NDALL., ST; \.
QUEEIy BEr8 DR
i
LORD JEFF
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0
1
Piedmont
Memorial Cem
ENGLISH MARKET SHOPPING CENTER
INCIDENT #17045
2316 EAST MARKET STREET
GREENSBORO, GUILFORD COUNTY, NC
GENERAL LOCATION MAP
gURuNGTON
Bessemer
NA C O RD
EASTLANDAVE \
i
NOLrs CHAPEL RD
— —
OL
c9AF 1-
G`RaHIC SCALE
1000 2000
1 inch = 2000 ft.
DRAWN BY:
DCV
APPROVED BY:
EAA
SCALE:
1"=2000'
DATE:
08/27/2021
FIGURE NO.:
1
4000
PROJECT NO.:
02172214.79
WwInisme03l.eom\rrcwG—nawN\WRShan\Prolxb\17\17-2210\1722u.7B—NWEG — Ena11M Yarkat Showing ConW\FiMro\GD\B.N WC 81ile11 M.I t SIapWiq GMer.d o— Ngwt 31. 2021 — VA/L. DAM

ill.Engineers Planners Surveyors
115 MacKenan Drivel Cary, NC 27511 1 t: 919.469.3340 1 license #: F-1479
www.withersravenel.com
WithersRavenel
APPROXIMATE
LOCATION OF
FORMER SERVICE
STATION
ENGLISH MARKET SHOPPING CENTER
INCIDENT #17045
2316 EAST MARKET STREET
GREENSBORO GUILFORD COUNTY, NC
SITE MAP
APPROXIMATE
AREA OF GPR
SURVEY
DRAWN BY:
DCV
APPROVED BY
EAA
SCALE:
1"=40'
DATE:
05/31/22
FIGURE NO.:
2
PROJECT NO.:
02172214.79
K:\17\17-221o\l72214.70-Ncom - fin Modal Shopping INnbr\OwIro\CADVion Hop F+wlIth Market Shopping C - 2022 Mro4a- Jun 32022 - MAX La

1
7.1
MW-1
_83.91)
4_ -r
MW-4
(83.29
Wigs -
4
MW-1D
(84.17) i 83.80
kAt-r
ofr
LJ
LEGEND
TYPE II MONITORING WELL LOCATION
TYPE III MONITORING WELL LOCATION
GROUNDWATER ELEVATION CONTOUR
(DASHED WHERE INFERRED)
(83.29) GROUNDWATER ELEVATION (FT)
GROUNDWATER FLOW DIRECTION
NOTES:
1.) AERIAL OBTAINED FROM THE LOCAL COUNTY GIS DEPARTMENT.
2.) GROUNDWATER ELEVATION IN MW-1D WAS NOT USED TO CONSTRUCT
CONTOURS
44
I..
�ROM
1
83.40
101,
nis +�
ot
tin
41/16 MW-3
(83.30)
1
•
�• i
GRAPHIC SCALE
0 20 40
i .
80
1"=40'
NWEngineers I Planners I Surveyors
115 MacKenan Drive I Cary, NC 27511 I t: 919.469.3340 license #: F-1479
www.withersravenel.com
WithersRavenel
ENGLISH MARKET SHOPPING CENTER
INCIDENT #17045
2316 EAST MARKET STREET
GREENSBORO, GUILFORD COUNTY, NC
GROUNDWATER FLOW MAP
DRAWN BY:
DCV
SCALE:
1"=40'
FIGURE NO.:
3
APPROVED BY
EAA
DATE:
05/31/2022
PROJECT NO.:
02172214.79
K\17\17 2210Vm>I4.7Y—Nc0EQ — English Marks( Shagging Cant.\Fnwo\oro\ea.. Map Engish Market Shagging c.M., — 2022 Yg4w— Juno 3, 2022 — uuN. UZ

Analytical Method
6200E - Volatile Organic Compounds
Calculated
Sample
ID
let
Collected
N
Dibromoethane.1.2-
Dichloroethane,1,2-
Ethylbenzene
Isopropylbenzene (Cumene)
MBK, Methyl Butyl Ketone
(2-Hexanone)
Naphthalene
Propylbenzene, n-
Toluene
v
N
V.,°'
E
I-
M
E
H
o
>
X
71-43-2
106-93-4
107-06-2
100-41-4
98-82-8
591-78-6
91-20-3
103-65-1
108-88-3
95-63-6
108-67-8
1330-20-7
MW-1
05/03/22
14 400
161
139
1,520
90.5
260
788
116
17,800
1,750
559
12,100
MW-1D
05/03/22
2.01
<0.500
<0.500
<0.500
<0.500
<1.00
<1.00
<0.500
<0.500
<0.500
<0.500
<0.500
MW-2
05/03/22
989
10.6
8.04
1,610
88
33.4
553
140
351
1,740
415
10,400
MW-3
05/03/22
<0.500
<0.500
<0.500
<0.500
<0.500
<1.00
<1.00
<0.500
<0.500
<0.500
<0.500
<0.500
MW-4
05/03/22
1.03
<0.500
<0.500
<0.500
<0.500
<1.00
<1.00
<0.500
<0.500
<0.500
<0.500
<0.500
Trip Blank
05/03/22
<0.500
<0.500
<0.500
<0.500
<0.500
<1.00
<1.00
<0.500
<0.500
<0.500
<0.500
<0.500
NC 2L Standard
1
0.02
0.4
600
70
40
6
70
600
400
400
500
GCLs for Groundwater
5,000
50
400
80,000
30,500
40,000
6,000
26,100
260,000
28,500
24,100
50,000
Notes:
1) All results provided in ug/L (micrograms per liter) or parts per billion.
2) Compounds analyzed for by laboratory but not listed were not detected above laboratory detection limits. See the laboratory report included in the
3) NC 2L Standard - North Carolina Groundwater Quality Standard as per NC Administrative Code 15A NCAC 02L.
4) GCLs for Groundwater = NCDEQ UST Section Gross Contamination Levels for Groundwater.
/
NL
= No Regulatory Limit Established
= Compound Not Analyzed or Not Detected.' Result f = Result Exceeds Laboratory Detection Limits.
4_ .
Result
= Result Exceeds 2L Standard.
- = Result Exceeds GCL Value.
4111111
I 1
r.r
g\
MW-2
lk
MW-1Dtill
f g
AL4 :Can
MW-1 It ' ! IP
_ F0
' *+ `
4-7 Y
VIII
gli lib
IN -
s (�
• l glia944
alAt 'I
i ll r-
; 1 Ilin tie"W-3 4111. AM
1
Ali MW-4
mr
m•G•1Am /
LEGEND
0- TYPE II MONITORING WELL LOCATION
`J TYPE III MONITORING WELL LOCATION
GRAPHIC SCALE 111
0 20 40 80
NOTES:
1.) 2013 AERIAL OBTAINED FROM THE LOCAL COUNTY GIS DEPARTMENT.
1 inch = 40 ft.
I/
115 MacKenan
W i t
Engineers
Drive I Cary, NC
www.withersravenel.com
h e rs
I Planners
27511 I t: 919.469.3340
Ra ve n e
I Surveyors
I license #: F-1479
l
ENGLISH MARKET SHOPPING CENTER
INCIDENT EAST MARKET
2316 EAST MARKET STREET
DRAWN BY
DCV
SCALE
1"=40'
FIGURE No
4
GREENSBORO, GUILFORD COUNTY,NC
APPROVED BY:
DATE:
05/31/22
PROJECT NO.:
02172214.79
GROUNDWATER ANALYTICAL DATA MAP
EAA
ID\17\17-2210\1722I4.70-NCDEQ - English Market Swiping Cyr\ EtwIroVALIV00. lap rah Market Shaping car - 2022 II0y4w- dine 3, 2022 - ALTN. U2

(989)
LEGEND
TYPE II MONITORING WELL LOCATION
TYPE III MONITORING WELL LOCATION
BENZENE ISOCONCENTRATION CONTOUR
(IN MICROGRAMS PER LITER, DASHED
WHERE INFERRED)
BENZENE CONCENTRATION
(IN MICROGRAMS PER LITER)
NOTES:
1.) AERIAL OBTAINED FROM THE LOCAL COUNTY GIS DEPARTMENT.
1
0
GRAPHIC SCALE
0 20 40 80
1 inch = 40 ft.
NWEngineers I Planners I Surveyors
115 MacKenan Drive 1 Cary, NC 27511 I t: 919.469.3340 1 license #: F-1479
www.withersravenel.com
WithersRavenel
ENGLISH MARKET SHOPPING CENTER
INCIDENT #17045
2316 EAST MARKET STREET
GREENSBORO, GUILFORD COUNTY, NC
BENZENE ISOCONCENTRATION MAP
DRAWN BY:
DCV
SCALE:
1"=40'
APPROVED BY: DATE:
EAA
05/31/22
FIGURE NO.:
5
PROJECT NO.:
02172214.79
e\17\17 2210Vm>Iw7Y—Nc0EQ — English Marks( Shagging Cant.\Fnwo\oro\ea.. Map Engish Market Shagging c.M., — 2022 Yg4w— Juno 3, 2022 — uuN. UZ

WELL CONSTRUCTION RECORD
English Market Shopping Center - NCDEQ Incident #17045 WR Project # 02172214.79
Notice of Intent - UIC July 2022

TABLE B-7
MONITORING WELL CONSTRUCTION AND LIQUID LEVEL DATA
English Market Shopping Center
Incident # 17045
2316 East Market Street
Greensboro, Guilford County, NC
Well ID
Date Installed
Top of
Casing
Elevation
(ft)
Well
Diameter
(in)
Well Casing
Depth
(ft-BGS)
Screen
Interval
(ft-BGS)
Date of Measurement
Depth to
Product
(ft-BTOC)
Depth To Water
(ft-BTOC)
Product
Thickness (ft)
Groundwater
Elevation
(ft)
MW-1
2/25/2003
99.99
2
15.0
15.0-30.0
02/28/03
--
16.00
--
83.99
05/01/19
--
12.64
--
87.35
11/13/19
--
16.65
--
83.34
08/06/20
15.30
84.69
07/06/21
--
15.75
--
84.24
10/11/2021 (pre-MMPE)
--
17.25
--
82.74
10/15/2021 (post-MMPE)
--
26.33
--
73.66
05/03/22
--
16.08
--
83.91
MW-1D
2/26/2003
99.76
2
45.0
45.0-50.0
02/28/03
--
15.60
--
84.16
05/01/19
--
12.62
--
87.14
11/13/19
16.53
83.23
08/06/20
--
15.31
--
84.45
07/06/21
--
15.75
--
84.01
05/03/22
--
15.59
--
84.17
MW-2
2/25/2003
101.11
2
15.0
15.0-30.0
02/28/03
--
17.67
--
83.44
05/01/19
--
13.74
--
87.37
11/13/19
--
17.70
--
83.41
08/06/20
16.40
84.71
07/06/21
--
16.80
--
84.31
10/11/2021 (pre-MMPE)
--
18.35
82.76
10/15/2021 (post-MMPE)
--
18.65
--
82.46
05/03/22
--
17.22
--
83.89
MW-3
2/26/2003
95.10
2
10.0
10.0-25.0
02/28/03
11.20
83.90
05/01/19
--
NM
--
NM
11/13/19
13.23
81.87
08/06/20
--
NM
--
NM
07/06/21
--
12.30
--
82.80
05/03/22
--
11.80
--
83.30
MW-4
2/26/2003
96.08
2
13.0
13.0-28.0
02/28/03
--
12.16
--
83.92
05/01/19
--
9.63
--
86.45
11/13/19
13.98
82.10
08/06/20
--
12.57
--
83.51
07/06/21
--
13.05
--
83.03
05/03/22
--
12.73
--
83.35
Notes:
1) Top of Casing (TOC) elevations & construction data provided by previous consultants.
2) NM = Not Measured.
3) BGS - Below Ground Surface.
4) BTOC - Below Top of Casing.
5) If LNAPL is present, groundwater elevation calculated by [TOC-DTW]+[LNAPL thickness x 0.8581].

CLIENT
BROWN INVESTMENT PROP.
JOB #
G-7525
BORING #
MW-1 D
SHEET
1 OF 2
PROJECT NAME
ENGLISH MARKET SHOPPING CTR
SITE LOCATION
GREENSBORO, NORTH CAROLINA
ARCHITECT -ENGINEER
z
cn
cn
SAMPLE DISTANCE (IN)
DESCRIPTION OF MATERIAL
ENGLISH UNITS
SURFACE ELEVATION
-o- CALIBRATED PENETROMETER
TONS/FT. 2
1 2 9 4 5+
I I I
PLASTIC WATER LIQUID
LIMIT % CONTENT % LIMIT %
X -- •- -- p
10 - 20 30 40 50+
I I I I I
STANDARD PENETRATION
LOO BLOWS/FT.
10 20 30 40 50+
10-
15
20-
25-
30
Asphalt and Gravel
Orange Brown Clayey SILT,
Petroleum Odor (ML)
Orange Brown Slightly Clayey
SILT, Petroleum Odor, Moist
(ML)
Orange Brown Clayey SILT,
Petroleum Odor (ML)
Orange Brown Clayey SILT,
Petroleum Odor, Moist (ML)
Tan Orange Brown Clayey SILT,
Petroleum Odor, Moist to Wet
(ML)
Tan Medium to Fine Sandy SILT,
Petroleum Odor, Wet (ML)
CO
FID =
450 (ppm)
FID = 860 (ppm)
FID = 90,800 (ppm)
FID = : 90,800 (ppm)
FID = : 5,340 (ppm)
FID = : 10,800 (ppm)
ITINUED ON NEXT PAGE.
THE STRATIFICATION LINES REPRESENT THE APPROXIMATE BOUNDARY LINES BETWEEN SOIL TYPES IN -SITU THE TRANSITIDN MAY BE GRADUAL
Q WL WS OR
BORING STARTED
02-26-03
WL(AB) ZwL(AC)
BORING COMPLETED
02-26-03
CAVE IN DEPTH
WL
RIG
FOREMAN S E I
DRILLING METHOD AUGER

ACCESS AGREEMENT
English Market Shopping Center - NCDEQ Incident #17045 WR Project # 02172214.79
Notice of Intent - UIC July 2022

Sharon Ghiold
DWM UST Section
1637 Mail Service Ctr
Raleigh, NC 27699-1637
Dear Ms. Ghiold:
RE: Site Access Agreement
English Market Shopping Center
2316 E. Market Street
Greensboro, Guilford County, NC (WSRO)
STF # 17045, Risk Intermediate: I85R
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. 132-1.
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.

English Market Shopping Center
STF #17045
March 22, 2011
Page 2
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.
AKA/ 6(/e/5.5e--____._
Type/Print Name of Owner or Agent
1.gc 67a f//'
Phone Number
pi N--• /%4;!-
Address
Mil,/fz- 97/Z
Cityf State/Zip Code
Date