WM0401485_Monitoring well construction permit application_20231020

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER Rt5UUK(;ts
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.
FOR OFFICE USE ONLY
1. Date: October 18. 2023
2. County: Stokes _ PERMIT NO. _ ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Huffman Oil Com an s James Barnwell Telephone: [phone]
Applicant's Mailing Address:.__ P.O. Box 730 Burlington, NC 27216
Applicant's Email Address (if available): ibamwell3 a huffmanO.net
5. Contact Person (if different than Applicant): _ Wayne Watterson Telephone: [phone]
Contact Person's Mailing Address: _ 8646 W. Market Street Suite 105. Greensboro, NC 27409
Contact Person's Email Address (if available): wwatterson smeinc.com
6. Property Owner (if different than Applicant): N.C. Department of Transport tion Telephone: [phone]
Property Owner's Mailing Address: 375 Silas Creek Parkway. Winston-Salem.,. NC. 27127
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number)_ 6066 NC 705 Hic hwav East. s Parcel No. 2117
City Sandy Ride County Stokes Zip Code 27046
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: UST
(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).
6066 NC 704 Hi::hway East: LUST Incident No. 29296, D&M Grocery
11. Type of contaminants being monitored or recovered: volatile or(ianic comt)ounds
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? . Yes s 16)
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401457
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet):. 50 - 125
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? _ Yes
If yes, give distance(s): 200, 300, 350 feet
15. Well Contractor: _Innovative Environmental Technologies, Inc. Certification No.: 3287-A
Well Contractor Address: 232 Highway 49 South, Concord, NC 28025
PROPOSED WELL CONSTRUCTION INFORMATION
1 As required by 15A NCAC 02C .0105(%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? 2'x2' concrete
material: Three [MW-16 17 18 Bolt -down cover locked exc}andable cap
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: Nov.2023
4. Total Number of wells to be constructed: _ Three 7. Estimated construction completion date: Dec. 2023
(add answers from 2 and 3)
ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:
a. All property boundaries, at least one of which is referenced to a minimum of two landmarks such as identified roads,
intersections, streams, or lakes within 500 feet of the proposed well or well system.
b. All existing wells, identified by type of use, within 500 feet of the proposed well or well system.
C. The proposed well or well system.
d. Any test borings within 500 feet of proposed well or well system.
e. All sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or fuel
storage areas, animal feedlots as defined in G.S. 143-215.1013(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
_Agent for Owner
Signature of Applicant or *Agent Title of Applicant or *Agent
Lvndal Butler S&ME. Inc. * If signing as Agent, attach authorization agreement stating
Printed name of Applicant or *Agent 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
well(s) as outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
t See attached sicaned Encroachment A(;reement _ NC Department of Transportation
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
Raleigh Regional Office
Wilmington Regional Office
2090 U.S. Highway 70
3800 Barrett Drive
127 Cardinal Drive Extension
Swannanoa, NC 28778
Raleigh, NC 27609
Wilmington, NC 28405
Phone: [phone]
Phone: [phone]
Phone: [phone]
Fax: [phone]
Fax: [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]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
- ,.
�as!-ingto� w!
GW-22M/R (Rev. 5-26-2022)

Well ID
Project Name
I
Project Number
22580285D
City
=0
ED&M
Well Permit Number
Proposed MW-16, 17, 18
48461Grocery
S&ME Staff
Installation Date
County
To be installed
Stokes
Sandy Ridge
Application
Drilling Contractor
License Number
Drill Rig
Well Type / Use
Innovative Environmental Technologies, Inc.
-
-
Flush Monitor Well
Water Level at TOB (0.01 ft-
BTOC)
Date/Time
Latitude
Land Surface Elev. (0.01 ft)
Drilling Method
-
-
Hollow Stem Auger
Depth to Water (0.01 ft-
BTOC)
Date/Time
Longitude
Total Well Depth (0.1 ft-bgs)
Borehole Diameter (1 in)
-
-
42.0
8-inch
TOC Relative to Ground 0.0 ft F
Depth Below Ground Surface (ft-bgs
Top of Seal - 3.0 0.1 ft-bgs
Top of Filter Pack - 25.0 0.1 ft-bgs
Top of Screen - 27.0 0.1 ft-bgs
Screened Interval - 15.0 0.1 ft-bgs
Bottom of Screen - 42.0 0.1 ft-bgs
Bottom of Filter Pack - 42.0 0.1 ft-bgs
Cave In - 0.1 ft-bgs
Total Boring Depth - 42.0 0.1 ft-bgs
Pad Type
2' x 2' Concrete
Protective Casing
Flush Vault (8" diam)
Casing Material
2-in Sch 40 PVC
Casing Interval (0.1 ft-bgs)
0.0
to
27.0
Screen Type
2-in Sch 40 PVC (0.010)
Screen Interval (0.1 ft-bgs)
27.0
1 to
1 42.0
Grout Type
Portland Cement T2
Grout Interval (0.1 ft-bgs)
0.0
to
3.0
Seal Type
3/8 in. Holeplug®
Seal Interval (0.1 ft-bgs)
3.0
to
25.0
Filter Pack
#2 Silica Sand
Filter Pack Interval (0.1 ft-bgs)
25.0
1 to
1 42.0
Development
Development Volume (gal)
Notes: Monitoring well permit application for MW-16, MW-17, MW-18; NCDOT Right -of -Way; 6066 NC 704
Highway East.
BTOC - Below Top of Casing
TBD - To Be Determined
For lithologic information
see attached boring log
Form Revision Date: 9/1/17 2:10 PM

_r v._: `i I.r•-1P"��•�� 4 i ,i l� i •i;...S^' ,. _•• J �• ' j.K+~ • ■ 1.`, jtso
f. '. 1•y5 ...1, '�. •�I 1i-�T �, ' �'
- ,A A,
r . r• sxo xuaacao,m ' ��r• 4.ii=� _, 1',s'h
luk
�
` o CEC7Aar..f.c 7
a pGN i i o easrwuw a +
(It
€ r.
� tit .: �� ; � "�� • s•; .
VA 66
.,,,/� t $' 4 • i N211'�J"HrtYr 2 F Y ' E «eE [fsrrwx
• f `tr.+.oa mn +lol oat,¢u"ICNia iy r q rcL r7'f� � . •J i .s.
. ,� it ` • n fos= i.�111 • �j 0 , �
.. T . � , ` ;rid � � PR!{' _ o. � �• �'� 1'% ��' rov4un.u:vr�` .r �`
Ift
".pis s '�,�"� •tar r ,�—.._------• ---- ---' .� i
�l ilC.t-H �� � + •l 1 , f R�!7F•+• Y�� � ,� .�'. uNr4 .- - �• 1 �
;I 4 j.i K7 r ;�*5rl .
�• o nIII, ?KTACHU"Ag k
Y i
r NC794 NN71 �JE
Ai 1
. •,F ;
ItMl .y• VV ,
tr r °• '+ :, ' ' A �r NOTE: INACTIVE WELLS: WSW-1, WSW-2, WSW-6
4: Sa s
�•�;; it i , 1' � , 4 �
SOURCE: 2022 STOKES COUNTY, NC PARCEL DATA DOWNLOADED FROM NC ONEMAP
LEGEND
® LOCATION OF OBSERVED APPARENT WELL STRUCTURE
® APPROXIMATE WELL LOCATION (NOT OBSERVED)
0 400 800
GRAPHIC SCALE (IN FEET)
her
W L
L
0 C
c
Lu " [
0
r7 Z
Lu F
0
W U u
Z
e
3
SCALE:
AS SHOWN
DATE:
MARCH 2O23
PROJECT NUMBER
22580285
FIGURE N0.
i'

STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
ROY COOPER
GOVERNOR
September 28, 2023
Stokes County: NC 704
J. ERIC BOYETTE
SECRETARY
Subject: Right of Way Encroachment Contract — RIW 16.1A — Job Number — E092-85-23-
00382 — Installation of One (1) Monitoring Well on the NCDOT Right of Way.
Mr. James A. Barnwell, III
Huffinan Oil Company
P.O. Box 730
Burlington, NC 27217
Dear Mr. Barnwell:
For your file, this letter is an addendum to the approved Encroachment Agreement. I am requesting
those who received a copy of the original to include this letter and revised/corrected Encroachment
dated June 23, 2023.
THE ORIGINAL CONDITIONS STILL REMAIN IN FORCE ALONG WITH THE
FOLLOWING CONDITION:
• An addendum to the Encroachment Agreement dated June 23, 2023. This covers an
addition of three (3) monitoring wells to the original agreement. The revised plan is
included within this package.
Sincerely,
1DocuSigned by:
SCd{f ,,balls
707888B5D87F4AC...
Scott A. Jones, P.E.
DISTRICT ENGINEER
SAFREO
cc: Andrew Bennett, P.E. • Stokes County Maintenance Engineer
Mailing Address:
NC DEPARTMENT OF TRANSPORTATION
DIVISION NINE / DISTRICT TWO
SILAS CREEK PARKWAY
WINSTON-SALEM, NC 27127
Telephone: [phone]
Fax: [phone]
Customer Service: 1-877-368-4968
Website: ncdot.gov
Location:
375 SILAS CREEK PARKWAY
WINSTON-SALEM, NC 27127

SPECIAL PROVISIONS — Page 1
R/W 16.1 — MCI Metro
E092-085-23-00382
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] to the
Forsyth County Maintenance office
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.
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.
6. The encroaching party shall notify the appropriate municipal office prior to beginning any
work within the municipality's limits of jurisdiction.
7. 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.
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.
9. 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.

SPECIAL PROVISIONS — Page 2
R/W 16.1 — MCI Metro
E092-085-23-00382
10. Encroaching party shall be responsible for obtaining all necessary permanent and/or
temporary construction, drainage, utility and/or sight distance easements.
11. 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.
12. No commercial advertising shall be allowed within NCDOT Right of Way.
13. The encroaching party shall obtain proper approval from all affected pole owners prior to
attachment to any pole.
14. Traffic control shall be coordinated with the Forsyth County Maintenance Office at telephone
[phone], prior to construction.
15. 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.
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.goy/projects/WZTC/Pa,ges/Training.aspx or call the NCDOT Work
Zone Traffic Control Section [phone].
16. 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.

SPECIAL PROVISIONS — Page 3
R/W 16.1 — MCI Metro
E092-085-23-00382
It also covers important safety knowledge for a wide range of work zone job
responsibilities.
17. 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.
18. 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.
19. Traffic shall be maintained at all times. All lanes of traffic are to be open during the hours of
7:00 A.M. to 9:00 A.M. and from 4:00 P.M. to 6:00 P.M. Monday through Friday, during any
time of inclement weather, or as directed by the County Maintenance Engineer. Any
violation of these hours will result in ceasing any further construction by the Encroaching
Party or their contractor.
20. 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.
21. Two-way traffic shall be maintained at all times unless designated by the County
Maintenance Engineer. Traffic shall not be rerouted or detoured without the prior written
approval from the County Maintenance 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 County Maintenance 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.
22. Work requiring lane or shoulder closures shall not be performed on both sides of the road
simultaneously within the same area.
23. 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.
24. 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.
25. Any pavement markings that are damaged or obliterated shall be restored by the encroaching
party at no expense to NCDOT.
26. 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=AOuYa5lW3dg&feature=youtu.be

SPECIAL PROVISIONS — Page 4
R/W 16.1 — MCI Metro
E092-085-23-00382
27. 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 336-896-2380.
28. 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, 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.
29. The contractor shall not begin the construction until after the traffic control and erosion
control devices have been installed to the satisfaction of the County Maintenance Engineer or
their agent.
30. 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.
31. 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.
32. 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.
33. The encroaching party shall notify the County Maintenance 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.
34. 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 10 feet below flowline of streams.
35. 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.
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

SPECIAL PROVISIONS — Page 5
R/W 16.1 — MCI Metro
E092-085-23-00382
non -working hours, no parking or material storage shall be allowed along the shoulders of
any state -maintained roadway.
36. 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 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 Minimum Depth of Cover
(Backream)
2" to 6" 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.
37. 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.

SPECIAL PROVISIONS — Page 6
R/W 16.1 — MCI Metro
E092-085-23-00382
38. 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.
39. Right of Way monuments disturbed during construction shall be referenced by a registered
Land Surveyor and reset after construction.
40. All Traffic signs moved during construction shall be reinstalled as soon as possible to the
satisfaction of the Division Engineer or their representative.
41. 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.
42. 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.
43. All driveways disturbed during construction shall be returned to a state comparable with the
condition of the driveways prior to construction.
44. 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.
45. 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.
46. 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.
47. All wiring and related electrical work shall conform to the latest edition of the National
Electrical Safety Code.
48. 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.
49. Excavation material shall not be placed on pavement.

SPECIAL PROVISIONS — Page 7
R/W 16.1 — MCI Metro
E092-085-23-00382
50. 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.
51. 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.
52. 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.
53. The Encroaching party shall notify the County Maintenance Engineer's office within 2
business days after construction is complete. The County Maintenance 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.
54. 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.

ROUTE NC-704
STATE OF NORTH CAROLINA
PROJECT D&M Grocery COUNTY OF Stokes
DEPARTMENT OF TRANSPORTATION RIGHT OF WAY ENCROACHMENT AGREEMENT
N
-AND- REVIEWDYRIMARY AND SECONDARY HIGHWAY
Huffman Oil Company
P.O. Box 730, Burlington, NC 2216-0730 I R11 CMS
Carbajal at 10:28 am, Jun 23, 2023
THIS AGREEMENT. made and entered into this the 23 day of June, 20 23 , by and between the Department
of Transportation, party of the first part; and Huffman oil Company
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) NC-704
.located on the southwest side of NC-704
with the construction and/or erection of: One monitoring well as shown on the attached plans, for the purpose of environmental assessment.
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
Nights, 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 th is 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 pollubon 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 herein
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 parry of the first part.
FORM RIW 16.1A (Revised February 2 02 1)

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.
DEPAR2 Kl� qd, .F TRANSPORTATION
DISTRICT ENGINEER
B ES707Rh§TjP�4TCENGINEER
CD{{ ,,bVi,t,S
ATTEST OR WITNESS:
' S cond 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.
S. 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.

May 18, 2023
North Carolina Department of Transportation
Division 9, Right of Way Office
1605 Westbrook Plaza Drive
Suite 201
Winston Salem, North Carolina 27103
Attention: Ms. Janet R Harris jrharris4Ccbncdot.gov
Reference: Right -of -Way Encroachment Agreement for Non -Utility Encroachment
on Primary and Secondary Highways (Revision 01)
D&M Grocery; Incident No. 48461
6066 NC 704
Sandy Ridge, Stokes County, North Carolina
S&ME Project No. 22580285
Dear Ms. Harris:
S&ME, Inc. (S&ME) is under contract with Huffman Oil Company to perform assessment of a petroleum release
from an underground storage tank (UST) spill associated with North Carolina Department of Environmental
Quality (NCDEQ) UST Incident No. 68461. The spill was discovered on March 25, 2022. Based on a review of the
Stokes County Geographic Information website, the subject incident is located on the property addressed as 6066
NC Highway 704 E, Sandy Ridge, North Carolina and identified by Parcel Identification Number (PIN) 6979-62-
2321; hereinafter referred to as the subject property (see attached Figure 1). As part of the assessment activities,
S&ME is requesting an encroachment in the NCDOT right-of-way, southwest of NC-18 (see attached Figure 2) to
install a monitoring well. This work is being performed at the request of the NCDEQ.
S&ME, Inc. (S&ME) proposes to install one groundwater monitoring well as part of our tasks for this project. The
monitoring well is needed to assess groundwater quality near the location where groundwater contamination is
present. The following information is our proposed location and description for the groundwater monitoring well:
Installation of one monitoring well on the NCDOT Right -of -Way southwest of NC 704. The location of the
proposed monitoring well is shown on the attached Figure 2.
The groundwater monitoring well will be advanced to a depth of approximately 40 feet below ground surface.
The groundwater monitoring well will be two-inch diameter flush -mount monitor well finished at the surface
with a square concrete pad measuring two feet by two feet (see attached diagram and photograph).
S&ME will utilize a North Carolina licensed driller to install the monitoring well;
The field crew will have the proper signage, traffic cones and number of personnel necessary to safely perform
work and monitor and/or direct traffic if needed;
Investigative derived waste (drill cuttings) generated during the installation of the monitor well will not be
placed on the NCDOT right of way;
S&ME will contact the District Engineer prior to the start of work to notify of the anticipated start date;
S&ME, Inc. 18646 West Market Street, Suite 105 1 Greensboro, NC 27409 1 p 336.288.7180 1 www.smeinc.com

Right of Way Encroachment Agreement for Non -Utility Encroachment
on Primary and Secondary Highways (Revision 01)
D&M Grocery; Incident No. 48461
6066 NC 704
Sandy Ridge, Stokes County, North Carolina
S&ME Project No. 22580285
S&ME will contract a private utility locator and also use NC One Call to mark out subsurface utilities prior to
commencing work.
The installation of the monitoring well will take less than one day to complete. We anticipate that S&ME
personnel may occasionally return to the monitoring well to collect groundwater samples, at the direction of
NCDEQ.
Please find enclosed one original of North Carolina Department of Transportation (NCDOT form R/W 16.1A Right
of Way Encroachment Agreement for Non -Utility Encroachments on Primary and Secondary Highways, which was
obtained from the NCDOT website and signed by the Senior Project Engineer. Also included are four copies of our
package which includes a figure showing the proposed location of the groundwater monitor well, a diagram of a
typical monitor well construction, figure of the approximate location of the proposed monitoring well location and
an example of a completed flush mount monitoring well.
Please contact us if you have any questions about this project or require additional information.
Sincerely,
S&ME, Inc.
""'�®1I /ll�tcll'�91G
Cody McMechen, G.I.T.
Staff Professional
[e-mail]
Attachments: Attachment I- NCDOT Form R/W 16.1A
Wayne Watterson, P.E.
Principal Engineer
wwatterson(@smeinc.com
Attachment II- Figures
Attachment III- Diagram of a Typical Flush -Mount Monitoring Well
Attachment IV- Photographs
May 18, 2023

COMPLETION REPORT OF WELL No. MW Sheet 1 of 1
PROJECT: D&M Grocery
PROJECT NO: 22580285D WATER LEVEL:
PROJECT LOCATION: 6066 NC 704 E, Sandy Ridge, North Carolina
DRILLING CONTRACTOR:
DRILLING METHOD:
DATE COMPLETED:
LATITUDE:
LONGITUDE:
TOP OF CASING ELEVATION:
DATUM:
LOGGED BY:
STRATA
WELL
o
0
m
DETAILS
WELL CONSTRUCTION DETAILS
DESCRIPTION
g
F--
o
LULU
p
J
J
}
w --
o
w
PROTECTIVE CASING
0
0.00
GS
Diameter:
Type:
Interval:
RISER CASING
5
Diameter: 2"
Type:
Interval: 0.3 - 15.0
GROUT
Type: Grout
10
Interval: 0.3 - 12.0
12.00
SEAL
Type: 3/8 in. holeplug
14.00
Interval: 12.0 - 14.0
15
'•
15.00
FILTERPACK
Type: #2 sand
Interval: 14.0 - 30.0
20
SCREEN
Diameter: 0.010
Type: PVC
Interval: 15.0 - 30.0
25
'.
LEGEND
El FILTER PACK TOC TOP OF CASING
30
30.00
■ BENTONITE GS GROUND SURFACE
BS BENTONITE SEAL
® CEMENT GROUT BOC BASE OF OUTER CASING
TSC TOP OF SCREEN
FORMATION BSC BOTTOM OF SCREEN
ENE
1 STATIC WATER LEVEL TD TOTAL DEPTH
CG CEMENT GROUT
COMPLETION REPORT
OF MONITORING WELL
SME
ENGINEERING • TESTING Sheet 1 of 1
ENVIRONMENTAL SERVICES

Right of Way Encroachment Agreement for Non -Utility Encroachment
6066 NC 704
Sandy Ridge, Stokes County, North Carolina
S&ME Project No. 22580285
op 74-M
XFP
- + •
•
N
N
O
Ar
d
Location / Orientation Not applicable
1
Remarks Example of a flush -mount monitoring well cover and
concrete pad.