WM0401537_Monitoring well permit application, WM0401537_20240604

1 125 East Morehead Street,Suite#104
Charlotte,NC 28204
office 980.585.1271
Atlantic M facsimile 980.585.1272
AAONLINE.COM
May 23, 2024
Shuying Wang
Hydrogeologist, Division of Water Resources
North Carolina Department of Environmental Quality
450 West Hanes Mill Road, Suite 300
Winston-Salem, North Carolina 27105
Subject: Monitoring Well Construction Permit Application
City of Winston-Salem Property
Former Wilco #103 Site
Winston-Salem, North Carolina
Incident No.: 16779
Mid-Atlantic Project No.: R0569.07
Dear Shuying:
Mid-Atlantic is pleased to present this well permit application. A copy of the Access
Agreements signed by the property owner is included as an attachment. If you have
questions, please call me at 980-585-1271.
With best regards,
MID-ATLANTIC ASSOCIATES, INC.
+ ---Z / �
Troy L. Holzschuh
Senior Project Manager
Attachments: Attachment A— Topographic Site Map, Site & Monitoring Well
Location Map
Attachment B — Well Construction Details
Attachment C — Access Agreement
ENVIRONMENTAL DUE DILIGENCE BROWNFIELDS STORMWATER INDUSTRIAL HYGIENE

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.
FOR OFFICE USE ONLY
1. Date: May 23, 2024
2. County: Forsyth PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring Well
4. Applicant: A.T.Williams Oil Company Telephone: [phone]
Applicant's Mailing Address: 311 High Street, Winston Salem, NC 27101
Applicant's Email Address(if available):
5. Contact Person (if different than Applicant): Troy L. Holzschuh Telephone: [phone]
Contact Person's Mailing Address: 1125 E. Morehead Street, Suite 104, Charlotte, NC 28204
Contact Person's Email Address (if available): [e-mail]
6. Property Owner(if different than Applicant): City of Winston Salem Telephone: [phone]
Property Owner's Mailing Address: P.O. Box 2511,Winston Salem, NC 27102
Property Owner's Email Address(if available):
7. Property Physical Address(Including PIN Number) Evergreen Cemetery, 2124 New Walkertown Road (PIN 6846-10-4487)
City Winston Salem County Forsyth Zip Code 27101
8. Reason for Well(s): Assessment, 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).
Incident Number 16779—Unknown permit numbers
11. Type of contaminants being monitored or recovered: VOCs by SM 6200B + EDB, MTBE, IPE&5 oxygenates
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes-2
Existing Monitoring or Recovery Well Construction Permit No(s).: Unknown Permit numbers
13. Distance from proposed well(s)to nearest known waste or pollution source (in feet): 60 (MW-11)and 200 feet(MW-12)
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Geologic Exploration Certification No.: 2580-A
Well Contractor Address: 176 Commerce Blvd, Statesville, NC 28625
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 8-inch and 2-inch e. Type of casing material and thickness PVC/Schedule 40
b. Estimated well depth 20 feet each f. Grout horizons 6 feet
C. Screen intervals 10 to 20 feet each g. Well head completion details Flush Mount and Stick Up
d. Sand/gravel pack intervals 8 to 20 feet each
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? Locking Plugs,
material: 2 bolted monitoring well lid& locked stick-up well -
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: June of 2024
4. Total Number of wells to be constructed: 2 7. Estimated construction completion date: June of 2024
(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. 143-215.10B(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.
Secretary
Sig atur of pplicant or Title of Applicant or*Agent
Sherry Polonsky `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.
See Attached Access Agreement
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 Washington Regional Office Winston-Salem Regional Office
225 Green Street, Suite 714 943 Washington Square Mall 450 W. Hanes Mill Road
Fayetteville, NC 28301-5094 Washington, NC 27889 Suite 300
Phone: [phone] Phone: [phone] Winston-Salem, NC 27105
Fax: [phone] Fax: [phone] Phone: [phone]
Fax: [phone]
Mooresville Regional Office -- -
610 East Center Avenue ; " W'" f ow 5a1e
Mooresville, NC 28115
Phone. [phone] l i) �( .+� `X f—. /f,�/lY
Fax: [phone]
AMoorosvihel
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rWilrington
GW-22MIR(Rev. 5-26-2022)

Monitoring Well Application May 23, 2024
Former Wilco #103 Page 2
Mid-Atlantic Project: R0569.07
Attachment A— Topographic Site Map and Site & Monitoring Well Location Map
Ift Mid Atlantic

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REFERENCES: SCALE =1:10,000
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SCANNED FROM 1:24,000-SCALE FORSYTH COUNTY,NC
TOPOGRAPHIC MAPS,PUBLISHED 2022,USGS. 0 425 850 1,700
2.PROPERTY BOUNDARY FROM FORSYTH COUNTY GIS. Feet
3.INSET MAP DATA DOWNLOADED FROM ARCGIS ONLINE.
DRAWN DATE:
TOPOGRAPHIC SITE MAP BY. SEPTEMBER 2023
FORMER WILCO# 103 DRAFT JOB NO:
Mid Atlantic 2500 NEW WALKERTOWN ROAD CHECK: TLH 097R0569.04
ENG. GIS NO:
WINSTON-SALEM, NORTH CAROLINA CHECK: 07G-097R0569.04-1
APPROVAL: RSM DWG NO: 1

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SUBJECT SITE PROPERTY BOUNDARY STREAM #3 SCALE: 1"= 40'

Monitoring Well Application May 23, 2024
Former Wilco #103 Page 3
Mid-Atlantic Project: R0569.07
Attachment B — Well Construction Details
Ift Mid Atlantic

DEPTH FROM GROUND SURFACE
LOCKABLE CAP TO TOP OF CASING (TOC)
FLUSH MOUNT
WELL PROTECTOR LAND SURFACE
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Construction Details -Type II (Flush BYAwN_57z._� DATE: February2o24
Mount) Monitoring Well
Proposed Off Site Well Construction Details DRAFT TLH JOB R0869.07
MW 12 CHECK: NO:
Atlantic Evergreen Cemetery, New Walkertown Road ENG CAD
Winston-Salem North Carolina CHECK: RSM NO: TYPE II MW—FLUSH-201
APPROVAL: RSM DWG
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REFERENCE:

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RISER
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ASSOCIATES, INC. MW-11
Engineering & Environmental Solutions Evergreen Cemetery,New Walkertown Rd CHECK: RSM Np TYPE II MW—STD-2011
Winston-Salem,North Carolina
APPROVAL: RSM DWG
REFERENCE:

Monitoring Well Application May 23, 2024
Former Wilco #103 Page 4
Mid-Atlantic Project: R0569.07
Attachment C —Access Agreement
10 Mid Atlantic

DocuSign Envelope ID: OFB4413A-ACEC-4244-AFOF-FC801A335F1B
STATE OF NORTH CAROLINA ) AMENDED AND RESTATED
)
LAND ACCESS AGREEMENT
COUNTY OF FORSYTH
THIS AMENDED AND RESTATED LAND ACCESS AGREEMENT (the "Agreement")
made and entered into as of the day of , 2024, between the CITY OF
WINSTON-SALEM, a North Carolina municipal corporation (the "Qfty"), and A. T. WILLIAMS OIL
COMPANY, a North Carolina corporation(the"Company").
WITNESSETH:
WHEREAS,the City is the fee simple owner of a certain tract of real property located at on New
Walkertown Road in the city of Winston-Salem,Forsyth County,North Carolina,said tract being identified
by the Forsyth County Tax Office as PIN 6846-10-4487 and being a part of the City-owned and-operated
Evergreen Cemetery(the"Property"); and
WHEREAS, the Company used to own and operate what is now known as the Petro gas station
(the"Site")located on tax PIN 6846-10-2656 and being immediately adjacent to the Property; and
WHEREAS,the City and WilcoHess,LLC,a Delaware limited liability company and,at the time,
an affiliate of the Company, entered into that certain Land Access Agreement dated August 28, 2003, as
amended by that certain Amended Land Access Agreement dated April 15, 2004 (as amended, the "Prior
Agreement"); and
WHEREAS,monitoring wells are located on the Property to detect and test for the presence of any
contaminants related to the Site; and
WHEREAS, as the former owner of the Site and the Property,the Company is responsible for all
obligations related to the Notice of Regulatory Requirements applicable to the Site, as issued by the North
Carolina Department of Environmental Quality(the"Notice"); and
WHEREAS, the City and the Company desire to amend and restate the terms of the Prior
Agreement, as set forth herein, to exclude WilcoHess, LLC from the Prior Agreement and substitute the
Company, as WilcoHess, LLC is no longer an affiliate of the Company,to ensure the Company continues
to have the access to the Property it needs for the Project, as defined herein below; and
WHEREAS, the City and the Company desire to enter into an agreement whereby the Company
shall have access to and be allowed to enter upon the portion of the Property as shown on Exhibit A,
attached hereto and incorporated by reference herein, for the sole purposes of the Notice and the Project;
and
WHEREAS,the City is not charging the Company for its use of the Property herein, and
WHEREAS,Company acknowledges that its access to the Property is a limited license and subject
to the terms contained herein.
NOW, THEREFORE, in consideration of the mutual promises, covenants, and conditions set
forth herein, the sufficiency and adequacy of which is hereby acknowledged, the parties hereto, and their
respective successors,assigns,executors,administrators,and legal representatives,hereby agree as follows:
1

DocuSign Envelope ID: OFB4413A-ACEC-4244-AFOF-FC8O1A335F1B
1. Incorporation of Recitals. The foregoing recitals to this Agreement are incorporated herein and
made a part of this Agreement to the same extent and the same effect as if fully set forth herein.
2. Scope.
A. The Company and its agents, officers, employees, contractors, and subcontractors shall be
allowed to enter onto the Property to conduct activities related to the Notice and the Project.
As used herein, the "Project" shall collectively include the following: replacing current
monitoring well MW-11 (as shown on Exhibit A hereto); installing one additional well
(MW-12) downgradient and southeast of MW-11; boring for and collecting groundwater
samples from the site monitoring wells; and collecting three surface water samples from
the Brushy Fork tributary.
B. The Company's access to the Property for the Project shall be subject to the following:
i. The Company and its agents, officers, employees, contractors, and subcontractors
shall have the right to enter the Property for the purpose of the Project only. Access
to the Property shall be limited to the purpose of ingress,egress,and regress related
to the scope of this Agreement.
ii. The location and route of access to the Property by the Company and its agents,
officers, employees, contractors, and subcontractors shall be determined by the
City's Cemetery Supervisor.
iii. The Company and its agents, officers, employees, contractors, and subcontractors
shall coordinate all entry onto the Property with the Cemetery Supervisor so as to
not interfere with any funeral services taking place on the Property.
iv. The Company and its agents, officers, employees, contractors, and subcontractors
shall ensure that any needed groundwater borings are not more than 7.5 inches in
diameter. The Cemetery Supervisor shall have the absolute authority and
discretion to approve(a)when and where holes shall be drilled and(b)the type of
machinery used to drive each hole(eg,mechanized or hand auger).
C. The Company and the City agree that the Company will not pay the City for the rights of
access and entry granted herein.
D. Nothing herein shall be construed to constitute or to grant permission to the Company to
abridge, infringe on, or encroach upon any other rights of the City or upon any rights of
any third parties.
3. Term. The term of this Agreement(the "Term") shall run from the date of its full execution until
the end of the Project, unless otherwise terminated. This Agreement may be terminated for
convenience by either party upon thirty(30)days' written notice to the other party.
4. Warranties. The Company warrants that it and its agents, officers, employees, contractors, and
subcontractors:
A. Will perform the Project in good faith, in a workmanlike manner, in accordance with the
standard of care in the industry, and with all applicable laws, regulations, and standard
practices regarding the same;
2

DocuSign Envelope ID: OFB4413A-ACEC-4244-AFOF-FC8O1A335F1B
B. Shall return the Property to the condition it was in prior to the execution of this Agreement,
including, but not limited to, grading, seeding, and strawing any portions of the Property
that the Company has disturbed; and
C. Shall promptly repair, at its cost, any damage to the Property caused by its acts or
omissions.
5. Release and Indemnity.
A. The Company and its agents, officers, employees, contractors, and subcontractors shall
release, indemnify, defend, and hold the City and its officials, officers, employees, and
agents harmless from and against any and all claims, suits,actions, losses, damages,costs,
expenses, impairments, obligations, liabilities,judgments, reasonable attorneys' fees, and
costs of litigation, of any nature whatsoever, including claims for special, incidental, and
consequential damages,arising out of,occasioned by,or in any manner connected with the
Company's or its agents',officers',employees',contractors',or subcontracts' scope of this
Agreement, their presence upon the Property, and/or their performance of any of the
activities contemplated hereunder,except those claims that result from the sole negligence
of the City or a City employee acting within the scope of his or her employment.
B. Said indemnity obligation shall apply to any damage to the Property, including, but not
limited to,damage to landscaping,fencing,grass,headstones,grave markers,or gravesites.
C. Said indemnity obligation shall also include any costs or damages related to the"removal"
and/or"remedial action"of any"hazardous substance" located on the Property as a result
of a"release"originating on the Site(all terms in quotations are defined in 42 U.S. Code §
9601).
6. Insurance.
A. Throughout the Term of this Agreement,the Company and its agents,officers,employees,
contractors, and subcontractors and its agents, designees, assigns, contractors, or
subcontractors shall obtain at its own expense and keep in full force and effect the
following insurance:
i. Commercial General Liability to protect the Company and its agents, officers,
employees, contractors, and subcontractors against any and all claims, demands,
expenses, costs, and liabilities to the extent proximately caused by the negligent
acts or omissions of the Company and its agents,officers, employees,contractors,
and subcontractors and its agents or employees, in the performance of these
services. The insurance shall also include coverage for explosion, collapse, and
underground hazards where required. This insurance shall provide bodily injury
and property damage limits of not less than $1,000,000.00 for each occurrence,
respectively.
ii. If this Agreement is for a design, engineering, or consulting service, maintain
Professional Liability insurance of at least$1,000,000.00 per claim.
iii. Maintain owned,non-owned, and hired Automobile Liability insurance,including
property damage insurance, covering all owned,non-owned,borrowed, leased, or
3

DocuSign Envelope ID: OFB4413A-ACEC-4244-AFOF-FC801A335F1B
rented vehicles operated by the Company and its agents, officers, employees,
contractors, and subcontractors in furtherance of this Agreement. In addition, all
mobile equipment used by the Company and its agents, officers, employees,
contractors, and subcontractors in connection with this Agreement will be insured
under either a standard Automobile Liability policy or a Commercial General
Liability policy. This insurance shall provide bodily injury and property damages
limits of not less than$1,000,000.00 combined single limit/each accident and shall
provide at least$5,000.00 in Medical Expenses(Med Pay)coverage.
iv. Maintain Workers' Compensation and Employer Liability insurance if required by
North Carolina law.
v. Return with this Agreement a Certificate of Insurance evidencing such insurance,
indicating that the policy has been endorsed to include the City as an additional
insured,but only with respect to liability arising out of operations of the Company
and its agents, officers, employees, contractors, and subcontractors or in
connection with the services described herein and excluding Professional Liability
and Workers Compensation insurance and stating that the coverage is primary to
any other coverage the City may possess. The Company and its agents, officers,
employees, contractors, and subcontractors shall furnish the City thirty (30) days
prior written notice of any cancellation, non-renewal (without replacement), or
material reduction of coverage or limits of any policy referred to herein. The
failure of the Company and its agents, officers, employees, contractors, and
subcontractors to deliver a new and valid certificate will result in suspension of all
work under this Agreement until the new certificate is furnished to the City's Risk
Manager. Insurance coverage required in these specifications shall be in force
throughout the Term. Municipal Exclusions,if any,for General Liability coverage
shall be deleted. Should the Company fail to immediately provide acceptable
evidence of current insurance in the form of a Certificate of Insurance at any time
during the Term,the City shall have the absolute right to terminate the Agreement
without any further obligation to the Company,and the Company shall be liable to
the City for all available remedies in equity and at law.
B. The Company shall be as fully responsible to the City for the acts and omissions of its
agents, officers, employees, contractors, and subcontractors and of persons employed by
them as it is for the acts and omissions of persons directly employed by it.
C. Contractual and other liability insurance provided under this Agreement shall not contain
a supervision inspection or engineering services exclusion that would preclude the City
from supervising and/or inspecting the project as to the end result.
7. Notices. Any notice or submission required or permitted under this Agreement shall be in writing
and shall be deemed to be received three(3)days after being sent by prepaid registered or certified
mail addressed to the Parties hereto as follows:
If to the City:
City of Winston-Salem
Attn.: Travis Cockerham,Real Estate Administrator
P.O.Box 2511
Winston-Salem,NC 27102
4

DocuSign Envelope ID: OFB4413A-ACEC-4244-AFOF-FC801A335F1B
City of Winston-Salem
Attn.: Scotty Speas, Cemeteries Supervisor
2124 New Walkertown Road
Winston-Salem,NC 27101
With a copy(which does not constitute notice)to:
City of Winston-Salem
Attn.: Angela Carmon, City Attorney
P.O.Box 2511
Winston-Salem,NC 27102
If to the Company:
A. T. Williams Oil Company
Attn.: Steve Williams
331 High Street
Winston-Salem,NC 27101
8. E-Verify. The Company and its agents, officers, employees, contractors, and subcontractors shall
comply with the requirements of Article 2 of Chapter 64 of the North Carolina General Statutes.
9. Divestment from Companies that Boycott Israel. The Company hereby certifies that it is not on
the North Carolina State Treasurer's list of companies engaged in a boycott of Israel in violation
of N.C.G.S. § 147-86.80 et seq., and that it will not utilize on this Agreement any entity on said
list.
10. Iran Divestment Act. The Company hereby certifies that it is not on the North Carolina State
Treasurer's list of persons engaging in business activities in Iran prepared pursuant to N.C.G.S.
§147-86.58 and that it will not utilize on this Agreement any entity on said list.
11. Public Records. All non-confidential information and documents provided by the Company to the
City shall be treated as a public record underN.C.G.S.§ 132-1 et seq. All information or documents
provided by the Company to the City and marked as "confidential" or with a similar designation
under N.C.G.S. § 132-1.2 will be treated by the City as confidential and will not be disclosed to
any person without the prior written consent of the Company, if it meets the criteria outlined in
N.C.G.S. § 132-1.2 (1)(a through d). However,the Company hereby agrees that said confidential
information can be reviewed internally by city staff and any appropriate city committee involved
in the process of awarding city contracts. The Company agrees to indemnify and hold harmless
the City,its officers,employees,elected officials and agents from all costs,damages,and expenses
incurred in connection with refusing to disclose any material that the Company has designated as
confidential pursuant to N.C.G.S. § 132-1.2.
12. Gender;Number. Words used herein,regardless of the number and gender specifically used, shall
be deemed and construed to include any other number, singular or plural, and any other gender,
masculine, feminine,or neuter,as the context requires.
13. Nature and Extent of Agreement. This instrument constitutes the complete agreement of the parties
regarding the terms and conditions of this Agreement, and there are no oral or written conditions,
terms, understandings, or other agreements pertaining thereto which have not been incorporated
herein. The laws of the State of North Carolina shall govern the validity, interpretation,
performance, and enforcement of this Agreement. Each party hereto acknowledges that in
executing this Agreement,it has carefully reviewed and had the opportunity to review the terms of
5

DocuSign Envelope ID: OFB4413A-ACEC-4244-AFOF-FC801A335F1B
this Agreement with counsel of its choice and is fully aware of the extent of its rights and
obligations under this Agreement, without any duress or undue influence being imposed on such
party. The text of this Agreement is the product of negotiation among the parties hereto and is not
to be construed as having been prepared by one party against the other but shall be construed as if
all parties hereto jointly prepared this Agreement. The language of this Agreement shall not be
construed presumptively against any of the parties to this Agreement.
14. Binding Effect. Subject to express provisions hereof to the contrary, this Agreement shall be
binding upon and shall inure to the benefit of the parties hereto and their respective heirs,
successors, and assigns during the Term.
15. Assignment. The Company may not sell, assign,or transfer its rights, duties, or obligations under
this Agreement without the prior written approval of the City.
16. Non-Discrimination Ordinance. As a condition of entering into this Agreement, Company
represents and warrants that it will fully comply with the City's Non-Discrimination Policy, as set
forth in Chapter 2, Section 2-8 Entitled"Policy of Nondiscrimination" of the Winston-Salem City
Code. As part of such compliance, Company shall not discriminate on the basis of race, ethnicity,
color, creed, religion, sex, sexual orientation, gender identity, gender expression, pregnancy,
veteran status,disability,age,marital status,familial status,protected hairstyle,political affiliation,
or national origin in the screening of applicants, the hiring and treatment of its employees, the
provision of the services set forth herein, and the solicitation, selection, hiring, or treatment of its
sub-grantees/subcontractors, vendors, or suppliers (collectively "subcontractors"), if any, in
connection with this Agreement or contract solicitation process if applicable, nor shall Company
retaliate against any person or entity for reporting instances of such discrimination. Company shall
enact employment policies consistent with this obligation to refrain from such discrimination and
shall provide evidence of such to the City within 90 calendar days of the first receipt of City funds.
Company shall provide equal opportunity for subcontractors to participate in all of its
subcontracting and supply opportunities, if any, under this Agreement, provided that nothing
contained in this clause shall prohibit or limit otherwise lawful efforts to remedy the effects of
marketplace discrimination that has occurred or is occurring in the marketplace. Company
understands and agrees that a violation of this clause shall be considered a material breach of this
Agreement and may result in termination of this Agreement, disqualification of Company from
participating in City contracts, or other sanctions. As a condition of entering into this Agreement,
Company agrees to: (a) promptly provide to the City in a format specified by the City all
information and documentation that may be requested by the City from time to time regarding the
screening of applicants, the hiring and treatment of its employees particularly if City funds were
used for such, and the solicitation, selection, treatment, and payment of subcontractors, if any, in
connection with this Agreement; and (b) if requested, provide to the City within sixty days after
the request a truthful and complete list of the names of all subcontractors that Company has used
under this Agreement, including the total dollar amount paid by Company on each subcontract or
supply contract. Company further agrees to fully cooperate in any investigation conducted by the
City pursuant to the City's Non-Discrimination Policy and to provide any documents relevant to
such investigation that are requested by the City. Company agrees to provide to the City,from time
to time on the City's request, payment affidavits detailing the amounts paid by Company to
subcontractors and suppliers in connection with this Agreement within a certain period of time.
Such affidavits shall be in the format specified by the City from time to time. Nothing in this
Agreement shall infringe upon the rights of Company afforded by state or federal law.
17. Miscellaneous. If any term of this Agreement or any application thereof shall be invalid or
unenforceable,the remainder of this Agreement and any other application of such term shall not be
6

DocuSign Envelope ID: OFB4413A-ACEC-4244-AFOF-FC801A335F1B
affected thereby. Whenever in this Agreement it is provided that any document or matter is to be
satisfactory to a parry or may be required by a parry, it shall be deemed to mean reasonably
satisfactory or reasonably required. Unless expressly provided for in this Agreement,any approval
or consent of a parry required hereunder shall not be unreasonably(in an ordinary business sense)
withheld. This Agreement may be changed, waived, discharged, or terminated only by an
instrument in writing signed by the parry against which enforcement of such change, waiver,
discharge, or termination is sought. The headings in this Agreement are for purposes of reference
only and shall not limit or define the meaning hereof. This Agreement may be executed in any
number of counterparts,each of which shall be an original,but all of which shall together constitute
one and the same instrument.
[remainder of page left blank intentionally, separate signature pages follow]
7

DocuSign Envelope ID: OFB4413A-ACEC-4244-AFOF-FC801A335F1B
SEPARATE SIGNATURE PAGE TO
AMENDED AND RESTATED LAND ACCESS AGREEMENT
IN WITNESS WHEREOF,the Parties have caused this Agreement to be executed by their duly
authorized representatives and signed under seal on the day and year first above written.
A.T.WILLIAMS OIL C MPANY
44-A—
Signature: [SEAL]
Printed Name:
Title: -
ATTEST:
Signature:
Printed Name: K� ►�.
Title: ''
If Company has a corporate seal,please affix the seal below. If not,please complete the paragraph below.
I, (Print Name) certify that I am the (Print
Position Title)for A.T.Williams Oil Company and that I am authorized to execute contracts on behalf of A.T.
Williams Oil Company, which entity does not have a corporate seal; however, for purposes of the statute of
limitations(NCGS § 1-47),both parties will treat this contract as if a corporate seal has been affixed hereto.
STATE OF NORTH CAROLINA )
COUNTY OF )
I, n� / r '/l a Notary Public of the State and County aforesaid,do hereby
certify that 6 lU�lf.S�t'4 personally came before me this day,and acknowledged that
he or she is the V,r C of A. T. Williams Oil Company, and that by authority
duly g1jen and as the act of the corporation, the foregoing instrument was signed in its name by its
, sealed with its corporate seal, and attested by
/ as its
`001111uanrp,14 /
�"'�``5, ,�. �,3ny hand and official seal,this the day of �/t_ /�f f� ,2024.
Sa,� NOTARY
A UBLIC `f
My Commission - C�
Expires
%.Mar.14,2028. o Notary Public
v�Q4AK % Oexpires: 3. �"7'• �V
nu�is
s

DocuSign Envelope ID: OFB4413A-ACEC-4244-AFOF-FC801A335F1B
SEPARATE SIGNATURE PAGE TO
AMENDED AND RESTATED LAND ACCESS AGREEMENT
IN WITNESS WHEREOF,the Parties have caused this Agreement to be executed by their duly
authorized representatives and signed under seal on the day and year first above written.
CITY OF WINSTON-SALEM
D—Signed by:
Signature: 5WA* NVU P4 [SEAL]
Name/Title: W. Patric Pate, City Manager
ATTEST:
D Signed by:
Signature: �°'"' UJ [SEAL]
A95F787tV17AdCF
Name/Title: Jayme Waldeck, City Clerk, or
Tatiana Banner,Deputy City Clerk
:Fxr.r.;:;:r,r,r,9:*****kkkkkktkkkk****:tkkkkkk:F:F:Fkkxr.xkkkkkkkk>'cxxxxxxxxr.xxktt***kkkkt.*:Y:F:F:Fkkkk
Approved as to form and legality. This instrument has been pre-audited in the
manner required by the Local Government
Budget and Fiscal Control Act.
This the day of ,20 This the day of , 20
FDOCUSigned by:
AkAr�res 646S 5/21/2024 Not required
Ange a armon, City Attorney Kelly Latham, Chief Financial Officer
Anargiros Kontos,Deputy City Attorney Michael Phelps,Deputy CFO
9