MO-9485_40926_G_NORR_20190816_Notice of Regulatory Requirements

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
MICHAEL SCOTT
Director
Ms. Debrah Carl
Circle K Stores, Inc.
2550 West Tyvola Road, Suite 200
Charlotte, North Carolina 27217
Dear Ms. Carl:
NORTH CAROLINA
Environmental Quality
August 16, 2019
Re: Notice of Regulatory Requirements
NCGS 14313-279.9 and 14313-279.11
Notice of Residual Petroleum
Circle K No. 2708383
873 Old Charlotte Road SW, Concord
Cabarrus County
Incident Number: 40926
Risk Classification: Low
The 20-Day and Initial Action Abatement Reports received by the Underground Storage Tank
(UST) Section, Division of Waste Management, Mooresville Regional Office on June 13, 2019 and June
20, 2019 have been reviewed. The reports document the results of soil and groundwater samples
collected for assessment around the former UST System removed on May 20, 2019 from the above
referenced facility. The review indicates that soil contamination exceeds the residential maximum soil
contaminant concentration (MSCCs) established in the Title 15A NCAC 2L .0411 and groundwater
contamination meets the cleanup requirements for a low -risk site but exceeds the groundwater quality
standards established in Title 15A NCAC 2L .0202.
North Carolina General Statute (NCGS) 14313-279.9 and 14313-279.11 require a Notice of
Residual Petroleum (Notice) to be filed with the Register of Deeds in Cabarrus County, where the release
is located, when a release from an underground storage tank has not been remediated to below
"unrestricted use standards". The Notice is required either prior to conveyance of a contaminated
property or prior to receiving a Notice of No Further Action. "Unrestricted use standards" for
groundwater are the groundwater quality standards and interim standards contained in Title 15A NCAC
2L .0202, and "unrestricted use standards" for soil are the residential maximum soil contaminant
concentrations (MSCCs) established in Title 15A NCAC 2L .0411. This site exceeds "unrestricted use
standards"for groundwater and soil.
The Notice must be prepared in accordance with the attached instructions and format. It must
contain a legal description of the property containing the source of contamination and legal descriptions
North Carolina Department of Environmental Quality I Division of Waste Management
Mooresville Regional Office 1 610 East Center Avenue, Suite 301 1 Mooresville, North Carolina 28115
704.663.1699

of any other properties which you own (or control) which are contaminated by the release. The Notice
must also include appropriate land use restrictions for these properties. In addition, the Notice must
identify all other properties (adjacent, adjoining, downgradient, etc.) on which contamination is known to
exist at the time the Notice is prepared.
The Notice must be sent to this regional office of the UST Section within 30 days of the date of
this letter for approval and notarization. The approved and notarized Notice must then be filed by you
with the Register of Deeds, and a certified copy of the filed Notice must be submitted to this office within
30 days of its return to you.
Effective October 1, 2004, the Department requires that all work following the submittal of the
Limited Site Assessment Report (Title 15A NCAC 2L .0405) be preapproved if State Trust Fund
reimbursement is anticipated. To comply with this requirement, a completed Preapproval/Claim
Authorization Form, encompassing the required remedial activities, must be received in this office within
14 days of the date of this letter. Upon completion of the preapproved activities, you should submit your
claim promptly. Reimbursement funds are budgeted based on completed preapprovals, but lengthy delays
in reimbursement can occur if claims are not submitted immediately following work completion.
Failure to comply with this letter is a violation of North Carolina law and may result in the
assessment of civil penalties and/or the use of other enforcement mechanisms available to the state. If
you have any questions regarding the actions or the rules mentioned in this letter, please contact me by
email at Trudy.Beverlykncdenr.gov or telephone at [phone]. If you have any questions regarding
trust fund eligibility or reimbursement, please contact the UST Section Trust Fund Branch at (919) 733-
8486.
Sincerely, $-�`I4�/ -O
Trudy Beverly, L.G.
Hydrogeologist
Mooresville Regional Office
UST Section, Division of Waste Management, NCDEQ
Attachment: Instructions and Form for Notice of Residual Petroleum
httl)s:Hdea.nc. aov/about/divisions/waste-management/ust/forms
cc: Aaron Williamson, Crawford Environmental, Services (via email)
Mike Downs, Cabarrus County Manager (via email)
David Troutman, Cabarrus County Health Department (via email)
9�- .
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North Carolina Department of Environmental Quality I Division of Waste Management
Mooresville Regional Office 1 610 East Center Avenue, Suite 301 1 Mooresville, North Carolina 28115
704.663.1699

INSTRUCTIONS FOR PREPARING A'NOTICE OF RESIDUAL PETROLEUM' REFERENCING
LAND USE RESTRICTIONS FOR FILING
The following is a list of instructions to assist in the preparation and filing of a Notice of Residual
Petroleum
1. The Notice shall be prepared in accordance with the format provided in these instructions and shall
include reference to the appropriate land use restrictions. (REWORDING OF THE NOTICE IS NOT
RECOMMENDED AND WILL SUBSTANTIALL YDELA YAPPRO VAL.)
2. The Notice shall include a description that would be sufficient as a description in an instrument of
conveyance of the (i) real property on which the source of contamination is located and (ii) any real
property on which contamination is located at the time the remedial action plan is approved and that was
owned or controlled by any owner or operator of the underground storage tank or other responsible party
at the time the discharge or release of petroleum is discovered or reported or at any time thereafter.
3. The Notice shall also identify the location (legal description) of any residual petroleum on other real
property on which contamination is known to exist at the time the Notice is prepared and that is a result of
the release.
4. The Notice shall reference any restrictions on the current or future use of the real property that are
imposed by the Secretary to protect public health, the environment, or users of the property
5. (IF REQUIRED BYDEPARTMENT of ENVIRONMENTAL QUALITY.) If the contamination is
located on more than one parcel or tract of land, the Department may require that the owner, operator, or
other person responsible for the discharge or release prepare a composite map or plat that shows all
parcels or tracts. If the contamination is located on one parcel or tract of land, the owner, operator, or
other person responsible for the discharge or release may prepare a map or plat that shows the parcel but
is not required to do so. Any map or plat shall be prepared and certified by a professional land surveyor,
shall meet the requirements of G.S. 47-30 and any requirements of the county Register of Deeds, and
shall be submitted to the Department for approval. When the Department has approved a map or plat, it
shall be recorded in the office of the register of deeds and shall be incorporated into the Notice by
reference. (ALL CONTENTS OF THE PLAT MUST BE DRA WN IN INDELIBLE INK) The plat
shall include:
a. Property lines, north arrow, scale, bearings and distances as appearing on the deed;
b. With respect to permanently surveyed benchmarks, location and dimensions of areas of the
property where contamination is known to exist in
groundwater at a concentration exceeding the standard or interim standard established in 15A
NCAC 2L. 0202 and/or
© soil at a concentration exceeding the residential maximum soil contaminant concentration
established in 15A NCAC 2L .0411.
c. The printed name(s) and title(s) and properly notarized signature(s) of individual(s) with authority
to legally bind the responsible party(ies) (i.e., responsible party(ies), an individual with power of
attorney for the responsible party(ies), officer of a corporation, etc.) (PRINTED TEXT,
SIGNATURES, AND NOTARYSEALS, AS WITH ALL MARKINGS ON THE PLAT, MUST
BE MADE IN INDELIBLE INK);
d. The following language: "The areas of contamination depicted upon the map are approximations
Revised February 5, 2019

derived from the best available information at the time of filing.";
e. The following language, for use by the Department, positioned in the upper left corner of the plat:
"Approved for the purposes of N.C.G.S. 143B-279.9 and 143B-279.11
(signature ofRegional Supervisor)
, Regional Supervisor
(printed name ofRegional Supervisor
Regional Office
(name ofRegion)
UST Section
Division of Waste Management
Department of Environment Quality
NORTH CAROLINA
COUNTY
I certify that the following person(s) personally appeared before me this day, each
acknowledging to me that he or she signed the foregoing document: (printedfull
name ofRegional Supervisor).
Date:
(Official Seal)
(signature of Notary Public)
(printed or typed name of Notary Public)
Notary Public
My commission expires:
f. Surveyor's certification and seal (using a permanent ink stamp).
6. The signed and notarized Notice shall be sent to the appropriate UST Section Regional Office.
7. After the Department approves, notarizes and returns the Notice, the responsible party shall, within
thirty (30) days of its return:
a. File approved Notice in the County Register of Deeds' office of the county or counties in which
the site is located; and
b. Send to the appropriate UST Section Regional Office, a certified copy of the Notice affixed with
the seal of the Register of Deeds and reflecting the book(s) and page number(s) where recorded
and a copy of the page(s) in the grantor index where the Notice is referenced.
Revised February 5, 2019
2

NOTICE OF RESIDUAL PETROLEUM
County, North Carolina
(Site name)
The property that is the subject of this Notice (hereinafter referred to as the "Site")
contains residual petroleum and is an Underground Storage Tank (UST) incident under North
Carolina's Statutes and Regulations, which consist of N.C.G.S. 143-215.94 and regulations adopted
thereunder. This Notice is part of a remedial action for the Site that has been approved by the
Secretary (or his/her delegate) of the North Carolina Department of Environment Quality (or its
successor in function), as authorized by N.C.G.S. Section 143B-279.9 and 143B-279.11. The North
Carolina Department of Environment Quality shall hereinafter be referred to as "DEQ".
NOTICE
Petroleum product was released and/or discharged at the Site. Petroleum constituents remain
on the site, but are not a danger to public health and the environment, provided that the
restrictions described herein, and any other measures required by DEQ pursuant to N.C.G.S.
Sections 143B-279.9 and 143B-279.11, are strictly complied with. This "Notice of Residual
Petroleum" is composed of a description of the property, the location of the residual petroleum and the
land use restrictions on the Site. The Notice has been approved and notarized by DEQ pursuant to
N.C.G.S. Sections 143B-279.9 and 143B-279.11 and has/shall be recorded at the
Register of Deeds' office
(name of county)
Book , Page
Any map or plat required by DEQ has been/shall be recorded at the
Register of
(name of county)
Deeds' office Book Page , and has been/shall be incorporated into the Notice by this reference.
Source Property
of is the owner in fee
(owner's name) (city & state of homeowner)
simple of all or a portion of the Site, which is located in the County of , State of North
Carolina, and is known and legally described as:
Revised February 5, 2019

(Insert Real Property Description Here for Source Property)
Additional Affected Property Also Subject to Restrictions
of is the owner in fee simple of a portion of
(owner's Name) city & state oiowner)
the Site, which is located in the County of , State of North Carolina. Petroleum
contamination is located on this property at the time this Notice is approved. This property was also
owned or controlled by the underground storage tank owner or operator or another party responsible for
the petroleum discharge or release at the time the discharge or release was discovered or reported, or at
any time thereafter. This property is known and legally described as:
(Insert Real Property Description Here for Additional Properties Owned or Controlled by Any Owner or
Operator of the Underground Storage Tank or Other Responsible Party, if Applicable)
Additional Affected Property Not Subject to Restrictions
Additionally, residual petroleum is also located on the following property. The following
property is not subject to land use restrictions pursuant to N.C.G.S. Section 143B-279.9(b). The
following property is known and legally described as:
(Insert Legal Description of Other Real Property Affected by Residual Petroleum Not Owned or
Controlled by Any Owner or Operator of the Underground Storage Tank or Other Responsible Party, if
Applicable)
For protection of public health and the environment, the following land use restrictions required
by N.C.G.S. Section 143B-279.9(b) shall apply to all of the above -described real property. These
restrictions shall continue in effect as long as residual petroleum remains on the site in excess of
unrestricted use standards and cannot be amended or cancelled unless and until the County
Revised February 5, 2019

Register of Deed receives and records the written concurrence of the Secretary (or his/her delegate) of
DEQ (or its successor in function).
PERPETUAL LAND USE RESTRICTIONS
[Restrictions apply to activities on, over, or under the land. Choose one or both of the following as
appropriate.]
Soil: The Site shall be used for industrial/commercial use only. Industrial/commercial use means a use
where exposure to soil contamination is limited in time and does not involve exposure to children
or other sensitive populations such as the elderly or sick. The real property shall not be
developed or utilized for residential purposes including but not limited to: primary or secondary
residences (permanent or temporary), schools, daycare centers, nursing homes, playgrounds,
parks, recreation areas and/or picnic areas.
Groundwater: Groundwater from the site is prohibited from use as a water supply. Water supply wells
of any kind shall not be installed or operated on the site.
ENFORCEMENT
The above land use restriction(s) shall be enforced by any owner, operator, or other party
responsible for the Site. The above land use restriction(s) may also be enforced by DEQ through any of
the remedies provided by law or by means of a civil action, and may also be enforced by any unit of local
government having jurisdiction over any part of the Site. Any attempt to cancel this Notice without the
approval of DEQ (or its successor in function) shall be subject to enforcement by DEQ to the full extent
of the law. Failure by any party required or authorized to enforce any of the above restriction(s) shall in
no event be deemed a waiver of the right to do so thereafter as to the same violation or as to one occurring
prior or subsequent thereto.
IN WITNESS WHEREOF, has caused this Notice to be executed pursuant to
N.C.G.S. Sections 14313-279.9 and 14313-279.11, this day of 120_
(name of responsible party if agent is signing)
(signature of responsible party, attorney or other agent if there is one)
(Title of agent for responsible party if there is one)
Signatory's name typed or printed:
(Note to be deleted on final document: Preparer of document must assure that the correct
acknowledgement is used and complies with changes effective October 1, 2006.
Choice One: Instrument signed by one person
NORTH CAROLINA
COUNTY
(Name of county in which acknowledgment was taken)
I certify that the following person personally appeared before me this day, acknowledging to me that he or
she signed the foregoing document:
Date:
Revised February 5, 2019

(Official Seal)
expires:
Choice Two: Acknowledge by attorney in fact
NORTH CAROLINA
COUNTY
(Name of county in which acknowledgment was taken)
(signature of Notary Public)
printed or typed name of Notary Public)
Notary Public
My commission
I, , a Notary Public for said County and State, do hereby certify that
, attorney in fact for , personally appeared before me this day, and being by
me duly sworn, says that he executed the foregoing and annexed instrument for and in behalf of the said
, and that his authority to execute and acknowledge said instrument is contained in an instrument duly
executed, acknowledged, and recorded in the office of in the County of
, State of , on the day of 20 and
that this instrument was executed under and by virtue of the authority given by said instrument granting
him power of attorney.
I do further certify that the said acknowledged the due execution of the
foregoing and annexed instrument for the purposes therein expressed for and in behalf of the said
WITNESS my hand and official seal, this the day of , 20_
(Official Seal)
expires:
(signature of Notary Public)
printed or typed name ofNotary Public)
Notary Public
My commission
Choice Three: Conveying security interest in personal property of a corporation
NORTH CAROLINA
COUNTY
(Name of county in which acknowledgment was taken)
a Notary Public for said County and State, do hereby certify that
personally came before me this day and acknowledged that he is
of and acknowledged, on behalf of , the grantor
the due execution of the foregoing instrument.
Revised February 5, 2019

WITNESS my hand and official seal, this the day of , 20
(Official Seal)
expires:
Approved for the purposes of N.C.G.S. 14313-279.11
(signature of Regional Supervisor)
, Regional Supervisor
(printed name of Regional Supervisor)
Regional Office
UST Section
Division of Waste Management
Department of Environment Quality
NORTH CAROLINA
COUNTY
(Name of county in which acknowledgment was taken)
(signature of Notary Public)
printed or typed name of Notary Public)
Notary Public
My commission
I certify that the following person(s) personally appeared before me this day, each acknowledging to me
that he or she signed the foregoing document: (full printed name ofRegional Supervisor)
Date:
(Official Seal)
expires:
(signature of Notary Public)
printed or typed name ofNotary Public)
Notary Public
My commission
Revised February 5, 2019

Beverly, Trudy
From: Beverly, Trudy
Sent: Friday, August 16, 2019 10:33 AM
To: Aaron Williamson; Mike Downs; David Troutman
Subject: Circle K No. 2708383 - Incident #40926 — Notice of Regulatory Requirements
Attachments: MO-9485_40926_G_NORR_20190816_Notice of Regulatory Requirements.pdf
Please see the attached Notice of Regulatory Requirements letter for Circle K No. 2708383 located at 873 Old
Charlotte Road SW, Concord, Cabarrus County, North Carolina (Incident #40926).
Trudy
zf���[D
.E
t)epar4nent IOU OUaIIIV
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy.Beverly(a)ncdenr. gov
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
Office Mailing Address:
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Branch's Underground Storage Tanks Website Address: htips://deq.ne.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: https://deq.nc.gov/about/divisions/waste-management/ust/ast-pry
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
htips://deq.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-management- i� s-maps
File Review Procedures:
https://deq.nc.,gov/abouVdivisions/waste-managemenVust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
https://edocs.deq.nc.gov/WasteManagement/Search.aspx
Document Submittal & UST File Names for Laserfiche Policies:
https: //files.nc. gov/ncdeq/ W aste°/`20Management/D W M/U ST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal%2OMemo%2OUpdate.
https:Hfiles.nc. gov/ncdeq/Waste%20Management/DWM/UST/Corrective%2OAction/UST%2Ofile%20names%20for%2OLaserfiche.docx