WM0701127_Application_20200611

Groundwater Management Associates, Inc.
4300 Sapphire Court, Suite 100
Greenville, North Carolina 27834
Telephone: [phone]
www.gma-nc.com
The Groundwater Experts
June 11, 2020

Mr. Robert Tankard
NCDEQ-Division of Water Resources
Aquifer Protection Section
943 Washington Square Mall
Washington, North Carolina 27889

Re: Monitoring Well Construction Permit Application (GW-22MR form)
Valhalla Water Treatment Plant, 1608 Virginia Road, Edenton, Chowan County, North Carolina
NPDES Permit Number: NC0032719

Dear Mr. Tankard:

Groundwater Management Associates, Inc. (GMA) continues to assess chloride-related contamination in
Edenton, Chowan County, on behalf of Chowan County. One application to construct six additional
monitoring wells (MW18, MW19, MW20, MW22, MW8D, and MW9DDR) and property access agreements
signed by the property owners (Virginia Vogedes and C.T. Dixon Jr.) are attached. The wells to be
installed are of Type II construction, and are to be installed to estimated depths ranging from of 15 to
230 feet (see attached well diagrams: Figures 3 – 8). A topographic map, a map of the existing and
proposed new monitoring wells, and figures of the design of the proposed monitoring wells are attached.
We are working to secure access for a northern monitoring well but are having difficulty with property
owners granting access. Mrs. Farmer verbally stated she will grant access, but her property is just north
of Cofield Road (MW21b option). We plan to move forward with the six wells for now with a tentative
start of drilling the week of June 22, 2020; if not then, the week of June 29th or July 6th. Please call me
or Katie Hackney at [phone] if you have questions. Please send a copy the well construction
permit to me at 4300 Sapphire Court, Suite 100, Greenville, North Carolina 27834. Thank you.

Sincerely,
GMA

Samantha Kofroth, P.G.
Project Hydrogeologist

Enclosures: 1 Well Permit Application, including: Property Owner Information Table, Site Location Maps,
Monitoring Well Construction Diagrams, and Property Access Agreements

cc: Chowan County (Attn: Kevin Howard) – responsible party
RES/SGI, Inc., attn. (Stuart Spruill) – well contractor
Katie Hackney- GMA, Greenville

Z:\GMA\158101-Chowan County Valhalla WTP\MW Const_Permits\Well Construction Permits\202005 \WCpermitcover_20200611.docx
FOR OFFICE USE ONLY

PERMIT NO. ISSUED DATE
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
PLEASE TYPE OR PRINT CLEARLY

In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery wells.

1. Date: June 11, 2020

2. County: Chowan

3. What type of well are you applying for? (monitoring or recovery): Monitoring

4. Applicant: Chowan County Telephone: [phone] Ext:1

Applicant’s Mailing Address: Kevin Howard, County Manager, Post Office Box 1030, Edenton, NC 27923

Applicant’s Email Address (if available): [e-mail]

5. Contact Person (if different than Applicant): David Tawes Telephone: [phone]

Contact Person’s Mailing Address: Chowan County Water Department, Post Office Box 1030, Edenton, NC 27923

Contact Person’s Email Address (if available): [e-mail]

6. Property Owner (if different than Applicant): See Attached Table Telephone: See Attached Table
Property Owner’s Mailing Address: See Attached Table

Property Owner’s Email Address (if available): See Attached Table

7. Property Physical Address (Including PIN Number) See Attached Table

City Edenton County Chowan Zip Code 27923

8. Reason for Well(s): Groundwater Assessment
(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: Water treatment plant
(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 in cident no(s).

NPDES Permit #NC0032719

11. Type of contaminants being monitored or recovered: Chloride
(ex: organics, nutrients, heavy metals, etc.)

12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 20

Existing Monitoring or Recovery Well Construction Permit No(s).: WM0701172, WM0701177 and WM0701204

13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Range from 600 to 2,250 feet

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: Stuart Spruill Certification No.: 2193

Well Contractor Address: Post Office Box 402, Williamston, NC 27892
PROPOSED WELL CONSTRUCTION INFORMATION

1. As required by 15A NCAC 02C .0105(f)(7), attach a well construction diagram of each well showing the following:

a. Borehole and well diameter e. Type of casing material and thickness
b. Estimated well depth f. Grout horizons
c. Screen intervals g. Well head completion details
d. Sand/gravel pack intervals
Continued on Reverse

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)

2. Number of wells to be constructed in unconsolidated
material: 6

3. Number of wells to be constructed in bedrock: 0

4. Total Number of wells to be constructed: 6
(add answers from 2 and 3)
5. How will the well(s) be secured? Flush mounted,
bolted man-hole cover or locking, stickup with bollards

6. Estimated beginning construction date: 6/22/2020

7. Estimated construction completion date: 7/1/2020

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 hereby agrees that the proposed well(s) will be constructed in accordance with approved speci fications and conditions of
this Well Construction Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
Subchapter 2C) and accepts full responsibility for compliance with these rules

Senior Hydrogeologist, see attached agreement
Signature of Applicant or *Agent Title of Applicant or *Agent

Katie Hackney, PG * 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
wells as outlined in this Well Construction Permit application and that it shall be the responsibility of the applicant to en sure that the
well(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).

See attached agreements Same as applicant
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant)

DIRECTIONS

Please send the completed application to the appropriate Division of Water Resources’ Regional Office:

Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]

Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]

Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]

Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]

Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]

Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]

Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW -22MR Rev. 3-1-2016
GW-22M (Rev. 5/11)
Table 1. List of Property Owner Information
Valhalla WTP Edenton, Chowan County
MW8D and
MW9DDR 689800104205 C.T. Dixon Jr.; Marsha
Gregory (daughter)
1623 Virginia Road
Edenton, NC 27932
2016 Rocky Hock Road
Edenton, NC 27932
252-482-3082
252-333-5215
(Marsha Gregory cell)
inactive irrigation WSW4 yes 850' W Y (attached)
MW18, MW19,
and MW20 689700282038 Virginia B. Vogedes and
Hattie Byrum Off Virginia Road 104 Blount Street
Edenton, NC 27932
252-333-0063
(Ginger Vogedes)no no 1,500' SW Y (attached)
MW22a 689700382038 Virginia B. Vogedes and
Hattie Byrum Off Virginia Road 104 Blount Street
Edenton, NC 27932
252-333-0063
(Ginger Vogedes)no yes 2,250' SE Y (attached)
MW22b 689700471074 Virginia B. Vogedes and
Hattie Byrum Off Virginia Road 104 Blount Street
Edenton, NC 27932
252-333-0063
(Ginger Vogedes)no yes 2,600' SE Y (attached)
MW21a 689800211184 Church of the Lord JC of the
Apostolic Faith
1641 Virginia Road
Edenton, NC 27932
P.O. Box 103
Edenton, NC 27932 252-482-8063 no yes 1,580' N N (no
response)
MW21b 689200216531 Martha M. Farmer 1650 Virginia Road
Edenton, NC 27932
1650 Virginia Road
Edenton, NC 27932 252-333-0668 no yes 2,075' N Y (Verbal)
Acess
Granted?
Y/N
Well IDMW ID
* The distance (in feet) is measured from the source area to the proposed monitoring well.
Well StatusProperty Owner's
Address
Distance &
Direction
from Site*
Parcel Number Property Owner's Name Property Address Telephone Water
Service
!.
$
LEGEND
Date: 2/27/2018
Project No. 158101
TOPOGRAPHIC MAPFile: DRAWINGS/158101 TOPOV2
Figure 1
0 1,000 2,000500
Feet
VALHALLA QUADRANGLENORTH CAROLINA-CHOWAN COUNTY7.5 MINUTE SERIES (TOPOGRAPHIC)CONTOUR INTERVAL=2 METERSMAP DATED 1981
VALHALLA WTP, EDENTON, CHOWAN CO., NC
!.SITE
AD
AD
AD
AD
!>
!>
@A
@A @A
@A
@A
@A
@A
@A
@A
@A
@A
@A@A@A@A
@A
@A
@A
¨A
¨A
¨A ¨A
!.
@AD
E
E ¨A
CCW2
WSW3
CCW1
WSW5
WSW6
MW3MW2
MW1
WSW4SW5
SW4
SW3
SW2
SW7
SW1
SW6
SW9
SW8
MW4
MW6
MW5
MW7
MW8 MW9
MW10 MW11
MW13
MW12
MW14
MW2D
MW9DDMW9D
MW13D
MW17
¨A MW16¨AMW15
SW10
SW11
¨AMW9DDR
MW8D
¨A¨AMW18
MW19
MW20
¨A
A
¨A
MW21a
MW22a
MW22b
¨A
$
¨AMW21b
VIRGINIA RDC
O
F
F
I
E
L
D

R
D
LEGEND
Date: 6/4/2020
Project No. 158101
PROPOSED MONITORING WELL LOCATIONS
VALHALLA WTP, EDENTON, CHOWAN COUNTY, NC
File: DRAWINGS/158101/ PROPOSEDMW202005
Figure 2
0 500'SCALE IN FEET
!.SITE
PARCEL BOUNDARIES
ROAD CENTERLINE
SURFACE WATER
!>MUNICIPAL WSW
AD INACTIVE WATER SUPPLY WELL
@A MONITORING WELL, TYPE II
¨A MONITORING WELL, DEEP TYPE II
@AD ABANDONED MONITORING WELL
¨A PROPOSED MONITORING WELL
SW SAMPLE + STAFF GAUGE
SURFACE WATER SAMPLE
E STAFF GAUGE
PROJECT : Chowan County Valhalla WTP LOCATION : 1608 Virginia Road, Edenton, Chowan County, NC
DRILLING METHOD AND EQUIPMENT USED : Truck-mounted drill rig, mud rotary
WATER LEVELS :START :END : LOGGER :
2 3
1 4
1-gravel cement
2-bolted steel manhole cover
1.0'3-locking, expandable plug
4-land surface
9 5
2.0'5-2-inch PVC casing
6-2-inch, slot 0.01" PVC screen
8 3.0'
15'7-#2 DSI filter gravel
8-bentonite chips
9-neat cement grout
6
12'7

6"
EPA Type II Monitoring Well Completion Diagram
(MW18)
Chowan County Valhalla WTP
NPDES Permit #: NC0032719
Figure 3Groundwater
Management
Associates, Inc.
13'
PROJECT : Chowan County Valhalla WTP LOCATION : 1608 Virginia Road, Edenton, Chowan County, NC
DRILLING METHOD AND EQUIPMENT USED : Truck-mounted drill rig, mud rotary
WATER LEVELS :START :END : LOGGER :
2 3
1 4
1-gravel cement
2-bolted steel manhole cover
84 3-locking, expandable plug
4-land surface
9 5
87 5-2-inch PVC casing
6-2-inch, slot 0.01" PVC screen
8 90'
100'7-#2 DSI filter gravel
8-bentonite chips
9-neat cement grout
6
10'7

6"
EPA Type II Monitoring Well Completion Diagram
(MW19)
Chowan County Valhalla WTP
NPDES Permit #: NC0032719
Figure 4Groundwater
Management
Associates, Inc.
PROJECT : Chowan County Valhalla WTP LOCATION : 1608 Virginia Road, Edenton, Chowan County, NC
DRILLING METHOD AND EQUIPMENT USED : Truck-mounted drill rig, mud rotary
WATER LEVELS :START :END : LOGGER :
2 3
1 4
1-gravel cement
2-bolted steel manhole cover/or stickup
144 3-locking, expandable plug
4-land surface
9 5
147 5-2-inch PVC casing
6-2-inch, slot 0.01" PVC screen
8 150
160 7-#2 DSI filter gravel
8-bentonite chips
9-neat cement grout
6
10'7

6"
EPA Type II Monitoring Well Completion Diagram
(MW20)
Chowan County Valhalla WTP
NPDES Permit #: NC0032719
Figure 5Groundwater
Management
Associates, Inc.
PROJECT : Chowan County Valhalla WTP LOCATION : 1608 Virginia Road, Edenton, Chowan County, NC
DRILLING METHOD AND EQUIPMENT USED : Truck-mounted drill rig, mud rotary
WATER LEVELS :START :END : LOGGER :
2 3
1 4
1-gravel cement
2-bolted steel manhole cover
34 3-locking, expandable plug
4-land surface
9 5
37 5-2-inch PVC casing
6-2-inch, slot 0.01" PVC screen
8 40'
50'7-#2 DSI filter gravel
8-bentonite chips
9-neat cement grout
6
10'7

6"
EPA Type II Monitoring Well Completion Diagram
(MW22)
Chowan County Valhalla WTP
NPDES Permit #: NC0032719
Figure 6Groundwater
Management
Associates, Inc.
PROJECT : Chowan County Valhalla WTP LOCATION : 1608 Virginia Road, Edenton, Chowan County, NC
DRILLING METHOD AND EQUIPMENT USED : Truck-mounted drill rig, mud rotary
WATER LEVELS :START :END : LOGGER :
2 3
1 4
1-gravel cement
2-bolted steel manhole cover
74 3-locking, expandable plug
4-land surface
9 5
77 5-2-inch PVC casing
6-2-inch, slot 0.01" PVC screen
8 80'
90'7-#2 DSI filter gravel
8-bentonite chips
9-neat cement grout
6
10'7

6"
EPA Type II Monitoring Well Completion Diagram
(MW8D)
Chowan County Valhalla WTP
NPDES Permit #: NC0032719
Figure 7Groundwater
Management
Associates, Inc.
PROJECT : Chowan County Valhalla WTP LOCATION : 1608 Virginia Road, Edenton, Chowan County, NC
DRILLING METHOD AND EQUIPMENT USED : Truck-mounted drill rig, mud rotary
WATER LEVELS :START :END : LOGGER :
2 3
1 4
1-gravel cement
2-bolted steel manhole cover
195 3-locking, expandable plug
4-land surface
9 5
205 5-2-inch PVC casing
6-2-inch, slot 0.02" PVC screen
8 220'
230'7-#2 DSI filter gravel
8-bentonite chips
9-neat cement grout
6
10'7

6"
EPA Type II Monitoring Well Completion Diagram
(MW9DDR)
Chowan County Valhalla WTP
NPDES Permit #: NC0032719
Figure 8Groundwater
Management
Associates, Inc.
PROPERTY ACCESS AGREEMENT
CHOWAN COUNTY
C/O MR. KEVIN HOWARD, COUNTY MANAGER
POST OFFICE BOX 1030
EDENTON, NORTH CAROLINA 27932
ATTN: Katie T. Hackney, PG
GMA, 4300 Sapphire Court, Suite 100, Greenville, North Carolina 27834
RE: Agreement for Access to the Property for completion of Groundwater and Surface
Water Assessment and Monitoring at the Incident Known as Chowan County Valhalla
Water Treatment Plant, 1608 Virginia Road, Edenton, Chowan County North Carolina
NPDES Permit Number: NC0032719, (GMA Project # 158101)
Dear Mr. Howard:
I am the owner representing the Virginia B. Vogedes Properties (Chowan County PIN Numbers
689700282038, 689700189746, 689700170689, and 689700083880) located "off Virginia
Road," 1528 Virginia Road, "off Virginia Road," and 1511 Virginia Road, respectively, Edenton,
Chowan County, NC. I hereby permit Chowan County and/or its consultant(s) to enter upon the
property for the sole purpose of conducting investigation and monitoring of groundwater
contamination per 15A NCAC 2L Regulations for completion of continued groundwater assessment
and monitoring and any additional required assessment or corrective actions approved by the North
Carolina Department of Environmental Quality (NCDEQ) for the project identified above. I am
granting permission with the understanding that:
1. The groundwater investigation and monitoring activities will be conducted by Chowan County or
its consultant(s). These activities will include borehole drilling, monitor well installation,
groundwater sampling and testing, surface water sampling and testing, and/or water-supply well
sampling and testing.
2. The cost of the investigation and monitoring, and any construction and maintenance
conducted at the site, shall be borne by Chowan County. Chowan County or its
consultant(s) shall protect and prevent damage to the surrounding lands to the extent feasible
consistent with the activities being conducted.
3. Unless otherwise agreed, Chowan County or its consultant(s) shall have access to the site by the
shortest feasible route to the nearest public road. The Chowan County or its consultant(s) may
enter upon the land at reasonable times and have full right of access during the period of the
investigation and monitoring, as directed by NCDEQ.
4. Chowan County or its consultant(s) will contact Mrs. Virginia Vogedes and the farm
tenant/manager, Mr. Johnny Layton, prior to conducting any field work with at least 48 hours of
notice. We will also contact them to discuss and mutually agree upon any potential permanent
monitoring well locations prior to installation.
Page 1 of 2
PROPERTY ACCESS AGREEMENT
5. The information derived from the investigation and monitoring shall be made available to the
owner upon request, and is a public record in accordance with N.C. General Statutes 132-1.
6. The monitoring wells will be permanently abandoned per 15A NCAC 2C regulations immediately
following regulatory closure of the incident by NCDEQ.
7. The activities to be carried out by Chowan County or its consultant(s) are for the primary
benefit of Chowan County and/or its consultant(s). Any benefits accruing to the property owner
are incidental.
8. The Chowan County or its consultant(s) is not, and shall not be construed as, an agent,
employee, or contractor of the property owner.
9 . Any claim which may arise against the Chowan County or its consultant(s) shall be governed
by applicable North Carolina General Statutes and as otherwise provided by law.
10. Any accident or injury of a Chowan County employee or its consultant(s) and/or contractors
related to investigations, monitoring, construction and maintenance described above related to
investigation, monitoring, construction and maintenance described above shall not be held
against the property owner. To the fullest extent pOSSible, Chowan County or its consultant(s)
and/or contractors shall hold harmless the property owner from and against any and all claims
and liabilities including but not limited to medical expenses or attorney's fees resulting from an
accident and/or injury while performing investigations, monitoring, construction and
maintenance performing investigation, monitoring, construction and maintenance on the
owner's property. Chowan County and its consultant(s) and/or contractors are required to carry
Worker's Compensations Insurance, Employer's Liability Insurance, Comprehensive General
Liability Insurance, and Professional Liability Insurance where applicable.
I agree not to interfere with, remove, or any way damage the wells installed by Chowan County or
its consultant(s) and/or their equipment throughout the life of the investigation.
Sincerely,
VAA~ b · /J tX,~
Signature
\1 i r@)i Cl ;" ~. \I ~e-d eS
Type/Print Name of Owner 0 gent
1 D Lf J) I au nt s t
Mailing Address
f::d ejIJ+o n / ~J C -;y 7 t)'3~
City/State/Zip Code I
Telephone Number (Home/Cell, if applicable)
~I /
Date
Telephone Number (Work/Other)
Page 2 of 2
PROPERTY ACCESS AGREEMENT
CHOWAN COUN1Y
c/o MR. KEVIN HOWARD, COUN1Y MANAGER
POST OFFICE BOX 1030
EDENTON, NORTH CAROLINA 27932
ATTN: Katie T. Hackney, PG
GMA, 4300 Sapphire Court, Suite 100, Greenville, North Carolina 27834
RE: Agreement for Access to the Property for completion of Groundwater and Surface
Water Assessment and Monitoring at the Incident Known as Chowan County Valhalla
Water Treatment Plant, 1608 Virginia Road, Edenton, Chowan County North Carolina
NPDES Permit Number: NC0032719, (GMA Project # 158101)
Dear Mr. Howard:
I am the owner representing the c.T. Dixon Property (Chowan County PIN Number 689800104205)
located 1623 Virginia Road, Edenton, Chowan County, NC. I hereby permit Chowan County and/or its
consultant(s) to enter upon the property for the sole purpose of conducting investigation and
monitoring of groundwater contamination per 15A NCAC 2L Regulations for completion of continued
groundwater assessment and monitoring and any additional required assessment or corrective actions
approved by the North Carolina Department of Environmental Quality (NCDEQ) for the project
identified above. I am granting permission with the understanding that:
1. The groundwater investigation and monitoring activities will be conducted by Chowan County or
its consultant(s). These activities will include borehole drilling, monitor well installation,
groundwater sampling and testing, surface water sampling and testing, and/or water-supply well
sampling and testing.
2. The cost of the investigation and monitoring, and any construction and maintenance
conducted at the site, shall be borne by Chowan County. Chowan County or its
consultant(s) shall protect and prevent damage to the surrounding lands to the extent feasible
consistent with the activities being conducted.
3. Unless otherwise agreed, Chowan County or its consultant(s) shall have access to the site by the
shortest feasible route to the nearest public road. The Chowan County or its consultant(s) may
enter upon the land at reasonable times and have full right of access during the period of the
investigation and monitoring, as directed by NCDEQ.
4. The information derived from the investigation and monitoring shall be made available to the
owner upon request, and is a public record in accordance with N.C. General Statutes 132-1.
Page 1 of 2
PROPERTY ACCESS AGREEMENT
5. The monitoring wells will be permanently abandoned per 15A NCAC 2C regulations immediately
following regulatory closure of the incident by NCDEQ
6. The activities to be carried out by Chowan County or its consultant(s) are for the primary
benefit of Chowan County and/or its consultant(s). Any benefits accruing to the property owner
are incidental.
7. The Chowan County or its consultant(s) is not, and shall not be construed as, an agent,
employee, or contractor of the property owner.
8. Any claim which may arise against the Chowan County or its consultant(s) shall be governed
by applicable North Carolina General Statutes and as otherwise provided by law.
9. Any accident or injury of a Chowan County employee or its consultant(s) and/or contractors
related to investigations, monitoring, construction and maintenance described above related to
investigation, monitoring, construction and maintenance described above shall not be held
against the property owner. To the fullest extent pOSSible, Chowan County or its consultant(s)
and/or contractors shall hold harmless the property owner from and against any and all claims
and liabilities including but not limited to medical expenses or attorney's fees resulting from an
accident and/or injury while performing investigations, monitoring, construction and
maintenance performing investigation, monitoring, construction and maintenance on the
owner's property. Chowan County and its consultant(s) and/or contractors are required to carry
Worker's Compensations Insurance, Employer's Liability Insurance, Comprehensive General
Liability Insurance, and Professional Liability Insurance where applicable.
I agree not to interfere with, remove, or any way damage the wells installed by Chowan County or
its consultant(s) and/or their eqUipment throughout the life of the investigation.
Type/Print Name of Owner or Agent
~ oJfp rio e-ky f/ a c.-l~ f<C>A-,L
Mailing Address
£.' de-,vlo/ll n.C-· ~79'5 ~
City/State/Zip Code
.2 S~. 4 ~~-..3 0 8"~
4--/.5 ---;lolt.,.
Date
Telephone Number (Home/Cell, if applicable)
Ce...// :l s~-3 33-0 9tf~
Telephone Number (Work/Other)
Page 2 of 2