WI0600229_Permit (Issuance)_20210504

NC Department of Environmental Quality — Division of Water Resources (DWR)
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are `permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C.0200 (NOTE: This form must be received at least 14 DAYS prior to injection)
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C .0229):
1) Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small -Scale Injection Operations — Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells is located within an area that does not exceed five percent of the land surface
above the known extent of groundwater contamination. An individual permit shall be required to conduct more
than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells - Used to inject ambient air to enhance in -situ treatment of soil or groundwater.
5) In -Situ Thermal Wells (IST) — Used to `heat' contaminated groundwater to enhance remediation
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE: April 15 , 20 21
PERMIT NO. WI0600229 (to be filled in by DWR)
NOTE- If this NOI is being submitted as notification of a modification of a previously issued NOI for this site (e.g.,
different injection wells, plume, additives, etc.) and still meets the deemed permitted by rule criteria, provide the
previously assigned permit tracking number and any needed relevant information to assess and approve injection:
A.
B.
Permit No. WI Issued Date:
WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) Air Injection Well Complete sections B through F, J, M
(2) Aquifer Test Well Complete sections B through F, J, M
(3) Passive Injection System Complete sections B through F, H-M
(4) Small -Scale Injection Operation Complete sections B through M
(5) X Pilot Test Complete sections B through M
(6) In -Situ Thermal (IST) Well Complete all sections except K
STATUS OF WELL OWNER: Business/Organization
Deemed Permitted GW Remediation NOI Rev. 2-14-2020
Page 1

C. WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): Servco Distributing Company, Bob Gresham
Mailing Address: P.O. Box 310
City: Albemarle State: NC Zip Code: 28002 County: Stanley
Day Tele No.: Cell No.:
EMAIL Address:[e-mail] Fax No.:
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: NCDOT, Saunders, Richard B, Engineering Technician
Company Name
Mailing Address: 130 South Sutherland Ave. Monroe NC 28112
City: Monroe State: NC Zip Code: 28112 County: Union
Day Tele No.: Cell No.:
EMAIL Address:[e-mail] Fax No.:
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Aaron C. Long, Principal Engineer
Company Name Excel Civil & Environmental Associates
Mailing Address: 625 Huntsman Court
City: Gastonia State: NC_ Zip Code: 28054 County: Gaston
Day Tele No.: 704-853-0800 Cell No.:
EMAIL Address:[e-mail] Fax No.:
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Former Servco 0911
302-304 Caswell Street PIN 6474-11-75-0360
City: Wadesboro County: Anson Zip Code: 28170
0
(2) Geographic Coordinates: Latitude**: " or 34 .96864
Longitude**: " or 80 .07794
Reference Datum: Accuracy:
Method of Collection:
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: 25,030 square feet
Land surface area of inj. well network: 270 square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: 1 (must be < 5% of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 2

H. INJECTION ZONE MAPS — Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and
vertical extent of the contaminant plume in soil and groundwater, changes in lithology, existing and
proposed monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus
existing and proposed wells.
DESCRIPTION OF PROPOSED INJECTION ACTIVITIES AT THE SITE — Provide a brief narrative
regarding the cause of the contamination, and purpose, scope, goals of the proposed injection activity:
The pilot injection will be completed by installing 1 4-inch injection well. The well will be installed to a total
depth of 25 feet below grade level with a screen interval of 20-25 feet. The injection includes a total volume
of approximately 3,500 gallons for the pilot test. The injection process will take one to two days to complete.
See Section J below and attached SDS sheets for details on the injectants, and see the attached figures for
injection locations. The goal of the injections is to remediate the presence of benzene and other hydrocarbons
around MW-3R.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: 1 Proposed GW-1 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 20-25
(3) For Proposed wells or Existing wells not having GW-1s, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as -built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
K. INJECTION SUMMARY
NOTE: Only injectants approved by the epidemiology section of the NC Division of Public Health,
Department of Health and Human Services can be injected. Approved injectants can be found online at
http://deq.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection/ground-water-approved-injectants. All other substances must be reviewed by the DHHS prior to
use. Contact the UIC Program for more info if you wish to get approval for a different additive. However,
please note it may take 3 months or longer.
Injectant: Klozur One Total Amt. to be injected (gal)/event: 1,763 lbs @ 61 g/L
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Amt. Water to be injected (gal/event): 3,500 gallons
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 3

Total Amt. to be injected (gal/event): 3,500 gallons
No. of separate injection events:1 Est. Total Amt. to be injected (gal): 3,500 gallons
Source of Water (if applicable): municipal onsite
L. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
A subsequent groundwater sampling event will occur approximately 45 days after infection.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: I hereby certify, under penalty of law, that I am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false inforrna . 'r n. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well an -_^ appurtenances in9e9rdance with the 15A NCAC 02C 0200 Rules."
Signatture of pp 'cant �J
Pe 3 Srp;
Print or Type Full Name and Title
Property Owner (if the property is not owned by the Well Owner/Applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent
to allow the applicant to construct each injection well as outlined in this application and agree that it shall be
the responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction
Standards (15A NCAC 02C .0200). "
"Owner" means any person who holds the fee or other property rights in the well being constructed. A
well is real property and its construction on land shall be deemed to vest ownership in the land owner, in
the absence of contrary agreement in writing.
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send 1 (one) hard color copy of this NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR w UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 4

Monitoring Report
Former SERVCO No. 00911
Wadesboro, North Carolina
November 13, 2020
Incident No. 22317
Excel No. 24094
GROUNDWATER CONDITIONS
LIQUID LEVEL DATA - July 8, 2020
Well ID #
TOC
DTP (ft)
DTW (ft)
PT (ft)
WTE (ft)
MW-2R
100.00
--
17.71
--
82.29
MW-3R
100.52
--
16.01
--
84.51
MW-6R
101.38
--
10.49
--
90.89
MW-7R
100.42
--
10.99
--
89.43
MW-11R
99.73
--
13.60
--
86.13
NOTES: All data provided in feet / TOC — Top of Casing Elevation / DTP — Depth to Product / DTW — Depth to Water
PT — Product Thickness / WTE— Water Table Elevation. MW-11R DTW collected 9/1/2020
MW-2R set to datum of 100' elevation — datum is not connected to previously destroyed/missing wells
Excel Civil & Environmental Associates
www.excelengr.com

Monitoring Report
Former SERVCO No. 00911
Wadesboro, North Carolina
November 13, 2020
Incident No. 22317
Excel No. 24094
TABLE B-4
HISTORICAL GROUNDWATER ANALYTICAL DATA
Well ID No.
Date
Benzene
Toluene
Ethylbenzene
Xylenes
MTBE
IPE
Naphthalene
GCLs
5,000
260,000
84,500
85,500
20,000
70,000
6,000
MW-2
2/26/07
4,900
15,000
2,200
12,000
340
< 250
< 1,200
MW-2R
5/2/19
1,160
350
847
2,678
129
19 J
87.1 J
11/25/19
852
728
1,130
4,940
152
19.9
653
3/17/20
3,600
990
1,450
4,280
222
34
304
MW-3
2/26/07
17,000
24,000
1,800
10,000
660
<250
< 1,200
7/12/07
23,000
31,000
2,200
11,000
960
260
610
MW-3R
5/2/19
10,000
29,100
3,980
19,670
284
206 J
533 J
11/25/19
10,900
23,400
1,970
15,510
237
95.7 J
1,250
3/17/20
7,920
16,700
2,100
11,400
274
140 J
454 J
MW-5
7/25/01*
8,060
3,500
1,020
4,860
2,500
4,140
190
10/31/01*
9,030
2,440
876
4,030
2,030
3,360
220
2/26/07
850
< 1,200
140
540
< 250
< 250
< 1,200
MW-9
10/31/01*
11,600
3,650
1,500
2,800
1,410
158
270
2/26/07
690
330
170
610
27
80
95
MW-6R
10/31/01*
11,600
3,650
1,500
2,800
1,410
158
270
7/8/20
0.445 J
< 0.278
0.15 J
0.456 J
1.07
24.3
< 1
MW-7R
2/26/07
690
330
170
610
27
80
95
Excel Civil & Environmental Associates
www.excelengr.com

Monitoring Report
Former SERVCO No. 00911
Wadesboro, North Carolina
November 13, 2020
Incident No. 22317
Excel No. 24094
7/8/20
1,540
414
2,300
7,379
< 2.02
161
586
MW-11R
9/1/20
344
2.11
1,500
550.47 J
< 0.101
26.4
372
NOTES: Data provided in ug/I (ppb — parts per billion) / MTBE — Methyl Tert Butyl Ether / IPE — Isopropyl Ether / GCLs — Gross Contamination Levels / Highlighted data
indicates levels above GCLs / * - Indicates data from WLC sampling activities
Excel Civil & Environmental Associates
www.excelengr.com

EXCEL CIVIL 8c ENVIRONMENTAL
ASSOCIATES, PLLC
625 HUNTSMAN COURT
GASTONIA, NC 28054
(704) 853-08000
Figure 1 - Topographical Map
Source: U.S.G.S. 7.5 Minute Topographic Map
Wadesboro, Quadrangle, 1993
fl
N

J
MW-4
MW-7
M W-1
DIESEL
___________
I I
I ,
- 1 ,
I O 1
I y 1
1
,
I ,
I j
GASOLINE
L_____
1---------
1 -1
I GASOLINE 1
1
__,
I I
GASOLINE /
L______ _-JI
KEROSENE I
MW- 7R
MW-9
1
I
I
1
I
1
I
1
I
1
1
I
1
MW-5
CA S
431 MW-6R
NOTES
Map adapted from site plan completed
by Wallace -Lee Consultants dated 12/27/04
UST - Underground Storage Tank
Onsite structures removed, shown for clarity
MW-10
ELL STREET (HW 74)
MW-6
LEGEND
Property Line (Approx)
Right -of -Way (Approx)
Former UST System (Approx)
Former Dispenser Pump (Approx)
<O� Monitoring Well Location
MW-11R
MW-11
Excel
CI vll & Environmental Associates, PLL C
625 HUNTSMAN COURT, GASTONIA, NC PHONE : [phone]
PREPARED FOR : SERVICE DISTRIBUTING CO., INC.
FORMER SERVCO NO. 00911
302-304 CASWELL STREET, WADESBORO, NC
MAP TITLE :
PROJECT NO. :
24094
FIGURE 2 - SITE PLAN
GROUNDWATER MONITORING REPORT
DRAWN BY : ACL SCALE : DATE :
1" = 30' 9.26.2020
REVISED BY : BJPJ

N
W
J
E
r
MW— 7
NS
7/08/2020
1,540
11,633
DIESEL
MW-7R
MW— 9
NS
I
I
I
1
I
1
I
I
1
I
1
I
I
1
1
1
MW-10
NS
NOTES
Map adapted from site plan completed
by Wallace -Lee Consultants dated 12/27/04
UST - Underground Storage Tank
Data from collected on 3/17/20, 7/8/20, & 9/1/20
Data provided in ug/I
BTEX - Summary of Benzene, Toluene,
Ethylbenzene & Xylenes
Onsite structures removed, shown for clarity
Line dashed where inferred
CASWELL STREET (HWY 74)
MW-6R
7/08/2020
0.445 J
< 1.329
MW— 6
NS
LEGEND
Property Line (Approx)
Right -of -Way (Approx)
Former UST System (Approx)
Former Dispenser Pump (Approx)
<O� Monitoring Well Location
Date Sampled
Benzene
BTEX
Constituent Levels Shown
Benzene GCL Isoconcentration Line
NS — / Well Not Sampled
MW-11
NS
MW-11R
9/01/2020
344
2,396.58
Excel
civil Ln vlronmental Associates, PLL C
625 HUNTSMAN COURT, GASTONIA, NC
PHONE : [phone]
PREPARED FOR:
SERVICE DISTRIBUTING CO., INC.
FORMER SERVCO NO. 00911
302-304 CASWELL STREET, WADESBORO, NC
MAP TITLE :
FIGURE 4 - GROUNDWATER CONSTITUENTS MAP
GROUNDWATER MONITORING REPORT
PROJECT NO. :
24094
DRAWN BY : ACL SCALE : DATE :
REVISED BY : BJPJ
1" = 30' 9.26.2020

MW-4
N
W E
MW-7
MW-1
1 1
I \vim _ ---- 1
DIESEL i 2
----
------ ---j I OJ
1 �
I ,
I j
I ---1
I GASOLINE I
I
1 -1
I GASOLINE I
L
I GASOLINE I
------ -J
'
; 11 1 � KEROSENE
11 L
183
MR
[82.29
CANOPY
MW-9
83'
I
I
1
I
1
1
I
84'
1
I
MW-10
84' / 85'
MW-3
[84.51']/
85'
86'
87'
88'
89'
MW-7R
[89.43']
90'
MW-5
CAS
NOTES
Map adapted from site plan completed
by Wallace -Lee Consultants dated 12/27/04
UST - Underground Storage Tank
Onsite structures removed, shown for clarity
Elevations derived from data collected July
and September 2020
BUILDING
ELL (Hw 74)
89'
88'
LEGEND
Property Line (Approx)
Right -of -Way (Approx)
Former UST System (Approx)
Former Dispenser Pump (Approx)
Monitoring Well Location
MW-11
87'
Estimated Water Table Contour
[99.99'] Water Table Elevation
86'
MW-11R
[86.13']
Excel
CI vll & Environmental Associates, PLL C
625 HUNTSMAN COURT, GASTONIA, NC
PHONE : [phone]
PREPARED FOR:
SERVICE DISTRIBUTING CO., INC.
FORMER SERVCO NO. 00911
302-304 CASWELL STREET, WADESBORO, NC
MAP TITLE :
FIGURE 3 - GROUNDWATER CONTOUR MAP
GROUNDWATER MONITORING REPORT
PROJECT NO. :
24094
DRAWN BY : ACL SCALE : DATE :
REVISED BY : CBD
1 " = 30' 11.12.2020

Kim whirs WOK
Call before y:udig.
APPROXIMATE LOCATION OF
OVERHEAD ELECTRIC
APPROXIMATE LOCATION OF
UNDERGROUND GASUNE
APPROXIMATE LOCATION OF
UNDERGROUND WATERUNE
APPROXIMATE LOCATION OF
5' CONCRETE SIDEWALK
NOTES
Map adapted from site plan completed
by Wallace -Lee Consultants dated 12/27/04
and NCDOT Site Map dated 7/5/07
UST - Underground Storage Tank
LEGEND
Right -of -Way (Approx)
Water Service (Existing)
Gas Line (Existing)
Proposed Monitoring Well Location
P
Utility Pole
30 15 0
GRASS
MW-3R
CCS14/1.
1.
STR
EET
30
60
Fire Hydrant
MW-#R (0) Existing Monitoring Well Location GRAPHIC BAR SCALE
GW-# Proposed Injection Well Location 1" = 30'
Owner/Developer:
SERVCO
P.O. Box 310
Albemarle, NC 28002
74)
Design by
ECEA
625 Huntsman Court
Gastonia, NC 28054
P - [phone]
VICINITY SKETCH
NTS
ISSUED FOR CONSTRUCTION
� ecea
w•rw•...r.....w
625 HUNTSMAN COURT
GASTONIA, NC 28054
NC LICENSE NO. P-0129
PHONE: [phone]
FAX: [phone]
WEB: www.excelengr.com
PROJECT It 24094
DRANK BY: BJPJ
CHECKED BY: ACL
DAIS 2/15/2021
SCALE 1n . 30'
FORMER SERVCO
NO. 911
MONITORING WELL INSTALLATION
I
I.
I
le
i
SHEET C-3.0
PROPOSED LAYOUT

STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
ROY COOPER
GOVERNOR
March 1, 2021
Excel Civil & Environmental Associates
625 Huntsman Court
Gastonia, NC 28054
J. ERI.c BoYETTE
SECRETARY
Subject: One Type II Monitoring Well for fluid injection for the former Servco location at
74 and Rutherford St.
Encroachment Number: 21-006-A
Dear Mr. Long:
Enclosed are the executed copies of the subject encroachment contracts. These encroachments
are approved subject to the attached provisions. Please read these provisions
if you have any questions about these special provisions, please contact Ben Saunders, Engineer
Technician, at [phone] in Monroe.
Sincerely,
Brett Canipe, P.E.
Division Engineer
TP
cc: District Field Copy
File
Marling Address:
NC DEPART MENT OF TRANSPORTATION
DIVISION OF HIGHWAYS, DISTRICT 3
130 S. SUTHERLAND AVENUE
MONROE, NC 28112
Telephone: [phone]
Fax: [phone]
Customer Service: 1-877-368-496a
Website: ncdot.gov
Location:
130 5. SUTHERLAND AVENUE
MONROE, NC 28112

Special Provisions — Encroachment #: 21-006-A
Pre -Construction
Contact Offices & Outside Agency issues/contacts/info
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 to Ben Saunders at telephone [phone] or
email to [e-mail] to the District Engineer's office
If the construction falls within the limits of an NCDOT managed construction project, five (5)
business days advance phone call to the Resident Engineer, Mx. XXXX at (###) ###-#### or
email to XXXXXX@,ncdot.gov.
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.
b.
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.
5. The encroaching party shall notify the appropriate municipal office prior to beginning any work
within the municipality's limits of jurisdiction.
6. 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.
7. This agreement does not authorize installations within nor encroachment onto railroad rights of way.
Permits for installations within railroad right of way must be obtained from the railroad and are the
responsibility of the encroaching party.
8. At the option of the District Engineer, a preconstruction meeting including representatives of
NCDOT, the encroaching party, contractors and municipality, if applicable, shall be required.
A pre -construction conference held between a municipality (or other facility owner) and a contractor
without the presence of NCDOT personnel with subsequent construction commencing may be subject
Page 1

Special Provisions — Encroachment #: 21-006-A
to NCDOT personnel ceasing any work on NCDOT right-of-way related to this encroachment until
such meeting is held. Contact the District office to schedule.
9. At the discretion of the District Engineer, a NOTIFICATION FOR. UTILITY / NON -UTILITY
ENCROACHMENT WITHIN NCDOT RIW form (See corresponding attachment) with the
scheduled pre -construction meeting and associated construction schedule details must be completed
and submitted to the District Engineer's office a minimum of one week prior to construction. This
document may be sent by mail, fax, or emailed to Ben Saunders, Engineering Technician II.
rbsaunders cincdot ov, 704-322-8101.
10. 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.
Legal & Right -of -Way Issues
11. 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.
12. 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.
13. Prior to the approval of any privately maintained facility within NCDOT right of way which the State
of North Carolina is not the fee simple owner, written permission that each and every property owner
affected by the installation shall be provided to NCDOT by the encroaching party. (See
corresponding attachment.) ROW must be verified through deeds or plats (copy provided to
NCDOT office).
14. Encroaching party shall be responsible for obtaining all necessary permanent and/or temporary
construction, drainage, utility and/or sight distance easements.
15. 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.
16. No commercial advertising shall be allowed within NCDOT Right of Way.
17. The encroaching party shall obtain proper approval from all affected pole owners prior to attachment
to any pole.
18. The installation within the Control of Access fence shall not adversely affect the design, construction,
maintenance, stability, traffic safety or operation of the controlled access highway, and the utility
must be serviced without access from the through -traffic roadways or ramps.
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Special Provisions — Encroachment #: 21-006-A
Bonds
19. A Performance and Indemnity Bond in the amount of $x,xxx.xx shall be posted with the District
Engineer's Office by the Party of the Second Part prior to beginning any work within the NCDOT
Right of Way. The bond shall be held for a minimum of one year after a satisfactory final inspection
of the installation by NCDOT. The bond may be held for a period longer than one year after
completion if, in the opinion of NCDOT, the size or complexity of the installation warrants a longer
period.
20. The release of the bond is subject to a final inspection by NCDOT. Contact the District office to
schedule a Final Inspection and to request release of the bond. When requesting the bond release the
encroacher must reference the State or Local Encroachment number.
Work Zone Traffic
21 Traffic control shall be coordinated with the District Engineer and the Division Traffic Engineer,
Tony Tagliaferri, PE at telephone [phone], prior to construction.
22. WORK ZONE I RAFFIC CONTROL QUALIFICATIONS AND TRAINING PROGRAM
All personnel performing any activity inside the highway right of way are required to be farniliar 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.gov/projectsfWZTC/Pages/Training.aspx or call the NCDOT Work Zone Traffic
Control Section (919) 8I4-5000.
23. 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
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Special Provisions — Encroachment #: 21-006-A
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 2018 NCDOT Specifications for Roads and Bridges and Standard
Drawings, Division 11. It also covers important safety knowledge for a wide range of work
zone job responsibilities.
24. 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.
25. 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.
26. 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.
27. 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.
28. Traffic shall not be rerouted or detoured without the prior written approval from the District 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.
29. Work requiring lane or shoulder closures shall not be performed on both sides of the road
simultaneously within the same area.
30. 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 AL4NUAL
ON UNIFORM TRAFFIC CONTROL DEVICES.
31. Traffic shall be maintained at all times. All lanes of traffic are to be open during the hours of 6:00
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 District Engineer. Two-way traffic on one 12-foot lane
shall be maintained at all times. Any violation of these hours will result in ceasing any further
construction by the Encroaching Party or their contractor.
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Special Provisions — Encroachment #: 21-006-A
In addition, the Contractor shad not close or narrow a lane of traffic, detain and/or alter the traffic
flow on or during holidays, holiday weekends, special events, or any other time when traffic is
unusually heavy, including the following schedules:
HOLIDAY AND HOLIDAY WEEKEND LANE CLOSURE RESTRICTIONS
1. For unexpected occurrence that creates unusually high traffic volumes, as directed by the
Engineer.
2. For New Year's Day, between the hours of 6:00 A.M. December 31 st and 9:00 A.M.
January 2nd. If New Year's Day is on a Friday, Saturday, Sunday or Monday, then until
9:00 A.M. the following Tuesday.
3. For Easter, between the hours of 6:00 A.M. Thursday and 9:00 A.M. Monday.
4. For Memorial Day, between the hours of 6:00 A.M. Friday and 9:00 A.M. Tuesday.
5. For Independence Day, between the hours of 6:00 A.M. the day before Independence Day
and 9:00 A.M. the day after Independence Day.
If Independence Day is on a Friday, Saturday, Sunday or Monday, then between the hours
of 6:00 A.M. the Thursday before Independence Day and 9:00 A.M. the Tuesday after
Independence Day.
6. For Labor Day, between the hours of 6:00 A.M. Friday and 9:00 A.M. Tuesday.
7. For Veteran's Day, between the hours of 6:00 A.M. Thursday through 9:00 A.M.
Monday.
8. For Thanksgiving Day, between the hours of 6:00 A.M. Tuesday and 9:00 A.M. Monday.
9. For Christmas, between the hours of 6:00 A.M. the Friday before the week of Christmas
Day and 9:00 A.M. the following Tuesday after the week of Christmas Day.
Holidays and holiday weekends shall include New Year's, Easter, Memorial Day, Independence
Day, Labor Day, Thanksgiving, Veteran's Day and Christmas. 'The Contractor shall schedule his
work so that lane closures will not be required during these periods, unless otherwise directed by
the Engineer.
32. Temporary and final pavement markings are the responsibility of the encroaching party. Final
pavement markings and sign plans shall be submitted with the encroachment request to the Division
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Special Provisions — Encroachment #: 21--006-A
Traffic Engineer prior to construction. Final pavement markings shall be thermoplastic unless
otherwise directed by the Division Traffic Engineer or District Engineer.
33. Any pavement markings that are damaged or obliterated shall be restored by the encroaching party at
no expense to NCDOT.
34. 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.corn/watch?v=A0uYa5IW3da&feature--voutu.be
Roadside Environmental
35. 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 XXX XXX XXXX.
36. When surface area in excess of one acre will be disturbed, the Encroacher shall submit a Sediment
and Erosion Control Plan which has been approved by the appropriate regulatory agency or authority
prior to beginning any work on the Right of Way. Failure to provide this information shall be
grounds for suspension of operations. Proper temporary and permanent measures shall be used to
control erosion and sedimentation in accordance with the approved sediment and erosion control plan.
37. The Verification of Compliance with Environmental Regulations (VCER-1) form is required for all
non -utility encroachment agreements or any utility encroachments when land disturbance within
NCDOT right of way exceeds 1 acre. The VCER-1 form must be PE sealed by a NC registered
professional engineer who has verified that ail appropriate environmental permits (if applicable) have
been obtained and all applicable environmental regulations have been followed.
38. 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.
39. No trees within NCDOT shall be cut without authorization from the Division Roadside
Environmental Engineer. An inventory of trees measuring greater than 4 caliper inches (measured 6"
above the ground) is required when trees within CiA right of way will be impacted by the
encroachment installation. Mitigation is required and will be determined by the Division Roadside
Environmental Engineer's Office.
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Special Provisions — Encroachment ft: 21-006-A
40. Prior to installation, the Encroaching Party shall contact the District Engineer to discuss any
environmental issues associated with the installation to address concerns related to the root system of
trees impacted by boring or non -utility construction of sidewalk, roadway widening, etc.
41. The applicant is responsible for identifying project impacts to waters of the United States (wetlands,
intermittent streams, perennial streams and ponds) located within the NCDOT right-of-way. The
discharge of dredged or fill material into waters of the United States requires authorization from the
United States Army Corps of Engineers (USACE) and certification from the North Carolina Division
of Water Quality (NCDWQ). The applicant is required to obtain pertinent permits or certification
from these regulatory agencies if construction of the project impacts waters of the United States
within the NCDOT right-of-way. The applicant is responsible for complying with any river or stream
Riparian Buffer Rule as regulated by the NCDWQ. The Rule regulates activity within a 50-foot
buffer along perennial streams, intermittent streams and ponds. Additional information can be
obtained by contacting the NCDWQ or the USACE.
42. The contractor shall not begin the construction until after the traffic control and erosion control
devices have been installed to the satisfaction of the Division Engineer or their agent.
43. The contractor shall perform all monitoring and record keeping and any required maintenance of
erosion and sediment control measures to maintain compliance with stormwater regulations.
STIP {or Division Managed) Projects
44. State Transportation Improvement Project (STIP) **-XXXXXX is scheduled for future construction.
Any encroachment determined to be in conflict with the construction of this NCDOT project shall be
removed and/or relocated at the encroaching party's expense.
Construction
General
45. 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.
46. 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.
47. Any REVISIONS marked in RED on the attached non -PE sealed plans shall be incorporated into and
made part of the approved encroachment agreement.
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Special Provisions — Encroachment #: 21-006-A
48. 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.
49. The encroaching party shall notify the Division 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.
50. 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 5 feet below flowline of streams.
51. At points where the utility is placed under existing storm drainage, the trench will be backfilled with
excavatable Plowable fill up to the outside diameter of the existing pipe.
52. 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 non -working hours, no
parking or material storage shall be allowed along the shoulders of any state -maintained roadway.
53. No access to the job site, parking or material storage shall be allowed along or from the Control of
Access Roadway.
54. Guardrail removed or damaged during construction shall be replaced or repaired to its original
condition, meeting current NCDOT standards or as directed by the Division Engineer or their
representative.
55. The resetting of the Control of Access fence shall be in accordance with the applicable NCDOT
standard and as directed by the Division Engineer or their representative.
56. Right of Way monuments disturbed during construction shall be referenced by a registered Land
Surveyor and reset after construction.
57. All Traffic signs moved during construction shall he reinstalled as soon as possible to the satisfaction
of the Division Engineer or their representative.
58. 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.
59. 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.
60. All driveways disturbed during construction shall be returned to a state comparable with the condition
of the driveways prior to construction.
61. Conformance with driveway permit review should be required in conjunction with this encroachment
agreement. In the event there is a conflict between the driveway permit and the encroachment
agreement, the District Engineer should resolve the conflict and notify the parties involved.
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Special Provisions — Encroachment #: 21-006-A
62. 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.
Engineering
63. 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 Policy on Street and Driveway Access, NCDOT Asphalt Quality Management System
manual, and the approved plans.
64. Prior approval for any blasting must be obtained from the Division Engineer or their representative.
65. Regulator stations, metering stations, cathodic test stations, and anode beds are not permitted within
NCDOT right of way. Header wires are permitted.
66. Non -Utility Communication and Data Transmission installations (ground mounted type or Small Ce11
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.
67. All wiring and related electrical work shall conform to the latest edition of the National Electrical
Safety Code_
Location within R/W
68. All utility access points, such as manholes, vaults, handholes, splice boxes and junction boxes shall
be located as close to the right of way Iine as possible and shall not be placed in the ditch 1 ine, 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.
69. Fire Hydrants shall be of the breakaway type. Hydrants shall be placed near the right of way line. In
curb and gutter sections with written approval from the District, the hydrants may be placed at 6'
behind the back of the curb or minimum 2' back of sidewalk.
70. Luminaire and/or utility poles and guy wires shall be set as close to the Right of Way line as practical
and outside the Clear Zone in accordance with the latest version of the AASHTO Roadside Design
Guide (See corresponding attachment) or made breakaway in accordance with the requirements of
NCHRP Report 350. Any relocation of the utility poles from the original design due to Clear Zone
requirements shall require a re -submittal for the utility design.
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Special Provisions — Encroachment #: 21-006-A
71. Luminaire and/or utility poles shall be seta minimum of 5'-6" behind face of any guardrail or
otherwise sufficiently protected. However, standard placement may be reduced to 3'-6" behind face
of guardrail when posts are spaced 3'-1 V2", or where speed limit is less than 55 MPH.
72. Hot box (aka ASSE 1060) or Safe-T-Cover type enclosures covering utility main pipe joints,
backflow prcventers, valves, vent pipes, cross connections, pumps, grinders, irrigation assemblies,
transformers, generators, and other similar large appurtenances shall be located outside sight distance
triangles and off of the NCDOT Right -of -Way.
73. Sprinkler heads shall be located a minimum of 10 feet from the edge of pavement, edge of shoulder,
or back of curb whichever is greater and shall be directed so that water does not spray or drain on the
roadway surface, sidewalk, or passing vehicles at any time. Upon completion of the installation and
prior to activation of the system, the Encroacher shall contact the District Engineer to schedule a test
of the system to verify the spray pattern. Sprinkler systems shall not be operated during periods of
high wind or freezing weather, or to the extent that the subgrade adjacent to the pavement structure
becomes saturated. NCDOT reserves the right to require immediate termination and removal of any
sprinkler system which in its judgement and opinion adversely affects safety, maintenance, or
operation of the roadway.
Excavation
74. Excavation material shall not be placed on pavement.
75. 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.
76. The utility shall be installed within 5 feet of the right of way line and outside the 5-foot minimum
from travel lane plus theoretical 2:1 slope from the edge of pavement to the bottom of the nearest
excavation wall for temporary shoring. If the 2:1 slope plus 5 feet requirement above is met for
traffic, then temporary shoring is typically only necessary to protect roadways from damage
when a theoretical 1:1 slope from the edge of pavement intersects the nearest excavation
wall. This rule of thumb should be used with caution and does not apply to all subsurface
conditions, surcharge loadings and excavation geometries. Situations where work within this
1:1 slope is not Permitted include groundwater depth is above bottom of excavation or
excavation is deeper than 10 feet or in Type B or C soils as defined by OSHA Technical
Manual. Temporary shoring may be avoided by locating trenches, bore pits, and other
excavations far enough away from the open travel lane, edge of pavement and any existing
structure, support, utility, property, etc. to be protected. Temporary shoring is required when
a theoretical 2:1 slope from the bottom of excavation will intersect the existing ground line
less than 5 feet from the outside edge of an open travel lane as shown in the figure below or
when a theoretical 2:1 slope from the bottom of excavation will intersect any existing
structure, support, utility, property, etc. to be protected.
Open Travel
14 Lane
11 min 11— /
Theoretical %v
2:1(H:V)/ V
Slope
Page j 10
Existing Ground
Line
Edge of
Pavement
Bottom of
'••• ' Excavation

Special Provisions — Encroachment #: 21-006-A
Temporary shoring shall be designed and constructed in accordance with current NCDOT
Standard Temporary Shoring provisions (refer to
https://connect.rtcdot.gaviresources/STecifications/Pages/2018-Specifications-and-
Special-Provisions.aspx and see SP1 1 R002).
a. Temporary excavation shoring, such as sheet piling, shall be installed. The design of the
shoring shall include the effects of traffic loads. The shoring system shall be designed and
sealed by a licensed North Carolina Professional Engineer. Shoring plans and design
calculations shall be submitted to the Division Engineer for review and approval prior to
construction. (See NCDOT Utilities Accommodations Manual for more information on
requirements for shoring plans and design calculations,) Trench boxes shall not be accepted
as temporary shoring and will not be approved for use in instances where shoring is
required to protect the highway, drainage structure, and/or supporting pavement or
structure foundation.
b. Al] trench excavation inside the limits of the theoretical one-to-one slope, as defined by the
policy, shall be completely backfilled and compacted at the end of each construction day. No
portion of the trench shall be left open overnight. Any excavation that is not backfilled by the
end of the workday must address any safety and traveling public concerns including
accommodations for bicycles, pedestrians and persons with disabilities.
c. The trench backfill material shall meet the Statewide Borrow Criteria. The trench shall be
backfilled in accordance with Section 300-7 of the latest NCDOT Standard Specifications for
Roads and Structures, which basically requires the backfill material to be placed in layers not
to exceed 6 inches loose and compacted to at least 95% of the density obtained by
compacting a sample in accordance with AASHTO T99 as modified by DOT.
d. At the discretion of the Division Engineer, a qualified NCDOT inspector shall be on the site
at all times during construction. The encroaching party shall reimburse NCDOT for the cost
of providing the inspector. If NCDOT cannot supply an inspector, the encroaching party (not
the utility contractor) should make arrangements to have a qualified inspector, under the
supervision of a licensed North Carolina Professional Engineer, on the site at all tithes. The
Professional Registered Engineer shall certify that the utility was installed in accordance with
the encroachment agreement and that the backfill material meets the Statewide Borrow
Criteria.
e. The Length of parallel excavation shall be limited to the length necessary to install and
backfill one joint of pipe at a time, not to exceed twenty-five (25) feet.
77. All material to a depth of 8 inches below the finished surface of the subgrade shall be compacted to a
density equal to at least I 00% of that obtained by compacting a sample of the material in accordance
with AASHTO T99 as modified by the Department. The subgrade shall be compacted at a moisture
content which is approximately that required to produce the maximum density indicated by the above
test method. The contractor shall dry or add moisture to the subgrade when required to provide a
uniformly compacted and acceptable subgrade. The option to backfill any trenches with dirt or either
#57 stone or #78 stone with consolidation with a plate tamp and without a conventional density test
may be pursued with the written consent of the District Engineer. If this option is exercised, then
roadway ABC stone and asphalt repair as required will also be specified by the District Engineer.
Directional bore
78. Boring equipment will be provided of a type and size to facilitate boring in the local geologic
conditions and shall he able to facilitate the encroachment work.
79. When Horizontal Directional Drilling (FWD) 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
l3entonite (or equivalent material) slurry is recommended. Monitor flow rates to match the
Page 11

Special Provisions — Encroachment #: 21-006-A
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
(Backream)
2" to 6"
Minimum Depth of Cover
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 I.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.
80. Provide a means of collecting and containing drilling fluid/slurry that returns to the surface such as a slurry pit.
Provide measures to prevent drilling fluids from entering drainage ditches and storm sewer systems. Prevent
drilling fluid/slurry from accumulating on or flowing onto pedestrian walkways, driveways and streets.
Immediately remove all drilling fluids/slurry that are accidentally spilled.
81. Transport waste drilling fluid/slurry from site and dispose of in a method that complies with Federal, State and
local laws and regulations.
Aerial clearances
82. 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.
Pagel 12

Special Provisions — Encroachment #: 21-006-A
83. In relation to the bridge, the utility line shall be located with minimum clearances as indicated on the
attachment for NCDOT Required Clearances for Aerial Installations by Encroachment Near
Bridge Structures.
84. When closing a road for aerial installation the road or lanes should not be closed for more than 10
minutes at a time.
Pavement Detail and Repair
85. The paving of this roadway shall be in accordance with the latest version of NCDOT Standard
Specifications, Sections 6I0, 1012 and 1020. The Contractor shall follow all procedures of the
Quality Management System (QMS) for asphalt pavement - Maintenance Version (see
hops://co nnect.ncdot.goviresources/Materials/Material sResources/20 1 8%20 Q MS%20 Asphal
t%20Manual.pd0. The Contractor must adhere to all testing requirements and quality control
requirements specified. The Contractor shall contact the NCDOT Division QA Supervisor prior to
producing plant mix and make the Supervisor aware that the mix is being produced for a future
NCDOT road. Contact the District Engineer to determine the NCDOT Division QA Supervisor.
Only NCDOT approved mix designs will be acceptable. A Quality Control Plan shall be submitted
(as Directed by the District Engineer) to the District Engineer's Office prior to asphalt production
utilizing form QMS-MV 1. Failing mixes and/or densities are subject to penalties including monetary
payments or removal and replacement. To minimize traffic queuing in construction areas, the
possibility of traffic detours may be considered when working on high traffic routes even if traffic
control is used. The District Engineer may require traffic detours.
86. When paving beyond utility installation is involved, a Roadway certification report sealed by a
Professional Engineer shall be submitted to the District Engineer's office indicating the following:
• Pavement thickness by type
• Pavement density, core and/or test locations
• Base thickness
• Base density
• Subgrade density
Test frequency and method shall be in conformance with the NCDOT Materials and Tests Manual.
Test must be performed by a Certified Technician including name and Certification number on report.
87. "Potholing" pavement cores to expose existing utilities shall be made with an 18" diameter
keyhole pavement core. Pavement core locations shall not be placed in the wheel path
whenever possible. Vacuum excavation shall be utilized to expose underground utilities.
Pavement cores shall be repaired within the same working day. The pavement core shall be
retained and reused to fill the core hole.
The excavation shall be backfilled and compacted with select material to the bottom of the
existing pavement structure or as indicated by the District Engineer. The retained core shall
be placed in the hole and secured with a waterproof, mechanical joint. if the pavement core is
damaged and cannot be re -used, the core may be replaced with the surface mix, S9.5C. The
asphalt patch shall match the thickness of the existing asphalt or four inches, whichever is
greater. All materials must be listed on the NCDOT Approved Products List (APL) found at:
https : //apps. ncdot. gov/vendor/appro vedpro ducts/.
Page 113

Special Provisions — Encroachment #: 21-006-A
88. The minimum pavement design for pavement repair shall be according to NCDOT Standard Drawing
654.01
(https://connett.ncdot.gov/resources/Specifications/2018StandardRdwyDrawings/Divi sion%2006%2
OAsphalt%2OBases%20and%20Pavements.pdf) and shall include a mechanical overlay extent to be a
minimum of 25 feet each side of the pavement repair area OR as directed by the District Engineer.
89. Pavement cuts shall be repaired the same day the cuts are made unless an asphalt patch cannot be
accomplished the same day due to material availability or time restrictions. When the asphalt patch is
not feasible, the following apply:
a. The pavement cut shall be filled to the surface with ABC stone and in plated per NCDOT's
Standards and Specifications. (In low speed areas (35 mph or less), metal plates may be used
to cover excavated areas.
b. Once the cut is filled, a minimum 3/4-inch steel plate shall be placed and pinned to prevent
moving. Plates shall be designed large enough to span a minimum of 1-foot on all sides on
the pavement cut.
c. Install and leave "BUMP" signs according to MUTCD until the steel plate has been removed.
Once the flowable fill has cured, remove the steel plate, and mill/fill according to the
directions of the District Engineer.
d. All pavement cuts must be sealed with NCDOT approved sealant to prevent future pavement
separation or cracking.
90. 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.
Post Construction
Cose out/ Inspection
91 The Encroaching party shall notify the District Engineer's office within 2 business days after
construction is complete. The District 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.
92. At the discretion of the District Engineer, a final inspection report may be provided to the
encroaching party upon satisfactory completion of the work.
93. A written acknowledgement of the completed work by the District Engineer's office begins the one-
year warranty period associated with the performance bond.
94. 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.
Page I14

Special Provisions — Encroachment #: 21-006-A
95. The encroaching party shall provide the North Carolina Turnpike Authority (NCTA) with an
electronic copy of coordinate correct as -built plans within two weeks of installation completion.
Failure to provide the as -built plans may jeopardize future approvals within NCTA right of way.
96. A copy (in PDF format) of the completed ground water analysis shall be given to the District
Engineer, including detailed drawings of the "as -built" wells showing location, depth and water level
in well.
Page I 15

Special Provisions — Encroachment #: 21-006-A
Attachment Form
NOTIFICATION FOR UTILITY/ NON -UTILITY ENCROACHMENT WITHIN NCDOT RIW
Instruction for Use:
This form Must be completed in its entirety and submitted directly to the designated personnel in
the District Engineer's office via email, fax or hand delivery a minimum of one week prior to
construction for the encroachment. If the designated NCDOT personnel names are unknown by
the person completing this form, please contact the District Engineers office to determine that
contact info. Division 10, District 3 Office, Monroe, NC - 704-218-5100
Date: _ Submitted by Name:
To: District Personnel Name: Ben Saunders
District Personnel Email: [e-mail]
District Fax No.:
This notification is to inform you that we (encroaching party or their contractor) will begin construction
work on the following project in a minimum of one week.
Encroachment number
(assigned by NCDOT) for the project:
Construction start date:
Approximate ending date:
Contact NCDOT inspector a minimum of 72 hrs. in advance to set-up Preconstruction meeting in the
District Engineer's office or other location as directed by the District Engineer
Preconstruction meeting date & time:
Preconstruction meeting address:
Type of project:
[Examples: power, telecommunication, water, sewer, gas, petroleum, other (describe)]
Contact Info for this project:
Contractor Company Name:
Contractor Contact Name:
Contractor Phone Number:
Contractor Email:
NCDOT Utility Inspector Name:
NCDOT Utility Inspector Phone:
NCDOT Utility Inspector Email:
NCDOT Utility Project Manager Name:
NCDOT Utility Project Manager Phone:
NCDOT Utility Project Manager Email:

NCDOT Hold Harmless Declaration for Private Facility FORM
Private Facility Encroachment
Hold Harmless Declaration
Encroachment Agreement Second Party: Encroachment Number:
County:
The party of the second part of the above -referenced encroachment agreement agrees to indemnify and
save harmless the North Carolina Department of Transportation from all claims of liability for the
overburdening of right of way easements caused by the installation of private facilities owned by the party
of the second part and installed under the approval of the above -referenced encroachment agreement.
Second Party: Attest or Witness:
Date:
Published by NCDOT Utilities Unit 7/17/2017
Separate Form to be signed by each property owner affected by the installation.

i certify that i have read and understand these approved Encroachment provisions
Encroaching Party (Primary Contact)
Name:
Phone #:
Primary Contractor to Encroaching Party
(Point of Contact)
Name:
Phone #:
NCDOT Encroachment ID#

ROUTE Highway 74
N. Caswell Street
PROJECT Former Servo() No. COUNTY OF AnsonE OF NORTH CAROLiNA
911
DEPARTMENT OF TRANSPORTATION RIGHT OF WAY ENCROACHMENT AGREEMENT
FOR NON -UTILITY ENCROACHMENTS ON
-AND- PRIMARY AND SECONDARY HIGHWAYS
Excel Civil & Environmental Associates
625 Huntsman Court, Gastonia, N.C. 28054
THIS AGREEMENT, made and entered into this the , of 1 y M 1 20 2,, by and between the Department
of Transportation, party of the first part; and Excel Civil & Environmental Associates !
625 Huntsman Court, Gastonia, N.C. 28054
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
Rotes Highway 74 & Caswell Street located 302-304 West Caswell Street
Wadesboro,
with the construction andlor erection One Type II Monitoring Well For fluid injection.
of:
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 ES 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 parry of the second part binds and obligates himself to install and maintain the encroaching facility in such safe
and proper condition that it will nal 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 far any repairs or maintenance to its roadways
and structures necessary due to the Installation and existence of the facilities of the party of use 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 tacitilies, That the said party of the second
part binds himself, his successors and assigns, Ib promptly remove or alter the said facilities. in order to conform to the said
requirement, withoul any cost to the party of the first part.
That the party of the second pan agrees to provide during construction and any subsequent maintenance proper signs, signal
lights. flagmen and other warning devices for the protection of traffic in conformance with the I test Manuel on Uniform Traffic
Control Devices for Streets and Highways and Amendments or Supplements thereto, Information as to the above rules and
regulations may he 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 this encroachment.
ll is clearly understood by the party of the second pan 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 oonslruction 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 preceuIran
during construction and maintenance to prevent eroding of soil; silting or pollution of rivers. streams, lakes, reservoirs. other water
impoundments. ground surfaces or other properly; 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 Commrssion, 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 ebstIng 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 deny 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 pan agrees to have availabie al the encroaching site, at all limes during construction, a copy of
this agreement showing evidence of approval by the party of the first pail. The party of the first part reserves the right to stop ail
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 wntten notice to the Division Engineer of the party of the lust pan when all work contained herein has
been completed. Unless specifically requested by the party of the first part, written notice of completion of work an highway
projects under construction will not be required.
That to 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 small work unlit the facility has been brought into compliance or removed from the right of way et no cost to
the party of the First part.
That it !s agreed by both parties that this agreement shall become void if actual construclion 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
FORM RAN 16.1A (January, 1981)

parry of the second part from the party of the first part
RNV (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.
ATTEST OR WITNESS!
Cq••r eM _t;leV4ne
DEPARTMENT OF TRANSPORTATION
BY:
Asst. Manager of Right of Way
110P1 G- L N
Second Party
INSTRUCTIONS
y c 60-.AX74
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 Manager of Right of Way. 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 paint, 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.
T. 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.
8. Horizontal alignment indicating general curve data. where applicable.
9. Vertical alignment indicated by percent grade, P.1, station and vertical curve length, where
applicable.
10. Amount of material to be removed and/or placed an 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. Inctude 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
starling of installation included in this agreement.
16. Method of handling traffic during construction where applicable.
17. Scale of plans, north arrow, etc.

Workforce Safety Plan: COVID-t9
o et -it
NCDOT Encroachment ID#:
WORKFORCE SAFETY PLAN
FOR ENCROACHMENT ACTIVITIES: COVID-19
EFFORTS THE N.C. TRANSPORTATION INDUSTRY 15 TAKING TO STOP THE SPREAD OF COVID-19
The North Carolina Department of Transportation (NCDOT) and their partners expect al! parties involved in
the delivery of transportation projects to abide by the guidelines issued from the Centers for Disease
Control and Prevention (CDC) and the North Carolina Department of Health and Human Services (NCDHHS).
Response to COVID-19 is rapidly evolving; new information and guidelines may be issued from the CDC,
NCDHHS, or other state or federal agencies. NCDOT and their partners should review the current CDC and
NCDHHS guidance, including the resources listed at the end of this document, for up-to-date information
on how to respond to COVID-19. Additional guidelines may be issued by state or federal agencies that
should be followed in addition to the guidance included in this document.
Though certain Americans with Disabilities Act (ADA) requirements have been relaxed in response to the
pandemic, employers must still maintain all information about employee illness as a confidential medical
record in compliance with the ADA. If an employee is suspected of having or tests positive for COVID-19, it
is essential that management keep the identity of the employee and details related to the employee's
health confidential.
Below are precautions required by NCDOT and from encroaching parties and their contractors performing
construction within NCDOT Rights of Way. The term employee refers to any person on a job site within
NCDOT right of way for the purpose of constructing or inspecting the work related to construction of a
facility under an approved encroachment agreement and where that employee may or may not be under
employment by or under contract to NCDOT.
EMPLOYEE WELLNESS
• If an employee has not yet reported to work and develops any COVID-19 symptoms (i.e. fever,
coughing, or shortness of breath) — STAY HOME and immediately:
❑ Call a health care provider
❑ Self -Isolate
a Communicate with your supervisor
o Remain calm and follow all instructions from your health care provider
• Employees who appear to have acute respiratory illness symptoms (i.e. cough, shortness of breath)
upon arrival to work, or become sick during the day, should be separated from others and sent
home immediately. The potentially affected employees should immediately follow the steps
outlined above, which includes immediately contacting a health care provider.
• Should an employee show symptoms of acute respiratory illness or be diagnosed with COVID-19, all
other employees who have worked in close proximity to the affected employee during the last 14
Updated: 4/1 1/2020
Page 1

._ 0o6-A B5
Workforce Safety Plan: COVID-19 NCDOT Encroachment ID#:
days and all encroachment points of contact indicated at the end of this plan should be notified of
potential exposure to the disease without identifying the affected employee.
■ Consideration should be given to employees at "High Risk" of severe illness from COVID-19, who,
per NCDHHS, include employees:
❑ Over 65 years of age, OR
o With underlying health conditions including heart disease, lung disease, or diabetes, OR
❑ With weakened immune system
• "High Risk" Employees should be given the opportunity to discuss alternate work
arrangements/duties with their employer or take leave according to their company policies.
• For guidance on confirmed positive tests for COVID-19, refer to the most recent version of the
"COVID-19 Guidance for Employees on Encroachment Job Sites within NCDOT Right of Way"
located on last page of this plan.
PERSONAL HYGIENE
• Clean hands often by washing with soap and water for 20 seconds. If soap and water are not
available and hands are not visibly dirty, an alcohol -based hand sanitizer that contains 60%-95%
alcohol may be used.
• Avoid touching your eyes, nose, mouth, or other parts of your face.
• Do not breathe, cough, or sneeze on another person or into the open air. Employees should cover
their noses and mouth with a tissue when coughing or sneezing (or an elbow or shoulder if no
tissue is available).
• A facemask for covering nose and mouth is encouraged on the job site.
• Appropriate gloves are encouraged while performing functions of the job.
CLEANING/DISINFECTING
• Wash stations and/or hand sanitizer are encouraged on each project site.
■ Appropriate cleaning staff should clean frequently touched surfaces and objects with disinfectants
at a minimum of once per day.
o Office/buildings: door knobs, light switches, phones, computers/keyboards, copy machines,
elevator buttons, toilets, faucets, sinks, countertops, paper towel dispensers, desktops,
handrails, folders, vending machines, counters, tables, cabinets/knobs, etc.
o Shop Yard/Jobsite: vehicle/equipment door handles, keys, gear shifts, steering
wheel/operator controls and levers, fuel pump dispensers, touch points on machinery, etc.
o Electronic equipment: cell phones, computers, keyboards, etc.
• Appropriate cleaning staff should sanitize/disinfect facilities and work areas after persons
suspected/confirmed to have COVID-19 have been in the facility or work area.
Updated: 4/11/2020 Page 2

z1—o°6 h
Workforce Safety Plan: COVID-19 NCDOT Encroachment ID#: I— A
o It is recommended to close off access to areas used by the ill persons and wait as long as
practical, 24 hours if possible, before beginning cleaning and disinfection to minimize
potential for exposure to respiratory droplets. Open outside doors and windows to increase
air circulation in the area if possible.
o Appropriate cleaning staff should clean and disinfect all areas used by the ill persons,
focusing especially on frequently touched surfaces.
GENERAL
• Increase communication measures between all parties regarding schedule, daily activities, etc. to
reduce/minimize worker exposure in accordance with but not limited to the requirements below.
• Minimize on -site personnel such as subcontractors, work crews, QC personnel, and inspection staff
to those required for that day's activities. If work is postponed or cancelled, immediately notify
appropriate parties.
• Practice "Social Distancing" whenever feasible. Social Distancing is designed to limit the spread of a
disease by reducing the opportunities for close contact between people. All personnel have the
responsibility to remind each other to stay 6 feet or more apart. Examples of Social Distancing
include:
o Reducing face-to-face exposure by using conference calls and video conferencing
• If an in -person meeting is absolutely required and cannot be rescheduled or
attended remotely, the meeting is limited to a maximum of 10 people while
maintaining Social Distancing of 6 feet or more.
o Avoiding unnecessary travel
• Do not congregate at lunch or breaks. Bringing your lunch is encouraged.
• No communal coolers or drink stations are allowed. Supervisors should confirm with employees
prior to beginning work for appropriate hydration and nutrition availability to employees for the
duration of the employee's shift and without direct contact with others on the job site.
• First line of communication should be by phone, rather than in -person.
■ Do not shake hands.
• Do not share iPads, tablets, pens, or clipboards for signing or any other purpose. Take pictures as
proof of attendance at meetings.
■ Sharing of Personal Protective Equipment (PPE) is strictly prohibited.
• Vehicles, equipment, and tools
a Limit the number of people riding in a vehicle together.
o Wipe down and disinfect vehicles after each trip.
a As much as possible, do not share tools or equipment. If a tool or piece of equipment must
be shared, the parts of it that are touched should be sanitized between uses.
Updated: 4/11/2020 Page 3

Workforce Safety Plan: COVID-19 NCDOT Encroachment ID#:
RETURN TO WORK
• The following criteria must be followed for an employee who is tested for Covid-19, or asked to
self -quarantine by health officials, or has contact with another employee with a positive test result
to return to work:
o at least a 14-day quarantine; OR
❑ release by a health care provider.
• In accordance with CDC guidance, the following criteria must be followed for an employee with a
positive test result to return to work:
o at least 14 days from positive test notification; AND
o at least 3 days (72 hours) have passed since recovery defined as resolution of fever without
the use of fever -reducing medications and improvement in respiratory symptoms (e.g.,
cough, shortness of breath); AND
❑ at least 7 days have passed since symptoms first appeared.
NCDOT may require certification of fitness to work from a health care provider.
ADDITIONAL RESOURCES
NCDOT and their partners should review the CDC and NCDHHS resources listed below for up-to-date
information on how to respond to COVID-19. Additional guidelines may be issued by state or federal
agencies that should be followed in addition to the guidelines included in this document.
• NCDHHS COVID-19 Resources:
❑ https://www.ncdhhs.gov/divisions/public-health/coronavirus-disease-2019-could-19-
res ponse-no rth-ca rol i na
• NCOSHR Communicable Disease Emergency Policy
o httos://oshr.nc.gov/policies-forms/workplace-wellness/communicable-disease-emergency
• OSHA Guidance on Preparing Workplaces for COVID-19
o https://www.osha.gov/Publications/OSHA399Q.pdf
• CDC COVID-19 Resources:
o https://www.cdc.gov/coronavirus/2O19-ncov/index.html
AGREEMENT
The encroaching party shall adhere to the requirements of this plan in order to continue work under their
approved encroachment agreement. Violations to this plan could result in the violating entity not being
allowed to continue work or all work ceasing as determined by the NCDOT District Engineer or Resident
Engineer.
PROJECT POINTS OF CONTACT
Updated: 4/11/2020 Page 4

-Lj- 6G6'i4
Workforce Safety Plan: COVID-19
Name:
86,
NCOOT
54'[-,(Jer5
Yorl
NCDOT Encroachment ! �3
Encroaching Party (Primary Contact)
Name: Aaron Long. PE
Phone #: 70q Phone #: ?Q q . 915. MI 6
Primary Contractor to Encroaching Party
(Point of Contact)
Name: Bran Vest
Phone #: 9 10. b59.335°
Updated: 4/11/2020 Page 5

COVID-19 Guidance for Employees on Encroachment Job sites within NCDOT Right of Way
CONTACT GROUP
What PROJECT SITE Personnel
Should Do
No exposure within 6' and longer than 10 minutes
Advise of POSITIVE test without identifying the
affected employee*
Site personnel without direct contact may
continue onsite work or follow their company
policy
Continue hygiene & disinfecting measures
Advise of POSITIVE test "'
Continue hygiene & disinfecting measures
Continue hygiene & disinfecting measures
Continue hygiene & disinfecting measures
NCDOT District Engineer/Resident Engineer notifies Encroaching Party's primary point of contact and Contractor Point of
Contact, CDC and, if Resident Engineer has oversight for the job site, FHWA any Consultant Firms working for NCDOT
Encroaching party representative notifies other Contractors, Sub -Contractors and Suppliers with exposed Employees
Encroaching party representative or Contractor point of contact notifies appropriate NCDOT District Engineer or Resident
Engineer and a!I other Contractors, Sub -Contractors and Suppliers with exposed Employees
NCDOT notifies CDC, and as appropriate, FHWA and any Consultant Firms working for NCDOT
What your CREW Should Do
Exposure within 6' and longer than 10 minutes
Advise of POSITIVE test without identifying
the affected employee*
Directly exposed crew self -quarantine for 14
days
Continue hygiene & disinfecting measures
Advise of POSITIVE test without identifying
the affected employee*
Crew may continue onsite work or follow
their company policy
Continue hygiene & disinfecting measures
Continue hygiene & disinfecting measures
Continue hygiene & disinfecting measures
What YOU Should Do
Notify your supervisor
Self -quarantine for 14 days
Self -quarantine for 14 days
You may continue onsite work or follow
your company policy
Continue hygiene & disinfecting measures
Continue hygiene & disinfecting measures
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Relationship to
Confirmed
POSITIVE Test
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SAFETY DATA SHEET
KLOZUR® ONE
SDS # : 7775-27-1-3
Revision date: 2017-01-31
Format: NA
Version 1
PeroxyChem
1. PRODUCT AND COMPANY IDENTIFICATION
Product Identifier
Product Name
Other means of identification
UN/ID no
KLOZUR® ONE
UN 1505
Recommended use of the chemical and restrictions on use
Recommended Use: In situ and ex situ chemical oxidation of contaminants and compounds of concern for
environmental remediation applications
Restrictions on Use No uses to be advised against were identified.
Manufacturer/Supplier
Emergency telephone numbers
Classification
PeroxyChem LLC
2005 Market Street
Suite 3200
Philadelphia, PA 19103
Phone: [phone] (General Information)
E-Mail: [e-mail]
For leak, fire, spill or accident emergencies, call:
1 800 / 424 9300 (CHEMTREC - U.S.A.)
1 703 / 527 3887 (CHEMTREC - Collect - All Other Countries)
2. HAZARDS IDENTIFICATION
OSHA Regulatory Status
This material is considered hazardous by the OSHA Hazard Communication Standard (29 CFR 1910.1200)
Acute toxicity - Oral
Category 4
Skin corrosion/irritation
Category 2
Serious eye damage/eye irritation
Category 2B
Respiratory sensitization
Category 1
Skin sensitization
Category 1
Specific target organ toxicity (single exposure)
Category 3
Oxidizing Solids
Category 3
GHS Label elements, including precautionary statements
EMERGENCY OVERVIEW
Page 1 / 9

KLOZUR® ONE
SDS # : 7775-27-1-3
Revision date: 2017-01-31
Version 1
Danger
Hazard Statements
H334 - May cause allergy or asthma symptoms or breathing difficulties if inhaled
H335 - May cause respiratory irritation
H319 - Causes serious eye irritation
H315 - Causes skin irritation
H317 - May cause an allergic skin reaction
H302 - Harmful if swallowed
H272 - May intensify fire; oxidizer
Precautionary Statements - Prevention
P261 - Avoid breathing dust.
P285 - In case of inadequate ventilation wear respiratory protection
P271 - Use only outdoors or in a well -ventilated area
P280 - Wear protective gloves/ protective clothing
P264 - Wash face, hands and any exposed skin thoroughly after handling
P210 - Keep away from heat/sparks/open flames/hot surfaces. - No smoking
P220 - Keep/Store away from clothing/combustible materials
P221 - Take any precaution to avoid mixing with combustibles
Precautionary Statements - Response
P305 + P351 + P338 - IF IN EYES: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to
do. Continue rinsing
P337 + P313 - If eye irritation persists: Get medical advice/ attention
P302 + P352 - IF ON SKIN: Wash with plenty of water.
P333 + P313 - If skin irritation or rash occurs: Get medical advice/ attention
P304 + P341 - IF INHALED: If breathing is difficult, remove to fresh air and keep at rest in a position comfortable for breathing
P342 + P311 - If experiencing respiratory symptoms: Call a POISON CENTER or doctor
P301 + P312 - IF SWALLOWED: Call a POISON CENTER or doctor if you feel unwell
P330 - Rinse mouth
P370 + P378 - In case of fire: Use water spray for extinction
Precautionary Statements - Storage
P403 + P233 - Store in a well -ventilated place. Keep container tightly closed
Hazards not otherwise classified (HNOC)
No hazards not otherwise classified were identified.
Other Information Risk of decomposition by heat or by contact with incompatible materials
Unknown acute toxicity
0% of the mixture consists of ingredient(s) of unknown toxicity
Page 2 / 9

KLOZUR® ONE
SDS # : 7775-27-1-3
Revision date: 2017-01-31
Version 1
3. COMPOSITION/INFORMATION ON INGREDIENTS
Chemical name
CAS -No
Weight %
Sodium Persulfate
7775-27-1
95
Potassium permanganate
7722-64-7
< 1
Trade secret
Proprietary
< 5
Occupational exposure limits, if available, are listed in section 8
4. FIRST AID MEASURES
General Advice
Eye Contact
Skin Contact
Inhalation
Ingestion
Most important symptoms and
effects, both acute and delayed
Indication of immediate medical
attention and special treatment
needed, if necessary
Remove from exposure, lie down. Show this material safety data sheet to the doctor in
attendance.
Rinse thoroughly with plenty of water for at least 15 minutes, lifting lower and upper eyelids
intermittently. Consult a physician.
Wash off immediately with soap and plenty of water while removing all contaminated
clothes and shoes. Get medical attention if irritation develops and persists.
Remove from exposure, lie down. If breathing is irregular or stopped, administer artificial
respiration. Call a physician immediately.
Do NOT induce vomiting. Call a physician or poison control center immediately. Rinse
mouth. Drink 1 or 2 glasses of water.
Itching; Redness; Coughing and/ or wheezing.
Treat symptomatically
5. FIRE -FIGHTING MEASURES
Suitable Extinguishing Media
Unsuitable extinguishing media
Specific Hazards Arising from the
Chemical
Explosion data
Sensitivity to Mechanical Impact
Sensitivity to Static Discharge
Protective equipment and
precautions for firefighters
Water. Cool containers with flooding quantities of water until well after fire is out.
Do not use carbon dioxide or other gas filled fire extinguishers; they will have little effect on
decomposing persulfate.
Decomposes under fire conditions to release oxygen that intensifies the fire.
Not sensitive.
Not sensitive.
As in any fire, wear self-contained breathing apparatus pressure -demand, MSHA/NIOSH
(approved or equivalent) and full protective gear.
6. ACCIDENTAL RELEASE MEASURES
Personal Precautions
Other
Environmental Precautions
Keep off any unprotected persons. Avoid contact with the skin and the eyes. Avoid
breathing dust. Wear personal protective equipment.
Never add other substances or combustible waste to product residues.
Prevent material from entering into soil, ditches, sewers, waterways, and/or groundwater.
See Section 12, Ecological Information for more detailed information.
Page 3 / 9

KLOZUR® ONE
Methods for Containment
Methods for cleaning up
SDS # : 7775-27-1-3
Revision date: 2017-01-31
Version 1
Vacuum, shovel or pump waste into a drum and label contents for disposal. Avoid dust
formation. Store in closed container.
Clean up spill area and treat as special waste. Dispose of waste as indicated in Section 13.
7. HANDLING AND STORAGE
Handling
Storage
Incompatible products
Control parameters
Exposure Guidelines
Wear personal protective equipment. Use only in area provided with appropriate exhaust
ventilation. Avoid dust formation. Handle product only in closed system or provide
appropriate exhaust ventilation at machinery. Avoid contact with skin and eyes. Avoid
breathing dust. Remove and wash contaminated clothing before re -use. Reference to other
sections.
Keep containers tightly closed in a dry, cool and well -ventilated place. Keep away from
heat. Do not store near combustible materials. Avoid contamination of opened product.
Keep away from food, drink and animal feedingstuffs. Avoid formation and deposition of
dust.
Acids, alkalis, halides (fluorides, chlorides, bromides), combustible materials, reducing
agents and organic compounds.
8. EXPOSURE CONTROLS/PERSONAL PROTECTION
Chemical name
ACGIH TLV
OSHA PEL
NIOSH
Mexico
Sodium Persulfate
7775-27-1
TWA: 0.1 mg/m3
-
-
-
Potassium permanganate
7722-64-7
TWA: 0.02 mg/m3
TWA: 0.1 mg/m3
-
-
-
Chemical name
British Columbia
Quebec
Ontario TWAEV
Alberta
Sodium Persulfate
7775-27-1
TWA: 0.1 mg/m3
-
TWA: 0.1 mg/m3
TWA: 0.1 mg/m3
Potassium permanganate
7722-64-7
TWA: 0.2 mg/m3
TWA: 0.2 mg/m3
TWA: 0.02 mg/m3
respirable
TWA: 0.1 mg/m3
inhalable
TWA: 0.2 mg/m3
Appropriate engineering controls
Engineering measures
Provide local exhaust or general ventilation adequate to maintain exposures below
permissable exposure limits.
Individual protection measures, such as personal protective equipment
Eye/Face Protection
Skin and Body Protection
Hand Protection
Respiratory Protection
Hygiene measures
Eye protection recommended. Chemical goggles consistent with EN 166 or equivalent.
Wear long-sleeved shirt, long pants, socks, and shoes.
Protective gloves: Neoprene gloves, Polyvinylchloride, Natural Rubber.
If exposure limits are exceeded or irritation is experienced, NIOSH/MSHA approved
respiratory protection should be worn: particulate filtering facepiece respirators.
Keep away from food, drink and animal feeding stuffs. Do not eat, drink or smoke when
using this product. Wash hands before breaks and after shifts. Keep work clothes separate,
remove contaminated clothing - launder after open handling of product.
Page 4 / 9

KLOZUR® ONE
General information
SDS # : 7775-27-1-3
Revision date: 2017-01-31
Version 1
Protective engineering solutions should be implemented and in use before personal
protective equipment is considered.
9. PHYSICAL AND CHEMICAL PROPERTIES
Information on basic physical and chemical properties
Appearance
Physical State
Color
Odor
Odor threshold
pH
Melting point/freezing point
Boiling Point/Range
Flash point
Evaporation Rate
Flammability (solid, gas)
Flammability Limit in Air
Upper flammability limit:
Lower flammability limit:
Vapor pressure
Vapor density
Density
Specific gravity
Water solubility
Solubility in other solvents
Partition coefficient
Autoignition temperature
Decomposition temperature
Viscosity, kinematic
Viscosity, dynamic
Explosive properties
Oxidizing properties
Molecular weight
VOC content (%)
Bulk density
Crystalline solid
Solid
Light tan
odorless
Not applicable
6.6 (1% solution)
180 °C (Decomposes)
Decomposes upon heating
Not flammable
No information available
Not flammable
Not applicable
No information available
No information available
6.07E-30 mm Hg at 25°C
No information available
2.59 g/cm' (crystal density)
No information available
575 g/I @ 25 °C
No information available
No information available (inorganic)
No evidence of combustion up to 600°C
81 °C (SADT)
No information available (Solid)
No information available
Not explosive
oxidizer
mixture
Not applicable
No information available
10. STABILITY AND REACTIVITY
Reactivity Oxidizer. Contact with other material may cause fire
Chemical Stability Stable under normal conditions.
Possibility of Hazardous Reactions None under normal processing.
Hazardous polymerization Hazardous polymerization does not occur.
Conditions to avoid Heat. Moisture.
Incompatible materials Acids, alkalis, halides (fluorides, chlorides, bromides), combustible materials, reducing
agents and organic compounds..
Hazardous Decomposition Products Oxygen which supports combustion.
11. TOXICOLOGICAL INFORMATION
Product Information
Unknown acute toxicity
LD50 Oral
0% of the mixture consists of ingredient(s) of unknown toxicity
Sodium Persulfate: 895 mg/kg (rat)
Page 5/9

KLOZUR® ONE
SDS # : 7775-27-1-3
Revision date: 2017-01-31
Version 1
LD50 Dermal Sodium Persulfate: > 10 g/kg
LC50 Inhalation Sodium Persulfate: >5.10 mg/L (4h) (rat)
Serious eye damage/eye irritation Irritating to eyes.
Skin corrosion/irritation Minimally irritating.
Sensitization Sodium Persulfate:. May cause sensitization by inhalation and skin contact.
Information on toxicological effects
Symptoms Symptoms of allergic reaction may include rash, itching, swelling and trouble breathing.
Delayed and immediate effects as well as chronic effects from short and long-term exposure
Irritation
corrosivity
Irritating to eyes, respiratory system and skin.
None.
Carcinogenicity Contains no ingredient listed as a carcinogen.
Mutagenicity Did not show mutagenic effects in animal experiments
Neurological effects Not neurotoxic
Reproductive toxicity This product is not recognized as reprotox by Research Agencies.
Developmental toxicity None known.
Teratogenicity Not teratogenic in animal studies.
STOT - single exposure May cause respiratory irritation.
STOT - repeated exposure Not classified.
Target organ effects
Aspiration hazard
Eyes, Lungs.
No information available.
12. ECOLOGICAL INFORMATION
Ecotoxicity
Ecotoxicity effects
Ecotoxicity effects of component substances
Sodium Persulfate (7775-27-1)
Active Ingredient(s)
Duration
Species
Value
Units
Sodium Persulfate
96 h LC50
Rainbow trout
163
mg/L
Sodium Persulfate
48 h LC50
Daphnia magna
133
mg/L
Sodium Persulfate
96 h LC50
Grass shrimp
519
mg/L
Sodium Persulfate
72 h EC50
Algae Selenastrum
capricornutum
116
mg/L
Chemical name
Toxicity to algae
Toxicity to fish
Toxicity to
Microorganisms
Toxicity to daphnia
and other aquatic
invertebrates
Potassium permanganate
72 h EC50: 0.43-0.80
96 h LC50: 2.97 - 3.11
48 h EC50: 0.06 mg/L
mg/L
mg/L (Cyprinus carpio)
(daphnia magna)
96 h LC50: 3.16 - 3.77
mg/L (Cyprinus carpio)
96 h LC50: = 2.3 mg/L
(Lepomis macrochirus)
flow -through
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KLOZUR® ONE
Bioaccumulation
Mobility
Other Adverse Effects
SDS # : 7775-27-1-3
Revision date: 2017-01-31
Version 1
96 h LC50: 1.8 - 5.6
mg/L (Lepomis
macrochirus) static
96 h LC50: = 2.7 mg/L
(Lepomis macrochirus)
96 h LC50: 1.08 - 1.38
mg/L (Oncorhynchus
mykiss)
96 h LC50: 0.769 -
1.27 mg/L
(Oncorhynchus mykiss)
static
96 h LC50: 3.3 - 3.93
mg/L (Carassius
auratus) static
Persistence and degradability Biodegradability does not pertain to inorganic substances. The organic components are
biodegradable and can be expected to contribute to BOD.
Does not bioaccumulate.
Dissociates into ions.
None known.
13. DISPOSAL CONSIDERATIONS
Waste disposal methods
Contaminated Packaging
This material, as supplied, is a hazardous waste according to federal regulations (40 CFR
261). It must undergo special treatment, e.g. at suitable disposal site, to comply with local
regulations.
Empty remaining contents. Dispose of in accordance with local regulations.
14. TRANSPORT INFORMATION
DOT
UN/ID no UN 1505
Proper Shipping Name Sodium Persulfate Mixture
Hazard class 5.1
Packing Group III
TDG
UN/ID no UN 1505
Proper Shipping Name Sodium Persulfate Mixture
Hazard class 5.1
Packing Group III
MEX
UN/ID no UN 1505
Proper Shipping Name Sodium Persulfate Mixture
Hazard class 5.1
Packing Group III
ICAO/IATA
UN/ID no UN 1505
Proper Shipping Name Sodium Persulfate Mixture
Hazard class 5.1
Packing Group III
IMDG/IMO
UN/ID no
Proper Shipping Name
UN 1505
Sodium Persulfate Mixture
Page 7 / 9

KLOZUR® ONE
Hazard class 5.1
Packing Group III
ADR/RID
UN/ID no
Proper Shipping Name
Hazard class
Packing Group
UN 1505
Sodium Persulfate Mixture
5.1
III
SDS # : 7775-27-1-3
Revision date: 2017-01-31
Version 1
15. REGULATORY INFORMATION
U.S. Federal Regulations
SARA 313
Section 313 of Title III of the Superfund Amendments and Reauthorization Act of 1986 (SARA). This product does not contain any
chemicals which are subject to the reporting requirements of the Act and Title 40 of the Code of Federal Regulations, Part 372
SARA 311/312 Hazard Categories
Acute health hazard
Chronic health hazard
Fire hazard
Sudden release of pressure hazard
Reactive Hazard
Yes
No
Yes
No
No
Clean Water Act
This product does not contain any substances regulated as pollutants pursuant to the Clean Water Act (40 CFR 122.21 and 40
CFR 122.42
Chemical name
CWA - Reportable
Quantities
CWA - Toxic Pollutants
CWA - Priority
Pollutants
CWA - Hazardous
Substances
Potassium permanganate
7722-64-7
100 Ib
X
CERCLA/EPCRA
This material, as supplied, does not contain any substances regulated as hazardous substances under the Comprehensive
Environmental Response Compensation and Liability Act (CERCLA) (40 CFR 302) or the Superfund Amendments and
Reauthorization Act (SARA) (40 CFR 355). There may be specific reporting requirements at the local, regional, or state level
pertaining to releases of this material
Chemical name
CERCLA Hazardous
Substances RQs
(40 CFR 302.4)
SARA Sec 304
Extremely Hazardous
Substance RQ
(40 CFR 355 Appendix A)
SARA Section 302
EHS Threshold Planning
Quantity
(40 CFR 355)
Potassium permanganate
7722-64-7
100 Ib
US State Regulations
U.S. State Right -to -Know Regulations
This product contains the following substances regulated under state Right -to -Know laws:
Chemical name
Massachusetts
New Jersey
Pennsylvania
Illinois
Rhode Island
Sodium Persulfate
X
Potassium permanganate
X
x
X
California Proposition 65
This product does not contain any Proposition 65 chemicals
International Inventories
Page 8 / 9

KLOZUR® ONE
SDS # : 7775-27-1-3
Revision date: 2017-01-31
Version 1
Component
TSCA
(United
States)
DSL
(Canada)
EINECS/EL
INCS
(Europe)
ENCS
(Japan)
China
(IECSC)
KECL
(Korea)
PICCS
(Philippines
)
AICS
(Australia)
NZIoC
(New
Zealand)
Sodium Persulfate
7775-27-1 (95 )
X
X
X
X
X
X
X
X
X
Potassium
permanganate
7722-64-7 (< 1 )
X
X
X
X
X
X
X
X
X
Trade secret
(<5)
X
X
X
X
Mexico
Mexico - Grade
Slight risk, Grade 1
16. OTHER INFORMATION
NFPA
Health Hazards 1
Flammability 0
Stability 1
Special Hazards OX
HMIS
Health Hazards 1
Flammability 0
Physical hazard 1
Special precautions J
NFPA/HMIS Ratings Legend
Revision date:
Revision note
Issuing Date:
Special Hazards: OX = Oxidizer
Protection=J (Safety goggles, gloves, apron, combination dust and vapor respirator)
2017-01-31
Initial Release
2017-05-01
Disclaimer
PeroxyChem believes that the information and recommendations contained herein (including data and statements) are
accurate as of the date hereof. NO WARRANTY OF FITNESS FOR ANY PARTICULAR PURPOSE, WARRANTY OF
MERCHANTABILITY OR ANY OTHER WARRANTY, EXPRESSED OR IMPLIED, IS MADE CONCERNING THE INFORMATION
PROVIDED HEREIN. The information provided herein relates only to the specified product designated and may not be
applicable where such product is used in combination with any other materials or in any process. Further, since the
conditions and methods of use are beyond the control of PeroxyChem, PeroxyChem expressly disclaims any and all
liability as to any results obtained or arising from any use of the products or reliance on such information.
Prepared By:
PeroxyChem
KLOZUR - Trademark of Peroxychem
© 2017 PeroxyChem. All Rights Reserved.
End of Safety Data Sheet
Page 9 / 9