WQ0029894_Final Permit_20230119 (3)

DocuSign Envelope ID: 74CBD4B0-99A7-4527-A320-CCEB5C3A639E
ROY COOPER
Governor
ELIZABETH S. BISERr,z.� a2
Secretary
RICHAM E. ROGERS, JR. NORTH CAROLINA
Director Environmental Quality
January 19, 2023
Stallings Oil Company
300 S. Weslyan Blvd, Suite 200
Rocky Mount, NC 27804
Subject: Monitoring Well Construction
Permit # WM0501533
Former Zip Mart #15
NC DOT center median of Sunset Ave.
Rocky Mount, NC 27804 — Nash County
Mr. Discoll:
In accordance with the application received on January 17, 2023, we are forwarding herewith
Monitoring Well Construction Permit No. WM0501533 effective January 19, 2022, issued for the
construction of a monitor well system (installation of two wells). Please be aware that some counties
have well construction programs, and you may be required to obtain a well construction permit
This Permit will be effective from the date of its issuance and shall be subject to the conditions and
limitations as specified therein. Please note the addition of stipulation #3 to the permit enclosed. If you have
any questions about this permit, please contact Tyler Clark at [phone].
Sincerely,
ocu Signed by:
E�D
ale t.SS0, f,
2916E6AB32144F...
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
Enclosure
cc: RRO Files/Laserfiche
D E Q ,fJ North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 1 1611 Mail Service Center I Raleigh, North Carolina 27699-1611
NORTH CAROLINA (J1(�.'�O'�.(�OQO
Department of Emlmnmenfal Duali�

DocuSign Envelope ID: 74CBD4B0-99A7-4527-A320-CCEB5C3A639E
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and other applicable Laws,
Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
Stallings Oil Company
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of two monitoring wells owned
by Stallings Oil Company, 300 S. Weslyan Blvd, Suite 200, Rocky Mount, NC 27804. The wells will be
located in the center median of Sunset Avenue, Rocky Mount, NC 27804, on property owned by the
NC Department of Transportation. This Permit is issued in accordance with the application received
on January 17, 2023, in conformity with specifications and supporting data, all of which are filed with
the Department of Environmental Quality and are considered integral parts of this Permit.
This Permit is for well construction only and does not waive any provision or requirement of any other applicable law or
regulation. Construction of any well under this Permit shall be in strict compliance with the North Carolina Well
Construction Regulations and Standards (15A NCAC 02C .0100), and other State and Local Laws and regulations pertaining
to well construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to an adjudicatory hearing upon
written request within 30 days of receipt of this Permit. The request must be in the form of a written petition conforming
to Chapter 150B of the North Carolina General Statutes and filed with the Office of Administrative Hearings, 6714 Mail
Service Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit is final and binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to other specified conditions,
limitations, or exceptions as follows:
1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these wells are being
installed as part of an investigation for contamination from an underground storage tank or dry cleaner
incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement issued by another
agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as part of the Permit
application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A NCAC 02C .0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of Water Quality's
Information Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with 15A NCAC 02C
.0113 and a well abandonment record (GW-30) shall be submitted to the Division of Water Quality's
Information Processing Unit within 30 days of the well abandonment.
7. If the well penetrates any water -bearing zone that contains contaminated waters, the upper three feet of the
well shall be grouted within one day after the casing is set or the well abandoned.
Permit issued the 19th of January 2023
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
DocuSigned by:
LPt9Q1APRARR91
ain t,SS& f. At.ain ut t) 6r
dd1
Scott Vinson, Regional Supervisor
Division of Water Resources
By Authority of the Environmental Management Commission
Permit No. WM0501533
D E Q�� North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 1 1611 Mail Service Center I Raleigh, North Carolina 27699-1611
NORTH CAROLINA 919.707.9000
Depanmem of Envlmnmenml Dual

DocuSign Envelope ID: 74CBD4B0-99A7-4527-A320-CCEB5C3A639E
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
PLEASE TYPE OR PRINT CLEARLY
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery wells.
1. Date: 1/16/2023
2. County: Nash
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring__
4. Applicant: Stallings Oil Company Telephone: [phone]
Applicant's Mailing Address: 300 S. Wesl an Blvd Suite 200 Rocky Mount NC 27804
Applicant's Email Address (if available): btolman(a)bmtco.net
5. Contact Person (if different than Applicant): Scott Driscoll Telephone: [phone] x2627
Contact Person's Mailing Address: Geological Resources, Inc., 113 W. Firetower Rd., Suite G, Winterville, NC 28590
Contact Person's Email Address (if available): sdriscoll@(Ieologicalresourcesinc.com
6. Property Owner (if different than Applicant): NC Department of Transportation Telephone: [phone]
Property Owner's Mailing Address: 1501 Mail Service Center, Raleigh, NC 27669-1501
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) State of North Carolina — 2400-2500 Block in Center Median of Sunset Ave
City Rocky Mount County Nash Zip Code 27804
8. Reason for Well(s): IAssessment .
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
9. Type of facility or site for which the well(s) is(are) needed: Former UST
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
Are there any current water quality permits or incidents associated with this facility or site? If so, list permit and/or incident no(s).
NCDEQ Incident No, 15091
Type of contaminants being monitored or recovered: Petroleum
(ex: organics, nutrients, heavy metals, etc.)
Are there any existing wells associated with the proposed well(s)? If yes, how many? 20
Existing Monitoring or Recovery Well Construction Permit No(s).:
Distance from proposed well(s) to nearest known waste or pollution source (in feet):
Are there any water supply wells located less than 500 feet from the proposed well(s)?
If yes, give distance(s):
No
15, Well Contractor: Justin Radford Certification No.: 3270
Well Contractor Address: 3502 Haves Road Monroe NC 28110
PROPOSED WELL CONSTRUCTION INFORMATION
As required by 15A NCAC 02C .0105(f)(7), attach a welt construction diagram of each well showing the following:
a. Borehole and well diameter e. Type of casing material and thickness
b. Estimated well depth f. Grout horizons
C. Screen intervals g. Well head completion details

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Cl. 5anaigravei pack intervals
Continued on Reverse
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
Number of wells to be constructed in unconsolidated
material: 2
Number of wells to be constructed in bedrock: 0
Total Number of wells to be constructed: 2
(add answers from 2 and 3)
How will the well(s) be secured? Locking/Manhole
Estimated beginning construction date: Jan 2023
Estimated construction completion date: Jan 2023
ADDITIONAL INFORMATION
As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:
a. All property boundaries, at least one of which is referenced to a minimum of two landmarks such as identified roads,
intersections, streams, or lakes within 500 feet of the proposed well or well system.
b. All existing wells, identified by type of use, within 500 feet of the proposed well or well system.
C. The proposed well or well system.
d. Any test borings within 500 feet of proposed well or well system.
e. All sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or fuel
storage areas, animal feedlots as defined in G.S. 143-215.1013(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Signature of Applicant or *Agent
s
Printed name of Applicant or Agent
f1 t e (- w 02 1:-
Title of Applicant or *Agent "
* If signing as Agent, attach authorization agreement stating
that you have the authority to act as the Agent.
If the property is owned by someone other than the Applicant, the property owner hereby consents to allow the Applicant to construct
well(s) as outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
RTE Attached
Signature of Property Owner (if different than Applicant)
Printed name of Property Owner (if different than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water Resources' Regional Office:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: (252)
t'
-w
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
'105
0

DocuSign Envelope ID: 74CBD4B0-99A7-4527-A320-CCEB5C3A639E
STATE OF NORTH CAROLINA
ROUTE US64 PROJECT Zipmart #15 COUNTY OF Nash
DEPARTMENT OF TRANSPORTATION
-AND-
ical Resources Inc
3502 Hayes Rd
Monroe, NC 28110
THIS AGREEMENT, made and entered into this the
RIGHT OF WAY ENCROACHMENT AGREEMENT
FOR NON -UTILITY ENCROACHMENTS ON
PRIMARY AND SECONDARY HIGHWAYS
day of 120 , by and between the Department
of Transportation, party of the first part; and Geological Resources Inc
party of the second part,
WITNESSETH
THAT WHEREAS, the party of the second part desires to encroach on the right of way of the public road designated as
Route(s) US64 (center median) , located 2412 Sunset Ave., Rocky Mount, Nash County, NC
with the construction and/or erection of: Two Type II monitoring wells. Wells are being constructed to dertermine the extent of ground water
contamination.
WHEREAS, it is to the material advantage of the party of the second part to effect this encroachment, and the
party of the first part in the exercise of authority conferred upon it by statute, is willing to permit the encroachment
within the limits of the right of way as indicated, subject to the conditions of this agreement;
NOW, THEREFORE, IT IS AGREED that the party of the first part hereby grants to the party of the second
part the right and privilege to make this encroachment as shown on attached plan sheet(s), specifications and
special provisions which are made a part hereof upon the following conditions, to wit:
That the said party of the second part binds and obligates himself to install and maintain the encroaching facility in such safe
and proper condition that it will not interfere with or endanger travel upon said highway, nor obstruct nor interfere with the proper
maintenance thereof, to reimburse the party of the first part for the cost incurred for any repairs or maintenance to its roadways
and structures necessary due to the installation and existence of the facilities of the party of the second part, and if at any time the
party of the first part shall require the removal of or changes in the location of the said facilities, that the said party of the second
part binds himself, his successors and assigns, to promptly remove or alter the said facilities, in order to conform to the said
requirement, without any cost to the party of the first part.
That the party of the second part agrees to provide during construction and any subsequent maintenance proper signs, signal
lights, flagmen and other warning devices for the protection of traffic in conformance with the latest Manual on Uniform Traffic
Control Devices for Streets and Highways and Amendments or Supplements thereto. Information as to the above rules and
regulations may be obtained from the Division Engineer of the party of the first part.
That the party of the second part hereby agrees to indemnify and save harmless the party of the first part from all damages
and claims for damage that may arise by reason of the installation and maintenance of this encroachment.
It is clearly understood by the party of the second part that the party of the first part will assume no responsibility for any
damage that may be caused to such facilities, within the highway rights of way limits, in carrying out its construction and
maintenance operations.
That the party of the second part agrees to restore all areas disturbed during installation and maintenance to the satisfaction of
the Division Engineer of the party of the first part. The party of the second part agrees to exercise every reasonable precaution
during construction and maintenance to prevent eroding of soil; silting or pollution of rivers, streams, lakes, reservoirs, other water
impoundments, ground surfaces or other property; or pollution of the air. There shall be compliance with applicable rules and
regulations of the North Carolina Division of Environmental Management, North Carolina Sedimentation Control Commission, and
with ordinances and regulations of various counties, municipalities and other official agencies relating to pollution prevention and
control. When any installation or maintenance operation disturbs the ground surface and existing ground cover, the party of the
second part agrees to remove and replace the sod or otherwise reestablish the grass cover to meet the satisfaction of the Division
Engineer of the party of the first part.
That the party of the second part agrees to assume the actual cost of any inspection of the work considered to be necessary
by the Division Engineer of the party of the first part.
That the party of the second part agrees to have available at the encroaching site, at all times during construction, a copy of
this agreement showing evidence of approval by the party of the first part. The party of the first part reserves the right to stop all
work unless evidence of approval can be shown.
Provided the work contained in this agreement is being performed on a completed highway open to traffic; the party of the
second part agrees to give written notice to the Division Engineer of the party of the first part when all work contained herein has
been completed. Unless specifically requested by the party of the first part, written notice of completion of work on highway
projects under construction will not be required.
That in the case of noncompliance with the terms of this agreement by the party of the second part, the party of the first part
reserves the right to stop all work until the facility has been brought into compliance or removed from the right of way at no cost to
the party of the first part.
That it is agreed by both parties that this agreement shall become void if actual construction of the work contemplated herein
is not begun within one (1) year from the date of authorization by the party of the first part unless written waiver is secured by the
party of the second part from the party of the first part.
FORM R/W 16.1A (Revised February 2021)

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R/W (161A) : Party of the Second Part certifies that this agreement is true and accurate copy of the form
R/W (161A) incorporating all revisions to date.
IN WITNESS WHERE -OF, each of the parties to this agreement has caused the same to be executed the day and
year first above writte i.
DEPARTMENT OF TRANSPORTATION
0 1) L cis : BY:
. x 4 `y a:
DIVISION ENGINEER
ATTEST ORWITTNESS°`��-:
Geological Resouces, Inc.
Secretary
INSTRUCTIONS
Geological Resouces, Inc.
Vice President, Account Management
Second Party
When the applicant is a corporation or a municipality, this agreement must have the corporate seal and
be attested by the corporation secretary or by the empowered city official, unless a waiver of corporate
seal and attestation by the secretary or by the empowered City official is on file in the Raleigh office of the
State Utilities Manager. In the space provided in this agreement for execution, the name of the
corporation or municipality shall be typed above the name, and title of all persons signing the agreement
should be typed directly below their signature.
When the applicant is not a corporation, then his signature must be witnessed by one person. The
address should be included in this agreement and the names of all persons signing the agreement
should be typed directly below their signature.
This agreement must be accompanied, in the form of an attachment, by plans or drawings showing the
following applicable information:
1. All roadways and ramps.
2. Right of way lines and where applicable, the control of access lines.
3. Location of the proposed encroachment.
4. Length and type of encroachment.
5. Location by highway survey station number. If station number cannot be obtained, location
should be shown by distance from some identifiable point, such as a bridge, road,
intersection, etc. (To assist in preparation of the encroachment plan, the Department's
roadway plans may be seen at the various Highway Division Offices, or at the Raleigh
office.)
6. Drainage structures or bridges if affected by encroachment.
7. Typical section indicating the pavement design and width, and the slopes, widths and
details for either a curb and gutter or a shoulder and ditch section, whichever is applicable.
8. Horizontal alignment indicating general curve data, where applicable.
9. Vertical alignment indicated by percent grade, P.I. station and vertical curve length, where
applicable.
10. Amount of material to be removed and/or placed on NCDOT right of way, if applicable.
11. Cross -sections of all grading operations, indicating slope ratio and reference by station
where applicable.
12. All pertinent drainage structures proposed. Include all hydraulic data, pipe sizes, structure
details and other related information.
13. Erosion and sediment control.
14. Any special provisions or specifications as to the performance of the work or the method of
construction that may be required by the Department must be shown on a separate sheet
attached to encroachment agreement provided that such information cannot be shown on
plans or drawings.
15. The Department's Division Engineer should be given notice by the applicant prior to actual
starting of installation included in this agreement.
16. Method of handling traffic during construction where applicable.
17. Scale of plans, north arrow, etc.

DocuSign Envelope ID: 74CBD4B0-99A7-4527-A320-CCEB5C3A639E
STATE OF NORTH CAROUNA
DEPARTMENT OF TRANSPORTATION
Roy Cooper
Governor
October 19, 2022
Geological Resources Inc.
3502 Hayes Rd
Monroe,NC 28110
SUBJECT: Encroachment Contract - Geological Resources Inc.
Route(s): US 64 ( Sunset Ave )
Encroachment Number: E042-064-22-00222
Nash County
Dear Sir:
J. Eric Boyette
Secretary
Attached for your files is a copy of right-of-way encroachment agreement R/W 16.1A that has been
properly executed. This contract covers the following:
Two (2) Type II monitoring wells. Wells are being constructed to determine the extent of ground
water contamination.
The Encroacher shall notes the District Engineer's Office [phone] prior to beginning work.
The Encroacher shall provide 24 hours notification for inspections.
This encroachment is approved subject to the standard and special provisions that are attached to
and made part of the encroachment contract.
KGB/BLL/rim
Attachments
cc:
Mr. B. L. Liverman, PE- District Engineer
Nash County Maintenance Engineer
Respectfully yours,
UocoSigned �y
For K. Bowen
L�'ABt=A31782784EF...
Bobby Liverman, PE
District Engineer
PO Box 3165 - Wilson, NC 27895-3165
Nash County Encroachment Letter PH: [phone] FAX: [phone]

DocuSign Envelope ID: 74CBD4B0-99A7-4527-A320-CCEB5C3A639E
Standard Provisions
1. Approval may be rescinded upon failure to follow any of the provisions in this permit and may be
considered a violation of the encroachment agreement.
2. The Encroaching party or their contractor shall provide the following notices prior to
construction activity within the NCDOT Right of Way:
a.Three (3) business days advance phone call at telephone [phone] or email to
[e-mail] to the District Engineer's office
b.If the construction falls within the limits of an NCDOT managed construction project,
five (5) business days advance phone call to the Resident Engineer, Ms. Kim Moore at
[phone] or email to [e-mail].
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 parry until the construction or maintenance meets the
satisfaction of the Division Engineer or their representative.
3. Prior to beginning work, it is the requirement of the Encroaching Party to contact the
appropriate Utility Companies involved and make arrangements to adjust or relocate any
utilities that conflict with the proposed work.
4. It shall be the responsibility of the encroaching parry 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 parry 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. 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.
7. 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 parry to verify the right of way.
8. Encroaching party shall be responsible for obtaining all necessary permanent and/or
temporary construction, drainage, utility and/or sight distance easements.
Nash County Encroachment Letter

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9. WORK ZONE TRAFFIC CONTROL QUALIFICATIONS AND TRAINING
PROGRAM
All personnel performing any activity inside the highway right of way are required to be
familiar with the NCDOT Maintenance / Utility Traffic Control Guidelines (MUTCG).
No specific training course or test is required for qualification in the Maintenance /Utility
Traffic Control Guidelines (MUTCG).
All flagging, spotting, or operating Automated Flagger Assist Devices (AFAD) inside the
highway right of way requires qualified and trained Work Zone Flaggers. Training for this
certification is provided by NCDOT approved training resources and by private entities
that have been pre -approved to train themselves.
All personnel involved with the installation of Work Zone Traffic Control devices inside
the highway right of way are required to be qualified and trained Work Zone Installers.
Training for this certification is provided by NCDOT approved training resources and by
private entities that have been pre -approved to train themselves.
All personnel in charge of overseeing work zone Temporary Traffic Control operations
and installations inside the highway right of way are required to be qualified and trained
Work Zone Supervisors. Training for this certification is provided by NCDOT approved
training resources and by private entities that have been pre -approved to train themselves.
For questions and/or additional information regarding this training program please refer to
https:Hconnect.ncdot.gov/projects/WZTC/Pages/Training.aspx or call the NCDOT Work
Zone Traffic Control Section [phone].
10. The party of the second part shall employ traffic control measures that are in accordance
with the prevailing federal, state, local, and NCDOT policies, standards, and procedures.
These policies, standards, and procedures include, but are not limited to the following:
a.Manual on Uniform Traffic Control Devices (MUTCD) — North Carolina has adopted
the MUTCD to provide basic principles and guidelines for traffic control device design,
application, installation, and maintenance. North Carolina uses the MUTCD as a
minimum requirement where higher supplemental standards specific to North Carolina are
not established. Use fundamental principles and best practices of MUTCD (Part 6,
Temporary Traffic Control).
b.NCDOT Maintenance / Utility Traffic Control Guidelines — This document enhances the
fundamental principles and best practices established in MUTCD Part 6, Temporary
Traffic Control, incorporating NCDOT-specific standards and details. It also covers
important safety knowledge for a wide range of work zone job responsibilities.
11. 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.
Nash County Encroachment Letter

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12. Two-way traffic shall be maintained at all times unless designated by the District
Engineer. Traffic shall not be rerouted or detoured without the prior written approval from
the District Engineer. No utility work will be allowed on state holidays from 7:00 PM the
night before through 9:00 AM the day prior to, following or during local events without
prior approval from the 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.
13. Work requiring lane or shoulder closures shall not be performed on both sides of the road
simultaneously within the same area.
14. Any work requiring equipment or personnel within 5 feet of the edge of any travel lane of
an undivided facility and within 10 feet of the edge of any travel lane of a divided facility
shall require a lane closure with appropriate tapers per current NCDOT Roadway Standard
Drawings or MANUAL ON UNIFORM TRAFFIC CONTROL DEVICES.
15. Any pavement markings that are damaged or obliterated shall be restored by the
encroaching party at no expense to NCDOT.
16. 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 252-
640-6427.
17. 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.
18. 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 I acre. The VCER-I form must be
PE sealed by a NC registered professional engineer who has verified that all appropriate
environmental permits (if applicable) have been obtained and all applicable environmental
regulations have been followed.
Nash County Encroachment Letter

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19. 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.
20. 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
21. 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.
22. The Encroaching Parry 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 parry immediately if any violations are cited.
23. 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.
24. 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.
25. 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.
26. Right of Way monuments disturbed during construction shall be referenced by a registered
Land Surveyor and reset after construction.
27. 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.
Nash County Encroachment Letter

DocuSign Envelope ID: 74CBD4B0-99A7-4527-A320-CCEB5C3A639E
28. All traffic control, asphalt mixes, structures, construction, workmanship and construction
methods, and materials shall be in compliance with the most -recent versions of the
following resources: ASTM Standards, Manual on Uniform Traffic Control Devices,
NCDOT Utilities Accommodations Manual, NCDOT Standard Specifications for Roads
and Structures, NCDOT Roadway Standard Drawings, NCDOT Asphalt Quality
Management System manual, and the approved plans.
29. It is the responsibility of the encroaching parry 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.
30. 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.
Special Provisions
1. 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.
2. Traffic control shall be coordinated with the District Engineer at telephone (252) 462-
2550, prior to construction.
3. 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.
4. Traffic shall be maintained at all times. All lanes of traffic are to be open during the hours
of 7:00 A.M. to 9:00 A.M. and from 4:00 P.M. to 6:00 P.M. Monday through Friday,
during any time of inclement weather, or as directed by the District Engineer. Any
violation of these hours will result in ceasing any further construction by the Encroaching
Party or their contractor.
5. No trees within NCDOT ROW shall be cut without authorization from the Division
Roadside Environmental Engineer. Mitigation is required and will be determined by the
Division Roadside Environmental Engineer's Office.
6. 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.
Nash County Encroachment Letter

DocuSign Envelope ID: 74CBD4B0-99A7-4527-A320-CCEB5C3A639E
7. 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.
8. 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.
9. Excavation material shall not be placed on pavement.
10. 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 Parry.
Nash County Encroachment Letter

DocuSign Envelope ID: 74CBD4B0-99A7-4527-A320-CCEB5C3A639E
STATE OF NORTH CAROLINA
ROUTE US64 PROJECT Zipmart #15 COUNTY OF Nash
DEPARTMENT OF TRANSPORTATION RIGHT OF WAY ENCROACHMENT AGREEMENT
FOR NON -UTILITY ENCROACHMENTS ON
-AND- PRIMARY AND SECONDARY HIGHWAYS
Geological Resources Inc
3502 Hayes Rd
Monroe, NC 28110
THIS AGREEMENT, made and entered into this the 19 th day of octobel-20 22 , by and between the Department
of Transportation, party of the first part; and Geological Resources Inc
party of the second part,
WITNESSETH
THAT WHEREAS, the party of the second part desires to encroach on the right of way of the public road designated as
Route(s) US64 (center median) , located 2412 Sunset Ave., Rocky Mount, Nash County, NC
with the construction and/or erection of: Two Type II monitoring wells. Wells are being constructed to dertermine the extent of ground water
contamination.
WHEREAS, it is to the material advantage of the party of the second part to effect this encroachment, and the
party of the first part in the exercise of authority conferred upon it by statute, is willing to permit the encroachment
within the limits of the right of way as indicated, subject to the conditions of this agreement;
NOW, THEREFORE, IT IS AGREED that the party of the first part hereby grants to the party of the second
part the right and privilege to make this encroachment as shown on attached plan sheet(s), specifications and
special provisions which are made a part hereof upon the following conditions, to wit:
That the said party of the second part binds and obligates himself to install and maintain the encroaching facility in such safe
and proper condition that it will not interfere with or endanger travel upon said highway, nor obstruct nor interfere with the proper
maintenance thereof, to reimburse the party of the first part for the cost incurred for any repairs or maintenance to its roadways
and structures necessary due to the installation and existence of the facilities of the party of the second part, and if at any time the
party of the first part shall require the removal of or changes in the location of the said facilities, that the said party of the second
part binds himself, his successors and assigns, to promptly remove or alter the said facilities, in order to conform to the said
requirement, without any cost to the party of the first part.
That the party of the second part agrees to provide during construction and any subsequent maintenance proper signs, signal
lights, flagmen and other warning devices for the protection of traffic in conformance with the latest Manual on Uniform Traffic
Control Devices for Streets and Hicihways and Amendments or Supplements thereto. Information as to the above rules and
regulations may be obtained from the Division Engineer of the party of the first part.
That the party of the second part hereby agrees to indemnify and save harmless the party of the first part from all damages
and claims for damage that may arise by reason of the installation and maintenance of this encroachment.
It is clearly understood by the party of the second part that the party of the first part will assume no responsibility for any
damage that may be caused to such facilities, within the highway rights of way limits, in carrying out its construction and
maintenance operations.
That the party of the second part agrees to restore all areas disturbed during installation and maintenance to the satisfaction of
the Division Engineer of the party of the first part. The party of the second part agrees to exercise every reasonable precaution
during construction and maintenance to prevent eroding of soil; silting or pollution of rivers, streams, lakes, reservoirs, other water
impoundments, ground surfaces or other property; or pollution of the air. There shall be compliance with applicable rules and
regulations of the North Carolina Division of Environmental Management, North Carolina Sedimentation Control Commission, and
with ordinances and regulations of various counties, municipalities and other official agencies relating to pollution prevention and
control. When any installation or maintenance operation disturbs the ground surface and existing ground cover, the party of the
second part agrees to remove and replace the sod or otherwise reestablish the grass cover to meet the satisfaction of the Division
Engineer of the party of the first part.
That the party of the second part agrees to assume the actual cost of any inspection of the work considered to be necessary
by the Division Engineer of the party of the first part.
That the party of the second part agrees to have available at the encroaching site, at all times during construction, a copy of
this agreement showing evidence of approval by the party of the first part. The party of the first part reserves the right to stop all
wnrk iinlass avirinnnn of annrnval can hP shnwn_

DocuSign Envelope ID: 74CBD4B0-99A7-4527-A320-CCEB5C3A639E
R/W (161A) : Party of the Second Part certifies that this agreement is true and accurate copy of the form
R1W (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 writte) -
=' DEPARTMENT OF TRANSPORTATION
DocmSignedby!
.. 0 - .: _Q BY: Ba y., For K . Bowen
LZ 18FlNGINEER
ATTEST OR'WITNESS.
Geological Resouces, Inc.
Secretary
INSTRUCTIONS
Geological Resouces, Inc.
Vice President. Account Management
Second Party
When the applicant is a corporation or a municipality, this agreement must have the corporate seal and
be attested by the corporation secretary or by the empowered city official, unless a waiver of corporate
seal and attestation by the secretary or by the empowered City official is on file in the Raleigh office of the
State Utilities Manager. In the space provided in this agreement for execution, the name of the
corporation or municipality shall be typed above the name, and title of all persons signing the agreement
should be typed directly below their signature.
When the applicant is not a corporation, then his signature must be witnessed by one person. The
address should be included in this agreement and the names of all persons signing the agreement
should be typed directly below their signature.
This agreement must be accompanied, in the form of an attachment, by plans or drawings showing the
following applicable information:
1. All roadways and ramps.
2. Right of way lines and where applicable, the control of access lines.
3. Location of the proposed encroachment.
4. Length and type of encroachment.
5. Location by highway survey station number. if station number cannot be obtained, location
should be shown by distance from some identifiable point, such as a bridge, road,
intersection, etc. (To assist in preparation of the encroachment plan, the Department's
roadway plans may be seen at the various Highway Division Offices, or at the Raleigh
office.)
6. Drainage structures or bridges if affected by encroachment.
7. Typical section indicating the pavement design and width, and the slopes, widths and
details for either a curb and gutter or a shoulder and ditch section, whichever is applicable.
8. Horizontal alignment indicating general curve data, where applicable.
9. Vertical alignment indicated by percent grade, P.I. station and vertical curve length, where
applicable.
10. Amount of material to be removed and/or placed on NCDOT right of way, if applicable.
11, Cross -sections of all grading operations, indicating slope ratio and reference by station
where applicable.
12. All pertinent drainage structures proposed. Include all hydraulic data, pipe sizes, structure
details and other related information.
13. Erosion and sediment control.
14. Any special provisions or specifications as to the performance of the work or the method of
construction that may be required by the Department must be shown on a separate sheet
attached to encroachment agreement provided that such information cannot be shown on
plans or drawings.

DocuSign Envelope ID: 74CBD4B0-99A7-4527-A320-CCEB5C3A639E
TYPE II MONITORING WELL
TYPICAL CONSTRUCTION DETAILS
CONCRETE PA
GROUND SURFACE
0'-
GROUT CEMENT
BEN TONI TE SEA
SAND FIL TER PACK
PROPOSED WELL DEPTH 15' BGS
6R
Geological Resources, Inc.
MANHOLE COVER
Traffic bearing; flush mounted; domestic steel
BLOCKING WELL CAP
.441
2 INCH DIAMETER
SCHEDULE 40 PVC CASING
a ° (PROPOSED CASING LENGTH
a OF 2 FEET)
a
TOP OF BENTONITE 2' BGS
TOP OF SAND PACK X BGS
0.010 INCH SLOTTED
2 INCH DIAMETER
SCHEDULE 40 PVC SCREEN
(PROPOSED SCREEN LENGTH
OF 10 FEET)
END CAP
Note:
1. This diagram is not to scale.

DocuSign Envelope ID: 74CBD4B0-99A7-4527-A320-CCEB5C3A639E
LEGEND
0 TYPE // MONITORING WELL
TYPE N MONITORING WELL
(4) RECOVERY WELL
— — PROPERTY LINE
1
1 STREAM BED
1 MW-14R
MW--B
0
1 MW-2
1 MW-14 (40
MW--10 0 ZIP MART #15
0 MW-13
0
1 � I I
W-2 I FORMER I
MW--21 MW-22 I STALLINGS I
a UST SYSTEM I
I I
BP STA T/ON 1
PROPERTY 1
I TA TTOO ' SHOP MW-3 MW0-25
0
DW-1
1 MW-20
1 0 MW015
*RW--3
I @)RW--S MWO 7
MW-18
MW--17 O
1 MW--9 0
1 0
RW-1
n MW 2
RW-4 MW-23---,
L"Wn
--190 MW-16R RW-6 LL J-L J
J
Proposed Well Location J W-16 M o4
GRASS & SIDEWALK
0
FORMER
CANOPY w/ FORMER
DISPENSER ISLANDS
MW-5
O
GRASS & SIDEWALK
SUNSET % VENUE -
Proposed Well Location
MW-12 was destroyed
120' M o'2
MEDIAN
a
rwI
1
SITE MAP
0 15 30 so
Zip Mort #15 2412 Sunset Avenue
6R ( IN FEET ) Rocky Mount, Nosh County, NC Incident # 15091
Geological Resources, Inc. 1 inch = 30 ft Date: 0JI18114 Drawn by. ECH I Figure: 2