WM0501590_Final Permit_20231019

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
Mr. Dari Amad
Moore's Citgo
106 Brockton Ridge Drive
Garner, NC 27529
Sent Via Email
NORTH CAROLINA
Environmental Quality
October 19, 2023
Subject: Monitoring Well Construction
Permit # WM0501590
Moore's Citgo
305 South Church Street
Kenly, NC 27542—Johnston County
Mr. Amed:
In accordance with the application received on October 19, 2023, we are forwarding herewith Monitoring
Well Construction Permit No. WM0501590 dated October 19, 2023, issued for the construction of a
monitoring well. Please be aware that some counties have well construction programs, and you may be
reauired to obtain a well construction aermit before installation.
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 Michael Hall at [phone] or via email at
[e-mail].
Sincerely,
DocuSigned by:
UAVU,SSu. -e,
82916E6AB32144F...
Vanessa E. Manuel, Assistant Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
Enclosure
-Permit
-Application Package
Ec: Rae Trajano Brown, Geological Resources, Inc.
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: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
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
Moore's Citgo
FOR THE CONSTRUCTION OF A MONITORING WELL owned by Moore's Citgo at mailing address 106
Brockton Ridge Drive, Garner, NC 27529. The wells will be located on the property owned by the North
Carolina Department of Transportation at 405 A South Church Street, Kenly, NC 27542. This Permit is
issued in accordance with the application received on October 19, 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.
ocuSigned by:
E�D
& f, �l.atn.ttit,(,2916E6AB32144F...
Vanessa E. Manuel, Assistant Regional Supervisor
Division of Water Resources
By Authority of the Environmental Management Commission
Permit Number: WM0501590
Permit Issued: October 19, 2023
D E Q �J 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
NORrH CAROLINA �/ 919.707.9000
oepanmem or environmental auaii

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
IYVRI rl IiNRVLII9N I.JCrNRI Mr- IY I yr CIYvIRVIJMENTAL 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.
Date: 10/19/23
2. County:
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Dari Amad Telephone:
252-452-1848
Applicant's Mailing Address: 106 Brockton Ridge Drive, Garner NC 27529
Applicant's Email Address (if available): dar ddari(a'�man.com
5. Contact Person (if different than Applicant): Rae Brown Telephone:
252-227-3005
Contact Person's Mailing Address: 113 West Firetower Road, Suite G, Winterville NC 28590
Contact Person's Email Address (if available): rtbCa�geologicalresourcesinc.com
6. Property Owner (if different than Applicant): NC DOT Telephone:
919-739-5300
Property Owner's Mailing Address: 67 Jr Rd Suite 700, Selma, NC 27576
Property Owner's Email Address (if available): jtwilkins2 a(�ncdot.gov
7. Property Physical Address (Including PIN Number) 405 A South Church Street (NC Pin 265720-92-0292)
City Kenly County Johnston
Zip Code 27542
8. Reason for Well(s): Suspected contamination
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
9. Type of facility or site for which the well(s) is(are) needed: UST
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
10. Are there any current water quality permits or incidents associated with this facility or site? If so, list permit and/or incident no(s).
Incident 7709 / 47395
11. Type of contaminants being monitored or recovered: petroleum
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 8
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0501567
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 40'
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Justin Radford Certification No.: 3270A
Well Contractor Address: 3502 Haves Road, Monroe NC 28110
PROPOSED WELL CONSTRUCTION INFORMATION
As required by 15A NCAC 02C .0105(f)(7), attach a well construction diagram of each well showing the following:
a. Borehole and well diameter e. Type of casing material and thickness
b. Estimated well depth f. Grout horizons
C. Screen intervals g. Well head completion details
d. Sand/gravel pack intervals

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29U sued on Reverse
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Locking
material: 1 Expansive well cap
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: Nov 2023
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: Nov 2023
(add answers from 2 and 3)
ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:
a. All property boundaries, at least one of which is referenced to a minimum of two landmarks such as identified roads,
intersections, streams, or lakes within 500 feet of the proposed well or well system.
b. All existing wells, identified by type of use, within 500 feet of the proposed well or well system.
G. The proposed well or well system.
d. Any test borings within 500 feet of proposed well or well system.
e. All sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or fuel
storage areas, animal feedlots as defined in G.S. 143-215.10B(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
nrrnr&;nra With 16A N( A( n7r.
kW JAwalu
Signature of Applicant or *Agent
Rae Troiano Brown
Printed name of Applicant or *Agent
Project Manager
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.
See attached DOT agreement NC DOT
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
Raleigh Regional Office
Swannanoa, NC 28778
3800 Barrett Drive
Wilmington Regional Office
Phone: [phone]
Raleigh, NC 27609
127 Cardinal Drive Extension
Fax: [phone]
Phone: [phone]
Wilmington, NC 28405
Fax: [phone]
Phone: [phone]
Fayetteville Regional Office
Fax: [phone]
225 Green Street, Suite 714
Washington Regional Office
Fayetteville, NC 28301-5094
943 Washington Square Mall
Winston-Salem Regional Office
Phone: [phone]
Washington, NC 27889
450 W. Hanes Mill Road
Fax: [phone]
Phone: [phone]
Suite 300
Fax: [phone]
Winston-Salem, NC 27105
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
GW-22M/R (Rev. 5-26-2022)

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
PROFESSIONAL SERVICES AGREEMENT
In Reference to Proposal # 23-536
I. SERVICES. Geological Resources, Inc. ("GRI") proposes to perform the services for the
undersigned client ("CLIENT") at the fees and costs set forth in the scope of services and cost proposal
attached hereto and incorporated herein by reference (the "Services"). GRI represents and warrants
that the Services will be performed in a manner consistent with customary industry standards. No other
representation, warranty, or guaranty, expressed or implied, is intended.
II. FEES. GRI reserves the right to revise its fee schedule subject to thirty (30) days written notice.
In the event GRI revises its fee schedule, CLIENT shall have fifteen (15) days from receipt of notice of the
revision to determine whether to terminate this Agreement. Any revision to the Services shall be
pursuant to a written change order agreed to in advance by CLIENT and made a part of this Agreement.
III. CONFIDENTIALITY. The Services are solely for the benefit of CLIENT. This Agreement shall not
be construed as creating any contractual relationship of any kind between GRI and any third party. The
information and materials provided by GRI to CLIENT in connection with the Services shall be utilized by
CLIENT only for the purposes contemplated by this Agreement, and shall not be provided by CLIENT to
third parties without the prior written consent of GRI, except that GRI agrees that information and
materials provided by GRI to CLIENT may, if required, be provided to and used by governmental
regulatory agencies, CLIENT's attorneys, and pursuant to any valid court order. GRI agrees that all
reports and other documents prepared for CLIENT pursuant to this Agreement are the property of
CLIENT. GRI also agrees that it will not disclose to any third party any documents, reports, laboratory
data or other information generated, created or produced for CLIENT pursuant to this Agreement unless
required by law, pursuant to a valid court order, or upon written instruction of CLIENT.
IV. CLIENT DISCLOSURES. CLIENT shall notify GRI of any known or suspected hazardous substances
or conditions on the property upon which the Services are to be performed which in anyway relate to or
affect the Services and GRI shall have the right to rely on the accuracy of such CLIENT -furnished
information. Thereafter, GRI shall take all reasonably necessary and appropriate measures to protect its
employees, agents and subcontractors against such possible hazards and to prevent adverse impacts to
the environment. The cost of such measures shall constitute a revision to the Services and shall be
managed in accordance with Section II of this Agreement.
V. RIGHT OF ENTRY. GRI is to have free access to the applicable properties at the times and on the
dates Services are scheduled. Delays to GRI are subject to waiting time charges to the extent such
delays are caused by CLIENT or its employees, contractors or agents. GRI shall take reasonable and
customary precautions to prevent damage to CLIENT's property. CLIENT understands that the discovery
of certain hazardous substances and conditions and/or the taking of preventive measures relative to
these substances and conditions may result in a reduction of the value of the property upon which the
substance or condition is found to exist or on which the preventative measures are taken. Accordingly,
CLIENT waives any claim against GRI and its subcontractors and agrees to defend, indemnify and hold
GRI and its subcontractors harmless from any claim based upon the diminished value of real property
allegedly arising from the discovery of a hazardous substance or condition or the taking of a preventive
measure, unless such claim is based upon GRI's gross negligence.
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DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
VI. INDEMNIFICATION. GRI will defend, indemnify and hold harmless CLIENT and its
representatives, agents, employees and successors and assigns from and against any and all claims,
suits, actions, losses, penalties, fines and damages of any nature whatsoever, including reasonable
attorney's fees, expert witness fees, consultant fees and court costs (collectively "Legal Claims and
Costs") arising or resulting from (1) GRI's breach of this Agreement; and/or (2) GRI's negligence or
intentional misconduct. In addition to the specific provisions set forth above, CLIENT will defend,
indemnify and hold harmless GRI and its representatives, agents, employees and successors and assigns
from and against any and all Legal Claims and Costs arising or resulting from (1) CLIENT's breach of this
Agreement; and/or (2) CLIENT's negligence or intentional misconduct, and (3) the existence of any
hazardous substance or condition at any site(s) where Services are performed, unless the negligent
conduct of GRI exacerbates and causes the spread of such hazardous substance(s) or the development
of such hazardous condition.
VII. PAYMENT TERMS CLIENT agrees to be responsible for all charges as set forth in the GRI
Proposal # 23-536. The work outlined will be payable by the CLIENT in the following manner:
A. For NCDEQ Trust Fund Non -Reimbursable Costs (as outlined in Proposal # 23-536), CLIENT is
responsible to pay those items in full thirty days from the date of invoice.
B. For NCDEQ Trust Fund Reimbursable Costs, GRI will submit a co -pay reimbursement package for
those costs to the North Carolina State Trust Fund Program. GRI will wait for payment from
CLIENT until the North Carolina State Trust Fund Program has reimbursed CLIENT these costs.
Therefore, upon receipt of the Trust Fund reimbursement check, CLIENT will endorse the check
and send it to GRI within 1 (one) business day of receiving the reimbursement. ** If the
payment has not been received within 90 days of the claim submittal, CLIENT must submit
payment to GRI immediately. Additionally, as GRI completes the reimbursement package for
NCDENR's payment, CLIENT is required to sign the appropriate documents as requested.
Vill. COMPLETE AGREEMENT. This Agreement, along with its attachments, including the GRI
Proposal # 23-536 incorporates all of the provisions and contemporaneous discussions, representations,
understandings, and agreements between the parties with respect to the subject matter of this
Agreement. The terms and conditions expressed in this Agreement shall not be altered except in
writing, signed by both parties.
IX. APPLICABLE LAW. This Agreement is governed by, and will be construed in accordance with
the laws of the state where such property is located.
Executed as of the latest date set forth below.
GEOLOGICAL RESOURCES, INC.
By:
Date: 08 22 2023
Dari Amed
(Moore's Ci y C)
f
By:
Date:
_1
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DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
DISCLAIMER
Johnston County assumes no legal responsibility for the information represented here.
y
Result 1
id: 03003005
Tag: 03003005
NCPin: 265720-82-6363
3�5 Mapsheet No: 265720
Owner Name 1: SHRI GANESHA INC
Owner Name 2:
Mail Address 1: 403 S CHURCH ST
Q40 Mail Address 2.
S� Mail Address 3: KENLY, NC 27542-0000
rt'� Site Address 1: 405 A S CHURCH ST
Site Address 2: KENLY, NC 27542-
G Book: 03853
4 a 7 Page: 0039
G, " 4 Market Value: 430690
SSW Assessed Acreage: 1.700
Calc. Acreage: 1.670
Sales Price: 407500
1
ti _ ,•' Sale Date: 2010-06-02
4L '\ 3
Proposed well location \
5
306-113
306-C \
4. �\
306-113
Scale: 1:629 - 1 in. = 52.4 feet
Johnston County GIS
(The scale is only accurate when printed landscape on a 8 1/2 x 11 size sheet with no page scaling.) October 5, 2023

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
1-o'-
o�
o�
S GNURCH 51
1'.500-FOOT RADIUS
•
265720-82-9003
LEGEND
---- Ditch
Street Centerlines
— — — Hydrology
Adjacent Parcels
Johnston County NC parcels_2020
F0 150 300
L Fe
l I I I
_1 inch = 300 feet
N COLLEGE AVE
FIGURE 3: SITE VICINITY MAP
MOORE'S CITGO
j o2 305 SOUTH CHURCH STREET
KENLY, JOHNSTON COUNTY
NORTH CAROLINA
INCIDENT NO. 7709 / 47395
GRI NO. 5285
PREPARED BY:
GEOLOGICAL RESOURCES, INC.
SEPTEMBER 1 2022
0 500-FOOT RADIUS
o �\1,000-FOOT RADIUS Geological Resources. Inc_

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
TYPE 11 MONITORING WELL
TYPICAL CONSTRUCTION DETAILS
CONCRETE P
GROUND SURFACE
0,—
GROUT CEMENT
Sf N TONI Tf - SEAL
L
MANHOLE CO Vf R
Traffic bearing; flush mounted; domestic steel
,,—LOCKING WELL CAP
01
2 INCH DIAMETER
SCHEDULE 40 PVC CASING
(PROPOSED CASING LENGTH
OF 2 FEET
a.
7L� TOP Of SEN TONI TE 2'865-
0.010 INCH SLOTTED
2 INCH DIAMETER
SCREEN SCHEDULE 40 PVC SCR
(PROPOSED SCREEN LENGTH
OF 10 fff-T SAND f -1L TER PACK
PROPOSED WELL DEPTH 15'BGS END CAP
Moore's Citgo
Kenly NC Note:
1. This diagram is not to scale.
GRI 5285
Geological Resources, Inc.

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
s,w- STATE,y�v
PJ
rya Mv�'�
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
Roy COOPER ERIC BOYETTE
GOVERNOR October 12, 2023 SECRETARY
Rae Brown
Geological Resources, Inc.
3502 Hayes Rd
Monroe, NC 28110
SUBJECT: Encroachment Contract - Geological Resources, Inc.
W Goldsboro St Monitoring Well
Route(s): SR 2167
Encroachment Number: E043-051-23-00431
Johnston County
Dear Mr. Brown:
Attached for your files is a copy of the right-of-way encroachment agreement R/W 16.1 that has been
properly executed. This contract covers the following:
Installation of I monitoring well.
This encroachment is approved subject to the standard and special provisions that are attached to
and made part of the encroachment contract.
Sincerely,
Jeffrey Wilkins, Assistant District Engineer
FOR Keith Eason, PE, Division Engineer
DKE/jtw
Attachments
ecc: Jennifer K. Collins - District Engineer
67 Jr Rd Suite 700
Selma, NC 27576
PH: [phone]
Website: www.ncdot.gov

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
Special Provisions
1. The Encroaching party or their contractor shall provide a three (3) business days
advance notices prior to construction activity within the NCDOT Right of Way to the
District Engineer's Office by phone call at telephone [phone]. The Encroaching
party or their contractor shall also have a copy of this Approval Package (cover letter
and provisions) on site at all times during construction.
Failure to provide Approval Package when asked or 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.
2. 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.
3. All maintenance associated with the utility and/or sidewalk will be the responsibility of the 2nd
or 3rd party (If applicable) and not NCDOT.
4. Backfill material placed around utility lines, curb and gutter, manholes and/or drainage
structures in NCDOT R/W outside travel lanes shall be placed at a maximum of 6 inch loose
layers and each layer thoroughly compacted, obtaining a minimum of 98% density in
Accordance with AASHTO T99 as modified by NCDOT. If this installation involves
construction within any roadway travel area the final subgrade layer shall obtain 100% density.
for sll material to a depth of 8 inches below the finished surface of the subgrade. NCDOT
reserves the right to require density testing on backfill placed around any structure or utility
with in NCDOT Right of Way. Approval, or recommendations for compliance, will be
provided upon receipt and review of the report. 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.
5. Excavated areas adjacent to pavement having more than a 2 inch drop shall be made safe with
a 6:1 or flatter slope and shall be designated by appropriate delineation during periods of
construction inactivity including, but not limited to, night and weekend hours.
67 Jr Rd Suite 700
Selma, NC 27576
PH: [phone]
Special Provisions Website: www.ncdot.gov Page 2 of 4

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
6. A minimum of Three (3) feet clearance is required for trenched utility installations beneath or
near drainage pipes, headwalls, and a minimum of two (2) foot clearance below the flowline of
streams. All lines shall be placed around the end or under all existing storm drains. There
SHALL be no lines placed over the top of any existing storm drains.
7. At points where the utility is placed under existing storm drainage, the trench will be backfilled
with excavatable flowable fill up to the outside diameter of the existing pipe.
8. In no circumstance should any installed utility have less than minimum depth of 2 feet below
the roadway ditch grade, 3 feet below roadway travel surface, or 3 feet below natural ground in
a fill section. At no time should all utilities be installed that conflict with any roadway ditch.
All utitlies should be installed within 5 feet of the ROW line, and at least 5 feet from the edge
of pavement. All utility crossings under any NCDOT road including service taps/lines shall be
installed by a boring method.
9. All utility access points, such as manholes, vaults, handholes, splice boxes and junction boxes
shall be located as close to the right of way line as possible and shall not be placed in the ditch
line, 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.
10. Precast concrete manholes or structures of any type shall be preapproved by NCDOT for use
within highway Rights of Way and shall be installed flush with natural ground. Manhole rings
and covers, valves, and storm drainage grates and frames shall be traffic bearing types
approved by NCDOT for use within highway Rights of Way.
11. 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. After installation
is complete, markers should be placed noting the line to prevent risk of accidental damage for
all fiber installations.
12. Hot box (aka ASSE 1060) or Safe-T-Cover type enclosures covering utility main pipe joints,
backflow preventers, 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.
13. Open cuts will not be allowed for any utility installation, repair, or service tap without written
approval from District Engineer. Transverse open cuts will only be considered on select
secondary roads with an ADT of less than 1,000 VPD.
67 Jr Rd Suite 700
Selma, NC 27576
PH: [phone]
Special Provisions Website: www.ncdot.gov Page 3 of 4

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
14. 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.
15. 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. Well cap shall be flush mounted with the ground/pavement surface in
areas within the clear recovery area and the routine mowing boundaries, with the frame and
cover designed for HS 20 loading. Any contaminated soils encountered in construction as
spoil from the well installation shall be removed from the Right of Way prior to completion of
the wells. After the monitoring well has served its intended purpose, the encroaching party
shall fill the well(s) in a manner approved by the Division of Environmental Management.
Any above ground obstructions shall also be removed from the Right of Way.
67 Jr Rd Suite 700
Selma, NC 27576
PH: [phone]
Special Provisions Website: www.ncdot.gov Page 4 of 4

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
Standard Provisions
Pre -Construction
Contact Offices & Outside Agency issues/contacts/info
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 a three (3) business days
advance notices prior to construction activity within the NCDOT Right of Way:
a. For all work inside Johnston County contact the Johnston County
Maintenance Department by phone call at telephone [phone].
b. For all work inside Wayne County contact the Wayne County Maintenance
Department by phone call at telephone [phone].
Failure to provide these notifications prior to beginning construction is subject to the
District 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 District Engineer or their representative.
3. NCDOT reserves the right to further limit, restrict, or suspend operations within the Right of
Way if, in the opinion of NCDOT, safety or traffic conditions warrant such action.
4. 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.
5. 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.
6. The encroaching party shall notify the appropriate municipal office prior to beginning any
work within the municipality's limits of jurisdiction.
7. NCDOT approval of this Encroachment Agreement covers only the area with in NCDOT
R/W and does not grant permission to work in any RAILROAD RIGHT OF WAYS, Wet
Land, Sensitive Environmental Areas, Private Property Etc. Permits and permission must be
obtained from the appropriate authorities.
8. 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.

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
9. The encroacher shall furnish verification signed by a Professional Engineer certifying this
utility was installed as shown on the final approved construction plan. A Contractor
Certification Memo is attached to the encroaching parry's contract and shall be signed,
sealed, and returned to the District Engineer's office upon completion.
10. The encroaching parry SHALL contact the Division's Bridge Maintenance Department at
[phone] before excavating around any bridge, culvert, or cross line.
Legal & Right -of -Way Issues
11. All COST, LIABILITY and MAINTENANCE of the installation SHALL be the
responsibility of the encroaching party.
12. 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 District Engineer's office or
their representative prior to construction or during construction, if an issue arises during
construction to warrant changes.
13. 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.
14. 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.)
15. Encroaching party shall be responsible for obtaining all necessary permanent and/or
temporary construction, drainage, utility and/or sight distance easements.
16. 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.
17. No commercial advertising shall be allowed within NCDOT Right of Way.
18. The encroaching party shall obtain proper approval from all affected pole owners prior to
attachment to any pole.
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DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
Work Zone Traffic
19. Traffic control shall be coordinated with the District Engineer or the Division Traffic
Engineer at telephone [phone], prior to construction.
20. 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].
21. 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.
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DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
22. The traveling public shall be warned of construction 48 hours before start and during any
work within the NCDOT ROW with complete and proper signing and traffic control devices
in accordance with the current NCDOT Standard Specifications of Roads and Structures and
NCDOT Roadway Standard Drawings. No work shall be performed in the Right of Way
unless this requirement is satisfied. NCDOT reserves the right to require a written traffic
control plan for encroachment operations.
23. 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.
24. Traffic shall be maintained at all times in both directions. 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.
25. 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.
26. If this installation requires traffic stoppage written approval must be received from the
District Engineer before work should take place. Appropriate law enforcement shall be
available on site to direct traffic.
27. 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.
28. Work requiring lane or shoulder closures shall not be performed on both sides of the road
simultaneously within the same area. Any traffic control including lane closure or detour
shall be the responsibility of the encroaching party notifying the DOT of closure or detour
one week prior to closure.
29. 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. Work inside the
median of a divided highway will require lane closures on both sides of the roadway.
30. Any pavement markings or reflector that are damaged or obliterated shall be restored by the
encroaching party at no expense to NCDOT. The encroaching party SHALL repaint all
existing lines through the construction area if damage occurs.
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DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
31. 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, if it cannot be maintained safely and up to
standards within the Utility Work Zone. 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
hqps://www.youtube.com/watch?v=AOuYa5lW3dg&feature=youtu.be
Roadside Environmental
32. 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 [phone].
33. 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.
34. 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 all appropriate
environmental permits (if applicable) have been obtained and all applicable environmental
regulations have been followed.
35. 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 attached seeding instruction. 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.
36. 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 C/A 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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DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
37. Prior to installation, the Encroaching Party shall contact the County Maintenance Engineer's
office 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.
38. 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.
39. The contractor shall not begin the construction until after the traffic control and erosion
control devices have been installed to the satisfaction of the District Engineer or their agent.
40. 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.
Upcoming Projects
41. Should the installation of the entirety or any portion of the utility be deemed, by the
Department or delegated authority for project representation thereof, be in conflict with
future project construction or future utility relocations in the area, FOR ANY REASON, the
Encroacher/Utility Owner will need to perform necessary relocations within a period
not to exceed 30 calendar days and entirely at the expense of the Encroacher/Utility
Owner.
Construction
General
42. All materials and construction shall be in accordance with NCDOT standards and
specifications, including but not limited to, the current NCDOT Standard Specifications of
Roads and Structures, NCDOT Roadway Standard Drawings, and NCDOT Policies, &
Procedures for Accommodating Utilities on Highway Rights of Way.
43. An executed copy of the encroachment agreement, provisions and approved plans shall
be present at the construction site at all times. NCDOT reserves the right to stop all
work unless evidence of approval can be shown. 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.
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DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
44. All drainage pipe shall be installed on a straight uniform grade. All pipe protruding inside
drainage structures shall be cut off and properly grouted, leaving box with a smooth inside
finish.
45. 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.
46. All disturbed or damaged areas are to be fully restored to current NCDOT minimum roadway
standards or as directed by the District Engineer or their representative. Disturbed areas
within NCDOT Right -of -Way include, but not limited to, any excavation areas, pavement
removal, drainage, curb/gutter or other features.
47. The encroaching party shall notify the District 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
District Engineer or their representative.
48. 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.
49. Guardrail removed or damaged during construction shall be replaced or repaired to its
original condition, meeting current NCDOT standards or as directed by the District Engineer
or their representative.
50. Right of Way monuments disturbed during construction shall be referenced by a registered
Land Surveyor and reset after construction.
51. All Traffic signs moved during construction shall be reinstalled as soon as possible to the
satisfaction of the Division Traffic Engineer or their representative.
52. All driveways disturbed during construction shall be returned to a state comparable with the
condition of the driveways prior to construction.
53. 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.
54. 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.
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DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
Engineering
55. 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: ASTMStandards, 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.
56. Prior approval for any blasting must be obtained from the District Engineer or their
representative.
57. All wiring and related electrical work shall conform to the latest edition of the National
Electrical Safety Code.
58. Curb cuts and ramps for handicapped persons shall be constructed in accordance with the
current NCDOT "Standard for Wheelchair Ramp Curb Cuts" and the Americans with
Disabilities Act (ADA) Accessibility Guidelines for Buildings and Facilities.
Excavation
59. Excavation material shall not be placed on pavement at any time.
60. 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.
61. All utilities 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 should. 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 this 1:1 slope is not recommended 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.
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DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
Open Travel
Lane 5 ft Existing Groun
min Line
Theoretical Edge of
2:1 (H:V) V Pavement Bottom of
Slope H _Excavation
Temporary shoring shall be designed and constructed in accordance with current NCDOT
Standard Temporary Shoring provisions (refer to
https:Hconnect.ncdot. gov/resources/Specifications/Pages/2018-Specifications-and-
Special-Provisions.aspx and see SPI I 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 District 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. All 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 District 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 times. 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.
62. Excavated areas adjacent to pavement having more than a 2 inch drop shall be made safe
with a 6:1 or flatter slope and shall be designated by appropriate delineation during periods
of construction inactivity including, but not limited to, night and weekend hours.
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DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
63. In no circumstance should any installed utility have less than minimum depth of 2 feet below
the roadway ditch grade, 3 feet below roadway travel surface, or 3 feet below natural ground
in a fill section. At no time should all utilities be installed that conflict with any roadway
ditch. All utilities should be installed within 5 feet of the ROW line.
Pavement Detail and Repair
64. All utility crossings under any NCDOT road including service taps/lines shall be installed by
a boring method. Open cuts will not be allowed for any utility installation, repair, or service
tap without written approval from District Engineer.
65. 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
66. The Encroaching party shall notify the District Engineer's office in writing 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, curb/gutter, or other highway design features.
67. At the discretion of the District Engineer, a final inspection report may be provided to the
encroaching party upon satisfactory completion of the work.
68. A written acknowledgement of the completed work by the District Engineer's office begins
the one-year warranty period associated with any required performance bond.
69. 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.
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DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
North Carolina Department of Transportation
Subdivision Road Construct, Driveway Access, and Encroachment Installation
Contractor Certification Memo
(Date)
(District Engineer Name & Address)
RE: CONSTRUCTION CERTIFICATION
County:
Driveway Permit #:
and/or Subdivision I.D. #:
and/or Encroachment #:
Recording Information (if applicable)
Route(s) and/or Street(s):
Project Name/Phase/Description:
I, , have reviewed the construction withinthe right-of-way
and/or easements required under subject project(s) for the above development and in
accordance with the design drawings approved by the North Carolina Department of
Transportation (NCDOT) on the following dates:
Driveway Permit #:
and/or Subdivision I.D. #:
and/or Encroachment #:
Date:
Date:
Date:
Construction reviewed includes the items listed on the reverse side of this page. My
inspection and attached testing report(s) and/or supporting documentation indicate the
construction within the right-of-way and/or easements have been constructed in
accordance with the standards established by current NCDOT Standard Specifications for
Roads and Structures, and with the approved plans.
Name:
NCPE#:
Signature:
EAL
Received by NCDOT:
Rev. Div. 4 - Dist. 3

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
North Carolina Department of Transportation
Subdivision Road Construct, Driveway Access, and Encroachment Installation
Contractor Certification Memo

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
STABILIZATION REQUIREMENTS:
Stabilization for this project shall comply with the time frame guidelines as specified by the
NCG-010000 general construction permit effective August 3, 2011 issued by the North Carolina
Department of Environment and Natural Resources Division of Water Quality. Temporary or
permanent ground cover stabilization shall occur within 7 calendar days from the last land -
disturbing activity, with the following exceptions in which temporary or permanent ground cover
shall be provided in 14 calendar days from the last land -disturbing activity:
• Slopes between 2:1 and 3:1, with a slope length of 10 ft. or less
• Slopes 3:1 or flatter, with a slope of length of 50 ft. or less
• Slopes 4:1 or flatter
The stabilization timeframe for High Quality Water (HQW) Zones shall be 7 calendar days with
no exceptions for slope grades or lengths. High Quality Water Zones (HQW) Zones are defined
by North Carolina Administrative Code 15A NCAC 04A.0105 (25). Temporary and permanent
ground cover stabilization shall be achieved in accordance with the provisions in this contract
and as directed.
SEEDING AND MULCHING: (East)
The kinds of seed and fertilizer, and the rates of application of seed, fertilizer, and limestone,
shall be as stated below. During periods of overlapping dates, the kind of seed to be used shall
be determined. All rates are in pounds per acre.
All Roadway Areas
March 1 - August 31
50#
Tall Fescue
10#
Centipede
25#
Bermudagrass (hulled)
500#
Fertilizer
4000#
Limestone
March 1— August 31
September 1- February 28
50#
Tall Fescue
10#
Centipede
35#
Bermudagrass (unhulled)
500#
Fertilizer
4000#
Limestone
Waste and Borrow Locations
75#
Tall Fescue
25#
Bermudagrass (hulled)
500#
Fertilizer
4000#
Limestone
September 1 - February 28
75#
Tall Fescue
35#
Bermudagrass (unhulled)
500#
Fertilizer
4000#
Limestone
Note: 50# of Bahiagrass may be substituted for either Centipede or Bennudagrass only upon
Engineer's request.
Approved Tall Fescue Cultivars

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
06 Dust
2nd Millennium
3rd Millennium
Apache III
Avenger
Barlexas
Barlexas II
Bar Fa
Barrera
Barrington
Barrobusto
Barvado
Biltmore
Bingo
Bizem
Blackwatch
Blade Runner II
Bonsai
Braveheart
Bravo
Bullseye
Cannavaro
Catalyst
Cayenne
Cessane Rz
Chipper
Cochise IV
Constitution
Corgi
Corona
Coyote
Darlington
Davinci
Desire
Dominion
Dynamic
Dynasty
Endeavor
Escalade
Essential
Evergreen 2
Falcon IV
Falcon NG
Falcon V
Faith
Fat Cat
Festnova
Fidelity
Finelawn Elite
Finelawn Xpress
Finesse II
Firebird
Firecracker LS
Firenza
Five Point
Focus
Forte
Garrison
Gazelle II
Gold Medallion
Grande 3
Greenbrooks
Greenkeeper
Gremlin
Greystone
Guardian 21
Guardian 41
Hemi
Honky Tonk
Hot Rod
Hunter
Inferno
Innovator
Integrity
Jaguar 3
Jamboree
Justice
Kalahari
Kentucky 31
Kitty Hawk 2000
Legitimate
Lexington
LSD
Magellan
Matador
Millennium SRP
Monet
Mustang 4
Ninj a 2
Ol' Glory
Olympic Gold
Padre
Patagonia
Pedigree
Picasso
Piedmont
Plantation
Proseeds 5301
Prospect
Pure Gold
Quest
Raptor II
Rebel Exeda
Rebel Sentry
Rebel IV
Regiment II
Regenerate
Rendition
Rhambler 2 SRP
Rembrandt
Reunion
Riverside
RNP
Rocket
Scorpion
Serengeti
Shelby
Sheridan
Signia
Silver Hawk
Sliverstar
Shenandoah Elite
Sidewinder
Skyline
Solara
Southern Choice II
Speedway
Spyder LS
Sunset Gold
Taccoa
Tanzania
Trio
Tahoe II
Talladega
Tarheel
Terrano
Titan ltd
Titanium LS
Tracer
Traverse SRP
Tulsa Time
Turbo
Turbo RZ
Tuxedo RZ
Ultimate
Venture
Umbrella
Van Gogh
Watchdog
Wolfpack II
Xtremegreen
*Note: Kentucky 31 will no longer be an approved NCDOT Tall Fescue Cultivar after
December 31, 2015.
On cut and fill slopes 2:1 or steeper Centipede shall be applied at the rate of 5 pounds per acre
and add 20# of Sericea Lespedeza from January I - December 31.

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
Fertilizer shall be 10-20-20 analysis. A different analysis of fertilizer may be used provided the
1-2-2 ratio is maintained and the rate of application adjusted to provide the same amount of plant
food as a 10-20-20 analysis and as directed.
TEMPORARY SEEDING:
Fertilizer shall be the same analysis as specified for Seeding and Mulching and applied at the rate
of 400 pounds and seeded at the rate of 50 pounds per acre. Sweet Sudan Grass, German Millet
or Browntop Millet shall be used in summer months and Rye Grain during the remainder of the
year. The Engineer will determine the exact dates for using each kind of seed.
FERTILIZER TOPDRESSING:
Fertilizer used for topdressing on all roadway areas except slopes 2:1 and steeper shall be 10-20-
20 grade and shall be applied at the rate of 500 pounds per acre. A different analysis of fertilizer
may be used provided the 1-2-2 ratio is maintained and the rate of application adjusted to provide
the same amount of plant food as 10-20-20 analysis and as directed.
Fertilizer used for topdressing on slopes 2:1 and steeper and waste and borrow areas shall be 16-
8-8 grade and shall be applied at the rate of 500 pounds per acre. A different analysis of
fertilizer may be used provided the 2-1-1 ratio is maintained and the rate of application adjusted
to provide the same amount of plant food as 16-8-8 analysis and as directed.
SUPPLEMENTAL SEEDING:
The kinds of seed and proportions shall be the same as specified for Seeding and Mulching, with
the exception that no centipede seed will be used in the seed mix for supplemental seeding. The
rate of application for supplemental seeding may vary from 25# to 75# per acre. The actual rate
per acre will be determined prior to the time of topdressing and the Contractor will be notified in
writing of the rate per acre, total quantity needed, and areas on which to apply the supplemental
seed. Minimum tillage equipment, consisting of a sod seeder shall be used for incorporating
seed into the soil as to prevent disturbance of existing vegetation. A clodbuster (ball and chain)
may be used where degree of slope prevents the use of a sod seeder.
MOWING:
The minimum mowing height on this project shall be 4 inches.

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
ATTACHMENT FORM
NOTIFICATION FOR UTILITY / NON -UTILITY ENCROACHMENT WITHIN NCDOT R/W
Instructions 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
Engineer's office to determine that contact info.
Date:
Submitted by Name:
To: District Personnel Name:
District Personnel Email:
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:

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
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.

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
Attachment for Clear Zone Guidelines from AASHTO
TABLE 3.1 JCant'd)
[U.S. C1lslornary Units
11
FGRESLOPES
BAC SLOPES
DESIGN
DEMCIN
SPEED
ADT
IV:6H
IV:51-1'1`0
IV314
1V:311
lV:5HTO
IV:611
or User
1VAH
TVAH
or Flatter
40mph
uNi) R-i5o
7-10
7-10
'*
7-10
7-10
7-10
or
750- 1500
10 - 12
12 - 14
10 - 12
10 -- 17
10 - 12
less
1500 - 600C
l 2 - 14
14 - 16
t*
12- 14
12 -14
12- 14
OVER 6000
14- 16
16-18
P*
14-16
14-16
i4- 16
45-50
UNDER 750
10-•12
12-14
**
8-10
8-10
10-12
tnph
750- 1500
14- 15
16 - 2t}
**
10 -12
12-14
14-16
1500-60W
lb - Is.
20-26
f*
12--14
14--ib
16-1$
OVER 6000
2V 22
24 - 28
rt*
14-16
18 2a
20 -22
55 mph
UNDER 750
T 2 - 14
14 -18
**
8 - 10
10 - 12
10 - 12
750- 1500
t6- 18
20-24
•*
10- 12
14--15
16- is
1500--60DO
20-22
24-30
"
14-16
16-19
20-22
OVER OM
22 - 24
26 - 32 #
;*
16- 18
20- 22
'22 - 24
$Orrtph
UNDER 750
16-18
20-24
**
10-12
12-14
14-16
750--1500
20-24
26-32*
as
12-14
16-19
20-22
1500-6000
26 -- 30
32 - 40 *
,"
14 -18
13 - 2 2
24 -- 26
OVRRB{M
30-32*
36-44*
**
20-22
24-26
25-28
65-70
UNDER 750
18-20
20-26
**
10-12
14-16
14_16
rrph
750 -1500
24-26
M-36+
d*
12-16
16-20
20-22
1 �1 00 6000
28 - 32 *
34 - 42 #
' *
16 - 20
22 - 24
26 - 28
OVI✓R6000
30-34'
38--461
*•
22-24
1 26-30
1 28-30
Where a site specific investigation indicates a high pmhahility of continuing craslres, er such occurrences are indicated by crash
history, the designer may provide clear -zone distances greater than the clear-zvnc shown in Tahle 3.1. Clear zones may be limited to
3U ft COT practiealily and bD provide 4 consistcnr roadway template if previous experitnes with similar projects or designs indicates
satisfactory performance.
-Since O&OVery is less likely an the unshielded, iraversilble I V:311 slopes, fixed objects should npt be present in the vie!Mity cr the toe
of these sk*es. Recovery of high-speed-,rhicles that encroach beyond tfre edge of the shoulder may be expected to occur beyond the
toe Of slope. DeWrminaiion of 1ho width of the recovery area at the toe of slope should take into coasideratiun right-of-way
availability, enviranmenlal Concerns, wowmic Factors, Safety rui 4 and crash hisuydEs. Also, the cUslancc belween ilie edge of the
through traveled lane and the beginning of [he 1V:3H shape should influence the remveryam provided at the toe of slope. While the
application may bc limited by several factors, the fumslope parameters w1dch may enter into dtbunainiug a nwximum desirable
recovery area are illusirated in Figure 3.2.

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
TRENCHING METHOD
5.00' MIN.
NOTE:
A minimum of five (5) feet clearance is
I
required for trenched utility installations
I
beneath or near drainage pipes,headwalls,
and a minimum of two (2) foot clearance
5.00'
EXISTING PIPEt
below the flow line of streams. All lines shall
MIN.
- -
— — — — —
be placed around the end or under all
existing storm drains. There SHALL be no
J
I
lines placed over the top of any existing
storm drains. 17.At points where the utility
is placed under existing storm drainage, the
5. 0 0' MIN.
I
trench will be backfilled with excavatable
I
flowable fill up to the outside diameter of the
— � — � — 2,00' MIN,
5. C), VlN. � \— — — — — — — — — — — — — — — — — — — — — —
\ - - - - - - EXISTING PIPE

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
ROUTE
PROJECT
STATE OF NORTH CAROLINA
COUNTY OF
DEPARTMENT OF TRANSPORTATION
-AND-
Geological Resources, Inc.
3502 Hayes Road
Monroe, NC 28110
RIGHT OF WAY ENCROACHMENT AGREEMENT
FOR NON -UTILITY ENCROACHMENTS ON
PRIMARY AND SECONDARY HIGHWAYS
THIS AGREEMENT, made and entered into this the 12 day of Oct 120 23 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) SR2167 (West Goldsboro Street) , located Intersection of South Church St & Goldsboro St. Johnston County
with the construction and/or erection of: one monitoring well
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)

DocuSign Envelope ID: CA7693BF-79CC-4CD8-9FF4-2468EBF76B29
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
%4 fry
' -� BY: Lt/�
b.'. i ...
FOR: COVIMN ENGINEER
ATTEST OR 1/1/l TTNESS°
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.