WI0400625_GW-1_20240520

NC Department of Environmental Quality (DEQ) — Division of Water Resources (DWR)
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are `permitted by rule" and do not require an application to be submitted and an individual permit
be issued when constructed in accordance with the rules of 15A NCAC 02C.0200 (NOTE: This form must be
received at least 14 DAYS prior to iniection)
GROUNDWATER (GW) REMEDIATION INJECTION PERMIT TYPES:
(1) IN -SITU GW REMEDIATION PERMIT TYPE (15A NCAC 02C .0225)
• In -Situ Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
• In -Situ Small -Scale Injection Operations — Injection wells located within a land surface area not to exceed 10,000
square feet (SF) for the purpose of soil or groundwater remediation or tracer tests. If area to be treated exceeds 10,000
SF do not use this NOI; an injection Permit application shall be submitted, and a Permit issued per 15A NCAC
02C .0225(f).
• In -Situ Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy to develop a full-scale remediation plan for future implementation, and where the surface area of
the injection zone wells is located within an area that does not exceed five percent of the land surface above the known
extent of groundwater contamination. Also, if pilot test is going to be conducted on separate groundwater
contaminant plumes do not use this NOI; a Permit application shall be submitted, and a Permit issued as per
15A NCAC 02C .0225(f).
• In -Situ Thermal (IST) — IST wells `heat' contaminated groundwater in -situ to enhance remediation.
(2) AIR INJECTION PERMIT TYPE (15A NCAC 02C .0225)
These permit types are used to inject ambient air to enhance treatment of soil or groundwater.
(3) TRACER WELL PERMIT TYPE (15A NCAC 02C .0229)
These permit types are used to inject substances for determining hydrogeologic properties of aquifers.
(4) AQUIFER TEST PERMIT TYPE (15A NCAC 02C .0220)
These permit types are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
DATE: May 16, 20_24 NOI TRACKING NO. W10400625
o be filled in by DWR)
DIRECTIONS- Submit this NOI only for (1) New deemed `permitted by rule' injection project or (2) If there is going
to be a different permit type (listed above) used for a previously issued NOI.
NOTE- After this NOI is processed and acknowledged, any supplemental or additional injections still meeting the
criteria referenced in Section G below shall be reported using Injection Event Records (IERs) and using the NOI
tracking number provided by DWR.
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1)
Air Injection Well .......................................
Complete sections B through F, J, M
(2)
Aquifer Test Well .......................................
Complete sections B through F, J, M
(3)
X_Passive Injection System ...............................
Complete sections B through F, H-M
(4)
Small -Scale Injection Operation ......................
Complete sections B through M
(5)
Pilot Test .................................................
Complete sections B through M
(6)
Tracer Injection Well ...................................
Complete sections B through M
(7)
In -Situ Thermal (IST) Well ...........................
Complete sections B through M
Deemed Permitted GW Remediation NOI Rev. 3-1-2023 Page 1

B. STATUS OF WELL OWNER: State Government
C. WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): NCDEQ-DWM, UST Section. Federal & State Lead Program: Attn: Kristie Oseguera
Mailing Address: 1646 Mail Service Center
City: Raleigh State: NC Zip Code: 27699-1646 County: Wake
Day Tele No.: 919-707-8169 Cell No.: NA
EMAIL Address: Kristie.oseguera&deq.nc.gov Fax No.: 919-707-8165
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Gregory Brian Byers
Company Name NA
Mailing Address: 1481 Pads Road
City: North Wilkesboro State: NC_ Zip Code: 28659 County: Wilkes
Day Tele No.: 336-215-7129 Cell No.: NA
EMAIL Address: greg3979kgmail.com Fax No.: NA
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Flora D'Souza, Environmental Project Scientist II
Company Name WithersRavenel, Inc.
Mailing Address: 115 MacKenan Drive
City: Cary State: NC_ Zip Code: 27511 County: Wake
Day Tele No.: 704-919-1242 Cell No.: 704-517-3035
EMAIL Address: fdsouzagwithersravenel.com Fax No.: 919-467-6008
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Southern Country Store — 3979 Sparta Road: NCDEQ Incident #45339
City: Mulberry County: Wilkes Zip Code: 28659
(2) Geographic Coordinates: Latitude": 36.2437280
Longitude":-81.189135'
Reference Datum: Google Earth Accuracy: +/- 5m
Method of Collection: Google Earth
"FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: square feet
Land surface area of inj. well network: square feet (< 10,000 ft' for small-scale injections)
Percent of contaminant plume area to be treated: (must be < 5% of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev. 3-1-2023 Page 2

H. INJECTION ZONE MAPS — Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
L DESCRIPTION OF PROPOSED INJECTION ACTIVITIES AT THE SITE — Provide a brief narrative
regarding the cause of the contamination, and purpose, scope, goals of the proposed injection activity:
Cause of Contamination: The Southern Country Store site previously operated as a gas station and had a release
of gasoline from underground storage tanks.
Purpose: The purpose of the injection is to reduce dissolved phase contaminant concentrations to reduce risk at
the site.
Scope: The scope of this injection event will be to place an Oxygen Releasing Substrate (ORS) sleeve into the
water table between 52 and 55 feet below ground surface within the submerged screen.
Goals: The goal of the placement of the ORS sleeve is to reduce contaminant concentrations in groundwater near
monitoring well MW-4.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: Proposed 1 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): between 52 and 55 feet below ground surface within the submerged
screen
(3) For Proposed wells or Existing wells not having GW-ls, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as -built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
K. INJECTION SUMMARY
NOTE: Only iniectants annroved by the enidemiologv section of the NC Division ofPublic Health. Denartment
of Health and Human Services can be injected. Approved iniectants can be found online at
hllp://deg.nc. gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection/ground-water-approved-iniectants. All other substances must be reviewed by the DHHS prior to use.
Contact the UIC Program for more info if you wish to get approval for a different additive. However, please
note it may take 3 months or longer. If no iniectants are to be used use N/A.
Deemed Permitted GW Remediation NOI Rev. 3-1-2023 Page 3

Injectant: Provect-ORS Sleeve Total Amt. to be injected (gal)/event: One 3-foot sleeve
Total Amt. to be injected (gal/event):
No. of separate injection events:I Total Amt. to be injected (gal):
Source of Water (if applicable): NA
L. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
At the direction of the NCDEQ, WR will obtain groundwater samples from the site monitoring wells within 6
months time to determine the efficacy of the remedial approach. Samples will be submitted for laboratory
analysis of volatile organic compounds.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "7 hereby certify, under penalty of law, that I am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the I5A NCAC 02C 0200 Rules. "
Flora D'Souza, Environmental Project Scientist II
Signature of Applicant Print or Type Full Name and Title
Property Owner (if the property is not owned by the Well Owner/Applicant):
"As owner of theproperty on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(I5A NCAC 0 2 C . 0200). "
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
See attached access agreement
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send 1 (one) hard color copy of this NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 3-1-2023 Page 4

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FIGURES
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Notice of Intent - UIC May 2024

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::WithersRavenel
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WELL CONSTRUCTION RECORDS
Southern Country - NCDEQ Incident #45339 WR Project # 23-0307-EH
Notice of Intent - UIC May 2024

Print Form
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
John Allen
Well Contractor Name
4196-B
NC Well Contractor Certification Number
AmeriProbe
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, Coun), State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural E]Municipal/Public
Geothermal (Heating/Cooling Supply) Residential Water Supply (single)
Ilndustrial/Commercial Residential Water Supply (shared)
IIrri ation
Non -Water Supply Well:
X (Monitoring Recovery
Injection Well:
(Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
PIAquifer Test �Stormwater Drainage
Experimental Technology Subsidence Control
F�IGeothermal (Closed Loop) DTracer
Geothermal (Heating/Cooling Return) r3Otber (explain under #21 Remarks)
4. Date Well11/11/2022 s) Completed: Well ID# MW-1
5a. Well Location:
Southern Country Store
Facility/Owner Name Facility ID# (if applicable)
3979 Sparta Road, Mulberry, NC, 28659
Physical Address, City, and Zip
Wilkes
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.2437513 N 81.1890819 W
6. Is(are) the well(s): BPermanent or ®Temporary
7. Is this a repair to an existing well: DYes or INo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 60 (ft.)
For multiple wells list all depths ifali ferent (example- 3@200' and 2@100)
10. Static water level below top of casing: 53' (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 8rr (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
For Internal Use
14. WATER ZONES
FROM
TO
DESCRIPTION
53 ft.
60 ft.
ft.
ft.
15. OUTER CASING for multi -cased wells OR LINER if a Hcable
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 f1.
45 ft.
1 2 in' I
SCH40
PVC
16. INNER CASING OR TUBING(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17.SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
45 ft.
60 ft•
2 in.
0.010
SCH40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
39 ft.
Neat Cement
Poured Through Augers
39 ft•
43 ft•
Bentonite
Poured Through Augers
ft.
ft.
19. SAND/GRAVEL PACK if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
43 ft•
60 ft•
#2 Sand
Poured Through Augers
ft.
ft.
20. DRILLING LOG attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
See Consultants Logs
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certi_attion:
CLLK y"
Signature of Certified Well Contractor
12/7/2022
By signing this form, I hereby certify that the well(&) was (were) constructed in accordance
with 134NCAC 02C.0100 or 134NCAC 02C . 0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test' 24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type' Amount' completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

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PROVECT-ORS SAFETY DATA SHEET
Southern Country - NCDEQ Incident #45339 WR Project # 23-0307-EH
Notice of Intent - UIC May 2024

Provectus
ENVIRONMENTAL PRODUCTS`
1.
2.
0
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 1 of 5
PRODUCT IDENTIFICATION:
PRODUCT USE:
MANUFACTURER:
PROVECTUS ENVIRONMENTAL
2871 W. Forest Rd., Suite 2
Freeport, IL
61032
PRO VECT-ORS
Soil and water treatment.
EMERGENCY PHONE:
USA: ($15) 650-2230
TRANSPORTATION OF DANGEROUS GOOD CLASSIFICATION:
Oxidizing Solid, n.o.s. (Calcium Peroxide), Class 5.1, PG H, UN1479
WHMIS CLASSIFICATION:
Oxidizer
COMPOSITIONANFORMATION ON INGREDIENTS
Ingredients
Calcium Peroxide
Inorganic Nutrients
PHYSICAL DATA
Chemical Formula CAS No.
Ca02 1305-79-9
Percentage
75%-85%
15%-25%
Appearance White & brown granules
Physical state Solid
Odor threshold None
Bulk Density 500-650g/L
Solubility in Water Insoluble
pH — 11
Decomposition Temperature Self -accelerating decomposition with oxygen release starting from 275
degrees Celsius
4. HAZARDS IDENTIFICATION
Emergency overview
Oxidizing agent, contact with other material may cause fire. Under fire conditions this material may
decompose and release oxygen that intensifies fire. This product contains <1% non -respirable crystalline
silica. The NTP and OSHA have not classified non -respirable crystalline silica as carcinogenic. Long term
exposure to hazardous levels of respirable silica dusts can cause lung disease (silicosis). ORS does not
contain respirable crystalline silica.
Potential Health Effects:
0 General_________________________ Irritating to mucous membrane and eyes.

Provectus
ENVIRONMENTAL PRODUCTS`
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 2 of 5
•
Inhalation
•
Eye contact
•
Skin contact
•
Ingestion ------------------
5. FIRST AID MEASURES
•
Inhalation
•
Eye contact ---------------
•
Skin contact
•
Ingestion -----------------
6. FIRE FIGHTING MEASURE
Flash Point
• Not applicable
Flammability
• Not applicable
Ignition Temperature
• Not applicable
Danger of Explosion
• Non -explosive
Extinguishing Media
• Water
Irritating to respiratory tract. Long term inhalation of elevated levels
may cause lung disease (silicosis).
May cause irritation to the eyes; Risks of serious or permanent eye
lesions.
May cause skin irritation.
Irritation of the mouth and throat with nausea and vomiting.
Remove affected person to fresh air. Seek medical attention if effects
persist.
Flush eyes with running water for at least 15 minutes with eyelids
held open. Seek specialist advice.
Wash affected skin with soap and mild detergent and large amounts of
water.
-If the person is conscious and not convulsing, give 2-4 cupfuls of
water to dilute the chemical and seek medical attention immediately.
Do not induce vomiting.
Fire Hazards
• Oxidizer. Storage vessels involved in a fire may vent gas or rupture due to internal pressure.
Damp material may decompose exothermically and ignite combustibles. Oxygen release due to
exothermic decomposition may support combustion. May ignite other combustible materials.
Avoid contact with incompatible materials such as heavy metals, reducing agents, acids, bases,

Provectus
ENVIRONMENTAL PRODUCTS`
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 3 of 5
combustible (wood, papers, cloths etc.) Thermal decomposition releases oxygen and heat.
Pressure bursts may occur due to gas evolution. Pressurization if confined when heated or
decomposing. Containers may burst violently.
Fire Fighting Measures
• Evacuate all non -essential personnel
• Wear protective clothing and self-contained breathing apparatus.
• Remain upwind of fire to avoid hazardous vapors and decomposition products.
• Use water spray to cool fire- exposed containers.
7. ACCIDENTAL RELEASE MEASURES
Spill Clean-up Procedure
• Oxidizer. Eliminate all sources of ignition. Evacuate unprotected personnel from equipment
recommendations found in Section 9. Never exceed any occupational exposure limit.
• Shovel or sweep material into plastic bags or vented containers for disposal. Do not return spilled
or contaminated material to inventory. Avoid making dust.
• Flush remaining area with water to remove trace residue and dispose of properly. Avoid direct
discharge to sewers and surface waters. Notify authorities if entry occurs.
• Do not touch or walk through spilled material. Keep away from combustibles (wood, paper, oils,
etc.). Do not return product to container because of risk of contamination.
8. HANDLING AND STORAGE
Storage
• Oxidizer. Store in a cool, well -ventilated area away from all source of ignition and out of direct
sunlight. Store in a dry location away from heat.
• Keep away from incompatible materials. Keep containers tightly closed. Do not store in
unlabeled or mislabeled containers.
• Protect from moisture. Do not store near combustible materials. Keep containers well sealed.
Ensure pressure relief and adequate ventilation.
• Store separately from organics and reducing materials. Avoid contamination that may lead to
decomposition.
Handling
• Avoid contact with eyes, skin, and clothing. Use with adequate ventilation.
• Do not swallow. Avoid breathing vapors, mists, or dust. Do not eat, drink, or smoke in work
area.
• Prevent contact with combustible or organic materials.
• Label containers and keep them tightly closed when not in use.
• Wash thoroughly after handling.

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ENVIRONMENTAL PRODUCTS`
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 4 of 5
9. EXPOSURE CONTROLS/PERSONAL PROTECTION
Engineering Controls
• General room ventilation is required. Local exhaust ventilation, process enclosures or other
engineers controls may be needed to maintain airborne levels below recommended exposure limits.
Avoid creating dust or mist. Maintain adequate ventilation. Do not use in closed or confined
spaces. Keep levels below exposure limits. To determine exposure limits, monitoring should be
performed regularly.
Respiratory Protection
• For many condition, no respiratory protection may be needed; however, in dusty or unknown
atmospheres or when exposures exceed limit values, wear a NIOSH approved respirator.
Eye/Face Protection
• Wear chemical safety goggles and a full face shield while handling this product.
Skin Protection
• Prevent contact with this product. Wear gloves and protective clothing depending on condition of
use. Protective gloves: Chemical -resistant (Recommended materials: PVC, neoprene or rubber)
Other Protective Equipment
• Eye -wash station
• Safety shower
• Impervious clothing
• Rubber boots
General Hygiene Considerations
• Wash with soap and water before meal times and at the end of each work shift. Good
manufacturing practices require gross amounts of any chemical removed from skin as soon as
practical, especially before eating or smoking.
10. STABILITY AND REACTIVITY
Stability
• Stable under normal conditions
Condition to Avoid
•
Water
•
Acids
•
Bases
•
Salts of heavy metals
•
Reducing agents
•
Organic materials
•
Flammable substances
Hazardous Decomposition Products
0 Oxygen which supports combustion

Provectus
ENVIRONMENTAL PRODUCTS"
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 5 of 5
11. TOXICOLOGICAL INFORMATION
• LD50 Oral: Min.2000 mg/kg, rat
• LD50 Dermal: Min. 2000mg/kg, rat
• LD50 Inhalation: Min. 4580 mg/kg, rat
12. ECOLOGICAL INFORMATION
Ecotoxicological Information
• Hazards for the environment is limited due to the product properties of no bioaccumulation, weak
solubility and precipitation in aquatic environment.
Chemical Fate Information
• As indicated by chemical properties oxygen is released into the environment.
13. DISPOSAL CONSIDERATIONS
Waste Treatment
• Dispose of in an approved waste facility operated by an authorized contractor in compliance with
local regulations.
Package Treatment
• The empty and clean containers are to be recycled or disposed of in conformity with local
regulations.
14. TRANSPORT INFORMATION
• Proper Shipping Name: EHC-O
• Hazard Class: 5.1
• Labels: 5.1 (Oxidizer)
• Packing Group: II
15. REGULATORY INFORMATION
• SARA Section
Yes
• SARA (313) Chemicals ------------------------------
No
• EPA TSCA Inventory --------------------------------
Appears
• Canadian WHMIS Classification
C, D2B
• Canadian DSL..........................................
Appears
• EINECS Inventory ------------------------------------
Appears

::WithersRavenel
Our People. Your Success.
ACCESS AGREEMENT
Southern Country - NCDEQ Incident #45339 WR Project # 23-0307-EH
Notice of Intent - UIC May 2024

UNDERGROUND STORAGE TANK SECTION
September 7, 2022
c- �n �v
Nam® �
Ms. Kristie Oseguera 0�.
DWM UST Section
1646 Mail Service Center
Raleigh, NC 27699-1646
RE: Site Access Agreement
Southern Country
3979 Sparta Road
Mulberry, Wilkes County, NC 28659
Incident #45339
Dear Ms. Oseguera:
I am/We are the owner(s) of a parcel of property, located at or near the incident in question,
and hereby permit the Department of Environmental Quality or its contractor to enter upon said
property for the purpose of conducting an investigation of the groundwaters under the authority of
G.S. 143-215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation and remediation shall be conducted by the UST Section of the Department's
Division of Waste Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the
Department or its contractor. The Department or its contractor shall protect and prevent
damage to the surrounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the
shortest feasible route to the nearest public road. The Department or its contractor may enter
upon the land at reasonable times and have full right of access during the period of the
investigation.
4. Any claims which may arise against the Department, or its contractor, shall be governed by
Article 31 of Chapter 143 of the North Carolina General Statutes, Tort Claims Against State
Departments and Agencies, and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon
request and is a public record, in accordance with North Carolina G.S. 132-1.

6. The activities to be carried out by the Department or its contractor are for the primary benefit
of the Department and of the State of North Carolina. Any benefits accruing to the owner
are incidental. The Department or its contractor is not and shall not be construed to be an
agent, employee, or contractor of the landowner.
I/We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
Signature
sec tf Qr �°�s
Typel rint Name of Owner or Agent
22& - 9 1� -v7s7
Phone Number
Email Address
Address
City/State/Zip Code
Date
RE: Site Access Agreement
Southern Country
3979 Sparta Road
Mulberry, Wilkes County, NC 28659
Incident #45339