WM0401332_Monitoring Well Permit Application_20211213

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
PLEASE TYPE OR PRINT CLEARLY
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery wells.
Dec 8, 2021
1. Date:
2. County Yadkin
FOR OFFICE USE ONLY
PERMIT NO. ISSUEDDATE
3. What type of well are you applying for? (monitoring or recovery): Piezometer
4. Applicant: _ Randy Conrad _ Telephone: [phone]
Applicant's Mailing Address1499 SW 101h Street, Boca Raton, FL 33486_
Applicant's Email Address (if available) rconrad ac universalengineerinq.com
5. Contact Person (if different than Applicant) N/A Telephone:
Contact Person's Mailing Address: _
Contact Person's Email Address (if available):
6. Property Owner (if different than Applicant): Jerry Lee Sherrill Telephone:
Property Owner's Mailing Address: 130 Oleander Dr, Bermuda Run, NC 27006
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 486700909709
City Flam_otonville County Yadkin Zip Code 27020
8. Reason for Well(s): Measure water levels
(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. Aoricultureal
(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)
Unknown
11. Type of contaminants being monitored or recovered: N/A (ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? No
Existing Monitoring or Recovery Well Construction Permit No(s).: N/A
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): N/A
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: Randy Conrad Certification No.: 4501-A
Well Contractor Address: 1499 SW10th Street Boca Raton, FL 33486
PROPOSED WELL CONSTRUCTION INFORMATION
1. As required by 15A NCAC 02C .0105(f)(7), attach a well construction diagram of each well showing the following:
a. Borehole and well diameter e Type of casing material and thickness
b. Estimated well depth f. Grout horizons
c. Screen intervals g Well head completion details
d. Sand/gravel pack intervals
Continued on Reverse

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated
material: 0
3. Number of wells to be constructed in bedrock: 3
4. Total Number of wells to be constructed' 3
(add answers from 2 and 3)
5. How will the well(s) be secured? Above Grade Well protector
6. Estimated beginning construction date: Dec 8, 2021
7. Estimated construction completion date Jan 30 2021
ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following
a. All property boundaries, at least one of which is referenced to a minimum of two landmarks such as identified roads,
intersections, streams, or lakes within 500 feet of the proposed well or well system.
b. All existing wells, identified by type of use, within 500 feet of the proposed well or well system.
c. The proposed well or well system.
d. Any test borings within 500 feet of proposed well or well system.
e. All sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or fuel
storage areas, animal feedlots as defined in G.S. 143-215.10B(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant hereby agrees that the proposed well(s) will be constructed in accordance with approved specifications and conditions of
this Well Construction Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
Subchapter 2C) and accepts full responsibility for compliance with these rules
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Signature of Appli nt or *Agent Title of Applicant or *Agent
Randy Conrad
agreement stating Printed name of Applicant or *Agent
the Agent.
* if signing as Agent, attach authorization
that you have the authority to act as
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the applicant to construct
wells as outlined in this Well Construction Permit application and that it shall be the responsibility of the applicant to ensure that the
well(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water Resources' Regional Office:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
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Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR (6111)
GW-22M( Rev .Sell)
GW-22MR Rev. 3-1-2016

1

August , 2021
RE: Land Purchase and Sale Agreement (the "Agreement") by and
between Jerry Lee Sherrill et al, as "Sellers", and Synergy
Materials, LLC, as "Buyer"
We, Jerry Lee Sherrill, Wilma M. Sherrill and Heather M. Decastillia, individually and
as Trustees, hereby grant our consent to Synergy Materials, LLC or its assigns to drill and
equip up to three (3) water well monitoring wells on the Property identified in the
Agreement, in the approximate locations shown on Exhibit A attached hereto, prior to
Closing of the sale of the Property. We understand and agree that in the event the Closing
does not occur, the wells will be abandoned in accordance with applicable regulations.
Additionally, we grant our consent to Synergy Materials, :LLC or its assigns to file a plat
application or other application(s) necessary to subdivide the Property generally as shown
on Exhibit A attached hereto, prior to Closing. In the event that Closing of the sale of the
Property does not occur as allowed by the Agreement, Buyer hereby agrees to vacate any
plat or other subdivision of the Property, at its sole cost and expense, as soon as reasonably
practicable after it has determined that it will not purchase the Property. Buyer shall also
pay, prior to delinquency, any increase in ad valorem taxes assessed against the Property
for periods prior to Closing, to the extent that the increase is a result of the subdivision of
the Property. Buyer's obligations under this paragraph shall survive the termination of the
Agreement. To the extent that this letter agreement conflicts with the terms of the
Agreement, this letter agreement shall control and shall be deemed to so amend the
Agreement.
All capitalized terms used herein have the meanings given to them in the
Agreement unless otherwise defined,
Seller • _ f Agreed by Buyer:
Synergy Materials, LLC
Jerry ee S ern , n■ i' i uaI ly and as a Delaware limited liability company
Trustee
Y11��tr;I k By:
Wilma M. Sherrill, individually and as John E. Mitchell, III
Trustee
Heather M. DeCastillia, individually and as
Trustee
President

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TELESCOPING OR HINGED COVER
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Typical Overburden Well Construction
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. _ BOTTOM OF
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TOTAL DEPTH
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