WM0401332_Well Completion Records_20220222

ROY COOPER
Governor
ELIZABETH S. BISER
Secretory
S. DANIEL SMITH
Director
Mr. Mark Stephens
Colinas Group, Inc.
2031 E. Edgewood Drive, Suite 5
Lakeland, Florida 33803
NORTH CAROLINA
Environmental Quality
December 13, 2021
SUBJECT: MONITORING WELL CONSTRUCTION
PERMIT NO. WM0401332
COUNTY: Yadkin
FILE NAME: Lowder Road Site
Dear Mr. Stephens:
In accordance with your application received on December 9, 2021, we are forwarding herewith:
1. Monitoring Well Construction Permit No. WM0401332 for the construction of three (3)
monitoring wells on a large agricultural tract off Lowder Road in Hamptonville in Yadkin
County.
Henceforth, correspondence and data relating to this well shall be designated as specified in the
subject heading above. This Permit will be effective from the date of issuance and shall be subject
to the conditions and limitations as specified therein. If you have any questions regarding this
permit, please contact me or Jim Gonsiewski at [phone].
Sincerely,
/—RacusigeeJ by:
145B4 DE22SC34A
Lon T. Snider
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ — WSRO
cc: Jerry Lee Sherrill
Randy Conrad— Universal Engineering Sciences (Electronic Copy)
WSRO Electronic Files
Laserfiiche Files
DE
`
t1.r+iwrt 4alin.x.ww6i.1
North Carolina Department of Environmental Quality l Division of Water Resources
Winston-Satcm Regional Office ! 450 West Hancs Mill Road, Suite 300 i Winston-Salem, North Carolina 27105
336.776.9800

. 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
Resources' 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 Resources' Information Processing Unit within 30 days of the well
abandonment.
7. The County Health Department may require a county monitoring well construction permit.
Please contact the health department for their requirements.
Permit issued the 13th day of December, 2021
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
JJ A__ocu Sign rd by:
5.46
.. 11340E225nfi4 E4..
Lon T. Snider, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
By Authority of the Environmental Management Commission
Permit No. # WM0401332
North Carolina Department of Environmental Quality i Division of Water Resources
Winston-Salem Regional Office 1450 West Hanes Mill Road, Sulte 300 I Winston-Salem, North Carolina 27105
336.776.9800

For Internal Use Only:
WELL CONSTRUCTION RECORD (GW-I)
1. Well Contractor Information:
Randy Conrad
Well Contractor Name
4501-A
NC Well Contractor Certification Number
Universal Engineering Sciences
Company Namc
2. Well Construction Permit it: WM0401332
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well;
Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑ Municipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
Z Wc4la > 100,000 OPD
Nun -Water Supply Well:
IoniIorWg
❑Recovery
Injection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remedialion
❑ Salinity Barrier
❑Stormwatcr Drainage
❑Subsidence Control
❑Tracer
DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 2-8-22 Well ID#
5a. Well Location:
Jerry Lee Sherrill
Facility/Owner Namc
Lowder Road Site
Facility 1Dk (if applicable)
Physical Address, City, and Zip
Yadkin
County
486700909709
Parcel Identification No, (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lallong is sufficient)
N
6. Is(are) the well(s): libermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or No
If If this is a repair, fill out known well construction information and explain the nature of the
repair under 1421 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: 535
For multiple wells list all depths if different (example- 3@200' and 2@I00')
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter: 3-9 (in.)
12. Well construction method: Wire line Coring
(ft.)
(ft.)
(i.c. auger, rotary, cable, direct push, ctc.)
FOR WATER SUPPLY
13a. Yield (gpm)
13b. Disinfection type:
WELLS ONLY:
Method of test:
Amount:
Form GW-I
14. WATER ZONES
FROM
TO
DI!SCR1PT10N
ft.
ft.
ft.
ft.
13, OUTER CASINGlfor
muhlKned wets OR LINER (lf a 1kahk)
FROM
TO
DIASlITER
1IIICkl0.88
MATYRfAt-
0 ft.
94 ft.
6 In•
Sch.40
PVC
16. INNER CASING OR TUWING
g strtermal closed -Iwo)
FROM
TO
mAMCT£k
TAICK.' ES4
MJITI:R M.
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FRS1S1
to
DIAMETER
SUIT SIYR
T1TCKVRsS
HATER IA 1.
rt.
ft.
In.
R,
rt.
in.
18. GROUT
FROM
10
MA'1KR1A I.
EMPLACEME\T METIIOD&ANIMA f
0 ft.
90 ft.
Grout
Tremie - 180 gal
ft.
ft.
ft.
ft.
19. SANDIGRAYEL
PACK
(if applicable)
I.R(M
to
MATKKIA I.
EMFLACEMLNT 2wt HOD
ft.
rt-
N/A
ft.
ft.
20. t7RILLING
LOG (snub
additional sheets If memory)
FROM
TO
DSCRTPr1OS (ruler, kmrdnns, se7Vrock I]9r. ?Aga We. Os.)
ID ft.
90 ft.
Overburden with fractured granite
'90 ft-
535 ft.
Granite 100% recovery
ft.
D.
ft.
ft.
ft.
rt.
ft.
ft.
ft.
ft.
21. REMARKS
Well is open hole from bottom of casing to depth
22. Certification:
Signature ofCe led Well Conn actor
By signing This form, I hereby certf that the well(s) was (mere) constructed in accordance with
15A NCAC 02C.0/00 or I SA NCAC 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 construction info
(add 'Sec Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Mullion ►Vella: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells produring over 100,000 GPI): Copy to DWR, CCPCUA
Permit Program. 1611 MSC. Raleigh, NC 27699.161 I
North Carolina Department ol'Environmental Quality - Division of Water Resources Revised 6-6-2018
MW-1

For Internal Use Only:
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Randy Conrad
W ctl Contactor Name
4501-A
NC Well Contractor Certification Number
Universal Engineering Sciences
Company Name
2. Well Construction Permit #: W M 0401 332
List al! applicable well construction permits (i.e. UIC, County, Stale, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ lndustrial/Commercial
❑lrrigotion
❑Municipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
r1W1116>100.00 CPD
`N,on-Water Supply Well:
�Nlonitoring
njection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothermal (Hcating/Cooling Return)
4. Date Well(s) Completed: 2-8-22
5a. Well Location:
Jerry Lee Sherrill
Facility/Owner Name
Lowder Road Site
❑ Recovery
❑Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑ Other (explain under #21 Rcmarks)
Well ID#
MW-2
Facility 1D# (if applicable)
Physical Address, City, and Zip
Yadkin
486700909709
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the well(s): ® ermanent or ❑Temporary
7. is this a repair to an existing well: ❑Yes or INo
If this is a repair, fill out known well construction information lain the nature of the
repair under 021 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
tLillr[l:
9. Total well depth below land surface: 490
For multiple wells list all depths if different (example- 3@200' and 2@100')
(ft.)
10. Static water level below top of casing: (ft)
If water level is above casing, use "+"
11. Borehole diameter: 3.9 (in.)
12. Well construction method: Wire line Coring
(i.c. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Form GW- I
14. WATER ZONES
PROM
TO
DESCRIPTION
ft.
ft.
ft.
O.
IL OUTER CASING Ifer multi -aid want Z OR LINER Of op lkahle)
PROM
TO
111AS1F:ri:R THICKNESS
MATERIA I.
0 11-
90 ft.
6 in.ISch.40
PVC
16. INNER CASING OR TUHINGIcalbcrmi [ie00,41 111
FROM
r0
UTASIETER
THICTL'•T'SS
MATERIAL
ft.
ft.
In.
ft.
ft.
In.
17. SCREEN
FROM
TO
EDAM ETFR
ST.OTSIYA.
THICKNESS
MATERIAL.
ft.
ft.
in.
ft.
ft.
In.
18. GROUT
FROM
TO
MArRRO. •
EMPIACEAELNT METIIOO & AM01J 1'
0 ft.
'90 ft.
Grout
Tremie - 180 gal
ft.
ft.
ft.
ft.
-
I14.SAND/GRAVEL PAC%
(if ayglkablrl
FROM
In
NA r1.R1 A1.
}11FIACE'si ENT MIEI ILOO
ft.
ft.
N/A
ft.
ft.
20. DRILLING
LOC (attach
additional sheet, if neeennryt
PROM
TO
DESCRIPTION {retpr, RAH mi. glareOt qpc. Rnln ,Leg. itt.I
0 rt.
90 ft.
Overburden with fractured granite
90 ft.
490 ft.
Granite 100% recovery
ft.
ft.
11.
ft.
rt.
ft.
ft.
ft.
ft. ft.
21. R1:1MAFIRS
Well is open hole from bottom of casing to depth
22. Certification:
Signature of Certified Well Conn actor
Date
By signing this form, I hereby cergfy that the well(s) was (were) constructed in accordance with
15A NCAC 02C.0100 or 15A NCAC 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 construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Welts: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. Far Iniect€on WFIIi: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open-I.oup Cenlhermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 108,O00 GPI): Copy to DWR, CCPCUA
Permit Program. 16i I MSC, Raleigh, NC 27499-1611
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

For Internal Use Only:
WELL CONSTRUCTION RECORD (GW-I)
1. Well Contractor Information:
Randy Conrad
Well Contractor Name
4501-A
NC Well Contractor Certification Number
Universal Engineering Sciences
Company Name
2. Well Construction Permit #: WM0401 332
List all applicable well construction permits (i.e, U!C, County, Slate, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑ Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Wells > 100,000 GPD
Non -Water Supply Well:
)XD4onitoring
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifcr Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 2-8-22
5a. Well Location:
Jerry Lee Sherrill
Facility/Owner Name
Lowder Road Site
❑Recovery
❑ Groundwater Remedialion
❑ Salinity Barrier
❑Stomtwatcr Drainage
❑Subsidence Control
❑ Tracer
❑ Other (explain under #21 Remarks)
Well ID#
Physical Address, City, and Zip
Yadkin
County
MW-3
Facility ID# (if applicable)
486700909709
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iallnng is sufficient)
14, WATER ZONES
'FROM
'fi 1
In:SCRI I'TION
ft.
ft.
ft.
ft.
15. OUTER CASING (far
multi -cased welts) OR LINER Of au Ikablel
FRDSI
TO
DIAMETER
7111CliNi'SS
:MATERIAL
0 ft.
80 ft.
16 in•
Sch.40
PVC
16. INNER
CASING OR TUBING
Otcotbrnnal dosed -Moo)
FROM
Tit
DIAMETER
IIIICKN'i\S
MATERIAL
ft.
ft.
in,
ft.
.
in.
17. SCREEN
FROM I
'f0
DIA'llflIR
SI.O I'SIZE
•I'IIIERNRSl
MATERIAL
ft.
ft.
In.
ft.
ft.
is
1R. GROUT
FROM
ro
MATERIA .
FAIN ACrAILrr Mkt] 0D & AMDUNT
0 ft'
.80 fit•
Grout
Tremie - 160 gal
ft.
ft.
IL
ft.
19. SAND/GRAVEL
PACK
(If appllrnblr)
FROM
10
HAfERIAL
KM PIACEMi:.:l' 71I.1'110a
h.
ft'
N/A
fL
ft.
to. DRILLING
LOG Ialtieb
addlllonal sheets If nneesanryl
PROM
'fO
D1iaCRIP II11R(wine• k.rdneu• laiVanck 17ae. min 61r.ele-1
0 fit'
.80 fit•
Overburden with fractured granite
80 fit•
540 ft.
Granite 100% recovery
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
11. REMARKS
Well is open hole from bottom of casing to depth
22. Certification:
N W c
6. Is(are) the well(s): 011ikermanent or DTemporary
7. Is this a repair to an existing well: (iYes or do
If this is a repair, fit/ out known well construction mfurmalion and erplain the nature of the
repair under 021 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
dli nod:
9. Total well depth below land surface: 540
For multiple wells list all depths i11 different (example- 3@200' and 2@/00')
10. Static water level below top of casing: (ft.)
If wafer level is above casing, use "+"
11. Borehole diameter: 3.9 (in.) /'+
12. Well construction method: Wire line Goring
(i.e. auger, rotary, cable, direct push, eta.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Form GW-I
Signature ofCcrtify'cd Well Contractor Date
By signing this form, 'hereby certify that the wells) was (were) constructed in accordance with
ISA NCAC 02C .0100 or ISA NCAC 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 construction info
(add 'Sec Over' in Remarks Box). You may also attach additional pages if necessary•
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. Far All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For lnlectIan W@Ils: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells ruducieg over 1011,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC. Raleigh. NC 27699.1611
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018