WM0401365_Monitoring Well Permit Application_20220511 (2)

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
PLEASE TYPE OR PRINT CLEARLY
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery wells.
1. Date: May 5, 2022
2. County: Yadkin
FOR OFFICE USE ONLY
_ /
LRMITNOv'UMG'-k013A.D", ISSUED DATE �;)1'6i ((7)
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Mark Stephens for The Colinas Group, Inc.
Applicant's Mailing Address: 2031 East Edgewood Drive, Suite 5, Lakeland, FL 33803
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): same
Contact Person's Mailing Address: same
Contact Person's Email Address (if available): same
6. Property Owner (if different than Applicant): Three Oaks Quarry, LLC. as agent Telephone: [phone]
Property Owner's Mailing Address: c/o 500 Duke Drive Franklin Tennessee 37067
Property Owner's Email Address (if available): NA
Telephone: [phone]
Telephone: same
Lowder Road Site
7. Property Physical Address (Including PIN Number) Parcel ID Nos.487700146238, 487700229893 487700012708, 486700909709, and 487700208955
City Hamptonville County Yadkin Zip Code
8. Reason for Well(s): Monitoring and Pumping Test
(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: Proposed Quarry
(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).
No
11. Type of contaminants being monitored or recovered: Not Applicabe
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes three monitor wells
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401332
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Unkonwn
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: Yadkin Well Drilling - Matt Brown
Well Contractor Address: 1908 Hamptonville Rd. Hamptonville, NC 27020
Certification No.: 3036
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: o
3. Number of wells to be constructed in bedrock: 5
4. Total Number of wells to be constructed: 5
(add answers from 2 and 3)
5. How will the well(s) be secured?
Steel Locking Well Cover
6. Estimated beginning construction date: 5/9/2022
7. Estimated construction completion date: 5I27/2-22
1.
ADDITIONAL INFORMATION
As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:
a. All property boundaries, at least one of which is referenced to a minimum of two landmarks such as identified roads,
intersections, streams, or lakes within 500 feet of the proposed well or well system.
b. All existing wells, identified by type of use, within 500 feet of the proposed well or well system.
c. The proposed well or well system.
d. Any test borings within 500 feet of proposed well or well system.
e. All sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or fuel
storage areas, animal feedlots as defined in G.S. 143-215.10B(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
Agent for Synergy Materials, LLC and Three Oaks Quarry, LLC
Signature of Applicant or *Agent Title of Applicant or *Agent
Mark Stephens * if signing as Agent, attach authorization agreement stating
Printed name of Applicant or *Agent 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
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).
see attached contracts and authorizations
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water Resources' Regional Office:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
ire At& la I
„lett 1=m
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]
7
ngton
GW-22MR Rev. 3-1-2016

MONITOR WELL INSTALLATION
Typical Bedrock Well Construction
TELESCOPING OR HINGED COVER
CONCRFTF FII I
GUARD POST
•
CONCRETE
KEY PADLOCK -+{ .
PROTECTIVE CASING-4-
2'X2'X4' CONCRETE
PAD
OVERBURDEN MATERIALS
CASING
Casing -
6-inch Sch 40 PVC for monitor wells
8-inch Sch 40 PVC for Pumping Test
Well
GROUT
BEDROCK
OPEN HOLE IN BEDROCK
NO CASING
Nominal 4-inch open hole for monitor wells
and nominal 6-inch for pumping test wells
THIRD GUARD POST NOT SHOWN
OVERSIZED CAP OR
UNDERSIZED PLUG
VENT
DRAIN HOLE
CONCRETE FILLED
GUARD POST
CONCRETE
3'
TOP OF
BEDROCK
MINIMUM
BOTTOM OF
CASING
DETERMINED IN FIELD
Well Depths will
vary from 370
to 415 feet.
BOTTOM
OF WELL

May , 2022
Landowners' Consent
RE: Land Purchase and Sale Agreement by" and between Jerry Lee Sherrill et al, as
Sellers, and Three Oaks Road Quarry, LLC, assignee of 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 Three Oaks Road Quarry, LLC or its assigns to drill and
equip up to five (5) 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 that in the event the Closing does not occur, the wells will be abandoned
in accordance with applicable regulations.
We also acknowledge that Synergy Materials, LLC, 'predecessor in interest to Three Road
Quarry, LLC, has previously drilled three water well monitoring wells on the Property. The 5
wells to be drilled pursuant to this consent are in addition to the existing monitoring wells.
All capitalized terms used herein have the same meaning given to them in the Agreement.
SELLERS:
Jerry Le She ill, I di i`y and as Trustee
Wilma M. Sherrill, Individually and as Trustee
Heather M. Decastillia, Individually and as Trustee
BUYER:
THREE OAKS ROAD QUARRY, LLC,
a Delaware limited liability company
i
t.f, s /c1
hn E. Mitchell, III
President
1