WI0400133_GEO THERMAL_20120518

Beverly Eaves Perdue
Governor
AT~-
NcD.EM~
North-Carolina De-partment of Environment ana Nat □ratResources--­
Division,of Water Quality
Charles Wakild, P. E.
Director
May 18, 2012
Rivermill Village, LLC
Post Office Box 128
Saxapahaw, NC 27340
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Pennit Holders
PermitNumber: WI0400133
To Whom it May Concern:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A · Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
''permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http ://portal.ncdenr.org/web/wq/ap s.·
If you have any" questions·regarding your current permit or the rule revisions, please feel free-to
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer
N°~i..c 1· 01. u..1 aro 1na
JVatural/11
AL
.,
·'
Station name/Location Northing Easting Elevation F.G.
VRS/CMR STATIONING
VRS_0l49 799673.942 1905666. 768 502.87
VRS_0S64 799738.701 1905451.349 435.795
VRS_0821 799424.631 1905792.714 450.974
VRS_0832 799445.196 1905574.204 438.593
Station name/Location Northing Easting Elevation F.G.
BUILDING/CONTROL POINTS
BLD CRNR 799443.716 1905599.135 465.05
BLDGCRNR3 799544.87 1905519.44 468.332
LHS BLD CRNR 799669.738 1905668. 723 489.144
MSGCP 799702.249 1905668.147 489.575
STORM 799391.555 1905816.575 456.068
STORN 799380.718 1905813.298 455.481
STORO 799387.239 1905839.84 455.579
CNTRSM BLDG 799709.386 1905586.903 485.24
EOB RHS 799682.069 1905519.72 481.814
Station name/Location Northing Easting Elevation F.G.
CIRCUITN
N-1 799716.59 1905526.172 483.76
N-2 799719.973 1905476.214 480.908
N-3 799728.032 1905451.934 479.645
N-4 799705.343 1905447.358 478.478
N-5 799700.249 1905478.98 479.441
N-6 799704.139 1905504.642 483.245
N-7 799705.585 1905423.018 476.8()2
N-8 799706.737 1905397.254 476.206
N-9 799676.214 1905435.726 476.746
Station name/Location Northing Easting Elevation F.G.
CIRCUIT C
C-1 799531.159 1905663.451 471.182
C-2 799500.958 1905568.145 465.203
C-3 799531.159 1905663.451 471.182
C-4 799519.217 1905569.424 466.991
C-5 799531.159 1905663.451 477.48
C-6 799533.264 1905585.052 467.137
C-7 799529.212 1905643.679 471.43
C-8 799530.052 1905631.635 471.182
C-9 799531.159 1905663.451 465.422
C-10 799526.004 1905653.609 472.213
C-11 799542.969 1905611.68 477.48
C-12 799528.998 1905699.935 435.426
C-14 799522.401 1905725.485 451.144
C-16 799519.955 1905741.644 473.517
C-17 799519.722 1905593.413 468.042
Station name/Location Northing Easting Elevation F.($.
CIRCUITS
5-1 799483.171 1905564.537 463.964
5-2 799418.618 1905803.424 456.712
S-3 799449.494 1905579.918 461.973
5-4 799466.758 1905550.319 462.741
s-s 799434.339 1905557 .526 462.474
S-6 799416.254 1905571.733 468.508
S-7 799391.278 1905598.606 460.369
S-8 799418.618 1905803.424 456.712
S-9 799414.426 1905639.591 460.45
S-10 799434.339 1905557 .526 462.474
S-11 799411.935 1905660.338 459.892
S-12 799416.108 1905620.226 460.937
S-13 799409.068 1905739.592 457.846
S-14 799418.618 1905803.424 456.712
S-15 799412.397 1905681.015 459.597
S-16 799418.618 1905803.424 456.712
S-17 799434.339 1905557.526 462.474
S-18 799434.339 1905557.526 462.474
S-19 799406.302 1905759.311 457.176
S-20 799412.173 1905720.357 458.498
S-21 799385.979 1905806.176 455.544
S-22 799418.618 1905803.424 456.712
S-23 799418.618 1905803.424 456.712
S-23 799388.923 1905762.978 457.153
S-24 799434.339 1905557.526 462.474
S-25 799422.534 1905822.174 456.74
S-26 799418.618 1905803.424 456.712
S-27 799386.935 1905784.56 456.735
S-28 799418.618 1905803.424 456.712
S-29 799434.339 1905557.526 462.474
S-30 799403.336 1905816.345 456.306
S-31 799434.339 1905557 .526 462.474
5·32 799529.04 1905619.292 466.837
3
Kill
�9E
479.64 5 N -�-
EOM WS
480.9D8
483.760
476,206 47& 478.478 +-5 45
47'
K
-9
474
If =
a� rs

46a,937
jL C-�S
i
6.991
r-
I
477,480
UPPER 4iLL
5.422
8 I 472,2 463
BRICK BUILDING
435.426
-14
-15 C-17
6 - 3 460,
-16
473.517
Gaa-6

C13--L0-C A10 %=;Of
Top
Top -
Tap 9attom —
14faii 11F�GIWAf1Oli: "humbd
G�fcCa_t 3 3 ' TOP—D— Sm-'rn , Fl
NM WELL Lei Str •
S. tltlCLL L11M+3CHe& Oft Bafq LrandafflfQ [] hAlmkpfl}!F'u * ❑'
0 A{pif:La1kw al ❑ Pam" IM klf 9 wr 1y
—
r H"*&L NMI ER TREATtEW SM-Mg-07,ge
RESIDENTM WaLX7B�!
1V" C.mwina Depanwm ofFavku mm 4nd Nww*i Peiaumm M09l 6h OFWaw QM11W
WFJA,CONTEtACMK,LZRTKIFICKfFOr46-. tl l-! 17
fL Tot OF CAM13 la --'—FT. Acme LaM SUUW
'Top f]r *.�x,p �balaw tmld s lary
0 mfrance tmaaftneaa wHd 15A NCAC 3C of 1.
KEE m of Tsar. �t
t otsl!# GTidLi: Fib is � Aramt %
Tf>a� $apnrn
Tcp
hbak" a
t cAamr.! offlpah
Tgp. BaftM ___•_ Ft
Top .9v#om ­ F�__
S. GROLlr L7a0h , Mon
afrffyawc Qum Q (Am u,a] : Tf7J7 Halhxn Ft
Tap = Sodom F
+ L►i .:S i 4 a; in i A )- i'lE. ��� F4, TOO— auftmi—
t949a1 MwncN�iM Oi-fardgf. � Lad Me., POWA. ap VAN ; Top 0at{pfi�_ FL
CiCY n CQUMY !'' l ; Tap 9fflL0m Ft.y Jn. UL
T0P0GRAPHIC!iAWSEiTrL — w&m*
l%R'+ W C!VIft CIFW Banda i 7 : It. &M Oi QMVF . VACPL
an f4LrFelrL
L^Tn LAE „�f' j�• ' ' CAMS OR j&X M DID :Toy _ Fk
Lo"Rm lkn: 1' t� • ' ens nay 7mam2m co : zac. SCOMIL . _..
L.eriLlda rsMlYida flpie (j -gmwhio map : TOP FI.
ownwaf womwwma STOINPoo a Usastvamw ftfom-cmd(a
p11/ km gym! i 1, &MWLJ rVW LOG
a. FACILM ftm o1 ft tflskWff %Mw the well is SOLO d l TOP 8n1 m Ford Horn Dawyoum
R '.tom F' �• J;A�•Ma
1,
L.k fir'
r
kii Plwm flirfleCal
a. TMAL DL TfI' _
a. 0MaAIBLL VMMACK M*KTMG lA1 ML.i 'ES M NCOr
_ "ATERLOW. DOWTOpofC,AAV. �•�� F`r.,
Wm -% ' RI4W" Tap orC#M"j
InOFlf�lE7yCG5
= tMMSf� • w
RL"C 13G
i
EL
r-A-' )t)
oeAT'�
81 Wnit wMn 30 days of ompk6on to! Divk as of libW Q"ft - kftnis{tm pravg�-ft form C-Nv-1 C
INT {IbiE >Gervkc Cwdw, imkmlgi4 MC a'A98a-169, Pharoa : 1219) 0074WO Rev. mg

t"-Ib-culu m"du 1WHEEL L-IRTER TREATMENT 828-3G9-Ft740
mop
Na th Ca fto T)q=nesa of Ew4miRoI andNammd Re969rce- VivKiea pT WGW Qwffly
' vVZU CONT RA(7rx)rt: CEELTIFECATION P 3424-1
I. VAML
wren cetlstadW (h*vkkmD NM*
indx" WowTrfeAtmw, ing _ _Y
welt o c mr Nm*c.I
Fr
anklin
cay ar raw! SW* Vp Code
(828] -,160--QM
Am code >PPWW awy bef
f- WELL 70m,
WELL cowmu Tmw 1SER1v1ri MiMal
GTmm ASSQClATED PEfitdlTlr(1T4wr=md— . _
MlY& VVELL !Q
a.1rtU.L tip �Chgdi sin. t3a1q 1fAgri7tarll� � � i!
hT1911wL Odd O 1
DATE OR j ten,-�
4. VJCLL LOCAMM
1735 Road
CITY w COXI'VARIMNce
TOPOGRAPmC 1st GErrwG: fir,& rlpphlpow howl
IATMJM *3/�J� ' I(�tL j_-D
�} 1� ab OR Ty Y�/7.�fV V�1 M
oP
Do
uwk dewhn*hidb hr m Affs Qrgpa whk nw
(Axsadal dtreAtbs rw l+ W"� lgpa rrsxA al.de
fh4 brm dr@htlii+q aps)
R FACTLM 04wo at: the b4tinw tiEtwm she we is woatwq
*70,1 f. ;a. _ f1 1 i�1 i fr;
_A
AM WO FVWM Mwgmff
a TRATAL PEPTW.
bi aQ:l9 LN mL RLo.FLmm Mama YIeu? TES m No LUf
r- VMTM LrM B dew Top of Caft. _ j L`] FT:
it" "F' RAODW Top of Cevkgy
oL vtW oR 9& '� Fr. AbM t,W1cl Si02W
-rep of cute taTrir%Wd &%r bftw WO 04feaa =w Tp4't
It ►flr4ow In accordmmwvg h TSA NCAC xC At A
e. YIELD (Up*. LJC-� WDM of
ok varot a ter• ~
r r 11 ae�ta� ap Somem
Tap— Baltic:!_. Tap Somm
Tqp flop + T09 Boum
Tkkamaw
i. CASikkG"- d6ttrael;ar tlitiEphl liriiit�tE
Top_
= L OFAXfT: Davth
R Ms:7R1 n: 4eeth DiamaLa S1al Sirs la rlel
Tarr B*on — — ft ar. in. _
Top OQonv —Ft,_in- in.
Tap 13 _ Ft. ln. In, -
14 L 4,A DOCIPA EL PA C&-
Top--P9dprn Ft._
t tii grim
rap �
Top E aftrrl
Ft.
it. OPLUW LOG
= Top Sam"
m
FlxF AdW [lWC**W
rn�
1,24
I
9 qfe
---41—
IocilpCYamTILV ieIATTl1�
WeOONTREFUMrM►WOgM4=Vv7m
. "A W-W � .1111
Tm-r A 6t]" nF nYa
E
�c TUFF TrF>
ELL C Ofs
PRI TM NAM OF Plan N C4KWrRW nNi3 Tm w�Li
Subm t YMhin 30 4"v of celnlpi©tion bw. t7tvMhm of WMw Quaff Fwml ow-t h
a lei? Am savi comwr mo tw% me y/m-1Rf I. Phan = pi 9)11 4m r Rev. 2m

kR3SCb F HFd 1L WR I Fly TFEATMENT ET�8-369-fir 48 p+ l�
JVTI
'! QA RESIDE
AL Btai, C [i wN a
I 14m0hcarnlFnH r*Fxrtment ufEpriea WW N PCIPnunCcs- I"31Ylsion of Went Qpmhy
WS:LL CONT['RAC TOIL' C.IX 1rICA'IiON # _ L x L1
t Tor of CAWN is rr. Abmm tare sm%ce
tY� _ �{ -rap ct cwe I z1or below find mrrr�oa -W+ee��
..1' ■ wdo� i eaoordffM WM 1SA NCAC?2G . l tt! ,
1,Jri"oaF'iC
ry � wa TtiRFs L 1r i �. �`TM. TIPIi� + �"m
' P _ _ C� c1 k. �1 ; Fap (J --^ -Top-- &I'm%
Cfj or Tawn mate zip Gads : red — -Top 1__
.ONO : Top Boom Top n
so mn�er - TWA*M"
W1fE W7 iC �_S_,r���_ : Tap F - -- -
E. CRONY': D"M R'c rod
u ►►�n a< G7 Raoar�t3r» : T W
m�ea+Fi i aa,ecu t!�u : Tvp
Pam tt mum--L"'
� we,�, L�octcTivrh
cart [... . Sub*400n, Ld No., Rom. Do CDOM
any. "� couKryjl k-OBJN-t-
TOPOGRAPHel LAW SEnM. i"" app"
LAYftiME �'s��c• "DMSCM Jx.ii t7C1C DD
tour; ig'A '-19 ' nx-�" OW Oil 7Az&UMM DD
LmA*Wv*vftiQta= DNoFapl*.-p
r +Q(AMAm ht &Wxdb7 aLOW kpomap andaMW16dtn
this km ,Ient+=kv GPs)
VAR LMV 04mm gf 1% Iw wwms wheno ow wan is iocamd.)
i I
Arft code F•'f me rwmbw
h. DO" Yf= PATWE Ex67il a yd%.L9 YES ❑ NO'�
a, WATER LOM S mw Top ofC amg: _ 11- `Fr.
P@v +'rAbmQYopof
: IL tam owth aftmrbr awe sm Nku m+
Top aaaarr�._� F[._ In. to
T-P +_ n � _- in. _
Top ROM F�_ h � In.
iR eA3iI fGMVEi. PACK,
DRm aim ml, w
Top Howe FLU^
Tov.�eiotmm �i,�
11. MiUMG LOG
TOP eatim
IS,
Fi) MBOM DO[arF#1W
ae
a -
- tSAtIC/C��� 'Rtk. ►i1�As, ' �Y � co�rrGr 7Mb
Te1RE 141W� WELL, �' - DATE w
T4AMFCFP'
� oH THE I
Subm t wkin 30 d "w o1 eowgft w ta: a►F•iv an of Wow O+ify - *wbm=om Drop Farm Caw-td
1IM7 U28 Sv.4ft Cam, laic 2MIp616% prr W : ("s) M)F.A3 a Rev.2=

k" TRWEF1 [ATER TFEATMENT 82B-'?S9-B74B
Pt<1GiE11
J 11
r .. F wonh Ca ynn nay nPrnvlmm+xnt aPd Nak,ttf Repu rm.4- ty3vlRM of W ax 4asb
WELL CO4V'l€RACTOR Ci;tt7lF?C'► MOM # 3424-ri
1.1FI1a1. f+ L�R:
: d. " 4r CASUM W FT Abm* LMO.SurbW
Top d casino fem avo aft ba m ww w ftm mvy rr*AM
.�� _ -_ .,, ...—
%Vw 0"Oo k" Name
■ YOi 1�l1nC IR ava4i0erxJ9 wilh i bA fVCAG 2C 011S.
AB�0 {gym}: ARTl$w GF?MI ,
3494 Aboda Road
pl1S Ad*m
TER � ulm (dog*
r�ranklln NC
: 'rope ^ TM-- BOmem
_
—C4 OF Town alm's Gads
? Top Boa om— Top BotlrJr L ____
(828
yiop , _ t3utbm— i'ap Buitarn
Anm 0ed6 Phm m na*
t YI�Lr. IIdFt7[ 1A71(lRSr
33---
: r. Gam: Dvpib r p t Yualtiht try
VVEU CONST UGI)ON P
OTHER A88OCJATEV PERMiTM�ap0imbwL _ �
Top— ^— ra —
_
'
Top - --- ft.
:
7� +AMLL USE lC" Om 8a) LbraWfrlg p Mulfo0dFuft(3
L QIWT: 'methv
M ri AgftWM-W l l 1ewwv U 1(
trl*00np Obw I t (M -p3
Top FL
■.vmtk
SCR 8*0 16aat.MW
1735 a i am QuwzRgw_
: Top1t__ In.
fsb" Nft *m taam..CAMRM*. Rubdligo[1, tat No - rout +DP 090e0
; T114 8001n - f t. Ifti fn
C#1Y; CMwT, AIH{ wM
Top n Ft.--h
+ tOPOtlR/PM I LAND $T 7'TWQK (drat% appmpmw 4*
M UVAM L)FIS fad t3�
: 10. LAl OMIAM PACK.,
„�� _
LJi7lT1A7E MS OR X U.�Ui% XX)0[ M
DoP� i�8 �
�"
To0_n s t
-
L[iWWWE ' MM OR ZLXUMgM DD
T R_
uMw*Aw41ud11 aatl0r+�8 0 q"mp?* NIMP
(rpae�ORolpddl►1raZfDa an r i.ISG$ICQQ►raaPirPdrftalCJJedt�p
_
: TnP_= _ t'i•— _
'
Iarnr rraf aa�7C GPB�
' 11. DFDLU #!3 Lori
8. F4CRICY jIylrm of to IktskA" s kwo ft w A Is Ada
: Top�y Boiftm Fem~ D"u-f bm
Sunnesm-Rhw- Mg
Farligr trNnle Faaary Of (a �lic;ble]-IZ35
Mond
Be d3Wmw-r-bjamh
90Kar
1
�tsloh�lr3►ei _ _�. �
�
�����ire�l. _ _
C otp ar rftn zo
V
Jobe Ankm
��
MMOVAdftm
CAy ar Tom Strap Zip Cods
IL MUMMOM
AM COW MMM nipnM
L WELL '
A Griirt•r CEk'fl
MVLY:i:ffTOTAL
UEP?ti
t
h. DOM uELL �Jlm mmmse Yi u? vre C1 w fv
MC C T>F'I
L s 1nrJ�1'£R L&M ack w Tap of C•sr n _ r J F7
Lt1se'+' If 11DM Tap of CeeirW
PRWTED NAME OC PERSON 6awlRiJC-Fi Tli VWELL
tl tbmlt nidthtn 30 dqv of *mVivam io: ah tY km of Water Aua ter - kft mat kbn ,& Fa r O
1817 6W 9w0m Cyr, RaMigi 1, NO 379WIS t, Phone: (In g)
ADi4

VAit,
w "i r t North. CarabtnaDepmttmenr nb'Eavirnnment and Nstural R,es m ump DtAsim a[ Waftr QaaW
v34�4 A
wE�.L CoN�'RAC-IoR CE.ETmcATjorf #
i. WELL ODN RIYCTDI
Michael S. MCC
Well CCttiraclx Ordivldual) Name
Tarbgel ffgig Trews ent. Inc
won Cwftc or C wp" Name
3 94 Ceomia Road
Srwt AWm=
FMQK in Nam_ 20734
chy ar Taws+ awe zip Code
:L Vft- , WrIO MATiGN:
WELL CONSTRUCTM one WI04l Ei$33
OTHM ASSOCIATEO PEAMit'#{Fi +pplice
SITE WE.L )D Og■ omwe] h,_ 51-
3. WELL USE (Chu* One B4 6Awduri%❑ Mw4prdlPmbft p
irdnChdBVCpmnlemW p AWtw%uW ❑ Rec+"V o WoWon
lnipt and Odw II ({lst use)
DATE
4. WIdLL LOCATKW-r
17=mgaa ethlle m Church_ Road
[Ste ONdn , Niar> m& Ccnvmwfay, Subs Mdm, Lot No., Zip )
CITY 0—haw cwNTY_1lai7]
TOPOGRAPHIC 1 LAND SETTMG' 0** apprapfts baQ
41%O a OVaBey E]FMt i7Rk4p pC+v
LATITUDE 35 " EMS OR 3X.X70CC XXX DO
LONG1TUDE 75 •� • DINS OR 7XXXMVM DD
L,aftksAanp Lda aounoa; p3Ps oropogrepNc map
(bcatlan of wa# mzW bw shower an a t W3S bpv map &%*ftowd to
this " NMX us" Gm
L FAC1t17Y (Nerve of tive business vitw a the vva0 is Ioaaled.)
.+i, - • .r a
!■ •f �� : Ira � • ..- •F
err •u.r
Aron code fshom number
& WELL DETIALS:
e. TOTAL DEFT}[:
b. DIM W&L PJWU= EXbax M WELL? YM p mo d
d. TOP OP CAMW la FT. AbM f,.ird 81E'AeCd•
*Top a ca*vg *H*m led sUm below Iand surface nY r qL"
a variance In aecardw= vAC 15A NCAC 2C . iI&
e. YIELD (ffm): MUTHM OF I ES +�
f. DL911liFEMIN: Type AMOMIN t
g WATO ZOM depth):
Tap ft tom T sattwL -
Top aoHorrt BGsarn
TOP soporn Top m
Ti
T. Ci19Elbdi: Dept! DberrMlrr gist Ild�e w
PL
sop Bvttam
Top Ft
8. GROUT: E)apf)I N51M1i4
Top 90ttOML,— FL
Top Battprn FL
1L SOMEblb: Depth akwww Not st m maeom
Top Botmm FT,—ht In.
Top avtborrs R, il. In.
Top f wffL— Ft Ire. Tn-
10. SA OMF A11EL PACK:
�fMt+ 8tai
Top ®ovwq— Ft
Tap BCliorn FL
11. DF4L bNG LOU
Tqp Bad =
C>
12, Fd3gAF LS:
c WATER L EVF1. Below Top of Caltng Michag] S_ Mcrh i(a
{uve -' N Abm Tapp d Csalns} PRtNTrzD NAME OF PERSON CONSTRLJCMIG THE MU
Farm GW--ib
s�mft �M 30 d� ofc�rrbpldl#itaFt ia: Dhrbliarl or water gnailty - � �,
iGil W) Gervisa Corder, FtmkdQh, NC 77EWI61, Pham : MIS) 8DY-OW Fier. 200

oPF-as~C:oia tan:lu iHi$hEL WTER TRERTMEW B2e-369-074B
PRGE:15
cmmwtxTtolq
*w* CwuNm r)e wfxwK arEnv3rpri["wr and Nmir i gmmua- 17wWan oYWafar Q%Wfty
WEM COi•1TRAMB [MRTUrICA'i'' M # "
r •;
wELLCOMMUMIM r sYV- rQ40�}�
OTHER ASSOCIATED Pf R3R1Ta�{`
WE VVIF[LL 1f so )
3. V .L Un (chw* am Fleur) k+ronlX" 3 IdurkrprtPaw Lj
UF%Wwno poser © iig Me)
41. V03LL L*CATM
1735 ChMT&Rgad
CITY_ CIX1MTy- @ o--
TOPOC3RA&4'iiC I UWD SETTING; W►rrst rppropraft W4
d600 r'1VA t ❑FM GTRf4P OOr,-
UTffUDE V�� "iJM�pR lf.11 %IUUDG:iif DO
Lowrwoe IL-:--, DMs UR z&,&w92=L pa
j Mft oa&3r4tk de sawor� ❑rMwrapM map
jrx�eiaai ar+r<einai,ar f7a an ■ t�s i'� nfi1P ertdait�cheC �
etiG Elam �,+ar++r� ref
L RAM" {f'fGM a1 fr+a hVWrMfi wall a tDMMd.)
"Teo of G"N fmnwu wiw bow bod Awlaw r7y o4ift
a [tEiA RilrTilOi? {1F Tiffii7A._.
TOMSaflom Tap
- BOWM-
T-o, �a— SM. _ - Top "L-
: Top 90twir Toi► Baum
ThAdoKow
:7. ruwak Puy"~ VPN%Vt Mbhriai
TIP= F
Tap iiva=
p
' To�•, ��
T*O I�Z CJ�� FL—&n&UkjWA
TDp i F+.
Tap - Pl.
4 3cr
ink Dwo DIMPOW swato Al[ak."
Top _ � 6offarrt f=t a in.
= TOP , FE kr )n-
14L SAtXMCRA IFf- PACK:
08PA slow idlcM" Mi
: Top AU6W Ft -
Tov
T ft
Too &aml
.n I
Arwrww* Pin votapbdr
L VAMI WrA"- ` 1 m HCfGiiNomrrfr 7iMT±►R►i AN w �Of TKS 11RiN
q Z � � � 1W IJChC>�. MYcii ' iJG 'AIA7aN 7l4 CO1^f Uf iW6
s- TCMAL DEPTH! L—J[ : w caRp o
a. DdE'6 VMLJL*WMAt'$ MW1t#C fiiiKL7 ► eglo NOW
sir► OF cERrl>Z>_ st_ coRMACTUR� ATE
e.. wu►T� L�v�. sowMr Tap od Ce�ieep: ,��`F-r.
(i1.e'r" x�+iv�v r4p ar Cw.hg] : p MAME�of PMOV COMS TFrJCT( 4G IM WEtL
submit WWWR W do" al oom€pkWon tv. Mvisian after Qua tar - Wdw=bM pn lev.2/09 to
if'J17IM Sorvloo Cwkbr, Rakh^ 114C 2M2 M. Phan.: (M) WY-634

�7
Z VML�o0�'nUO�f�
Wri
Ikka
Y11r3 � it
SIRM d L
aoa.
d.'il[df1�10�E '
��LDtiQ
wRRcWAMwM pWmft
pll�ll�OCiIC{R°FI Pa�11Td�f
atL' LUBIIak pda�#t�a0�
a�
,Tm Pkir MW
arr: t-04/14Iran
wry
'IAPF101WIorrs�
v aW Z vMW p at a Neu fl
LAIR=
Rer�CI
b.0 10 ON 0 Toposm%e m p
l.F�JTY.arao�*s�priM7w.�w1. woo.a
t�t�li�cllmr
wm a-} M. ;�
a. ,mot. -,
LaMVMMLRM%A=MMTMVAU2
a 9Rio[t�.srfoni►1'i�pafC..i�p: -
Y
IVIDPaADMO /_—PT-Mw*Laud&sbW
�� ln.moAre+.. wlh 1�11 irCa�C�� mom_
s6 low ammyt. i r
a. VAIMa
T. Wmm adb DtWWW 1kaIM111
L 02001': VSW mWmd
aAlkv _d
ftpn-
P.._.Tq
IL WFAW. DR* okmww mot am miW
A VANOM1 L PAM
Dam am item
P=tL—QL— Rom... -
iiaptaim Lm
Fm'n To
+m++.w.rr sore�rxw�`rx�s ri.��r�.aa�am.+�n+
PROMMMANEWPIMMCON
ftbmkdwodgbdU**MvkkmofWowa=MtywNWSOdq% Mtn V*wmm m apt., � n,
aes7 �e�v�. r..nde—may Mc4f1T Rhon. Fho. �tq rs-rnta��.

u7"10-C. AM f ; 11 lFM-EEL WITER TRFRTMEW SM-369-0740 FPGE17
Al AN
. + ' Na tlr Cuolm ThTurbrNft of £rrvrammcft aftd WWral Rcae+uvr9- Diviswn of Wift'r QWkV
WILL liONTMCTC)R CER'iHICO.T N[ tl 3424-A
HMV w..
h• �
►t Ra u
I
L V05LL WPCREAT"-
wFu C{!lwii' ucmN Pm VVM400133
DTHM ASSOCATM f RlIA1T#(p/;�pp�r+r�
3.1TP WM-L f��fif 1.� C, F - -
DATlr OPA-M
r-gr 5-ign m -- 00[ 4TYAfBitnaM _
70POGRAPMC 1 LAND SETTIF - lstlfrsi appra owu bowl
3YOv>r UFW n.RWM C OVW_
Low -ram WAS on M
LGRUCIGANWILIda DOM 039 i rgmor4pw map
{kMMIM d mud be ON*" mr a U= NN aw vidaccud ad to
lw Rpm r1w vsft GPq
3. FAGT-r" QV.1 a or ft Gtahm w vre vw ►+ail is iKaw )
.i.E:.:.". 10si f
I -
Ar" Cfid6 Phom rArtw
t VA&L 47ETRA 8: '
lk DOn MAL PMWLAM jWTM UV.L? /YES0 NOV/
x WATM LM Bal+w Top of Cowa 16, FT.
(L 4 +' 9 Ab4w Top rr1 CaahO
d TOP OF C SM R . At ova Land SU!(fr4e'
Top a =wm krmi n*w ahw trelow ww swsca mq rcgo "
a wtotwoo in sexKdarroo vA%h 18A MCAC 2C .0111 B.
o. YIELD 4MNW: i - TF►CO O� 3 8 f `�
s. CIiGFb rjpvX_%'�� le S
MEMar)ir�f (tfeplti]:
Top._ enelorR_____� Tpp �o�►sL�
Top 8otmm Top l*rn
Top &Oon+ rou — aofiw
r. WAMOr Vftkp►+t mctww
: Toni
Top Howl —
Top Bcftm—pt�—
a. GRL2- - Ord
7�
Top .. _ mom - A
Tap 60M— Ft.
_. —
IL N cam: D"Ah
Db:wuftr
slat elf} ow ig hd
TapL____r, Btrdvm
Fk 1n.
in.
Tap BWttio1_
RL in.
WL
I& SAM% MlVp. 4AC*L-
POPM
GIZ6
G%Wrlst
' Tlgf Bv41TnT!
Ft. _
Top Bdtwt+
Ft
' Top Ft•
11. OML11MG LOG
Top Boft n
FOMM
C-r
13DD DOSMIPW
12. R4Edtl Mft
.40011WAWClIEW TTW INArCOROAWCWrrH
Ish rIT.AG.7{'w kc T A COPY OF THO
r �13r1t�
RT1 }xxfTRCA DATE
FRINTFL] Nl1 M 4F FERN COMTROCTM THE WELL
w
Bubmt IA Oda 30 dsryo of �kw&m tw. Cif Sian of WaW QuOty - #tr onnow Pmomasft PFr3CiW-T6
18i T WM 9wv" O#rE�rr, l�a�rk h, NG 2MIl-itn. Phone : (Glg) WT er�148

sff Nit Caraljoa T�gmt as�imrsar+►t and 1Vanuel Resouro� IYt+isian d W �a}Ity
■nu mt+t' iw-um cm?1w- AlrtcK P # 3424 A
1. wa&
a IT tau -Tt 4 t�.
:... _:.
Air t si. .
�..
L -1 ffato
Am eoda Fhww rm bEY
WELL CONSrAU=MPOZW*3YjO4QQj33
RTtMR ASSOVATM PERWfN[iFapfC=W) .__
ML UM (Cho* Ow sort Mmdwft r3 MwkqmW►oc a
! t Ihwbmfjsa l 7 Reoo► oy U ki n d
kop"ano omm 1`3PH
CLm.ibMlC` couWilr@_
TOaOORAPMC r LAND sE TMM- Mhod ropwMk b0
nr qBY DFW ORM90 ©O#
LAMUCE Dug OR go
LmMusAm*ftuda mw= Ora L-lrww.-Pft MOP
rboom ON" nnLWAW rnaaar ar} a us"" map fro
m b-m #ea V"V GPI
Cr_ FACUTY OW* d ft buWow urwe H* we9 is laol od•i
Aae•(�1a
i.lfl®1 DEiTurR.B: C r' r
b. DOW tML MWLACR DWDJ4 WELL-7 YES r s NO rq'
s.TER LEM BrAIVTOP d C 10V
(} +• it Abmm lap of CaLMM
7'op of am" !or►rMro6'sd i6O b * w is W =two mmr M-Vm
■ vadaxx frr Swwow= wAh JSAL W..MC 2C .pti L
a ]'IELD ap"o:AL21.M!T#Igo of utITAi 3t.jL' t, g1�T[aM: Tie Arnp�l
Yi %m MOM (dspft
Tip 8oitx,,
TOP BOOM Top Bo1 m ______
Tap____, Saw" Tep %Otkw!rL—
. 3flivia�i�!
:7_ CA*/I�ff}QC bionwbtr WOW uktorw
• Top V gpq _����r- •-
Tqp ff.
% ti0AEo1r+ fit
1010�k1f: �. MaI+rdaf AOIfwd
Top Bara — a
Top bomm ► n,—in, in. _ - - -- -
In
W 9ANDRUI U PACX--
1Dapm
'TcW
Tq�_BaSom Pt
r� r._ -
ZZ. OFM- "G LOG
Tap BOOM ForMdQn OeWfpiioE'
;M1 l a
1
r
� f�f
4�� I ��WM=ffVACCOFMOXXWMf
7f : A COPY OF 7NM
= sr•
. .. '
--
PRIpIiEO htECW PEfr•'a N C.bN8TMXTING THE WELL
Rev. R
Submt7Nhin 30Op of wmpW t to: s�Y1�im of Wahl atfc mGdon Pmfts *. ev. z►a9 Mfh
1617 UW Sanfta Zwftr, PjO*W . NC 27'�1E#, Phom : (9s11) 4= R

c/
P
r
NO&Crratd�a4dNfift dA=aoimpl*vwftQ1vf2lE Qnlw*
LYMLLOf&w
s' VOM �.'�pM��
:w U=VftL��►IM-8 VW R
�. MwT�R � w T14fM�w�TLaP of I.'avir��.
d Tw OP G,'!1!� � '
! FT Abx* LapelerAror S
"1tip d � f�ppNredo�. Yd a�tia. any �
• mko #pepdree+rw flV1li1L'J�C Af1f1.
a 1rN[il �: r � .f�f4iCD Gr:S�Ri'
Q. fw�>7Cii■� fd�plbx
% CJIi�IRie �! p�ludir nrrwtdmr �
L OMOR:
t somm Doh t)lo! lr eixftB Aftw>a
PNOL-Tq- IL
Im4.- T4k-
7
iarr�ara� 71r:1+lY�i�R/I��tAp�4RirYlTh1
�11M71�7'�.��.L I���i1 O0lYRs�i�
f lST 'IrFs w f �I f7 PWM M&P"r3I-M G GM mod. fty law

F . r
l� ft" a rkv a adt o Rk%pv COBiL
(ohm*
fib" 11igr�in depe4
mkaer, a* W or
I�or�gi4ad� �rrea� d cre Q Toposalrbk Mm
pea�rld�R�laal�rort■ W�7opet�p �
6Rx4��dbE��aA�nofq�p+� .
War -ow
i - 3.
Aes aft- PWW n{ RW—
Ton
a vrkt Qwkw
&W�►*ff��a .
d. 7'POF s 1_____PIew�� A➢aur
hmwmffbmsw
�YapI A -orrr�h t i�R C mw"
IL
.r-
� 1MiF�i�yd�Pf�
mwR.......rs
L MUMP.. VWM memo �
ftffk.Tkq5d.. ------�—
ftwq-_TO-RM
a eolem Dwa vk radw ld Aft VAWW
I& MKOMMAL PAM
OW& lt, w wm
ftn
un
yt� �
P
!{gyp I�YC�Y71AT11#S►N�LYIl11/001�1}tIL� R��►1
�a aC 1�7. /gl[�AiO�pOltYq' �JO'YCi'arR
w91 DMM
E
**a* alter avt bW to tho Dkfth r, ofW4w QUWW W" 30 ftw Pow affix9mgm go, FwmaVMb

cl-i3
c wAL
sirm fiawme
rti I
fi } rye i14 l� i +��_r [i •... .•:y f:��s-y�.*i�f'14 it. '.�-si:3
a
OWIM
�l+11lQLID� _
YMdLapliC?ZC+yA�iM�� .- .
ORF®!l59�i1C�Ci�ip ,
i.%1�LY��dgo;�lh�'�tk'+�t
Om iz
w r
• sm no
��
Ljl � —....rUMOMM
�.•...�..r....,� iaadl�ill�rr�t�
..:.w
I pid ilaia �obeee�c 0 •0 Tie nrV
L i�AG�ii�F7r s++...e�r�ee•.�.ys+..x
W�.11E9
or dada
aMs■ Plger����
tw LLUE"" .
a. TOW.�R
b.MrIm-��1.11 PlAOe pF '" 4VEM pjM
a tRrM ftlak r' is
d "pop OMq p PT. AW"Lam Vwmw
WON WA mum mw
4vownMak1�.DIk1000F'i'RR[
AarR
7. COAMQ Dope ,,00ff� Ott►
Ta
R OROUM OWM O �
* SMOW. DWM Odom
AVO TO PL--- tL
I&SROMRWILPACM
Dope am N*w
r -0.
• � aS
&*rdtS&ofthW to do CWI@ anof%W* Gum IWVlb 30 cis. AM W"Wm Mt.. ftp&*^
1e171 go slew C~- old doh No ZYMM44H 1 win" "M "IM14 s an @a Fbm uw

� !'
Dot mm
'tom
*AOLDW
OR!!�llA1�' CpKi�E�C�1TlpE�+�3ie1
�.1��-�AB��t�akllp�l��ea46faa�Oe�•� ��
Apbdwrsa RNVAK z
iieza
�8
+� iPIBIJ.t�
T+ WnAw ;
Q mwQ maw n pw a li OiE+:r .
� �►��i N�6r�de�,
LrJk017L10E ..... � is:�rirr�
Leff aog a raosoor MOPS A TopoVmo3e =p
r� 11�1,1
RIA
coo
illw nods � PM�q�
tVELL MSM
o. Tpiri1.
b. aaW*UL=pk MOBYMWK ?, Ym ma
a
� "4"'�llbOwe itfpd
P-d
f� lft wo Im
7. awft DOOM OMMM6w Tm*mm4n*w Usuft
RM.. D- — T'
IL Scanw. D"m owns f ads -a MoAdd
PMM.To--., R..—VL h
ONO 4w NW,*"
AWL�•o r w -
riJWAARM tom
IA 7-
ill
1�Avo�Y�MNf1M
M1AFlIdAOQYa7lMiA�G '
�! r
ADWIR
ONE
Out -11 lift„ Flomw*lb

}
6� � 7,46
nr�w�v�r
AWWW
ano■O MUMMA Ww*wg
�m me PM13
Mr.
� ti f r t.r'G'f
aar, Zif
�oPa�11PHGltAND SUTWIR
eQWco•llbft0 PAt n MdW.o
bw
�mrd>l�a*..4
i +dw>rinep�mde �owr+aa: G S'Jp8 Tcposvil raw
LRMLtl1f alAss�awwlw�rlw�resa..s��nx
WWICIF
co"T L.r
M111LRO ADDlIMM .
Clyar'iam m;
G—aZ - Fb MnWBIW
brtW<1.�J�biJyCi �ONrfM IAIW.1.� YM NIX
4L iw apaA m a f PT *b" Land
lNldll�Yd'��IN
■vallr�.+�lnaedeedirll�wl�ri�lIIIGAC�F�t1d. � �
vma Opel
1RM
I 011ie,"
T. amm all momvw vowd
ham r
Tv. smmoARNAL PAGM
M* #fir Miilydrl
7i�1!lY.kt710 L�
IA —
I OaK�r�ff11�11�tAiN1�1�111/11�1C� IIiA0001/MIe�1IlFN
1M Nis[s��If;L0�1�[I�s�1>t1'ir1YAA�A<IMr:�1gp AL�1*7�
�laap �rlrt�l�I.+.
8ehe nttllMr alp�rl� ti>a ii ivr� a�lRear r #n �tl . A�hle MUL, rzindil to
r r� t nr— trc a�voast PWA Nei PIR TSI-MI prep. fbmc 7'

r�
0 4�,ff t4t
r r_(
wale GIMir
za
� ibda
a r -
>r.tl�l� � f
_ 3�1'�lhllllL ID�1r
MIIa4mamwommPm&aw
pl MAMCMMWPNWt
trAp#mn"%A>f
ma*nmmA&M pwa
IMLSliIMRtsOil
cav- 4C6wY,.m—o
r-
�
s T is papa p �► l9 � � �.--�.-
M0 111 E*b OY
k adWmdiei;im+
t Iae 'I Is IOMR a ms a Tapasmo a mmp
• r / _l � �►trj�
v�
t6 AMMLRWq 1W%UU VW NOW
a. %lLlo MMLOlaarMoctOmor.
c(�
d. ttya'`Y��F OF��q'itllRtr�hNy��:..,. �� ■��/'P/r�.>w�ryFlyi��{ &A&
+�Xja�i1M1fdWW� ISK WAC2MA �l9� y
t wwwrmk�
&
7 WI�IQs Cw�� � �—Dleeilcarhr� 111# l�
MOM"
7
MOM-- TAR_
c scraw. l.'+aOM Lllmuftr BfOtd� hAinfd
AIIWL..._..,.�._
jFftm_TO_R-
RIM TO
AOOCRraw
CVWAWJOWAVH
wxwd�wsaaar►�e��oaawae. r+aw�
Isri"Os ok&id W IW OhIMM G#Vft r� n 20 d� IMilg z waam Yqt., ramowLfb

ILw*Lqwnvm,oft
4- IIJ
any-r��os
r
s�v.o
w�u.�ms7��+rn�a
WNRASIOCKMPERMI Now*)
LVWLUCRWW W
hp$mhA0wwfwWD
h N oatme ¢wtux�
Tawmqcwumm�Ac Ph
yea.
ctm • vc�rr
o Shp o vzmw a "Mi n mten COL-7
""poftb" 1ft1roladv�1R,
LA'1!'MDm _. .—.-ram =kmh% vamma& aw
LIOIilQfil]OE _ k x&dwd h
lows PC 13 ON • D Tapogmp63p mop
Ba �sr8.�ar�:�rrre�w�rrnn..��r�a.
or
Ge Phm
LViLLWAM
i. TOTAL 90
b. DaTAlIMPLAMWALLS You
a Kr=LffMG*"TQPa( f%.
Mm"AbMTapdawkw)
7W OPo 7aa AT. ►lbw* UK d BinArcr
=A� l&
116
f OMMC,W- TM
JJ LC ftr�--To—
�•�� Fmm--rbw —
IL
FmxL_Tq_
41R �'�. PAOfi
��ptR it3 b�
Prom To _ Iktll09041 f 0
wit3•�*]
tL iAMPOM
el
o grrl 6p bn d11 r Quap r whin , Aft Mica Msf , Pnlma -lb
* Cr�1rr— 1iiG +�iT PWWNor ?33-7MSAWM. PAMIM

&VmLamu%vxm
r
Vhd N9xib
a C,, 00
pq TA11M1 IC om
AM NO,
ME ZS
. �wat.oQr
i1A4�6�r1�lyilrllellp�
,mot r
7=ooaaM,rfAm *= P
�ru�a�rnNo: .
0 ft"a vow gr t A Rk%w
dsim4ompr bbw ytwbsbdwsll�
LIK TUT ..r mtssst, ammbar
TOPogi OAC MP
Ommdm mOOMbs , al cos� Opanxp olld
f■
• ■ >r mac: -
1..
{ }
Asscu". M—Mgww
& nasaWftLMM%"Rorr"%tvLLI? NM N
a i�pc1®eealv®.�sJaMtli+Ret{.'al�:�.
C' 8
i � 0lr;f�IB I�,.� j.^._P'f. IlpeirM Lt�14 �ra[krG�
smWm lnln aeaald�erw�11 t�R'JIG
�. �.D [f 1�►k f! OE �T
esWAX
7. NO avnowr 7m&mww*o M"w
s. osovr:
a. sue: Do* owmftr OWNS
aapds �!s �
ti �� we
��►ru 7
rrr.r.irwr�
tLRESWOM
}
IO01�1'�r7ilRilyM�LN�CdiI�IG1� ■iAppLs�{Ir
Y�UIe1117C�1r1lLC NKf710KrA�GP71�
ggln THBVNRL
ACTM
SIbn*gbp or%PW to 00 DMAM of Wdo Qwft WINIft7 30 do*. Aft boa MSG, Fb;mo*'ta

, ril 1�� 10 Wi. I JK77'7�-k o., -75 v7m- .1-9 T � I
a
1L�f1Ol�1'l4�Gi'Gi� �.
Vff�n-K L
wa Gomm" fla.p-1rrw.
GIMI AC�a
Mar imam%
ATM �, MzLa
� M�.u� iCpe��arlia e�aq a��npp �
hslpC�� .Oawip ,ate boa
DMOVAUJtt
DID_ AMC MV
4.VMLLLOMNnM
um= -M-04 GMWW@4W
�s+wm�a�e
ja6t�l�ao�e.omeac !� OPS 1J Yaiem�
b� I�ar�►�F Aq�oep�va�
i 1WlM!ll:es�a�r.ee�rwr.a.1.�.�r+hr rasa
. s
ka; d� Firm -.r aw
&VX 1.va7wAft
a Tvw
�. DMMir"WM=QnT"vA"? "m is
a'�RL�1.9eiyrrlbpdCrr�
4Me � �116aM'�ba e�
e9
n" rtd ppd r�or balaw Ind ads ieMpr aegrhr
�'+�IiMoa! In 1vih ibN M"J1C7C.0ltb.
� Di�'I�iP41d:�faR_��^Awao�!
4 M3�
muru-To- Fmffl...TC.
L 00M. *Mplh md2w"
Kaw
AVL-— - -
L MFXW DWb amem
PAM
06-A :d
'srii?�in'r�'��� -'• •.rs:; ---•�--:fie � .s.l
aubMU *0 OfigkW b fhiw L7tY1 M Of f aUM# 90, 00 -- .9M IMMISM VOL,
pmw idm6 pm Mm 5 4u 9. my uw

for
+ I1' t•4 I [a:
e.vw LLCarmAvmit
Wrl Qmrwipr Kwo
WW C r t 1, Comom Puna
GgyorTam ibb MP Cod*
Z V"LLSilqDAt41Tm
WELL c ONSTMOT" Pt;Ntt'"appAowlat
OFMASBOCVMPEAfi1R#PfI-
r. nf" +am Mhm* Ap0+Wabia emq rid
M F+acnwafyd
hbowe 1101ma Pd arts
Q11T!
TM COMA= MKI ftC
4. VMLLfrG�ICI101�
CJ'fY: • [�DUFfili
l
TQP0WAPHr.ILAND
*Pa a Yww a Font a Ftidp a opw
4a'"� � � Ygbo m �Fa►
LAMUDE
� � 6► ■ dtrimM� �o�
tafinwimowe
eo+rraae a aps a Tupogmphk map
oxmkn otswf rrxw bt aba on a 8� aab
fb disibm� r�,oraa�p �S]
r1 M OF FACLIIY,
ISIRIMrMOREM
qqi a Tom Bob X GoW
C— }
Ama aoem • Rrr mrabor
ILVAEi.flarALS:
b. DOW WELL R04ACE BOTCMg WELL? YEW NOW -
me -4, Wfibor. Top of cmw
Div
a TQ OF CASM s _ - _ PT. Abort LMW Mslaw
?op etsm'rq uInmlad mbar* Ar bmwrbm mar mqft
avw1anm!naaomdm wWMISAFICACx.as18.
& VILD ammy. - NSTWD or Ttsr AaLho
t rm,ow,d
Or ramie mom oh*
Rm-TcL--
Fmn__'rFftffL_ Tq-�-_
7. CliYlM Doph DMmaYr 7%*wm*tV* !bean
& a mmr: Dom Wrtwar
Fmrn^.a' _.T96&
Fonk_Tq. Ft.
!. BCEItiB�F: � DMrrMaar tBot iima �1NEe�imi
.-�x►- fi.
1R &ANDMMVEL PACK'
Depth st iv aWN
Ftart��ro R.
Pv-T4- R
FMm_Tc Ft__
ls�►GTi �l_l.�!,.T�
it ItiEaMMM
�1Mp�an7.�t4tCgwlslyllWlMaRAND7Ml17 AC�Y4F7Na
AwaPoo reriwwTo ate,
8M WATM CF CERT1k M WF.L;, CCNiMCM DATE
POUNTM wWE OF PB 90N CONS Rl,MNO THE WELL,
9utmit the aioinW to 6s Division of vvnw ata ty wain 30 drys. Amw boonnot km MuL, FtwMgWib
ig1? URU BWVI" Cwtbw - ftWgk NC 27fOS-16 [7 PhW* Fla @thy Tm-it I aft M. ft .2w

m�} ±_•+L!_ i--.-" cif i.��..i�i�.:,■1� �ii._ it
F. , 1 ■
c"SLOMMamm
Weg r liO
wr
a.w.u.w�faaLn�
ar�n Aaeoc�� Ps�AiT ipf sppioetxaf
L VMLLU4 [ Pw*ApObOb BONY hlWMA MW*VOPA&M
viol AgbdmM AM b*cUG
Tie PAO Ra
am rY
soPOOPAPicILAND
13 stage o VON o Fu in a
LACffMZ
� � ip s 3rei�1 a�
Latiloaddiva #e muNw 11 CPS a T'op Wapbk mop
P4aM� af�raRmratt h�aban cR a Wt�mpo npp and
ae�dfvehrs ihreu �►iratad� �
FACLftrriDWaos
NAMEOF!PACLIW
STOIWA
emrAcr (- - _ _ _.
CZgr or Ada
Arm coda - Fbwo rkobBr
1�.1M91�f111[se
a. TOM
b. R=WRLmf FU=wwMMYft1? YM Not(
tU�s "+"bAbnwTopn!
0//
d IW OF CAt 0 f Ft. AboMo LaW WNW
am In Wft ISA NOW 70 M
r. VELOmmm or Im
sr
per: Type
MWOM
a. on, ZO
"� ftiffL—T*--
Dwo :
IC oftoLti` Dom #[d� w 1iort+nd
;; T d
FMM `.wT4.._.__ --
. - To - - pt,-� hi.
10. 8AMORNM PALM
000 �a
Ilixthlim um
Fmm To Fa maom [,tiraadptlm
rtil
A-40 �q3n_ (,L=nle
t REwkvm
Vl Ll1Qr
iooMMEWcerwrimal srr LLwrrvm
�.1 MolYs la,%VKL d0lalia■IClR;af al'wrONn0lua�a but x COMP ar 1enY
I 11�avmw= roya l-f►FVA"CAVw M
i
� M 4f�i11R� bP i�N D�YfRl41� 4�w t/P GL11 VIrlih�il aQ Aftw h'dbelOOM MUL, RM&N-lb
1017 qle s - do caeflar — nddl h, uc xrarS. m Phases "M om 78 "Is am uc Awlm

w
_�_ , � `�' YI!=.�ii�.t- '�J.��,-. +� '!7E�zl��T!l.�I"�� :r-�rw,�•r►
wjmW-OMRVAVMx
a raat+ wor
ZVPA.avoIpxrxo .
Amon ONUDO
s�
MA wu
ICPCMFO"ru�s�rrw�
130*6 15► 0 R! 011fr�e
i lrRmgYEn�s no+soec M CM 4M TopospWs amp
d ��br�l�eato�rrq�4i ��m+4
Z Fir-��1=�ari+�r�a Mnrr�ar�.raaa+ra��r�rn<
hoop
GIRWTj
tl�l.�iRpk
a YC1C1mtLR�■1-4ibK'tbpcf C��
�rs�+"RAba�isp aF
C lc2--.
d �w"MitmtMEW*
•wEi�ne+lnaae*dNr�eaw�ti�AHcJrC2C.� ;
CFIMWT
7. CA=10t Don Mow& Tm*w-~ M:ftw
1. MO= Do* mm"
fZ RJ4l�IB11101�.l�AR'K:
ff,Dllf6k!!p LOR
a�
f
ftb" it It pthl to So D*hft i of%V4W QW t WMIn SP &{Ise. ASM Er+lbrwoftft got..

L
Al.,.a 17 Jr. 1 .)
AM OWN- Pbow# otw
srnal.� -
QilRRl1l11lGC1Ai�tEJtl�F�Qf�ppehie,% --
1s.iPA{L{r9E
eRMato A000own r t�
baip���Q Ochma OWKA)
UN COM.Offl— AM ftC
a, VkgLLLOGI'[1Q11t
Cr1 Y: CiMHT►r��
ICPCNffIAP ILAW8ff fit .
0 sbp. a v"W 0 FM o m4p p aErir
*be* b*
ia6mdoliw ina - emm UM 2 Tvpoep} temp
Rvcabn de�T Ago - w • Lssd epo mw aid
as�dieellrl6wt►ne�Fae9rp �p
�+wmLiY �s.F.»...srer�w..5+�wm.s. wr7a3ioriaa
WMOFFAMM
WFREUACORMi
Cr4FW Covet wee Zp CeO
CoNnfcrpmoo" - --
AMAM_
Mmde thaw Rreher
LYe�iLlfsTAREc
b, Do VdLLPM4AC5IXMrrMW9LLT VE SO fXW
c. V*VL tLSMMIWWTGpr1L,--*w.
�'wEAboa Top of
� T1iIs! a�e1s Is 3 - -- �.11he■� Lagd inP�r
'rbp d �elrl� �rplleMRF allhf hifw 6&nd eur�eaa � �
•1leelrrpelrlAppe�derMlaVO fbllHl AC2CRIM
a VMS ZONO
rmn—a?.Q.Tck
Fom--To��Tb
Fwt--Ta rmffL—TC--
s. aFXxrr. owift P51 -
kwp__ To R -
FmnL_Tp
L GCREOW. N7 cupow awsw Moh"W
Fina% _Tq,—F ,_� In.
IL UWARS G. PAS
Dep an was"
Fftm�Tc_ Ft
1tAMMIM Las
FMM 'ra FamwOw
• 1
- I- f �.
&�iiffl 9 11-owarm. w -- . .-
nN>�cao„rnea.aa�srwiat+ow�MesTwv+� earvs��re
�caxaretaa�+�aeq±rot+as�aeRa�es. �
O�NA RR� CA7n
1%1bmg the MBi[ 101he Dh*WR GfVAdWQURWWWh 30 dMM- AMW El'.Atlh�Wgt,
4EI7 i1#E Ce1r��— !iC Ef11�•t$47 Phom mIL MO) rn-i� oand 3". �I

L
wag OWNWO orc r, w
�� W%vw* fi' �2'�
GTtER�FdII,'liFA�F
�^ rr1r1�
yy "a no
fma
�c►LIW��rsp� . .
0 up o%uw 0 Fa 0 m4p a cw;z.
���t� �b0�1¢I�■
LaTrr�� .-..ems or
I�ad*lie aom+oa: 0 Lam$ 0 Topo�ic mbp
bWwddirMwAwinatv" gas L as fq"MWana
Maut�riv�pr.�
w�aF ��aurr�k��
ar �Oa+N
�mrr er�3.� F� r�nb�r
L W61
a TtWALOMIML
b. ACli i+ll:'l.L IwlJk MMMw vM l.? Y®►0
a ►WTBt �9�N►Abare�74�pot��i}�.
d TCPCPGASM D Fr Abed UMdSWft r'
'hpdaG�i�wiod i114rbrfaw�sidwMr naq� eYg4�
am I vAhluNQAC2Cr li&
s. vmaap*. E! �I[ bOq�rtiil'
It DESU frCSTK W-
�. VINI EM=
Fwa&O- Tkia'" ftyL--TNL -
PAWL —Tq _ FeerL. Tq...r_.._
7 CAMM DW& Wow TmwwmWddt* -Iii I
FWL-Ta PL
L ONMr. Daft F SM" -11-n.
d
4.LL.`�y
F=L-T*��y
S. SCIMNi D"M MvMw am so
FrW�Tq�ft �w _..K .win M-
8�
il�v sae
FOM To F fp[Sccs
of
iaaha�r weowew�a�+�
aawa�w►,� ar�wo�a►rn•ar�r► eorraR�ra
Subrgttffis wf&W Ol OM QjYt1km of VftA rQw ft Wkbi 30 days.. Ann bftnoa b1! Mpt, FafaiOW-lb
1�17 Ya1i �fYibr Ca�M'• — !IC #�qW-�17 Hone Ifa (9fdj 73a-7�laaeR Ste. �ex�T1Cq

s.*owlijwwft
WWrCoer WNW ' r
p
CCTPwli �
t" Map erg
�.'�3t►il:� C
F7fi�1�LL0�►L� - ��-l��
0iliiRJB'D P!��#
4.1=10CA! M
Mw ITT VOW 13 FW 13 f by U
i,J�171f'!�R ..� � *iarr�aum�frar
F�ro�r -
r�oF�r
SIMI
C4
�ol�aodi►- �awnisnbas
arretoar�ee
gr 71ii» t i aw
b� wftvwLgto"=M TIl"wKLT VM ME
a 1JI:riC Me �Tq�4M-jv 7—t'�
�imalaYeokt�0[r7�Is����NC'JIG�Id �_
o. L�!'ra?llit�Y4�phx
T. Cam MA
PAW-To�pt�v
Oman
It AVM PJ4Cd[:
FMB--Toft,.--
H�1lILl�p iAt;
U6 FAIPAM
tne-- rwr ear dea V"
riRM?tn�.�ARF�TAC�r�7r�
IIC�QKY 'L'li1lR'N�t4�l�l. ,
..r
its a�l�[r>� ap the plrlsia v1F1lIIG�1rr�1�l�► url ita 2Q dn%
""BOB-- B-eeyio�Ani■r..l I�C?.l�•t�lT Pbw&lw Tsf-7�l��aat � �- O _

'LvL*o""uwymft
r
Wc� �xtarAnd-
sr
f
jvr* dw
2.
m was oiv.,....:
�R11x�J1�CC'GCf� P�Cd�
tte
a�s�.t��a�c�plae�.om4MvdweMd3 �
rAM
"M OOMWXL� Ala ma
uOWN aIAA►Drift a Po*Fa
to a�fi�l die
_ Exam a C� 0 Yopo�bm4p
c d. wiedw6 a An -I @ Uv fto mwmw
�.�i� i��fltyeG'1��1�NMIr CM7R�l����
MMAp -
Anr ;mlt• mum o vftl
9 Iva &
116 ZKCW1oLMKA=1oW1MVVULT VOF9 {
Nre�i�Wore'�a�[
i "Wwoomm■ PT.IV MLMd�
s tatr � •cco�ilrno� rr�ii fdAi�1G�K3Q L A1maomopvw
7 ChAft coo p er tw*l• w -eta Wdow
ZZL
amms- Dope aef laf swan Ambft
�� — �
ftxw
Ita V-PAS an t l
FMML-T*-R�-
�TkL-PL.-
IIJXtPJAW L490
L ti
�w
IL RELVAM
�a
12MISKM--mm- wVAMWMa lPLC= rAorra WVK
7Mf1��170.1sr<ROCrrgF�flAllilAF�A� 1Mb7lMTA �MOr'iN�
1l111d�liliL'�1 11POW 1MdLCwpm r

my-le-coltl L":llt TP-RHEEL WATER TREATMENT e2B-364-07Ae
o
I71'
? Cerutires l fCps rt otErtv&omner+t and Nournl 1[exawx2- Division Of W&%-r Qne*
WUL ODN"AC TOR C£STUVATIOT4 0 34!�A
WELL CON511RLlC ION PFllfi-
❑rI,IEN ASSDCLATW PIERMt�i wot;-t a]
� .. —
VvELL W" -1 1!
X "ELL UOR (Ch:dt On* 804 MaWft 0 NAM*dpgtn2l&iC ❑
n jai 0 Rwamzy ❑ kocSon ld
pxm '
�. *GML U=Tk;
1.�at►�ttrlQh_� R�
Mod k&4w Iwwnbm. cAmn+nft vuhdf"dsw f.Ae No, POML ZIP Cam)
GTY; gw, CosjwY
iP9pC 1 GAIVD 8E'T�ITIG: (ofvt� �vproQrisnAooq
DVrtllW C3FW rjFIW& 00ftir
I A"rJUE OR LX_"RC cxxxx DD
(faaom on a ems Raw map &wxmmw 7e
ArJdtt l�rnf N nvf eni�y �
¢ FACUff Wwt off* b►iaimos whew Ow Ked is b=wdJ
Ann a 9W K—ft rar+nner
4. TMAL OE'Fi1'!'.
b. lM W L VM4-'i VU1.1 NOEe
.. c. YUATim LEVEL BwmTop ofQw6w --17 F) .—FT.
(Use ' +' ilAb0W TGp of Casww-
: d TOP Or CAMO 13 •— FT. Abm larml 9~
glop � caauy iiefmiessled a6�r below isrd nK�+taa � tsip�
a YsftNl4l1 iq acb4fdaflLsl tr,�!!t'16uR �iGJ4C 2C .i]1; 8.
4k YIELD (upro, mf m OF n8T !J
L D*e"TCTww: AmvfrAt; jE[F
.up . _ iW am Sop IiMrn
YuOt—. L— TOP - Bak--fi
top aowff — TJOp P-O= 1 —
r. c► : OVA
Top_ l7ft"
Top Bottxq
Tap ,. FI
� -
rap amorrL- M.
a acKmAk DOM
$ r�. a�lacww
Top BOWRL._ Fx______,dn. h-
Top FZ
ln- tn.
TOP_ ftom it.—ln
wt.
sum 011"
:ram Ft
- Top Fl
11. ❑RIU-9 R LOG
TOP eakm
FaffAm f umamtlp m
Sod
IL RMI113I.
IGL]I�YL'�R riYA10.r snat,L�¢ r+>;SIsuG11Go8+�wm�
-1wr ,zCONaf ar
PriCr
,�l+is�AL�YCF�
R
�
� ��f.�.�-►1..•
�C1AT�
�.
.
' P� NAM OF PERSON ColSTRllCTm Tlie wEt.L
$mbm!k wMin 38 da" of ampioWn to: Miss" of illfstWQWW - it wlm*mftgm=m& FW 2+Qg-ib
fiat 7 SO-%wvi" C mftr, fbWet, HC 9rrOWIC1, Phmn -- (tilts) W7.63W

i
#.mL*Owf?j4wft
wel ftRe lb (ko"W etWO
W N
tiTlti3 I ADCf M+i
� tit�,L'�ls�G�pRI1ti'101k '
*=W8Lo fW.a"aa.,_
A 1NMl t-k9 kws" AppiraiMAqftuftmM k#§dWG
l I it Oaf" OMB w )
TM AkC MC
4.iM LL0041 1k
�: ►►.
t
LATU= T * a
to ■ aer� hrre.e
i 1ousift& a MS 0 Tapogtath& mp
MMepe��:11►�14a 1'nof � �
�, iACt;JfY s�.+r.■ew.en�n.wrres�r,rr.e�.a
WASOF
Ck arTmm &Ali&
Aw mda - PliorrM nte*w
�.►A�l.of#1�+fie
b� DL1lt H91'�11� ■tMtTM� �71.T r� �
C. inGil'�t LMl�81Y1Mr Tbp d �v: gT.
(4!w �tJltta�Tbp a[CWnQy
SI
IL TW W CASMM !i ADM UM ak�aer
y hh war40AI�MR�C iB. now
r. b!P ONSEj: 11RftOR OF ZBT�
L WMtMMim /Mrroabt
t•
Rwja—nL�—Rw
ORMrr, nose, mom mw"
�Te �
It. tom: 000 a w"aw Oman Mow
iX�PAM- sw mom
RM-'MM_
tt�ua t�oa
Fftn To Fa MSOM ONaoft
ILNMNWAM
t LI to,-
info��r��rwezwmeo ucump�rwoao�iar%Ww
�M6MQ�NeI. 1/0�1R1A[A�YC��
116Bd�1' lM��1 7DTlrt CrIR�
ME
N COMMOMM WN ME
Smhnk the a ftWW tc #0 OhrW= of WWw off ► t 30 tLq w ► MI.- bONM tiaa trot., Sam ew-t a
stirw� 8amiva Cnfer - MC 2FUS-107 fbw.uw

• 1 ■ 1 i.y
■�'. ■I �i',K'� I'� •'■f
op>� � �r
s�e■itr�na�a �� � r� •�
�� 7i„-�4'�.a���
AL. aa4r
�.�� - ,_
��.��
����
�����s
���
�+a .� .��
� y�
irE00�tjf� P,IrO RIB
4 M�6LiOC/1�
p3'Y: • D�tAIl1I
iLip'D�1PI�►LIMOi�r�i�C
� sue. o w� n rye 0 �. n
�or�rruo� ,,,,,,,
in:iiad Amr1
�one�ca � !�8 fl Topo�apbic mrg
�dMrlrNt►II�p1Md�1/ �: b�611pp Illd
sA�dln ��%OCli1�7 �
a �l'i1r ■p.1...irs.pw..r.l�frRwwll�r■a
Fnri.rr�r ID �(I[
� aF pl�c�rrt
a�rA�q�
c7yar�ro�r �e ��
CG1�171Ai'TP� .,.. _ ,�
wawa s
Gear Ili WAr
14� RIpIrR nl>n�lr
i.�lEL CETI�
a` Tvn� � �
� �swaL�x��marna+�uf � �
s" lR�lei.CKB.�dowika�dorir��
�LJrs �"�A1vrrTapdC�gy
S�
O. �V� `�� � � AaaMIL��IM
s, ��Y��oofs+®�,
c � �
� ���_�
r C� � a,n,a.► n�le�we;�llr �w.lw
�� � �
Te�_�� -
s. !plR�F arpa Qlna+lre 8bt4b IYWpI�
� �ItB. PACK
L1rpN1 #IM iMI�M1E
�..._._..� R_______
Ra�,�To Pt,��....,�..
ii�11L�q LOid
� TO FQlip�10[I LINp%1�Ofl
� �� �T—
C`:rr�rz
�..��
r-,
IDOl��4�r7[N*7!lN11144111�fOi1p1111a1tm p11>GppMr'�1M111
ptll�ll��6�ilKIQ>�f� pl6pii>' A C�V �"11/�
meoolrerw�a»Irr math anpeil.
_ a�
Y � oats`-7� i�.�
9ubre�it !h� ari{�Inl �► tlrr Dih►�bm1 of YY��C �tlnllq► trt�lia iD d�1:� Aim � flit., Pana�klr-tb
i6f � fRt� arrive Cater-1�ty !+!C �i�.+1w7 Pllww ffa p1Yy 7ii-io"t� axt �Ok iM.f2Rl

i. VmL c*
Wtil �1h�
39T111yEIA0F111�/
2
-
L VMLLMUFACWt
WMWSLIMMUOM
w L 0ammom PWAVW
a�►�aar�Pr�rr+�pf�+*� .�,
541 Amu
T" oowmznme fte
4.111t6LOCO 1101t:
Cliy: QQlUwY,
70FS�f+FAC1LJItG�7i'>�l0:
ti sh+ a liiAtq► a ow o mck+ �
[a•dlqpopAwbm .
LJC[i11M -- Rsrrer8�4r
LQFtWMN ._. _— is s sold
Lt4tu6dlao�s+dw num Q WS 0 Topo$m*c map
aftmodbowwrodaft wv
LPwLnxas aftmwAnvams»"
pommmwq*
""OFF
cwcr7"P wi•u �� .
CONTACT
SDI M
armrTum Bob
C 41$L O"ALM
& Tom
60
4 7wopFT.A4"Lxwau ow
•. 1f�.0 �pan� �..11R�1�QPrt'A��
R amwpwnmtTy AMOM
AWL�,Tq pa%.....,To
CASM 010 PAROW Tmdwmmvgm MOWN
RM—CLT4�rt
Re�n�7 fb
�.-
!n.
1LUNDMWAILPACM
ftwm�To—R
Ffw&-T4..t.._Rt
1i.DRx jm umg
Fmm To pan"" Dum"m
ICI Y priiW11� L1�1�4L/IfllfibMAMOMOMMM Pf
7A1IdIQ .1IM.LOOt f■fAl AIA}TIRTA*Map"
In � �1 orom
F-
6vmln=opcvt"lwwftLC0VfRAGTOR DUE
&d3M[t tlM or%ftd ip !M of 1i1h1i�r rvM � �0 d�ra. Atblx JLNbrRnllari L�1Qt, Form w*ib
Tar ud oww" com r—iad.l i1, HC VMta7 Pbm*%&"73-7+a 6wmmL RDV.i n

ILWM
�er�o�ws11 00,
n zoom"
� oodF Phan*,a�r
�.w■�.aialalo
tlAwi;Iri.�
WetLODNWF11UMMPERM rl%w 111 . -
onMMPffWTfP
� ��
IL MAuLomqlm
vlr. 19 oau�ITy. Abo- -
r �
IbtH� 1Uw�L
TOPC d W M I LM MUM :
El a" 13 vmw 0 jw Iff mw* Ia
��� ]Agriaireirirrr,
LKfrp" �. oiwlwr.ao irar
LO�f11nE r„_ � �aAwd#�re
iatiAiddloo r3e paora*s Ii�B Topa�api�ie so r
Aar�rd�Yu�lralx+*n oo a i�lM lapr� ad
il�fbdlDMlk#�►aetnirS #�
N. #�t'.1�1r-aa�..r.i.ar►sri�tr�ti
i'ACafi1'1riU(ir�pML
MI M OF FACUTY
COffACT
MRNJWCi/YDE1RP�9
Mom" %do -
Il�r* axlf - �wif 1Nlii�sr
& VAMLo!'IAms
t iiiM
Ii'ma mL NI maz MAIM o VIM mx(
a Maf�R1A1�B.Nldoo►Tbpelpi+ip:
tu.. w i114bn+� � at
s�
jL IWOFWAMINf ' Il - FT.AbftU ld
+IAl .-A P-WMIMRWDIIIIII1R
VW W* ?.-0 - 4wor "m _q I �-�
Mwwmw: ►�.
a vie
Ron , Rar".-To
� orxwr.�anph .� MdWlw
�pt
M. sd WIII: DWMi ohiartr moron mdww
11 �PAM M1MitW
IIAPtLLN O Los
ftn To Fwm�AW Guile
i �i��Y'Ra�'FI1�71� 1fII�Lii7A�� 11ApCCiaAlC�ylgli!
�i►Mv1i?7Q�R W Ir1i�SNg1NO �!� R O.'try�71/a
1MJQw11��i�f�l�M�'1�D
JL
DATE
ROM OF FWAM tHMWDMW—WWM-
9rih"* I* O ftWW fa Om MviWOn or Waft numft MrM*l AO dqw AUX il- 111 Mg, AMOV m
1Ai7 wn Sm Y Combe -- ft%igtt. He 27m Ir ptHM Na 0" 7=4g'li# Ma M. RW.lW

1 !. ■
i rr. �•• wx i' �.
R
as zo GIBn
t�1I1��DpR
hol-
Ori'HIti�At4CCi11T� t�t�
arn�
TtMIE 00MNl p!!b ► W PMI
�rrtlL�.u�crnto�
arrtr: pDUWY
TOPOORAPWILANDOMPM
(8loeip[ f� hgti �Mi. ap �)
13 am" 13vdva ft n 04"a
(a�rsl�nlp begaa�eyrl.�
LXtlWZ _. mia I��rwlpia
Li01V� ..— � ti R dNIlTi1�d �I�Ii
F.� dellloe11 1 tt GIPS 13 Topagpqftimp
pbe�a drdmoptbli�Ihorml ary � lopan�s�[
tL teACILRIF lt�rs�ar�llrw!!■Mlllaar.sr M�.1lL
win OF
Clpr a �+•ri �
Am cOmcOm - PIYelm rnimoD w
i<.i11l�a.t��
R TOOMOL
b.p= VML tp U" Epn'!'M"WlLL? Yt3ttsi
SS
IL Tap Cr Go"* Ab" LLW O~
t~ �:
7 COARM DW% ow mw TM*WMWGW AlONW
rmk-Q—f -- �
4� M�Ied
rmm wTv—
s. ate: o 1pm OUnOW arot�e
.__...__..—�R..� h
1R WOURRIALPRCM
D" an and w
pxm---'o pt-____.
FMM—Tb-- R�
i
ra�.r■TO � ■
r �.:•� r -r.
i0D"Myomov11iirtlNIIINLV NACCOP=M=MIl111
7mIIENC7Q.71- Ima-Am"Crim
I 111p layf/fflu0oom
Bubrr n to OrWOM * the DMWan cfVrm h Duty WIg*l #Q ds". A%W pdonr OM Nor,
1017 AW On imam CMMW — W. �l i#i7 t�bW* "& �pM 714-M 5 4M #tw. IM

wr �•
COW To" Who ZOOM
ILTALLOPOWATM
amWILL Qap
wea. CONg"UMM Apr
rJllilADWC MPM1"GPOPPlu bi
S.1IIIot,elY (ifiralcA�a�hM� �� ��
DR7E
i'rEIffi me pbc
t �' i•saC�ilfd�
asp C'+kuf V~
1��. teexr„
�PONOWILA DipYiM
nab" q MAW o PM o plus Q
LGHOIiIAII „�, � irs�il���
Ladtudalia a� ac - m o: D OM ti Tagngmptk mop
0 OFOOMWAO Now = t ww"ow and
oftonodbfkAmjYIWbd p ww
�1MYC�I.frY. rrrw+arrw�w.��wfy+.� i�wa►.a
I�ACI�'1►�iYYsdidEilr]
OMMI ADVAM
10 I ON
MQU O ADO .,. �.�.
C*arTum elalr lj d
I M9 Daft PhUM xoMIb F
LVELLOCAM
� TDY11R 'Y
b. DOfVOLLOOMMMO UTAI .L? Ym Mop
ILVKMLAILDWWTQPlkfo Re
OR'w VAb" Too of C+ri
S/v
avoumin
.. m■LoNr�+�roaar�r�
ftw�%� P.
T
*.lax C"m &Wnow Aetem hlldrirl
IM &VXMWWOM PACK,
a" an AIeI�IW
1f�RLMl� LA/
FM Ira Fofflad n ommo'nn
ltomo +ramarr erA1s�wrmr sos��trrn+
�waa�ax�►rrts�wms�eaa►�+rw�ew+�>swr � cow aF�rs
�ewaeeeir�� oNNat
1di7 Wf :iaYiCM �I�r !�!G p'?'p4�i7PlIO�N�i10.� ems. �11� blbfi1MM4111W.. pbna QNF-46
pNlj Tpil-Mj$@4ML Ra1►AM

•:�� if i , !xf►'.%L!. �... ai:� l�Ijl�.��� �4ii'y■11. ._��f�'i7
■ 1 ■ \:
IL MLOONWACMft
N"
hbown
A� oa4w
rre1.L a�rs�trcEac� �tner
vn��ssoc�+r'reD�rrr��_ � -
�.�.Ltii{C��deA�p/�
AMC. w
1�
TMODWUM me A
a WANLL LOOMMW
an: • '�' oaxrrr
�crL#WC�7�r
� sn 13 vift a pw C 04.I, aem
1� � da0 �b.it d�larti
LGF+IORLiGt �.. �. ��y iss��oa!
La3i�ddlas�gi4da m a n R ON I Tolpaomphk amp
�ddAlfwb�paatpo6p�1 �+�Rin4
a r�rr� M •.......�r..M■�■wlq..r.�r rr,�
COM=
1 Phome+oaA
R VAI L OETAL1la
a TLRJil.
e. VMT= L1BY1i1l"Tcpof CWft �.
(VmwlfAbwATopuFQm"
67
d TWOP1� i i Ft. Ab M L" &RtW
aftweWM Nagppidor�erw�l1 i�1N "same �
.. N=1W* 70,
rA�eNoo aF . � 0: K--
OMME
F
7 mom owe Dleoreav T*bwmvmw aftId
Pmm,_TOR .
Fmm _Tq.F�.-
Pmnt
#. awNW. Dq* okmow adore IN 'I
AWP�Ta . ft.--PL ter. &L
RvnL-Tct-ft6 _r.. fie.
I& SAMBOR M NCM
Dwm so MOWN
Te Ft-_
i1�RRJ.�EO L+OR
Flmn To Famotm Daawlpi m
owMSCamol�7fiUr11lsVMLUM�MAOC XVM
:IR "&wMv2kv A.w. tltlC11a-avmdwmo71d1'ACOWC TAO
iR6CRal—wwP*WJMI 7tfmlY" C WNK
1l17 Y� 1Mevb� C+�dr - R !tC Ylriii7 Ph pm ft t!?/j r>4164w1 Id

NoNRESIDE1VTUL WELL CONSTRUCnON RECORD
r `forth Carolina Depxrmtent ofEnvireasment and Naitual Aescurws- Division ❑fWater Quality
WELL CONTRACTOR CE1tTMCAT1ON #
1. WELL CONTRACTOR:
-$Janley S-e- er - 2185-A
Well Contractor (Individual) Name
Id lull Gg=eraial
Well Ccntraew Compwy Name
$275 TpumamtDriye
Street Addrean
emi2his TN 38125
City or Town State Zip Cods
( 01 1 748-9095
Area coda Phone number
2. WELL INFORMATION:
A
d. TOP OF CASINO is 1 FT, Above Land Surface'
'Tap of casing terminated atior below land surface mey raquIIra
a varlance In accordance wEth I5A NCAC 2C ,011B-
e. YIELD (gpm): 2_ 7 _ METHOD OF TEST -Air
:1. OIS1NFECTI0N: Type HTty Amount _8 Q7- --
9. wATSR ZONES tdepth):
Top-&L-- a*dwr Top Bottom
Top Bottom Top Bottom
Tap Bottom Fop Bottom
T Nckrreset
7. CASING: Depth DLarnaler walght Material
WELL COI STRUCTION PERMIT# Tope Bottom&L­ FL -
OTHER
ASSOCIATED PERMIT#@ appAcaNel ; Top 9ottom Ft
SITE WELL ID #{it appileat>le} 5$ - TEST WELL TOp Bcftl — Ft
3. WELL USE (Chock One Box} Mo ltoring,3 MunrcfpaWublia ❑
lndushia;Cammrrrelal 0 Agriculture; C7 Recovery ❑ Injection if
Irrigation? Other 0 (list use)
DATE DRILLED 3
4. VVEU LOCATION:
735 5axaDahaw-Bethlehem Church Road
(Street Narna, Numbers. Cornm,vflty, Subdi mlorz, Lot No., Parcel. Zp Code)
CITY: Saxa{]ahaW COUNTY Alamance
TOPOGF,APHIC I LAND SETTING: (check approptlsm bm)
Al, p ❑veitey ❑Flat ❑Ridgy 00ther
LATITUCE 36 - 66 - d5ACCO ' DMS 0R 3XXXKX)0=X 0O
LONGITUDE 79 . t8 - 7.9Ot?u • DMS OR ZA.& )0=X DD
LeWx1elloig1tude Seurat: Q13PS acpographio map
&estAon cf weN must be sham on a USGS topo map rndatteched fa
this foray N. not using GPS)
F. FACILITY (Marne of the buCnesa where the well is located.)
-- Saxanahaw River Mill
Facility Name Faclity ION {If applicable}
1735 5axanahaw-RetblejaixChurrh Road
Street Address
—aSaxajZ8hgw NC 2Z140
City or Town — slam Zap code
juatin15ev -j--T Wilson ..
Contact Name
5012 Meal Ed
Melling Address
Ck or Town Stale ZIP Code
(919 3$3-9.9;35 �.
Area code Phone number
S. WELL DETAILS:
a. TOTAL IDEPTH: 450,
8. GROUT-. Depth Matoriai Mathad
TOP 0 ftsom 450 Ft.Bentcn[tWA8 pumped
Tap Bottom Ft
Top Bottarrr Ft.
S. SCREEN; Depth Diameter am Size Material
Top
Bottom- Ft in.
= Tap
Bottom Ft In -
Top
Bottom Ft In.
: 10. SAN[WORAVEL PACK:
Depth size
: Top
Boner%- Ft.
Top
t3oti>7m Ft
Top
Bottom Ft�
: 11. DRILLING LOG
In.
in -
in.
Material
Top Bottom Formalton Description
�0-6Q— Send and Clay
60 1z0 _ Hw:dmnd &Gnmte -
0 450 MIX of Mite/B!!iq gran3te
I
1
r
1
12. REMARKS:
Geothermal bse Only
I w8T oQ 99"Y CERTFY r�T Tins WELL WAS CON=TEb IN ACO DRDANCE wilts
ran W-kC sC, WELL CONSMUCTION sTOMFUS, AND TMT A COPY or TM
REDDRD R48MEN PROVID®TOTHE WELL M7EK
h, Ot3E8 WELL REPLACE EXISTING WELL? YES ❑ NO q% : SIGNATURE OF CERTIFIED WELL CONTRACTOR ��
C. WATER LEVEL_ BelawTop of Casino: 6A FT. s 11L)L_SEi2Er
(Use'+' if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
S bil- st Y+thi:r 30 �� A complulan ago: Jiv1�IaLt Of :'iA rho-L-itY - 1"I'% natu t Iftcessitt4, Faint Gw-tb
Rev. 2109
Zia 1T :Audi Zar V .''seder, Rx794►,, MC 37W*.164, Phorit . ;d1i] N -64I MJ

No11iREmExTzAa WELL CONSTRUMON PECGRD
Noah Carolina Der3rtment of Fnvironm at and Nsturrf Resources- Division of VAC% Quedin
NKLL C0rcFRACT0R CERTIMATxv'q # 3424-A
1, WELL COK-1`RAICTOP-
h6ichg 5. kQyre
Wei Cvnhactor(kidividuala Name
Tayheel Water TreaLfne # Inc
Well Contractor company Name
3494 Georgia Road --
Sbvet Address
Franklin NC 28734
City or Town Slate ZIp Corte
8[ 2$ i 369-0740
Area code Phone number
WELL. CONSTRUCTION PERMIi*W4400133
O T HER ASSOCiATEO PERI4 78(iF appli=ws)
SITE WELL ID #(4 appom") )- 9
S. WELL USE (Check Or* Box) rAan tr?riflg Ll Munlrapai PublicCl
InduelrlaKom[nerrtsl ❑ A0oal Ural p Recovery 0 Injed:nrs i�
Inigadoru 0#mr ❑ [list use}
DATE DWI LED 10 - I
4, 7ASLL LOC t •TW`
1735 Saxaaahaw-Bethgham Church Road
(Steal Narr.R• Kumbssa• Crlrrlmu ft Subddrir lore, Lot No-• PTiorl, Zia Coda)
CITY: 5axapahaw cotlwTYAlamance
TOf)MRAPNIC 1 LAND SETTING: (aw, spprn"te box)
V&ope OVetley 0Fiat ❑Ridge Oth�
LATITUDE 34 _ _' " DM5 OR 3x.xxxxxxxxx Dp
LOW!TUDE TTi " DMS OR 72. xxxxXXxg[ VO
LetfxlelloMitude source: D33P3 Qfopegraph:c map
{rnceon or Mill must be ahocm on a USGS Opc map ard*ttaGlled to
Ws 1tar n rTn of asing GPS)
'S FROMM $Na►ne of #* buMnem where the well Is Ivcated-)
Facetty Name Fedtity ID. (lf appf eble)
Saxanahaw-i3�ath C'hunch Read
Street Address
lqalmhaw NC 2734�
City br i ~ State Zip Code
Cnnlact Name
Ill iRng Address
,sa=0FIbm NC 27430
City or Town State Z•Ip Code
Area =110 Phorre dumber
8. WELL OETIXS:
a. TOT.1DEPTft:_ :f 0- — -
b Do--5 wELL REPLAce Ls7[ -n"G 1NELL7 YES 7 NO W
s9
= d TOP OF CAVNG 15 " FT. Abave Land Surface'
'Top of casing lorminated odor below land surface may reruke
a variance in sccordenm vAth 15A NCAC 2C .0--11&-
r} i
c. YIELD fgpml:. E11fGD 4F TEST�. NSINFECTIOIf:� Type Amount
g. VNATER Z1FES (dapfn):
Top_ acttam 'pop Bottom
Top Bottom Top Botpoq
Top Bollorn Top Sottorr
Thlc?ncoW
: Y. CASING: Depth- .4� Diarnaltar We#ght IAateriai
Top L3otiomJ';*ty�;�
Top 8� �-
Tcp softoln Ft- --
S. GROUT.- Depth Material A Method
Top_ eoftar _ Ft. -V
Top Bottom Ft.
Top Bottom Ft._ —_-
S. SCREEN: Depth Dbwn&w SRX SLta Vatertal
Top 8uttom Ft. in. In -
Top Boom Ft. in. In.
Tap Bottom FL in. _ Irl.
cis. SANDECI'MEL PACK:
Depth Sixo t wdal
Top EottCm Ft.
Top Rrft rn . FL
Tap f3cttorr7 Ft.
: 1f. DRILLIVG LOG
Top BrAtom
1
1
1
f
1
�i�Y�t4l1+JiLS:_Ei� d�ll !t'
Form "on DescOptiors
-�_,i i
,•-�1;- L'•Ev
I U0 HER£ay CERTIFY T r THI: • WAS CrY¢3Tk'h'. _6 7•: AC{:�RAAfu:Jr N.rh�
• 1C'. N'.r:2C, lrEu. G rMUCTI R:'rCR:'GCt FI.7 t:. CQ.•}Y 4F THIS
:RECCE ! �ryM T• L o
SIGNATURE OF CERTIFIED WELL CON OR DATE
c. WATER LeVE .9etow Top of Casing;, FT. -Michael S- IIIFc0urt?
(Ilse •>• rAboue Tap of Gaslrt,7) : PRINTED NAME OF PERSON CONSTRUCTING THE 'ELL
Submit within 30 days of CompMon to: 01vieion of WaUr Quality - InfGmurfion Pmccaasin0, Rev, 2A39
1617mail Service Centur, "sigh. NC 27899-161. Phone :[phone]•6300

- SMA, SIB
I IONR.ESIDEMUL
WELL CONSTRUCTION RECORD
4 i
North CaroNna rAparunent of Environment
and Natural Resources- Division of Wt:t.r Qua1it}'
-. WELL CONTRACTOR CERTIFICAMN # 3424-,1
1. WELL CONTRACTOR-.
: d. TOP OF CASING IS ' FT, Above Land Surh=*
1N i
'Top or csaing terminn[ed allot below land surface may require
Well Cordrector 0ndJAdstaij Name
a variance In eccotdariCe uufttr I6A NCAC YC ,0118.
Tarheel Water Ireatment. Irlc
:a YIELD iepr►t1: _ _ fai�TifoO IaF TEST i i
well Contractor company Name
: f. DISINFE =M: Type Gh).t^. i ,; A-- Amount
3494 Georgia Road
Street Address
; p. WATER ZONES (depthy:
FranWin NC 734
; Top_3L-"� cottwn Top Bottarrt
City or Town State ZIP Cade
: Top Bott-r ToA Bottom^ _
( 828 l 369-0740
: Top Bottom Top Bottom
Area Code Phone otimber
Tbkknes.l
x. WELL INFORMATION.-
re
T. Depth Dtaetar Might rdatarial
WELL coNsTRucnclsi PERIVIIT'!F W104�00133
= Top�eotbom �.
OTHER ASSOCIATED PERMIT00 aw"bie)
;Top t3attam Ft---,-,
SITE WELL ID *PF apptcam) " �� -
'Top Botto Ft'—
a. WELL M (Check One Box) Monhartng ❑ MuNcipallPublic ❑
industrleUCorrsTsercial ❑ Agricultural ❑ Recovery p fn)eWon
= S. GROUT: Depth Material method
' I
IMgefiann Ofte+ pbst'4ej
: Top Bottom Ft.
DATE DRILLED—;:,-
; Top Bosom Ft.
WELL LOCATION:
S. SCREEN: Depth Dlamsear Slot Slit: amrMl
1735 . axwahaw-Bethleham Church Road
' Top Bottom Ft. inin,
Nam,
(Street Ha. Humbms. Ccma=fty, Suhdhfiaion. Lot No., Perrot. Zip Cade)
: Top Bottom Ft. In, in.
CITY: SaxaDahaw couNTr Al n e
- Top Bottom Ft. in. In.
TOPOGRAPHIC r LAND SETTING: (dock sae box)
MrSope G7Vafley []Flat oRktgee ❑Mer
: ttl. BANDIGRAVEL PACK:
LATITUDE � .��a' � fe � " DMS OR 37(.X14of7C74= ❑D
Depth size M14sEatltd
LONGITUDE13�. ' OMS OR 7�K C[}
Top bottom F'L
: TGpBo=nl FL
tAdfigWong&Ae source: ;�`P5 DTapograpnic map
: Top Sotton'L,_ Fi
fWaftn of wedmusthe stwml on a LWS fopo wrap artWtvCha7d to
d* rum I rat uakty GPSy
; 11. DRILLING LOG
0. FACILITY (Name of the bu rA= where the well Is located.)
Top Bottom Fornu lon Description
N;#j1 FR,encra�-
r�R,q
Fadity Name Faculty IW (if applicable)
_1
Street Address
sax aahnw -- I'Jr, - 27340
1
..
City or Tow Stata Zip Code
1
John jordcaD
Contact Name
P_ 0- E3ox 128
1
_
Mailing Address
1
sbXaDSLiaw NC __ 27430
1
_ _
City or T(*vn Stet$ Zip Code
12. M7ARKS:
{ �}
Area code Phone number
O�T�L$: 1
• i OO KSiMY CERT1 THAT . WELL WAS TRkXTEU M ACMROANCE WMA
: t5h NCAG2C1WE nrs UC ON ST S. AND TMTA COPY OF Tt115
TOTAL DF-PT)i: y
: RECOR S aE My T C NER.
b, DOES WELL REPLACE EXiBitUG WELL? YES 1] NO CV
■
: g1 NATLIR1y OF C RTIFIEfl f I L CONTRA�� DATE
c- WATER L IEVEL Below Top of Casing: - FT.
(Else -+• ff Above Top or Casing)
' PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Sub.nh within 30 esys of cornptWon to: Dividon of Veater Quality - Intarrtlafinn Procea*ing' Form Gw it,
Rev. 2/Q9
1817 M&Y Service Canter, Ralalgk MC ZM9-781, Phone. (919)
$07-6300

flit R ESME1VMI L WELL CON5TRI3CTTON RECORD
North Carolina DaPartrtsnt OfEnlArnnmant nWNsWW Resinvoes- Div4sion of Wafer Qualit►
WELL CJNTRACTDR CIER7 WICATION # 3424-A
1. WEILL CO TRACTiOR:
Welt Contractor (101vidual) Noma
T arhgM1 Water Treatment, Inc _ _--
well C.or► eew Company Name
3,494 G-porgig Raao _
S'treat Addre"
Fran'-Jin _ NQ 28734
City or icwn State Zfp code
$8 28 _ t 36 07'40
Area axle Phone nuwbw
2. V L IiiFORMATFON:
WELL CONS -RUCTION PERmrr* W30400133
OTHER ASSOCIATED PERK M(tf @*`kaisle)
W SITE FLL ID W apA�t:iri � l _
3. Y4ELL USE (CImat* One 8m) Morocdng 7 Mttn(dP& JPubltG -�:J
lndusl►IaloComnwcial ❑ Agricultural - R000very C injection
krrlgabona Other © lust LIM)
DATE DRILLED IL ` 1 3 T ! ❑
4. WELL LOCATION:
1735 Saaaaahaw-Bethleharn Church Road
(SbW FFame, Nuftma, Cwnmaniry. 3ubtiAslon, Lot No Par*, Mp Code)
CITY: Saxamhaw COUNTY Alamance
TOPOGRAPHIC I LAND SETTtNa kcheck sppmpr** boxI
dblope ❑ Valley ❑ F3at O Ridge ❑ O Uw
L .TrruDE 36 " EMS OR 3X-X1W0nXX DO
LONGITUDE 75 " Dms oR 7 -mnmxx Do
LatlludellonshAe source: C13pS piapographic map
0ocWon of weg mast be shown on a USGS Wc map andelfached to
"i6VM #rot uaArg GPS)
S. FACILITY (Dame of the business vjWe the well Is locited.)
—SLYMaho
FacHity Name
Facility IEW of applltabie)
IZ3 5,.SaxjaMham:hefhi0
iM-rhji ch Ram --
Street Amass
NG 27344
_.Saxanahaw .,
City or 7pwn
_
State zap Coda
Sohn Anrdn--
Corttad Now
MaWQ Aiddtas
27434
_5ayjaflahaZ'
City or Twm
_ _ roc _
State Zip Code
Area Gods Phone rAgnber
R. YYELL DETAILS: )
w TOTAL OEM.,
is. DOES WELL FJW LACE E]itl9T1NG WELL? YES 0- Nd 5/
r- WTER L.ML Below Top of Casing: , . _—FT.
(Else '-V if Abm TUp of Casing)
d 7M OF CASING 19 FT. Above Land Surface`
--Top of cRaing tarrdneW odor below larw surface may require
a vrrIsnce in actoordanoe wish 1$A NCAC 2C .011S.
a. YIELD (gpm): METHOD OF TEST
- f. M"FECTM: TypR �� Amcurtt .55
g. WATER ZONES {depth}:
Top INO aotiam Top soaorn
Tap Bottom Tap Bottom
Top Bay xn Top Bottom
ThkJmosal
7_ CAS�I+f' 4. NEB' Dl luffie ar v Mcwrial
Pt
Top Gott FL
Tap Bottorrr -Ft. _- -
8. GROUTDepth Material McMod
TOP. Sottcr� Ft.
Top Soitcn7 R
TOP. Bottzrn Ft.
0. SCREEN: Depth Diamettr SW Srss 8faterlal
Top _Bottom Ft. in, in.
Tap Sobom Ft !n. In.
Top 8odmr FL in. ln.
: 10. SAIi0liGtlAVEL PACK-s
pApth Sl�a gnateriat
Top Bolcom Ft
Top Bottom Ft.
Top Si clam =t.
1 i. DRILLING LOG
Top Bottom FOrrmailon Description
7 r + —
—IZ46L
PWzT:V FTO'�
■
CZ HER90Y CEPTIFY INAT TH S WAS CONSTRUCTft NACCORGMZE WITH
I NCAC 2;.; El CC-4J-rRJCr 7AyW�ARM AND T AT A CMI OF lHe
RECORD "'"$4ry CM `)1P f owN
'� -� !D
sue. TiJ c TIFI L CO - on
'PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Sunk whin 30 dny a of completion to: Mouton of Watw Quallty - Infornution Processing,ev. 21Og-lb
tu
t617 :Raid 5enfte Center, Raleigh, NC 27699.161, Phoele ;. t919j 807-MO

XONIZESIDENTUL WELL CONSTRUMOY
North Carolina Depsftteat ofFavironmtrat andNahual Resources- Division of%ber Quality
WELL CONTRACTOR CERTiF'ICATTiON # 3424-A
1. WELL CONTRACTOR;
M' l r
Well CorttmaW (lr4vkW Name
Tarhee_Waig Treatmsnt, Inc
Well ContrackwComparty Name
3494 Qgoraia Road
Streat Addrou
Franklia- - NQ 2$734
Cky or Town State Zip Code
15I09--
: d, TOP OF CASING lS ' =FT-. Above Land SUrproe•
'rnp of casing temWu tad atbr below lend sun!*a may require
a verfaance In acsardance vdM 1SA NCAC 2C i i8,
a. YIELD (pprm): OD OF TEST �T_ _ c .1 ��Z-5
f. DISINFECTIOIN: Type �ount 3 3 �Q
9. WATER TPNES (depth):
Top ! SWWt Top Bottom
Top Bottom Top 8otiam
{ 28 ] jU&M = Top Sodom Top Bottom
Area code Phone [umber ThlcknesW
L WELL INFORMATiOti: T. CAST c: D gianwlsr L:'alght Matwrlcl
WELL CONSTRUCTION PERmrrs W10400133 Too $�noI
OTHER ABSOCtATEO PERMa#(k appE bio)- Top Bcdarti Ft.
SITE WELL ID t' iit eppk"s) t lop Bottom F[
3 WELL USE (Check One Box) Alanttoring Q httatidp8flPubt1c ❑
IndustrlaYComnarclal p Agricultural ❑ Reaonery ❑ injecUon Of
lrrigaallon❑ Ober ❑ list ua:ey
DATE DRIL.L>F!!3
& WELL LOCAT[Oft
1735 Saxaoahaw-Bethfeham Church Road
(sever Hanoi. ffio"M Cvrnn w tq; saamdhrw-, Lot No.. Pam w, 7]p code)
cny: Saxaanahaw COUiaNAIManre_
TOPOGRAPHIC 1 LAND SETTING: (dick epps FbM bmo
56ope ❑valley ❑Feat CJM*e E;Other
LArlTili]E DMS OR 3x.)OCXfDWM DO
LONGITUDE n' l� 07.E " dMS OR 7x X]cQOc?f?[xls !3c
La9tude1l"R ode mote- VP3 Qropographlc map
0"Oon of "0 must be RVA on s USG5 taps map andetteched to
a*► "11notuskvGP3]
tf. FACILITY (Naam of thu business where the weft is located-)
8. GROUT: Depth M3tCalaSl Malfwd
Top_ y4LSotto Ft
Top Bottom Ft.
Top Bottom Ft. -
9. SCREEN: Depth Dtsmstaa' Shalt Size Ma:term
Top Bottom-- Ft. k1. In.
= Top Bottom Ft. In, In,
Top Bottom Ft. in. In.
1 O, t3r'1 A3RAVEL PACK:
Depth Sirs
Top Bottom FL
i op Bottom Ft
Top Bolt rn.
1 i. DRILLING LOG
Top Bottom
Facility Name Facility ID# (if apptimble)
1735 AaxanahRw Ratii(aham Chtjrrh Rmri
sires:Address �
City or Tom state Zip Code T�25.
John JardarL
Corrtact Hama
Mailing Address
.9=13ahAlw NC 2743f1
Cgy or Town Stitt Zip code
Area cede Phone number
6. t MJ- DETAILS:
a. TOTAL DEPTH:T r-! --
b. DOES WELL REPLACE tOL1 nw *%ZLL7 YES ❑ No Y/
1
12. REMARKS:
Ft
Water'at
Fcxm #on Description
ra-111..z. --
�0 HERJre1 THAT 7 t31 WA$ Ca TF JCMD all ACCOr ANCE WITH
1eA tJGAC !7H Nair AaVo THAT A COPY OF TWS
S NATURE OP CERTIFIED VVELL CORATE
a WATER LEVEL Below Top of Casing: FT.
(Use '+• If Above Top of Casing) PRINnD NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1h
Submit wlthln 30 days of completion to: Division of Water Quality - Irdarnro lion Proce"ng. Rev. 2ftiB
1617 Mal! Service Cantor, Raleigh, NC 27699.161, Phone., t919) 807-6300

7s�•
1. WELL CONTRACTOR-
NoNAR-5l.DEWU L WELL C 0NEMUC 10N. RECORD
North Carofirm Depounent of Fnvi o mn�-r r snd '%Iaaural Resourc.:s- Division of Wcwr Qu.2tty
WELL CONTRACTOR CE11i'[ E"CATM14 0 3424--A
Wes corttractor (InoivkL* Name
-Terheej Water TreatMent, inc
Vved Contractor C np" Name
4 or i Read
Street Ad&M
Fr nkfin NQ 2 i
City ar taw„ state lap Cade
(828.3 3 s-o74
Aran code Ph" ncmlber
z. VVELL If+F(ft4ATI0N:
WELL CUNBTRUGTiON PERMITS Wf0400133
OTHER ASSOCIATED PFRMIU(N ape *)
SITE WELL IDOfdsppka 4) 13
3. WELL USE (Ch" one 8000 Mor taring ; II<1lrn6dpallPL4* I'
IndustriaYCOMMOrClal Ll AgrImAtural L3 Recovery L3 hi"n of
InigatlonLi Oitm (Hot we)
U.ATE DRII.Lr
4. V EL.L U=T1Ck:
1735 Saxagahaw-Beth(eham Church Road
(Sheet tNarwe, Nwbm. Com aft SubdkWon. Lot NO, PwW, Zlp Code)
Crm!5, axahaW GouNTYA 8R18[106
TOPOGRAPHIC J LAND SETTING K appmprwis t>apo
S'SIOpe ovallay nFlat ❑RIdge ❑Qtt t
LATITUDE 36 " ❑MS DR 3x.xx>ngav= oc)
LONGITUDE � � ' DMS OR 7X.XXXXXMXX 00
LatftLrdeAongkude sourm: 03PS Qropogmphic map
(k oeVon of mWfi must be shmvn an a USGS topo wrap andauached to
Mils /wm Ynot I *&V OPS)
0. FACILITY (dame of the buns where Me vmA Is located.)
�5
Fadtlty Name
Facolly IDa (tf apptic*12 )
7.35 5;axanahayv_
Street Addnem
5axaaahaw
N-r' 27340
_
C81y or Torn
State Zip Code
Cor ad Name
140ft Address
Raxnahew
NG 2Z4134
City or Tower
state Zip Code
Area code Phone number
4. MLL DETAIL B:
a. TOTAL DEMi: � ),�
tL DOES YYELL REPLACE EXISTIAO WELL? YES C No fVV
IS/1-03
d TOP OF CAsltitx W I— ' Fr. Above Land Surface'
'Top of casing teffrkwted atlor below sand surface may require
a variance in accordance VAth 1 M NCAC 2C .0918.
g, YIELD tgpmfi _ LMTHOD OP TEST r� �
e DISIHFECTipli: Cypv, Cj j,C i1t� • Aral t
:Cl. WATER-VONEB (depth).
Top 60 Botts rn Tap Bottom
Top Bottom Tap Bottom
Top Bottom Top Bottom
Thlcknesal
7. TO� 80W -i7it:mrtee rr'!�i ht �dZltaarssl
p Ju, ..
Top Bottom,
TOP. eoxt n:(__R �
8. GROUT-
Top Salta
Material
Fit
Method
@G -
' Top Boltorn
Ft.
i
Top Bottom
Ft,—
A SCREEti: depth
Dtematsr Stgt
size Material
Top Baitom
Ft. In.
in,
Tt10Bottom
Ft—h.
In.
Top HottOm
Ft. in.
In,
is aANDIGP AVEL PACK;
Depth Size
lip 9atturn Ft-
Tap 9Otiom Ft.
Top gottom Ft
11. DRILLING LOG
mmerlel
= Top Bottom Formation De*Wpgon
12. R#>JUM&
GeON191-1181,63e Only
1 oa FEREFfYCERTI'orw. FYTNAT AeLLWAS CTED INACOCGRRANDE*M1
16%NCAC�^} ►nl ucrs�;ti x:.aTHATACOPY aFrrus
RErf'�Q.R/!il�kR TO
SfGNATtffkE OF rER11FW wE CONTRACTOR DATE
c. WATER t.EYEL Below Top of Caning: _ - f -- F-� : AAimpAl 6- Mqf—'turn
{flee "+' d Above Top of Caging] : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit o t in 30 ft of com etioo to: Division of W.*W QuW infommtion Praoe�sflt . Farm GW-#!,
Y$ P! �Y � Rev. 20
1617 Mnit Service Center, R delgh, LTC 2764E-161, Phyla: [phone]

.b,
/4/
- � y 1ON .gyL.�ME1fAL WELL C0.51RL�cxIax cyan
l' North Carolina Mvarunmt ofr-avironrntnt and Namnd RL*ouw*— Dmsion of Water Quality
=: • WML CONTRACTOR CERTWICATION # 3d24-.1
1. Vrc%L CONTRACTOR:
Michael S. McClure
Well Contractor (Ir.9Wk ml) Name
Ta ! Water Tre tm nt Inc
Weil Contrww cootpany U&M
3494 Get3raia Road — -
;a'eet Addreua
Fra Ali n NC 28734
City Pr Town State Zip Code
t 28 r 36"744
Area Coale Doane MRIO r
Z. VWEELL INFORiHATION:
WELL CONSTRUCTIONPERmnW11040033
OTHER ASSOCIATED PE.RMITNIf aV3mWa]
SITE WELL tD 1n(trapo=blal�
3. IN,ELL USE [check One EWo Monitoring :1 MunicipairPirlafle C
industrisKommerefal p Agrioultural ❑ Recovery o IMeotion {
Inigationp Other 0 (Ilat use)
DATE DRILLED t1--
3. V*V-LL. LOCATION:
17N Sexapahaw-Bethisharp Church Road --
(Streat Nem4. N, rtwi, Carrww*. Subdlvkion. Lot He., FaroW, Zip Code;
CIT7: aC'3.'CaDt haw COUNTY A eimance
TOPOGRAPHIC ! LAND SETTING; (ea=x apprap tm box)
r Vallay OFtat ORidge 00tler
EATITLIpE '6•4.�&`' ❑MS OR 3X,)Ot?Po()C1G0 rap
LONGITUDE �` I'll! 01.0 ^ DM8 nR 7x-xyxxxxltlL DD
Latittafe wVlside source�PS Qropograptge map
{locaban of wplr rnud be out a USGS tOFa map 8rdatfW,#*d (r:•
this ofm tr1w usbv GPS)
& f.WLrrY (Nam of the Wshms whore the well is lomted.i
t S J .-
FadIXyy Name Fec ty IDS (11 appticable)
3 a "ip ha
City or Town State Zip Code
jewh LJOLdan
Contact Narm
_P-0- Box 'i2_�! — --
Malllny Addnasa
wanah2mi _ _ _ NCB .974,i❑
C-rty or Town Stale Zip Code
Areas ooda Phone ruRrttaer
6.'1A%LL DETAILS: .
a. TOT::L DEPTH: _
d. DOES WELL. REPLACE tDtfSTING''VEL.L7 YES C 140 -V
1
e. WATER LEVEL, Below Top of Casing: - I, CA:0 FT,
(Use ." If Above Top of CasMo
d. TOP Of CASWMG t$ FT. Above Land Surface•
'Top of owN terminated atlor below land uu•face may require
a variance in eacerdence with 15A NCAC 2C .01 t8.
r. na.D (apm): 1 apt=T>Feo>3 OF TEsr i'� ► { i{ [. r
E OMFIS+CTiON: Tj►pe „ r, Au++cirM
: o ►YATERZONES (depth):
Top 1 t �' z - Eotior Top emoin
Top L._ Top Bottom
Top Bi tom Tap Bottom
lrhlc�
]. cmwe- Deptlsj,,jj DIM~ vwftht ILetartal
Top-a—Eto6torrt Ft. —
Top Bottom Ft
Top Bottw F1. _
GROUT,.
Top
Depth
�
AAaterlaf kletilod
Ft. ad.h.A�
Too
BcftffL.
Ft.
Top
Bottom -
FL
!. SCREEN:
Depth
alarnotar slat Stu lYtaterkal
Top
Bottom
FL ln. tn.
Top
8oftorr�_ Ft. In. In.
Top
Bottum
Ft. In. in.
10. SAI.01GRAH£L PACK.
Dwh
Sim 11111aterlal
Top
Bottom
Ft._ --_--
Top
Bottwn
Ft- w
: Top
acttom
FL _
11. DRILLING LOG
Top
Bottom
Formation Desc6pbori
L
= 12. REMARKS:
100 WEREDY C£FTiFY TVAT WELL WAS C Rti'r20 IN ACCOPJ HCE WTH
1r S IrG:CZG, WELL 1+�&TR' $Tgti3 r N�7 THAT A COPY �'r}{#S
Ikk3 Li•yi,WEaI K .
7 V -2
SCMATUIRE OF rCERTIFI D WELL CONTiCA60R DATE
Mirhsal:al -q Mi-..r..11Oro
' PRINTED NAME OF PERSON CONSTRUCTING THE 4VI_LL
Submitvvfthin 30 d" of completion to: Division of Ylater ©ua ft - Irt�orrrmtion Processing, Rev. ARev. 21b9
1617 Mail SeMce Ceater, Raleigh, NC 27a99-161. Phase : (919) OOT4360

L' N .ES.TDI£NTL-ii. WELT. C01fSTRUCTI0X RECORD
'_':arth Carotin:. Department of Envircamcnt and NMva' Resources- Division of WLgle- Qvaiity
WELL C014TRACTOR CERTIP-CATION # 3424,1
1. WSLL C MM%CTOR:
MICha i S. M --lure
Well Contras (IndLvllAA Name
Tarhee-I-Witer Tr
Well CaWa= Company Name
3494 Georde Road
Street Address
_- Frandn -- .-- _NC 28734
Gffy Or Tam Smite zip owe
8t?8369-0744
Area code Phone numirer
Z WELL WF0itil7ArOfN:
WELL CONSTRUCTION PERM T# Wi040133
OTHER ASSOCIATED PERMIMif gK&Iebw)
SITE WELL 110 ir(ff appliCAw& _S—�
3. WELL USC (Oheck One Sax) MonItortr►Q r} fAranldpWfPt IICC3
IndustrlaXamiT>ramW :3 Agricultmi C3 Rewvery Q Injection
kdpttonL3 Other J (Ifs# use) __--
UATE DFUL LW j 2k ' 1
A. WELL LOCA11ON:
1735 Sexaciahaw Be#hleham Church Road
(street Name, Nurxga, Caemurxty, Sint i+Arior,, t A No- pareft ft Code)
am SwmciahW - _ COUNTY Alamance
TOPOGFfAW C t LAND sMft3: t opmprtate bwo
DVa ft 0 Flat O RWge '- Other
tAT,TUDE '-� ' we OR 3X.XMat7ClUf) 00
LONGVWDE 75 ' DM5 OR 7X.XXYXXX= DO
Latltude►tongitude 50UM& 03PS 0Cap0gMpNC InItp
(► x*lon of refill must be shown on a USGS lopo map andattached to
WS Jbfm if rw Vsb+p DPS)
4, FACILITY (Name of the business where the %eli is forated.)
Saxanahaw Him(- , lil Finn=
Facility Name FadLHy 100 (0 apptltaWe)
1735 Saxaoajaw-RA h eham Churn, Rai3fi^ -
stmat Addrem
5axaniijnAw - NC - - 27340
City or fovm grate tip code
.John .tor a i _
contad NAM
P-C Box 12A
"Rng Address
Saxanpbaw Nr 27430
City or Town Stale Zip Code
,5/5
FT. AN" Land surface'
'Top of casing terrnttwted oVor below land surface may require
a variance In accomanca vdth 16A NCAC w .we.
o. YIELD (gpm); fL MOD OF TEST ► t'�
f. DISiNFECTIOrf; Ty". _ Amount : `y
g. WATER ZONES tdep":
: Tnp
Bottom
Top __ Bomm
Top
IlWom
Top Bottom
Tap
Bottom
Top Bottom
Th6cxrtasnrJ
7. CASING;
M'
DF�.atar Irt LLlrwiat
Tflu
Bottom
top
Bottom� f ►= - - --
Top..
Sottam
Ft.
B_ GROUT:
Depth_
illlets+ie! Metod
Top— --
BomrrPOD
Ft,
Top
Bottom
Ft,
Top
Bottom
Ft-
S. SCREEN.
Depth
Dfamatmr t3fot Sirs Matorial
Tap
ealt"T
Ft. in. _ A.
Tap
l3ohom
Ft. In. In.
Top
Bottom
Fl. in- In- _
it> SAND)Qft;dlEL PACT[:
L]epth size
Tap Bottom Ft.
Tup BnttVrr�_ Ft
Top saririom Ft
11. DRILLING LOG
'vaGarlai
Tap Bottom For matlon O"Miptlarr
�r
1
1
1 -
1
I
1
I Z REWARKS:
Area cotle�o�l� Pf3erte nclrr►ber lei
IL WELL ��� - I L'� F#E31t�Y CFF;jW-F
a i WAS TRLiC i ED IN ACCOFQANCE-4,TH
• 1CA NPr:C ZC, VTI STAR ANOTHAWXCPYOFTMSREOOa. TOTAL DEM. 4(so mryse L' Nut
b. DOES WELL REPLACE EXISTING V6rML7 YES F'J W � : S / � OF CERMED VVELL CONTRACTOR � DATE
C. WATZR LVEL Below Top of Casing: - -.L ❑ _ -.FT. Mbael S. McClure
(Ilse "+ if Above flop of Cash¢) 'PRINTED NAME OF PERSON CANSTRLICTINGTHF-WELT
Form Submit t-vid (,i 34 of corm loWn'to: dlrlslon of Water Quality inforrns don Prooming, Rev. t�Ufl-1b
� P � - Rev. xAng
1617 Mail Se ca Cantor, ftWAgh, NC 27699-161, Rhone : (919) h0lf-16=

(3 N'i MENTD9 VML , C0UCn0,,N n
Worth Carolina Depar mom of Envimanrimt and Na u al RosoumAs- Division of Water Qualit•
►SELL CDNTR c-m CER-rmcATTO:ti # 3424 A
1. WELL CONTRACTOR;
Michael S. MCCIL
Well Contractor 01IO Vldtlal) Name
WAter imlment. Inc
Well Cotfracw Company Name
Sbust Addrm
F3ranWin NC 287,34
Ctty or Town State zip code
8L8 369-0740
AM Cade Ptrone nurnber
2. WELL MOMATION:
wELI, coNsmucTIoN PERM T# WIQ400131
OTHER ASSMATED P£RINTFi1(ir ovPlk-ble)—
SM WELL ID #Tappkalai ', --� i(7
3. WELL USE (ChWA One sox} Monlloong El MurdC"UPub% V
1ndustiiaV4Comrmerc;IM ❑ Agrlmdturai ; Reoovery r it 9dIon Sf
"aborip Oftr ,a !list use)
DATE DWILL rD
4. WELL LOCATION*
1735 Saxaoahaw Bethleham Church Road
(112109 NM*. NumbsM CaMoniw, Subdivision, Let He., Parcae, 21p Cede)
cay: Saxapahaw couNTY-Wamaric _
TOPOGRANC I LAND SETTING: (OwK* spF aprltt*
Alope ❑Valleey C JFW ©Ridge ❑Queer
-LATITUDE 0 7 ',a'_ 6T. 7 - ams OR Lxxm004Wa oD
LONGITUDE AM'I i - a _ DIVIS Oft 7X,&Q9Q9QM DD
Lat144allcng1tude source: PS CropograpNe map
(kedborr o1 wu# must be ev�t an a UdGS topo map andaidwhed to
this form ff aaf ush7p GPS)
d. FACILITY (Name of the busimas wtws fist: well Is located.)
Fatty Name
FadRy KV (11 appilcaMe)
'-
! 1Road
Sbv*t Addms
saxanatig lac
N.G 27340
City or Tavm
_ _.
'stilts ZIP Code
cerefaot Name
P_O_ RnY 128 -
-
irtaNktg ABdrm
5>3xan
_ chew
PLC 27430
CAI or Town
State Zip Code
L 1
Area coda
a. WELL. DETAILS: ,
a. TOTAL DEPTH,
D. VOES WELL REPLACE 9WTIMO NELL7 YES ` NO V
e. WATER LOM Below Tap of Ceaft: - � � , FT.
(Use `+• tf Above Top of Casing;
rt.
J1e�
TOP OF CASING l$ "~ FT. Abu" Laced Surface-
-Top of caging terminated attor below land surface may require
a variant~ in awordence with 1 SA NCAC 2C .0118.
YIELD (gpm): "I:TIff]D rEsr
DISiNFECTIM Type I Amount
g. WATER ZONES (depth):
Top savour Too—Bouwr
Top Sottwn Top Sottorm
Top Bolmorn Top "Orn
Thlekrlar,�l
7. CASTING fiapth DiNnew VwWght ldatvrllll
Top Batts , r FL -
Top —
Top Sot3om Ft
A. GR i3OM Mate" Method
Top Bottom _ Ft. eci
Top Bottom Ft.
Top Bottom Ft.
D. SCREEN: Depth 04 0" t e am size Note"
Top BMom Ft_On. in,
Top Bcdom Ft. tn. in.
Top Bottom Ft. in. in.
io. WIDIQRAVEL PACE:
Depth Slag V twtal
Top BaHom Ft. _ --
Top Bottom Ft
Top Bottom Ft.
11. DRILLING LOG
Top 13ottom
_r 52
Zai!Z1
r
12. REMARKS
100 HEREBY CERTIFY' THAT Um WELL WAS eetiTRl1.:'t� 1NACOMANCE'10m�1
• 1M tICA= M' C3NS ' 'r1-:1 STAti ors AIW TtiATA CQFY oFTtt1B
nTURE QF CEfi FIED CONrRACWR DATE
: PRINTED NAME OF PERSON CONSTRUCTING THE WSJ,
SubmitwMin 30 ttayls of commotion to: 0tvision of Water Quality - IrIfomsstion Processing, Form J09
Rev. ?J09
1617 WI Service Cents:, Raleigh.;iC 27899-1161. Phone, (919) B07-GWQ

I=
>; N;�N RESID I1 A 4L WELL CONSTRUCTION RECORD I
North Crrolina Deparh wW. of Ea ironment and Nan r it Aesotrtr:s- Division of Water Quality
w. r
+ ;.;r• WEMCONTRACMRCERTMCATl101v 34 4-A
1.11YELL C011TRAGTOR:
: d. MP OF C1.5I140 IS — FT. Above Lard Surf%W
Mtchael_ . Ijj ;GJLlrta
'Top of casing terminated at/or below land surface may require
well Contraclor (ir4flduet) Name
a variance in socordenco)A is 16A NCAC 2C t111 B.
Ibih e i Vbter T=tm%A Inc
Welt Corttrrarlot Cutrspanyr Afame
: a. YMLD (Wm): ^C-2n_ M ETWO oil TEST 1�# i `
,c49Gorda Road
: } DISMFECT*N: Typed (z►7� t4'rtorrrrt� It 5
Street Rddrttae
; !} WATE ZOtW_3 (depth):
Fran in NC_ 28724
iopY}BWnrn Top Battorn
City pr Town Stste zip Cade
Tap Bottom Top Bottom
(0 8 369-0740
Top Bottom Top E4ttorn
Area Code Phom rwrnbet
Thicknees)
2 1i 2LL INFORMATION!
: 7- C G: m4zLn DldsnlEar Wilight 7tleEartel
WELL CONSTRUCTION PERM(r* WIQ490133
:Top Bpaom -•
O1TiER ASSOCIATED PEIRMIT:(d e��e)
:Fop Sodom
SITE WELL 10 go apP&Cft ri <Z
:Top 90 FI
3. $VELL USE {-hw* One Box) MOnRcHing 73 MtmfdpatlPublfcQ
S, GROUT`- Depth mxkvw
��
Ir"trt&XomrwcW a Agrteult ml C Recovery E Inlectlon t��
�Mealhod
' Tflp� Ft C�
irrigatlono Other L) lick usej
: Tpp _ 13ottonr FL__ _.
DATE DR&LEID �
= inR 8ottam Ft.
4. VALL LOCATM:
; 0. SCRaw- Oapth Diameter SM Stm Matsrlal
17 Saxeoahaw-Bethleham Church Road
:Tap Bpttom FL ►n. In.
(Surat Nam, Nut6m. Commwtily, Sabdl++wtw lot No., Pwcar, Nip Cede)
; Tcp Bottom FL In. in.
CITY: SaxanehaW COUNTY Rlarnance
Top Bottom FL {n. In.
TOPDGRAPHIC I LAND SETTING: (stodgy apprcpristc boxy
Slope ❑Valley MI'lat ❑Ridge '70ther—
:40.SMiDlt'RAVELPACK.
LATTTUCIE 36 " DUS DR 3X.XXX cX*= DD
D°p'h sips hlabertaf
— -
:Top i3GttDrTi Pt,
LONGITUDE 75 " DUS OR 7x.xxx]O(x7[)o[ DD
: Tap p mrk_Ft.
LabtudeRongtkade source: BPS C7t'0pographle map
: Top 6ottorr► FL
Rocadon of weU must ba shown an a USGS logo map eVWtw:hed to
*h 1$km ffnd osiv GM
: 11. DRILLING LOG
S. FL' .ILRY (NwTw of the busir"s %,% tera the well to *rated.)
pop Sodom Faimahon Description
Sa mabaw_ l.►w Mil. Sam%
Faci ty Name t aaky ti]tNr (it i A-P ]
1735 5aranahaw-Rpth{aham Cbj j:rtt R d�...
� ].s.� — �-E." - ---
Sheet Addraas
1
say'aaah NC MAD
l
City or Town State 4 Cade
.c,
� yin
�
P-0 R x 128
_
Melling Addrsse
saxo LaklElw Nr, 2743
!
_
City or Town Stale zip Cade
12. REITARf[S:
Aim COde thane rh7S ibex • �LI I�if I F
& VT—" 1 DO
�NHGE�RC.Rj
C9M 18' LL WA�-
SCXTTisEADrtaN^.00r' C�DMI9C6EVITH
ReCC4e
aTOTAL DE?T ) Ii
bDOM WELL REPLAC3 EXN8 I�Li7 YESE3 NOrV • •�.•
$ OF 1 ED W_ CDNTRAt,` m - r—DATEr
a WATER LEVEL Below Top of Casing:
(flee '+• If Above Top of Casing) : ' iRINTED Nr;ItIE OF PERSON CONSTRUCTING THE WELL
Form GW-lb
Submit wlililn 30 dayo of comp"on to: Dh► ion of WAer Quality - Inforrnadw Pro"Wrq, Rev. 2108
1817 Gail Swvlre Center, Raleigh, NC 27699-151, Phone : (919) M-4300

i, ;t N lti'. ES.l�. NTl� WELL CONSTR;ICT[Ov RI CORD
:t Norta CaralinuDjpanmcweFEnvhw awnt andAstura) lkewum%s-1fh'ision of Water QIa:lity
v 1 WELL CONTRACTOR CERTIFICATION # .1424-e4
r;.
1.1f1EU CONTRACTOR:
Mic l SMcClure
WOR Cordrac W JlydtVWw4 Name
Tarheel LVsteF Treaiment, Inc- _
welt Garfeclor CompwW Name
Franklin _ NC 28734
—city a Twn SWe Zip node
3+ 28 369-0740
Area cafe Ph" rAWb r
Z WI U INFORMAI'lQY:
WELL CONSTRUCTION PERMITS VIQIQgl
5/8
C TOP OF CA81N[i M r oe FT. Above Land Surface'
'Top at catbrg hsrminEted W& below land sulamay regWe
a variance in accordance with 16A HCAC 2C .UT 18.
e. YIELD {gpmj. , z METHOD OF TEST A I ... rwl j
t. DISINFECTION: Type -11 i. c> Amoo t : 7:Z �C � je jY
V. WATER ZONES (depth): v
Top Eottom Top Fattorn
Top Bottom Top Bottom
Top Bottom Top— Bvttorry
ThitJu%W:.f
: 7. CASING: [ "-, Dlwrtetar Weight 111%orrial
Tope 8o•,lnr t�—
OTH1=R ASSOCtATED PFRM[TaE(a aw ral*) : top EoOom €t.—
f = Top Boff wr-' ^ Ft.
SITE WELL Ib"sppnc*Ne —
3. WELL USE (Check One Boxy Nlmkorfng 0 MunicipaUPublic p
IndusbiaKommsrcial C. Arorlculturai ❑ Ramvery 0 Injection
InlgatlonE2 O#wr Q Illst use)
DATE ORILLEO - "'%_t C.
414WELL L.00ATKW.
1735 S21xwahaw-Bethleham Church Road
($bW Nam, Number:. 0%nmurMy. SuWMakm, Let No., ftmol, Zip Code)
ary. SaxapahaW cour4TY Alamance
TOPOGWH1C I LAND SETTING: (&ack bom)
Slope oVatey oFIet ❑Ridge ❑ether
LAIMDE 36 " DMS OR 3X.: )0O()0o= DC
LONGITUDE 15 DMS OR 7x,xxxxxxxxx 00
LaftidellongkAle s0Ufw:'rzPW8 ©rom mphia map
(loc mbn of wad mu he shown err a bws two map xnOSttacw to
this form If not Jeng GAS)
5. FACILITY tNikme of the. t swwsa wher,rx the weR is ioeltad.)
—13alacilha
FKMty Name
FadUtlf IDS (R a le)
-i gL—U% hR - r_th
ftW9m Churrh Read
Slyest Andreas
.;axs ahSMj
hir- 273A
CSy or Town
Stela Zip Code
J:ohridQfdr-
-
Cattact Nam
P_()- P&IX--28----
Mailing Address
--
274SO
saxanahaw
CRY or Town
151O
State 4 Cade
3. GROUT: [7epth
mate?" Memod
Tap Bottwl�
f t."4 i
Fop Bottom
Ft. _ -
= Top Sattam
Ft
: 9. SCREEN.' Depth
Dt:•metar Slut alto Material
Top $otlam
Ft In. In.
' Tap Bottom
FL in. in.
Top 9ottom
Ft. In, in. -_--
10, 3MDIGRAVEL PACK;
Depth
sew Materbl
Top Batom
Ft
= Tot 13attom
Ft.
Tap . _8ottom
FL _
11. DRILLING LOG
Top Bolcom
Fomration Desarlptivn
Yll_
1
1
1
r
1
11 REMARKS-
Area code Phone rRimber
s. L'JEl.L DETAILS: t oo rr':ReW r�TIF' T Th YYML WAS t:oMFW E0 el ACCORD',liCeWr►:'.
16A NCA,; 2P. %2LL - STRU •24-CA S, APO "T.: CJPY OF In
S : RC-=q0V4q0MN vl TO : L N
a. TOTAL DEPTH:
b, DOES WELL REPLACE EWTING WELL? YES L NO qr f � f
slo�a� c�nFlEn weLL aHTr�c�t7a �aATE
c. WATER LEVEL Below Top of Casing- ��_ FT• Micheala--im -
(Use "+" It Above Top of CaNV) : PRIM1TTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-lb
Submit within 30 (ivy t of completion to: Division Of Water QllBilty - Intorn atios Processing, REV. ?jog
1617 141.0 Service Center, R11,16191h, NC 27699-161, Phone: [phone]

NT WELL CONS,TRUCTi4N RECORD
North Carolina Department of Environment arrxiNarurai Reenurrs9- Division of Water Quality
WELL CONTACTOR CER IFICAT:,ON 4 3424-A
1. WELL CONTRACTOR -
welt Corwectar OndvWual) Name
T'orbeel Yygter TrealMg& Inc Well Corrkador Company Nance
�494 Sae[sia_ Read -
Street adores:
1'n28734
City ar Tavarr State ZIP Cade
${ 2$ y 369-0740
AMa Dade Phorm number
tk TOP OF CAMG IS � FT. Above Land Surt w
'Tap of owing terminated atior below sand surfaca may require
s variance in av-ardamf a with 15A NCAC 2C .01 TO
& YIELD (gpm): 11 METHOD OF TEST '
f. DIWHFECTM,.1i1* L}'i�Ci : i 1e _ Amount �I��°
a WATER ZONES (deplh):
Top_LL-_ Bottom
Top Bottom
TOP Rodom
Top Bolorrr
Top Bottom
Top Bottom
Y. WELL 1INFORPAX114H: : 7. CAWNtir D"th Dieme"
VVELL COMT► UCTIO14 PERmiT* W1Q4W133 ; Top--D-- emomfg3— nt.
OTHER ASSOCIATED PERMIT#f(ifappi:=b ,)
SITE WELL ID Air apOkai%s) -'S {
3. V —EU USE (Check One Box) Monitoring E, i»unicipallPuhNIG ❑
IndusM6Y0 nxnerdal ❑ Agriotdiural ❑ Recovery ❑ tn*wn g�'
Infigatfono Ovt er ❑ tat use)
DATE !:?RILLEI3
C] 71--j9 KellfACGRA
1735 Saxnahaw-Bethfeham Church Road
(Shoat NAM, Nwrrbera, Crnnmun4. SubdivWon, Lot No., Pr%xg. Zip Cme)
CITY; S,axaaahavv col wy Namance
TOPOGRAPHIC I LAND SETTING- oheck approprfne box)
N'Slnpe OVaflgr VFW ❑Ridge 00mer
IATiTUDE 38 " QMS OR 3u.a0onaoaoot DD
LONGITUDE 75 —' - Dms OR 7x,MXXX")CK ❑D
LatftudeltongftAe soLn& ' P Qropagraphlc map
(faEikbn of st+telf mue be afi.7071 our Y USWT'"map sadaftached to
rh{s rrm i1 not usAng GPS)
6. FACILITY (Name of the business wlIere the vO la lona?sd.)
Facility Nerne Pad* IDA (d aFFllkaw)
IT35 SaranaW--Bafhleham_Chi irch Roar}
Street Address
City or Twan state Zip code
cordad Name
P0- Rnx12$
Making Addm "
Saxanahaw NC _97430
City or'rrnm slate Zip Code
Area code
Phone nurritw
6. WELL DETAILS: �
a. TGT,.L DEATH; L
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO,a(
r
e. 'elf -TER LEVEL Below Top of Casfng: 0 0. FT.
(Use "f' if Above Top of Casing)
Top Bonxrr Ft.
ToP Botlom Ft.
Thlclt
WtAght fllater'isi
T GROUT: Depth rr +-��_ Material ��
Top BatlGm `�7t� Ft.
Top Bottom Fi.
: Top Betfom Ft
9. SCREEN. depth Dfcmewr Wolt St" IAetarlai
Top Bottom Ft.__Jn. In.
Top Bottom Ft in, in.
Top Bottom FL in. In,
10. 301013RA1 EL PACTS
Owl Slurs M"prbrl
Tap '?attom Ft.
Top BoWm Ft
Top Bottom Fi
11. CRILLiNG LOG
Tap Botforn Formation Descrlplian
- 1
1 -
I
i
1
12. REMARKS:
S Da .4E AiSY CERT V TH. -H 'r: LL wA3 STRL..TEO tN A.Cr.ORC W.S NTH
t_Ak r:C'-.VE'+::,ON R. T.^•!5f'Ar�C �iC�THAT It. Copy OFTWI
RE.rO _ PR 11F �1 OMER.
StGNATU GERTI IE13' LLCONTRAC`�P DATE
PRINTED NAME OF PERSON COrNMUCTING THE WELL
Sui3:nit u^ibin 34 days of completion io: Division of Water Ouallty - lnfomwtian Prccasabng, Farm Rev. 2fiM108
1017 'Fail Service Center, 10,11e(gh, NC 2759S-161, Phone : (910) 807.fiM

NON .AMIDE M WELL CONSTAUGTION, MORD
North Camlinrr .T]epartrrrant of Environmmt end Natura3 ResooA=- Division or WSW ounfity
WELL CONTRACTOR CERTIFICATION # 3424-A
1.W ELL GAR:
cli el S.-McClure _
Well Cartita wbx (individual) Name
TDrhC21 Wester Tres gnt. Inc
well Corrttacw con+pnoy Name
3494 Qgorci "goad
Street After
Franklin NC_ _ 28734
filly ar Town - State Mp Code
$f 28 ? 369-0740 _
Amoco* Piton mrow
Z. WELL INFMIMATMId.
WELL CONSTRUCTION PERMfT'N W10404133
OTHER ASSOCATED PERMITO(a apR=bk)
SITE WELL M dkIFappik&wj. - �5 2 L-1 .
3. VMLL USE (Check One Soil) Morifl[Ning ❑ MtJnicipal!"Ic
Indu9titoYConwrmciat ❑ Aoricutturel ❑ Recovery ❑ Indevtlon &(
irrigation[] Ofw ❑ flist use)
DATE DRILLED r -
'. WF_LL LOCATION_
1735 Saxauahtw-Bethleham Church Road
(S"Ot 1 OMe, Flrarrrberi, i,'pprrkd ft. Subalvleion. Lot NO.. FWOW, zip Caller
cl1Y- Saxapahaw COUNTYAlamance
TOPOGRAPHIC 1 LAND SETTING: (do* Cosa boil
�S" OVltivy OFMat ❑Ridge ❑C>thar
LATITUDE 20 ' DMS OR 3l[-XX*OODOOt DD
LONGITUDE0 ^ DMS OR Tom. DD
latittxWongittlde towc& JOPS 1CITop)grephic reap
(tvcatiore of naN retest GR ShOM an a USGS topo map andattached to
Mi31brrrl Nrlot Ir8ft GM
S. FACILITY (Name of the ixialneos where the t%5 Is locsted j
Fadlity Nwne Faditty !D# (9 aWirebla)
'Q
City or Tom state zip Code
�lohn Jordan-
Coract Name
P-Q, 1309.12A
)Nailing Address
city or TOM state zip C;oder
Area code F"m nur<9w
S. WELL DETAILS:
&. TOTAL DEPTH.
b. DOES WELL Ft&�L=E ZXMTING WELL? YES C NO V
r. WATER LEVEL Below Top of Casing: FT.
(Use "+' if Above Top of Casing)
5:2 6
d. TOP OF CASING tS ` F r_ Abava Land SurtaaW
'Top of casing terminated atlor below land stuTaee may squire
a varlanoe In ac=i:iance with ISA NCAC 2C A118.
e_ YIELD fgpm): �L METHOD OF TEST
f. DiSMFECTIOM TYPe� ►L [C fl Amount _
a• WATER ZONES (depth):
Tape Bottom Top Bottom
Tap gottoas Top 6ottorn—__�
Top Bottom Top 6OMT
TIhlcknc3sa:1
7. CASING
h
Dhrrletrtr (?.?lariat
,.ftwo-
Top
-FL
Top
A36 morn
Ft. -
S. GROUT:
TOP-0
Depth
Bottom 4b
Metwwl Me"
FL�� �_
Top
Battorn
Ft
= Tap
ROMM
FL
9. SCti}:EM:
owh
Dlemeter Slot 91m ll4atarrat
Top
Bottom
Ft, in. in.
Tvp
B9otliom
Ft irk in.
Top
Boliorn
Ft in. in.
ta, SANMIRAVEL PACK.
Depth situ i?atertal
Top Bottom Ft. _
Top t3dinm Ft _
Top Sattom Ft
11. DRILLING LOG
Tap BottDm Fommilcn Deipilp%lari
_i Y .. r
1
�! Q�' —
e
r
1
1
1
12. REMARKS:
100 HEREBY CI A8C(*WMJCTE ACCORWWCE M-a 1
'.BAN �C � tIdELL ND' MA A 00" W TKS
R6C.ORD Q'Bem MW
SiG Tt1RE aF CERTIl;7 D YVELL frACOR-� r)ATE
= PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit %vMin 30 des of Gott! ietlon to: DiVbWon of Water Quality Information P Form r3vY-tti
Y P tY +�• Rev. 2148
1817,Mall Ser'ike Ceror, Ra(algh, TIC 27690.161, Phom : t919) 807.6300

SO,V LDENTMLWELL CONSTRiTCUON REQUD
Nurlh Csralsrra Deputment of Environm.nt and TlydurW R�,..urcx s- Division of Water Quailt►
WELL CON: [iACM C;rRMCAi70N # 3424-A
1. VMLL COMTRACTOR:
Mi_ghgo1 S. McCure -
~ Conbw o ¢nawduatj Marne
Tarheel Wpter reatment. ing
well Contract" Campany Name
3494 Qeoraia Road
Sbwt Address
- - Franklin -- hIC 28734
City or Town State ZIP Cade
(828 369-0744
Area code Phone number
2. VOLL INFORMATION:
WELL C(MTRUCTION PERMITO W10400 1 33
OTHER ASSOCIATIM f MVITO(ifgoicabi*)i
SM WELL M slat apokmej—_-Is :' 1
3. WELL USE (Check One Box)1MWoring C+ Atunicaipat/PublIc E
lndustrielf0boundaW ❑ Aprkaathsat G Recovery C{ InAcdbn td
trdgatlonq velar p (list beef
GATE DRILLED—& -L:S — IV
4. WELL LOCATION:
1735 Saxaoahaw-$ethleham Church Road
(9aaat Marne. Nt►raabara. Cenrraaniry, SubtBvlalxr, i.et Ko., Prnced, ;alp C�1
crm. Saxanahaw couwyAlamance
TOPOGRAPHIC 1 LAND SETTM. (do& arz*rin a box)
MSlope ^Valley CFM ❑Ridge ❑Otter
LATITUDE 36 • DMS OR 3x.xrocxVOM DO
LONGITUDE 75 .`' " DMS OR 7x,xxXc3U &6 DD
LalttudeitangAtuda souroe: �APS tjopographic map
(AxvUfon of aged mast be Mom an a USGS topo may andaftached to
ffrb llarrn If not =V GPS)
S. FACILITY (Name vf" business where the v►Iell Is Iv ated.)
_fjaX=ahiiw River Mill Rf4nm
Factlity Narrae Facilk tw {rl saawia;9ej
1735 Saxarlahaw-Hgthlj;ham ('hiirrh Rnad
Stred Ada ffm
City or Tovm State ZIP Code
.Sn2-/
d. TOP Of CASING 18 � FT. Above tend Surface`
'Top of cartrsg ierrnlneted etbr below Ind surface may require
e vertance In aocordance with IM NCAC i .0118.
& YIELD (Wm): MEIWW OF TEST
_ r
r. t»�r�cTlat+t: Tye �.hla r, n �.. Anaoturt ��
I. WATER ZOMES (depth);
Top
Bottom Top SottCrn
= Top
So# rte Top BOttGm
' Top
Bottom Top Sottorra
7. CAS1P :
f]" Dimnetar Vftight Matorlel
Top ❑
Bottom Ft.
Top—,—
aottem T
Tap
sow Ft ~ �_
= B. GROUT: Depth Male►ml Method
Top Bottom 450 Ft.
: TOP Bottom FL
Top sottorrs FL
S. SCREEN. Depth Dismaatir Slot8tse Material
Top Bottom F3 In. In. _
Top BWforn Ft In- In.
Top Bottom Ft. In, In.
10. SANWGRAVEL PACK-.
Depth Size Matewlel
Top BotEpart Pt.
Tap Baiiarn Ft.
Top Bottorra Ft.
11. DRI WNG LOG
Top Bottom
f�i1�
1
�J
1
Fvrmatlwa DescripUay
� -+i 0►-11 r
John jordiin
Contact Neese - 1
P_0- Box 12$-
FAffing Addms 1
1
City or Town Slate Zip Cods
1 g. Rtrilh>s KII,
C!Use Only
Area code Phone number �
3 a DE= $: f pR MERE13Y CERTIFY T Till L :VAB C RUMM IN ACCORCANCE 1ATTH
t}
7 1 = 1FA NCAC w'ar : STAra � NDTKAT A COPY Dr- THPS
Rl!'.'OR 'tiE>raJ OViL E 8!.
it. TOTAL DEPiH:�
b DOES WELL REPLACE EMSTiHC3 ALL? YES q NO V,' S! NATURE OF CERTMEO WELL CONTRACTOR CAPE
WATER LEVEL Below Top of Casing: _ �S�L? FT. M+t#taa# 5. flAr CiLArt3
(Use '+' If Above Top of Casing) 'PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submru t-vOln 30 days of completion to: ClIvision of ]Muter Qual - Irttomiation Procea,,-i g. Form GW !b
� �f Rev. 2J09
1617 ft l Sonelco Caritm Raltltgh, NC 27629.10', Phond : [phone]

`;Noiy J? Es,(DEA"rmL WELL CONSTRUCTION RECORD
i '�onh Carolina DesrtmenroFEm7merc.nt ors: �aTurpl Resource.-s- l�iti ision of Water Quality
r-. WELD CQ'4TRAC FOR C£RTF FCAPUN # 3424-A
I. DELL COW*1' RACTOR
Michael S. McQ
Welt Contractor individual) Name
Tarheel Water TrealmenL Inc
Well Cordrat'ior Cor v" Name
3494 Georaia Road
fleet Addmm .�
Frprklin N 28734
.t:ly or Tam State Zip Cafe
8 8 369-0740
Area Cade Phonic nrxrrber
2. WELL INFORMATION,
WELL CONSTRUCTION PERMITO W14490133
OTWER AWAXIATED PERMITC(ktapoxabla)
SITE VVEL L ID #of appKaqbi.'..
3, WELL USE (Check One Box) Monitoring = MunlcLpa'..'Pupiis
b%hm rialei;omm&cW j Agri�wrai a Recovery D to a -,Von &e
lrrfgatio o Olhe.+r C jw use)
DATE 1X1ILr Fn _ - _I,'_— l L
4. WELL LQCATIrO l:
1735 Swmoahaw-Bettlleham Church Road
{Steel Name. Numbers, C6mmunity. Sui7r M5W. Lot No., Panel, Z`p Cod()
err: Saxaoahaw couNrr Alamance
TOPOGRAf7HIC r LAND SETTING: (rrredr app►mvWn box)
WSlopa '] VA{ley ,Flat E7 ROge C 0rwr_
LATITUDE ��`' DMS OR 3%,XVCXX'-D C DC-
t_oMG TUDE " DMS oR 7xjxXkXXXXX DD
Latltudellorrg We sourc& S Z�fopograpt-ic mep
( eawn of well must bey own on a USGS tapo mft andaMwhcd to
WS fomr irnot i:OV'3r ers)
6. FAVUTY (Nam of the bushes �&ftrt the %e:l's locate-J.)
V
Fwifty Harm Faafty tD# (it app icwe)
735_$axl4rlaha Ek+ 1iSb;;m Church Rrad
Steel Andreas
Saxanahnyj . _ _ . NC 27344
City or Town State zo Dade
John JoEdan .�.
Gordan Nam
WlIng Addrea3
- S$Mnahaw NC 274 M
City ar To" state Zip Coup
�-
e- TOP OF CASING FT, Above Lar 3 9xfFce'
'Top of casfng terminated atlor betori land surface may require
a variance 1n amordance whit l5A NCAC ZC .Ot 18.
i. YIELD (Uprrr}: MIcTFtO0 OF TSST " r !
V. Dlsitrt:ECTiatr: ryp ,'0 Amcutn :�
9• �ATW ZONES (depth):
Top Bottom Top Batton
i'op Bottom Top acttorn
Top Bottom Top Bottom
ThIcknoW _
7_ CAS}flG..N%Papfh Diameter splptR pGalorlaE
Tog _ Bottom
Tog Bolomr. rL `rt
i op Ft.
: 9, GR UT: Depth mahnai Method]
Top_ Bottom_
Top 9rtt4m Ft. �1
Top aotxam Ft,
9. $GREEN: Depth Dlnmawr "$lot Stm matanal
Tor Batten Ft. In. In.
Top Botto-,t Ft. !n- in. _
Top Bottom Ft. in. In.
10, SANDIGRAVEL PACK.
Depth sirs v4bktat
Tap E3attrm _ El, ,_ _`
Top Bottum Fi
Top Bottom Ft.
11. DRILLING LC G
Top FA1twmn
1
1
_ f
r
12. REMARKS:
Forn,ftn Oescriptiorr
7
Area Code Phone number
a. tittELLL DETAILL': J :: on HFAt -P - CErT?" Tr. Tn, ELL r.a yoNMIJG l: ALG0RUU'u -E y.,rH
L :SA hide' :b U- JN " •5, 0Ar0VyCx'TW'
PL TOTALOEATH: ` r• ` k p A
b. DOES WELL REPLACE c-�MTIiSG WELL? YES E; NO :�01 'cif NAT�'R� � CER73 WEL! COHTRACUP- DATE��
c. WATER EF-ML Below Top of Casing: FT. . M►�y�LL tkci`Jilm
(Use'+' if Above Top of casing) : PRINTED NAME OF PERSON CONMUCTfNG THE W-'LL
SubrTiit wtthin 30 days of compiation to. Di►►ision of'r sUs Quality - Infonrtation Procassi � to
n$+ RRevew- . 2,u9
1617 4".slff Sorvkw Center. Raleigh. W 27698-161 . Phone : (ale) 8074=

NON, RS1,F)E TIAL w ELL CONSTRVCTYON RECORD
North Carolina F)epRstrr)ent aFEnk irorur.:rrt ,md N'A,)rni Ra5.7tut :s- i7i-•:51rn of Wetrr Quality
•�' �. VF ELL CONTRACTOR CERT[FICA Ta )ON # 34141�,A
A. WELL CONTRACTOR;
Michael r
Weil Contractor W ivlduaS Name
Arbegil Walgr Tr atment Inc
Well Contraclor Company Name
3494 GeorgRoad .
Steel Adurass
Fra:i).ilin NG 2$7a
"or Tom �S'Ale Zip Code
Area code Phone number
2. WELL II4FORnATIM
WELL CONSTRUCPON P£Rmrr t W)04QQ 133
OTHIER ASsOCKTEd PERMITi(eeQplo.ela)
SITE WELL IDN{I arpumble) Sa
]. Uy.-U- USE (Check One Box) Mon1trAng r=' MunicipaVPubiic r-
InduatriatrCorrurlerciat Agrlrallhrral G Recovery r injaCtion q
irrfgationo Outer ID (4>!<t use,, -
❑ATE DRILLED i b-IS - 1 --
•", WELL LOCATION:
1735 Saxawhaw-Bethleham Church Road
(Shaer Home. Nmgiem Comrnun ft. SubdwWvn, Lat N4., Psrc• 11, Zip ^ode)
CITY- SWWDahsty — couNTY lamance
TOPOG-RAPHIC 1 LAND SE-MNG: (check rppmpftw bax)
MUPe OValley CiFl9t DRidge 00theF
LATITUDE 36 •_ " DMS 4R 3x.)=xx)(xxx DD
LONGITUDE -b " ❑MS DR N.7ocyxxxt DE)
L sfitudcAongttLdb sourm: Lj3PS Qropagraplk map
(Iocabra + of WN rnu& be shown on a LlSGS topo map ondattachad to
Uw form h'not ulft GPS)
5, FACILa 1 :' (Name of the buslness vuhart• the w:11 It! ocated.,
-qaxaDaUw
Fadity farms Facrity JD# (9 apptieabie)
1735 R;axgnahaw- Pml h,a an! t^ rchRoad
Street Address
City of rows 5t ft Z1p Code
jonn. Joda n
Contact Nacre
P_Q_ Rox 128 _
MaINW Address
Saxanaiaytl _ NC _ 2T430
City or Town State Zip Code
Aria coda Phone number
6. WELL DETA&S:
a, TOTAL DEPTH: 0
h. DOES WELL REPLACE F-X STING VOELL7 YES O NO ZBI
C, WATER LEVEL Below Top o'. Casing; -!NW—Fr.
(Use'{ if Abom Top of CaSing]
,�
d. TOP OF CAMHG IS FT. Above Land Surface'
'Top of casing terminated allor below land surfave may requira
E variance in acc,: lance with 15A NCAC 2C .0718.
' a YIELD (ypm]: RWTHDO OF TEST
f, DISINFECTION: TYM-L111010 Ag AmanrK jhi t-5
g. WATSIR zoo- Z (depth):
Top Sottcm Top ._ Bottom
Top Bobo Bottom
Top Bcmom Top t&Wa
Thioknassl
. 7. CASING: baps Dian QW Wolght Is&WW
Top _ softom-6�- lrt-
, Top Bottcm
Topes om F3 r v
T GROUT: Depth , f mate" ASe
Top Bottom FL
Top 8attom Ft
: 9. SCREEN: DWb
Dismasor Mot Ekxs Wkywrtai
'fop Bottom
Ft.
In. in.
Cop BotWr
Ft.
kt, In. �.
TAP Bottom
FL
—in. in.
10. SM0rQRAVFL PACK.
Depth
Stm I449toriar
Top Bottom
FL
Tap rsottari
Ft
Tnp Bottom
Ft.
11. ORILLINO LOG
Top Bottom
Formation Desarpidon
r
1
1
1
r
1
1
12 REMARK&
I RC MEf;.8" CEfMFY j T !19 M LL WAS CONSTR TF9 IN ACC0:4UAME V rrH
1.;k NCi.0 2C. VYRI C;c .•J ! 8 M S S• T%f .7 A C01 1'OF TIn
RE�:.7R0 Y 7Q ELL
St NATtJRf F CERT1 WE ONTRAL` OR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Subm1ii t Wn 30 days of completion to: Divisien of VVsW Qusifty - Infonnatlon Proussing, Rev, MD
1617 FIAIH Servias Genus, R alolgls, i!C 2; 699-131, Ph ona - {919) 807.63M

1 1► o Y l �.'"rSSIDENTIAL WELL C[HYMUCTION PXCORD
NCath Carolina Departmmt of Envi=mmnt and Natural Resoump. Division of Wow Qw ty
WELL Coi-r AC'[tt]R cFjtj- PICATiOIr( # 3424 A
1. VIELL CONT'RACTCIR:
Mighae[ 5. McClure
Vumll Contractor (Indn "l) Name
Terheel Water Treatment, Inc
Well Contractor Company Name
3494 Georgia Road
Street Addrema - —
Franklin NC 28734
City or Town state Zip Code
(828 369-0740
Area coat Prone rxanber
2. 7r ML rNFORMATION:
wELL coNSTRucTioN PEfilut17llt W Q400'133 _
OTHER ASSOCIATED PERMIW *pplkrmw*)
SITE WELL ID tf(If eppikablm)
3. VMLL USE (Check Otie Box) Monitoring ❑ Mwlcipal/Pubfic Q
Industx "ornami-Oat a Aijacuftural G Ramvery ❑ lr4ectton by
Irrigation❑ Outer Cj(Ilst use
DATE MILLED /-C
& WELL LOCATION:
1735 5axaoahaw Bethleham Church Road
(Street Name, Numbers, Community. Smbdvi•lar. W No., Pared, I}p Coda)
cffr. Saxanahaw couNw— amfince
TOPOGRAPHIC l LANE] SETTWG: (cfiecu appra ilft II)MO
I'ISlope O V-1hey ❑ Flat ❑ Ridge p Olher
LATITUDE �_ _ _ ` ' Dms Oft 3lt.it'xoDoo Di DID
LONGMME i. ' DIVAS OR 7x.x*wDp= DID
Latliudellongltude soume�5 ENPographic map
(kmft7 of �a must be on a USG$ fWo map anoWdecrhed to
[life 1t#rm gnat usurp GPS)
& FACILM (Name of the buskins where ft well is )owted.)
TENT-
•.- r � ► 1
Area code Phone rwmber
S. WELL DETAILS: ,
a- TOTAL DEPTH: � ,)X_ - -
Ix DOES V,1ELL REPLACE EUSTING VE LL7 YES O NOW
a. WATER LEVEL Below Fop of Casing: FT.
(Else "+• if Above Tao of COng)
d. TOP OF CAr.91HG IS Above Land St oon'
`Top of casing terrNnated a llor below land surface may require
e variance In accofdance wlth IBANCAC 2r- 115
a YIELD (gpmy: �� Ir:ETHOL OF TEST
f. p{SiNFt7CTit]N: TOO 41La. `� Amcunt,2 2 LW4
g. WATER ZONES (depth):
Top
Baftom
Tap
Bottom
Top
Sodom
Top
Sott M
Top
gntlom
Teo
Bottom
ThlcktneaW
7. C11513+,G:
Depth
Dismater
. Weight tlamerlal
Too_ $otter►+ y ia.=!
--
Top
Bcftgm Ft,
Top
Bottom FL
8. GROUT: Depth Mat"is i Method
Top,- _ Bottom)Ft, t��_
Top Bottom Ft.
Top Bottom Ft.-
S
. SCREEN: Depth Diameter Slut size atatarial
Top f30ttam Pt. tn. In.
Top sonom Ft, In, in.
Top Bottom Ft in. in.
10. SANOtGRAYtEL PACK:
Depth size
Top Bottom Ft.
Top Bottom--- - _ Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
1
1
1
1
1
i
1
feateriai
Formalion Descriptim
7
1 u�
12. REAEARIC9:
f an FAY corxx Tw1T is W4 Mus coets3wcTm INAccort mor= waH
S4A rECAC zc we f7N5J CTiDN srrtNCuS; 140 TiiAT A CpPY OF THIS
4� PIiOV' EDrTa t r ��►( i/
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit vsifitfrt 30 daye of compWian to: Division of Water Qualky - hdiumallan PrvceBsIrlg, Fenn OW -lb
Rev. 2%
1917 RWI Ser► Ke Critter, Raleigh, NC 27SWIS1, Phone: (919) 807-SM

IV, & ram►- ' ��` L Wn L CONSTRUCTTO.N RECORD
North C.wolinx Dep tr'unerF, of Enviroamcet pnd Natural Re5ourm- Division of Wa.r Quality
,: WEELL CONTRACTOR CERTIFICATION # 3424-A
t. WILL CONTRACTOR:
Michael S. McCh
Weill CWMraCtor (Indvidual) Name
T$rheel Water Treatment. Inc
welt con#acw Company Name
_ 494Gearcia Road _
Stmat Address,
Fral3k1in _ NC 28734
City of Town Stato zip Code
(828 F 369-4740
Area code Phone m ntw
Z WEt.L 1114FORMAT11ON:
WELL CONSTRUCTION PERMIT* W1O494133 .
OTHER ASSOCIATED PFRMIT1ikd ■ppiieabie)
WE WELL 10 *pfuppkawo) -S --��5
I tAtaL USE (Check One Box) Monitoring Ei Municipal/Public I~
IndustriattCom wClai to Aoriculturai 'C! Recovery C] Injection tt
k0gsUorh j Other [2 (list use)
DXTE DRILL#_p L D `� C-- � D
4. WELL LOCATHM:
1735 Saxavahaw-Bethleham Church Road
(Strad Namq, Nwrsbem. Communhly, Subdtvitim. Lot No.. ParW, 21p Code]
CIT-r: Saxapat aw cousin Alamance
TOPOGRAPHIC i LAND SETTING: fd,w* spprovwo ba")
t Pa []Vat* n FNt G Ridge L2 Other
LATITUDE ❑IAS OR 3x.xnatxcl xxx pp
LONGITUDE i5 ' OVIS OR Z x»()o aM OD
L8&kK Iongia.ide source: MPS DTopographic map
(*X:0 do of well mustba Shown an a USGS taps map aWat[ached tb
Ohio form if not using GPS]
5. FACILITY (Nano of Me bus ass where tt•a we!i Is located.)
FBdilty Name Fadlity 1D# CK applicable)
Y 17am-Church_Rcisa
Street Aldreas
City or Tswsm State Zip Code
John .lordan - --
ComactName
Maiang Address
City or Town State ZO Code
Area code Phone number
S. WELL DEFAIi R:
a. TOTAL DEPTH:
b. DOES ► ELL REPLACE E.ti:MNO WEiO YES ::j NO
' d. TOP OF CASING tS FT. Above Land SWYare'
'Tap of caBIng terminated ntior Wow land surface may require
a variance in acrordence with 1 SA NCAC 2C .U118.
4. YIELD (qpm): � WITHOO OF TEST V
otslN�cTtah: Type Qits
g. WATER ZONES fdepih);
1 Top
Top Bottom
Top ao(L m
Elvttom
Top 8o
Top ttom
Thlc{�rwssJ
:7- CA81NG: E30"Mi Dtmne!7�- ht eatnrfel
rop—D ad,, LQ�
Top Bottum _
TOP Bottom Ft
B. GROUT: Deptii
Material Method
TBattam R. _f, j
Tap Sottorn_ Ft.
:Top WarnFt.
S. SCREEN: Depth Dlaaratnr Slot Six* material
: ToP Bottom Ft.
ln. In.
Top Bottom Ft
In. In,
Tap Sottom Ft.
In_ in.
10. SMDIGRAVEL PACK:
= Depth
Stare Watertat
' Tvp Bottom Ft
Top BCtI*M_ Ft
Top BCtt ff Ft
1 i. OMLLING L03
Top Bottom
FonmaonD mriptian
-�-�-_
_5C,
�
r
1
1
1
I
12. REMARKS:
100 HEREErt CERTIFY' TH . 8 ti ED IN ACCORDANCE WITH
t 5A NGA C L TeL+. 1 VI r A C OpY CF THIS
C EEN 0 D`7o
4) ;v JO
SIGNAFUR5f61VttRTAcDWEM CONTRACTOR^ DATE
C. WATER LEVEL Betaw Top of Casing:C173F4� S. III�C IuCf?
(tJSe "+' if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form
Zubmit.ta► thin 30 days of t orrtpietion to: i3Malon of Water Qual(ty - Informn,>;Rev.
Information Prooessi, Gvv-tb
Rev. ?Jt)9
1617 Po9 1 Service Center, PzWU r, NC 7M9-161, PRonu : (919) 8074WO

;r NONAESII3E MAL WELL CONsrltirMONT REC011D
North Curolina]grkment of Em immneni and Natural Resource---- Division of Wat�zr Qual''ly
Wir,LL CONTIRAC OR CES' rncAmN # 3424--A
!, MIELL COiIITRACTOR:
Mom+ h el S. MrQucg
Well CoomcW (Irtdlviduai) Nstn9
Tarhael "later Treatment, Inc _^
Well Corttraaor ComMW Name
M94 Georgia Road ...._
S"M Addrasa
F nkfln NC 28734
City or Tovm State Zip Code
C 28 ] 3F-9-074Q
Area oode Phase number
2.. WELL DIFORIAAT*N*
WELL CONST UCTION i7ERmrrs WINOO133
OTHER ASSOCIATED PSRMIT#(d sppi"blc)
SITE VVELL IDA*(tlepWl tto., � S
3. WELL LME (C ck One Boxy Monitoring 0 MunlapallPubllc-�
IndusVlaYCo imrasal [:I Agricultural L-? Recovery r; Injection N(
ln1g0*M[1 ottw --j [List use)
DATE DRILLED !r —,/C fG'�
4. rVELL LOCATION:
735 Sax a -Bethlehem Church -Road
(Street Name, NonbsM CammdrRy, Subdivitrion. LotNa,. Pwtst. Vp Code)
CITY: SaxaOahaW CoUNTYAjai1 once
TOPOCMA€': f IC 1 LAND SE TING: (sixth apprwp Uta Lwg)
Slope EIValtey =Flat ❑Ridge ❑Other
LATiWOE " DmS tit 3x.xlacDD
LONGITUDE 'r' ' DAIS OR 7x•x*mx*w DD
Latitud&longlLde source: r2[]TWgMphj map
fkKzffon of wsg muff bo Sawa on a USGS taps map andartachW to
this Airm 0nor using GPS1
S. FACILITY (Nrsne of life bolness v4we the well is Iocated.`
SaYanabaw Rivar_Mill RL-no _
Facia y #lw tr FeC.l14f 1W (If sppiicabie)
173!j SaXallahaw-Rathlsaham Church Rnarl
Street Addmu
Saxonabaw NC �>7.Un
CAY or Term State Zip Gode,
,lahn Jnrdan
Ox"et Name
Mailing Address
5axanabaw NC__M430
CVy or Town Slate Zip Code
Ares cods Phoneounnber
6. WELL DETAILS: �
a. TOT.;L DEPTH:
h DOES WELL REPLACE FX115TiNG WELL? YES 0 No V
d TOP OF CA31MG 13 —'�"r F7_ Above Lsl od Su -[am'
'Top of rasing terminated Atlor belnw lend surface may require
a variance;n Accordance with 15A NGAC 20. 118.
a. YIELD (gprny METH00 OF TEST "[
f, Di.SiNFECTION-Type AravarrK i [ f
9. WATER ZONES (depth):
Top RMOM Top Sodom
Top Bottom Top Bottom
Top Bottom Top I3ottorn
TA1ClcnasaJ
: 7. CAS1I4&. -Daps - bkan-ter�ai�g - �ASatartal
TaP� B_attarr,� Ft,_'�-�..
Tap Bonam _ Ft
Fop 40Dm R.
B. GROUT; Depot Malarial Medlod
Top_om� aoitRL-�-�-
Top Sodom Ft.
Top I3otzt Ft._
9, SCREEN: Depth l3k never am Star Ifta veal
Top Bottom Ft. rn. in.
Top Sollars+ Ft. in, in.
Top 6otlom Ft. In. in.
1 Q. SANOAXI.AVEL. PAM.
Depth SIM
Tap _80M,'
i op Bottwn Ft
Top Bottom Ft.
: t+. DRILLING LOG
Top sattom
1
= 1
1
1
1
I
12. REMAR ".
Mcftrial
Formatlon Deartlolon
r" ..T-
I pQ ! ;ER`P1' CER^ f T+'!AT TY' 3L wAB C tlTRi,^TED 1N ACCOri'ANM WIL-i
7y.l1w5� C - "STA.'7�k;C7Tr4.TA COPY OF Tlil6
: RFC �.EE PR8 TkE ER.
51G RE OF CfRT'i D UVEI-L CONTR,i L T; OR DATE
c. WATER LEVEL Below Top of Gs kV,. AFT.
(Use "+' if Above Top of Casirip) : PRIMID NAME OF PERSON CONSTRUCTING THE WELL
Submit v4thln 34 teas of aomniotinn to: Dhft�ion of Water Quality InforRvItion ProcimsIn , Fnrr++ Gov-16
y''S � ' 8 Rjsv, zi09
1617 flail Service Center, FWolgh, NC 27SW161, Phone : [phone]

NONRESIDENTIAL WELL CONSTRIbCTION RECORD
North CKralina Dtpart=nt of Environment andNaftnt Resources. Dirision of Warty Quaiit)
WELL CONTRACTOR CERTEMATION # 3424-A
1. WELL CC"TRAGTOR;
-M chagLS, cQjurg ._
Well Contratior (tndMdual) Name
Tarheel Water Treatment- Inc _
Weil Contracior Comp" Name
1494 Gecrgla Road -
$treat Address
Franklin _ _ NC 28734
City or Towns slate Zip Code
Areas code Ptflna number
L WELL INFORMATIM,
WELL coca ucTioN P£RmiTaF Wla4Q0133
OTHER ASSMATED PERMITP(if aivmable)
BfM W ELL iG IC.r appllrahtel _ �] �^
3.;'rELL USE (Cher: Om Box) MoMorhrq C, MuniOpaWubho 0
kUN5 rlallCoemefCW C1 AgftAtural El Recowryf-- rejection i�
irrlgetlono other Cl (list use)
DATE DRILLED if ,
4. WELL LOCATION:
1735 Saxapahaw-Bethleham Church Road
(StmatNanw Kabor, Ccmrnunfty, Subdivision. Lct No., Pond, XTp Code)
cay- SaxaDahaW couNTYAlamance
TOPOGRpsF111-110 ► L AKD SETTING: (61mak appmvaaw b=)
''9iope C]Valley QFW CRldge [)Other
L4TTTLME 36 ^ DMs OR 3x.xM0=xaD( DD
LONGITUDE 75 " OMS OR TX.X)(XXrXMM DO
LatitudeA Iftide source: D3P3 aTopographlemap
{I on of :swif must be shown on a USGS typo reap andart mhw to
this {aim fr rot wing GPM
3 FACILfTY Name 3f the busir034 where the well la looted.)
_S.5 w tar Mill P.dm
Fac&ty Narxe Facility JD* (Jf qvdc")
-1735 SaxanabayLBgtb!
street Address
City or Tow Stale Ap Code
Ommad Name
e.0- Box 128 _
IAaNtng Addrese
---,,9,-xianah;;►15L NC 27 ao
CHy or Ton State Zip Code
Areacode Phone r wtw
6- IATELL DETAILS; l
a TOTAL DEPTH:
b. DOES NELL REFU40E KSTMNG WZELL7 YES [I NO
5J7
: d. TOP OF CAMNG IS ��FT. Above Land Surfsoe'
'Top of casing terminated actor below Sand surfsoa may require
a variance in aqcordance YAM I$A NCAC 2C
a. YIELD Igprn):. Yit:TF4Oa OF TEST l �•�
f. DISINFECTION: Typ• [g
p. MTER ZONE th):
Top 9Mtoml3Crttarrr
Top Bottarn Tap pasty
Tap •wlom Tap Bottom
Thic#nasal
'I. CASING: Depth � Dicmater weight I; alsrial
Top i3morn
Top Bottom
Tap om Ft.
: S. GROUT.
Depth
Material Medwd
Top �
Sottarn,
fit��'.u�. �i��•_
: Top
Bottom
Ft.
' Tap
Bottom
Ft
S. SCREEN.
Depth
Dterneesr Slot Sl:a xx3ferial
: Top
Bottom
Ft in- in.
'fop
Bottom
Ft, in. In.
Top
t3Dtlorn
Ft In. In.
10. SAAWGRA►!EL PACK:
Depth
41w VAtarw
: Top
i9fittom
Ft
Tap
l3atfom
Ft
Top
Bottom
Ft
: II. DRILLING LOG
Top Bottom'
. 1
1
1
1
FormMo_ n fDeacripCon
• I l:0liEREBY C94 rIAT We 'NAS CANS Cl cJ IN?..^.CQFLC'#'10E KITH
5 A NCAC 7C- W U.1 ONSTR Ta,]' TAf(Odr: 6 T14AT A C07Y OF THIS
: RECORD VlD T R.
I' ram-
lv o ► I �v t7t ITi4A�— �~
rw WATER LEVEL Below Top of Casing: a��_ET- Michaels- s- M ca sire -
(tlse '+' ilAhow Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING T"E WELL
Submat ,Afidtn 30 of cam cation to: Division of Water Qual Iniamvation Processing, Form Gefir-��
� � � - Rev. 2109
1617 :::SIi Service Center, R�Mgtt, .'JC 276"-161, Phone: (M) 807-6M

1 '!�° oN.�sD�i� WELL CONSTRUCTION RECORD
` �- r : �^
North Carogna De, Pertinent oafn 7ronmatt and NatuseE �saurce4- Di�isicn of LTVxtcr Qnatit•
•�.� •,y , `� WELL CONTRACTOR CERTiFICA-Mi4 3424-A
1. TIYELL COl37itlYC R;
Michael S. McClure
~ Cor*actor jlnrlywkk"y Name
Tartleel Water Treatment, Inc
wall Q(drartor Comps y Name
3494 Georclia_Road
Street Addrm
Frgn',-dio _ NC 28734
City or Town state Zip Cade
8l 28 369-0740
Area code Phone number
Z WMI INFDi4 ATIOW.
WELL, CONSTRUCTION PERMITt_W10400133
OTHER ASSOC IATED PER d a,,ni .4b}
SiM WELL rD Ike "I ,
3. WELL USE (Check One Box) Mon4oting L7 MunicipailPubllo
lndMtrWCsJMMrd1l ❑ Agricultural :) Recovery L Injectiol s I(
Inigailonp Otm ❑ Ilat use)
DAW
4. WELL LOCATM:
1735 SaxacIphaw Bethleham Church Road
(S"d Nana, Numbem t OMMnay, SubdWFaiorv, Lot No., Parosl, np Coda)
Cmr: �5axapahaw _ couNTY AjIgmance _
TOPOGRAPHIC I LAND SETTING: ichedr appmrim =Q
Slope r±VAItey OFIet ❑Ridge ❑Other
LATTTUDE �'! " DMS OR 3X-XnXK.X C of DO
LOWrrUDE �_ _ " oms OR 7x.xxu&mM Do
Latiiudaftvltude seurta:,>;�PS 0ToPNmPNc [trap
goUtror+ Or sra40 must bC Sho WM are a USGS tWo m+4,o efrdvdtached to
thb M" If W ualrw GPP
3. FACILITY (Nam of Itra business v"fe the well is located.)
- samnat8
Faailty 1hi me FoLoW IDF Iff appNcatrie)
Steel AdWm
�sax.goehaw NC 27340
Oily or lawn Stale Zip Code
dQ Jordaa
CoreAd Narne
2Q- Box 128
Meiling Address
C4 cw Town Stale Zip Gode
Arne aod6 Phone nw9w
6 AVLL DETAILS:
a. MAL DEPTHLl
-
D. DCe9 if:ELL REPLACE E>001i G 4'fEU? YES C NOV
c. WATER LEVEL Below Top of Casing: ��FT.
(Use `+' irAbove Top of Casing)
: d TOP OF Cll INO Is —Abm Land Sue"'
"Top Of caOng termineted actor beiaw land srwrace may mquira
a verlance in accordance Wth ISA NCAC 2C .0116.
a. YIELD} (gpsn): r� METHOD OF TEsr��
I. DISINFECTIO[4. i]IQa An14t+rtt2tt b6dOrk-3
g. WATER ZON ottom y thy
Top BBamom
Top Bottom Bpttotn
Top. m top Bottom
Th[can
- T. CASING: Qegt Dlametar w0ght w1fift tAt
Top- 9ontprif,
Tv, tau
8. GROUT: Depth Material W411od
Top
_0 - Boftrq4�j). Ft.�
: Tap Boftm Ft
Tap Bottom Ft
8. SCREEN: D00h Dlsrrrator slot $Ixe Ldateri:.l
Top I Bottom Ft In. in.
: Top Mom Ft. in. in.
Tap BDtlan Ft. In, In.
10. SANDIGRAVEL FLACK:
DOM St be u nter&ni
Top Boltom Ft.
Tog Bottom Ft
Tap Bottom Ft.
11. DRILLING LOG
Torpl Bottom Fo"llon Deseripbon
I
1 �
: 1
1
1
12. REMARKS:
I DO FILyi£SY CERTIFY THAT 18 AE l Wi v� 67ttL�T� I CORr.il'.:'.E4: nl
% I%k N,,rz.2C 1 CO, Cnot1 ST s, AND T OF THIS f
: rtECORp� *VA } toy
- TOTH
SIGNATURE OF C • TihiED _ L CLT-RACrOR DATE
PRINTED NAME OF PERSON CONSTRUCTING TiiE WELL
Submit w.lthl"s 30 drysof connAptlon to: Chsision of Water Quality - Infornwdon Proce"hV, Farm tb
1617 M, !f Service Canter, Ralelgh, NC 27699-184, Photo : (919) 807-63M Rev. 2J%
68

No RF IDL WELL CONSTRUCTION RECORD 9
Nwh Carolina Departmmm of Envirooment sad Natural Resour=- MvWon of Wow Quality
WELL CONfRACTM CERTIMCATIO)N # 3424-A
f. WELL CONTRACTOR:
Michael. S. MCClur
wa ContraeW pndAAd " Now
Tgr_hee! Water Treatment. Inc
Well Conhador CompwW Name
3494 Gagrgia Road
street Addrete
Emoklio _ NC 28734
City or Taws SUM Zip Code
M28369-0740
Amcafe PhmrwAw
2. WELL fNFORilATIOW.
WELL CONSTRUCTION PERMITo Wf Q400- i
OTHER AWDCIATEO PFRWN( r;wbw)
3, WELL UBE (Check One Box) Monitnrlrg ❑ MunldpdtPpbli[ C1
InduatrieUCommerciel F) pgkxttural Q Reooveryo Iftomon N(
itrlga4mD Dlfler 4 ON use) _
DATE DFdLLIW jQ 2&-.IQ
4. WELL LOCA110W.
17 5 Saxe a w-Bethlehem QhuLch Road
(Street Name. Numbers. Cow-ilft. subdw%lon. Let No.. Perao. Zip CaO)
CITY: SaxaDahgw _ _ coumTY Alamar,--,e
TOPDGRAPHIC I LAND SETTING- tdndr apprnpftw bw)
❑Valley ❑Flat ©Fudge ❑Other
IA-n ruuE 36 ' DMS oft 3x.xxx)oG' xxx Do
LOWAT UDE 75 _�-' ' DIVIS OR 7-, xx� DO
La ion9PjAe source: 03PS aopographic mep
(bofie rl of weH must ft alrcwn ow v 11SGS tope map arld8ow. d m
wl kvm irsat using GPS}
!I. F'ACIL11Y (Norm of ttie Wetness w1we the wel Is located.)
■il � I if - 1
■ :.■ i
,Uft owe Ph" number
6. %M-L >AE'fAU: �
i TOTAL DEPTH: , _
tr DOES WELL REPLACE E=Tma wELL? YES o NO IV
n. WATER LEVEL Selow Top of Ca&W,. ,
(Use W It ACova Top of Casing)
f- TOP OF CAatltlG is FT. Above LwW Swf*
'Top of rasing kundnaled stlor below tend surface may require
e varWm* io accardanoe v^"i i bA NCAC ZC . I16.
R YIELD Olpmy s�7—UMDD OF TEST Y
R OWNF.TM. Type Amotl� !'Jre t'�
% WATER MWES (depth]*
Top Bottom To Bottom
Top Bottom Bottom
flop Bottom Top
—�:�
y. CASING: "" ia[ner rt iIat
ae
cTop,_ F-rep Bottom
Top ! R
S. GROUT: Dspily Filet@m metlad�
Top. Bomamg!�Q Ft
Top Bottomm Ft
Top Boltorn Ft
f. SCREEN: Depth DIAMeler 8iet Stet 1laterld
Top Bottom Ft In. In.
Top Bo torn L Ft. In. in.
Top Sodom Ft in. In.
10. MNINGRAVEL PACK
Depth stop
Top Bottom Ft
Top Bothsrtl R
Top Sottorn Fi
: IT. URILLNG LOG
P1111 ertel
Top Bottom Formai}on Description
1
1
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit W11thin 30 days of com to: Division of Water Quality - Wo mttW Processing, Fans GV+t-tb
D � �• Rev. 2"
151T Mail $wlce Cattier, Ra!■lgh, NC 2716W161, Pho ; (919) 9 f 4M

SWr,
1 'f � +SI 1VTMWEf�L C{7NSTRUCTIUN RE RD
' Warth Carolbd Depamrnent of Environment ^nd Natural Resources- Division of Water Quality
, s -•: WELL CONTRACTOR CERTWICATION # 3424-A
1. WELL CONTRACTOR*
Mi S. McGiure
Well Consrareur (Indvidtlsl) tame
•i'arhul Water Treatment. Inc
Well Coroactor Company Flame
3494 Georgia Road _
Street Address
Franklin NC 28734
City a Town State rip Code
6�__) 369-0740
Area code Phone number
2. ►`i E L NIVORr4ATM:
VVELL CONSTRUCTION PERMIT0 W10400133
OTHER ASSOCIATED PERM,(TE(f aWkabis)
SITE WELL iD 40 appimbia) IS M 3 n
3. WELL USE (Check One Boxy Monitoring r-1 A+ ltmicipalrPubtle ❑
kmiustrtor-ornmaralal i i Agricultural Recovery [1 Injocdcn M(
irrigation❑ Other q list use)
DATE DtR LED - A7
M7 S �14i0i►T t l E,6i$
1735 Saxaaahaw-Bethleham Church Road
(Street Nr:ma, Nwnws. Community, SutxSvisian. LO No.. Parcel, ZIP Code)
CITY: SaxaDahaw COUNTY Alamance
TOPOGRAPHIC t LAND SETTING: {Check appFCPIate txrx}
n(Slape Valley ❑ Rai O Ridge 001her
LATITUDE !3 " iws OR $7 xxx)DLY w ©D
LONGITUCC ;L` —' ' Dh*S DR 7X.MjM= DD
Lath4alt"hude sourae*PS Diopog,aphir reap
[Meaflton of we# must be on a USGS topo map andettacW to
MIS flarm lyfw uslr+gt GPM
b, FACILITY +Plante of the br, Wness where the weR is lor�FtWj
—Sa.-,B ►
Faciflty Nome Fadit [DO (if apocahte)
Street AWrm
SaxanaWgW -, .. NC _17
C" or Tawn Stele zip Cade
Jthn Jnrdgri
Ccrdact Notre
P_O_ Box 128 _
Mailing Addmea
,Saxanahaw NC 2743Q
City at Town State Zip Code
Area oWe Phone number
5, VIELL DETAILS; �
a. TOTAL DEPTH: L l
M DOE'S V ELL REPLACE EXISTIT. IG WELL? ? YES 'i NO t(
d. TOP OF CA3WO IS � FT. knave Land Surface'
'Top of caning terminated allot below land surface may require
a variance in accordance AM ISA NCAC 2C -018.
.a, YIELD (gpm): -r"76tETHOD of TEST"
' f. DlS(XFECT)Of*: Tgpa at
Q. WATER ZOAW3 th}: "
Top Bottom T T 8vttorn
Tap BattOra liottWn
Top Bottom Tap i�tkm
Ttackrn
1. CASING; 0* DWm06ar�:Tilght Matalhal
Top_ Bottom
Top Bottom
Top l37ttotn Ft
GROUT_ Depth M84 TOP-0— BotwmottvR1�b� Ft, Zgjftn
eq. 32ro
Tap Bottom FL
Top Bonor Ft.
9. SCREE#: Depth Diarrnetar Slot Sko MaGrial
Top Bottom Ft. ln. In.
'fop Bottom Ft In, IrL
Top Bottom Ft. In. In.
19. SMDIGRAVEL PACK+
Dsph atza
Top Bottom Ft,
Tap Bottom Ft.
: Top 9etfam Ft.
: 11. DRILUNG LOG
Top Bottom FoRnalion Do--v0pllnri
>t
12. REVARKS:
• 100 HERE . CERT; HAT THIS L AR
STRL . ED IN A +WRDANCZ-WITH
s6A rWE NSTRUCr N Np
TA COPY CS THIS
s aE ovio�n . Lf�
l
51 NATURE OF CEFtTft iE t'1t>rLt
ONTRAMM— DATE
C. WATER LEVEL Below Tap of CNWM: -- ----- FT. Michaal S- McClure -
Rise '+" if Above Top of Casing) " i3RINTED NAME OF PERSON CONSTRUCTING THE VL`aL
Submit writhlrl 30 days of wmplation to: Divislon of Watw QuaI4 - Into-r stlon Procassing, FAlec. ev. orm Ow-1❑
2148
1617 'Mail Service Can:ar. Raleigh, NC 2TSS ISI, Phone . (919) COT-6300

'fi x NON RRSIDEATI9l WEL L CONS£RIIMOlIi RECORD
North Cam iu,a i]epartrrtcnt of EztvironrDen# and Natural ]IeSatrtq;�r- Div Won of Water Qtsaiiry
5. WELL CONTRACTOR CERTiFICATIOI€ # -3424-R
4ape•'r -
4. WELL CONTRACTOR:
Michael S. McClure
Well Gondactor (Individual) Narne
Tarheeidater Treatment, Inn .. T
Well CaWaMr Cornparay Harm
3494 Ggmia Road
Street Address
rangy - NC 28734
City or Town Slate Zfp Code
Sr 2a 569-0740
Ares coda Ph" nw"r
L WELL INFORMATION:
WELL CONSTRUCTION PERMrT WIMQ1y33 --
OTHER ASSOCIATED PERMITtit applfa3hle}
SITE WELL ID i{d apokmi ts) 3-it - -
3. VVELL USE (Check One Bw) Nlvnitodng C] MunicipaliPubllc E.]
Industrlal/Cornmarclal 9 Agricultural ❑ Rocovery n injection 9(
InIgationo Other 0 [list use]
rlmm mi-Len -27
1 735 Saxacahaw-Sethleham Church Road
(Sheet Hama. Numbers. Community. Sub*Adoa, Lot No- Parcel. Zfp Coda)
CtiY_ SaxaDahaw couN-Ty►Q amance
TOPOGRAPHIC 1 LAND SETTING: (dm" appropriate b-)
Mope CIVaAey OFlat DRidge ❑Other
LATITUDE 38 " DMS OR 3x.XMOfX] XXX DO
LONGITUDE 75 � " DIAS OR 7 7�o DO
LatlfudeAomltude source. E13PS QTapographie map
{Iosat (on of well moat be shown on a USGS topo reap andeftached to
d713 lbrrtt ffnot uafng GPS)
& FA ALrr Y (Name of the bt k*m where the v e4i Is located.}
.__,B]4a
FeClitty Name Facility 1DR (ff arppliCab"
IZ35 Saxanahaw--RF-1thinham Church Road
Street Address
,qA.XRnahaW - -, NG 97,140
City or Town State Zip Code
John Joridan
Contact Name
p_0_ Box 128 __.. .
Maliing Address
_Saxanahavy F NC 2743Q
Clty or:own State Zip coda
d_ TOP of CA8 No IS FT. Above Land Surface*
'Top of casing t uminated altar below farad surface fray require
a variance In accordance with I $A NCAC 2C .0115.
a YIELD (Spm): METHOO OF TEST J
t DtSINFECT[OII: :Typo Artlount '7
g. WATER ZONES (depth):
Topjf� SOttom Top Bott❑m
Top Bo tam Top Boawl
Top Bottom Top scunrn
TislGtutYaal
7. CASIXG- Olffifn er Wa ht Imaiedal
Top--(L— Bottom Fl.
Top Bottom
Too Ft
8, i/�: Depth material Method
Top Bottom Ft.��
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Dramslrr Blot Size material
Top Bottom Ft in. In.
Top Bottom FL Ir.
Top Bottom Ft. In.
: 10. WL4DIGRAVEL PACK:
Depth 93n
Tnp 9otiorn FL
Top Boltnm Ft.
Top 9otlorrFt
t1. DRILLING LOG
Tap Bottum
A<Zb/
1
i
!
42, REI%4AKSt
In..�-
IrL — _____ -
ma6t+ICl
Formation Daaaiplion
150r'
Area code Phone number Ci
8 WELL DETAILS: 100 HE4M C��Tnt� FIAT AS CON CT9 w ACCORDA►IC& YV"
f M NCA Z UTR iON H $ ANO THAT COPY OF TKS
0. TOTAL OEM-lt;=co BEFN 0V1 To cL R.
b. DOES Y'ELi REPLACE MaSTIND WELL? YES I7 NO : 5RATURE Of CERTIFIED WELE<bNTRACToFt� DATE
c. VIATER LEVEL Below Top of Casing: t'7 FT.
{Use "+' if Above Top o? Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 tip of completion to: Division of Water Quality information Proee�ssinlL Form G'O9
days p �]f - Rev. TIDE
1517 M" Service Center, Raleigh, NC 27699-161, Phone :[phone]M

NONARESMEMIAL wz>< L cwsmuc mN REcoRp
North Carolina DVarknom of Environment ardNatwral R==*s• Division of Water QUW*
WELL. COPi MUOR CERTIFICATION #t 3424-A
i. VM LL CONTR11CT01tt
Michael S. MpQlure
wag CnnlraCtor tkwmdu* Name
Iarheei Water Treatment, In
Well Cor*%caor Company Name
8tneat A.W w6
Franklin NC 28734
City or Town sum zip Code
8t 28 _369-0?4 p
Area Code Phone Msttber
2. WELL INFORMATION-
w1ELL coisimx-noN PEwT* Q4[f 1
OTHER ASSOCIATED PERM sWkaN*)
SITE WELL 1D V ap0ksblr
3. Ws1- U8E (Check Dr* Boxy M1x1lWnp p muradpal/publfo c
lnWasbl"Om merdlal ❑ AgOwltural Q Recovery B lnie Wn N(
Irdgavoncl 0sw (listtuuse)
DATE DRILL. -O -'�-
4. VW.LL LOCATION:
1735 Saxaaahaw-Bethlehem Church Road
(SU" Nam, Numbwrs, Camrium , Subftsbn, Lot W. Pad, Zip Cade)
CITI' Saxaoahaw _ cowry,61Smance
TOPOGRAPHIC 1 LAND SETTIM tctndr apprvplaw baq
V'310pe ❑Valley ❑F1at ❑M p oOlher
LATITUDE 36 - ums OR 3x.7 0000M DO
LONGITl3Dr: 75 "OMS oR 7xaaoo mm. all
Letitudellongltude coons: p3PS Uepographk reap
(ftsdon of we✓il must be shmm on a USGS tnpa MOP errdaltwhed fo
w3 fwm not UakV GPS)
S FACILITY (Narm of the N sh)m whwe the well Is hooted.)
.q
■ ■ a 1
14 �
real war.a
- ■ w � 1
Area code Phow number
S. WELL DETAILS:
L TOTAL DEPTH: —
III. MIES WELL REPLACE IixtBTIN3 WELL? YES ❑ NO LV
a WATER LPL Below Top of Caatnp: _' FT.
Noe 't" dAbwe Tap of Casing)
d 'COP OF CASING 18 _'�� FT. Above Lent! Surface'
'Top of cuing to n-ike- sVor below land surface may require
a vatWM In accordance with ISA NCAC ZC .07 Ta.
i. YIELD (gpm): METHOD OF TIEST J
= f. owNFECTiow Type ti Amount
g, WATER YG11E8 (depth):
Top, Bottom Top Bottom
-
TOP Raft rl Top 80&XrL._
Top aomorn Top 80ttorn
7TrlcJrnas.f
7. CASING:
Dep Diinnatw VYvlght mshwlal
: Top^
Boft _ Ft.
-Top
Boslom
ToP
B F
' S, GROUT,
Top2_
Depth Material
Bot 46D FI.
Top
Holt mo Ft.
Top
Bottom FL _
- 9. SCREEN: DWh 012rop sr Stet st m Matsrkd
Top
Bottom Ft In. in.
Top
Bolt m FL in. tn. �.
Top
Bolton► Ft. In. In- - - - - -
11 SAIiWRAVEL. PAGK:
Depth Sloe flutertaf
Top
Sotsam Ft
lag
8dtam Ft.
: ToP
Horiwv F't
11. DRILLING LOG
Top Bottorn
21
1 _
1
1
:1L REMARKS:
Formawn c' ftolplion
sf / _
»w ■
I DO HERECY TIFY T 14a CQNVPUG= IN ACCORDANCE WM4
f EA THAT A COPY OF TKM
REC WEN V TMRAILIq
RE OF CEFMFl NTRAG� . DATE
MichaRl R- MCCIUM
PRINTED NAME OF PERSON C014S RUCTING TH E WFLL
Submit within 30 days of completion to: GIVIsion of Weser 4uaff#y - Information Procri+asing, Farm QW 1b
Rev. ?J(iA
1617 'Tall Service Center, Raleigh. NC ZFEW161, Phom : (848) 8074=

Central Files: APS SWP
05/23/11
Permit Number W10400133 Permit Tracking Slip
Program Category Status Project Type
Ground Water In review Major modification
Permit Type
Injection Mixed Fluid GSHP Well System (50M)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
- acilit
Facility Name
Rivermill Village
Location Address
1735 Saxapahaw-Bethleham Church Rd
Saxapahaw NC 27340
Owner Name
Rivermill Village LLC
Version Permit Classification
Individual
Permit Contact Affiliation
Justin Ramsey
PO Drawer 2011
Durham NC 27702
Major/Minor Region
Minor Winston-Salem
County
Alamance
Facility Contact Affiliation
Owner Type
Non-Govemment
Owner Affiliation
John M. Jordan Jr.
Managing Member
PO Box 128
Saxapahaw INC
273400128
Scheduled
orig Issue App Received Draft Initiated issuance
Public Notice Issue Efleative
Expire
on
05/06/10 03/01/11
c 1 1 f 11
�,
f
Re,wlated Activities
Rea ues,�dlReceiv�:--d Events
Heat Pump Injection
Additional information requested
03/17/11
Additional Information received
03/17/11
RD staff report requested
03/18/11
RD staff report received
05/06/11
Outfall MULL
Waterbody Name Stream Index Number Current Class Subbasin

MA
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Division of Water Quality
Coleen H. Sullins
Director
May 31, 2011
John M. Jordan, Jr., Managing Member
Rivermill Village, LLC
P.O. Box 128
Saxapahaw, NC 27340
Ref: Issuance of Injection Well Permit WI0400133
Issued to Rivermill Village, LLC
Saxapahaw, Alamance County, North Carolina
Dear Mr. Jordan:
Dee Freeman
Secretary
In accordance with the application received on March 1, 2011, I am forwarding permit number WI0400133 for the
construction and operation of a vertical closed-loop geothermal mixed-fluid ·heat pump injection well system to be
located at Rivermill Village, 1735 Saxapahaw-Bethlehem Church Road, Saxapahaw, Alamance County, NC 27340.
This permit shall be effective from the date of issuance until April 30, 2016, and shall be subject to the conditions
and limitations stated therein, including the requirement to install well identification tags as specified in Part
Il.3 and to submit well construction records as specified in Part VIl.2. Be sure to read the entire permit to
ensure that you are aware of all compliance requirements of the permit.
You will need to notify this office at least 48 hours prior to beginning construction and operation of the injection
well system. In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must
submit an application to renew the permit 120 days prior to its expiration date. This permit is not transferable to
any person without prior notice to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or [e-mail] if you have any questions about your permit.
cc: Sherri Knight, Winston-Salem Regional Office
WI0400133 Permit File
Alamance County Environmental Health Dept.
Best Regards, /~ 0-~-
Michael Rogers, P.G. (NC & FL)
Janice Scott, Mid-South Geothermal, 8275 Tournament Dr., Suite 185, Memphis, TN 38125
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-163G
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity I Affirmative Action Employer
NOnehC 1· _ ort aro. 1na
,Naturafll1 •
NORTH CAROLINA
1 •.
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Rivermill Village, LLC
FOR THE CONSTRUCTION AND OPERATION OF 57 TYPE SQM INJECTION WELL(S), defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at Rivennill Village, 1735 Saxapahaw-
Bethlehem Church Road; Saxapahaw, Alamance County, NC 27340, and will be constructed and operated in
accordance with the application received March 1, 2011, and in conformity with the specifications and
supporting data submitted, all of which are filed with the Department of Environment and Natural Resources
and are considered a part of this permit.
This pemiit is for Construction·and Operation of an injection well and shall be in compliance .with Title ISA of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit ~hall be effective, unless revoked, from the date of its issuance until April 30, 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 31st day of May, 2011.
~oleen H. Sullins, Director
\ Division ofWater Quality
By Authority of the Environmental Management Commission.
Permit #WI0400133 UIC/SQM
ver. 03/2010
Page 1 of 5
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (ISA NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II-WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number [phone] and the Winston-Salem Regional Office Aquifer Protection Section Staff,
telephone number [phone].
2. The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation comers) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
3. One well identification tag per grouping or 'cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g).
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
Permit #WI0400133 UIC/SQM
ver. 03/2010
Page 2 of 5
PART IV-PERFORMANCE STANDARDS
t
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including · the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
ground water resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written · approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight ( 48) hours prior to the initiation of the operation of the facility for injection, the
Pennittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number [phone]. Notification is required so that Division
staff can ·inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
PART VI-INSPECTIONS
1. Any duly auth<Jrized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, ·premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Division representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
Permit #WI0400133 UIC/SQM
ver. 03/2010
Page 3 of 5
PART VII -MONITORING AND REPORTING REQUIREMENTS
• I
1. All required documentation shall be submitted to:
Aquifer Protection Section -UIC Program
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
[phone]
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Winston-Salem Regional Office within 30 days of
completion of well construction. Copies of the GW-1 form(s) shall also be given to the Permittee and
retained on site to be made available for inspection.
3 . A copy of the site map updated with manifold locations required in Part II.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Winston-Salem Regional Office within
3 0 days of completion of well construction.
4. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection will be established and an
acceptable sampling reporting schedule shall be followed.
5. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Winston-Salem Regional Office, telephone number [phone], any of the
following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
( C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
6. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
7. -In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
Permit #WI0400133 UIC/SQM
ver. 03/2010
Page 4 of 5
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a· well is taken
completely out of service temporarily, the Pennittee must install a sanitary seal. If a well is not to be used
for any purpose, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l).
Notification shall be submitted to the addresses given in Part VII.1 of this permit.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 1 SA NCAC 2C
.0214, including but not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if the
Director finds such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
{C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that failure
to do so could lead to the contamination of an underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the well
through a pipe that extends to the bottom of the well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been removed, the
casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout
injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment.Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.1 of this permit.
Permit #WI0400133 UIC/SQM
ver. 03/2010
Page 5 of 5
Rogers, Michael
From: Rogers, Michael
Sent:
To:
Tuesday, May 10, 2011 10:05 AM
Knight, Sherri
Subject: RE: Rivermill Village
Hi Sherri-
We would prefer a signed copy. Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://portal.ncdenr.org/web/wq/aps/gwpro/permit-applications#geothermApps
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
From: Knight, Sherri
Sent: Friday, May 06, 2011 4:09 PM
To: Rogers, Michael
Subject: Rivermill Village
Attached is the staff report for Rivermill Village. If you want a signed hard copy, let me know. Thanks.
Sherri Knight, PE
NC DENR Winston-Salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
1
OF W A 7k�, QG
State of North Carolina
p Department of Environment and Natural Resources
Division of Water Quality
o -c
Aquifer Protection Section
Regional Staff Report
May 5, 2011
To: A uifer Protection Section Central Office
Attn: Michael Rogers
From- Sherri K.ni2ht
Winston-Salem Regional Office
I. GENERAL SITE VISIT INFORMATION
1. Was a site visit conducted? ® Yes or ❑ No
a. Date of site visit: April 15, 2011
b. Site visit conducted by: Sherri Knicht
c. Inspection report attached? ❑ Yes or ® No
Application No.: WI00400133
Regional Login No.;
d. Person contacted: Justin Ramsev and their contact information: (919) 730-641 S ext.
e. Driving directions. From Winston-Salem. take 14w-, 52 south to the_1-40 East,_ Follow I-40 East to exit #147
(Graham/Pottsboro)._Turn right on NC-87 and go approximatel" 10 miles to Chinch Road on. the left. Go
--1.12 mile to Saxapahaw Bethlehem Church Road, Rivernill Village is on the right at 1735 Saxapahaw
Bethlehem Church Road.
II. PROPOSED FACILITIES FOR NEW AND MODIFICATION APPLICATIONS
1. Facility Classification: (Please attach completed rating sheet to be attached to issued permit)
2. Are the new treatment facilities adequate for the type of waste and disposal system? ❑ Yes or ❑ No
If no, explain:
3. Are site conditions (soils, depth to water table, etc) consistent with the submitted reports? ❑ Yes ❑ No ® N/A
If no, please explain:
4. Do the plans and site map represent the actual site (property lines, wells, etc.)? ® Yes ❑ No ❑ NIA
If no, please explain:
S. Is the proposed residuals rrauagement plan adequate? ❑ Yes ❑ No ® NIA
If no, please explain:
6. Are the proposed application rates (e.g,, hydraulic, nutrient) acceptable? ❑ Yes ❑ No ® NIA
If no, please explain:
7. Are there any setback conflicts for proposed treatment, storage and disposal sites? ❑ Yes or ® No
If yes, attach a map showing conflict areas.
FORM. APSRSR 04-I0 Page I of 5

8. Is the proposed or existing groundwater monitoring program adequate? D Yes D No !ZI NIA
If no, explain and recommend any changes to the groundwater monitoring program: __
9. For residuals, will seasonal or other restrictions be required? D Yes D No !Z1 NIA
If yes, attach list of sites with restrictions (Certification B)
FORM: APSRSR 04-10 Page 2 of 5
ID. EXISTING FACILITIES FOR MODIFICATION AND RENEW AL APPLICATIONS
1. Are there appropriately certified Operators in Charge (ORCs) for the facility? D Yes D No~ NIA
ORC: Certificate#:__ Backup ORC: __ Certificate#: __
2. Are the design, maintenance and operation of the treatment facilities adequate for the type of waste and disposal
system? D Yes or D No
If no, please explain: __
3. Are the site conditions (e.g., soils, topography, depth to water table, etc) maintaineq. appropriately and adequately
assimilating the waste? D Yes or D No ·
If no, please explain: __
4. Has the site changed in any way that may affect the permit ( e.g., drainage added, new wells inside the compliance
boundary, new development, etc.)? D Yes or D No
If yes, please explain: __
5. Is the residuals management plan adequate? D Yes or D No
If no, please explain: __
6. Are the existing application rates (e.g., hydraulic, nutrient) still acceptable? D Yes or D No
If no, please explain: __
7. Is the existing groundwater monitoring program adequate? D Yes D No~ NIA
If no, explain and recommend any changes to the groundwater monitoring program:
8. Are there any setback conflicts for existing treatment, storage and disposal sites? D Yes or D No
If yes, attach a map showing conflict areas.
9. Is the description of the facilities as written in the existing permit correct? D Yes or D No
If no, pleas·e explain: __ _
10. Were monitoring wells properly constructed and located? D Yes D No~ N/A
If no, please explain: __
11. Are the monitoring well coordinates correct in BTh1S? D Yes D No ~ NI A
If no, please complete the following ( expand table if necessary):
Monitoring Well Latitude Longitude
0 ' " 0 ' " -
0 I " 0 I ,, -
0 I " 0 I " -
0 I " 0 I " -
FORM: APSRSR 04-10 Page 3 of 5
0 ' " 0 ' " -
12. Has a review of all self-monitoring data been conducted (e.g., NDMR, NDAR, GW)? D Yes or D No
Please summarize any findings resulting from this review: __
13. Are there any permit changes needed in order to address ongoing BIMS violations? D Yes or D No
If yes, please explain: __
14. Check all that apply:
D No compliance issues D Current enforcement action(s) D Currently under JOC
D Notice(s) of violation D Currently under SOC D Currently under moratorium
Please explain and attach any documents that may help clarify answer/comments (i.e., NOV, NOD, etc.)
15 . Have all compliance dates/conditions in the existing permit been satisfied? D Yes D No [gl NIA
If no, please explain: __
16. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit?
□ Yes [gl No □ NIA
If yes, please explain: __
IV. REGIONAL OFFICE RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? D Yes or [gl No
If yes, please explain: __
2. List any items that you would like APS Central Office to obtain through an additional information request:
Item Reason
3. List specific permit conditions recommended to be removed from the permit when issued:
Condition Reason
4. List specific special conditions or compliance schedules recommended to be included in the permit when issued:
FORM: APSRSR 04-10 Page 4 of 5
Condition
5. Recommendation:
Reason
D Hold, pending receipt and review of additional information by regional office
D Hold, pending review of draft permit by regional office
D Issue upon receipt of needed additional information
!Zi Issue
D Deny (Please state reasons: _)
6. Signature of report preparer: ____________________________ _
Signature of APS regional supervisor: _________________________ _
Date: _____ _
V. ADDITIONAL REGIONAL STAFF REVIEW ITEMS
This is a modification ofWI0400133 which was issued as a SOW. Wells have been installed and all are underground
{ covered) at this point. The proposal is to charge the system with glycol. Layout of system may have been modified
somewhat in the N well field. Mid-South Geothermal has GPSed wells and should be sending that info. Buildin2:s
are connected to municipal sewer. Closest water supply well is approximately 300 feet from the geothermal system.
FORM: APSRSR 04-10 Page 5 of 5
l
Rogers, Michael
From:
Sent:
To:
Subject:
Knight, Sherri
Friday, May 06, 2011 4:09 PM
Rogers, Michael
Riverm ill Village
Attachments: Staff Report-Rivermill Village.docx
Attached is the staff report for Rivermill Village. If you want a signed hard copy, let me know. Thanks.
Sherri Knight, PE
NC DENR Winston-Salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
1
Rogers, Michael
From:
Sent:
Justin Ramsey [e-mail]]
Thursday, March 17, 2011 5:07 PM
To: Rogers, Michael; macj@jordanproperties .com .
Subject: RE: River Mill Village geothermal permit WI 0400133
Michael,
Good afternoon . I can address your questions below.
1. We will be adding a glycol solution.
2. The wells have been installed per the SQW permit that was approved last year, but they have not been activated
or commissioned ..
Please let me know i.f you have any additional questions. Thanks.
Justin Ramsey
[phone]
From: Rogers, Michael [mailto:[e-mail]]
Sent: Thursday, Marcti 17, 2011 2:57 PM
To: maci@ i ordanproperties.com
Cc: i [e-mail]
Subject: River Mill Village geothermal permit WI 0400133
Mr. Jordan-
We received your SQM geothermal well application. I have a couple questions.
What is the additive you're going l'0 be using, R-22, glycol, ethanol, Environol, etc.?
Has the facility been constructed and the wells installed?
Thanks
Michael Rogers, P.G. (NC & FL}
Environmental Sp.ecialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] {put to my attn on cover letter
http://portal.ncdenr.org/web/wq/aps/gwpro/permit-applications#geothermApps
E-mail co"aspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
1
Beverly Eaves Perdue
Governor
John Jordon
Rivermill Village, LLC
PO Box 128
Saxapahaw, NC . 27340
Jl;A
.MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H; Sullins
Director
March 16 , 2011
Subject: Acknowledgement6f Application No. WI0400133
1735 Saxapahaw-Bethlehain Church Road
Injection Mixed Fluid GSHP Well System (SQM)
Alamance
Dear Mr. Jordon:
Dee Freeman
Secretary
The Aquifer Protection Section of the pivision of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on March 1, 201 l..This application package has been assigned the number listed above and will be reviewed by
Michael Rogers .
.The reviewer will perf01;m a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests. ' · ·
Please be aware that the Division's Regional Office~ copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 -90 days after receipt of a complete
application. · ·
Ify~u have any questions, please contact Michael Rogers at 919-715-6166,· or via e-mail at [e-mail]. If the
reviewer is unavailable, you may leave a message, and they will respond promptly.
PLEASE"REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
C ~ ~
for Debra J. Watts
· Supervisor
cc: Winston-Salem Regional Office, Aquifer P_rote.ction Section
Midsouth Geothermal (Janice Scott)
Permit Application File WI0400133
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard , Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org ·
An Equal Opportunity\ Affirmative Action Employer
Ni¥tti Carolina
JVaturntlu
NORTH CAROLINA,
DEFARTMENI' OF ENMONNWNT AND NATURAL RESOURCES (NCDENR)
API"CATION FOR FFYMIT TO CONSTRUC]C AND/OR USE A WEWS) FOR
INJEMON WITS A [rEOTMRMAL EIKA'T PUMP SYSTEM FOR.-
DME M WELL S
New Permit APPlieatiou OR f Renewal (cheep one) '
(sew U�Sa- 4 �- �tL1► .i GWt � � t
DATE: — 201-
"XLMiT NO. „ QY ) / 1,7 0eave blank if NEW pennit appiiation)
A. PROPERTY OWNER($)/AP'P'LtCANT(S)
Lin mac, ri Property Owner listed on pmpe* deed (if droned by a btu'in= or ,Smm meW agency, steee name of
entity and a representative wlauttK ty for signature): ' *'� ���- � G L LC_
(1) Mailin Address:
City: 1State: h)6 Zip Cade: 33 C County; A } ty''► x DW
Home/Office Tole No.:
EMAIL Address; IM ft JOtrkco alLywk r� co vy--.
� �r''
(2) l"bysical Address of Site (if different them above): a��•Ci1t7 'MAR C3V%k
City, state: N G zap Code);), � - 6_G Vy�1Cjy. k ?
Home(=ae Tole No" Cell Mn -
EMAIL Address:-- 4'LN`)Ee
IL AUTBORMD AGENT OF OWN ;� xF ANY or the Permh Alpplicaat 4gg ngt own the subject property,
attach a letter from thepropertyowner authorizing Agent to install and operate MC welt)
Company Name: ` ► \� Lvf--N
Convict Person_, N N�e iN S�Q 1+ —<' A40W:'Ca 1NL�,P v\
Address:
City: �- stata-2 C Zl Code: ..�_tY ► �
Office Tefa No.: �q " �a �' J E✓ cell No.: qiq
Website Addrw9 of Company, if an}r: L�1W . J' Ly u "t . U n
C. STATM OF APPLICANT
Private: Federal Commercial:
State: Nfird ipal, Native American lands;
CFP /WC 5QM Wdl Permit Application (RniwJ 7r2OM
Pap I
MAR 0I Zoo

D.
E.
F.
WELL DRILLER
.: , .. u�1sZHR5'►a1.��ti� ►r1[el9r►��w�lR
NC Corr
Cont ug
Addrsas
City _ tip Code:,_ CaunEy:
Oftioe isle Na: .►oe Na, 001
HEAT PURE
Company
Contact P
(ff diiltiel vat than 461fer)
Address. 0-81111M
Zip Code-
( .
a
INJECTION FROCEDIM (briefly describe haw the injection well(s) will be used)
G. WELL CONSTRUCTION DATA Oft to 9XftJLz. Egmft RREMAL
r�
(1) Proposed date to be construM Aber of borings: � 1
t� t
Approximate depth of etch boring (feet}._
(2) Chemicaladditives to be hoed in closed -loop system (only those chemicals indicated have been approved):
,______R-22 _,,_�prcWlene glycol ethanol
need prior approval by NCDENR before use)
(3) 'fie oftubing to be used (copper, PVC, etc}: �
(4) Well casin& is the wells) cased? (check either (a.) YES 2r (b.) NO below)
othw(uther additives will
(a) YES if yes,1hen provide casing inf wMation such as D= (steel, PVC, plastic, etc.},
dew, and egerg of casing appearing above g"A-.
(b) NO
(S) Grout (material surmundit well casing anchor piping);
(a) Grout type. Cenwe Bentonira
(b) Grout depth of tubing (reference to land surfkm).
ptlher (specify)
ftM2-- to 4"C (feet)
If'well has cmirig, indicate Um depth: Gam to (feet}
H. MRCTION-RELATKD EQUIPMNT
Attach a db rum showing the Cnginewing layout or proposed modification of the injection equipment and exterior
PIOWtubing associated with ttfe ittgectlon operation. The manufacturer's brochure may provide mpplemerntuy
lnftmation.
GPU/C.1IC 30M W01 Pcrmi! Appfics6m (Revised 712008)
Page 2
M
MAR a 1 jo 11

L LOCATION OF WXWS)
Attach two copies of maps shm ing the following information:
(1) InchWe a site map (en be drawn) sbowiW buildings, prVe* litres, m4hoe water bodies, potential sources
of gxatmdwat er eantaminWon and the oriendon of and distawes between the p posed wall(s) and any
existlag wall(s) of waste disposal facilities such as septic tar*3 or drain fields loczW within 1000 #bet of the
geotheraml hest pump well system. Lsbe1 all feztures Clearly and blghdq31tWartt�.
9) Include a thpogrephic map of the wee extending one mile from the property boundaries and
indicate the facility's location and the map name.
J. POTABLE WATER 'RE )
Are there any potable water well(s) on the subject property or adjacent pmp8nies7 )(YES NO
If Yea, than indlcace tocadon on attwhed map(s),
Y. CKRT MCATION
Note: This Permit Appliraflon must to signed to' exch Person appearing of the rewnW legai property deed.
"I hereby certify, wider penalty of law, that I have personglly examined and am familiar with the !r►f rmation
submitted in this document and all 0whments themta and that, based on my ftsquiry of those individuals
ktuuedialOy responsible for obtait* said Wonnatian, I believe that the infaa rrtatrom is true, accurate and Complete,
I am aware that there ate sigttifsew penalties, including the possibility of £trees and iarprisomneM for submitting
false 1t AMnstisom I a&me to emmuct, operate, maintain,, rep&, and If applicable, abandon the injection well and
ail related appurremmm in accordance with the approved speciflcatiom and conditions of the Permit."
Sigztsta[e vFlsrogarty/IOwa+erlApAlicetet � � j�
Print or Type Full Nam
Sigea ProgKOwoKAppflcant
Paint or Type Full Name
Signature of Authorized Agent, if any
Print or 'Type Full Name
Please return two copies of the completed Application peakAp to:
A oi" Caroilr a DFNR-AWQ
Aguffer rmt+ecdon Swfiion
UIC Pmgrm
1636 Mail Service Center
Rale*b, NC 276".1636
Telepbone (919) 7W221
W4RC 5QM Were ?*TM Appr , (RwvWd rrxaoal MAR 0 12011 FSP 3

i Fj c F. l 0 n 2
1
C+7HSFRUCT10 4
Nwfh iWmfn Wed "if
P.O. Drawer 2011
Durham, NC 27702
phone., (919)-M-Ws
FR%; (919)482-OW
FAX COVER SHEET
DATE: !I
r
COMPA.�:
FAX NUMBER:4 7.33' ql
FROM-
RE;NL?! LL
MESSAGE:
YOU SHOULD RECETVE_6 _ PAGE(S), INCLUDING THIS COVER SHEET. IF
YOU DO NOT RECEIVE ALL OF THE PAGES, PLEASE CALL US AT: [phone].
MAR 01 2011

MIIIM."SMID ..SPEllflUl~NO•-::'IERFU ~~...::.=,U!UD 5IOI.D Rll'IIE!IElfl",llilllEa Cll0ll QI~ ~lQ~
.. ram_ ti �• ; \ �A7EaORLil� .w.•a.. .,..
� yet '"�...,�: ' Ft� � - - _ • . _ ~ � �� � �..-r�sr .�I•-•
IN
''; - �,. �: .., ^•t= , a �,�� .--'�x-'� •_ _--i-•-- T"- � ate':-'..
Jig -
No
IZ
p •'Se YT i,. - - ••�-f__r.������w..---� h - �� i 'Y' �• <�.`x�±r-=�•:s •7:rF: '-� s._ —
'F�."i�; .. . s - •a =s,�• __. - 'z:�� , i� =fir: � � ' •'d+�-�
�t "• '�; v - �" • ` ..� _ e • ���- � a'�s'1�l�,l�. t i�!i�-.*'.`}� ` €�T,f�R[N�LL
• YraAr _ _;` 1 '-� �.'• •-dry '-•°'ti R=''�+'.�w.d+
` � aim - ;�� •7:sa€: �� � - _ _ � _ F. _ .� f�}'!: :- �.. .••.. ••�i. `_ .• \x �•y ��'�
- •''�ti.. ' � ak -�-. .__-�.- _ _ �. � �, �Y �i1 J w �-' �Fr.1C4_ `� . �ti �.;�ti
`_ ''�� - _ r_ .. I• a"�_ ram:-��C?"4` .�`' •��'' a•. ��
•,�_ 'i N I,.• _ 'i�.`sf''' i3 v. y .� �•. _.._�•i',-.� 5 + `1+55•ii €=-ti;•.�\r �...-..
- _ rurmn�.o..� r'�± -� - �� �, r!' _ 'f _ - \ ter.. =. ��'-���; •'i t\ �y in' �w
t - � '• - _ - - ti .1�! .� ,. 'T� �••..:.. `� _V=+'i' iindhrm+INhek
ti � �1�1�,� f � ,�f '� ••ia•�- ►ice 1 �'� .
' � �~�., - _ _ _ _ -. •I � f yL?� .: • a tiffs=. • �• _,- -
f, tit

~
l>
;:CJ
C>
~
r,,..>
c:::, --
~
l!.,r,.nleteid.f J:";eid. -'1 WR.Its
Al. ~-d~4.I -,~ w.tlls
S. ~ida,'l.ttal --r8i>
AM RECEIVED MAY 10 20
h�CD�h1R
Nonni Carolina Depal t wt of El vironment and Natural Resources
Division of Water Quality
Beverly craves Perdue Colson H, Sullins Dee Freeman
Governor Di3' Wr Secretary
SWIM
Rivetmill Village, LLC
MM Jordon
PO Box 128
Saxspxbaw, NC 27340
Subject; COMMON.
A.cknowkdgerrwat of Timm to Con*uct Type 5QW xttject oo Well Syeenm
Permit No. W104001.33 5�t/+� l U� r n� � L{1
1735 Sanpol ow nothlefram Church Rd. Saaxgmhaw, NC-27340 . ?(O L&
Dew Mr. Jordan-,
On 4/2WO10, the A9uiter PrOlection Sectibtr (APS) received aoOCaOM of your iatftt to cnnwwt a closed-lcOp OW-Y
geotbermA injection well system for the opera6cn of a ground-w=* hoed pump toem od at the ddrem wftenced abase. TWR i-tter
is a eorrWOM es p& you app,[icatfft recatvad an 41=12Mt1. The ApplictOm nmeavW as 41271MG did- sot tat lade R&wmM
village, lr LC as maer ner the suavy. An Mvidual permit is eot re[A ed for tha'co=ftz ion and opanxtion of this type of
gaoa rmAl injection well system ns long as the fbilowing conditions ate met:
1. T'he injection well scum eonulus enaly potable wetter,
2_ The injection well ayftm is constructed in acordence WO .well conss;uction standards specs ted in North
CafuliM AdtttW92%nve Code TWO i SA Sectim 2C SuWbWw .9 213, ash
.3. The regumbd notification farm and amocistedmaps have been *=Vfetmly and act.urm2y submia &
Fadur+e to comply with all of tl = coadst}ons Rot7estimites a violation of the North CPT+ he Well CaestrtvOn Act end North Carolina
Admbdstrative Code Title 1SA Sectiob 2C SubchapL-r .4M1 I(u)(2), Additionerlly. you should roMwt. ft.4j=M= Connty HoWth
Depwt:xtcot its they may have anti banal regeixe v; for dds +Type of sytttem. Naaeatln 4iA= with eppliceble Mo., county, or
m=cgW mRm and rogulimom may result in the assessumnt of civr"t Peaal4es.
Please veatact Mine Rogers aI [phone] or L icha-4 RUM89a dear, if ywu have errs *Mdoms.
s+ly,
firDebm Watt
Supervisor
CC. Winston -Shinn Regional Qfiae- APS
APS Ceases! Files - P=* No. WJMM 133
Ass ancc Cavmy Health reps.
MWUUIh Ste M. Memphis, 7N 38125
AQUIPER PROTECRON SECTION
IM Maui Sancti cerrw, Sategh, MWM Carona 2MO-10 .
Lacafen: ZM GrRbi 9ou*i d, RaWp. Nndh Carer 2nN
Phone: q!$733.322'i 1 FAX 1,. 919.7154598; FAX 2: B19 71S4M %Ct&ww 8tdviaa: I-M42b6748camifin
Interne: w�kad�148h' o�r0 _
$
��i
An EquE6 OnAa*n+ruv } ►akmaGre AEAon "cmDk7--

C� R State of North Carolina
Department of Environment and Natural Resources
6U a,
Division of Water Quality
Aquifer Protection Section
Regional Staff Report
May 5, 2011
To: Aquifer Protection Section Central Office
Attn: Michael Rogers
From: Sherri Knight
Winston-Salem Regional Office
I, GENERAL SITE VISIT INFORMATION
1. Was a site visit conducted? ® Yes or ❑ No
a. Date of site visit: April 15. 2011
b. Site visit conducted by: Sherri Knight
c. Inspection report attached? ❑ Yes or ® No
Application No.: W100400133
Regional Login No.:
I--.
d, Person contacted: Justin Ramsev and their contact information: 919 730-6418 ext.
e. Driving directions: From Winston-Salem, take Hwy 52 south to the _1-40_East. _ Follow 1-40 East to exit #147
(Graham/Pottsboro). Turn right on NC-87 and go approximately 10 miles to Church Road on the left. Go
—1.12 mile to Saxapahaw Bethlehem Church Road. Rivermill Village is on the right at 1735 Saxapahaw
Bethlehem Church Road.
111. PROPOSED FACILITIES FOR NEW AND MODIFICATION APPLICATIONS
1, Facility CIassification: (Please attach completed rating sheet to be attached to issued permit)
2. Are the new treatment facilities adequate for the type of waste and disposal system? ❑ Yes or ❑ No
If no, explain:
3. Are site conditions (soils, depth to water table, etc) consistent with the submitted reports? ❑ Yes ❑ No ® NIA
If no, please explain:
4. Do the plans and site map represent the actual site (property lines, wells, etc.)? ® Yes ❑ No ❑ NIA
If no, please explain:
5. Is the proposed residuals management plan adequate? ❑ Yes ❑ No ® NIA
If no, please explain:
6. Are the proposed application rates (e.g., hydraulic, nutrient) acceptable? ❑ Yes ❑ No ® NIA
If no, please explain:
7. Are there any setback conflicts for proposed treatment, storage and disposal sites? ❑ Yes or ® No
If yes, attach a map showing conflict areas.
8. Is the proposed or existing groundwater monitoring program adequate? ❑ Yes ❑ No ® NIA
If no, explain and recommend any changes to the groundwater monitoring program:
9. For residuals, will seasonal or other restrictions be required? ❑ Yes ❑ No ® NIA
If yes, attach list of sites with restrictions (Certification B)
FORM: APSRSR 04-10 Page I of 3

m. EXISTING FACILITIES FOR MODIFICATION AND RENEWAL APPLICATIONS
1. Are there appropriately certified Operators in Charge (ORCs) for the facility? D Yes D No~ N/A
ORC: Certificate #:__ Backup ORC: __ Certificate #: __
2. Are the design, maintenance and operation of the treatment facilities adequate for the type of waste and disposal
system? D Yes or D No
If no, please explain: __
3. Are the site conditions (e.g., soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? D Yes or D No
If no, please explain: __
4. Has the site changed in any way that may affect the permit ( e.g., drainage added, new wells inside the compliance
boundary, new development, etc.)? D Yes or D No
If yes, please explain: __
5. Is the residuals management plan adequate? D Yes or D No
If no, please explain: __
6. Are the existing application rates ( e.g., hydraulic, nutrient) still acceptable? D Yes or D No
If no, please explain: __
7. Is the existing groundwater monitoring program adequate? D Yes D No~ N/A
If no, explain and recomme~d any changes to the groundwater monitoring program: __
8. Are there any setback conflicts for existing treatment, storage and disposal sites? D Yes or D No
If yes, attach a map showing conflict areas.
9. Is the description of the facilities as written in the existing permit correct? D Yes or D No
If no, please explain: __ _
10. Were monitoring wells properly constructed and located? D Yes D No~ N/A
If no, please explain: __
11. Are the monitoring well coordinates correct in BIMS? D Yes D No~ N/A
If no, please complete the following ( expand table if necessary):
Monitoring Well Latitude Longitude
0 , " 0 , " -
0 , " 0 , " -
0 , " 0 , " -
0 , " o· , ,, -
0 , " 0 , " -
12. Has a review of all self-monitoring data been conducted (e.g., NDMR, NDAR, GW)? D Yes or D No
Please summarize any findings resulting from this review: __
13. Are there any permit changes n~eded in order to address ongoing BIMS violations? D Yes or D No
If yes, please explain: __
14. Check all that apply:
D Currently under JOC D No compliance issues
D Notice(s) of violation
D Current enforcement action(s)
D Currently under SOC D Currently under moratorium
Please explain and attach any documents that may help clarify answer/comments (i.e., NOV, NOD, etc.)
15. Have all compliance dates/conditions in the existing permit been satisfied? D Yes D No~ N/A
If no, please explain: __
16. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit?
□Yes ~No □NIA
If yes, please explain: __
FORM: APSRSR 04-10 Page 2 of3
IV. REGIONAL OFFICE RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? D Yes or [81 No
If yes, please explain: __
2. List any items that you would like APS Central Office to obtain through an additional information request:
Item Reason
3. List specific permit conditions recommended to be removed from the permit when issued:
Condition Reason
4. List specific special conditions or compliance schedules recommended to be included in the permit when issued:
Condition
5. Recommendation:
Reason
D Hold, pending receipt and review of additional information by regional office
D Hold, pending review of draft permit by regional office
D Issue upon receipt of needed additional information
[81 Issue
D Deny (Please state reasons: __ )
6. Signature of report preparer: }1-!4.M ~ Ct .-------:--;.~--'-"------,-~J,...,.......... _________________ _
Signature of APS re1,ional supervisor: --~-----~L-z~__.,.___~-............... ¾~--j_j_.,, _______________ _
Date: 5/c;, /J, Ir·
V. ADDITIONAL REGIONAL STAFF REVIEW ITEMS
This is a modification ofWI0400133 which was issued as a SOW. Wells have been installed and all are underground
( covered) at this point. The proposal is to charge the system with glycol. Layout of system may have been modified
somewhat in the N well field. Mid-South Geothermal has GPSed wells and should be sending that info, Buildings
are connected to municipal sewer. Closest water supply well is approximately 300 feet from the geothermal system.
FORM: APSRSR 04-10 Page 3 of3
T 51
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coieen H. Sullins Dee Freeman
Governor Director Secretary
5/6/2010
Rivermill Village, LLC
John Jordon
PO Box 128
Saxapahaw, NC 27340
Subject: CORRECTION:
Acknowledgement. of Intent to Construct Type 5QW Injection Well System
Permit No. W10400133
1735 Saxapahaw-Bethleham Church Rd, Saxapahaw•. NC 27340
Dear Mr. Jordan:
On 412$12010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onh
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced. above. This letter
is a correction as per your application received on 4128/2010. The application received an 4/27/2010 did not include RivernWl
Village, LLC as owner nor the survey. An individual peradt is not required for the construction and operation of this type of
geothermal injection well system as long as the following conditions are met:
1. The injection well system contains only potable. water,
2. The injection well system is constructed in accordance with well construction staildards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and. North Carolina
Administrative Code Title 1SA Section 2C Subchapter .4211(u)(2). Additionally, you should contact the Alamance County Health
Department as they may have additional requirernents for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of cavil penalties.
Please contact Mike Rogers at [phone] or Michael.Royersgnedenr;_ov if you have any questions.
Sincerely,
J
orDD0Wa —� `�' `��
supervisor
cc: Winston-Salem Regional Office - APS
APS Central Files - Permit No. W10400133
Alarnance County Health Dept.
MidSouth Geothermal (Janice Scott) 8275 Tournament Drive. Ste 195, Memphis, TN 33125
AQUIFER PRCTECTIQN SECTION
1636 Mail Service Center, Ralegh. North Carolina 27699-1636
Lo cation: 2728 Capital Boulevard, Raleigh. North Carolina 27604 (�}
Phone: [phone] i FAX 1:919.715-0588; FAX [phone] Customer Service: 1-�77-623-6748 r%Tr. f11
Intemet: www.nowaterauality.org
An Equal Oppo0unity k AMrmabve AOw Ernp?oyer ���ur�tll�

Permit Number · WI0400133
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
1735 Saxapahaw-Bethleham Church Rd
Location Address
1735 Saxapahaw-Bethleham Church Rd
Saxapahaw
Owner
Owner Name
Rivermill Village LLC
Dates/Events
NC 27340
Orig Issue
05/06/10
App Received Draft Initiated
04/27/10
Re g ulated Activities
Heat Pump .Injection
Outfall N~IU .
Scheduled
Issuance
Central Flies: APS_ SWP_
05/06/10
Permit Tracking Slip
Status
Active·
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Janice Scott
8275 Tournament Dr
Memphis TN
Major/Minor
Minor
Region
Winston-Salem
County
Alamance
Facility' Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
John·M. Jordan Jr.
PO Box 128
Saxapahaw
Public Notice Issue
05/06/10
NC
Effective
05/06/10
381250851
27340
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
��fe-1 iPd� s °v�
APR 2 8 WO
NORTH CAROLINA
D13PARTMENTOP BNVIRONMENT AND NAT URAL R13SOURC138
NOTMICATION OF ENTl;NT TO CONSTRUCT A CUMED-LOOP GEOTHMMAL
W&T.In- ONLY INRCTION WELL SYSTEM
In AccordnuceNVIth itia llm4lons of NCAC Tiily 15A W!,0200
i'rl!!r or• i�ila lire !'agrrired 1l�v! Iunriar! aurl r11rrA is arhtlrss or! the brrckilrrge.
HATE; Ai}r)I..I_�I . ,., 2010
1YeI17)yla Car(j7mra(1wr: (110 additives) in
coutimsous p1phig that complataly fsoiatos Ilia ffuld flom Ilia crlvirolnrloni (Lo.
clnwy -loan 7
Yos _}(� Canilulto completwl; tills form.
No Do Not c001)11ete 11118 Perin. C01111Y]t1 OIller UIC Apl1II0at1011 f0ru1B fat' 11181n11fug
aitller n W wolf (Qm-loop wall ImICC llug potable wntor Into tho fiqulfbi) or a 5QM ►vafl (aloscd-
loop wall conhilaInggdollye stlail ns It B2, e111a1ro1, or alher ntttifraaxo or cannsion 11111ibiFors}.
A. PROPE>'I'I'Y OWNEA(S)IAPPLICANT(S)
1,131 s=.ulf Property Owner listed on praparty {Iced (1f awned by it business or goverranclu agalley, &into uan►e or
willly mid (i repmscidAlNo ►W oulhority for slgirnlluv):—KVjW&!4—L-L ��� � w!�kLtti;
(Ij Mnlllilg AltilrosR; � �$ _
City. �, YZ,6,VXcid sfate;tv�-zip code;. AMy Cauntyl 19 r •
HomelU�Iao Tole i�aa a'I d Cell Na,: X4 • a 4- S Z:?
Br11Rfl Address: InAc `CJ DIC w bs le: Ivies + l'Idt'�1lL"�111��e, ee-frti
w�h'I" ICS'.f6rl�
(2) Physical Address of Wall Site (If dlltbrew than above): _ ] 735 5a:tfr1 I v.13e trleii rC1I nd
City: • __snxakehm __ _ SMIG" tLc Zlp c04e: -e? '2 5 _1 Colwiy: I'rl�lrFirl/!C P_
Horne/off3eo Fate No,; _ �5!2-- 1 e- _ Coll No'. _ -5'� ine-
13, All H611mr-m AG1~NT OP OWNER, IF ANY (if the Pormil Appllenitl 00 im3 alvu tl1U s1lbJMl properly,
t}linoll a letter 11'om tiro propody owtlar aulltorlxing Agoni to lnslali f►nd opernfo UIC well)
Coulpauy Nall 0;r-�51 � 'l�pr•3
Contact Person,usno —,�,,� �1 BMAJL�A d(Al es n,ro, � wia4,ti•co,k
Address: 3vlZ. �?��
Cit,V51nta: zlp Carla; 7,770.5 Comity: -- s�/A __
Office Tolo No,
Wabsllo Atldross of Canlpatry, lfsny:.��,.?�,L,, . c.���U �• � na
OPU1111C SQ%V Nod nCl 11w arIillcist Porel (Ravfssd8/1008) t'nga 1

C, WEl.,L DRrLLEU INl.lOUMA'flON
Company Nmne: MldSouth Qcothcrmnl. u,c
\Voll Drlllcr Contraotor·a Nnmo: .....i:K=o....,n...,.ne....,11"""', J=o=rd=m"--1 ________________ _
NC conrmctor Col'llflcnUon No.: ..... N;..:..C=-'\ ...... V=C-=26=6=9...:.•h-=-----------------
Confucl Porson"-; ..... Ja.v.111.:.zlc~e ~8C....,O:,ull _________ Bcu.Mu..A .... H-· ._.A_dd...,reaSiau3i~)s=co::'-llt,l,l,lr@!l'll~)lu:,(dx.::801.1,1ll.1,1,1lh,0:go=-=o-lh~Plw'IJ1u:lOwl,~co~m
Address: J!Z1S Tournmnen! Dr. Ste 185
Clly: Memphis Zl1>Codo: .... 38 .... 1 ..... 25 ____ Comlly: =S=hc,....lb-y ________ _
Office Tolo No.: 901-748•9095 Prue No,: 901-71a.9097
D, UEA'f PUMr CONTRACTOR INFORMA'l'ION (If dlrforonl Hum ch'llhw)
Co111p1my Name: MJdS0111h Oeolhcnunl. LLC
Contact Persmi; Jnnlco Scou. ofr. Mgr
Addross: §275 'l'oun1n11lol)I Drlvo, Ste 18S
· RMAIJ, Adtfross;[e-mail]
Clly: Memphis ZIJ> ·code: ...,38.....,12..,.S ___ Co1111ly: Sllelby
Office 'J'ele No.: ...1'9 ..... 0 ...... 1-...... 74 ...... 8 .... ·9..,.,,09 .... s _______ Fax No.: 901-MS-9097
E, STATUS Oll APPLICANT
Pedoral: ConunercJRI: Prlvato: X
Slnlo:_ MunlolJ>nl: _ Nullw American Lnnds: _
F. INJECTION PllOCEDUJUt (brieny describe how the h\lccllon woll(s) wlll ho used)
Closed-Loop gcochernml water somco heal 1mmp
G, WELLCONS'rRU.CTIONDATA
(l) Proposed dale lo be eonstruoled: n!}er 4/13/10 Number of borings; _,._.51 __ _
Ap1>ro:<i01alo doptli of cnoh boring (feel)t _ ___,.,,4 ...... 50 ..... ' ____ _
(2) Type of h1bfng lo bo used (c opperi PVC, elo): ...,.H=D ..... PB=-<pF"'lfl .... s.....,tlo~u-tp....,& ________ _
(3) Well ct1sl11g, Is tho wcll(s) cnscd? (check either (a,) Yes m: (b.) No bolow)
(R) Y('s ___ if yes. -lhen provide casing lnrorma1lo1\ below
Typo: _gnlvunll[ed 1teol __ bJaok steel ____plastlo_· other (s1aeolty)
Cnslng dcplh: From ___ lo ___ feet (l'ofororu:o lo land surfuto)
Cnslng oxfcnds lo nbovo ground ___ Inches
(b) No _X __
(4) Orout Info (material surrounding woll cnslt1s ru1d/or piping):
(n) o,·0111 ty1>e: -Neal Cemenl__ Bentonllo ....xx._ Olher (spcclly) _____ _
(b) Orout placement: Pumping___ Pressuro__. · Olhc1· __
(o) Orout de11th or h1blng (reference to IRnd surface): &om JL_ to _450 (feet)
If well hlls cnsJng, lndlcnro grout doplh: &om ___ to ____ (feet)
OPU/UIC SQ\V No1IR"nllo11 oflatcnl Pom1 (Rovlsal 812008) Pnao2
RECEIVED I DENR 1 DWO
At uVer ProtfK:tion SI=t 601`1
APR 2 S 2010
H. 1613 $CTION-REI ATM EQUIPmMM'
AIIach n diogrnnt sItowhtg 11io eaglncerlltg layoul or proposati mod lficalIOn of 11to htjcoft oit egtilpill citt nand exterior
plpiitgAtilsing assooWed ►v[til 11to lli cctloll oporallntl. 'fits ntnnnfaclnror'a broelturo nsny provlde ssgtplelneniary
Ittforlualtoil.
1. LOCA'l I0M OF WELL(8)
Atlnclt Iwo ooplgs of nialss shnwing tlse followllig lnfounn11a(n
(1) snellydo a She Me)) (call be, bitlldings, properly lines, swfacc valor bodies, poloutlal
sources ofgion»dwaler canlnm#nallou and 1ho oriotllatlon of and dlstancos between [Ito proposed woll(s) rind
ally oxis[hsg well(,$) or wasto disposal fnoli[]les stiah as saptio larks or dmin fields loaaled WIMIll 20D feel Of
Me geothermal bent pump well systain. Label all features olenrly and lalc[udo 6 Itorth arro►y,
(2) Tito No Map rlmtlst show lira stsbjeol ^01y hl Mallon to ilia surrmindhtg area by nshig nt lens( (Wo fixed
referoiteo pohils soot as fonds, slraants, atiMov Itlghway, latorsealions.
,1, CERTIFIC K1'IDN
Nolei This Perznit Appllcaflan nlizat Uosigued byJah ttaraon nl)panrFtzg on the
recaJ'tled loan Property dead.
"1 hereby cartifY, tmdar poually of law, that i linvs personally oxamincd and oin famillor ►vilh ifto hiformatiott
stlbmilicd bt 1his docttnsew and all aliaelmtuonts Ilsoreto and [lint. based an my btgnlry of filoso Irtdlvlduals
hnntcd1At0ly v6span51ble for obIntuit tg said ilifort uallon, I hWove I(lot llio Intorinntloa 3s lmo, acourato alid contplelo.
I alit Aware blot 1Moro me aIgamcnil t penalties, Ill lalnding limo nosslblIIly of thaos and lrnprlsownelmt, fbr siiitlnillbig
fnISO htforistatlaD. I agree, to construct, operate, utabilnhi, ropalr, Anil if alp )IIaAblo, abandon IIle Iltjection Nye]] nod
a[I roIaled npplirtcaom ees In tic corttouco whit tits approved spectflo of ON candillozns of Iho Permit."
Slgnalsio6l'Propdrfy 0 %a e r/App I lcom
Prhtt or'ryp0 hull Nantc and $11lo
3IgttaImo of Properly O►vnojMpill lenil t
Print ot'Ulto 171"attto mid title
ofAul Roilzed Agont, If any C . !
P
Prinl orTypa hull Mono
Please rehirn tWo copes of file comillatad Applleafloil package to:
North Caroiiva DENR-DWQ
Aquifer Peofeetloi► Soction-UfC Progrnat
1636-MftII Sol-vtee Conlor
Raleigh, NC 21699-1636
Telapholte [phone]
rip UAJIC low Noilncni[on ol'Wcni Farm Mcvlxcd 812008) lltp3

TA,
NCDENR
North Carolina Department of Environment and
Division of Water quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
51&2010
John Jordon
PO Sox 128
Saxapahaw, NC27340
Natural Resources
Subject; Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10400133
1735 Saxapahaw-Bethlehani Church Rd, Saxapahaw. NC 27340
Dear Mr. Jordan-,
Dee Freeman
Secretary
On 4/27/20I0, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermaI injection well system as long as the
following conditions are met;
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2), Additionally, you should contact the COUNTY County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Rogerstarncdenr.Lov if you have any questions.
Sincerely,
ko
-for Debra Watts'
Supervisor
cc: Winston-Salem Regional Office- APS
APS Central Files - Permit No. Wh 4OO13?
AMaLmanee County Health Dept,
MidSouth Geothermal (Janice Scott) 8275 Toumament Drive. Ste 185, Memphis, TN 38125
AQUIFER PROTECTION SECTION
1636 Mail Serulce Center, Rai elgh. North Carolina 27699.1636
location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] l FAX [phone]; FAX 2: 919-715.60481 Customer Service: 1-877-623.6748
Internet www,rs, vatsraualftv.arg
ort lhCarolina
An Epuar Ouportumiy � ASfirmafive Action Employe-,

Permit Number WI0400133
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
John Jordon
Location Address
1735 Saxapahaw-Bethleham Church Rd
Saxapahaw NC 27340
Owner
Owner Name
John M Jordan
Dates/Events
Orig Issue
05/06/10
App Received Draft Initiated
04/27/10
Re g ulated Activities
Heat Pump lnjectio_n
Outfall N~ IL!,
Scheduled
Issuance
Central Files: APS_ SWP_
05/06/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Janice Scott
8275 Tournament Dr
Memphis TN
Major/Minor
Minor
Region
Winston-Salem
County
Alamance
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
John M. Jordan Jr.
PO Box 128
Saxapahaw
Public Notice Issue
05/0ij/10
NC
Effective
05/06/10
381250851
27340
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
\a C400I3?)
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND (NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY IINJECTION WELL SYSTEM
TYPE 5QW WELL(S)
In Accordance With the Provisions of NCAC Tit to l5A 02C.0200
Print 01• type the required l+V01•11141fou mid mall 10 add► ess on the hack page.
DATE: April 14_ _, 2010
Well Type Conflrmaiio►i: Does the proposed system circulate potable water only (no additives) in
continuous piping (lint completely isolates ilia fluid from the environment (i.e.
close_ d-loap)?
Yes _h_ Continue complethig this form.
No Do Not contp[eta this form. Complete other UIC application forms for installing
either a 5A7 well (aped -loop well inmectin potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature):
(1) Mailing Address:
City: [,ram 1� State.AW-Zip Code: X13Y 7 County.. _A&21L-ram e_
Horne/Office Tele No.: 3361 -- S12 2_ Cell No.:
Email Address:__ .41 c ; W 104 4) Website;
(2) Physical Address of Well Site (ifdiFferent than above): 1735 Saxavaha►v-Sethleham Church Road
City: SaxaPaha►v State: NC Zip Code: _,;�%i.�� County: /�eice
HomelOffiCe Tele No.: 51e.nG CeU No.: %'pl cam.
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach n letter from the property owner authorizing Ageot to install and operate UIC well)
Company Naive:
Contact Person: _ �uST+�_ EMAIL.Addres . p.t•u� ���+1 • Gq�+.
Address:5y17 OAd12-0
-
City: ;� State- LL_LL2ip Code:
♦♦5 Ciy:��A
Office Tele NCellNo.,1
7_�-4q/ 9
Website Address of Company, if any: _ c-v L—n -_ 7-+■5��•' �`"
(;Pt11t11C 5QW Notification of Potent Form (Rcviscd 81208) REGENED) OVA; OVVQ Pete I
A uifef PfrAarlinn Sedan
APR 21 2010

C. WELL DRILLER INFORMATION
Company Name: MidSouth Geotherma l, LLC
Well Driller Contractor's Name: _K=e~n_n~et~h~J_ord~ai:_1 __________________ _
NC Contractor Certification No.: _N_C~W~C~2~6~6~9--A~------------------
Contact Person-=-: -"-'Ja=n=ic"'""e'--"Sc....=c~o=tt _________ ---=B=M=A-=I=L"""'A"""'d=d=re=s=s:-js=c=o=tt ®-=Dll=·=ds=o=u=th""'"g=eo=t=he=r=m=a=l.c=o=m
Addl'ess: 8275 Tournament Dr. Ste 185
City: Mem phis Zip Code: =.a38::a...::.1=2Sa,..___ County: --=S=he=l=-by,______ ________ _
Office Tele No.: 901-748-9095 Fax No.: 901-748-9097
D. HEAT PUMP CONTRACTOR INFORMATION (ifdiffcl'cnt than driller)
Company Name: MidSouth Geotherma l, LLC
Contact Person: Janice Scott . Off. Mgr
Address: 8275 Tournament Drive . Ste 18S
EMAIL Address:jscott@midsout bgeothermal.com
City: Mem phis Zip Code: ~38_1_25 __ County: Shelb y
Office Tele No.: 901-748-9095 Fax No.: 901-748-9097
E. STATUS OF APPLICANT
Federal: Commercial: Private: _x_
State: Municipal: __ Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed-Loo p geothermal water source heat pum p
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: after 4/13/10 Number of borings: --""5~7 ___ _
Approximate depth of each boring (feet): __ 4=c.5~0, _____ _
(2) Type of tubing to be used ( c opper, PVC, etc): =----:;H=D=P=E_p=la=st=ic=--p=i=pe=--------------
(3) Well casing. Is the well(s) cased? (check either (a.) Yes ru: (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: __galvanized steel __ black steel __plastic __ other (specify)
Casing depth: From ___ to ___ feet (reference to land surface)
Casing extends to above ground ___ inches
{b) No _x~_
( 4) Grout Info (material surrounding well casing and/or piping):
(a)
(b)
(c)
Grout type: Neat Cement __ Bentonite XX Other (specify) ______ _
Grout placement: Pumping__ Pressure__ Other __
Grout depth of tubing {reference to land surface): from _o __ to 450 (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC SQW Notification of Intent Fom1 (Revised 8/2008) Page2
H. INJECT [ON -RELATED EQUIPMENT
Allach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the Injection operation. The manufacturer's brochure may provide supplemental-y
infortmtion.
I. LOCATION OF WELL(S)
Attach hvo copies of snaps showing the following information.
(1) Include a Site Map (can be drawn) shoving: buildings, property lines, surface water bodies, potential
sources ofgrourudwatef contamination and the orientation of and distances between the proposed well(s) and
any existing wells) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system. Label all features clearly and include a north arro►y.
(2) The Site Map inist shave the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, snrearns, and/or lrlgh►vay intersections.
J. CERTIFICATION
Note, This Permit Applicttion must he signed by eaeb parson appeAring on the
recorded legal property need.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this docttmeat and all attachtnents thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe Ihat the information is true, accurate and complete.
I am aware that there are significant penalties, i.nciading the possibility of fines and imprisonmetit, for submitting
false information. i agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
al] related appurtenances in accordance with the approved specifrca • And conditions of the Permit."
Slgnalt Prop y ner/Applicant - - -
Print or Type Full Name and title
Signature of Property O►vnerlApplicant
Print otYfype ]r ne and title
1-£lgb urc of Authorized Agent, if any
�..:"a`IznJ •-ti.,� r✓ �'J. �- yri i�'I P.t�+p�f+�r�
Print or Type Full Name and tis e
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUlt1iC 5QN t+tatificafiou of 6itenr corm (Revised S1Z4478J RECEIVED / DENR / ❑ � Pa 3
Aqu fttr Prm8clfon Section
APR 27 2010

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF MENT TO CONSTRUCT A CLOSET} -LOOP GEOTFIERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5QW WELL(S
Iit Accordance With [lie Provisions of NCAC Title 15A 02C.0200
PHnt or ope the reguh-ed inforninflon a►rd nand to address on the back page.
DATE: Al �rii 14 , 2010
A
0
!Ve!1 Type Caj7rmallo►v Does the proposed systeut circulate potable water onl► (no additives) in
continuous piping tliat completely isolates the fluid front the environment (i.e.
closed -loop)?
Yes _X� Continue completing this form.
Na Do Not complete this form. Complete other UIC application fortes for installing
either a 5A7 well (open -loop well biie� ctutg potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other a:itifreeze or corrosion inhibitors).
PROPERTY OWNER(S)IAPPLICANT(5)
List each Property Owner listed an property deed (ifo► wed by a business or govermnent agency, state name of
entity and a representative ►vlaulhority for signature):
(1) Mailing Address; _ _ 012 AW AR6 _
City: _� ec "" State:% -Gip Code:. Q;13Ya County: .'
Hone/Office Tele No.: .7.3,6 - 3 ~ &12 Z Cell No.: X6 - 117/ eZ 3V
Email Address:_ fit- ' W .'ALWebsite: _ lt��r��� I'11�t'r_mlx&&w. "C','
�rlt/k'��It"$'- f (fir►...
(2) Physical Address of Well Site (if different than above): _ 1735 5axapahaw-Bethleltam. Church Road
City; SaxaPahaw _ State: NC ,Zip Cade: a7,25-3 _County; ��rrixw
Honte/Office Tele No.: _ � , m c Cell No.:
AUTHORIZED AGENT OF OWNER, IF ANY (if the Perinit Applicant does not a►vn the subject property,
attach a letter from the propeity owner authorizing Agent to install and operate UIC ►veil)
Company Name: f L. - r�STfl��tr7 i�t�3
Contact Person: SuST��•1 _ EMAIL Address-_t a.n,s. w,_[��,t-cot., i
Address: _'>0tZ_ �-)OAd- `�,,
City: �� a^ State: .f Zip Cade: 7i77dS County: 4dA
Office Tele No. O)_30-3-Z63,5 Cel!No.Agll )7'2q�)-&we
Website Address of Company, if any;_ r.►�z, _c,,� __ �IS�n� cam_ +�-�
RECENE❑ 1 QENR I DVQ
GPUIUIC 5QCV Notificasion of bite nt Form (Raised 912009) Aquifer Proiactfoil Secgortw 1
APR 2 7 2010

.,
C. WELL DRILLER INFORMATION
Company Name: MidSouth Geothermal. LLC
Well Driller Contractor's Name: _K~en_n~e~th_J_o_rd~w~1 ___________________ _
NC Contractor Certification No.: _N~C~W_C~26~6~9~-A~------------------
Contact Person.:...: ""'"Ja=n=ic"""'e'--'S=--=c;..cco~tt _________ ----'E=M=A=IL=--'--A=d=d"""'re=s=s:....,..js=--=c=o-=tt@--=m=i=d=so"----"u=tl=1g=e=o=th=e=-=-rn=1a=l.a...=.c-=01a.=.11
Address: 8275 Tournament Dr. Ste 185
City: Memphis Zip Code: =38=--=1=2..::;..5 __ County: --=S=h=el=b.,_y __________ _
OfficeTeleNo.: 901-748-9095 FaxNo.: 901~748-9097
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: MidSouth Geothermal, LLC
Conta~t Person: Janice Scott, Off. Mgr
Address: 8275 Tournament Drive. Ste 185
EMAIL Address:[e-mail]
City: Memphis Zip Code: ____ 38......;1=2~5 __ County: Shelby
Office Tele No.: 901-748-9095 Fax No.: 901-748-9097
E. STATUS OF APPLICANT
Federal: Commercial: Private: _x_
State: Municipal:_·_ Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed-Loop geothermal water source heat µump
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constrncted: after 4/13/10 Number of borings: __ 5_7 ___ _
Approximate depth of each boring (feet): __ 4=5~0-' _____ _
(2) Type of tubing to be used (c opper, PVC_. etc): ,:..::H=D-=--P=E~p=la=st=ic'---'p=ip=e'----------
(3) Well casing. Is the well(s) cased? (check either (a.) Yes m: (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: _galvanized steel __ black steel ___plastic __ other {specify)
Casing depth:. From ___ to ___ feet (reference to land surface)
Casing extends to above ground ___ inches
(b) No X
( 4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite XX Other (specify) ______ _
(b) Grout placement: Pumping__ Pressure__ Other __
(c) Grout depth of tubing (reference to land surface): from _O __ to 4.50 (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC SQW Nolificallon of Intent Fonn (Revised 8/2008) Page2
H. UIJECfi ION -RELATED EQUITMENT'
Allach a diagram showing the engineering layout or proposed modification of (lie injection equipment and exterior
piping/tubing associated with (lie injection operalion. The manufacturer's brochure may provide supplements:-y
information.
1. LOCATION OF WELL(S)
Attach Wo copies of snaps showing the following information,
(1) Include a Site Map (cart be. drawn) showing: buildlags, properly lutes, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing wells) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump ►vela system, Label all features clearly and include a north arrow.
(2) The Site Map must show [lie subject properly in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or Wghtvay intersections,
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this docu:Wien! and all atteclunents thereto and that, based on my uiquiry of lhose individuals
iininediately responsible for obtaining said information, I believe that 1he 1nFormation is trine, 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 wet/ and
all related appurtenances in accordance with the approved specifeea 'u Lik and conditions of Ilie permit."
Signaty • 'PtnpiO aer/Applicant
Print or Type FuU Naive and title
Signature of Property Owner/Applicant
Print or TypeFulLNaine and title
Soature of Authorized Agent, if any
�f� / Print or Type Frill Name and tine Please return t (Ocopies of the completed Application package to:
North Carolina DENR-DW4
Aquifer Protection Section-UIC Program
1636 Mail Seiviee Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5Qw Notiticadw of hitent romi (Revised 8MOK) RECEIVED / DENR r 0V4 Page 3
Aquifer Proterlian SO.Mlott
APR 27 2010