WI0400146_GEO THERMAL_20100716

Permit Number WI0400146
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
636 W Main Street
Location Address
636 W Main St
Elkin
Owner
Owner Name
Joseph
Dates/Events
NC
H
Orig Issue App Received
07/16/10 07/12/10
Re g ulated Activities
Heat Pump Injection
Outfall
28621
McCulloch
Scheduled
Draft Initiated Issuance
Central Files: APS_ SWP_
07/.~6/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Randan Cutter
6105 Rest Home Rd
Claremont NC
Major/Minor
Minor
Region
Winston-Salem
County
Surry
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation ·
Joseph H. McCulloch
636 W Main St
Elkin NC
Public Notice Issue Effective
07/16/10 07/16/10
28610
28621
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
y
AVA
MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Joseph H. McCu11och
Cicely C. McCul.loch
636 W. Main Street
Elkin, NC 28621
Coleen H. Sullins
Director
7/16/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0400146
636 W. Main Street, Elkin, NC 28621
Dear Mr. & Mrs. McCulloch:
Dee Freeman
Secretary
On 7/12/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl y
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 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 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 aJ?-d 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 .021l{u)(2). Additionally, you should contact the SmTy 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.Ro gers@.ncdenr.gov if you have any questions.
Sincerely,
0~0-~
ft;r Debra Watts
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. W10400] 46
Surry County Health Dept.
Supervisor
Innovative Environmental Drilling -Randall Cutter -6105 Rest Home Rd, Claremont, NC 28610
Evans Heating & Cooling, Inc. -Mark Evans•-· 2297 Rich Hill, Glade Valley, NC 28627
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.ncwaterquality.org
An Equal Opportunity I Affirmative Action Employer
NirthCarolina /Vaturattu
NORTH CAROL.iNA
DEPARTMBNT OF BNVIRONMENr AND NAnMAL RESOURCES {IKMM4R)
f I ' • 1 I :� i i ! fl ice:', 1 ,iyl� ' � ! : i _i '
TWE 5-9—W. Rridum
In Awe whiz dw provisions of NCAC Title ISA: 02C.4200, ph=*
complete tide notifimdon and mail to a&Wn an iba but pw obw f or I= is€ n).
DATRr. Qom. r - 20/ \�] � Q' c)o1
A.
a
iYeN fte CvwjSmWm: Does the prvpaeed systam ciraalsafae pot" v
aft (no additim) m
. corsfinuou piping drat compbftly isoMw the &W fiam the envirenumstt (i.e.
0l0A&d4Q sa]?
Yes 7{ Condmie oompw" this form.
No Do Not aamphft Wes farm. Complete outer UIC spplicWw forms for irtsWlentg
aither a 5A7 wall (twloop wW potable wsw into tM squi r) or a 5QM wall (dosed -
loop men! oaubdabtg mod_ 'ate such as &-22, edwwl, or ofer noffmaze or corrosion inhihitm).
P°ROPZRT7i CW1f8nWArPLWAMT($)
Lbt gMProperty Owner fiwvd meet propntty deed (if orornsid by a bps or gsfvetrmia>Et agency, apnte name of
en tty and a rewalt4WQa wlhudumity fro dgrastuma
I
(1)
(2)
Mailing Addr w: 6M W. Main ft
City:. --Elkin Std= Zip Coda, ?6& ,_ CounW-Stun►
Hwooffice Teie No.: � %455 �133 C01 NQ,,
Email Addnm: wetasiw.
Fi ysk*l Addmesa of Weis Site (if ditvat thus above): Same
City: Stste: Zip Code: Cote ir.
HomnnK)ffie `lick No.: C61 No.:
A Ate` OF OWIqM IP ANY (if d*Ralmit Appiicaat k m m lira saubjed property,
stt ah a k her ttadm th o ptoparly o+w ow sssutiturif g AW* 10 kwftil awed o pe ra t: UIC wdl)
Company Now:
Conte Persow EMAIL Adds m,
Address:
CIty:
Stut& Zip Coda County:
CWOW Tele No.: Cell No
Webs* Address of Company, lfany: RECEIVED I DENR I DWQ
AQU1FP P-RCITFCTIDN SECTION
c;rui W SQW NiWfiffaMiaa atb*Mfto MAAW I XMP JUL 12 2010 p4o i

IT r
CannMY l Ir�nvvc�tive t3nvironmentat Dre'itinit
Well ljlf w Ca*aoWs Nanw ENdIA F_ Cutler
NC Conkactor C rdflicadon No.: I $-A
C40tactYerson_ �#ssndallCttttcr -- ---F,lAILAddrx:_nd�ue.coms -- I
Addrem: s 105 Rest Home Rd.
City: , Clareroant Tip Coda: _ - 28510 Ca": Catawba
❑ Ice Tale No.: , _ 5U&IM _ .. _CA Na: :M229469,5
]0. HRAT PUMP CONTRACTOR ROVM nON (N dfflkjrent than driller)
Cogrpeeq► Name: Rww Flea fing dt Castro& Inc.
Lbntact Person: ]f� S�►aas EMAiL �t+esa; _ � ,_
Address- 2297 inch Hill Rd.
City: p Cads: 2M Cam*
O#Sce Tole No.: c33s1 321Cell Na.:
IL BTATUS OF APPLICANT
Private: X Fedeisf: Cornmexial:
Rae: Mnnfolp d: Name American bands:
F. INJEMON PSOCEDURIC (brfeft describe how the injection wolfs) will be led)
;3
a VVIM L Mig'1<7tllit'1'ION DATA
(I) Proposed bate tobe oWWvebad: ASAP Number of boorftx d
Approximate depth of ea* boring (fedt)c 12 s'
(2) Type of tubing to be used {copper, PVC, etc): PoLygibylene
(3) Nall casing Is the well(s) cceaeV (check either (a.) Yes M (b.) No below)
(a) Yes if M then provide casfOeg information below
Type: .� Alvanimd steel sck stal____plastic other (specW)
Casing depth: From to £eet (raiecencse tD tend surface)
Casing extends lao above ground mhos
(b) No x
(d) Oraot fr o (material aumoundift well cash* andlDr piping):
(a) Grout type: Neat Convent
(b) Grout place nt: PumphML_x Pressure enter
(c) [trout depth of tubing (ref MC6 OD Lnd sunFace): from 0 tD _125 (foot}
If well has cosin& indwAW graw depth! from to [
GPUAAC sQw NedlRoM€ne of lam! Fwm (Rewind tO} Poe 2

a IMC M-BEI ATIDEQU PMENT
Attach a cl#a pm sbowing the enginoaring hyoid or pmpoeed madift Lion of the injed w equiprr>enrt wW mterim
pipirrgltu t maodWW with do inject3im operatiaa. The moadhotumWa brochtae mq pmvide sgMlenicutuY
lion.
LOCAMN OF VAU1 8)
Attach two cqm of maps showing the following mfornndkm:
(I) Imlude a Site Map (can be durmo showing: bmidimm properly lines, mrbw wear bodles, paterdal
eamsm of gmandwatcr contamumam and the oda"on of and dimmm betwena do proposed we**) sod
my a6sft walla) or waste dispomd f irides mch as septic t mlts or drain f ands located w� 20D fid of
the poth m d beat ptm wall system. LAW all features ckwty and , AwWh g�-
(2) The Site heap moat show ft subject pn IWW in relation W the surm mding am by uslag at kart two fbred
knee Points such PA wads, atr+e n% mAW highway lnww: ion
J CERTMCALTION
NOW This hermit Applkatiun mart be fined byqLcb peraam appearbig am the
recorded legs[ poreperty deed. -
"I fmwft certify, under pmslty of raw, ihat I hmm permnally mmmined and am fimiliar' with the reformation
wbmiikd In this doemnent and all athchmeaft thereto and that; bweel an my iaqulry of thoae wdivlduals
immodis * respamibie for obahm g said $heir wdac, I behave that the won. is Vu% a cmm to and complete.
I am aware that -there we olgatfimt pamMM iwudrrwg the possMiky of Ems and iWWommil, for zubmittintg
false bObn win I egroo to eonalruct, openft maintain, mp&, and if applicable, won. Ow i *xWon wall and
all related apprbrbertancm in sewn In m with the a2prvYgd sppcificgkdom and 9p ubdom ofthe Fe mV
Sig&eftm of Pmperty OwnedAppikaat
Lc:.. IV(. 0—Ct-.1/0
Print or Ty * Ptlll area bale
84patmm of Pmpwty OwrodApPlicaat
61-claC- mcCu «hC.
Print. or Type Pwl Nam and title
Signature of Audwriaed Agent, if any
Print or Type Fell Name and title
Please rettxrt two Copies of the cvmpl W Anfficadw pwkro tm
North Cared= DZNR DWQ
AgW&r Pr otee im Sectiom4HC Propmm
1636 Mail Service Caster RECEIVED / OENR 1 DWQ
Rabigb, NC 276"-1636 AOU1FfiR 'P;?OTFrT1()R gCT1ON
Tdq*oue (9M U54M JUL 1$ 2010
arUMIC SQW Mo fagm of Wot Fwm Ot"ind oases) PW3

t
20.00'
Joseph E. & Cicely C. McCulloch
636 W. Main St.
Elkin. NC 28621
W. Main Street

Sony Co., NC -- Printable Map
Page I of I
5urry County, NC
DISCI AmM The infarrmban owdakied on this pWe is NOT to be o x%Mm d or used as a mkgW desalpW. Map hIb matim Is
believed to be accurate but accumq is not guarwAsed.
Parcels
ParoM 0- 4951-13-02-8535
Owner.
MCCULLOCH JOSEPH E
MICCULLOCH CFCELY C
EL{4N,NC 2082 MM
Deed Book-1]717 Pg. OD19
Subdtvhftn:
TownshlF: EUGN
Calculated Acreage:1.42AC
Building Value: $188,460
Qutbuildinga Value; "m
tend Vakm-. $40.250
Farm Use Vim: s0
Aesessod value: $227.300
Other Attributes
at ac*t 14OW4. "gm
Fire Distrlets: Voting Districts:
Name: ELIGN CITY District Name: SOUTH DISTRICT
School Dlirb iets: Precinct Name: EDkIn #k1
hWJlwwrw.web&.AfWe m d& A mWddm Ow. htta' Mww.anWgs
httpJ/arcims.webgrismthnrJsurry/printWe2.asp 7/7MI 0

f-
20.00'
Joseph E. & Cicely C. McCulloch
Safi W. Main St.
i:7lr;n_ No 7Rk71
W . Mail: Street

Sway Co., NC -- Printable Map
Page 1 of 1
5urry County, NC
IMSCLMMEH; The Information oxft W on th!a page is NOT to be construed or used as a "legs! descript1W. Map uftmastion Is
believed tD be a=jmla brat a=mcy is not guarantsPd.
Parcels
PaMM Kk 4951-13-02-OM
Owner:
MCCULLCCH JOSEPH E
MCCULLOCH =ELY C
an w tuM ST
ELMMC 288213M
Heed Boob 0717 ft 0019
Subdivision:
Townshlp: EUUN
Calculated AcrrWs: 1.42AC
BuUdbV Vskts:
$185.450
Outbuildings Value:
$SOD
Land Value:
$40,2W
Faint Use Value:
$0
Assessed value:
$227.300
Other Attributes
at PC** 14SM4, MRS
Fire Districts: Voting Ohrmcts:
Name: ELM CITY Dhdrld Name: SOUTH DISTRICT
SdwW : Prednct Name: EkIn 01
NWM*W.weW4ie[ Anderson &Amddw, hr- htWJMrww.anda%wg.Cam
hfpJ/mims.web&-neVnc/ rry/Wirftble2-aV M12010

I NNOVAT I VE ENV I RO 62 BE 71283
07r12/10 0 lmapm P. 001
l � -
FACSIMILE TRANSMITTAL SHEET
TO!
FROM:
Randall E. Cutter
COUPANY-
nAIT;
NCDIiR - DWQ
7/ 12/2010
PAX NUMBEW
'i WALNOJ OPPAGM; TN(3AJD114G COV!?R
919-715.OW
5
PHON nN11M11W
SENDARIS KRPRRRNCR NUMBER:
919-71"935
Rx.
YOUR RRF1(Rl3?4M NUM159%
McCoiloch
0 URGlANT 0 FOIL R13VIT+W ❑ PLUASK COMMI+NT ❑ PLEAS11 REPLY 13 PLEASL TWCYrLTS
N [71'LiSICON L1cii1+F1'S:
Following is the 5-QW application', For a closed loop (water only) ccathernial vlertical.
loops. We would Re to sta t ddJiqg d>Iis on July 19'", if pomb e:
Please forward me a copy of the Acltnowkdgr=t letter to .cam
Thank you,
Randall E. Otter CWD/Pl
lsmovacive Fxrvim=wntsl i]r1-fling
6105 RR%T I10MR RD. CLARWMONT. NC: 29610 B28.228-1695 FAX: [phone]

INNOVATIVE ENVIRO 8288671298 07112/10 08:06pm P. 002 ..
NORTH CAROLINA
DEPARTMENT OF BNVIRONMENT AND NATURAL RBSOUR.CBS (NCDBNR.)
7/12/2010 4:00 PM'•FROM: tax IED TO: 9197150588 PAGE: 001 OF 005
7/12/2010 4:00 P~• FROM: Yex IED TO: 9197150588 PAGE: 001 OF 005
7/12/2010 4:23 PM',FROM: Fax IEO TO: 9197150588 PAGE: 001 OF 0 05
7/12/2010 4: 28 PM'' FROM: ¥-ax IED TO: 9197150588 PAGE: 001 OF 006
IVLSIDENI L WELL CONSTRUCTION RECORD
North Carolina Depertmem of Environmerff. and Natruai Resources- Division of Wabrr Quality
WELL CONTRACTOR CERTIFICATION # 28I814
1. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (Individual} Nam
Innovative Environmental Dd1fing.
Well Contractor Company Name
6105 Rest Home Rd.
Street Address
Claremont NC 28610
City or Town State Zip Code
L 828 a 228-1695
Area code Phone number
2. WELL INFORMATION,
WELL CONSTRUCTION PERMIT* Wl0400146
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL 10 #(it appIi I:Aa) GL--I _
3. WELL USE (Check Applicable Sox): Residential Water Supply p
DATE DRILLED 06/21/10
TIME COMPLETED] 5:30 AM ❑ PM 3(
4. WELL LOCATION:
ciTY: Elkin COUNTY 5urlrlf
636 W. Main St. 28621
(Street Nsma, Numbers, Community, Subdivi0m. Lot No.. Pared, Zip fie)
TOPOGRAPHIC 1 LAND SETTING: (check appmpftte box)
jiSiope CI Vallay []Flat E i Rldge []Other
LATITUDE 36 " DMS OR 36.243363 DID
LONGITUDE 80 " DMS OR 80.862282 DD
Latihrdeflongitude source: R�.PS Oropographic map
(►ocation of we# must be shown on a USGS tvpa map andattached to
this form It not using GPS)
5. WELL OWNER
Joseph H.�
Owner Name
636 W. Main St_
Street Address
Elkin NC 28621
City or Town State Zip Code
3r 36 835-3133
Area rode Phone number
6. WELL DETAILS:
a. TOTAL OEM: 126
b. DOES WELL REPLACE E)USTING WELL? YES [I NO
c. WATER LEVEL Below Top of Casing: None FT.
(Use'+" ff Above Top of casing)
d. TOP OF CASING is N/A FT. Above Land Surface'
'"fop of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2C .i1118.
e. YIELD (gprn): NIA mismon of TEST NIA
I. DISINFECTION: Type NIA Amount
9. WATER ZONES (depth):
Top None _ Bottom
Top Bottom
Top _ Bottom
R"cCEI IM i DENR f 3WQ
AUG 10 no
Top
Bottom
Top._
Bottom
Top
Bottom
Thickness)
7. CASING:
Depth
Diameter Weight Material
Tap Norte
Bottom
Ft_
Top
Bottom
Ft.
Top
Bottum
Ft.
8. GROUT:
Depth
Material Method
Tap 0
Bottom 125
FL Bentonite _ Pumped
Top
Bottom
Ft
Top
Bottom
Ft.
9. SCREEN:
depth
Diameter Slot Size material
Top NIA
Bottom
Ft. in. in.
Top
Bottom
Ft In. in.
Top
Bottom
Ft- in. in.
10. SANDIGRAVEL PACK:
Depth Size Material
Top NIA Bottom Ft.
Top Bottom Ft -
Top Bottom Ft
11. DRILLING LOG
Tap Bottom Formation Description
0.0 138.0 sandy day wl broken rack
38.0 150.0 sand stonelrock
50.0 190.0 Granite
90.0 1125.0 Granite w/Quartz
1
1
1
1
1
1
1
1
12. REMARKS:
This is a Geothermal LOW well. No precise -cuttings I
samples taken.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 1SA NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVAIDW TO THE VELL 0,VVNER.
�- OBID912010
S! NATURE OF CERTIFIED WELL CONTRACTOR DATE
Randall E. Cutter
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: [phone] Rev. 2109

c rr �r '1 AEUDENTUL WELL CONSTRUCTION RECORD
RC
North Carolina Depaatment of 13nvirannaent and Natrual Restxu+5es- Division of water Qua1 Q� jf D i �41 DVVQ
•....-' i� DRnTcr1
WELL CONTRACTOR CERTIFICATION # 2818 A 201.4�0iIC�f�
1. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (Individual) Name
Innovatite Environmental Ddllino
Well Contractor Company Name
6105 Rest Home Rd.
Street Address
Claremont NC 28610
City or Town State Zip Code
828 a 228-1695
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10400146
OTHER ASSOCIATED PERMITA{If applicable}
SITE WELL ID Ire apoicawa) GL-2
3. WELL USE (Check Applicable Box): Residential Water Supply El
DATE DRILLED 96/24/1 ❑
TIME coMPLETED 5:3a AM 0 PM W
4. WELL LOCATION:
CITY-, Elkin COUNTY Surry
636 W. Main St. 28621
(Street Name, Numbers, CommuriRy, SuhdkWon, Lot No., Pgrcel, Zip Code)
TOPOGRAPHIC l LAND SETTING: (check sppmOate box)
I (Stope ElValley []Flat ❑ RMP []Other
LATITUDE 36 1 • DMS OR 36.243414
LONGITUDE 80 1" DMS OR 80.862303
n
..
Latitude1longitude source: @1bPS Qropographic reap
(baetion of well must 8e shown an a USGS tope map andattached to
this form if nor using GPS)
8_ WELL OWNER
Josegb H. & Cicely C, McCulloch
Owner Name
636 W. Main St.
Street Address
Elkin NC 28621
City or Town Stele Zip Code
3� 835-3133
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 125'
b. DOES WELL, REPLACE EXISTING WELL? YES ❑ Na it
c. WATER LEVEL Below Top of Casing: None FT.
(Ilse "t" If Above Top of Casing)
d. TOP OF CASING Is NIA FT. Above Land Surface`
"rop of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C -0118-
e. YIELD (gpm]: N/A II moo of TEST NIA
f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top None
Bottom
Top—_
Bottom
Top
Bottom
Top
Bottom
Top
Bottom
—
Top. _ _
_ 9ottorn
Thickness/
7. CASING:
Depth
Diameter
Weight 11 1W
Top None
Bottom
Ft
Top
Bottom
Ft.
Top
Bottom
Ft-
S. GROUT:
Depth
Material
Method
Top 0
6ouom 125
Ft.
$entonite_
_ Pumped
: Top
Bottom
Ft.
Top
Bottom
Ft
9. SCREEN:
Depth
Diameter Slot Size Material
Top NIA
Bottom
Ft,
In,
In,
Top
Boftorn
Ft.
in.
In.
Top
Bottom
Ft
In-
in-
10. SAf1DXMVEL PACK.
DOM sine
Tap NIA Bottom Ft.
Top BDfiam Ft.
Top Bu taut Ft,
11. DRILLING LOG
TOP WON
4.0 138.0
38.0 150.0
50.0 19Q.0
90.0 1125.0
1
r
1
1
1
1
1
1
1
Material
Formation Description
sandy Ciao wl broken rock
sand stoneirock
Granite
Granite w/Cluartz
12. REMARKS:
This Is a GQott p mlal Weft. No precise Cuttings I
smrrtples taken.
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUOTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPYOF THIS RECORD HAS BEEN
PRDVID DTOTHEWELLOWNEFL
08M, 201 Q
5 GNATUR flF CERTIFIED WELL CONTRACTOR DATE
Randall E. Cutter
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Procesaing, Form GW-le
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: [phone] Rev. 2/09

Y- AESMENTTAL WELL CONSTRUCTION RECORD
�. 4z North Carolina Department of E viro=col and Natural Resources- Division of Water Quality r<F EIYEU i u .l
WELL CONTRACTOR CERTiFICATIDN # Z$28 A A'u�I�Ft}�PRiiTFf'Tf1ii�1 fi�TIQH
AUG 10 2010
1. WELL CONTRACTOR:
g. WATER ZONES (depth):
Randall E. Clutter
rap Norte sottom
Top- - Bottom
Well Contractor (Individual) Name
Top Bottom
Top Bottom
lfjngmatiye Enypronmerlta) ❑rIIIIna
Top Bottom _
_ Top Bottom
Well Contractor Company Name
Thicicn89al
6105 Rest Home Rd.
7. CASING: Depth
Diameter welght material
Street Address
Top None Bottom
Ft
NC 28510
Top Bottom
Ft. _ - —
City or Town State ZIp Code
laP svttvm
FL
t 828 a 228-1695
Area code Phone number
8. GROUT: Depth
Material Method
2. WELL INFORMATION:
Top ❑ eottom 125
Ft-Bentonite Pumped
WELL CONSTRUCTION PERMIT# W10400146
Top Bottom
FL
OTHER ASSOCIATED PERmIT*(ii appt"bie)
Top Bottom
Ft
SITE WELL ID #(Ir appiirehls} GL-3
9. SCREEN: Depth
Diameter Slot Size Material
3. WELL USE (Check Applicable Box): Residential Water Supply p
Top wA Bottom
Ft. in- In.
DATE DRILLED 06/27/10
Top Battorrm
Ft in. in.
/
TIME COMPLETED 5:30 AM ❑ PM 5
Top Bottom
Ft. in. In.
4. WELL LOCATION:
10. SANDIGRAVEL PACK:
Depth
size Material
cay. Elkin couNTr Surry
Tpp fWA Bottom
Ft. _
636 W. Main St. 28621
Top Bottom
Ft. --
(Sbest Name, Numhwra, Community, Subdivision, Lot No., Pamel, 71p Cads)
Top Bottum
Ft.
TOPOGRAPHIC I LAND SETTING: (dwa awroprtaw box)
WfSlope OVatley ❑Flat ❑Ridge ❑other
11. DRILLING LOG
Top Bottom
Formation Descnplion
LATITUDE 3$ °_ . DMs OR 36.243399 DD
0.0 138.0
sandy day wl _b_roken rack
LONGITUDE 80 -OMS OR 80.862372 DD
38.0 150.0
sand stonelrock
l$titudeApngIbAe source: [f3PS Qropographlc map
50.0 90.0
Granite
(rocatdarr of well must be drown on a USGS hypo map andartached to
90•0 1125.0
Granite w1G)uartz
this form itnaf using GPS)
1
5. WELL OWNER
Josegh H. & Cicely Q. McCulloch
Owner Name
636 W. Main St.
Sheet Address
Elkin NC 28621
1
City or Town State Zip Code
/
3L 6 835-3133
Area code Phone number
12. REMARKS:
S. WELL DETAILS:
This is a Geothermal loop
well. Np precise cuttings.l_,
s. TOTAL DEPTH: 125'
samples t81t9ft.
b. DOES WELL REPLACE EXISTING WELL? YES p NO it
c. WATER LEVEL Below Top of Casing: None FT.
(Use -+- if Above Top of Casing)
d_ TOP OF CASING is N/A FT. Above Land Surface
•Tap of casing tenn'hated atfor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH I{A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVID,�D TO THE ]HELL WNER-
r-IZZ 11,1-er• 080M01()
IGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a. YIELD (gpm): NIA- METHOD OF TESTNA. __ Randall E. Cutter
f. DISINFECTION: Type N/A Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a
1817 Mall Service Center, Raleigh, NC 27099-161, Phone: [phone]W Revs. 2/09

RESIDENTIAL WELL CONSTRUCrIaN RECORD
North Carolina Depamnent ofEnvuxmment and Natural Resources- Division of Water Qua[WEGEiVE] I DENR I & I
WELL CONTRACTOR CERTMCATION ft 2819-A
AQ0FFWPunrF►,rnvr ^F(.TOI+C
-
AUG 10 20fa
1. WELL CONTRACTOR:
g. WATER ZONES (depth):
Randall E. Cufter
Top_None_
-- B❑tt❑m _
_ -
Tap
__ Bottom
Well Contractor (individual) {Name
Top
Bottom
Tog
Bottom
Innovative Environmental Olillino
Top_
_ Bottom
Top_
.-_ Bottom_
Well Contractor Company Name
Thlckneasf
61Q5 .Mst Home Rd.
7. CASING:
Depth
Diameter
WWght Material
Street Address
Trip None
Bottom
FL
l re ont NC 2851
Top
Bottom
Ft
City or Town State Zip Code
Top
Bottom
Ft.
— —
i 828 l 228-1695
Area code Phone number
8. GROUT:
Depth
Material
Method
2. WELL INFORMATION: =
Top E1
Bottom 125
Ft Bentonite_
Pumped
WELL CONSTRUCTION PERMIT# W10400146
Top
Bottom
Ft.
OTHER ASSOCIATED PERMIT#(if appucede)
Top
Bottom
FL
st-re WEI1 iD #[dapoicebie) GL-4
=
9. SCREEN:
Depth
Diameter
Sint
Size Material
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
Top N/A
Bottom
Ft.
In.
in.
DATE DRiLLEo 07/29/10
rap
Bottom
Ft
in.
in.
TIME COMPLETED 9:30 AM El PM �
Top
Bottom
Ft
In.
in.
4. WELL LOCATION.,
10. SANDIGRAVEL PACK:
Depth
s�
material
Y: Elkin COUNTY 5uny
CITY.
Top N1A
Bottom
Ft,
636 W. Main 5t. 28621
Top
Bottom
Ft.
(Street Nsme, Numbers, Community, SubdIvifilon. Lot No., P&MM, Zip Cade)
Top
Bottom
Ft
TOPOGaRAPHtC I LAND SETTING: (check appropriate t>ex)
&(Slope ❑Valley ❑Flat ❑Ridge pother
LATITUDE 36 °� " DMS OR 36.243348 DD
LONGITUDE 80 " DMS OR 80.862349 DD
Latitudellongitude source. Sjf>PS OT❑pographic rnap
(location of well must be shown on a USGS topo map andatfached to
this form it not using CPS)
& WELL OWNER
Owner Name
636 W. Main 51.
Skeet Address
Elkin ,. _ _ NC 2862J
City or Town State Zip Code
3r 36 a 835-3133
Area code Phone nUrnber
S. WELL DETAILS:
a. TOTAL DEPTH: 125
b. DOESWELL REPLACE EXISTING WELL? YES © NO al(
c. WATER LEVEL Below Top of Casing: Nona FT.
(Use "+' if Above Top of Casing)
d. TOP OF CASING is NIA FT. Above Land Surface'
'Top of casing germinated atlor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
11. DRILLING LOG
Tap Bottom Formation Description
0.0 138.0 sandy day wl broken rock
38.0 150.0 sand stonetrock
50.0 190.0 Granite
90.0 1125.0 Granite w/Ouartz
I
1
1
1
1
1
1
1
12. REMARKS:
This is a- Geothermal loop well. No Qrecise cutttngs 1
sampWa taken. - --
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
08/09/2010
SSt (NATURE OF CERTIFIED WELL CONTRACTOR DATE
a. YIELD (gpmy NIA METHOD OF TEST NIA Randall E Cutter
I. DISINFECTION: Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Infonnation Processing, Farm GW-1a
1617 Mail Service Center, Raleigh, NC 27699.1 fit, Phone: [phone] Rev. 2109

RECEIVED I DENR I DWQ
AQUlf=t=R·PROTFr.rtnN SECTION
AUG 10 2010