WI0500351_GEO THERMAL_20110215

Permit Number WI0500351
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
Jimmy & Katherine Parker SFR
Location Address
8120 Robin Crest Ct
Fuquay Varina
Owner
Owner Name
Katherine
Dates/Events
NC
A
27526
Parker
Central Files: APS_ SWP_
02/15/11 Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00 Permit Classification
Individual
Permit Contact Affiliation
Kevin Letchworth
Driller Well
PO Box 1958
Wendell
Major/Minor
Minor Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Jimmy D. Parker
8120 Robin Crest Ct
Fuquay Varina
NC 27591
NC 27526
Orig Issue
02/15/11
App Received Draft Initiated
Scheduled
Issuance
Public Notice Issue
02/15/11
Effective
02/15/11
Expiration
02/04/11
Regulated Activities
Heat Pump injection
Waterbody Name
Stream Index Number Current Class Subbasin
~iih ·
~CDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Jimmy & Katherine Parker
8120 Robin Crest Court
Fuquay Varina, NC 27526
Coleen H. Sullins
Director
2/15/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0500351
8120 Robin Crest Court, Fuquay Varina, NC 27526
Dear Mr. & Mrs. Parker:
Dee Freeman
Secretary
On 2/4/2011 , the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-on h
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 a s 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 ISA Section 2G Subchapter :021l(u)(2). Additionally, you should contact the Wake 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 assess!Uent of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Ro0 ers(a\ncdenr.gov if you have any questions.
Sincerely, ·
10,Q,~~
cc: Raleigh Regional Office -APS
APS Central Files -Pennit No. Wl050035J
Wake County Health Dept.
Supervisor
Lctco inc. d,b/a NW Poole' Well Co. (Kevin Letchworth -PO Box 1958, Wendell , NC '.!7591)
Srephenson Hearing & A/C Inc. (Tony Stephenson -343 Shipwash Drive. Gam er. NC '.275'.29)
AQJiFER PROTECTION S!:CTiON
1636 Mail Service Center, Raie~h, North Carolina 2769 9-163 6
Location: 2728 Capital Boulevard. Raleigi-;, North Caroiina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwateraualitv.o ro
~::i Ecual Op po rt u:<:y \ Affirm ai:ve Act::m Employer
NOne 1 r 1. ortn ---.-aro ma
1.. J n h nn, f.lt E /lf;.11,f,,1,u dtf
RECEIVED I DEIVA t LNU
Aquifer Ptotertion Sedian
NORTI I CAROLINA FEB 0 4 2011
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE SOW WELL{S)
In Accordance With the Provisions ofNCAC Title 15A 02C.0200
Print or type the required information and marl to address on the back page.
DATE:
k l:3 , 20 /1
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-loop)7
Yes I^ Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well injecting potable water into the agllifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or con-osion inhibitors).
A. PROPERTY OWNER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or gu crnment agency, state name of
09
entity and a representative wlauthority ; r signature): -3 ),_r. ,F, i h , Iter) G1�'
40+)-\-r \4 A . -/-1-t-r. .
Mailing Address: iii1 ;-' 0\,1)sIL Q l'-Pj- CT
City: t•_'<j 4 -j 1 aMI^ State: AA Zip Code: 2 757-G County: tic,]
Home/OfficeTele No.: lh- 23?-79`/7 Cell No.: '-if-)-75-3 53-37
Email Address: Website:
(1)
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code: County:
Ilome/Office Tele No.: Cell No.:
R. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not awn the subject property,
attach a Ietter from the property owner authorizing Agent to install and operate UIC well)
Company Name: � i 1 5 - qA k. -1 r-c •
Contact Person: T ✓IA 5 '_; arm EMAIL Address: 5 &t►y's-- iWgt0`, ''(,,
Address: 3L S lr-1ic�,��-
City: tie State: lilt Zip Code: 27.5d-9 County:
Office Tele No.: � I+`7 ^ 3 tf/5^ / .. -
Cell No.: � � �
Website Address of Company, if any: yL--tr°i s -} Are, ! ('�.•�+
GPIJJUIC 5QW Notification of intent Form (Revised 8r2008) ['age

C. WELL DRILLER INFORMATION
Company Name: tt'hrt3 . [ , t (o. Pod e (r 4ter
Well Driller Contractor's Name: J Ovine
NC Contractor Certification No.; G �}; AA
Contact Person: l U� . i Le I G4 e4 t' Tr. EMAIL Address:
Address: P _ _z / 4l S
City: 1.09411 Zip Code: 47591 County: 'Joke
Office Tele No.: (gig) A / --°l 1.3 Cell No.: _
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: i1--= irvev0-5.- 14) i 1/C :►-C.
* Contact Person: � 1-1 5 (1)-4'w'',5---'"" EMAIL Address:
Address: 3 Y3 $I? 1 w2151... r`
a
City: �,rq r .r Zip Code:
Office TeIe No.: 919".379r (3g Cell No.:
5=79 County: ..Yi 1.
wU �X55La
E. STATUS OF APPLICANT
Private: Federal: Commercial: 1,
Municipal: Native American Lands:
State:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: I11 I r Number of borings: 2
r
Approximate depth of each boring (feet): 30
(2) Type of tubing to be used (copper, PVC, etc): _ 10 P4
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (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 13entonite )J Other (specify) _ (0 Li)
(b) Grout placement: Pumping X( Pressure Other
(c)
Grout depth of tubing (reference to land surface): from C _ to -• cc:_ (feet)
If well has casing, indicate grout depth: from _ to - _ (feet)
GPU/tJIC 5QW Notification of Intent Form (Revised WOOS) Page 2

JAN. 4, 2011 4:45PM N W POOLS WELL CO
NO. 430 P. 5
INJECTION-RJI.ATED EQUIPMENT
Attach a diagram showing the engineering Layout or proposed modification of the injection equipment and exterior
pipingItubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I, LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(l) Include o Site Map (can he drawn) showing: buildings, property Fines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed wells) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields Iocated within 200 feet of
the geothermal heat pump well system. Label all features clearly and iiplude a_north Wow.
(2)
The Site Map must show the subject property in relation to the surrounding area by aging at least two fixed
reference points such as roads, streams, and/or highway intersections.
Jr. CERTIFICATION
Note: This Permit Application must be signed by ca person appearing on the
recorded fogs[ property deed,
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in thla document and ail attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and Qomplete.
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. I agtt:e to construct, operate, maintain, repair. and if applicable, abandon the injection well and
all related appurtenances in accordance with, approved specifications
and conditions of the Permit."
-7 621(14"\---
I ` (.y%nattue n perky Owner/Applicant
j; l 0. ar)
Print or Type Xi
Pe
Pull Name and title
Signature of Property Owner/Applicant
Print or Type Full Nar e.and4itto
ti
signature of :Authorized Agent, if any
Print or Type Pal Name and title
Please return two copies of the completed Application package tot
North Carolina DINR-DWQ
Aquifer Protection Section -WC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED I DENR, DWO
Aquifer Protection Section
FEB 0 4 tali
rnrTIT nr irrw rvatliicativn of Want Perm (Revised 8/2OO1)
Pgga 3

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department ut'Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # Z•
1. WELL CONTRACTOR:
Wig! Contractor (Individual) Name
N.W. Poole Well & Pump Co.
Well Contractor Company Name
PO Box 1956
Street Address
Wendell
NC 27591
City or Town Slate Zip Code
[phone]
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT/1
OTHER ASSOCIATED PERMIT/SO app/table)
SITE WELL 1D ISO applicable)
3. WELL USE (Check One Box) Monitoring p Municipal/Public p
Industrial/Commercial 0 Agricultural 0 Recovery° Infection 10
Irrigelionp Other (Ilstuse) ate/1 Cfoid,� /c
DATE DRILLED ] t g / [ (
4. WELL LOCATION:
VW [2c Chit' ,,L,.f "
(Street Name j.umberls,, Community, Subdivision, Lot No., Parcel. h p Code)
CITY: jw�t �,y7r1r,1 COUNTY kle-e
TOPOGR I IC f LAND SETTING: (check appropriate boxy
©Slope DVelieylal ❑Ridge °Other
LATITUDE f� '(/ ,Lit{ '13M5OR CID
f
LONGITUDE `y$' L-f j • 5. " DMS OR DIJ
Latitude/longitude source: D PS Dropographic map
(location of well must be shown on a USGS topo map a:rdaltached to
this form if not using GPS)
6. FACILITY (Name of the business where the well Is located.)
3 L , 1,1--,:,,, „ }
Fa nifty Name 1 :. Facility IDN (If applicable)
rest Address `
—� k_� �,. - �I Cs� _,_ : . . �-C c
�Ity or T� State Zip Code
Contact ame ,
\30% _)k---, .}� , ram C,I,
Mailli{gAddress al
City or Tolyn Slate Zip Code
qz7 - 295(
Area code Phone number
S. WELL DETAILS:
e. TOTAL DEPTH: 30,
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing:
(Use '+' If Above Top of Casing)
NO Or
FT.
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atior below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
a. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bolcom
Top Bottom Top Bottom
Top Bottom Top &hom-
Thicknessl
7. CASING; Depth Diameter Weight Material
Top Bottom Ft.
Top _ Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Mal
Top 6 Bottom .1 Ft.
Top Bottom Ft,
Top Bottom Ft.
Method
9. SCREEN: Depth Diameter Slot Size Material
Tap Bottom Ft. in. tn.
Top Bottom Ft. In. in.
Top Bottom Ft. In, in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bottom FL
Top Bottom FL
11. DRI W NG LOG
Top Batlom Formation Description
r
mil(
t t 5L(I tartf-
,Y. REMARKS: 1lf tiAk dojei bp AD le
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WffI1
15A NCAC2C. WELL CONSTRUCTION STAHOArRTDS, AND THAT A COPY OF THIS
Ream HAS
SIGNATURE OF
teLS
PRINTED NAME
Rt}�Q� E WELL_OWNER �
CERTIFIED WELL CON r'I ❑R 'ID TE
jir4,4
OF PERSON CONSTRUCTING THE WELL
Submit ►ttrithin-30 -raysof completion; tp:' Division of Water quality - information Processing,
1617 Mail Service Center, .Raleigh, NC 27699-161, Phone : [phone]
Form GW-ih
Rev. 210E

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department 'Of Environment raid Naluru] Rwwoitrces- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # �d, ✓
1. WELL CONTRACTOR:
utnei tiotels
Well Contractor (Individual) Name
N.W. Poole Well & Puma Co,
Well Contractor Company Name
PO Box 1958
Street Address
Wendell
City or Tawn
NC 27591
State Zip Code
(919 ) 266-9223 Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT/
OTHER ASSOCIATED PERMIT#(II applicable)
SITE WELL ID #(tt applicable)
3. WELL USE (Check One Box) Monttorfng D Municipal/Public Q
Industrial/Commercial ❑ Agricultural IJ Recovery Q Injection
Irrigation© Olhor (tit use) tat(/ I C06, %1xwp
DATE DRILLED! 1 j
A. WELL LOCATION:
�rz_ �f- etioA-
(Sfroel Warner fiumbers, Cammcmlty, Subdfvielon, Lot Nu., Parcel, bp Code)
CITY: r/Ai COUNTY Wl,i./e_e
T0POGII Pi IC 1 LAND Si I I ING: (clock appropriate box)
EISIope ❑Vathey #fat fRldge QOther
LATITUDE _35 33r OHS OR DR
LONGlTUOE "1-0'4(. SZ " IJMS 0R 0D
Latitudetlongilude source: MPS Ofnpographlc map
(location of well must be shown on a USGS topo map andaftecired to
this form flnut using GPS)
s, FACILITY•(Name of the business whore the well is located.)
iRic
FncfU Brame Name �_-FaClAty hrne Of applicable]
�.7 tier. `. CzR
Apt Arrrtring
1 fly or Trnviil Stale Zip Code
My S IrpivykKin
Conked franca
-
Maiflrag Address
City nr fawn Stale Zip Code
Area cede Phone number
R_ WELL DETAILS:
r
a. TOTAL DEPTH: 4 01
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (s3'
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
Top
Top
Top
d. TOP OF CASING iS FT. Above Land Surface"
'Top of casing laminated alfor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
a. YIELD (gpm): METHOD OF TEST
1. DISINFECTION_ Type `____ Amount
g. WATER ZONES (depth);
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Ropth Dlarneter Weight Malarial
Top Bottom Fl.
Top Bottom FL _
Top Bottom Ft.
8. GROUT: Depth Materi t /] Method
Top O Bollom .307 Ft. b,ni..c1*/ircfl _
Top_ Bottom F1.
Top_ 6ottorrl- Ft.
9. SCREEN: Depth Diameter Slot Slza Material
Bottom Ft. In. in. _
Bottom Ft. In. in.
Bottom FL In. In.
10. SAND/GRAVEL PACK:
Depth .Size Material
Top Haltom R.
Top Bottom ' FL
Top bottom FI.
• 11. DRILLING LOG
Top Bottum
Formation jDescription
1 Z r �5t71 4
60( 1 i'O/ " r' ,d
I
1
I DO HERESY CERTIFY THAT THIS WELL WAS CQNSTf{1CTED IN ACCOW?ANCE WITH
15A NCAC 2C. WELL CONSTRICTION STANDAODS, AND THAT A WA' OF THIS
RECORD S-a0EEN p To IIICwei.L_OWNNEEjR. 1 u1 1I
Z-S
0-NATURE OF CERTIFIED WELL CONTRA OR R TE
— fr,S__Ye•dji
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within' 30 days, :Of torn:001m to:.Eiviskln of Water duality - Information Processing,
1617 Moil Semite Cantor; .Ralolgh,.NEr'27899.161, Phone [phone]
Form GW-1 b
Rev. 2/09

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.. ,.
I Jimmy D. Parker do authorize Mr. Tony Stephenson to obtain work permits for 8120 Robincrest ct
Fuquay Varina I\IC 27526.
a
3
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
nt{,Eivl:u 1 DEAN i UM./
Aquifer Protection Sectiar,
FEB 04 2011
NOTII+ICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5QW WELL(S)
In Accordance With the Provisions ofNCAC Title 15A 02C.0200
Print or type the required information and mail to address on the hack page.
DATE:
1- ! , 20 L oo
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed_ loo_n)T
Yes t.‘9 Continue completing this form.
No Do Not complete this form. Complete other UIC application_ forms for installing
either a 5A7 well (open -loop well injecting 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 gci eminent agency, state name of
entity( and a representative wlauthorityfor signature): .I • l� �n-� a. c x )Lxt 0,c9
— —
J OA\ A . i^ )--tr .
Mailing Address: IV/ 0\(-)/N- CT
1
City: r irp State: Zip Code: 2 75 -(a County: 'lLe
Home/Of iceTel.eNo.: c11- 33?. 79V Cell No.: ~j►�i'� - ! 7 —
(1)
Email Address: Website:
(2) Physical Address of Well Site (if dift'erent than above):
City: State: Zip Code: — County:
Home/Office Tele No.: Cell No.:
I3. AUTRORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UM well)
Company Name: ► ci .A ..,-- 1'7 " 1 . r1-'(
Contact Person:-chi/kJ. :-+ i �" ti -` EMAIL Address: ?i� 3 �n►� � � � ""'
Address: .'+ i� � �c5 r"
City: 0 rn.-;°' State: A/C Zip Code: q >4-t f _County: ih)A"—`
Office Tele No.: 9/'H " 3 9� V�4 Celt No.: / ,2 2 ' 1
Website Address of Company, if any::))tqLe `,
1 10 4 A+ �" , (�• ^�
GI'[1MC5QW Notification ofintcntForrn (Rcviscd 8/2OO )
page I

C. WELL DRILLER INFORMATION
Company Name: - 411 Csu et6f Pav,I
Well Driller Contractor's Name: - es ill, �14 _
NC Contractor Certification No.: ...' 4
Contact Person: 16L/ vL 1_-P Jit pr 14 Address:
—
Address: P 6 P. , t91ix 1475-T
City: _t(r7 11y Zip Code: 1-75 , I County: 14.-)Ake
Office Tele No.: iel c tt L --qzCell No.: - — — - -
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: i t �vri-5-- 1 ?) ) (- i A/C- ,--(. ' — --
Contact Person: -NA 5-4v'.i-7--- EMAIL Address: -
Address: 3 Y3 i r+t-,q1/4lr / -
C ity: - 3`ti r .. ►r Zip Code: '75 ? 9 County: -- AI +43 -
Office Telc No.: �-37.° r C] Ceii No.: ` J - C'? ,)- - 57.5
STATUS OF APPLICANT
Private:
State:
Federal:
Municipal:
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA
(l) Proposed date to be constructed: - I l I ? 1111 Number of borings: _2-
Approximate depth of each boring (feet): jolt
(2)Typeof to be used (copper, PVC,.etc
g ( pP): _ OTC�_
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b,) No below)
(a) Yes if ycs, 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) Nu X
(4) Grout Info (material surrounding well casing andlor piping):
(a) Grout type: Neat Cement Bentonite )6' Other (specify) \‘u41
(b) Grout placement_ Pumping x Pressure Other
(c) Grout depth of tubing (reference to land surface): from 0
Ifwell has casing, indicate grout depth: from - to
(Tee:)
(feet)
Gl'U/1J1C SQW Notification of Intent form (Revised R/Z408) Page 2

•,JAN. 4.2011 4:45PM NW POOLE WELL CO NO. 430 P. 5
H. INJECTION-RELATED EQUIPMJJ;:NT
Attach a diagram shc>wing the engineering layout or proposed modifl.cation of tbe injection equipmont mid cxk:rior
piping/tubing assocfated with the injection operation. The manufactnrer's brochure may provide supplementary
information.
I. LOCATION OF WELL(S)
Attach two copie!i of maps showing the following information:
(l) Include a Site Map (can be drawn) showing: buildings, property line,, m.rface water bodies. porential
sources of groundwatel' contamination and_ the oric:nt11.tion of and dJstancea between the proposed well(s) and
any existing well(s) or waste disposal faoillties such as septic tanks or drain :fields located within 200 feet of
the geothermal heat pump well syste.111. LabeJ all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roa.ds, streams, and/or highway intersections.
J. CERTili'IC.A 'l'ION
Not.e: This Permit Application must be signed by gm pttsOn appearfn~ on the
recorded legal p;roperty deed.
11t hereby certify, undet penalty of Jaw, that I have personally examined and am familiar wlth tho foformation
submitted in thi& docll111ent and an attachttienlll thereto and that, based on my inquiry of those individuals
immediatoly ~sponsible for obtaining said i:nf'or.mation, I believe that the information is true, accurate and complete.
I am aware that there ate significant peJialties, including the pos1dbility of fines and imprlsonrmmt, for submitting
falso informati.un. I agree to construct, operate, maintain, repair, and if applicable, 1ibandon the jttjection well and
all related apPurtcnances in accordance with app.r<>ved specifications and conditions of the Pe:ntti.t,"
t-(--. ~ "1-"" 44 '\ .. '
if goature o roperty Owner/Applicant
-s,.-/V\ ""v D. @:,,-z ,~ e_(l,
Print or Type '#w l Nrune and ti.tie
Signature of Property Owner/ Applicant
Print or Type Full Nlll!le .and -litl.!'
~V-,_§tD
Si ~ature of Authoozed~gent, if any
~J '--1 _) "j-(~())·)Q,10SJ./d
Print or Type Fl\II N'll.lll0 and tftl e
Please return two copies of the completed Application. package to:
North CaroJiaa DENJt..DWQ
Aquifer Protection SectfonMUIC Progrqm
1636 Mail Service Center
Raleigh, NC 27699~ 1636
Telephone [phone] RE.CEIVED I D
Aquifer Protect~NnRS! D~Q ect,on
r.Prrnrrr. ~ow Nntlff011ticm c,£ Intent Fonn (Revised 8/2008) FEB O 4 2011 Pug!! 3
NON RESIDEAi IAL WELL CONSTRUCTION RECORD
North Carolina llepurlmcnt of Environment and Natural .ltc tirces- Division of Water (Natily
WELL CQNTRACTOR CERTIFICATION # 'ZeK
1. WELL CONTRACTOR:
ryc). LTOAris
Well Contractor (Individual) Name
N.W. Poole Well &Pun) Co.
Well Contractor Comparry Name
PO Box 1956
Street Address
Wendell NC 27591
City or Town Stele Zip Cole
(919 ) 266-9223 _
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(If applicable)
SITE WELL ID #(ff applicable)
3. WELL USE (Check One Box) Monitoring p Municipal/Public
Indnstrial(Cammercia! 0 Agricultural Recovery0 InJeciion J
!Meation© Other (its use) �f_Mar �nid J`W
DATE DRILLED I I [ l
4. WELL LOCATION:
(Street Nurne, Nunobem, Community, Subdivision. Lot No Par,Claf, Zip code)
CITY: + t vrof,? U D4r4 COUNTY i+"or. e-t1
TOPOGI2(IC 1 LAND SETTING: (check appropriate box)
13Slope 0Valleyeta( ❑Ridge ❑Other _
LATITUDE '117.tlt( " DAIS OR DD
LONGITUDE °'o' 4J . " DMS OR DD
LaIiIude1 ongilude source: COPS topographic map
(location of well must be Shawn on a 1JSGS Iopo map endaHacherf to
this form if not using OPS)
5. FACILITY (Name of the business where the well Is located.)
F lily Name , • FtwillfylD# (If eppllcatrla)
t Address r
oily or TuWlrl Stole Zlp Code
Contact I4aFne
M911199 Address FDi�l
Cily acne State Zip Code
t tti� ) WZZ 29 5(-o,
Area code Phone number
6. WELL DETAILS:
■
a_ TOTAL DEPTH: Zjti�
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOG.'
e. WATER LEVEL Befow Top of Caning:
(Use "-' if Above Top of Casing)
FT.
d. TOP OF CASING IS FT_ Above Land Surface"
"Top of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
a. YIELD (gpm): tern -too OF TEST ~
F. DISINFECTION: Type � Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom — Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top Bottom FL
Top Bottom Ft. -
Top Bottom Ft.
B. GROUT: Depth f Mater l
Top D _ Bottom 3CD Ft._ial, err il
Top Bottom FT.
Top Bottom Ft.
Method
7rIf
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. In. In.
Top Bottom Ft. In. in.
Top Bottom FI. In. In.
10. SANDIGRAVEL PACK:
Depth
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
zclop
loaf
f,Q' 1 3p1'
1
1
1
Size Material
Formation Description
12. REMARKS:�(
!fdose, y,. L IB
f Do NETTED? CERTIFY TT LAT'HIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
/5A NC4C 2C, WELL CONSTRUCTION STANOAIiJS, AND THAT A COPY Or TFDS
REcoRD FINS pEl JJyR T U THE WELL OWNER
P ,Y/L� 1 L
SIGNOF ERTIFIED WELL CONTRACTOR ' OJ/TE
j6L1 YS A 39-4 ,
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within'30 days of completion to:Division of Water Quality - information Processing,
1617 Mall Service Center, Raleigh NC'27699-161, Phone : (919) 8D7•6300
Form GW-1b
Rev. 2/09

. ► ONRESIDENTI}L WELL CONSTRUCTION RECORD
Norlh Carolina Department if Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # zeri" r
417
1. WELL CONTRACTOR:
[T /14 -I /1 JaA4S
Vlfetl Contractor (Individual) Name
N.W. Poole Well & Pump Co.
Well Contractor Company Name
PO Box 1958
Street Address
Wendell
NO 27591
City or Town Stale Zip Code
(919 ) 266-9223
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#t(N applicable)
SITE WELL ID Alf applicable)
3. WELL USE (Check One Box) Monitoring ❑ MLnro/pal/Public El
Industrial/Commercial p Agricultural r] Recovery CT tn)Bclion fT
Irrigation❑ Olher()Ist uB) lea4C P11.A ( c/ic/ kip
DATE DRILLED j t3'Jj1I (�
4. WELL LOCATION:
VeD r2o.441 crj - _A.. f
(Sim{ Nam umbe►a, Community, Subdivision, Lot N. Parcel,
}el, Zip Code)
CITY: iVary 1 t COUNTY Wn.�t_e
TOPOGRAPHIC 1 LAND SETTING: (check appropriate box)
❑Srope ❑Valley flat uRidge DOther
LATITUDE ',35f % ././14 r Li L( " DMS OR DD
LONGITUDE "yS'4(L5a "DMSOR DD
Latitude/longitude source: [J3PS Qropographk map
(location of well must be shown on a USGS fnpo map arklettached to
this form if not using GPS)
5. FACILITY (Name of Cho business where the we!! Is rocaled.)
,".e. P r
FCcIlliv Name •) q I Facility ID# (ff applicable)
{
1 t Addr ss
d ty or Tomt Slate Zip ode
Tee14,Contact flame rr
`l)]! Lam' �C • �{ �� t r
Malting Address
City;mwn State Zip Code
{q1 ] 1-4z2 - 2 5(4A
Area code Phone number
B. WELL DETAILS:
a. TOTAL DEPTH: JD i
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO g'
c. WATER LEVEL Below Top of Casing: r----- Fr.
(Uee'+" if Above Tap of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
`Top of casing terminated altor below land surface may regtrlre
a variance In accordance with 15A NCAC 2C .0118.
o. YIELD (gpm): METHOD OF TEST_
t DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bolcom Top Bottom
Top Bottom Top Bottom Top Bottom Top Bottom_
7. CASING: Depth Diameter
Top Bottom Fl.
Top Bottom Ft
TopBottom Ft
8. GROUT: Depth
Top Bottom 3c: FL,
Top Bottom Ft.
Top Bottom FL
Matelot
Nis
Thickness)
Weight Materiel
9. SCREEN: Depth
Top.
Top
Top
Bottom
Bottom
Bottom
Method
Diameter Slot Size Material
Ft. In. In.
FI. In. In.
Ft. In_ _ in.
10. SAHDIGRAVE_L PACK:
Depth
Top Bottom Fi.
Top Bottom Ft
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
/ /L
6,0( 1 3t:1
1
Sire Material
Formation Description
sr`If simso
12. REMARKS:
ye/414,4Ni cfo j_Lr Itak
I DO HERESY CERTIFY THAT TrfIS WELL WAS CONSTRUCTED IH ACCORDAIK E WiT#i
15A NCAC 2C. WELL CONSTRLR: i k1N STANDARDS, AND 11- AT A COPY OF TIi15
RECORD BEF Ro r I fE WELL OWNER.
g__
SIGNATURE OF CERTIFIED WELL CONT Oft D TE
j-an7e5 .Tv!
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within-40 p)Ylsion of Water Quality - Information Processing,
1617 Malt SerVl a Centtir, ,Raloltik hid-21899461, Phone : [phone]B
Form GW-Ib
Rev. 2/09

TAVAA
InVIM
n
ra
Site plan approved -as s:tmlyn for 6s,m .4 (.. ; ,
Any changes to site plan v ic's approval. Alisethaeks apply
for septic sterns and welds, rega rd ii} g aay..po ols;
tdditions:and/0r are:es.�ary gtr.+ctsrres. Applicants responsible
for prQtecfing all pvrtrrrrrs ft ;>r,. as t._ ic'system, rots,) is- area and
Veils from damage during ra.,s;t rrj-r: jou. Adhere to all Local and
State
:�"rrrrlec: by L(A L - gap Este +"-�
lead 00t
0
10 jsai ulgo OZ1•$

' .
I Jimmy D. Parker do authorize Mr. Tony Stephenson to obtain work permits for 8120 Robincrest ct
Fuquay Varina NC 27526.