WI0100141_GEO THERMAL_20120518

Beverly Eaves Perdue
Governor
A,'e,'f~--
B,,i.;1-~ ..
MCDEMR
North Carolina Department of Environment and Natural Resources
Division of-Water-Quality-----
Chartes Wakild;·P; E. --
Director
May 18, 2012
Macon County Government
5 West Main Street
Franklin, NC 28734
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WIO 100141
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.
Hydro geologist
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: 919.,'307-6464 \ FAX: 919.,'l07-6496
Internet: www.ncwaterqualily.org
An Equal Opportunity\ Affinnative Ac1ion E.mp\oyar
One North Carolina
/vaturall!f
N oN RE.)YP,ENTW WF.u. co~sTRUCTtoN REc·™
North C1rt1lina Ueportmmil umnvimnlllCllf mu.I N111ut11l Rc!lllun:C!t-Di~1ou ofW:ita-Qi.mli Ly
WELLCONTRACTORCltRTIF1CATIONN 3Y4:j II: _
1, WILL CONTRACTOR:
Well Conlna=r (lndlvlchltt) Nemo
Tarheel Water Tre atme nt
Welt Co"'1ael0r Comptny,Nama
3494 Geo rg ia BP
~Addresl
Franklin
City orTCN/1\
< 828 > 369--0740
'NH cade Ptlono IIUffiM!"
I, WEU. INf'OlllMATION:
NC 287a4,
St.119 ZJp Code
weu CONSTRIJCTtoN PERMtT•-~W~!wi:P ... 10=0,..,1..._4'-'1 ____ _
OTH!~ ~ClATED PERMlff<! appllalbl1)
lfTe WELL 10#{11•~).__B.:....,.,A.,_,_,l ______ _
I. WELL USE (Cheat Ont loll) Monitvrir,g O M1.1nlclpal1Pubfla 0
lnd1111lrl111Com1Ml'Ciat □ AQli01.1ttwrat O ReCOYCHY f.J lnjactlon 0
lmgelionO Olhorrl(liatUN) Closed looo Geotberra
DATliDAILLED ,,x .. gl.o -, \
•·WEI.I.LOCATION;
1166 Lotta Chu[ch Rd
(SIIHI Nlll10, Nllfflberl. COml'!llll'llfy, Slllldllialon, LIil ND .. i>scel, ZIP Coclal
c1TV: Franklin couNTY Macon
"TOP0GRAPMiC I IMO SETrlNC ; 1111ed& apfl'Dpfiare 11i1Y1
o&tope OValley ~lat CRidge OOlhtr, ______ _
KCPSTCD 36_ , ...... l""""~""~!CLROA3"~~cc
~116 IIT~D 75 1"0 •a 0 ~oAAA! CL R 011 h~D'lflftl' CC
LatllllOll/longltl.lde IOUIOI; C)3PS CJroPOGraphlc map .
(foe11t,on ol -11 mu41 Oa $hown on • IJSQS topo ,,,.P end■ftllched II>
fftia l'Onll ff not u,ing GPSJ
I. FACILITY (Name oft\e butlnNs wnara tha well II lo;aled.)
Mamo e1eme01arv
flcllity Name
1168 Lotle Cbvcm Rd
StrtetAdclreu
franklin
Cteyo,Town
Macao cauntv Qaveromeot
Contact Nam■
Mailing Acldreal
franklin
City or T OWl'I
r >..,...---,------~ eocle Phona number
I , WliLL DrTAIL&: J
•• TOTAL D!,TM! :3 Li f]
FIIOillty 10#; (If a.,,itcable)
NC 2823.4
Statt Zip Code
NC 26743
Slate Zip Code
lb. DOES WILL RIPUCE EXISTING WILL? YES C NO rJ/
o. WAlllltLIYIL9elowTopofC.1ln9: ~ FT.
(UM ·+· It' Abolla Tao of casing)
: d. TOP OF CAStNO 11 _,......, ___ FT. Abo1111 Lend Surface•
: •Top of (,Hing terminated attor below land wrface may require
: • wriance In acccl'danca witt, 15A. NCAC :2C ,0118 .
i •. YliU) capmt-'5a ¼:: METH0 0 oF TEST Slow Powo 1,. DIIINFECTfON: ~ HTC Amo~ftt 12 OZ
: g. WATI:R ZONES (dop~):
1 Top a,3Q Bottom. __
: Top, ___ Scflom ___ _ Tc;;., __ Bonom. __ _
j Top. ___ Bctom. __ _ Tc ~ ___ Boftom._ __ _
; 1. CASINO: Depth . Oiamr-ter
Tillcllnessl
Waight Material l Top_ eottom_ Ft .. __ _
; Top_lolom __ Ft, __ _
: Top_ 8ottom , Ft. __ _
: B. GROUT: Cer:1ttt M staril'II
: Top.L_ eo~...3.!:tQ Ft . .Jaw::111nite
1 Top_ Batmm_ Ft. was hed stool
;Top_aottom_Ft.__ __ _
' .
Method
Pumped
.mured
; I , ICR&EN: Deflth Dlamet.t:r Slot Ii• Matetlal
: Top_Boaom_Ft_,n. __ in. ___ _
Top_Boeom_FL_ln .. --(I).----
Top_Bollorn___,Pt. __ ,n. __ in, ___ _
10. UNDIOAAWL PACK :
Depth Si:a..J Material
Top __ ._.eottom_FL __________ _
: T09. ____ BottDm_Ft. __________ _
[ Top. ___ eotta"'_FL. __________ _ .
: 11. CAILLINQ 1.0G
.
Top Botlom
0 I /.t,()
7ilr)39t, ----'----____ , ___ _ __ __,,. ___ _
----'----___ , ___ _ __ _,, ___ _
--..:'-------'----
: 12. IIIMARKI:
1 easing Re111oved
Submit within 30 days of completion to: DIYl•lon of Water Quality -Cnfonnatton Pt0Ce$$lflg,
1117 llaH Servtce C.nltr, Rale lgll, NC 2?1H0 161, Phone : Cl19) I07-e300 .
Form GW-11;,
Rev. 1108 "
BECEIVED 02-20 -1 12· 15:20 FROM-828369 0740 TO-NC DENR P&S P002/003
02-20-2012 15:55 TARHEEL WATER TREATMENT 828-369-0740 PAGE3
NQN R E4fl DENTIAL WELL CONSTfl/CTlON RECO RD,
Nunh C11n1lina Dcpanmcnt afF.nvironraeiu 1111d Nan,ml ltnources• DiVia~ ~~Witter Oii~•Y.
. """.'· ,~j ~ ·"' -
' .r '• • 1 f ' •
• -I •
1, WIU. CONTRACTOR;
Wall Contractor (lndivilfual) Na'"e
Tarhee1 water Treatment
Well Contradet .Company lll1me
3494 G~omla BP
Street Addreu
__Ernn klin
Cityor TQWn
c828 l 369-0740
Alla.. Phone number
2, WILL INPOIUtATION:
...M.C 2S7 34
Slats Zip Code .
WELL CONSTRUCTION PERMIT# ..... W...,1:.:0..:-100=-1.,_4.,_,1=-----
OTHER A880CIATED PERMIT'(ll jDOIIClllle . .,.) ~A------
llff WELL 10a(lf •ppilclllllt) )jQ H 1, ~
3 , WELi. USE (Che~ One Box) MonilOllno □ Muntdf)al/Pul:llic o
lnduetrial/Cotllmerclal CJ Agtt~ulMtl □ RKOYlry O Injection O
1rr1g1111a,,c:, 0fler r/cn,, ""' C,to!jd 1000 Geotherre
DATE DRILUD J ,i .. J 5_ -J_
4. WILL L.OCATION;
1166 Lotta Church Rd
ISINlcl Nlll'llo , Numi:in. Comrlll,nilY, 8ubdivition, LCII ""°·· Paroel , ZIP c.ocie1
CITY; Franklin COUNTY Macon
TOPOGRAl'HIC I LAND ~eTnNG; (check IPflftlllllllll IIO'I)
os1ope ovauc~ •'" OR!do-CJOlhet. _____ _
..,.TCD 3'L 1A11u91111110•""1 CI.ROR 3Jtt~CC
l<NMFttTC975 i""""9""""011•t CL ROIi 1,t~ CC
IJtltudl/lonsr/lude source: C)aPS (Jropographlc map
(IOOfllion of weH n,u,t t» shown on • USGS to,o me,, ftfldatbto"9d as
this form ;r not IJ4itlQ Cl'$)
$. F.CIUTY (Name ot the busines1 wti.r• lh• we!l 11 lal.ll1ad.)
Mamo Elamaotarv
Faelllry Namo Facill\y ID# flf 1,Dpllcnlel
116& Lotta Chyrcb Bd
81rN1Add,-
f[8nktln NC 28734 c~ or Town ~ Zlp Code
Mamo county Government
Mlllll'\O AdclrtN
franklin NC 28Z43
CityorTown Bta1lt Zip Code
t , _______ _
Alff ooclt Pnono number
I. W!I.L DITML•:
.. TOTALOEl'TM. Lj<D I
t • . '
b, DOES WIU. UPLACE qlSTINO WELL? YE8 0 NO r;
G. WATEII LIVIL eerow Top of Casino: B-: FT,
(UN ••• If A~ Top of CMlngJ
: d . TOP OF CASINO IS ·• , -FT, -~!A'ci Sulface•
: "Top of eaalno ttrmll'lllld et/or below 1111d aul'face may requ1na
; a varlanc. tianae with 15A NCAC ·2C .0118,
: •· VIILD (1pmt: ____ Mm.ao o, 1HT Btaw Dawn
i f. DISINFECTION: Type HTC Amoont 12 02
: g, WATER ZONES (c:lepth):
: rop ···-..... e~ .,. _.--_ 8onom, __ _
[ Top ___ ~.-:::?: -l'i1g~p===-a.aoUom. __ _
: Tap____ ... ___ Top Bottom, __ _
: Thtcl111•ul
: 7, CAI G: 0.,th
jrop_uv"""""""""'==-
• ht
:Top_eo __ :.~;·c_~:_:_:_~;~::::.:--::~~...;:===
: &. GAOUT: Dap,lh . Mateiial
! Top_o___ eottom!:lal A. Benjgolte
: Top_· --Botlom_ Ft gghed §fgne j Top_ Bottom_ Ft, ____ _
/ t, ICIIIIN: Depth
Pumped
poured
: Top_8oaorrt_Ft. __ 111. _ in. ___ _
:ToP_SOIOrll __ Pt_ln. _ill, ___ _
j Top_Bottom_R._ln, _ tn. ___ _
: 10. IANDIGRAY6L PACK! ; °""' .... Mat9rial :T~, ___ eottam_Ft. __________ _
: Top. ___ eottum __ Ft __________ _
:T~, ___ aattD"'-R---_______ _
: 11. DAILLING LOG
Top BOltom
---'--------'-----I ----,,-----
' ___ , ___ _
--'.----' --, ,.------, ----
: 12. ltlMAIIICI:
/ Casiug Ren,o,ed
Formation Oewldtlon
IN~ W11ll
,. CCP'I 01' 'M8
~~~~$.;-~=-=-·-IJ-11--1 I
;SI ~ ~TE
i rd\O.t.A M~t\ve,
: PRINTI:D NAME CF Pl:RSON CONITftUCT1NG THI!!. Wl:LL
Subm" Within so dayl'bf campletion to:· DM1lon of Watei Quality ':' lftfOmtatton Pl"OGel&l"I,
1117 Mall tleMA Center, R11itgh, NC 27111-111, Phone : (111) 807-AOO
FormGW-1b
~1\1. 1/08
REC.EiVED 02-20-'12 15:20·· FROM -8283690740 ·. TO-~NC DENB P&S P003/003
02-20-2012 15:55 TARHEEL WATER TREATMENT 828-369-0740 PAGE1
NoNREsmENTUL wp,i. cONsmicnoN REQD!)
Nllflh Carolina Dc,panmcnt nf .envitonmeut and Natural .Resources• Oivisil)O ufW1io Q1&11liij ·
...., l I,; I I /I ' :· ·. ~
t, W&U. CONTRACTOR:
Well ConlrKtor (lndiVidual) Name
Tarheet Water Treatment
Well Conhc1Dr Company t.11me
3494 Georaia BP
Street Addrwn
--=-~ .... ra ..... o~k~ .... llo....._ __ ~----'-----'-"N......,C 287~4
City or Town State ~p Code
c 828 , 369-07 40
NH codla Phone l\urnoer
Z. Wlf.f. lNFORMA'TION:
•NELL CONSTRUCTION PERMIT4 WIO10O141 --~-·
OTHER ASSOCtAie.D Pf:RMIT#(if a~llle)_
SITE WELL ID #(ifipjllh:able,,_ ________ _
S, WEU. UIE (Chedc One Bole) Monitoring o MuniQlpa11Publlo □
lndut1ri1veommetelal O Agrlc,wwra1 o Racovary o Injection □
1rrioet1ono °"'*' ! 11111 "", Clqsed 1000 Geothe(fll
DATIORlu.&O {;! l·) Sl:>Wll
.. WILL LOCATION1 '~.-;JO ..
1166 lotl~yrch Rd . (Slnlel Naffll, N Ulffll!IUll!ly, SI.IDdlVINII, Loi No .. P11\l11, Zlp Codt)
cfTY: Franklin couNTY Macon
TOPOQR.YHIC I LAND SETTING: (Clhealt appn,priaee bOll
O&iapa CVBlley &tt=lat r.JRidot CJOther. _____ _
...-rco :,e_ 1""""1""'""'"''""1 Cl R OR 3X\'\lll0Utl8M!Nll CC
!CNrEISTCD75 ;""0 9,.."" .. ""I Cl. ROR 7'Je.~ CC
utHucle/lo"gltud• eource: ~PS (Jropographlc map
(TDOlltion ol well mult be MOWPt on • USGS topo m11p enadachltd a,
!hit 1b1171 if not uelng GPS)
5 , FACIUT\' (Narr,e of~ bulinett where Ilia wall I& k>Cated.)
Macon Elerneotarv ,ac11ty Neme
1166 I otla Church Bd
Street AddlNI
franklin
Macon County Government
ContaclN1me
Malling AddtUI
Eraoklio
City or Town
( >---------Ara aade PN!'le numlMf
I. WII.L DITN&.I: I
•• TOTAL DliPTH:._,_t-/_.__O ___ _
F81C1111y 10111 (If appllcallle)
NC 2673.4
Sttte Zip Code
NC 28243
8tn Zip Code
b. DO!S WIU. Rll'U&CI! IOOITING WEU..? ves O NO~
o. WATIR LIVIL hlow Top of C11lng~ -a f'T.
(UH ·+· If Aballa Tap of C11ing)
-. -' ...
; d. TOP OF CASING fS ,::, ~~~~ Su"-~ r
: 'Tap af ca&ing larmlllatad 81101' be1aw~r(d ,urfa~ may require
a variance In accordance with 15A NCAC 2c .o, ,e.
: e. vi ■Lo ,gpm,: ____ METHoo or: TEST Blow □awn
: r. DIIIN,EcTION: Type HTC Arn01mt 12 oz .
: g. WATER ZONES (depth):
~ Top.-= Bcttom __ _ • Top ___ Botttim. __ _
: Top ___ Bottom._ __ Top Bottom, __ _
Top BOllcllT\...__
Thiall-,
j 1. CASINO:~ Diameter
: T " Ihm, -~ rt -..,.
: Top __ __:_ Bott°"'-.,:;::::::::::. t
~Mltwl
---iTop_~_A .. __ _ ..... .
: 8. GROUT: Depth Maiertal Method
~ Top..Q.._eattom /'-"/0 F1, Bentonjte pumped
: TC19_ uonon,_ Ft washed stone POMred.
: Top_&ntoffl_FI .. ____ _ .
: 9, KREEN: Deplh Diamata, Slat Slza
: Tap. __ Balmm_Ft_tn. _ In. ___ _
: Top,__BoaDm_Ft.._fn, _In. ___ _
! Tap __ Batlaffi_A._in, _ ir,. ___ _
: 10, SANDIOMVI\. ,ACK:
: e>e,,111 lilt ;Tap. ___ Botlom_ft ___________ _
; T~. ___ Bottom __ Ft. __________ _
;Tap Sottonl_FL _________ _
: 11 . DRILLING LOO
Top Bottom a , _20
W 140 ---'.-------'~----__ , ,--------, ,.-------' :· ___ , ___ _
: 12, IIIIMARKI:
j Cash 19 Removed
FOffllltion Oetcrfptton
So,·/
JJ--rJO-J J
DATI!
Submit wtdlln 30 ci1f8 -completlon to: Dlvf1ion of Wate, Quality -1l1formltlori Praaas1n1,
1817 Mall leNlce c.-,w, Rllllah, NC 27"9-181. Pho,.. : (919) 807.e.soo
FonnGW-1b
~,'1/08
RECEIVED 02'---20~'12 l.i;..20 FROM-8283690~~ I,.,. TO -1'1C DENR P&S . P001/003
02-15-2012 13:09 TARHEEL WATER TREATMENT 828-369-0740 PAGE1
NON RF.SmENTUL wp;LL coNsT1WcnoN u coy
1'fonb Cnlillll ~t of'F.mirorunau ad Nahml R-OiviticMl,af W•tcr Qua~
Wefl~(~)Name
Jameel Water Treatment
w.i1 eor,1rac1nr C01T1peny Name
a,t94 Georgia RO
&net~
Franklin NC 28734
ettyo, TCMfl 8--Zip Code
< 828 > 369-07 40
Area code Phone numll9r
z. WEU. INflOflMA110N:
Wl!LL CONSTRUCTION ~ITn.,.W...,t=0_._100=-1.,_4,__1.._ ___ _
OTHER A880CIATEO NIIMt'l'fi,tr lllflliallllal
lfflW!LLIDl(l~l A -g-~-.,4
a. WELi. UM (CMcli Olle loll) Manl!Dltng O ~lcO
l~O AaltoUll\lfllO~Cll..-,nO
1,riglMofto Olhet~<Utt111e> Closed Jpop Geotberm
OAT£ DRILLIO / -/'9 ·-~
._MU.LOCATION:
1166 Lotta Church Rd
(SirNt Nlffll, Nufflblft. ~. !MldMlian , Lot No . Pll'QII, Zill Code)
CnY: Franklin COUffl'V Macon
TOPOGRAPHIC TL.AND &ernNG: I.,_~ 111011)
OSlape ova11ev ~11 oAidge CO!nef _____ _
l(GIIITCD 38_ 1.11u•a0 ~0 11 -•!CI.ROR3.ll~CC
lttW.-ra>75 · i••u1uuu•-!Q.ROfl ,-_._~!llll'JOCC
~ IOUl'IIII: [)JPS Qr~ map
~ ot,,,..mwto.--. an• usas ,-,,_, •ldlllllcllad eo
""' tom, If not UllinSI QPSJ
I. FACUTY (Name cttlhe bullfWN WIit,_ ._ ... la located.)
, l up fl, Colwklg l1.t1111il'l~t.'1 9/J{,r -'11Cl'>/ •lil••IJ twl~ •l1ilt ~Uf/11
: a Yllrillm:e in ICCIOIUl'ICle wteh 15A NCAC 2C .0118.
j •. mLD fDPfll>: ,;;; SD METH~ OP 11~, .Blow Ccw.o
: t. °'81NFECTION: TMM HTC ~ 12 oz
: ,. •1!" ZONI& (-,iltl): ' .
; TC>PCK i 1oaom M ¥ Top ~~o BonDm 2. '--2-
: Top, ___ Balmm_ ~._ __ lolDn, __ _
: Top, ___ lkllD'A,___ Top, ___ 1o1Dn1, __ _
; 7 . CASING:
; Top_loftonl __ A.. __ _
;TGD_lolcm_l'l .. __ _
;lop_.~Ft .. __ _ . .
: I . GROUT: Dept, 1.,(A Mnlfilll l Top_Q___ ~ Ft. BcD!Poito
;Top_Bal!Dff\_A., ____ _
: Top_l50llloffl_Ft.._ ___ _
:8.ICACIN r Oe.,a.
Mellod
furoPftd
:Top_Bollom_A._ln. __ In. ___ _
: Top_ao111crn_A,_ln, -in.----j Top_8oaDffl_Ft._ll\. _in. ___ _ .
~ 10. SANDtCMIAYIIL IIM:k:
Depth Sin
:ToP-.-~eaei.n...:...._~.-----------:Top ..... _..,lobm __ Ft.. __________ _
!Top ___ ,lollOln __ F.._ _________ _
: 11. DRIWNGLOG
Top 8olDm FanNlion l)nalpOo,\
Macon Etemeotarv
F .. Nenlt
1166 I oua Church Bd
Faaili1J !Di (If applicable} !s:::}~ ,,~-ft:o-7:;;~:t.5{~~¢( $(!,4
6 ~"'a/u ,6e., .,...Add,_
franklin
ClycwTown
Mamo County GOYftrnrneot
COntac:t Name
Mlllln9Addlau
Ecaoklia
(:l'Yo,Town
( ) AIN code -=Ph"'""o,-•-n111_m_tbe_, ___ _
I. Will DETAIL.I: •'} ,o a. TOTAL DIPTtti, __ ..,.._ ___ _
NC 28734
NC 28143
... ZiPCOde
b. DOU WEU. ~ IXIITINO WIU.? VESo NOf¥
e. WAftlU.IVIILBetowTopof~: 5"'0 FT.
(Uu ·+· "AblM Tao of c.no,
-~'·----_......,.,. ___ _
--..:'·-------'--------''----··--'-----. '----. '·---
: 1:11, IIUMRICI:
[ easing Renio,ed
lubnllt WltNn 30 AP d compllllon to: Dlvfalan of Wttar Qualtly • lnb,wllu., ~
1111 MIN..,...,... c.ntlr, RIIIW,I, NC 1r-.1e1, P1tOM : (11t) IO?.UOO
RECEIVED 02-15-'12 12:37 FROM-8283690 740 TO -NC DENR P&S
FcamGW0 t11
"811. 1118
P001 /010
02-15-2012 13:09 TARHEEL WATER TREATMENT 828-369-0740 PAGE:?
NoNREsmENTIAL wn L coNsn llcnoN REcoao
North Csolma DeJ,anmmt of EIMfOIIIIIIDf and Namral Raovrcet• °'vlsioe of Wirer Quality
W-el CcnhC1ot QndMdual) Name
Tarheel Wet er Treatment
Well Contractot Company Name
J4§M Georoia RD
811'NtAdd!Mt
franklin NC 2e 1 ~
011Ycir TO'MI S1all Zip Code
c828 1 369-0740
AIM coClt Phone number
I, WIU. INIIOIIMATIGN;
~ILL CONSTRUCTION PeAMIT#..._W...,,1-01.,_,,0=0 ..... 1 ...... 41.,__ ___ _
OTHER ASSOCl.41'!0 Pl"Mr1Jlf ilJIII..Jpble)·-=------
SrTI W!LL 10 #(if---1 (~ -i:,1,--SB
I. WIU. UN (Cnecik 0,,. BcNr) Moni1D1tna □ M\mldpallP\Alfle O
l~IIC«nmerclll C) .-.-,11ura10 Rtoowry O lnj8clicln l';I
lnfDIIIOfln °""' ~<•• .,.., Closeg loop Gaott,en
DATE DIIIU...0 /-~ 0 ., f . ~
'-WILL LOCA110N:
1168 Lolla Ch~d
l1n1tN11119, NU""""-:&ivicion. LCII .. O., i:inil,ZlpCode)
crTV: Franklin couNTY Macon
TOPOGRAPHIC I LAND S!TTING: (dlecll ~ ball
Oalape n~ ~ CFlldp OOltler _____ _
KCllllfCD 36_ i" .. "l"OAAAU! CL ROA~ ..... cc
loi.t.t=ISTCD 75 ,""""IUOUIIA! CL ROIi ,._ ....... _ cc
~nQIWI IGUlm: OPS CJl'opoorlphla ,_
{lor:eloti otMIIIPIUlll» MIOWII on• usas ,apo ,,_, •ndlllllciflade
#lis fotm If not 14""1 Ol'SJ
I. FACl.lrf (Nllme of hi bllllnNI-,,.,. flt MIi ls lllclalld.)
Mamo Eferneota™ Facilllt1 Name ,ac1111y ll)jt (If appllclble)
J 166 IAtfa Cburm Rd
8hlltAddl'Na
fcankfio NC 26234
C"YorTown Sim Zip~
Mar.an County Gavemment Conlllct Name .
Mallil!g Adel,_
Franklin
CltyfltT-
( , _______ _
Asllll code Pttone IIUIYlber
I. WEU.OETAIU:
NC 28243
Sll1t Zil!Code
ii _!~65:1
• 17,) ._11 'CUCit ,0 iti11t1f,1thv\l ~Ir.ii..,,,.,,-,\• ~ • ,.._
: a vananc.e In~ with 15A NCAC 2C ,0118.
~ •. ffl!lD fgp,n): ·-o-METHOD OP TI!IT Btaw Qnwn
; f . ~EC'(ION: 1')pe HTC Amourtt 12 oz
: I• WATIR IOND {dlpll):
: Top. ___ eoaom.___ Top, -Bottom __ _
;Top 9oaDin Top ___ ~,_ __
: Top Bolbn Top ___ ... rn, ...... __ . ~
: 1 , CAIINO: Olpltl Olwulu Weight MaNlriaJ
; Top_ 8alloffi_R...__ __
; Top_~_R . ..._ __
:Too_l!lalom_Ft. __ _
: a. GROUT: 0eplh l10 M9lll1al
~ TapJl__ 1ctom..«._ A . 8tntpnite
:Top_8ol!Dnl_Ft. ___ _
:Top_Solorn_FL ____ _
' :t, ICRED; Dap8I ~ llotSu
'
Mattlad
eumgeg
: Top_Boaom_n __ ln. _ 1ft. ___ _
: Top~Bclom_R._ln, _ In. ___ _
i Tap-~Ft._in, _in. ___ _
: 1t. UNDIGRAVIL ,ACK:
: Dapd, Ila
! Tap __ _,........,,...__Ft. ___ --------: Tap ___ lloftom_Ft _________ _
!Top. ____ loeom_Ft . -·-----------
: 11 . DRIWNO LOG
Too , llollam
1) I 7S-
5f I /fO __ , ____ _
I __ ..,, ___ _
. I ,--------____ , ___ _ ______ , ___ _
--'----__ , ___ _
: 12, RIIIMKI;
1 Casing . Remowed
FotntallOn Dw:ripCli,n
s~hJ t:_ e../e .....
; 1(10 HfRfBV CflfflFVTKl'I'. T!-411 W'1.L WASCON8111UCT"> I"~ Wfnl
! 1116-.cAC 2 L OCNmlUCTlON WfANOM09, MD™'-T ACIPYO, 1M8
•. lMM.avnc: L'i o
,. OOEI WEU.Rll'LACI UIITING WIU? ~ NO o/
:~ PAO".,at)~J.31-~•--
: t:J e.,..-....-/-;J 0 ·• /2...
c. WAlER"5YSl.8elCIWTopolCnillg: ~ •~ FT.
(UM·•• ff Atlo¥t Top Gf Calng) I
1Ubfflll wttNn 30 ~ of compMtton ID: Dimian of .Wltaf Quality • lnl'onnlUon .. ,.. .......
111 MIU llfWe. centM, Ralltgb, NC 11-.111, Pftone : ft1., IOJ.aGO
°" DATI: ✓-1a111..r
ELL
BECEI VED 02-15-' 12' 12 : 37 FF!OM-8283690740 TO-NC DENE P&S P002/010
0c-1S-201a 13:09 TARHEa WATER TREATMENT ScB-369-0740 PAGE3
NoN R1:."SmENTL« WELL coNsn ucnoN 11coll0
Nnr1h Csrolina Ilcpanmeat ofl;;nvinmmcnt and N1rwel Raources-Division of Water Quatily
' ~ I '°' ,~ 3065-A
~;.L,_ ............. ..,"}-
Woll COIWactor (lndlVidual) Name
Jameel Water Treatment
Wo11 C(Ultrador Comp8fly N11r,,e
34Y9 · t,eora;a i-tu
~Add,.•
Franklin
CityorTown
f 828 I 369-0740
,,,_ code Pflone flUfflNI'
2. wa.L INFORMATION:
NC ·29734
ZlpCode
WEI.I. CONSTRUCTION"Pl"MIT•:...tW..:.I ... 0"-'-1=00=--'-14-'-'1,_ ___ _
OTHER ASSOCIATED PERMlTi(lf appliclble,__,... ____ _
lff'I WEI.I. ID#(lf..,..,blo) A -J -ta
J . WELL USE (Check One Box) MOllllorlng O MunlclpellPUlllk l.l
lndustrlal/CommetMI O Aari~ 0 Recoffry O lnjec;ilion 0
IITlflllOl'O Ohr ,/(l't&'I UM) Closed loop Geotheg
DATI DRIUED /.,. / 7 -J .;L •
4. WILL LOCATION:
1166 Lotla Chu rch Rd
(S!Net )lame, Nl#nllel!I, CGll!m.-ill,, ~kin. Lot No., Plftlel, .lip C:00.J
COY: Franklin COUNTY Macon
TOPOGAAPHIC I ~D SETTING; ICIIOCII IDOnlOriall boa)
CSlope OValley itRat ORidge OOllof. _____ _
K(lilffCD 36_ iuoaoou•At Cl ROR a-~~ cc
100/FIITCO 't5 l'"'UIIIAAAAAIIIII CL R OR 1t:,c,cu1110et cc
~ IOUl'IIII: C)aPS C]ropograpt,IC mtp
(looaffoll ol wt# Mlllf I» IIIOMI on • U8GS CrJpo mep endelfaffltd lo
""' AMYi If not lll#Jfl GP8)
e. ,ACUTV (Name of ll'lt bllllneu wtlere the Mil ls localed,)
Macao Elemeotarv
,ac11ity Name FIOI~ 10# (If appllcablel
1166 Latia CbYcr-b Ba
S....Addrfft
Eraoklio NC 28734
City or Town Slate Zip Code
Macao County Govemrneot
Contact Name
Mallfng Add,_.
Eraoklin
CltyorTown
NC 28743
Sta• ZlpCod■
( >--------"'" cede Phone numbat
I. Wl!U OITAILI:
•· TOTAL DEPTH: /..,ts:: 0 1
b, DOIi WIU. IIIPLACI IXIITINO WELL? YES r, NO~
c . WATERLIYILBelowTopofC.""9: .s·o . FT. ,u .. ••· if Above Top o1 casino)
a variance in aca:xdanaa with 15A NCAC ~ .0118.
; e. YH!LO (OPffll: / ra METHOD M TIST Blow Dawn
~ I. O~IN_l'~TION: Type · HIC Amount 12 oZ
= •· z! :r" ,.~,: l Top BoUom ).. h 2-Top ___ Bottrlm,_ __
: Top ___ Boclom ___ Top BotlDm_
: Top ___ Balom ... __ Top Bo&tol\'I. __ _
'TNaMN.tl
: 1. CAIING: Depth D...._ Weight Mlllariat
j Top_llolloln __ Fl. __ _
: Top_&Olt.anl __ FL. __ _
:Top __ SalDm_R. __ _
: e. OROUT: -" Materiat
i Top.JL_ Bottom.§L Ft Bantpnjta
MelhOd
PMrnRftd ! TOP, __ eotlom_Ft.. ____ _ ! Top __ BOIIOn'I __ R. _____ _
:t. ICREIN: DtpUt
: rop_Boaon,_Fl. __ in, __ In. ___ _
: Top_ Bottom_Pc._1". _·_in. ___ _
1 Top_Bottom_Ft. __ 11'1. _ in. ___ _
: 10, MNDIOIIAYIL PACK: : °""°' s--Mel■,iaf
;~P---Soltom-~-----------; Top, ___ Bolotn..,___l'l. __________ _
jTop~~~---------
: 11 . 0RILLING 1.0G
: Top 8ot.n ·£8~ _ _., ___ _
---'----/ --,----
---'-------':-----/ ---,----
12. ASIIARQ:
: Casi11g Removed
Subm!J wtthln !O dap of completion to: OMston or.w.-Quality •. fflfOnnlllo.t Pnlowlfng,
1111 Mall .,,,_ Centlr, 111i.19h, NC 27 .... 111, PhoM : (111) I07-aoo
Fo,mGW•Ht
Rev.1/08
RECEIVED 02-15-'12 12 :37 FROM-8283690740 TO-NC DENR P&S P003 /010
02-15-2012 13:10 TARHEEL WATER TREATMENT 828-369-0740 PAGE4
NoN R&w,nENT1,a wa.LcoNsTRUCTioN ucoap
Nunh C.OliM Dlrpartf'IIQ'lt t'fEnviromnem and H11run1l Rnourora• n.v;11ion ufWatcr Quality
Well COnhctor (lndiviclulll N.-M
Tatheet Weter Treatment
Well eootrsc!Dr Cl)IT1pGny Name
3494 Georgia RD
S11N1Addten
Franklin NC 28734
City or TCIWII . St,$ zi, COde
r 828 • 36&:QZ◄O 11't'Mmdll~nUffllla'
I. WELL *'ORIIAflOII:
WELL CONSTRUCTION PERM!ff,..,,W~l""'0..:.100~1'-'4'--'-1 ____ _
OTHER ASSOCIATED PERMIT~IClll!le
lrrl WELL IO#<lttODIICiOlll ,,...,i. " 7
I. WIU. UII! (Cheoll One Booe)~ O Munlclpal/P\lblic; 0
ll'ICMtlilllComlftffllal O A;,1""81 □ "ICOWIY □ Injection 0 ,,..,...c 0ttsr/_~UM} closed loop Geotharra
DATI DAILI.aD i -IQ~ 12 ,
4. WIU. LOCATION:
J.t-61.!f!!St'a,~. ~ No., PIRJII, Zip Codel
cnv: Franklin COUNTY Macon
TOflOCRAPt-tlC I I.ANO HTTING: td!M 1DPrOCN11 tml
CSlaoe CValley ~ ORidge OOttlar _____ _
...-rco se_ iuA••_,.,.,... ..... , et. R OR 3a!'Jlutl'JGfMX cc
IOIIW: ISTCD 75 ; ....... AAUAAlllf Q. A OR ?,t:,ece~ CC
Lelltudlnong!tude aouim: [);PS CJrooog,ephlo 1111P
trc,cnon ol lflltl mu.If I»__, Olt • U88S lli,,o ,,,.,,.,_,,.,,_, ID
,,,. lbrm ,, not""'"" Q,.$)
I , FACIUT\' (Nlffll t:lf h lMI,-..__ lie well It tooallld.)
Mac;oo Elemeotacv
!=~ Name FIICillly ID' (If lppllcabi.)
1168· Lotta Church Rd
~Add,_.
Eraokllo NC 28134
City or Town Stall Zip Coda
Macon County Gavemment
Con1KtNeme
Ml-Add1811
Ecaok11o
CllyorTown
r '----------"-code Phone nUfflber
L WEU. DllTAft.S: r
a. TOTAL OPTH: L/f /)
NC 28243
8ta18 ZiPCode
It, DOU WELL IU!PUOa lDIIITINO WBJ.? V!I CJ NO ri/
c. WATER LIYILlalow 1-OIC...V: , S:O !'T.
(U• •+• "AboW Top d Cning)
• (QP ot (;l:i•"'II litmiw,le,g o~'ftf i;k.-r llt!O ~n'u~ mar r~lt'&
. • varia"°8 in eccollltnlle willt 15A NCAC 2C .0118.
; •· YleLD fgpm): l )_~ _ MmfOD OF TEST_Blow Qawo
: f. DISfNF&CYION: T~ HIC Amount 12 oz
: 9, WATIR ZOND (~): -l T~' !,? ~h .2= TOP.----~
; Top ___ lollom_ Top ___ lollom_12"J
:Too, ___ eoaom_ Too ___ lollom__
: 7. OAIINO: OepCh Oiallllr
!Top_Boeom_A._ __
1hloMeNI
Wotght
Jl
IWarial -o
~
: Top_lolom_P1 .. __ _
;Top __ !otfoffl_,t. __ _
: &. OfltOUT: o.,tt1 Mlllrtal
i Top..Q__ Bot!Ofn..§(L l'I. Bentonfla
: Top __ llolom_F\. ___ _
j 'f0p __ Bolklrn __ fl't . ._ ___ _ . :t, SCAEEN: ne,,lh 01MM11r SlalSl&e
MClllocr
eumpQd
: Top __ Battarn __ Ft._in. _ in, ___ _
: Top __ ~ __ A ._in. _in, ___ _
l Top_lclom_Fl_in. -in.----
: 10. IMDfGRAYIR. ,ACK:
: O.pth Size
;Top ___ .lolloffl.._l't. ___ --------
: Top ___ .llolDri,_'1. ___ --------
; Top ___ .BclllD,n_Ft. ___ --------
: 11 . 0..11.l.4NG LOG
Tap BatlDm
-IE~ __ ,._-__ _ ___ , ___ _ _ __,/ ___ _
I --,----____ , ___ _
--·',----____ , ___ _
: 11, REIWIICI:
j Casi11g Remo,ed
: tOOHEIIIEB'tcerr.Y114ATnGWEU.WAS CCN1111UC'1m1NIICCORIWIICS ~
: 19.-NCAC 2C. CONSfllUCTION STNIWIDI, #1) n-.T ~ et:Pf ~ TMIS
~
cJ\
IS>
•11!!00Rl> TOTHIW . l · /--/o ·I;,._
:SIQ ~ OAT1i
ll'a/1,LJ
IIINnlt wtltlln 30 _. of COfflplation to: Olwtelaft of Water Quatfly • WDmu1Uan Pl'DGmlng.
'17' MIit 8eMot Ctfttlr, Rnlgtl, NC 21a.1t1, Phont : (111) _,,.aoo
--0 -tft
t;!:
RECEIVED 02-15-'12 12:37 FROM-8283690740 TO-NC DENR P&S P004/010
02-15-2012 13:10 TARHEEL. WATER TREATMENT 828·369-0740 PAGES
. NON R ESIDENTIAL ll'l't I CONSQIJCTJON gcpap
Nonh Carolina ,._en, ofEaVUfflUIIID1 .,.t Nanmd 'Retolan:er· Oivia off(ICW Qualily
.B<XUtC L \IV,IU,cd fl S
W .. ConlnaDr (lndlwidual) Namt
.Ilrbnl Water Iceatment
Well Con1rall10r~ny Namo .
3494 Gegmja 80
BtrMI~
Franklin NC 28734
CltywTown Stall lipCodl
, 82§ > 3§9-0740
,.,. ..... Jlhonlnumoet
I. WELL ~Tai:
WEI.I. CONSTRUCTION PERMl'N...,W,_l;.:.O ... 10_0 .... 1-"4 .... 1 ___ _
OTMERA&IOC:IATID PEAM?lt___,.
anw wau. 1011C11..-..1 q.. -e2. -R
J. _WEU. USI (CMdl Ono 8Dll) ~ 0 ~nielf,aUPW!ie 0
,,_11i111Com.1•mll C AQrlaulinl O Aaclowl) 0 lflJtdDft C
Mud•O QI.,,/(,-?:' C!OSfd lpc;,o Geqtheg
DAn! DIIIUID / -l.. • t :;a_.
'-WELL LOCATION:
~LQUaCh~Rd I Nllllt, NYnOffl,munl;, m .tii No., Ptin.i, ze&ii.i
cm: Fran kttn COUNTYMac;on
TCIIIOClfWIHIC / LAND SlfflNG: (dies__. llaal
C6lllfle □Valley_.,.. 0"1dp CJO..,. _____ _
"91f1'C0 86_ 1"•0 e•oauu1 Cl R OIi 3~A ! ._ CC
ICNM'FC075 1""'ua•11"'"'""""1CLROII ~~ CC
~ toldOt: Q)PS Oopog,IPIIC INP
~ ol_,muet,_ __, on I USQS-.0 .... .dl!M#lod 111
llilbmlfl'Klf--,GPS,
.. ,~fNlffle-lltltulil-. ....... .., .. .,..,1
Mamo Elemeomrv
l'tallly ,.,.
1188 L nt(a Chyn;;h Rd
lltrMIAdd,._
Ecaoklio
C~o,Town
Macao Cavotv Goveromeot
Ml!MgMtllla
Elaoklio
C > AtNcode .,.Pi°ioN---IIWIIOet------
•• WEI.L OITM.$: ,
•· TOTAL. DIPTN; ',t,£tJ
NC 28234
Sin ZipCodt
NC 26Z43
Slal9 ZlpCodl
D. DOU WELL.....,_ IDU8YINO WIIJ.? \'l;SO NO#
o, WATU&.aVIL..._ TopdCaeilla: '5-/) FT. cu..·•• r Niove Top d Celint),
j065-A
a IMrial,ce ~ accardMCawtfl 15'.N01\C4C ,(i11 ll.
f e . YIELD (gpmt: Lf';!) -,,.OOM lHI' Bfow QQwn
; ,. -.. .
:• W~TIIIZCNt&SC~
.: Top~f f) 8all0m~.,J.. Top. ___ BoCIDl,I.
: TOP. ___ a.m.___ Tap~ ao '-11:.---.. -..... , :
j Too. ___ lmtD,n_ Tep •~11._ __
• Tlllclllll,. ,,Ftai ;7.CAIM:0..-Dinfllt ~
I Top_tlalDm_R . ._ __
: To,_1ottom_ Fl,, __ _
i Top_lallnm_ll\. __ _
---,,.11 ---__ .., __ _
.
: ,. GROUT: °""" MltlNI Melllod
~ Top.,L_ ~ Ft. QonbJjlft t?wD9cd
;Tap lolDffl-~-----l Tap_Boaont_,__Fl. ___ _
: I . SOU•: Dl'plt a..:•11• llot lia ..,.,
l TGp_ lotlDi,i_:__ i=.._1n, -in. ----
: Too..:.._lolfDm_ f:t._tn. _In. ___ _
(rop_9a1Dffl.._A,__jn. _in. ___ _
' :1t.lAltlllOMVIL,A1CtC: : .,.,.. .. ;Top_JJoaom_Fl. _________ _
;fop ___ OOIIDffl.___~-----------:Top. ___ ltGC!Dffl_Ft. _________ _
: 11 . DAIUJNGLOG
Top DalD1I
:#B~ __ 1~---
' --·'---, ___ _ --, ,------: --'~---__ , ___ _ __ , ___ _
: 12. IIIJIAMS:
~ Casing Rtnno,fld
Foffllallon 0Ncriptui,
,~d~
8ulNnft ~ • .,. f#-.npeaciort to: OMlion of Wallr Qualltr • Woa1,....-; PtHMllnl,
111? llllt..,.. Caller,........_ NC 27 .... 111, fthona: Cltl) II0'1-IIIO
l'GffllCW-1b
"4v.1AJI
RECEIVED 02-15-'12-12 :3 7 FROM-8283690740 TO-NC DENR P&S P005 /010
82-15-2012 13:11 TARHEEL WATER TREATMENT 828-369-074~ F>AGE9
NoNRRIDENfui nu CONSnucnor,gcog
Nonfl C.Olina Depam11eti1 of Etnitotuncnr ad NIWIII ~ Divi.,ioo of W.-~ity
,&>gee L wm;ams
. Wei ConnclOr (llldivldull) Nam.
Tortmet Water Imatment
Well ConlraeW Conll)any ~
~94 Georgia RD
Snet~
Franldln NC 287~
Citror Town 8-Zip Codt
, 828 > 369-0740
AIINICIDIII Ptiarienufflblr
2 . WEU. •l"OfUIATION:
WELL CONSTRUCTION PERMIT•...,W .... l.,._0..,,.1 00_1 __ 4'-'1 ____ _
OTHal ASSOCIA'm> PEAM"".'1:::7
1"9Wli.Ll01itll~l q....=..L.. -,
a. WIL&. UN (0'-dc One Boa)~ C ~ Cl
l~C ~ORecrMlyOlf!jlclial,CJ """""'° OIW rl1•1a1 Clo8ad loop GeolheQ
DATIDIIU.ID J,il.,/:J -::T,
4 , WILL LOCA110N:
11~urch~ IStteii ~ ' 0Jfflmlllliy, . ~at Ao .. Pan:111, &I r;ode)
crrv: Franklin . COUNTY Mamo
TOPOGAAPHIC / I.AHO IITilNO: (dlldl .,.,._ IIDII)
Ollope ova11e, .... ORldge 001111,. _____ _
..-rco 38_ j ....... Au .. uu1 Q.Aafl 3•~ cc
*M=IITC075 1" ....... 0 ...... "IC\.ROR '-~CC
~---: 03PS CJrllPOIIIIIPtlio lftlP ~ o,-,,,,_oe_,,.,;on • IJBGS qio ~--~ IO
lltl1 lbtm/ln« lollilf GPSJ
I. PNJIIJf"t ~ fl !he bulNII llltlfr9 lhl _, 111 localld.)
Macoo Eleroeoraoc
F--Nlffl8
1166 l,ptJa Churrb Rd
Bn,tAdd,_
Eraotslio
~or:rown
Marm county Government
MelAno Adelreu
ErankJio
cttyo,Town
( ) ANaQOde ..,,"'-io.,.....-nllfflber _____ _
f , WILL DETM.I: ,
... TOTAL OIPTM: "/W
NC 22Z34
8"'o ZlpCoda
NC 28743
.... Z'JpCodl
II. DOUWII.L IIIPI.MI ... TINO WILL? Vl8 C
a. WATM&.lftLlelowTapdc..m,: s e,:>
NOG/
FT.
(U.. ••• f ANve Tap of Caltl9)
; Vil .... ; i.,i,i'S.1"\i'tt..,, , •• .-,.. ..
a~ lfl tDOIIIGlrlOt wllll 15A NCAe 2C .011a .
i •. YIELD (gpmJ; ~-D METMOO 0, TUT SIQw [)Mn
: t. ~TION: T~ HTC -~..m,cv;ri . l 2 w
; • ~'TIIIZONIS (depth~
!T~'iO ~m.J..Y,h Tap,_ __ ~
;T., ____ BallDffl_ TOP.---~·---
1T~~--Bal1Dffl_ T~---~---
Th , ~
:7.CMINO:Dlflltl ......., ...._n 11.-111 [r~_..,,,._PI.. ___ . _\:) __ _
;Top_lollaffl_l'I ~71:_,__ i To,_ 8alom_ Pl._ __
:I. GROUT:.~ Mlllllfal ,.___
~ T•jl_ ~Fl 8a(l,mltf PutooM1
:Ton __ 8clelwn_Ft, ___ _
! Top_Balllffl___Ft._· ___ _ .
: t, ICRIIN: Depltl Dllc,alif llal-~
: Toc,-~fl._ln. _In.----
: Top_1o111,m_i:,._1n. _In. ___ _
i Toe,_ OOIIDffl_ Ft_in.. _ ii\. ___ _ .
: 11. tMIDIORAYl!A. PIICIC: : .,.,..-..
; TCIQ__,_JICIIDffi._,_Ft, _________ _
: Top __ loloffl_l'\,, ___ -------
; Tap lalOnl_Ft., ___ -------
: 11 . OAI\.UNG LOG
Top 8-n\ ,0,nlllm!Ow,tptan
ii~ __ , __ _
--'----
&${~,., .r-U-
____ , ___ _ ____ , __ _ _ _,, ___ _
--·'---__ ., ___ _
--·'---: 11. RIIIIARU!
~ -ees11,g Re,1,011ed
........ WMhtn 30ap f/loampllMon to: OiVi91on of w.-Quality. ~ '"°11•1'1•
1117 .... ..,._ C.....,, llallllh. NC ff .... 1t1, "9oM: (t11) I0'7.aoo
FGmlGW·1b
""· 1/DI
RECEIVED 02-15-' 12 12 ~.37 FROM-8283690740 ' TO-NC DENR P&S P00) 10
02-15-2012 13:11 TARHEEL WATER TRE~TMENT 828-369-0740
PAGE10
N.oNRB,SJDEN'fUL wn.L CONsz,11.cnoNgcgao
North Carofo111 Dq,at,men1 of £ovitollffW;ltt lfld NatUftl fleaounx,s. Diviiioir .ol':11,~ ~UiY
,. ~1:t.~ ,...;;,,riv • .;
Rcmr L wm;am§
Well Conl'ac:tot (lndillleiual) Name
Jarheal Water TreatmeJ1t ·---·----we1 ConhCIDr Company Name
3494 Gm,rol@ BQ
6trletAdcfrffa
fcanklin
City or TOIi!!
I 828 I 369-0740
AIUCIOCII Ptlorlll ~
a. WELL tNFOflMATIOH:
NC 28134
9'1111 ZiPCoda
WEU. CONff!WCTION PIAMmta~Wul~0,.:c10~0-.1:.;4'-.!1~----
OTHER Al80CIATEQ PEJIIMITlll(~iallllt~) -------
lffl WILi. iD tut..--,., It: I ._ f
a. MLL UII (Cnedt OM Boa)~ C ~III/Pvbllc C
lndullrilllCofflrnerGil Cl ~IO fteoovery O lnjldon 0
~o 0t1tenf fjf,f..-> Ctosed logo Geottten:a
D,\TIDfUUID ~"'f, I/
._ YtllU. LOCAT10tf:
l 166 Lotl a Churg, Rd .
(8beal Name, HuinOenl, COlllmllnll't, Stlbclivlilcin, '-"' No., Pnel, ZIP Code!
cnv; Frank lin couNTY Macon
TOPOQRAPHIC I LANO SETTING: ldleok ~ebmi)
O&lape c,vau.y ~ OAldoe □Ollor, _____ _ .....-co 38_ 1ou4Auu•u1 CC. R OIi 3~ CC
KH~ltTCD 15 1""""1""'"'""0 1 CL R OR 111 ...... ._ cc
.....,,.,,_,_ IOUflla! C)IPS CJT~ ffllP
(IIIUfionolnllllMt 0. 8"°'"' on• USG$ tipo ,,_, ~ ,_,
M lbtm dnot ual,Jo GPSj
I, ,.11:UfY (Name of lie IIUllneN ~ .... , ie loelltd.J
M.Rg)o e1emeotacv
~Nlffla
1 Um Lotta Cbwcb 8d
&ltMtAdd,eM
franklin
City or Town
Macao Couotv Goveromeot
Conlllct Name
Malling Add,_
Eraokllo
Cly at Town
( , ArN _.. -,,Pll::-IIOl-.,.-n-"m-'!'ibef ____ _
t.MU.DITMS:
•• TOTAL DU'rH: '::/ s:: 0 ,
NC 26Z34
Staw ZlpCOcle
NC 28Z43
6'»11 Zlt,Code
b. DO&I WEIL AIPLACR Ulll1NO WIU:7 VES O NO a/
c. WA'l'IRLEVIL&llowTapafc.i.: ~,,4 l'T.
(U.••"lfAlloYltTcipaf~~
•Tl>fl or c=it11tg t0rt'ni11,.l&J .. 111,,: >NtOlt "·' ,..
• •~ in aeoan1111cewiltl 1SA NCAC2C ,0118. ~ ~. mu,iapm): __ -r2 'MrntODOFTEST Slaw Down
i t lkSUWECTION: -rw,e l::t re All\~ 12 oz •• .
: g, WATlft ZOND (depltl):
~ TOP. _, Botlom -1'op,_ __ Bollo,,.._ __
;Top'-__ BollDl7'. ___ T~ MorTI, __ _
! TOP,. ___ Bollorn. __ _ 1'op. ___ ~ .
-: 7 , CASiNO: Dapttl D....._
jTop_Softorn__F1., __ _
: Top_loclam_A., __ _
; ToO_BoOom_R._ __
: 8. GROUT: 0eclll M--■1 i TopJL_~ Fl Bantpglt@
; Ta,_ Bol!Om,_ __ l't., ___ _
:Top_&oeam_,, ___ _
:t. lCRIEN: Depltl
~
MaflOd
Pumped
:Top_Bolom_Ft.__Jn, _ ~. ___ _
: Top_loaDm_Ft_ln. _In, ___ _
jToP_Boaom_Fl_ln. _in. ___ _ .
: 10. IMDIGIIAV£L PACK:
: .,..,.,. ·-IWlf'W ;ToP..__-~R, _________ _
;ToP--~''----------1 To,. ___ eo'°"'---Ft..._ ________ _
: 11. Of'ILIJNG LOG
: Tap BollDm
:i3=Ni -~'.----____ , __ _ __ , __ _
-----'---_..,-ii ___ _
--'.----/
--·'----
: 12. IWWIKI:
i Casing Remov ed
Fam,atiorl ~
~~·
SUbmlt wlthht 30 daya of comp.._ to: Dfl•f•ton of .. aw Gullfty • ........_ ~ll •tftt•
11n 1111, .._. c.....,, Aallllllti NC n..._111, Phone :,(t1t) I07.noD
RECEIVED 02-15~'12 12 :37 FROM-8283690740 TO -NC DENR P&S
l'ormQW-1t
~-1/08
P010/0
02·15-2012 13:14 TARHEEL WATER TREATMENT 828-369·0740 PAGE1
. NON R,:sIDENTUL 'WELL CONSTR~N ~f91tD -
North Caroline OepamnenrofErrvi.cwc:ut lllCt N&IClnl Rnowa-.Qjviiiaii"ijf''WNQualicy
Roaet L WUijgms
WIIC....(lndMdual)NlfN Tarheftl water Treatment ______ _
Wei ContreC10r Cclfflpany Name
3494 Gagtaia,RD
StreetAddT911
Franklin NC 28734,
Cllyot TCMII 1111D Zlp Code
, 828 , 389::PNQ AIM~,.._,_,,,_,
2, MY. IN~Tiall:
WlU. CON&TRUCTION PEAWT•, ... W.,ly:0,.:.1: OOs.,1 .. 4...:1 ____ _
OTHER A880CIATID PERMl~IPllllalM
IITIWIU.IDM......,_I Q -/., S:
a. WELL U&I (Ctlec:t. One Bo-, Monltortng t:l MunlciralllPwblio 0
•~o AerloultlntCJ Recau1i,c lftjldlaf\C
"'1gillonO Oller Jjllll ... , Cfoltd IOQp Geotho!III
DA~ NII LID Jf_--19 -,r~
4. WILL LOCA'nON:
M-66 LQtla Chu@ Rd
t H11111. Nuffletl, Communi;:~. GlNi:i .. ISiniii. zi COIMJ
cm: Franklin COUNN Maq,n
TOPOGRAPHIC I I.ANO seTTING; ,__. .,.......,., .
cs. ov•1 ~ □Ridal . □Oller·....,.. ____ _
·.-rco ~-1""" ............. ,a.RCM3l~CC
ll'<fllf llTCO 75 1""""1""""0 '"'1 Cl ROA ?R~..,,_. CC
~...-: ~ C)ra,091-6Di,iap
t,oc,1ioll "'"'"""' w "'°""'on, usaa ,-o,,_~ ei, ,,. «clffll ,,_.., GIii}
I. flACIJl'Y,..,._ flfh ---wt.....,_..,. ii looallcl.)
Nacrm EleroealJO , .......
11M Lotta Cbua:h Bet
SlratAddrNI
EraokHn
CffyOIITOWPI ·
M'"'® county Gpyamment
CONICiName
MllllnQAddtlaa
Fratiklio
c:ityorTOMI
( ) .
AIMoode -p1.;,.--IIU!ftbw------
... U..OITM.S:
.. 'NJTM.DIP'TM: ~
NC: 28734 a. ZlpCodt '
NC 28743
811111 ZIPCodl
b. DOU WIU. IIIPUCE l!JIIITINO WILU VIS C NO rJ/
L WAlllll l.DIL llelDw Tc,p of c.lnsl; ..,£ t) l'T.
(UM ••• If~ Too el Cellllgl
l •
, • "lop of~ tu,,~/.alQ .. 11;. ~ ,.n,.,, 1%,ral ..Uh ... .,.,., .• ,
, n•IINI 1ft ,-•cutth 1 SA NCAC 2C ,0111.
: •· YIW) ,.,....: ~2--Mm40D o, TEST: Blow Dawn
l f. DOIINFEC'nON: twe HTC Amount 12 AZ
~wr
; J. CAIIN: Deplll D...._ __,. .......
i Top_ Bolom_ Fl, __ _
: Top_lolam_,. __ _
;Tc,p_llollarn,___R .. __ _
: a. QAOUT: 0tDCh Mata1al
l Tap_Q_ IDIDm.A5'L Ft Benlpt)Jta
: Tc,p_BclODm_Ft., ___ _
;Tc,p_lolam_~-----
Wlflod
ewnACO
: ToP:--~Ft._ift. _in. ___ _
; Top_BollDm_Pt._lt\. _In. ___ _
~ Tap_ loCIDm_Ft._in. _ in. ___ _
'
: 1D. IANGfOIIAnL PACte:
: Det,I, :ToP, ___ lollaln_Pl. _________ _
:Too_lc,llllm_fll. _________ _
jTop____J5oaam_R _________ _
: 11 . OtUWNG~
; Top fJGlllffl
: ~~-2Jr-
! ·-g:{~
: I __ , ___ _ ___ , __ _ ___ , __ _
I
----:'---__ ., __ _
--·'---: ta. RUIARKS:
j -easir ,g Rem~ed
l'olmllllclft Duol;JIIDI,
§~~lei& 9nr..eu,.t.e
! I OO....,Clfffl'Y"Mrr1""1"ill.WAICCllll'TJIIIC19•~wm.
· ISIICIIC2C, ~ ~ITNCWIDI.IIHDltlllTAetarf0,1'19 '
:~~~~ jJ~ ~ /(.~-II
: SIGNATURE l&OMLL~ DAtt
i ~"' l-. Wt1u e+s : HilN 0 OF Pl!flioN QONS'T'AucrnNG THI WELL -
ltdillllft wtlhlft ••of curipllltain eo: DM9'Qn of W_,. a.in,. tilli:: •• Plf'Q 111tno.
1117111ft ._.. C...,, flllWtll, NC ff ... 111, "9om : (t1t) IO?.aoo
RECEI VED 02-15-'12 12 :41 FROM-8283690740 TO-NC DENR P&S P001 /010
02-15-2012 13:14 TARHEEL WATER TREATMENT 828-369-0740 PAGE2
N ONRESIDENT/AL MLL CONSJIYgJON -Jl&COIP
Nort!l C 111'\)11& IJcplll'lGlft'lt of Environmr:nt md ~•nnl RC!Dlll'Ca-Oi,ilior) of W.ataiOdalk)I .
Bggac L Williams
Wal ~ (lftdlwldla) Nlffle
Jameel Water Tmatroent
Well ~CoffiP9"Y NalN
~94 GeoroiaBP
B!Jeet~
franklin
Cll,orTOMI
< 828 > 369-07 40
Alltacode ~ l'll.lrllllef
I. WSU. INl'OIUIATION:
NC 2SZ34
ZlPCOdt
weu. CON8T'RUCTIOH PJRMnw~W ... li-.P.i.i10~0._.1...,4_1 ___ _
OT'HSt AIIOC~TIO PEAMJ1W(~
111'1 WW. f0 tor---1 IT=/-' U'
I, WIU. U81 10,,_. Ono Bo•) Monlai,O O MunidpeWubllG 0
l~OAltlcululllO~Olf'ljldDnO
lffllllDnO oe,-,r/(tietwa) CJosed loop Geptherra
nan DM 1,10 // • ".J • I I
'-WILL I.OCAflON: 1¼!6 LoUa Church Rd r Nania. JU!lbell, communiy, 6uDdMl!on, Lot No., Plnlel. ZiP Codi)
cm': Frankli n COUNTY Macon
TOPOGfW'ttC I I.AHO IITT'ING: ldllc:ll 111""•• 111111)
□Slope OValley .,,... Oltidge OC!hor ____ _
1C'@151CfC0 38_ l""H~AOAIIU•, Cl. ROIi k!'a•·~ CC
ICNWIITC015 i uueuuAAIIA I Cl,. ROIi ~.)('800d(l66C CC
IA&lt:de~ngilr,lde IOUl99: c,a,s QroPOSJl!!ph!O IIIIP flONfion ,,,..., ,,,.., • ..,... Oft• usaa ea,o mllP .,_/!Wllld to ,,,,_ _,,, ""°' _,, Gl'SI
I. ,acuTV (Name of IN Ml""' ..._,. Die WIii II lclaalld.J
Mamo Elemeotarv ,...,,..,.
J 166 I otla Cbvccb 8d ..........
Erankllo
Cllyo,Town
Macoo Cavntv Government
contlC:l't~•m•
MllillngAddlNe
EmokHo
cttYorTowt1
' ) ~ cadt -:::l'tlof=-n,-n-u,~Pl'lbel-------
1. WILL DliTNI.I: /
L TOTAL Dll'TH: Lr s ()
NC 28734
'""-ZJpCode
NC 26143
51-ZlpCOdl
II. DOU Wl!U ~ UllflNG Ml.L? YH □
c. WATP l.avtLIIIIMTo,dc.tllO; ro
(U. ••• It Abow9 Top d Clell'9)
7
•f~l1f~"11i 1',il1~ uVOf C.,..~.Y
• a vananoe ill~ wtttt 1~ NC.AC 2C .01 ta.
~ ,. VIEU> lm,m): / 6 I) MITHOO OF 'mt Stow Qown
: t. D&taNF&cnaN: rw,. HTC ~m '12 gz
: g. WAffRIONnl.,_.): ,L' irooz, I) BoftDnl Uy: To, ___ Bollom._ __ :i. ___ ~ ,..,, ___ BolDm.._ __
l To, ___ lallDrn, ___ TOA'----loaon!._ __
. .......
;Top_~.--~---
: Top_ 8cfflom_ R ., __ _
;Tap_loloffi_Pl. __ _
: ,. Gft()UT: °"" ....... Maflod
! ToP.JL_ DoeDl'n..sa._F't. a,ntiQjfl PYrnAftd
: ,.._ 1oa1wn_ ,t ___ _
: Top.;,,_.__ Balloffl_ ll'l. ___ _
: I. ICMIW; 0-,llt DIMletlr 8'°'Sillt IIIIIMW . :Top~llolom._Pt . .._ln. _in. ___ _
;Top_BollDm_Ft._!ft __ 1n. ___ _
!Top_llal!Dln_,.~n. _in. ___ _
'
: 11.1AND1111'&¥1L l'ACK:
: 'Dlpll Ila llatNt,f
: T~ $ 10n; F-.t ________ _
; Top_tlcillDln_l't _________ _ ;~p __ ..,,.__R _________ _
: 11 . OAIUJNC 1.0G
l~:i: : ____ , ___ _ . -_ __,, ___ _
' , __ _
I -----,---__ , __ _
--·'---__ , ___ _
: '12. RE.W.K&:
Submft _... ... 30 a,t ol ~ to: DM•lon of W..., Quallly. ~ PN a 1■1-
1ttT ... IIMae Ctdlr, Alllllth, NC 21-.1t1, Phone :(t11) I074IOO
RECEIVED 02~15-1 12 12 :41 FROM-8283690740 TO-NC DENR P&S ·""'-· P0027010
02-15-2012 13:14 TARHEEL WATER TREATMENT 828-369-0740 PAGE3
NoN R&'lDENTJAI~ WELL coNsJRucpoN R,:coap
N(lt1h C.arulino I.JcPfflm:!llt ot'EDVifonmeot Md N1tunll ll~~ l)i~~-~War~ Qualiiy Jeis~A -.• . · . ·:
Roger -L w1mams
Wall CGnVtcllor (lndl¥icl11al) Name
Iarheel Water Treatment
Well Con11'11)1w Company Norm,
3494 Georgja RD
Street Addrtll
frankUO NC
~OtTOM'I Stiillll
28734,
ZipCodt
c828 , 36~740
~aodePl'lclnellUf'llber
2. WEU. INFORIIA110N:
WELL CONSTRUCTION PEAMl'l'#-.,:W.:-,,,IO .... 1..xO:x.O..i.14 ... 1 ______ _
OTHI!" A8BOCIATl0 PERM.,.,,__.
lffl WELL ID #1(,r __..., ll" /-:Z
3, MLL UII (Cheeil OM BoJI) Mani&ortno Cl Munldptl/Public 0
•~!Mic ~10 Reoo-,o lnJeaio,lo
tnlclatiOno 01w JJ11et ua> Ctw;ed looo Geotherra
DATE O-.a.80 /(_-I K ~/7
4. WELL LOGATIOH:
1166 Lotta Church Rd (sireetName, NUn'!Oltl, Com~. Slbllwliloii, un No., Pwol. z~ Code)
crrv: Franklin couNTY Macon
TOPOGRAPHIC I LAND seTT1NG: (Cillel:t IOllrGPlllt llolll
CJSlopt OVallar fil'lat C"-COlhar. _____ _
..-rec 36_ 1""""'•,._. ........ , CL ROA a1~ cc
... Y:tSTCO 75 iuu1uuu""t CL ROA 11.xaa~ CC
~ taauree: 0W& C]l'opog,aphlO map
f/oedotl olMll lffllftN .,__,on• USGS "'PO,,,.,, .,,_,.,,,_,.-.c,..,..,_,,M ,o
11111 folm W IJOl llllnfl GPBJ
I. f!ACIJT'Y (Heme of the buliMM ......,_ !tit well 19 lelaald.)
Maroa Elementary
l'eclltyNanie
116ft I otta Cbyrcb Rd
IIC,Nt/ltdJJ,...
Franklin NC 28734
City0tTown State Zip Code
Memo County Gavemroeot
Contut'Name
Mell,lf Md,_.
Eraotc!io
C'IY«Town
NC 26743
Slate Zlf'Code
[ _J Am ;;a; ..,,,Ph.,...CIN_n\111,N_,--, ----
•• WILL OITM.S:
•-TOTAL Dfflk: ;tS-O
D, DOU WILL IIE.PLACI IXlfflNCI WILL? VE8 C NO~
~. WAl'III LPELhlowTapafCUillg: 5;°0 f'T.
(UN ••• it Above Top d CUinO)
,, ---. • r: · ~~-.. ~· ···fS· :. ~.':..: ~;~.!.~ ...
Top <;r i::.ttng to,nunJt~:.l ~'Ir., -Jtl,, "'''" . ..;i.,...,. ..
a vlllanoe 111 IICCICltd..-wfltl 1 ~ Ne.AC 2C ,0111.
: e. ~ELD fgpmJ: /0 o METMOo o, TIS1" arow Dawn 1,. Dl5tNFECTIOH: .,__ HIC MIOU"t 12 AZ .
' : II• WATIJI ZONES (d9plh): ! Too. .2" 0 ~ Top. ___ Batlorn, __ _
;Top,___ __ Boloffl_ TOP. BotlDm__
;T09.. ___ Boloffl_ Top Boeom..,.._ .
i Top_&oua,n_Ft .. __ _
! T11t1.__8ottom_Ft. __ _
!To,_lollDn!_Fl __ _
: e. GROUT; Depll MnNJ l ro,JL_ ~ 4§0' Fl Bentpnfte
: Top_BoC!Dm_A.. ____ _
;Top_lollDn!_R.. ____ _
Mdlod
pumped
: I. SCRHH: De,th DiafflatH Slat-.....,..,
;Top_Boctom_Ft._ln. _in, ___ _
: To,i_8oetom_Fl_li,. _Ill. ___ _
;Top_Bolllilm_Fl_ln. _ill. ___ _
: 10, IANDICIMV!L PACIC:
! Dellfh ·-:T~ ___ ..,._Ft. ___ -------
;T~---•IIDffl-Fl. _________ _
jTo,~_R __________ _
: 1 'I, DRILLING LOG
Top 8aCloffi
0 I ~0 2£1$?7
~I 1{t:O __ , ___ _
----''-----__ ., ___ _
./ ,-------, ,----
--:'----
: 12. twlMKI: l Caslug Remevecl
IIUIMnit wttlttn 30 -· of ~plMlon to: Division Of Wa&tr Qaallty • lflfonnlttan ~ ~GW•1D
"8¥. 11118 111' Mlfl ..,._ CenW, Allllp, NC 27 .... 111, PhaM : (11tJ I07_.. '·• ·
-RECEIVED 02-15-'12 12:41 FROM-8283690740 TO~ NC D~ P&S
02-15-2012 13:14 TARHEEL WATER TREATMENT 828-369-0740 PAGE4
NaN RES IDENTIAL )\'ELL coNsTRYAJON u ooap
Nnnh CsruliTW l>cpllfflntllt ofEovironrmit and N11tunil Jtesources-l>Msk\lliirWa'. ~~~
Rooer L wmiams
Wei <:or1tracb (Individual) Name Tarhee l-WAter. .... I .... re .... e:-""tm"""'e=n ..... t ______ _
Well Con1raC10r eomi,a,,y Name
3494 Ggqja 80
SlrNtAddrtte
Franklin NC 28734
Cly or TOW'! 8tlllll Zip C-
C 828 1' 389-0740
AIN clOdt P!IDfl9 ntlfflW
L WILL lll'OIWATION:
WEI.I. CONSTRUCTION PERMITtt._,W=l0:..a1..-0_0_14_1 ____ _
OTHER A880CIATEO P11'M~II' •IOlillllll
lffEWB.I.IO#(lflOIIICaDltl ' It ... I .. i
S. WELL USE (Check One Bolt) Monlloltno O Municip.UPubUc tl
lndulllalfCommen:illl c AlflCUIIINI □ ReolM,yo lnjeclian O
1n1get1ono 011w rl (1111 iae> c1oseg 1000 Geothema
DATE OIIIU.io / / -//, • U I
._ WILL LOOATIQN:
.Lo~hur;hRd _,;: , Cornffllll!IY, ~. Lot No., Pafflll, l1p Code)
c1TV: Franklin coumv Macon
TOPOGRAPtilC / LANO lffllNG; (dllall lPPIGPlilll buol)
Olltopt ov.i.y ~t O"ldtt cot. _____ _
..-rco ae_ iA•--•• .. ••1111 •1 Cl. R°" 3xMalti4llll9tl cc
ICNJEIITCD 75 i""""l0 •1141 •0 t CL ROR 11,lC&iWWW CC
L~ aauna: CJJPI C:Jr...-1o map
(l««ioll of•mwl N ._,on• USGS 11:.y)O """endt!lc"9d a,
thla lomt H nol llMV GPSJ
I . ,ACILl'rt (f(•IMI aA lt!a bUlilllN __,. ht _,I la localed .)
Macx>o EfementaN
F~NIIM
116ft I otJa Cbwcb Rd
SlrNt AddreN
Ecaoklin
Macao Covotv r,avernroeot
comact' Nlme
~,~~
Eraokllo
CllyorTown
C I A!Noodt ~Pllone--n-u-.,..,.-:---,----
t. WILL O&TMS:
L TOTA&. DIP'YN: J.-/f:t}
NC 28734
8'ata ZlpCode
NC 28743
S'lltl ZJpCCMle
b. DOU WILL IIPLACI IDD11NG WILL? VES r.J ~ a/
o. WA'TE" L1WL .._ Top dC-W.: 5 0
(UM•+" If Above Top flf c.ll'IO)
,.,._
-,~:·-;:.~ ·.,., 4~.,7 .) ' ., ~ . --...... :.__ .. ) -,(:~·' . ..: ,~. 7. --·-·-' . ,..,;;,., --.
'Top of c:ning wrmltla\ed et/or be,ow la~ $\lrl-ms ; ro.;utra
a vananct In aocadenm with 1SA NCAC 2C .011a.
1 ~. YIELD rgpm1: _c! o D Mmfoo o, TEST ..BJo.w Down
: f. DIIINFECTION: TWPe HTC · , Amount 3 2 0Z
: t , WATER Z~z'I ~ ! Toa.2' Q Top ___ ~
;Top lottom__ ToP, ....... __ 9clllDffl_
: Top ___ lomffl_ Top. ___ Ballllm, __ _
~
: 7. GAIINO: Dt,ctl o~, w.tgM 1111en11
I Toc,_Bolom ____ Fl __ _
; Top ___ 8cnlom_ A . ._ __
j Top_Baaam_R. __ _
: 9 . GROUT: 0tpffl ~
1 Top..Q._ ao.n~ Fl Boc,tpntte
: Top_Ualan_Ft. ____ _
: Tap_Bolom_,,. ___ _
' :t. SCRDN: Depth ~ --
Mtlhod
PufflQOd
: Top_Ballam_F1._ln. _In. ___ _
: Top_Boltcm_Fl __ ln. -if\,----
: Top_ 8a11Drn_ Ft._ln. _ Ill, ___ _ . ' .
: 10. IANDIORAW&. ~Aat:
: 0.pth Size
;TCIP·---~~----------;T~. ___ 8ot1Dm_~----------; Top_eatto,n_Pt. _________ _ . . .
: 11 . OM.LINO LOG
Top BoltDln
~~
--~.----__ , ___ _ , ___ _ --, ,------, ----
: 12-AIMMKI:
j easing RentOV od
: IOOHIMIV CSITl"'ITHA't,...WIU.WAIC0NITIM:TEOIN tcQlNWG~
:* ~~ ~~~~~-~~~ · 11 .. 1,·y/
l, -~~,;, .r
IUINnll wtlhln 30 up of camplltton to: Dlviliori of WMlr Quality ~ fnfofflldOft ~
1117 Mall...,._ c__,, lllltllfl. NC 27 .... 111,.~ile : '91tJ 111.aGO
RECEI VED 02-15-'12 12:41-FROM -8283690740 TO-"' NC DENH P&S P004/010
Ba-15·2012 13:15 TARHEEL WATER -TREATMENT 829-369-0740 PAGES
· No N R esmENTIAL wnL coNstpucnoN ucogp
Nonh Cwllna Oq,ar,mc,nr of l;avironmm ;md N1bn'll Re~ Pl~q~~-ra'~ .
Well ContrallDI' (lndMcMI) N.,..
Jameel Water treatment
Woll CoNlreetct Company Ncme
3494 Qeoroia BP
Slreel Addret1
Frankl!n NC 28734
Cllyo,Town 81m ZIPCoda
1828 ) 369-0740
AIMCICldt fltlol,ellUfflbef
l, WILL IN~TIGN:
WELi. CON8TAUCTION PIFIMtT• . ..,.W_._l ..... Q.1...,00=-1 .... 4 .... 1...__ ___ _
01l-f!" ASS0C'-t\Tli0 PEAMmt(if-lOlllle), ______ _
lffl Wl!lL IOll(lf.__..1._ __,{f...__-_;a,.:;;,_, ___ _
3, WILL USE ICneclt 0fte Boa) Monllomo O tAlniOipal/Public 0
lnd!MlallCorMwftllli O ~ □ Ramwe,y □ lnjeclllon·O
1mga11ono 011W r/(llll ~ Closed 1000 Geothe1111
DAffDfllU.eD 1./-'2,_:;Jl_
'-WILL LOCATION:
1166 LoS!S'urch Rd /iil,aiii -~ : Communii sii6dMsJon, LOI No , Pll'llll, ilp COde}
c1n: Franklin cOUNTY Macon
TOPOGRAPl'IIC I LAND SITTING: \IMlll ~ •>
Ollope OVlllly ~ QR!dge 1:JOller, _____ _
IWIITCD _3'5_ , ... U.UIIAAAUf ct:ROA 3kl'9t~ cc
1411WIITC075 111"0 1""""" .. "'"1 CI.ROR 1't~O!lefttCC
l.atilMldello,..._ to11n:e: CJ1P8 QrllpCIOlaptlio map
(loodon otwtllmuatbe.,_,, an• USQS q,o,,-.,,~1111>
lllt lo,m ii tlOf Witlf GPSJ
I . PAOl.ff'Y (Name of hi UMIN whtN h .a la loceltd.)
Maoao EteroeotaN ,._Name
1100 t aua Chucrb ffd
~~
frankJjn
CflyorTown
Maooo Qouotv Goveroa:umt
Qcnflld' Name
MalllngAddf'Na
Fr.aoklin
CftyarTNft
( )..,.,_ ______ _
AIUCICldt PtlOl'Mt"umbef
t. wel.L DITM.I:
•· ,or-. Dl"1N: '--/5= I
NC 28734
Stato Zif>Coclt
NC 28243
State Zip Cade
b. DOES WEIJ. IIIPLAGI IJUITINO WILL? ves Cl NO~
o. WATlll&.IVII.BelowTopofC-v: L O l'T.
(UM•+• if AbtNe To, ofCallllfl)
• ,.f'I')('. I
-f\..~ ._f '-'.,r~:·•J ;\J1 t11 -: J.l,,.1 y• ;.,-}-'.,, 'l ... ·:., I .,,;
a Vll\llf!C8 in IICIOOfdanCe wilh 15A NCAC 2C .011U.
i •. mu; cgpm1: 3 i> M1TH00 o, Tiff Blow Down
i f. D!$$,:4FEC1"10N; ~ HIC Amoum ..12 OZ
: g. WATIIIZONU (/~
~Top/ i(O ~ Top. ___ Bofton\...-
; l'op ___ !ofton\__ Topc--__ 8ollo!!'.__ __
j To,. ___ ..,,_ ____ Top ___ lCMllwn,_ __
: "· CAltNQ: Deplta ! Top_ Bolf0ffl_'1. __ _
:ToP_ioODm_R.. __ _
: Top_Balbq_FL. __ _
: I. QROVT: Deslll Ma1lnill
~ To,_Q_ aoctom...§0.:._ "· Btotooite
: Top-~Ft.. ____ _
j To, ____ lalmm_R.,_ ___ _
'
Malhoct
Pumped
! Top_eoaom,____l'r_in. _in. ___ _
: Top_lloeom_Ft._rn. ~ 1n. ___ _
j Top_BalD!n ___ Fl_in. _in. ___ _ .
: 10. UNOAMAY!L PAOt(;
: Depth Ila : Top,_ __ ~Ft .. _________ _
;Top ___ ~Fl. _________ _
: TOA BollDm...,;__ Ft. . ·---·------------.
: 11 , ORIWNO LCC
Top BolDm
~~ ---·',--------'----I ----------'.----I ,~------, ,----_ _..
: 12. RUM~:
j -casing Ren ,oved
; IOO ...... CERTlllY~TTH6WQLWo\S~1911~~
; 1.SJiNCAC :IC, Wa&. ~ ITMIWIOG. #G m\T ACCPV 0/Fnilfl
!~~~;;-~~~~-1/-9 -//
; 8 OR DATE . ,.
1~,-f
submit wtlllln 30 up of camplelioft IO: DhMkNI of Water Quallty • lnfllflMttan ,.._....,
1a17 Miff.,._ c.-,, R,i~, NC Z7 ... 1t1, Pho• : (1111 IOf ...
RECEIVED 02 -15-'12 12 :41 FBOM-8283690740 TO-NC DENB P&S P005 /010
02·15-2012 13:15 TARHEEL WATER TREATMENT 928-369-0740
N oN&smENTIAL WELL @ Ns:r1!££1JPJ!,atcpa.p
North C.-olml l)epamncnt offnviroomcot 111d N111Ural ~ Ow.fnof,W4ui, Qlyli1y
Koger L y~illiams
W.il ConlNelar (Individual) Nllffl8
Tart:,oel Water Treatment
Well Conhetr;r Company Name
34fHGeor,giaRD
SlrNlAdnlt
Frankfin NC 2BZ34
City 01 Town Sia Zip Code
1828 ) 369-0740
Ml oad9 fltloN llll!NNlr
Z. WILL INIOIIIIATION:
WELL CONSTRUCTIQN PERMIT#...,W....,1...,0 ...... 1"""00 .... 1_4_1 ____ _
OTHER ASSOCIATIO PEAM~-!Glllle
lfflW!U 10#(llll)flliDIIJleJ"-~~-4/ ______ _
S, WILi. UH (Ct!Mt °"9 Boll) Monitoring Q Municipal/Publlc □
lndullrfallComme,-10 ~ 0 fllCIOVelYC lnjec:IOn □
lffiga11of1C Qt-,~(Wua) Closed toop Gtpthe,m
DATI DRIUD /J.-Q] · ~ JI .
4 Wll.t. LOCATION:
1186 Lotta Ch~ Rd
(Strell Nlffle, NUlllbell, unily, SliOdM&lon, LalNO., Poraef, Zip COdel
cm: Franklin COUNTY Macon
TOf'OGRAPHIC I ~D SETTING: latleol ~ DI■)
OSlope ov•~ iil=111 Cftldgt OOIMr, _____ _
KGHTCD 39,. 1°••1au,-uu!ct..ROfl31......,.,...CC
lf'AF .. TCD 75 i .. ,. ........... A,. .. , CL~ DII 1Jt~ OC
~ IQlltOI: CJ3,S Qr.....,.ie Mllp
(loodoll olwtll mwt 0. MOMI Oft• US~ topo m,p~ to
tltll '°"'1 trnotllllt,o GPSI
5. NCLITY (NarM of o,e uinNa ..,_.. !tie WIii ii loolled.)
Macao Eteroeotarv
FtollllYName
1188 fotla CbYrc:b Rd
SlrMIAdd!'NI
franklin
City Of Town
Mamo Coamtv G())(ftmmeot
Contact Nama
u.m,. AddlUI
Ecaoktln
I J.._.. __ ,_ ___ _
AIH cocle Phone number
t. WILL OITM.a:
a. TOTAi. OIPTH: '-/)()
NC 28734
81918 Zip Code
NC 2SZ43
State ZipCode
b. OCN!I WILL Rl!PI.ACI IXISIINCI WILL? YES [J NO r,/
o. WATESILDILlelowTo,ote..v: .,5·~ n .
IUY •+• if Above foP of C.inO)
·-r 1)1) ..,r c,,.:;11111 ,.,r,nlm,;w ,..,;,.,, ;-;e1., ., :.tr,-.,
, a llffllflCe 1ft ecaanlianCt with 15A NCAC 2C .011 o.
1,. -.1E1.0 fa,mJ: 3 e> METHOD OF TEST BIQ)G( Dawn
~ ,. Dl&WFECTION : TP,' HIC Mount j2 oz .
: g. /~ZONU (depth): j TOP. lJ Bottom I ti~ Top. ___ &onu,n.._ __
: To, ___ 8aGDm,_ __ TQ llollDm_
)Top ___ Bclfforn Top. ___ llollam_ .
: f. CASING: Deplfl
: Top ___ Bottt>m_F'I .. __ _
; TOP, lolom_ Ft. __ _
'Thiel& ... .,
wew-
:Top, BallDm_R .. __ _
: 8. GROUT: 0t1)Ch PMi.rial
; Top.JL._ ~ ,a. &antQollQ
;TCIP: __ 1o1o,n_,._ ____ -
jTo,.,_8oeom_A.. ____ _
: t. !SCIIIIN: DePlh ..,_.
:ToP_Boaorn ___ Ft._t1t. _ 1n. ___ _
: Top_Bollom_Ft._11'1, _ In. ___ _
: To,-_laODm_Ft._ln. _In, ___ _
: 10.. UNDIGRAVEL PACtt:
: o.,tl\ .... Material : fop.._ __ loftanl.._Ft .. _________ _
: Top, ___ Golfanl_Ft .. _________ _
:Top. ___ eoaom___~-----------
: 11 , 0,.ILUNG.LOG
; Tap ..,,.
1 o,~ i ~:
. -~--' ,,--------, ,------, 11""'-__ _ -----'----__ ..,, ___ _
: 12. MMAIUC&:
~ Oashag R811toved
IN(an-tEWILL
Submit wfttllft 30 da,s of compteaon to; Olvlaton of Water Qualat,.;. tnbm.lUoft ,._...._
1117 llafl laMoe Centar, Aalllth, NC 27nt-111, Phone~ •• ,.,., ...
FonnGW•111
R,w.1AJ8 .
RECEI VED 02-15-1 12 12:41 FROM-8283690740 TO-NC DENR P&S P006/010
02-15-2012 13:15 TARHEEL WATER TREATMENT 828-369-0740 PFIGE7
N oN REsmENTUL ww. coNs1aycnoN ucoRD
Nonb Carollae !Jeplnmmf ofEDviromncnt and Natural Remunx111-Divisiun ufW11« _Qwilijy
WH,L CONTRACTOR C£RTIFICA1'ION ;I 3065-A
Wei Conmlclor (Individual) Name
Tarheel Water Treatment
Well Contractor Company Nsme
J494 G eo rgia RD
&INetAdd,..
Franklin
City or T owri
c 828 ; 369-0740
Arita IIIDde Alone i,vmber
2, WILL~TION:
NC 28734
State lip Code
WELL. CONSTRUCTION PERMl'T•'...:IW-"-=I0'-'1-"'00=----14_._1......_ ___ _
OTHER ASS~TED PERMmt(111D01101111eJ, ______ _
SITEWl:LL ID'(if~ .... , ,~E-· -_,/,__ _____ _
J. WELL USE (Chlldl One Ball) Monitoring O Munleipa~blic C
lndutlrial/Cammerolll C Agrlculturel O Racaw,y O l,uactiol, C:,
1"1gatloflo O!Mfr/<11•t111e) C~sed 1000 Geotherr11
DATtDRIU.ED //-.?-/1
ii. WELL LOCAllDN:
M!llol!;9;h~ Rd ( me~ ~ :-,;un11y, 81Ald!viaiall, I.al Ho., iiMtl, llD COGel
cm; Franklin colJNTV Macon
TOPOGRAPHIC I LAND SETTING: (chelilc IPP'OPl• IIOIO
OBlope OV1llay itR■t ORidge CJOltwr _____ _
i<@HTCD 38_ 1°0 1°011"""1 CL ROA 3~ cc
~M=IITCD 76 1°0 1•0110•111 Cl. R OR 7'lt'mJUUl-CC
~ongltud• aourw! 03PS CJropogr8flh~ map
(locdon olwellmu«bf dttJWfl on• USG$ _,up ,ntJabCMtJei,
M 1b1m II not ullnf GPSJ
s . rAOll.$TV (N•me "the bullnet, ..,.,. .,. well It locatad.)
Mecoo Eferoeota™ Faal!lty N11'ie Faoillty 10# (if applicable)
1166 LoUa Churct, Rd
hHIAdcllUI
ErankHn blC 28Z34
City a, Tawn State Zip COdt
Macon Couotv Government
Contact Name
M1illng Addreu
Franklin
City f1II TIMl'I
C 1 ________ _
N0a cede PhoM flUmNI'
I. WILL DITAILS! r
•. TOTALDiPTM :. __ 1-1,__SJ_V __
NC 2Bi43
S1ata ZlpCod1
b . DOU WEU. REPLACE EJUfflNO WELL'? 'VES Cl NO~
o. WATlfl LIVILBelowTop oft.ting; ;t0 l'T.
(UII ••• if Move Top of CUif'llt)
• f 1.>p ~f '-'.;Gi"b
: a ¥arlalle0 In aCICCl'dani:e With 15A NCAC 2C .0118.
~ •• vtELD 1ai,,n,~ ~ o METHOD OP ,..,1 Blow nown l r. OISIHFECTIOU: Type HTC 6',flount 12 az
' : I• WATIII ZONU (Cfo'°": ~ Top,6 'fD Bo~ Top ___ eoaom ____ _
; Tap ___ Boaom.___ T~ Botblt __ _
lTc,p ___ Batlon\___ Top Bottarn_.
; 7 . CASING: Depth DlalftltM
' : Top __ aotto,r, __ fl't • ._...,...._
; Top__:_ loaoffl_ F1. ____ _
jTop_~F..._ __
: It. GROUT: Depth Mlllllrial
~ Top...Q._ Bottorn..J5.(L A . Bantoolte
:Top __ lkllorn_A .. ____ _ i Top_ Baftont_ Ft. ____ _
'
Malhod
Pumped
: i. SCIIEEN: Depth Die!Mfaf Slot Ila Material
~ Top_Boctcm' Ft-in. _ In , ___ _
: Top_loltom_Ft_ln. -'"· ----l Top_loloft, __ ,1. __ 1n. -'"· ___ _
: 10. 8AHDIGRAVI\. PACK:
: Deptti ..
: Top ___ 9oftoffl_l'l. ___ --------: Ttip._ __ Bonom__F.._ _________ _
i TOO·----~FI,, __________ _
'
: 11. DRILLING LCG
Tap Boltam
IB~ ----'----__ _,, ___ _
----'----__ _,, ___ _
---'----/ __ _,,,_ __ _
----'----
: 12. AEIURU:
1 ~asln9 RemQved
su11mn wtthln 30 days or compteaon to:. Dlvl•ion of Water Quatny .; lnfOnnlltOn PfOCesllnl,
1111 Mlil a.nlN Center, Ralltigh, NC 27111-111, PltOM : (111) 807-IHO .
FormOW-tb
~-1IOI
' RECEIVED 02-15-'12 12:41 FROM-8283690740 NC DENR P&S P007 /010
02-15-2012 13:15 TARHEEL WATER TREATMENT 828-369-0740 PAGES
8lale ZlpCodll
2. WELL 1NFORIIATJON7
WELL CONSTRUCTION P!RM1-n.. ________ _
OTHER ASSOC~TED PERMITl(if .,,.._..),_ _____ _
IITIWEU.tD#(V ...... ). P-,2. ·-.--~-----
a. WELL USE (Ctledc One b} Monttor1ng □ MunlclileUPuDllc O
l~O ~Cl ReoMfYO lnjl«lonCJ
lnlgdonO OlherCl (list use) &~-~,~A,.«/
DAl'EDAiueD U-1--··I/ T
,. WILL LOCA110N:
,La~ f , 'I SC~•C> I
~~um..,., ~. SUlllllwlllan, LOI No.,,-.,_, .tip Colle)
CtlY: . £-,:a~4 _, __ COUHTV A?i:e,'-
TOPOGAAPHIC I U\NO SETTING: (CIIIMII .,_.. IIOl()
OSlope OVIIIV Olllll ORkfgl OOlher. _____ _
LATITUDE l!._• ___ • DMS 011 3x . .umrm DO
LONGIT\JOE ~•-• • DMS °" 71,l(UIIWXUl 0D
~~: (J3P8 [Jl'c,pggrtPhlOffllP
tloolllon olwelmUII bl .111cM, on. USGS IQf)O,,,., Mdllbalted.,
1h11 tbnn I nol ultlg GPS)
I. FACD.ITY (Name of !he IMlnetl .,_. lie WIii ii IOCIIICI,)
Fecll(y 10, (If~)
City or Town Stale Zip Code
Corad:Name
~Mdfftt
CltyorTown Stale ZJp Codi
( ) _______ _
Anll code Phone fflffllber
I, WILL DITML.I: ,
a. TOTAL oe,nt; L,/£1)
II. DOIi WILL REPLAGE Ul8TINO WB.L? YE$ O NO~--
e. WATl!llllVILBlllawTopofCUing: LG) FT.
(Ute•+• If Move Top of C .. lntl
"Toe> of Gating lerminate<I 11110, below land aurface may ,equ&/9
1 VIWfln08 ift~ance • 15ANCAC 2C .011e.
\ 't'IElD (OOMI: _ 2 " --METHOD o, TEST A.,; (.~ ll
~ ,. DCIINFEC1'10N: ~ dZcr Amount v~ '-'vp
: g. WA'ID ZONES (depttl):
; Top .2 '/ 0 E1G1tom ,2ff,L Top ___ BoUom. __ _
)rap eaaom __ _ Top eoaom_
:TOP. _____ Boaorn __ _ Top aouom. __ _
; 7. CAMIG: ~
: Top_ Bonom_Ft. __ _
j Top:-.._IGttoln_F\, __
;Top __ lklltDm. __ Fl. __
. :8. GROUT: Depltl Mllletial
l1'IOMNII
w.lghl
jTOP. ___ BallDm __ Ft. ___ _
; Top 8oaom_ F1,, ___ _ :T-. Bollam __ R, ____ _
:I.SCMD: O.,,U. 01.....e.r taolla
Mttnod
......,
\Top __ ~F1._1n. _ rn. ___ _
: Tap. __ Bottam. __ Ft._in, _In. ___ _
;TQP.. __ Boftoryt ___ FL_ln. _in. ___ _
: 10, MNDIGAAVEI. PACK:
: Dlplll ;Top,__eoaor,, __ R. _________ _
;Top._ __ 9ullam_Ft .. _________ _
:TOP. ___ aouom __ A. _________ _
: 11 , DRIU.INGLOG
: Tap 8otflom
'
--'~----'.---__ , __ _
--'-----__ , __ _
.
: 12. f1E11ARK8: ...u / . ------~9,..-... -e ... " .... m ....... , ... nt:t ....... i<~-----
lllllffill wtlllla 30 .-.of compltelon •= Oivteton of Wlltf Quallly • lnfln'ulfoll ~D1111• •
RECEIVED 02-15-' 12 12 :41 FROM-. 8283690740 . . . , .... ·ro-NC DENR P&S
Fom'IGW·1'>
Rew.2'09
P008 /010
02-15 -2012 13:15 TARHEEL WATER TREATMENT 828-369-0740 PAGE9
·NON hIDBNl'IAL WZLLCONS!RU9P~ BSCQRD
Nonh Carolina '[)q)lutmcnt of l::nvlrollfflerlt Mil Nittttn&l ilcsou.ri.'ri-'\)lvisir,i ofWriia 'Quality
-; ,--:-. t l
I. WELL INFORIIA110N:
WEU. CONmUCTION PERMITt ________ _
OTI-IER A$SOCIATED PERMl'Tt(f....-.). ______ _
ltTEWEU.IDl<ll~i.........,-£_-_3 _____ _
a. WIU. U8I (Chide One Bolf) MonilOl'fng CJ Munk:dpel/Pubtl 0
~o Ag,taAftlO Aeocwecyo lljeallonO
lnfgltlanO 0lllf C (lilt_.., _______ _
DATIDRIUID /()--i/-JI
'-MU.LOCATION: / ;,;;,tla. 7-y: .5t~oo
(Snet "?::11111. cornmumty. SUb11via1an. Loi~ .• PIIQlll, ZIP COC.)
CrtY; ~~ cou~rvdtk «;:t
TCPOGRAPHrc I LAND SETTING: <~-.....-oSlope av-, oAlt □Ridge oOlhet _____ _
LATITUDE .!!,_ • _, • OMS 011 3x.mxx,ocg: 00
I.ONGfTUOi~•----• DMSOfl 7g,xpppp DO
~ ICIUIIIIY. 03PS Of'opooraptlie map
(lot:lllian olwellflllltbl lihtltttl on• USGS ,a,o,,,,, a,ldlladleda,
tlllt bm I tlOI IAHff OPS,
I. ,ACllJTY (Neme of !ht lMinell _,.,. "'9 ... ii IOQl!ed,)
Facilily Name
Street Mdfels
atyor.Town
Contact Name
Malllng AddtMI
CilyorTawn
<-) Arieoooe '""Pt1_101_11e_""""°" _____ _
,. WIU. 06-.S; • '
•· TOTM. Dlmt: <,/5?)
Stale 2Jp Code
II. DOD W!LL IIIPUCI D1111NG WE.L? ves O NO g..,.----·
~ .TEALeiaeetowTopotCellng; 5:0 FT.
(U .. •+• If Above To, of C.1'"9)
. ,_ --. _,._
.. , ·--... ' "I .........
,. i, • ••
,\-:., .. -::,r ;,.;;:;~~: _ ,z _ ~ _ ~,. A!ArJ~ t .. ~i',J
: .,.op of CNlf10 let'mlneleO 81/orllelow,.. surface mlY l'llqU19
: av8'11nctintOCOfdeiioen41h 1MNCAC2C .0118.
; 0, YlEtO (gpm): / D !9lmf0D OF ~T A,#" (.,, IJ
~ f. MIN,lc:TION: Tr,e tfrl'/ Amount 'l'V '-.I/.:>
; t-WATER lONE& (depll'I):
: To,2 ~l) Boltom,il {/ ;J_ Top ___ Bollom_
I TQP. ___ eoaom_ ,.op BoUom._ __
;Tap. ___ aonom. ___ Top Bolasn. __ _
'"'....,_, ; 1, (;MtNG: ~ Dllmelor Wllgllt .....,
(rop_8-m_Fl. __ _
: TOP.. __ loltDl'll. __ fL. __ _
; TOR'---_Boltom__;_Ft __
: 8. GROUT: Daoltl Mlttrlat Method
: Top--'L_ 80ttom 'tSi) Fl &,.-1 -~~;....A-A~--
: Top __ a.m_ F ____ _
;Top, __ eaaam_FL ____ _ .
: t . ICIIIIN~ DopOI
; Top_ eoctom_ F1. __ in, _ In. ___ _
: Top __ BotlDm_ Fl._in. _ in, ___ _
i Top_&oaom_FL __ ln. __ In. ___ _
'
: 10. IMDIGRAVIL PACIC:
: Depctt ...
:T~.--BollGm_Fl,. _________ _
:Top __ BollDrn. __ Ft. _________ _
j Top __ ...,..Balom ___ Ft .. _________ _
: 11. OAIWNGLOG .
: Too BOt\Orlt
. .
' :~ Jj?,ys::,,
---.:'----__ ., ___ _
--i'----_ _:I ____ _
---'-------.:'-----''---
Fonmlian .,...tlDn
: 11. REIIMKS: / · -----<f..-~"'"a ... t,J,j.Ji...:,. .... t:: ... m=e;._. ____ _
s...,...,1n .1.0·•v•"' CIOIII--to: Dtvllkffl or w.,.aau,y . trnmldon Plil , ,:,a.,
RECEI VED 02-15-' 12 12 :41 FROM -8283690740 TO-NC DENR P&S
Fom,GW-,o
~-2I08
P009 /010
02-15-2012 13:16 TARHEEL WATER TREATMENT-828-369~0740 PAGE10
Z. WEU. INFORMAllON:
WELLCONSTRUCTIONPEAMIT•'---------
OlliER ASSOCIATED PERM':::::'1)
lfTE WEI.L 10 l(lf..-.a-),_,~r___-~·-.,._ ____ _
J. WILl U. (Checa One ElolQ MonllOnng O MontolplUP\JDllc 0
~ o ~o ~~ ~a
lmOtliOnCJ Ollt, c 1• u.> 'i t! e M ,~,HP I
DATIDNLLED /.,0 ~-ti
f. MLLL~: / 2c>ttL,3.,. r s~✓ia)
{en.t Name, NumtM111, Community, subdivizioit Lot No., lta!Qel, tip c:ode)
e11Y: H a11 t1,~ couNlY t114@n
TOf'06RAPHte / lAND SETTING; fc:ft«:k ~ llall)
oSlope OYllley Ofllt QRklge OO!n■r, _____ _
~TJTIJOE .!!,_•_• -• DMB Oft 3xJOOOOOOtlUl DD
LONGITUDE!!.._·__: • DMS 011 7vwe••r.x DO
~ 10U1119: CJ3P8 Dl'OflOll'IPhia ffllP
(IOceffottolwelmu.tllellNMlon•USGS-m-,~ID
"'11 ~ If not ""'11 G"SJ
I. ,ACIUTY (Name of 1h11 llulln■II ...... ttw •Nii locllad.)
Fadllly lat (If 8ppli0Nle)
SlreetAddnlls
CUyorTown 6ta1e ZlpCode
CortladName
ettvorTown Stlle Zip Code
( ) _______ _
Al9woadl PhoN numw
t. WEU DETA&LS: • /
•• TOTAL 'D8'ffl: 1./5'"6
b. D0E8 WELL REPLACE EJOlllNCI WILL'I ves a
II, WA1&R 1.1\111. Bltaw Top of Cllltl9; ) 0
(U ..... If~ T~ "'Cuing) C
: 7, CASING; 0.,. Dtlmatlr ....,..,
:T~. __ eouom_R. __ _
~Too..__Bollaln ____ Fi.. __ _
;Tap ____ Boaom_~.---
• : e. GROUT; 09pltl -
: Top_ BaaDrn __ Ft.. ___ _
' ;Top ____ Bottaffl_FI.. ___ _
;Top ____ BaeDtn,__A .. ___ _ .
: t. 'SCRE.EM: Deplh Dllmlfllr ltot&la ..... ,
]Top_Boaon1_R. __ in. -'"'----
;Top __ ltollom_Ft,_ln. _In. ___ _
~ Tap __ eouon,_f't.~. _In. ___ _
: 10, MIIIDIGRAVEL PICK:
: Dlpltl ......
; Top'---_Bollom__;_ Fl. ________ _
; TOp. __ BollDn\.._Ft. __________ _
: Tao ....... _~ __ Ft. ________ _
: 11 . DRUI~ LOG
: Top Boa,im .
~~ _ __,, __ _ __ , __ _ __ , ___ _
-~'---/ --,-----__ ., __ _
'. 12. REIIAR~ . ~ //e,·,,~ I
lubmlt wittM·M .b,_aamDlailonto:DtvlaloncfW..,.Qwllllv• ~-·111tna.
RECEIVED 02-15-'12 12 :4~ FROM -8283690740 TO -NC DENE P&S
F«mGYMD
P010/010
02-15-2012 13:25 TARHEEL WATER TREATMENT 828-369-0740 PAGE1
N oiv REsiDENTIAL w,u, coNmu.1cr10N ucoRD
No rth Carolina Depar1mcm of Eovlron1nent and NarutaJ Resnurce~ Oivisfon ('lrWll!tr Qu.ldity
. • """:I •• :.--II
2, WELL &NFORMATION: /
WEU. CONSTRUCTION PERMfTt wzo JOO I LI
O™EAASSOCIATED PERMITl(lf_....>::,--------
16TI W!LL ,0~11...,.,'----"p _____ ,_s .. -____ _
I. WEU. USE (Chclca One BoJ) Monlforl,. rJ Munlcipal/PuDlio □
~-□ ~l □~CJ~on □
1n1g1uanc 01Nw □ tust ~> 9 eal~~o~ I
DATE mau.eo /o · ,2 ,_ It
tsn-lN. tcllmDM. Commlll'litJ. SUbdMlion. LcK No., P11Q11, Zlo Coot)
CITY: P1~1 {<J1 A COUNTY MC(4!f-,, > 1'0POGRAPHIC I LAND SETI1NC: (dla:II IIIPIOP'il• llml)
□Slope □Valley □Fiat ORldgt COiier _____ _
't.AllT\JDE ~• ___ •DMSOR 31t>OOOOU0n•x DD
I.ONGITUOE~•----• DMS OR 7U!JRIWoC 00
u~ ICU'CB: ~ CJfopogr'PfliCmep
(toclll/otl °'"'''""' Of 111cM,t on• USGS •map andlbohed ID fJli.t brn If not uq Gl'SJ
I, FAC1Lffl' (Html of ltle ~ .... U. Mii 11 locllld,)
F~ ll» (tr ~bit)
SlreetMdrell
CityorTawn Sta ZlpCode
ConteccN1"'9
Mllng ~
City or Town State ZJpCOdt
L-) ,t;. ooele _Pfl_lOl_,__nlffller' _____ _
I. WIU. D£taiLS: r
,. TOt-.~: //CT
b..DOEIWIUUPUCIIJOl11NGWEU.? v~o NO.,__..
c. WATER L5VEL Beaow Toe, of Cning: . S-6 FT.
(UM ••• if~ Top of CIU10)
-f"'\ • • :f. ;_ .. ,,. !./ '"'.-. ... ~ _.~ I
-------c-..--.. -------·-
.
: 8. GROUT: DepCtl
irap, ____ eoaom_~----
;TOP. __ 8Gttom_Fr. ___ _
; TOP. __ Sattom __ Ft ___ _
j I. ICREEN: Deplll Dllnwllr alollla
: Top __ Boffom_ Fl~tn. _ ln. ___ _
: Tap, __ Ballom. __ ,1._1n. _ 1n. ___ _
1 TOf>.--BGICIOffi -Ft._ln. _In. ___ _
: 10, INIIMIIIAYIL PACIC:
: Deplt -.......
; Tap,,__Bolam_Ft. ________ _
(TOP. __ Bulom_.Ft ________ _
:Top ___ .lklltom,__FL ________ _
Top BOIOm
~~ ----'----____ , __ _
--·'---_ __,/ ____ _
--'---_ ___,, __ _ __ , ___ _
Wll'N
1118
/ iJ··,;J, • II
T . OATE t ,~,,.,,J'
8ullmlt wttl\ln 30 dava Of comollllori io: Dl¥111on of Wm, Oullltw • hfannillon Pftl Jlllia. ·REqEIV~D 02 -15-'~2 12:52 FROM-828369074~ TO-NC DENR P&S
FonnOW.tb
P00iT010
02-15-2012 13:25 TARHEEL WATER TREATMENT 828-369-0740
NON R ESIDENTIAL WELL CONSTRUCTION RECOM
• Ii• ' • '· I I,
1."WEL&. CONT~TOit: {._ t . I !j . . : d. TOP OF CASING IS~-FT. Above Land Surface•
Q_ O'il I' _ ., Vl{_fl tlf!LJ : -Top of culn; tem,iria1ed at/Or below l•nd aurfaoe may require
won Co11tr~1;;;lv~ua11 j "'a L I.. ~ , : 1 ¥1:1'1111100 in 11ca:,re1ance with 1 !IA NCAC 2C~.0 1 14. .,
11
lafn~e_ IJ.&:..l(t f.!?._o.,l,,,,., .. t ,#,,~ •. VIILD(gpm): lfD _ .. METH!90PTEST ______?: t.#
We Co™~~,-~ )/d, ; f, DISINFECTION: Type rftrz_ Amount c:.,~
SlreetACI~ v-.~ ~(. ?P,S'I/ i•itrES(de°llt: ~(,/111(.. ''" ~--,.,,._~ 'U '.T {,) Bottom Top~ __ Botram,_ __
Cliy or own State Zip Cod• j T~ Bollom · Top ___ eouom ~ 369--0 2Yl> ~Top. __ Bottom __ Top. __ !oll'Dm·--
Pnone numbar : Thlcllnntl
2, WELL INFORMATION: : 7. CASING: Depth Dtamer., Wolght
WELL CO,.STRUCTION PERMIT# WI. DJDD J 4 f : Top __ Bottom ___ .. , Ft.. __ _
Mat1'11I
OTHER ASSOCIATED PERMIT~IC.Dltl.~-------
lfTE WELL 10 #tif ••1cawe1,_-+T=----~'dP------
s. WILL UII (Check One Boll) Mon11011nu LJ MunlcipallPullliC: C
1ne1u1tri11/Cammercitl n AQrioullurwl i.l Reoover, O Injection o/
IITfgallOflLJ Oltltr u (list u•l 9<-'9'Yf h ,-..;
DATE O~ILt.llO I(!) -c25:-JI
4, WILL LOC TION:
~
( Name, Numblnl, Cdftmynily, SubdMaion, IA No., Paloel, p Cod«J
CITY: btS",, K'l,.._ COUNTY tfg;_C,()n
TOPOGRAPl-11C I t.AND.SeTI'ING: (ctleell lll)l)IOPMIG bolll
(.JSlope ov1111ey C]f:lal CJRidg• OO!Nr. _____ _
LATITUDE ~• ·---" OMS OR 3x.wgn•~IO( 00
LONGITUl;)E 7_S_• _____ • OMS Oil 7x.ltJOOCXJCX Q. DO
Latiludellontitude aource: [J3PS [Jl'opographic map
(IOc/fliOn of-11 muat be Mown on 1t USGS ropo mao andaltactled to
/t,if fO"" If ,rot llfi/lJO GPS)
5. FACILITY (Name or UI• businau w111ra tM MIii ii located.)
Facility N11me
Strati Addrna
City or Town
Conlllct Name
Mailing Address
City or Town
(_) ---------Area OCldl Phone number
,. WILL o·STAIL&: ±(I r
1. TOTAL DIPTH: __ ~~...,U""----
FacAity IOI (If appNcabl•l
State Zip Code
State Zip Coae
b. DOES WELL REPLACE HISTING WILL? Yf.S u
G, WAT!I, LBVIL Below Top of Castna: s= l)
(Use"+" if Above Top of Casing)
: Top_Botlom_A . ._ __
:Top_Bottcm __ FL. __ _
: 8. GROUT; Depth Malarial
: Top_Bottom_Ft .. ____ _
j TOP __ BollOm __ Ft._ ___ _
;Top_Bolmrn_Ft .. ____ _
: t . SCREEN! Dtptfl Ollm■t,r llot SIB Ml1erill j Top __ Bl.lttorn __ F1. __ 1n·. __ In. ___ _
: TC)p_Bottom_FL_l n. _In. ___ _
-: Top __ Bottom __ r:t. __ in. __ in, •----
: 10. SANDIORAVIL PACK:
: Depth Size :Top. ___ eottom_FL __________ _
:Tu". ___ aoaorn __ Ft,,, __________ _
i Top. ___ Bottom_f:L. __________ _
'
: 11, DR ILLING LOG
Top 9011Cm
~~ ---'·----
FormatlOn Description
~~rd
---'·-------'·---:---___ , ___ _
---·' ,-------,· -------'----: 12 , RIMAflKS:
· eubmlt wilhin:ao ,d~,i~:~mpetion .~,~'.:oa~~-•~ 0,--'1~1iy -~:, t~don Proctai~~-
· '.t81'1 Mall Service Ce~,•-llti.,NC 2711-•1PJ~Mrie :t,il1tt ... -!UGO ·:·' · •:•.•::.,~-· · · .:;•.· •, ''~'.:~':'.-7~
. . .. RECEIVED . 02-15:..., 12 12: 52 FROM~ 8283690740° . , . . TO-.. NC DENR P&S
FormGW-1b
Rev. ~/09
P002/010
02-15-2012 13:25 TARHEEL WATER TREATMENT 928-369-0740 PFIGE3
N oN R ESIDENTIAL w1-::a.1. coNsT11ucr10N RECORD
Nol'lh Camtinu Ocpurtmcnl of Environment ai,J NuLW".il Rc:Mu~q. Oivi~i•)ll ol' Water Qualil)•
Str~@;K7e A£ ,,2 (7:J</
City or Town State Zip Code
« 3t,6 i" 1~·· i>7 YD
Area code Phone number
J , WELL INFORMATION:
WELL CONSTR~CTION PERMmt w 'IQ I DI) I YI
OTHER ASSOCIATED PERMITt(ifeppiclllllt):-------
IITI weLl lO.ttlf appilallll,_) -'£ ... -_ .. _;! ___ . ___ _
3. W!U. UR (Cnedt One Bo..) Manltanng n Municipal/Public u
lnd11slrial/Commeldal □ AQrlcul!ura1 u Racowuy n lnjedfon CJ
lrtfgallori □ OlherQ (list use) ,~~rt&,~ J
DATI O,.ILLID ID ~~ I(-i/
4. WELL LOCATION: / / •n f/A.-~ 3-f~s_c:lif_iCC)....;:;...:... __ .,..,........,.---,-_
(S1 rliel Nana, Numbln, CcmmunKy. SubaM•on, LOI No , Parcel, Zip Cocle)
c1TV~ &e..~ I:'/."" courm //4~ t. ~ ''
TOPOGRAPHIC/ LAND SETTING: CCNdl .... boll)
OStope O~alley OFlal URIGD8 L.:JOther _____ _
LATITVDE ~• , ___ .. OMS QR ~\!)CICXXXJOOt DO
LONGITUDE 7.!,_• . "OMS OR 7x ISl'IXQIJIA DD
l.alilude/longllude IOUl'CI: 03PS OTO!l0Q111Dlllc map
(lot:atlon ol well m11at lie 111own on a IJSGS topo map aflddaoll1d to
I/Ill rtlfll'! If not using rJPSJ
I . P'ACIUTY (Name of Iha buslneu wher. lhe well I& klell~.)
Faoillty Name Feoillty IOI (if appllcaDte)
StreetAIJdress
CltyorTuwn Stale Zip Code
ContadNlme
M1U1no l\ddrosa
City or Town Stala Zip Code
( ' ) ~-------Area COdt Phone number
I , WIU. DITAILI: 1
•• TOTALO!PTH:, _ _,1/.._S}L-O __
b . DOES WILL 9'1PLACI Ull'nNO WELL? VES CJ NO U---
c , WATI" LIVl!L Below Top of Csaing: _ __,..~ ____ FT.
{Use ·+· if Above Top of Casing)
: d, TOP OF CASING IS ,:--FT:Above Land. irli~ · ~
: •Top of cning teffllinqa et/or below lend &\lrfaoe maytequire ·
: a varler1r.e In eci»rdanc;e wi1h 15A NCAC 2C .01 ~ e.
~ e, YIELO ,apm): .~ 0 ~_Jt1iTH,OD OF TEST ✓ 1,~ L-✓rf
~ ,, DIIINFICT1ON: ,Y,. ,~ Amount Pr ",,p
: g. WATER ZONES (depth):
:'TOQ -· ~---· --TO.-P ___ Bottom. __ _
!Top, ___ Bc,ttom. __ _ Top 80UOm. __ _
'. TOA eottam. __ _ T~---Bollom, __ _
ThltkneHI
: 7 , CASING: DepUI Dllfflttllr WalQht Mlteriat
: Top _____ Botlom, • ., • .,_,.,,Ft. __ _
! Tap_ BDttom_ Ft __ _
: Top __ Donam_FL __ _
: 8. GROUT: Depth Malallll MelllOCI
: Top __ Bottom __ Fl, ____ _
j Top_Sottom_Ft. ____ _
; Top __ Bottom __ Fl'-----,
Ditmetar Slot Sin
! Top_Boltu111_.F1. __ in, _ in, ___ _
:T~ __ Bollom __ Fl. __ !t). __ in, ___ _
: Top __ Bottom __ FI._Jn. __ in. __ _
: 10. UNOIORAVEL PACK:
: ~~h SIN : Top, ___ ~Ft. __________ _
: Top. ___ eouam __ Ft. __________ _
jTop_eottom_Ft.._ ________ _
'. 11, DRILLING LOG
Top BOiiom
~1 8£
-:!i:.~ yft,
----'-------''----__ _,/ ___ _
---'-------''--------'·----__ _,/, ___ _
---'·----
: ,,.. RE;MARKS: Jj . I : 9 { ~,r,wr.-""-ll ~ : .<:u .~ <~
FonnGW•1b
Rtv, 2/09
P003/010
02-15-2012 13:25 TARHEEL WATER TREATMENT 828-369-0740 AAGE4
NON R ESIDENTIAL WELL CONSTRUCT ION RltCORD
Nm'll, f.11r11lin11 n ~p511mi;nr of t::11v ironme1\t 11.nd Nu1.ur3J f' · ,., , T \' ~ 1 .ti
Srreet ~eea . / .-,-en. rta1,/,!'fr#,. ~fc:-;24/fy
Cil'forTown Sllte ZlpCode
,8:111 5 '9 -o?y c::,
Area oode Phone number
2. WELL INFORMATION: ·
W!LL CONSTRUCTION PERMIT# IA/II) JI)() 14 I
OTHER ASSOCIATED P~MfTJi_ ,pi:,1~1)
IITI WELL ID#flfiDplicallill,_.E_L-_-_.:,,~-------
1, WIU. UII (Check Ono Bax) Monltot1no □ Municlpal/PubUO O
lnduetriallCommercial □ AQriculiural O Rocove,y □ Injection 1J
lrrl;atlonu Other u (lilt uu) 'ft q (&.~/
DATE DRILLED / 0 -,..2 I • I I
•· WELL LOCATION: µ/fa ?-~ .SC:~«-I
(SVNI Name, Nl.llllbn. Communi,y, SubdiloillKll'I, Loi No., Parcet, 7.lp COCfel
CITV; &·,1irl,.... couNTY Mtte,,ri._
TOPo'GRAPHIC I LAND SETTING: (check 1pp111p11111 IIOIJ
OSIOpe □Valley □Flit □Ridge uONr _____ _
LATITUDE ~• ___ • OMS OR~~~ DO
LONGITUDE~•----• OMS OR 7XJQQOOtXWU DD
LatiWdellongilUde aource: Cl3PS oropc,g,aphio map
(IOClll/on of well 11141Bl be shown otl 8 IJSGS IOPO Met, BnClattac/lM ro
Mi! fo,m if not using GPS)
I. FACILITY (Namt of the businau Where the well I$ tocaled ,)
F1Gil~N1me Faculty II» (It lpplicable)
StreelAddroal
CttyorTown Stato Zip COCle
Con18at Name
Malllng MdNISS
City or Town State ZJp Codi
(_) Area cooa ..,,P,....II0_"9_n_um_b:-e-r ----
•· WEU. DITAll.8: ,
•• TOTAL DEPTH: __ ,l/S-0
b. DOH W!ll REPLACE EXISTING WEU. 7 YES O NO I!!""' -· C, WATER LIVEt. Below Top of ca.Ing:---~-...... FT.
(Use ••• If Above Top of Caair,1g)
: d , TOP OF CASING 11 -fl, Above Land Surface•
: "Top of casing terminated at/or below land aurfac:e ffltY require
; a variance in,.A..~anee with 15A NCAC 2C ,0JJ s.
: e, YIELO IVIHlll; -· (.) METHOD OF TEST ff,-;,-t,_.</f-j
~ ,. OISINflECTION: ~ l!?7t Amount f(v4f<P
: I • WATER ZONE& (depth);
: Top --Bottom __ _ Top, ___ BoUom. __ _
: Top ___ eonom __ _ Top ___ BoDOln~--
j Top ___ Bot!Dm __ _ Top ___ Botlom __ _
Thleltneaa/ i 7, CAIINO: Depth Dl1mtte, Weight Mawrill
; Top __ Bottom __ FL. __ _
: Top __ Bottom __ FL. __ _
: Top __ Botsom_F ___ _
: 8. GROUT: Deplll Ma11rl11I
: Top_Bottoffl_Ft ____ _
j Top __ aonom __ Ft. ____ _
: Top __ Bottom.:__ Ft. ______ _
: I . SCREEN: Depth Olamete, Slot Sid Malllrlat
: Tcp __ Sottom_. __ Ft, __ in, __ In. ___ _
: Top __ BotlOm __ . _ ~t. __ ·ilt __ in. ___ _
i Top __ Bottom __ Ft. __ io, __ In, ___ _
: 10, SAND/GRAVEL PACK:
: Depth llzo
: Top __ ,.Bottom_ Ft.. __________ _
: Top. ___ Bottom_ fl. __________ _
:Top ___ Bo~m_R _________ _
: 11. DRILLING LOG
: Top BOiiom
!~~ : tt, ¥r<>
: =-~--=---:~----.. · ,_. __ _
-, -.;~, I ,,-,-----__ , ___ _ __ / ___ _ __ , ___ _
: 12. REMARKS:
:SIGN
: PRIN
ForrnGW•1 b
Rr.,. 2/09
P004 /010
02-15-2012 13:26 TARHEEL WATER TREATMENT 828-369-0740 PAGES
N ON R ESIDENTIAL WELL CONSTRUCTION RECORD
?'forth Crsolina DeparuTh~l1l or l:n~ir,111mcn1 llfld Natural Rc:murccs-Division ofW11t~r Q1111ti1y ,.~"' . . .. ~ :·
!--~ ,,. .. T'rJN : ~ .. ,..., i ---, •• -
1, Wei.I. 1;0~ ',C TO~: . ,J I . \ ,. J ► C' : d. 'l'OP OF CASING '5 --· FT, ~e Land Surfaoe• ll oq ,er (., . IA.J, , , AIM,. J "Top of oaelng terminated at/or below land IU~ m,y require
Well Conlraclot(l ~hliduali Name r j _ . -7""': _ a varfa11ce 111 11COJrd1111c;e with 15A NCAC 2C ~ 1 &. ,
r'?:"1 ·· ."1 H I l ~./et rr Y / ~ 4 h¢t1 U-'I. cl-: a. YIELD (gpm): . / 0 METHOD OF TEST///;., /ft h
weu~;oq9mp~;s: f'4t ?,,t ~ f. OIIINFIC:TION:~ t1,7H Amount ~,t '11/?
Streel~s . .L..,,/' ~. -:,~~d.11· WATIRZONES(deplh): ~
L....!:_(i'1.4 ,,...._ ~ ~fT r.=,7 ;Top-i) 10 Bottvm J /~ Top, ___ eottom. __ _
City or Town State Zip Code : Top. ___ Bottom.___ Tap. ___ eottom, __ _ Li?J:., 769-· 07YO (Top. __ sottom. __ Top. ___ Bottom. __ _
AIU coda Phone number • Tlllellneul
Weight 2. WELL INFORMATION:
WELL CO~STRUCTION PERMIT•JMZ a I C,VJ 4 I •
OTHER ASS~IA TED Pf:RMI~ epp11eat11e)
llli WELL ID '{'if appllolblel,_~ ..... --_-.... / _____ _
3. WELL UBI (Chect One Box) Monitoring a Municlpal/Puttlc □
lnduslriallCommareiai u AQriCUllurat □ R~ Injection a
Irrigation□ OtherO (lilt~) ?(O ~,-11"(/
DAT! DAILLE0/0 '/~-//
,. WEU. LOCATION: . / / Z-of/4. • 3 -y ._SCAClf)·
IS1reel Name, N11111bct1", Com~unlly, Subdr.iaion, LCII NO,, P~r,, Zip Code)
CITY: h1111Kf,,,._, COUNTY~l'dl'\. ,.
TOPOGRAPI-IIC I LANO SETTING; lehoc:11 appropriata boll)
r,Slop(t nValley □Fial ORlcfge OOther ___ , ____ _
LATITUDE !!.._•_· · OMS OA 3.x.xxxlWO!xx DD
LONGITUDE 7.!,__• ___ " Dt.1S OR 7x,WIPO!XXX DD
t.alituCla/lOngituda ~rce: U.PS C]T'opographic mep
(IOc1Jlion of well must bt &110111111 Ofl II USGS fQP0 msp Bfld/Jrtlchtld ,0
this form If not usJng GPSJ
s. FACILl1V (Name of Iha IMilne&& whefe the well " localOd.)
Fac:illly IOI (if fppllcable)
Street Actdlell
CltYorTown Stele Zip Coae
Conlact Name
MeUing AddreN
City or Town S\ala Zip Cade
( , _"
Atu cede Phone nun,t,er
G. MLL DETAIL.I: ll 'O J
■, TOTALDIPTH:~-~-=_,, __ _
It, DOESWEl.t.RIPLACIIXIITINCWEU.? vesr:, NOC--
C, WATIII LIVIL Below Top of c,t1ng: _5 () FT.
(Use•+' If AbOWII Top of Cssln0)
; 7. CilSING: Dtpth _ Olamet8r
: Top __ eonom __ F1. __ _
[ Top __ !o11Gm_F1._ __
; Top __ Bottom __ Ft. __ _ .
: 8, GROUT: Depth Material Melho(j
: Top_eottom __ Ft .. ____ _
: Top __ Bollom_ Ft,, ____ _
; Top __ Bottom_ FL. ____ _
: 9, ICRIIN: Depth Diameter Slot liu Material
I Top __ Boitom __ Ft._in, _ In. ___ _
: Toi, ,, __ Bottom Fl. in . __ In. ___ _
: Top __ Bottorn __ Fl __ l11. --111, ---~
'
: 10. SANO/GRAVEL PACIC:
: De~ : ToP, ___ Bot!om __ Ft .. __________ _
:•~ Botto,n __ Fl .. __________ _
jTop ecnom __ Ft .. __________ _
: 11 , ORlLI.ING LOG
1·op eonom Formllion De&er!Dtion
ii~ __ 1 ___ _ ?~!4.Zn"' I£<;'-__ _,, ___ _ __ , ___ _
--'----___ , ___ _
--'----__ , ___ _
--'----
: 12. RIMARKS: d ht, /
: ~~~-~ ; ___ , .. ____(~
; I 00 HeRel!Y teRTIFY THAT THIS weLL WIIQ cr,01N Ar.e<lllOMICI! WI~
: 19" NCAC 2C, CONSTRUCTION 81ANI.WID8, AffU Tl-CAT It QOlt'I 01' THIS
: RfCOAO H/118 PR0\110,~ lj Ttl'J"~~
: ~~ /()••✓l'-1'/
I I u RTIFIEO WELL CON"fRA«;!oR' DATE
: <>li'e r ~ r w,//. e:'l,cj"
~ PRINTED NAMTOF PERSON CONSTRUCTING THE WELL .,
'
FoimGW•1b
RIV.2108
P005/010
02-15-2012 13:26 TARHEEL WATER TREATMENT 928-369-0740 PAGE6
NoNRESJDENTIAL Wl!LL c:ONS'l'RUCTION RECORD .
nf Env ir,,nr,,rn1l !Incl
: d. TOP OF CAIING ta -FT, Above Lana Surfece·
: •Top of casing terminated al/or below land eurf'ace may require
: a variance In aoco~a"oe with 15A NCAC 2C .01111.
\ a. YIEL0 (gpmt: -· k O McTHOD OF resr.A-~" ~ ... f'tl ~ f , DIIINPIC110N: 'TV ~ Amount 1/y CA!p
S~dress ,,. / , t"J 7? u : I • WATER ZONES (depth); bt<¾t:'f~ l'VC-"t..-~x :Top 2-JO Bo~ Top. ___ eoaom. __ _
Ctty or rown sin, Zip COde : Too 31 l) Bollom 15 ,_ T~ Bottom. __ _ =!L Ph~fn?m;, 0 2 ¥1' ! To, __ SoUom_ Top Thlc"=-~"----
2 . WELL INFORMATION: j 1. CASING; O.pth Dlametl r , WtlQht
WELLCONSTRUCTIONPERMIT# v.)ToJDt>I 4 / :Top_Bottom_Ft .. __
Matetllll
OTHER ASSOCIATED PER"1l~appicalll1)
arre WELL 10t(ll~bie) /::::__ -c;l ·~---· ----
a. WELL US! (Ch~ One Soll) Monitori"g □ Munldpal/Publk: Cl
1,:ICI0strlallComme,oiet □ ~ri~IMII CJ Recove,y O Injection 0
lrrtgltlonn Ollltt n 1,1,1 UM) 'j"e f ~,,,.... /
DATE DIVLI.IED /~ "/1 -//
•• WELL LOCATION;
(~~MmJ,.-!tllllll~~Ln. Lot No., P111CBI, ?Jp Code)
CITY: &~h K4 COUNTY /t(~ (Qt.I\.
TOPOGRAPHIC/ LAND SETTING: (dlll!lll epproprilta boll)
□Slope □Valley □Flat □Ridge □Ofler. _____ _
LATITUDE !!__ • • OMS Olt 3X.ll'XlCXIClt1ClCX DD
LONGmJDE !!..._• ---• OMS OR 7X.XlOCXlCXXXx 00
Latitudenongl1Ud• IDUIOa; ().PS C)rOl)Ollraphlc map
(loosffon of well must be shown OIi e USGS topo m,p alldattachfld lo
th/1 form if IIQt ulir,g GPSJ ·
•. FACILin' (Nlll'lt Of 1111 bullneu whlll'II "111 well la located.)
FeoilitY Name · Flcifity ID# (lf 1ppllcabk1J
Strtel Addrea,
City or Town Slate Zip CoG11
Conlllct Name
MHiling A,ddres&
City or Town State Zip Code
( '---------Area code Phone numw
I. W!LL OETAIUI: / / 0 /
1. TOTALD!PTH:._7..t...;:~~..__ __ _
b. DOU WILL QIILACI IXIST1NG WILL? YE.Su NO~
c. WATER L&VEL Betow Top of casino: -~ D FT.
(Use ·•• If Above Top ~r Casino)
': Top __ eonom __ ~t. __ _
j Top_ Bot\Um __ ~t.. __ _
: 8, GROUT; Depth Matertal
: Top __ Bottom_;___ F1 •. ____ _
\ Top_Bottom_ F1. _____ _
: Top __ Bottom_ Fl. ____ _
: t. ICR!EN: Deptll
! Top __ Boacm_FL_ln. _In. ___ _
: TOI>_ Bottom __ Fl. __ in. __ In. ___ _
: Top __ Bottom __ r=t. __ tn . __ In. ___ _ . -
; 1 D. SAND/GRAVEL PACK:
: Dtpltl Sa ;Top. ___ Bottom __ Ft .. __________ _
: Top. ___ Bonom_ Ft ... _________ _
:Top. ___ 9ottom __ Ft,, _________ _
: 11 . DRILLING LOG
Top BOltllm
~:ilc __ , ____ _
--·'----__ ., ___ _
---'·----/ __ _,I ___ _ __ , ___ _
---·'----
! 1:Z. RIMARKI:
: I D0 lieAl!IIV C:l!RTIFY THAT
! 15" TA COPY Or"THIS
: Rli
: _...~~~~~;;;;;;: ID -0:,1/
OR DATE
/Ci""U
'•"'' •• ' ' '"' ' ' ... ' • •' , • '.,., .. • • ': ,' •: .. ~~~··', :: , ' ,•,•:,,11,:.·. ~",, ',',"' \ .. ·:·.
S~bmlt wtttil,:..~o.~a~:Qf.c~ptetf~n to:.O.Marc-.:of .Witiir~t~·-~f,~--~-•··
111J;Mllilatrvic••.C.~r,.~t ..... , ~::17:1~11, ~:,19~··: fi'tt)~~•~·:•..i :r ••,:-.::· :· · ,•:•, .. · .... ~~~-:; ;~:,
FOffllGW-1b
Rev. 2/09
. RECEIVED 02-15-' 12 12 : 52 FFIOM-8283690740 TO-NC DENR P&S P006 /010
02-15-2012 13:26 TARHEEL WATER TREATMENT 828-369-0740 PAGE?
NON R ESIDENTIAL W§Ll, CONSTR\ICTION RltC(HtD
Nl)rth Cnniliml l)t,purtln\r.'1t of Elwiro1'Ul1cnt ;,t1d I Rw:iurces• Division of "• , Qu~lity
Well Cll'fl'llctor Comp~ Name O ✓
.:,~<t't if ~() '1'. ''«
S~dress ~,.n~
City or Town
c~f l 3'9 .... o7 c/D
Area code Phone numbat
2. WELL INFORMATION:
Stale Zip Code
WELL CONSTRUCTION PERMIT# W'Io/00 I Y I
OTHER ASSOCIATED PERMITlJ(lf applcMH), ______ _
81TI WELL ID f(lf•p1Ioe111a1, _ _.p..,_•_3 ______ _
a. WELL use (Chedl One 8oil) Monitoring o MunicipallPubUc u
l11d11Glli.11/Coml'llffliatr.'l AgriGullilral a Reco11e,y □ Injection □
ll'l'l9a110nu 011111, w (list uaa) f'<?tk,-,q/
DATE DRILLED / D --ly-II
ulldi\/iliOII, LOI Na., Pwcel, ljp CQdc)
CITY: --4:,._;,,.;;.;;~"4----COUNlY Al~,.,:\
TOPOGRAPHIC/ LANO SE1'TING: (cllacllc app,op,,a 1111111
uS1opo uvauey ul!'lat uRiago u0tl'l1r. _____ _
LATITlJDE .!!..._• ___ • OMS 0" 3X.l0CltXXICIOCX 00
LONGmJOE ~--· -DMS OR 7}(.lOOCIOUOOOt 00
La1illldeJlon91tudt source: [J3~S □ropograplllc: map
(IOCll/011 O( well muSI 0G Sl!Own on • IJSGS Iopa map S/ldatt,clled to
th/a form if not u~fflf GPS)
I. FACIUTV (Name of the buslneu Where Ille wen 11 located,)
Facility 101 (If appllQlblel
City or Town State Zip Code
Conlac:tName
Malll119 Addreaa
City or Town .__, ___ .. _______ _
Atea COdl Phone n1.1mber
I, WELi. DITAILS: »r 1
1. TOTAi. DlltTH: ':..t'U. (J
b. DOES WEI.I. REPU.CE !JCISTING WILL? YES U
C, WATl!R L!VEL Below Top Of Ca&h'IO : ,?; 0
(U .. ·+• If AOOve Top of Ca11ng)
ZlpCoao
.,.,
· d, TOP OF CASING IS --FT. Above Land su·~•
: ~op of casing terminated at/or below land surface may require
: a variance in accoraanoe with 15A NCAC 2C .0118 .
: •• YIELD (9pm); 6 t) METHOD OF TEST 1:. Y t .. J}
: f . D181NF!C,,O;;;;;F7 # Amount ~"( G sq;l .
: g. WATER ZONES (dBe_lh):
: T0'?3J6 Bottom3:3'sf: Top ___ eottom.___ __
: Top, ___ Botton, 1'op. ___ Bol!Dm, __ _
:Top ___ BOtlOm __ _ rop Bonam. __ _ . TlllCIIINUI
Weight : 7. CASING: Depth Diameter
;,T~--BotlOffl_ Ft.. __ _
\ Top_ . Bottom__ Ft.._ __
: Top_ Bottom_Ft.. __ _
: B. GROUT; De,M Maleriel
; Top __ Bottom __ Ft. ____ _
j Top_Bottom __ FI. ____ _
: Top_ 8ottDm_ Ft .. ____ _
: 9. tCR!EN: Depth Diameter Slot 81118 Matlrlll
\Tcp __ Bottom __ FL_ln. --in .----
: Top __ Bottom_ Fr. __ in, in , ___ _
j Top_Bottom_Ft_ln, _in, ___ _
: 10. UNDIGMVEL PACK:
: D1pt11 SU. lllllrlll
: Top. ___ Bottom __ Ft .. _________ _
: rop, ___ Bo1111m_ Fl ____ --------
; Top ___ eottom_ Fl, __________ _ .
: 11 . DRILLING LOG
Top Boflom
E~ ---'----___ , ___ _
---·'----/ ----'----/ ---·'-----___ , ___ _
: 12, RIMARKS: ·~~ l 9e~ i~
: 100 K!ftl!BY t;!ftTI~, lHM, ·rtt1t1 WI::::; ~ucrt:O IN M.iCUMOANCI! wm<
: 1SA ANOT""TACoPVOFTHIS :~ ~
;=./P->-~~~~~~~ /b--1~-II . RACffi>R CATE
,«#fk.S
TRUCTING THE Wl!l.L
FormGW,1 b
Rev. 2/09
P007 /010
02-15-2012 13:26 TARHEEL WATER TREATMENT 828-369-0740
NON R ESTDEN'llAL!&.ELL CONSTRUCTIO RECORD
CityorTow11
,?tJI', 3,z:-o? if¢ ..
Area COd8 Pllone number
Sin ZipCode
2, Wl!LL INFORMATION:
weLL cONsrRucr10N PERMrrw uJIQJ@I YI
O'l Ml::R ASSOCtATEO PERMITtJ! ipp11caD11,_ _____ _
SITE WELL 10 l(lt appllQIOleJ /::. -'-I ~, .. ,. __ _
3. weu. USE (Chedc One Boll) Mc1111torin11 n M11nioloel/Pubjlc □
ln<lualrlali'Commercial O Agriculttlral O Rec:ove,y u Injection o
lf'rigallonn Other □ Cff,tule} ?~c,f4_ t'tftM..,A I
DATEORILLED /D -(a ··//
4. WIU. LOCATION: /
JCat¼. I~ v Sc.4d0
(SVWI Nema, Numbert, Commllllity, Subclivi11on, LOI NO., Pumiel , ZiP Code)
crrv~ fu,,k_~-~---c~Lim 41"< etJ,..
TOPOGRAPHIC/ LAND SETTING: (cnack IIOptQjlllllt IMIX!
1:1Stope ovauai 0F1a1 nRkSQ• nOther_ .. ____ _
1.ATrrUOE ~• ·---• OMS OR 3x.JCltX)O()O(l(lf DO
LONGrruoe ~·-· "OMS OR 7x.x,uooouuuc DD
Llltib.ldellongltude source: [.):jPS tJropog,aphic map
(/Oallon of MIi must be sllawn on i, USGS tooo mso 1nd1rrached to
this form ff not using GPSJ
a. PACIUTV (lllame of ttle bu1lneu where lho well IS tacatad.)
FaciHiy Name Ftcill!ytDIJ(Wappllcabtel
Stn!el Add retl
Cil',orTown Siar. Zip Code
Contact Name
City or Town Stale Zlo Code
( I ---------Atoa code PIIOne number
I. WILL DITAILI: 1/r-,-. , ~ TOTALDE'1'H:. __ 7__,,~~ ... v __ _
b. ooes MI.L REPLACE EalSTING WELU YES O NO~
o. ,WATER LIYIL Be~ Top of Caalng:_~ ____ FT,
(Use •+• I{ AbcM Top of Ca11fng)
. . -
; d, TOP OF CAIING IS __,....,.....,....,,.,_,.FT.Above L811d Surface•
: 'Top of casing lermlnated at/or below lono BUlfece may require
: · a variance. in accordance with 15A NCAC ic .o, 18.
~ •· VIELDfapml: -D -· MITHooo,mT.d:~::_t..~h
j t. DISINFECTION: Type /r7N Amount 1/4i:: c ct/?
: g . WATER ZONES (Uaplll):
: Top -Bottom. __ _ Top ___ Sotlam, __ _
;Top ___ 8oll0ffl ___ _ Tgp ___ 8onom._ __ _
j Top. ___ Boaom._ __ _ Top. ___ Bonam, __ _
Tblcllnn.,
: 1, CASINO: Depth Diameter Weight Matertal
: Top_ Bo1111m __ , ___ Ft.,....,, __ A_
j Top __ Bottom_Ft __ _
: Too_eouom __ Ft •. __ _
: a. GROVT: Depth Materllll
: Tup __ eoucm __ ,..~----
; Top __ Bottom __ F, ____ _
: Top_ Bo1111m. ____ • Ft, .. ··-----
; 9. ICl'lllN: O.plb Dlamettr Slot SIie llltertal
( Tap __ Bottom __ FL __ ln, __ In. ___ _
: Top __ eottom_· __ FL __ ln. _ In. ___ _
: Top __ Bot1'10m __ Ft __ tn. __ tn. ___ _
: 10, SANDIGRAVlt. PACK:
: Depth Size :~IJ. ___ eonom_fL. __________ _
:Top ____ eonom __ Fl __ . ________ _
: Top. ___ Bottom __ Ft •. __________ _
: 11, DRI LLING LOG
:~i@s
'----, ____ _ , ____ _
'----'----, ___ _
'----
:·~······, ~e~•~I
j 10011!AmciA'rn·;.,:~;·wei.~~u~
: 151\ IONSTAN011ROS,IIHDTIII\TAC()PYOnMIS
: A TIit A.
j · /'t'J-&-11
: SIG .,_,,-+-.>---"""'~"'------.:.....::....;,"""""°~-,,,-..,... DATE
: PRI EWELl .
FormGW-1b
Rev,Z,08
P008/010
02-15-2012 13:26 TARfEEL WATER TREATMENT 828-369-0740 Pi:lGE9
NoN R EsJDENTTAL w1CLLcoNsTRuCT1otv -a~coRD .:•: .. ~:~· ::,
North Carolina Departmcnl url\nvir(mmt nr and Nan1ral Rc.sovrci,;~-nivi~ion nf W~~6'u~Jily· ·
C1ryorTown .
,~> 3G1 ~ "ZY't'
Ante code PIIOne number
8111111
2, WELL INFORMATION:
WELL CONSTRUCTION PERMIT# Wit>/DO {4 I
OTHER ASSOC~TE0 PF.R~ITf(J__ICl'llcaDle)_
lfTI WELL 1D tffl 111olicalel_i;;__~_-_5: ______ _
a. WILL UH (Check One Box) MOllltOtiflO a Munlelpal/Publle u
lnduatri111Commerc111 i.l ~rioultural CJ Recovery CJ Injection CJ
tmgattonn Other n (litt uael ;'f't fl,,,... I
DATEDRIU.Eo /o ·5 # 11
'• Wi.!->1,0CATIOJt. k-ff"-J'-f Sci'oo/
(S!IM4 Name, Num~. CO!ftmunily, SubdivislOI', Lal No .• Perot!, Zill Coal
CITV: &{JIIL7-COU~TV A-f~t!.d~
TOPOGRAPHIC / LAND SETTING: (chlok 1ppropriara tm)
uSlopo uva11ey uFlal URIClge tJotner _____ _
LATITUDE ~•----• OMS OR 31t,15MPXXXX DD
LONGrrUDE !L_• ---• OMS OR 7~~~ OD
LatitLIClellongitude source: OPS (Jrgpographlo map
(TOCetfon ofwel/ muat tJt allown on a USGS topo m.p anaartat:h1r1 tu
ttlla lbnn If 11c,f 11alng (JPS}
5. FACIUTY (Name ofltl• bu&ineu where the well ls located.)
FacilltVName FaClllty IOI llf appllallble)
City or Town Slate Zip Code
coniact Name
MalPno Addreu
C~orTown Stalll Zip COC!t ' ) ________ _
Area code Phone number
I , WEU. DETAILS: !(rl) ,,,
•· TOTALDEPTH: __ ~-°'--•'----
b, OOUW!LLll!PLACEEXISTINGWELL? YESO NOV ..
0. WATER LEVEi. Balow Top of Caelng;-_-___ ...,FT.
(UM ·+· If AboVe Top of CasinG)
. d , l o.i OF CASING IS .-ti . Aoove Llil nd Surtece•
: •Top of casing terminated 11/or below la"CI S1Jrfac:a may require
: e variance in acamtance wi11'1 15A NCAC 2C .Pf 18.
~ t, YIELD (Qpm); -0 _. METHOD OF:rlES'I' /''f t1"' £>4'-
j f, ' DIIINl'ICnON:,.,,. bfr'H Amount /At c-_r> p
: g. WATER ZONES (dGpln):
: Top -Bonom __ _ Top. ___ eotton!_
: Top ___ Bottom_ •.. Top BoltDm._ __ _
Top 8olt0m._ __ _
11,ic """" : 1, CASINO : Depth Dflnilltet Wllght llallrtal
: Tap __ Boaom_ Ft,, __ _
: Top __ Ballam_ Ft •. __ _
: Top __ 8cr11Dffl •. , --·~· Ft._ __
: 8. GROUT; Depth
: Top __ Bottom __ Ft., __ _
j Top __ ·Bottom __ A. ____ _
: Top __ 8ottom_ Ft.. ____ _
: t . SCR!EN: Deptfl Ol11'1'111ter llot 1111
!·Top __ Bottom __ Ft, __ ln. --In.----
: TOl) __ eoaom __ Ft. __ in, __ in, _____ _
; Top_ Bottom_ Ft._jn. _in. ___ _
'
: tO , IANDIGIIIAYIL PACK:
: DepCII Size
: Top_,., ..... Bottom __ Ft,_ _________ _
: Top. ___ Bottom_Ft .. __________ _
! Top ____ Bottom __ -FL. __________ _
: 11. DRILLING LO.O
; ' Top BoltDm
'
I ___ , ___ _
----'----____ , ___ _
---'--------'·------___ , ___ _
: 12. IIEMARKI:
: I 00 NI.AEOV CCRTI~ Tl
; 151, NCAC 2C, WE.LI. CONSTRl1eTIC'.IIII 8TANCAA0fl, ~0 THAT A CO,,,,, or: THI(\
: i.E THe : =:-!,~~~~~=~ . / ~ .. -J'". I/ j SI we ~ DATE
.f
FomiGW-1b
Rev,2/09
P009 /010
02-15-2012 13:26 TARHEEL WATER TREATMENT 828-369-0740 PAGE10
'->.
NON R ESIDENTIAL Wltl.l. C:ONSTIUIC.Tl()N ll~CORI{,(.\. ,,
·,~,f!\ . . North C:u-ollna l>epurlrmmt of En vironment a11il Na111ral R~uuN<l.~-Oivi~if11l Ill" W,.i.er Qutili1y
~-:' ~ ~~~J-~·~~: j ~i ~---,...
1,we1.1.co~·,~0R. / ,, /.. •// :d, TOPOFCAIINGIS ____ FT.AboveLanO Sulfaca•
ft, 0 ~ I' v·' /It// /~ ,i.f nt.f" .,.Of> of casing 1ermi11aled al/or below tand surface may require
-
Well C~r_(I idu N~~e __ : a wrlance In acco~ance wl111 15A .NCAC 2C -~ 8. , /)_
I (l.t" ~e V ~ I-tr lk -e/1rl '?tc : •. VIELD(gpm): -o ME~j)DOFTEST t ½r vd
WIii ~~;;
0m&i~·~"'f ~ ! r. DISINFECTION:TYI" 7/'-'?'H Amount I/ct b-4 p
Stree~ddress .,/ A// ., o-, ~,/ : ,. WATER ZONES (depth): C 'l"fl'.11 /.?l't,. /Ii'"-' 11'\a' 7 '!_ : Top -Bottom ____ To,ii _____ Bottom._ __
cu~ or Town State Zip Code : Top ___ BollOffl,___ Top,_ __ Bottom.._ __ _
1'f~) 3 6'?-t, 1~ ~ Top:._ __ eoaom. ___ Top ___ Bot\om,__ __
f.rea COde Phone number 'TlllckMN/
2. WELL INFORMATION ; : 7, CASING: Dtpth · Dllmettr WtlGht
WELL CONSTRUCTION PERMrTI kl :io JOO I.H ( : Top __ Bottom __ F\ .. __
OTHER ASSOCIATED PERMIT£ ,ippliQIJle)
SITI WELL ID t(lf app!ioable) , -~
i . WILL UII (Check One BOIi) Monitoring n MunlclPQI/Publlc t:J
lnduelri11/Commen:ill O A41riculll.lral U Recovery n lnJecti9n □
1mgauonu 01ne, u 11111 u•) ~( o ~ c,-tt I
DATE ORK.LED ✓D -f' -II
4. WILL LOCATION: / H tfc. "f -q s c.,('!'o
(Sltftfll N..,.,Numbers, Community, Subdlviaion, Lot No., Pan:.!, 7lp Code)
c11Y: t:AJ•"-rlt... couNlY 414. u--.
TOPOGRAPHIC / I.AND SETTING: (dleck 11ppropn11e 1,e4
n stope 11v.11ey □Flat uRldge cOlhtr, _____ _
LATITUDE ~. ____ .OMS OR 3lC .XlCPJ!'!lQ!! DD
LONGITUDE~', __ _' " OMS OR 7x !P!IIOUi!~ ,OD
Lllltud&/1011911\Jde sou,ca : 03PS Qropographlc map
flOctJtion· of wen muirt be shown Ofl a uSGs twio m,p anctattBdled to
this form if not using GPS)
I, FACILITY (Name of ltle buaine&G wne~ the well IS IOCAIACI .)
Fae.II~ Name Facili\y' 10, frf appllcab,_}
StroatAddl1tU
City or.Town Stale Zip Code
Conteel Name
MlliQng Address
City or Town Slate Zip Cocte
( ) _______ _
Area cocle Pho ne number
I , WEI.I. DETAILS: ~~o,
1 . TOTALDlftTH:, __ ~-'-'J:...: j-~--
11, DOEIWEU.REPIACE UISTINGWEU? YES □
o. WATI" LIVIL 8810w Top oA C11 i"g: ______ _:FT.
(Uee ••" If Above Top of Caaing!
: T°"--BoftOltl_ F\ .. __ _
: Top __ Bottom __ Ft.. __ _ .
: 8. GROUT: Depth
: Top_ So'IIOm_ Ft.. ____ _
i Top_._ BoUorn __ Ft. ____ _
; Top_ Bottom_Ft.,_ ___ _
Oiarnetar Slat Siu Mllltrill
j Top __ eottom __ Ft __ in. _In. ___ _
; Top_· __ 0onom __ Fl __ in. __ in. ___ _
: 'rop_eonom __ FL __ in. __ iri. ___ _
.
: 10, IAftDIGRAVEL PACK:
: Otpth Material
: Top ___ 8ottom_~----_______ _
:Top ___ Bottom __ Ft .. _________ _
jrop ___ eoaom __ · _Ft.. __________ _
: 11. DRILLING lOG
Top BOtiom
[) ,.___..~ ___ '/) -ea 1__..E'..r..1..1--_
1:'7 I SIS:0 _ ___,/ ___ _
---'--------''--------''----__ ....,;·,~---___ , ___ _
---'----___ , ___ _
: 12. REMARKS:
'•' • • ,.,.J • v•:,.1",,.:••, •: :{•, j •: :•• ' •,•,• 1 1, ••• / • ,' '-\,'1'/' ,,.,J,t • ',, 1:~1;,., • • :",', • • ...... , I II : ,'"I',' •
: Subl:'9~~in;~:&faY.s:~:c~~itlOfl to: D~~·~:o(~~~':i~ll'Y;:-···t~~ p~~~f.
. 1.,11;~~ :ltf'YI.~~ C•~-~l.•~~~ ~c 2~.,.,~1~.ij,~e ;:.(~•~-4H_O · ..... :_-· ·~. ·::.,.;· ·: : :'.::. ·:_ .. :, ~"ifi:
FormGW-tb
Rev. 2109
RECEIVED 02-15-'12 12 :52 FBOM-8283690740 TO-NC DENB P&S P010/010
02-1s-a012 13:as TARHEEL WATER TREATMENT 828-369-0740 PAGE1
/YJ).NR_ESIDENTIAL WELL CONSTRUCTION RF.CORD -
,. ,__ .....
1-WELL COMT~TOR: ~. ,/_ / J , : cf. TOP OF CASING IS -FT. Above land Surface•
'/"('O&;(~ L, l/f/l~/111.11,) : 'Tcpofca&lnQtermlnatadal/orbelowlandeurfaoemayrequiie
Well C~r (lftJlvlil) f>1amq ~ : 8 111111aiica Ir'! accordance with 15A NCAC 2C ,0J,18 , "'I
? Ii ~1r,q /,....,,,alt,"' ~~0t'-~"'": •· ·Y1ai>111om1: ,:J. t) !:':Ttf9DOFTEST.,/f,r ~,rr. Wall:rz;.;~~~~;, ,.~ ,I? p/ r ~ f. DISINFl!CTION: Typo....,.;~.....:. ... I'/'"..__ Amount J,~ C::. vp
S~ress /.. ·~ A./r ~ ~ ?, ; II• WATJUCINES (d8PlN.i,,-"J ~.,,_ J'('r,"-,,, --. 0 Y : Top~ Botan.""'«"""'".J"'" c_..._ Top.__ __ Bollom. __ _
CityorTown Slate ZioCOde :Top ___ 8attorn ___ Top ___ EIOftOm. __ _
,SJ.Vi Y,tf ,,.· o?c/"
Area code Phone number
2. WELL INFORMATION :
WELL CONSTRUCTION PEAMITt W1>'2LI.JQIL:/ l
O'TMEA ASSOCIATED PEAMIT!'if..•11Pl111lff) ______ _
SITI WELL ID t(if applicatlle) t.--"1
1, WEU. USE (Check One Box) Moniloring u MunleipeUPubllo O
lndu&lriallCommefClal u Agr1oulhlrat c:J ::: o lnjepon o
lmga6on□ OOl~llst use) ~ t~~ f
DATE DRILLED,tlZ-3-/f
t. WEI.I. LOCATION: . ~ / _z--p t/4 1 ~ '( .Su.•~.
(Stteal Name, NlimDM, Ccmmijnlly, Swbcliwtal""on-, _LGI_N_o-., P-.,-CWJ-,--Zl-D C-Odl-) -
Cl1Y: p,.,,.,. n~ COUNlY @<C~l't
TOPOGRAPHIC/ LAND smtNG: (Gheck 8ptl/Op,lfle bga)
nStope □Valley or:1at URldQe uott1et _____ _
LATrTU0E ~-___ • OMS OR 3x.,uooocl00Cll OD
LONGITUDE~·~-·---· OMS 011 71,xrmnn DD
lelitudeAongitude source: 03PS (Jl'cpog,.11hlo map
(location of Mil mull a. MOWfl 011 a VSGS toPO /NP andettldte4 to
this foml If not uilflQ GPS)
I , FACIUlY (Name of lhe buslnes& wt1e1e Iha well la located.)
Slree1Addreu
CttycrTown
ContaGtName
Malllna Acl(IIHI
City or Town
{__I Area code -:::p~.,on--, n-u-,m"""be_r ___ _
8. WIU. DITAILI: ,.
I , TOTAL. DEPTHl. __ l/a..-)(_~ __
Facility IDtl (If appUaab!e)
Zip Code
Slate ZJpCod11
b. DOEt WELL RIPLACf EJIISTING WILL? Yl::S n NO~.
c, WATlfU.EVELeelow Tep or casino: ~ 0 FT IUae "+" If Above Top of C11i-ng-) ___ _, •
Top ___ eottam. __ _
! 7. CASINO: Depth Diame18r
; Tc,p __ Botto,n_ Fl __ _
[ Top __ SOt!Om_Ft __ _
: Top_ Boftom___:__ FL._ __
: 8, GROUT: Depth
TtllckMttl
Wolght
; TOP, __ Sot!Dm __ Ft ____ _
j ToP_ Bollom_ Ft ____ _
: ToP __ Bottom __ Ft. ____ _
.
; I . SCREEN: Depth Diameter Slot &izt
Mathod
Mllel'iel
j Top_ Bonom_i:-t_ln. _In. ___ _
; Top __ Boitom __ i:,. __ ln . _ Ir\. ___ _
: Top __ 80\tQm_ Ft,_ln. __ In, ___ _
: 10. $AND/GRAVEL PACK:
: Depth Ila : Tcp _____ BOIO,n_FI ......... _________ _
: ToP. ........ __ Bo.tt.cm_Ft. __________ _
j Top, ___ .BoUOm __ Ft,..__ _________ _
Formation DnCliption S4"1 ~y
FormGW-tb
R111,2/09
P001 /010
02-15-2012 13:28 TARHEEL WATER TREATMENT 828-369-0740 PAGE2
NoNREs1DENTTAL -wv.u, coNsTRUcT10N Rr.c2Ro
N,1rt!i Curulinu l'JtpHl1:llf.:?lt of t!n~lr-onmel\t ru1d 1'/ll.l1,irol Re~mm:~-OivigiM of Wnter Qualit,y
,. WELL cor,,~ro~: t ~ _ ~· /k • 0 d . TOP ·oF CASING 1s _. FT. Al>ove Land surface• • /T<!J#J lr <" vv~ I If tl;,..I : "Top of casing terminated aVor beloW tand surface may req11irv
Well Con~~illuar"C/ 7.7,; fa fl!' : e 1111rianceln acz::orda"cawilh 15ANCAC2C .0118 .
· r Cl,, nRe .,,/flier , /'~ ,.I'_,.,. !..C ~ e. VIELD (gpm); .~ o~~E!_HOg OF TE$T 4 E,,AI-
Well C4:1~W"~tf?c:l? ~ ~ f. ol&IHFECTIO.N:Tw,e t:!:Tl7 Amouftt ?'vc.-'/
SIIGel ~~ £? r:2;7 3'Y~ ;~P~"'J-':P:!::f~_.z. Top ___ Bottom. __ _
City or Town.? " State Zip Caoe : TOP. ___ 8olt0fll,___ Top ___ Boaom ,re>f1 ;) Vf-&:>Jr? ~Top ___ Bottom, ___ Top. ___ BollDm:=====
Area code Phone number •
2. WELL INFORMATION: .
WELL·coNsmucnoN PERM1T1 WZI;, fl!0 ..... 1_4.J..J-J __ _
OTHER ASSOCIATED PERMITl<II W!°'1"'~..l......-------
&ITE WELL ID~if applicab•ls--~=--'=d" _____ _
3, WIU UBE (Clledl O"e B011) Monilori"g Cl Munlclpal/PuDllc □
lmMolri111Comrnercial □ Aortcultural u J,tccwe! ~ lnjeO!ionp
ln1gallonu Otha, 4:':u•I O'r!D~c L
PAT£ oRIL&.Eo .L_--::11>-rl
'· ~4iT10"t ~ I/ se-4-o I
(Sir 7-ne. Nul!DIIV, Community, SuD0111111011, LOt No., Parcel. Zlp e-r-
CITY: h!f~ J:f., COUNTY &trt:~
TOPOGRAPHIC I LAND SffilNG: tCIIICII 8PIIIOp,late lloJI)
□Siotle □Valle) uFiat r.,Ridge □Other. _____ _
LATITUDE ~•-•_: "DMS OR 3x.1;JOWJ009 OD
LONGITUDE~• ___ • 0'94S 0A 7x,ux1ocJOt gll 00
t.aliludellongltude souree: 03PS 1'71'0pograi,hie map
(locarion of wtlJ muat oe shown on I USGS topo mtp Q(ldttt.r:hed to ,,,,$ form if 1101 Uliflg GPSI
•. ,ACII.ITY (Name of Iha buelnee, wheNI "'' wtll IS loc:aled.)
F1cilityN11me Faolllty IOI (II applltable)
Street Addieu
City or Town State Zip Code
Mailing Address
City or Town Stata Zip Code
'-> ----..-----Ar■a ~e Pho11e number
$. WILL OITAILI:
a. TOTAL DIPTH: .,,. 7 0
,
b. DOES WILL RIPLACI EJU8TING WELL? ves u NO~-·
c. WATlll LlVEL 0e1ow Top ot cas ing ~ :S: 0 ,_:__FT.
(Use •+ • if Above Top of C&slng)
i 7. CA8ING: Depth Oi1f'lftl'
:Top __ Bottom_F ___ _
! Too_ Botto'"-•-:·· Ft. __ _
; Top __ eottom __ Ft._ __
: 8. GROUT: Daptn
Tftlcllneu/
Wtitht
: Top __ eoaorn_ Ft.. ____ _
! Top _____ Bottom_. __ Ft. ____ _
: Top_eottom_R .. ____ _
: I , . SCIIEEN: Depth Di.mttsr Slot Size
Mtlhod
Materlat
; ToP_eouom_ Fl. __ 1n. __ in. ___ _
\ Top_ Bottom __ Ft_ln. --In. ----
: Top __ Bottom_ Ft_in, __ in. ___ _
: 10, SAND/GRAVEL PACK:
: Otptlt Size
: Too _ .. __ ~_BoffaRL-fl. __________ _
:Top. ___ Bottom_Ft ___________ _
~ Too. ___ Boliom_ F,,, __________ _ .
: 11. DRILLING LOG
Top Bcnom
D 1 ~ ~~il(}
---'----/ ---':-----/ ,-------', ___ .,---___ , ___ _
;12,REMAR~
: I 00 Hl:RCllV CCRTIN THAT I HIS Wl!LL WAS CON5T1'U IN ,t,CCOR G I
; ISA !ilt'.At: r.. W~I I enNSTlltVOT•ON 8TANOM0e, ANO Tl;AT A COl1'f Qt= n.iis
: o ~ , 7r-~o-~/ ; llliCOll~MA$ fl~OVID!DTO~ ~
~ SIGN ~ F,CERTIFIEOW!L~ co~~ DATE
~ tf.!?£-t,,... ~ ~ //,,-,,,., f
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
FOffllGW·1b
Rev. 2/0D
P00 2/010
02-15-2012 13:28 TARHEEL WATER TREATMENT 828-369-0740 PAGE3
NON RESIDENTIAL WELL CONSTRU(:1'10N IU:C:ORD .
North Curulinu f'h.•p11rt1'1cnt oftnviro11m~11l a ,1 d NoL11ra) P..esoul'l:es, l)ivis ion of Water Qu ality
1-"•i:a.t. ;,,Jin i (l\t.1 "'~ / !1 'I/ , ; d. TO .. OF CASli'fG 18 _, ___ FT. ,!V>ov11 Lana Surface' ~"r <-., f:&L! l!!..QN : •,opotwIng1erminatedat1orbeIowlandsurfacemayrequire
Well Contracjr,~~~ual) 7me 1 • 1• -r-, , ~ -,-~ a variance In accordance with 1 SA NCAC 2C .0!l8,
i y I ? l v .. , ... r ! -•, ,',.•~· ,,. ' • C: •• YIELD (gpmj; _LP METHQDOF TEST ./9 IV L, f ,1
WellCo~'d¥"
9"~~e".9,et f&/ ~t. DIIINFICTION:.,.,,.Jrtf Amount VY k.ffj)
Street~ ~ 3 :"? : O, WATER ZONES (depth): ,/ r-f({<(, ~ ~ ~ lfll: Top ;io 3 Bottom 3o ~ Top ___ Bottom. __ _
City or Town State Zip Code : TOP. ___ Bottom.___ Top ___ eottorn._ __ _ <821:.1 36 'f -0 7 Sf?' i Top ___ Boaom___ Top ___ Bottom, __ _
ANNI COCle Phone numller : ThlollnNel
I, WELL INIIOltMATION: : 7. CASING: Depth Dlemeter Weight
WELLCONST~Uc;TIONPERMIT# u);I,Q/0014 I ;Top_Botlo,n_F, .. _ --
OTHER ASSOCIATED PERMl~ppticable),_______ : Top __ Botlom __ Fl.
SITE WELL 10 #(If •Olicalllel !.l -I \ Top __ Bollom __ f:l. ___ _
I. WELL USI (Check One Box) MonltDfing U Munleii,al/Publio n
lndualrial/Commercial n Agrioull\lral c:J ReccMIIY □ ln.)ec:tlon w
lmgallonr., Oltltr O (ihil u,e) f/ (? oh., (""6G /
DATE DRU.LED 9 "',,a 9 .... ( /
4, WELLLOCA!ON:.:? /, / ½+~ 7-f/.x 00_~·-----
(Slfee! mrne, NuMDetS, Cornmunil,, SlllldMilon, Let No .• Paroet, ZIP COUeJ
crrv: A4-, r1tt... COUNTY /JAa (0 'I\
TOPOGRAPHIC / LAND SETTING : Ccheck approp!llta Im)
ns1ope ovalley or-1st □Ridge uOtntr. ______ _
LATITUDE ~•-· "OMS o" 3.Jt.xxxx.xxx)Q{ oo
LONGITUDE 7.!..._• ___ • OMS O~ 71C.XICX,HIMI 00
LatllUClel!ongttude source: C):;PS OTopooraphle map
(location of wo/l m11/Sl be IIIOWl'I 011 Q USGS Iopa map 1tnd1J/tfJchel1 RI
t/111 romi if net 11,inr, GPS)
I, l'ACtLllY (Neme of Iha buislneN where lhe well ls lOCataCI.)
Facllltv Name Facility \o, (If &ppliClble)
street Addre11
City Or Town State Zip Code
comaca Name
MaNlno Addreaa
CitynrTown State Zlp Code
__ _,1 -=---------
Area code Phono numbllt
: 8. GROUT: Depth Matat1a1 Mel.hod
: Top_ Bottom_Ft. ____ _
! Top_ Bottom_ Ft. ___ _
: Top __ Elnttom __ Ft. ____ _
: t, SCREeN: Oe,M 01,meter Slot Sin M1eet11J
I Top __ Bottom __ Ft. __ in . __ in: ___ _
: Top __ Botlom __ Ft. __ ln . __ in. ___ _
: Top __ Bollom __ rt __ in. __ In . _...;._ __
'
: 10. BANDIORAYIL PACK:
: Depth : Top. ___ Bottom __ Ft .. __________ _
; Top ___ Botlom __ FL. __________ _
: Top, ___ Bonom_FL. __________ _
: 11 . DRILLING LOG
Top eoaorn Forma~on Description
jfj~ ----'~------'·----
v?j;i/}:f ff¾ Je~
I -__ , ,--------, .,----
I ---
: 12. REMARK&:
' -------r--"--t!~-=:::-:-~...;;;;.;:"-'-?'SI~---
; I OOMEAElll'~ATU:V , ...
, 1111l TACOPYOFTHl9 :,-
ING THE WELL
FomtGW-1b
Rev. 2/011
P003/010
02-1s-2012 -13: ea TARHEEL WATER TREATMENT 928-369•0740 PAGE4
f -;· •• ~ t-'"' ~
N oN &smENTIAL WELL coNs·rRuc~10~ 1t~i~~-·::.
1,
1, Wl:LL CON'tWICTO~ / ~ /i // : c,. TOP OF CASING IS ____ fi."Above Lan d Surface•
J J f2!!i'!../' C.. 1 U/ If I l(i"'1 J : .,.op of °''ing termineted avor below land '41rfaca may reQulre
Well ContraetOt (lndiyldusl)~ : a variance in ac:cotdane.e with .15A NCAC 2<;: .0118 .
BC (•£'.:t I W a4 y M"-le:~.,,,, 7,-c: •. YIELD (11pm): 1/0 METHOD OF TEST Ar t.~t r/-
Well C:fw'l~~aa:1-t /t'dr j,. DIIINFECTION:Type tft-d AfflOUllt '/¥<,.UJ'
s11ee1~resa •/ M "')o,., :,u : g, WATERZONEl(ded}); . "'-/-~u II K't, 4. ·'t, ~ r r .., L : Tep ,2 5?' Bollom ~ f'--Top 8otl0m. __ _
City or Town Smit lip Code : Top. ___ &ol!Ofn.___ Top. ___ Bottom. __ _
«?.iY, 3,9 -61 <{o ~·1op. __ eo1101n. __
AIN code Pilon• numbOr
2. WEU. INFOAMATION: -
Wf;LL CONSTRUCTION PERMITS W Zt'J / tJ0 J 4 [
OTHER ~CIATED PERa.UT~~~
SITE WELL 10 #(If epplial!H) ___ _,µ ___ -_;b_=------
S, WELL UII (Cha One BOlt) Monitoring I I M11nlel11&1/Pub11c □
lndu&tllal/Commercial O Aoriculll.ltal LI Reco~ n ln,Jeot!Qi □
lrri~lionn 0t11,r 11 (11st UN!' q P O -I-I.. I' tk: "
DATE DRILLED 2 -J(j __ ~/
,. weLL U>CATIO~. / /
"Tot/§, f--'/ .f!-Ao<? -
(Street Name,Numbm, Comfflllnlty, SYbcl""810il, l..ol Nu,, P11~. Z!p Code)
CITY: {::;e,",Kt ,.., COUNTY IU<,44· ~ -TOPOGRAPHIC I LANO SETTtNG: (WOii tfl!IIOII~• -i
□Slope □Valley CJF'lal URldge nOlher. _____ _
LATITUDE l!.,_•_• ___ " OMS OR 3X.XXlClOC!flllX 00
LONGITUDE !L_"_' • DMS OR 1.'g.XlOUClJC'S?(X OD
Llltitucle/longltude IOUrte: 03PS □fopagrapnlo ffleD
(location of well must be s11own 011 a USGS topo map anda/tQcllGd to
lfl/s form ff not using GPS)
I. l'ACILITV (Nam11 of Iha bu&1ness whfl" t,,e wen la located.) .
Feolil'IName Feoillty 10# (If 1pp11cai.1eJ
Street Adclreu
CliyorTown Stale Zip Code
COnlactName
Melling Address
City or Town Slate Zip COde
I_,)=·--------Area eooa Phone nUr11ber
I, WILL D.ITAILI:
•· TOTALDlftTH:. __ '-/_,_5i_,._O_" __
b. DOES W£LL RlftLACE UIITING ,WEU.? YES □ NO~
C, WAT£R LEVEL Below Top ofClslng: .r O FT.
-(UM ·+· if Above TOI> of Catino)
Top. ___ Bofforn, __ _
; 1, CASING: Dtpttl Diameter
: Tc,p_ Bottom_ Ft __ _
: Top __ 8oltom_F1.. __ _
j Top __ eoaom __ F1.. __ _
.
: 8. GROUT: Oeptl Materiel
TNctu,--,
W.lgllt
: Top_ Bottom_ Ft,._ ___ _
j Top_ Bottom_ Ft. ____ _
: Tc,p_ Bottom_ Ft.._ ___ _
Dlamttet Blot Sid
Matetlll
~ T09_. _ Bollom __ F,t. __ 111. __ in. ___ _
:TCIP--~-·_Ft._ln, __ In.----
: T09 __ BCIIIOII\....__Ft._ln. __ in, ~---
: 10. SANO/GRAVEL PACK:
Depth Bia
: Top. ___ eottom_Ft .. __________ _
: Top,_ ...... _Bottom __ Fl,, __ _
: Tap, ___ Bollum __ Fl.. __________ _
: 11. DRI_LLING LOG
: Top eoaom FonnaliOII DesoriotiOn
D 'fr m~
$V'~ ___ 1 ___ _
. ----'---. __ _,,. ___ _
I . :::::, ___ _
I
: 12, IUiMARKS:
, ~.1t:.~i,in ~:~y1 ,~~~mpa~c;n :to.;01v.1.~:ot.~•~,~~-~· -.~"·~~{
·· 11,~ MIM:,Sei'v~j,C.n~r.aa1tl9b,;·NC 27~1111.tll!hont\·•·t'1?.~f.•'-.,.... :!-..::\·., i' ... .-: ... .:;;.: .. ,:,·:
FormGW,1b
Aav.2/09
RECEIVED°' 02-15.:., 12 12 : 55 · FROM -·· ·s2s36°s0140· .. .. .. ·ro-Ne DENR P&s P004 /010
02-15-2012 13:29 TARHEEL WATER TREATMENT 828-369-0740 PAGES
NoN 'ENT/AL WELL CONSTRlJCTIO .
: d. TOP OF'CASING 18 --FT. Above Land Surface•
: 'Top of casing terminated at/or btlow land surface may require
Well Contractor 1 ,. /' -. : avari11ncei11aa:.ordancewith15ANCAC2C .~8.
q r t iv a k r (re(,,,tt,,;,,..,"rf : ,. YIELD (gpm): ~ l> METHoo OF re&T ( 1 1 v {.,,,J;/,-
wau eon1ra51yq";{:"Y &"".i1'.'' i: Re( ~•-DISINFECTIO~ tfCH Amount fv Gvf'
Stteet Addre ~ ~ A~ ? r>,;,y : •· w~ ZONES (depJht. C!,!' It "-,,,., ~ , tT ~.;,. : Top t'i,l.,S O Bottom .ii ~ .a. T~. ___ Bolklrfl_
Cl1yorTown 91a1t Zli,Coele : Top ___ eonom ___ Top. ___ uottom_.
,@.f I r,'f-07(/'a :Top ___ BollDm. ___ Top. ___ eottom,_ __
Atta cocre Pl1one number
2, WELL INFORMATION:
WELL coNSTRucr,oN Pe~Mrr•..W:Z:0100 /Ll l
OTHER ASSOCIATED PERMrrtJlr1llfllica-)
IITI Wl!Lt. ID '(lf appliOll:Jlf.~._ _ _/l..,.,__-_3 _____ _
3. WELL UBE (Ctltdt One Bea) Monitoring □ Munloioet/Publlc □
tnduslrial/Commercial □ Agricultl.lral □ Recove,y u 1,uact1on u
Irrigation□ Other~
D~TE DRltJ.EO ~ 9 -6', -//
•. weu LOCATION: ' /. /
(St,.; i&t.f uml. ;r,,,11;: s ~~OII, Lot No., Pllrtel, 2lO Codi)
CITV: B a11 ef,:,..,... COUNTY /4"it"~,,,.,.,
TOPOGRAPHIC / LAND SETTING: (dd llflOIOpriN bolrl
CJSlope CJValley □Flat □Ridge □Other ____ _
LATITUDE ~• ___ • OMS OR 3K,XXXXl0000l DD
LONGITUDE ~ ___ • OMS OR 7• !IOS!ll!Xll OD
Latitude/longitude aouroe: CJ3PS (JTopogrephlg map
(IOQ.rto,, of we/I muat be shown on fl USGS ropo map anaattaciled to
Utl• '°"71 II not 11•1"9 GPSJ
I, ,wu,v (Name of the bualnNI where lhe well 1, toc,tec,,)
Feoillty Name
Straet Acldrua
City or Town Sarte llP Coae
City or Town St,19 ZIP COCle
( ) ..,.,..-------Alea code Phone number
I, WEU. DETAILS:
a. TOTAL DEPTH:. _ _,'/.~n.;;;tJ __ _
b, 0011 WILL IUP~I UIITING WELL? YES Cl NO.--,
c. WATER LEVEL Below Top of Citing: !f::: 0 FT.
(Use·+· if Above Top of casing)
Diemewr : 7, CASINO: Olpth : ____.. : TQP_ 8011Dm_ Ft .. __ _
: ToP_Boaom __ t=t .. __ _
: Top __ Bollom __ Ft. __ _
: 8. GROUT: Depth Material Methocl
: Top_ BoltOfJI __ A-. ____ _
j ,.oP __ Bom,m __ Ft.. ____ _
: Top __ Bottom_ Ft,, ____ _
: 9, ICRIIN: Olpttl Dlametlr Slot Size
! Top __ Bottom __ F1. __ 1n. __ in . ___ _
; To,. __ Bottom __ F1. __ 1n. __ in. ___ _
: Top __ Bonom __ Ft. __ in. _. __ in. ___ _
: 10. SANDIOAAVEL PACK:
: Olplh Ila Mllltrlal ;Top. ___ Bottom_Ft.. __________ _
: Top. ___ Bottom.._FI,. __________ _
j Top. ___ Bort0m __ F1 .. __________ _
: 11 . DRILLING LOG
Top Ballam
,~ ~-U-
ftl J~ -----'----_--' ,------, ----__ _,! ___ _
·/ ,---------'----
: 12. Al!MARKS:
• -----~..,,._--"'7r'~:'""lli."::----=-::-----:--::-::tt-
:
0
1 00 H!Al!IIY Cl!ATIFY THAT THI
: lSA HCAC 2C WELL CONIIT'RUCTIO'I &T A CO~ I)~ !HIii
: Ill!
9'-,IG~ I/
;SI DATE
: tJ ~~,, , ,a~
i PRINTED NAM {OF PERSO UCTING THE WELL
Submit~-·" 30 :.ji'.of e~pt~n. io:\O.lwi•i~~}df.;:0111.ijtyh ~il~lifi~'
.~117 ~II ~l'ViCI! ~r, ~IJh, NC:-279n~1t1,"~d111,,:-~'1)"80'$;11Q~::~~!,; · <=~:-· · ·· 1·:'. 1 •• ···? ::":·>
FormAW•1b
~Ill. 2101
P005/010 BECEIVED 02-15-'12 12:55 FROM-8283690740 TO-NC DENR P&S
02-1s-201e 13:~ TARHEEL WATER TREATMENT BeS-369-0740 PAGE6
\..., ....
NoN REsmENTIAL WELL s::0Nsmucr10N ucoRo
Morth Carolina De,i:irtmcnl .,r ~.nvironmcnt aJ ILI
I. WilL C\Jtl7 Rlit.~ /, / /' • ; ~-TOP OF CASING IS~-... , .. ~--FT, Above L.and SuJlace-<•. n ~o I L. . U/ 1 " ot"' 5 : 'Top ~ OHl~g terminated atl_or beloW land surfece may require
Well Contra~ndividu1\j Name _ ~ ~ a 11an11nge tn !IXlOrd~c:e with 1 SA NCAC 2C -~ 18. /"I
~{t.J. rAe.o / .l-<)a. /..e p Jri~IH,,n.,,,/-:fi-c:e. YIELO(QPffl): -D ~~ETH000FTEST /q,v {_,.,1-J.
Well ~ctor Compa_!IY Name ? A ; i DISINFECTION• Type ff rtz Amount 1/q: C v 0 --l1/°47 ef l,-eo,5 ,-r ~ : . . F
Street ~dress ~ ~ : g. WA'tER ZONES 1aepll\):
f-i-'~~fl&!._I. ~ ;?f7J'C/ : Top .--BOl'IDIII. __ _
City or Town Slllte Zip COdo [ Top ___ Bottom. __ _
Top ___ 8ottom,__ __
1 9';11" 1 3 b -» -0 7 <lo l Top __ Bottom. __
Area code Phono numll9r :
Top. ___ 8o1t0m. __ _
Top ___ BottDm, __ _
2. WELL INFORMATION:
weu. coNSTRUCTION PeRMI,.. WZO!N> .... I 4 ......... J __ _
OTHER ASSOCIATED PERMI~;;?
IITI WELL ID#(ll1ppllcalll1,._1 -U.~-~-JE.;::;.. ____ _
1, WELL UH (Chectt One Sox) Monl10rin9 □ Muntclpal/Publlc n
lndualrial/Cammorclal u AQrieuttural o Recove,y Cl lnjeClion IV""
lnigationO 0Nr !? (tlat uaa}
DATE DRILi.ED T_-,;/"$ -ff
•• WELL LOCATION: f
ZQJ.(!,i. 7-4/ sc(;,ei
(Stml numee,a, ColMIUlli!y, SllbdlMion, Loi No .. Paree,, Zip Codo)
CITV! Q_ 411. K:lr ~ COUNTY /4gc O "'-
TOPOCRAPHIC / LANO SETTING: (Cllleit eppn,oriato llolll
OSlope r,Valley OFlal URidge OOttler. _____ _
LATITUDE !!,_•_• • OMS OR 3X.XJ000lXllX~ 00
LONGITUDE 7.!__•_• "OMS Ofl 7J,J5XHXQq DD
UlltudeJlongllude source: 1")3PS QroPOGtaPhlc map
(tocation ofwetl mu.st n shown on It USGS ,opo map enctsltlfelled 10
th/I '°"" ,, not using GPS)
s. ,ac1U1Y (Nllme of tne bu.slneu wnera 1ne well Is loea!8d.)
FtcilllYName Fecllity 10# (If ,ppllcable)
Street Address
City or Town Slate Zip Cede
contact Namo
CltyorTown ZlpCocte
( , _______ _
Alea cade Phone number
e. WILL DITAILI: I ¥g;, __ •· TOTAL l>EPTH;
! 7 '. CASING: Depth Diameter
: Tap __ Boaom_ Fl. __ _
j Top_ 8otlom_ FL. __ _
: Top __ Battom_Fl. __ _
; 8. GROLIT: !)ea#I Ma!Brial
Thlckn...,
Weight
! Top __ eottom __ Ft •. ____ _
! ToP __ eonom_rt. ____ _
: Tap_ Bottom __ r:1.. ____ _
; t . ICREEN: Oepttl Ollmewr Slot Slllt
Matortll
\Top __ eottom_Ft._ln. __ in. ___ _
: Top_Bottoni_Fl._ln, _In. ___ _
: Top_Boaom_R. __ ln. _ In. ___ _
: 10, IANDIGIIAVIL PACK:
: Oeptll llze : Top ___ Battom ___ Ft. __________ _
:Top. ___ eouom __ Ft ... _________ _
(r~ ____ Sollom__~.-----------
: 11. DRILLING LOG
: T~ Bottom
I D 1'??
!~~ : . I .;--__ ..,,----
---·' __ ,----__ _,/ ___ _ ___ , ___ _
I
----'----
; 12, REMARKS:
b, DOU WELL RE,LACIIXIITING WELL? YES CJ No i6.---"""" [s ;;:l;;;G~Ntf~,{;.~~~~~~~;::.~
r L, ~Jt~Ho.J
Cy-.2 !-I I
DATE
o, WATlflt.MLBelowTopofCasrng: ' ~-FT.
(UM ·+· if AbCMI Top of Casing)
''i ••,M~:;,,; .. •,, ·•.!"':• •, • ., • •• •:n•· .. ,• •· ,-f\l;.:,. ,,:. ·.r,·:,\'~\·,•.,:tr,1:. ,,,'-('•. \J•,:· 0 .. ·•-•,•,:,
,au~ll~~)~~-,. of.~,npl~n ~~lllort_·:~~~~-~1.!W,:.w:;::l~liP~j··
. i017-r .. lf.lervlc• Centef.,,IWelgh; NC 21.M~1e ,. Phor,e • CNa).IO'Jii.lHO:--. . -1-: ,.. .. :-.. : :-• )'•· : • •
·RECEIVED 02-15-' 12 12: ss · FROM~ 8283690740 .. · · ·: To-· · ·Ne DENR P&s
FormGW-1b
Rev. 2109
P006/010
02-15-2012 13!29 TA~L WATER TREATMENT 828-369-0740 PAGE7
NON R ESIDENTIAL ELL CONSTRUCTION RECORD
Yt\;·~_.,_,_.( ;-
.. -I"''
NHlu111t ' '
: d. TOP OF CASING IS ____ FT, Above Land Surface•
: "Top ot ca&ing terminateG avor below land surface may requi,. i ~ 11alia~ca inaccor~nce with 15A III CAC 2C .0118,.. _ /'I
·: e. VlE LD (gpm):-=.G?.'-77 Ml;THOD OPTEST/41 c~r
: f. DIIIN,tCTION: Typer, "r# Amount 1/v ,_,,~/J . -----'
Sllaal AddreJI"""'.' ,:A :v A YI ? 0-,_;,,, / ~ •· WATER ZONES (dept)):
-..---,,,.......;r___.:,1;...4(t-'-l/;...~_;_,,1_A ___ _.;.l'_--=-_ __,ro,,_~./;;;1_,r1 . TOD -Bottom.___ Top ___ ~
( ;4rown ~/ ~ Stale Zip CO<le j Top ___ e~---Top Bonom. __ _
1 -JGPL -()? Y§> : Top __ eottom.__ Top Boftom, __
Area code Phone number ThlckMSII
i 1 . CASING: Depllt Olemetier Welthl :,, WELL INFORMATION:
WELL CONSTRUCTION PERMIT# IA/ZOIC()J'-l /
OTHER ASSOCIATED PERMIT•:'Pllll cnl~)
lffE WE Li. iD 1111 •~el ,f}__ -· f
: Top __ Bottom_Ft. __ _
; Top_ Bot!«n_Fl. __ _
: Tap_· __ ao,iorn_ Ft •. __ _
3, WELL USE (Chec:11 One Box) Monltor'ttG n Municioa1/Public w ./·< a. GROUT: o•pu,
tndusbiallCommercial u ·Agnc111tural □ RICOWry □ lnjtolio.n g,"'"' : Top __ Bollom_ Ft .. ____ _
Mlterial Method
lrrigatiann Othero_)jistuse)_________ ) Top __ Bonom __ f:l
DATE DRILLED 7 'd<i .. I / ~. ToP_ Bottom __ Ft. ____ _
(Slteel Name~mDalll, Con,. ll'IU~lly, Subdivision. LO'I No., Plll'Cel, Top Colle)
CITY: b._4~ r,"4 ___ COUNTY.d{t1Ct1,~
TOPOGRAPHIC/ LAND SETTJNG: (Clleetl ap11111priala IIDX)
nsrope ~Valley uF1a1 □Rldg1 □Other. ____ _
LATITUDE 36 ----··-• OMS OA 3JC . .IOCXlUt!!!! DD
LONGfTUOE ~·-· • OMS 011 7)!.XXxY(Hgt ao
Lalitudllllongllilde soun:e: OlPS (JT'opographic map
(loctJtion of...,,,,, muat be lhQ111t1 on e USGS ,opo m;,p enctattached IO
thl• form ;, no, using GPS)
I. FACIUT\' CN•me of the bu11neu v,htre lhe well ii locatea.)
FacllilJN•m• Facility IOI (it applicable)
StrNI Adclreaa
City or Town State llpCDCle
Con1ac:1 Name
_Malling Addrt$$
City or Town S1e1e Zip cooe
< I ____ _
Are, oode Phone number
I , W!t.J. DETAIL&: ,
L TOTAL Dll'TH:,_i./..__,)}_2) __
b. DOIi WELL AEPLACI UIITINQ WELi.? VES t.J
c, WATER !£Ya Below Top of CHlng: _ .. ____ FT,
(Uae ·•• if Abo\le Top of Ca1lng)
: I. SCREEN: Deplh Dllrllllff Slot Sim Ml1erill
) Top_ Bottom __ F1. __ 1n. _ in, ___ _
: Top __ eottom_ Ft. __ 1n. __ in. ___ _
: Tap __ Bottom_Ft. __ ln. --In.-~--
: 10, SANDIGAAVEL PAeK:
: DellCh liza
; Top. ___ Botlom__ Ft. __________ _
;Top. ___ Botlom_R~-_________ _
: Top. ___ Sotlom,._ Ft.. __________ _
: 11. DRILLING LOG
Top Bottom ~~,j rz::_, Vl-C
---'----' ,,---------, ____ ,----___ , ___ _
I ---'----
: 13, REMARK.S i
FormGW-1b Rev .voe
P007 /010
•
02-15-2012 13:29 TARHEEL WATER TREATMENT 828-369-0740 PAGES
NON R ESIDENTIAL WELL CO NS1'1lllCTION RECORD
~for1h C:irolln11 Ocpartm~Jlt ofEnvin)n1h~nl ,111d Nu.111n1I RcsnuNc.~-Divisiclll of Water Qu."llity
'• •t c;i.L. -v~¾ ~ N • • •• L ,. . j / / ,1 . -A r : d , rc.;11 OF CAl:l1NG IS --FT. Above. Lano Surface· 0Jt 4 e C • (,A.A'' 6' o,.,,._, : ~op of caaing terminabld at/or below rand aurfaoe may require
Woll con~f~idual))laMJ. f /',.,. --r:: : a varnince In accordance With 15ANCAC 2C -0)18, L
./ (2 I' 1·~ I < ~/IY<'V • "H.a /~./, .,::, c ~ •. YIELD (11pm); k -ME.THOU OFTEST ,-47r. y f_.,.-;-if
Well C.9jlr~ Companpiama • 1 '7/ ; ,. 0I81N,eCT1ON: Ty,-tf--rJJ Amount 'lt( G,."p .2U'-I ~ef~!i «~ : --~----,
SU'eet~.,,// "-Ill? '21?~ r l ~;,., W~pll\): Top ___ Bottom. __ _
City or~ Stele Zip COde : Top ___ Bat'°"1,___ Top· Bottom. __ _ rM1 <{:_7,,. ,;, 7,/-~ ;Top ___ Bottom. ___ Top ___ Bottom. __ _
Am code P11ist.iiun11oer TlllollnWI
2. WELL INFORMATION: /
WELL CONSTRUCTION PERMITI . WZ1> / 8() 14
I
OTHERASSOCIATEDPER~rr~~::
51Tli WELL 10 #(iflPPfable)._·_.,L,2-'----"~------
: 7, CASINO: Depth Diamere,
: Top __ Bcmom __ Ft._ __
j Top __ Bottom __ Ft. __ _
: Top __ Boaom __ Ft ___ _
Weight
J, WELi. U81 (Check One Box) Mon110t1no CJ Municipel/P11blic □ . ; 8 . -GROUT: Depth Material
lndu11na11Comme,011 n AariOulturat o Recovery u lnjOCllonV i Top __ ecaom __ Ft. ____ _
Method
1,t1gallont,;1 Otna, r.J ! ul!!-,--~------: Top __ eoaom __ Ft
DATI DRILLID L.. -~ I-// ~ Top __ Bo110n1 __ Ft. ___ _
(Street~ Numbe11, Com1111,nii,. SYbd illialon, Lal No., Pa,ce11 ZiP Coool
CITY: r!..-<t4. /cl,._ COUNTY /4trc ('"'-.
TOPOGRAPHIC/ LAND SETTING: (Cllleck •~ ml
usiope ·uvauay t::iF1a1 □Ridge nother _____ _
LATITUDE ~ ·---• OMS OR 3X,XXXIW000C OD
LONGITUDE75 ____ • DMSOA ~ 00
Lalltudellongitude source: CJ3PS nrooo;rapni~ map
flOCfllOn Of"" mutt II• ahCwrl on • USGS '®o "'8i> and11tf8CMCY IO
111/s fo,m d no, USlflO GPSJ
I. ,ACIUTV (Namo of tr1• llu&intM Wflara the wen 11 located ,)
FICilityName Faclhty IDf tlf applicable)
Street Address
City or Tow/I Slate Zip Code
Conlac:t Name
MallingAdd'811
City or Tciwn Stale
: t. SCREEN: D1pth Diameter Slot Sa Meterlel
j Top __ Bottom __ Ft._fn, __ In, ___ _
;Top __ Bottom __ Ft __ in. __ in , ___ _
: Top_ Bottom_ Ft._ln. __ ,_ in. ___ _
: 1G. &AND/GRAVEL PACK:
: Depth Size
; Top. ___ Bottam __ Ft.. __________ _
: Top. ___ Bottom_Ft.. ___ --------
! Top, Bottom_ Ft. __________ _
; 11. DRILLING LOG -
Top Bottom
t) I~
~S!SJ) ----'-------':-------':--------'-------'----_, ___ _
---'----____ , ___ _
: 12. REMARKS!
Formation Detctlollon
!!l""~~
Farm GW.1b
Rtv.2/0a
P008 /0 10
02-15-2012 13:29 TARHEEL WATER TREATMENT 828-369-0740 ·1 .,. I , PAGE9
1 ·'
City or Town Stal8 ,« ) :i,,. _ 0 ?t.fi)
ZIDCode
Area code Phone numllOr
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT• W'Z()J()Q/4 I
: d. TOP o, CASING IS ..---FT, Above Land Surface• ! 'Top of ea&ing 1e<rmiriatr.,d avor Q810W lllM Sur1aea mey requlPJl
: a valiance in accordance wiU1 1 M NCAC 2C .D 118,
;e. VIILD(gpm):~,-~ODOPTll1 /4,. ~&-
: r. DISINFECTION: Type--'-----Amount Y'( <::,-"'-/J
: g, WATIR ZONES (depfl):
: Top -Bonom. __ _ Top. ___ 8ottotn_
: TCIP·--~eonom-. __ Top Bottom. __ _
:Top, ___ 11o11om __ _ Top ___ Bollom. __ _
: 1. CASING : Otpth Dtametar
: Top __ Bottom__ Fl._ __
\ToP_eottom_Ft.. __ _
ThiokrNIHI
WtlQht
OTHER ASSOCIATED PERMIT~•POlable)
IITI WELL. 10 ~If ljlpllC&Dltl B. -7 ; Top_ eottom_ fl .. __ _
J . WILJ. USE (Clleell One 8al} MOllltollng r:J Munleipal/Publlc IJ ! 8, GROUT: Depth
1nc1us1rla11COmmerc11110 AGtiOullural u Recovery u Injection~-\ Top_ Bottom_ Fl .. ____ _
lmg.itiono Oltl•~!:L/li:11 uso) ____________ : Top_ 80fl0/l'I_ Ft.
DAfllDRILLliO +,iJo,.. I( j Top_ 8ottom_~1. ____ _
Matellat
•. wau. LOc:.aT10N1 / / : 9. SCREEN: 01ptl1 Olal'llftar Slot SID Malltlal
1;".../1,r-J-r: j C..Ul(J ~ TOI)_ eouom_ Ft_in. _ in, ___ _
(8~ N11rnlllra, Community, &lbdilltllklll, Lot No.. Parcel, Zio Code) _r :Top_Oo1tom__F1. __ 1n, _In. ___ _
CITY: r(4,i t'l,,,. COUNTY . t11t£(;t!> ':"'.\ : ·loo_ Bon0/1\....._._ l=t._in. _ ;,,, ___ _
TOPOGRAPHIC I I.AND SETTING: (Checll. 1P~ ~
~Slope OYalloy C,Flat L1Rid91 CJOth'er _____ _
V.TITUDii !!-•-•---• OM:S o" 3151,oooonurx!( OD
LONQITUOI; ~•_: • OMS OR ~ DD
l.atin.tdellonallvde tource : C)lP& ['Jropograplllo "1ap
(10C1tlon of WQ/1 muet be ahOWn on e USGS ttipo map ant1attaohed n,
1/114: ~ lfnOf 11-'"9 GP$)
I, l'ACILITY (Name of lhe bullneat wt\ere tti. ~• i• io=~->
Facility Nam. Faclllty I[» (if •PJl)iCllblt)
City or Town Slall Zip Code
Citw or Town
I ) Am COCfe ""p,_nc,-ne-nu_m...,.b-er ____ _
I , WILL DETAILS:
t , TOTAL l>!PTH: 1 ~0
b. DOHWELLRIPI.ACE&Xll11NOWILL? VESCJ NOV
C, WAffR LEVEL Below Too af Caali\o: ----
(Use ·•· if Above Top of Casing)
: 10, SANDIOAAYeL PACK:
: Deoth -...rt.,
: Top~ __ 8011Dm_Ft .. __________ _
! : Top'--_....!Bonom_Fl __________ _
! Top ___ Boaom_F1.~--_______ _
: 11 . DRILLING LOG
ToP eonorn
¼:ZY:
2'.'.2 ~§a ___ , ____ _
' __ .... ,:--------'·-------·'.----__ __,/ ___ _
---·'----
: 12, "EMARKI:
Form811on O..crlption
r~?
r-µ .,,, : ;;;;~1;;::;o_,;~~;;.fu:~~~~;;~~~:--DATE
:PRIN
.. .:, .. '. ·•,'••·: •.~.,.· ........ ,, :, .,.,, ·'·'''• ·~ ... \,.,••• .. ~,,": ... • ·: ...... , .. , .. •,,• . , .......... ,
. ~1:1~·-t,fn.\O ~ ol,.~n,pl-~n. ~.,,piv.i~l!O"'.P.t~ .. ~rty·:• ~~n ,tOtftlf.n,,·
·111~ ~~~:&arv1e~~ftte!, ... ~1t1tft,J.,,;.rr••1,1~~~,: ~~,•>~1.◄•·•: .... .-.. •: :· · ,:: .... :.r,: : :,.,. -~., · :· ....
FormGW-1b
Rev. 2/09
,• "",,, '''f, •, t , ,•, '"• •' ''',. • , , ••' • '• !,', ,• '" ,,;,•, 1 ,, I .,•,
RECEI VED 02-15-'12 12 :55 FROM-8283690740 TO-NC DENR P&S P009/010
02-15-2012 13:30 TARHEEL WATER TREATMENT 828-369·07q0 PAGE10
NON RESIDENTIAL Wltl,L CONSTRIJ(.,.ION .RF..CORD ,:-
' • -·,.. Re.~,)u/'Ccls-Oi"ish)11 11fW:1w -Ouh itv•
tt;te.__ tf/C 413t/
City or Town stete Zip COde
,rl>.t , 3£1'" D?f/!) ~ Pl'lone number
2, WEU INFORMATION:
WELL CONSTRUCTION PERMIT• W I;lJIQ l) IL/ I
OTHER ASSOCIATED PERMIT!t ::'ble)
811'! WELL ID~llllpplallllt,_) _,;Jd...,· -'--~-------
3, WEU U81! (Clltdl One Box) Mo11itOling □ Muntc,paVPuDIIC CJ
lndi.iatrl811Commeri.ial n AQricu1t11111 □ Recover; u 1nJac:t1Dt1 ✓
1 mg,t1on□ Oltler 9-Jllsl UM)
DATI D"ILLED f;f_· " ., JI
4, WIU 1,-0CATION: /
.Jof/4 3-·r sd,o
(81reet NameA11m-, ~0111m11nitv, ~11bdMlion, t.ol No., Plll'CIIII, ZJp Coclt)
CITY: t1t'4, kin, COUNTY 11i,,,~Q-I-\,
TOPOGRAPHIC I LANO SETTING: lchlca app/OflliN OOJJ
U810po uvaltey r,Flat r:,Ridge CJOther _____ _
LATITUDE ~••-•---• OMS 011 3ll:lUutg,cxu OD
LONGITUDE~•---•---• OMS OIi 7x,XXXJCXXXXl DD
L1tltucl6'ono11uae source: C)3PS Qropogn1phlc map
(IOC8non of WOii mu.st be .Jiown on 8 USGS ro,,o map andaltat:lhed ,o
thia fonn if not US/fig GPSJ
s. FACILITY (Name of Iha bualnau whare ltle well ia located.)
Facility Name
StttetAdarau
City or Town State Zip coaa
Contact Name
Malung Address
City or Town
t l...,.... ______ _
Area code Phone numt>er
I, WELL DETAIIA: 'rl'I ~
I, TOTALDEPTH:~'/.._J,_v __ _
b, DOES Wl!U ll!Pl.ACE EXISTING WILL? YES 1::,
o. WAT!R I.ML eeiow Top ar Casing: StJ
lUse •+• If Above Top of C1111ln11)
Zip Code
FT.
; d, TOP OF CASING 18 -·· FT. Above Lancf"Surfac:e~
; "Top ot casing _ 1erm1nated al/Or oelOw 1ana surface ma~ require
: a variance 111 acoordance with 1 !IA NCAC 2C .0118.
~ •. YIELD ~gpm): / () 6 MITHOD OFTEIT A,"" L,/ f
~ f. DtBINl'!CTION: Type /f 7Ef: AmOunt Ytr" r.,,.f2
: O, WATER ZONES (depth); (
: TOPJ:it a Bottom "a/i TOP. ___ Bollom __ _
: Tep ____ Bottom.___ Top Bottom __ _
: Top:-__ Bottom.___ Too. ___ Bottom __ _
: 7, CASING: Depth Ol1metor
( Top ~-Bottom __ Ft._~
: Top __ BoUom_ Ft._~¥
'Top_ SOUIMI_ Ft. __ _
: 8. GROUT: 0.1)111 Malarial
TfllellnoHI
Wolght
: Too_ 8otlom_ Ft. ____ _
\ rop __ eouom_ R . ____ _
: Top_eonom __ Ft., ____ _
: t . SCREEN: DepUI Diameter Slot SIN Matot'lal
j Top_Bonom __ ft __ in. __ In. ___ _
:Top __ Bottom_FL __ in, _In, ___ _
j Top_ Bottom __ Ft. __ in. __ In. ____ _ .
: 10, SAND/GRAVEL PACK:
: Depth Size ; Top ___ Bottom __ A .. __________ _
: Top ___ Bottom __ Ft.. __________ _
i TOP-~Boltom __ Ft. __________ _
' : 11. DRILLING LOG
Top SDIIOm
~:i;= __ ...,, ___ _
Formation 0elcfiption
q:ji~:f;; NJ q r-za.--l,e ___ , ___ _
---'--------·'----I __ ..,, ____ _
----'--------'----
: 12. RIMARKI:
; 100 Mfft!ev C!"TI
; 1 l>Tt1AT.AC'Ol"'YOl'Tl1I1S
: ftE 7;1~-11
CR DATE
., ~11~
F PERSON CONSTRUCTING Tl-IE WELL
FOffllGW-10
Re¥.2/09
P010 /010
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depanmcnt of Environment and Natural Resources-Division ofWaterQµafity ·
WELL CONTRACTOR CERTIFICATION t, 3118·A
1. WELL CONTRACTOR:
Timothy R Ham by
Well Contractor {Individual) Name
Midsouth Geothermal
Well Contractor Company Nam•
8275 Tournament Dr Suite 185
Street Addreu
Memphi s TN 38125
C ity or Town State Zip Code
1 901 > 7 48-9 095
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# ... W'----IQ._1.._0 ... 0._1._4'""1'------
OTHER ASSOCIATED PERMI~~ e~lcable)
SITE WELL 10 #{If appllcabla ),-+lJ~~--'--------
3. WELL USE (Check One Box) Monitoring O Municipal/Public D
lnduatrl al/Commeretal.D Agricultural D Recovery □ Injection D
I rrigation □ Other.J(llstuse) Closed loco Geotherrn
DATE DRILLED I~ -'J j,-If
•• WELL LOCATION:
1166 Lotla Church Rd
(Street Name. Number&, Community. Subdivision , Lot No ., Parcel , Zip Code)
c1TY: Franklin couNTY Macon
TOPOGRAPHIC I LAND SETTING; (check ~ate box)
ostope □Valley i{F111 □Ridge □Other. ______ _
LATITUDE ~ ---· OMS OR 3x.xxxxxxxxx OD
LONGITUDE~ ·---· oMs oR 7x.xxxxxxxxx oo
Latitude/longitude source: [PPS OT'opographic map
(locallon of well mu,t be shown on a USGS lopo map and11tt11ched to
this form If not using GPSJ
5 . FACILITY (Name of Iha business where the well ls located.)
Macon Elementarv
Facility Name
1166 Latia Church Rd
Street Addreu
Franklin
C ity or Town
Macon County Government
Contact Name
Mailir,g Addre1■
FrankHn
City or Town
--~> -----------Area code Phone number
8. WELL DETAILS:
a . TOTAL DEPTH: q ) -:::,'
Facility ID# (If eppllcable)
NC 28734
State Zip Coda
NC 28743
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES O NO ry
c . WATER LEVEL Below Top of Casing; -5:"" 0 FT.
{Use•+• If Above Top of Casi ng)
-----------.
: d. TOP OF CASINO IS 2 'FT':~ Lano,Surfape: •
: "Top of ~sing terminated al/or below land surface may require
: a variance In accordance with 15A NCAC 2C .0118.
~ e. YIELD (gpm): d<:l ·· 3:.0 METHOD OF TEST Btow Down
! r. DISINFECTION: Type HTC Amount 12 CZ
: g. WATER ZONES (depth):
:Top ___ Bottom ___ _ Top ___ Bottom._ __
;Top ___ Bottom. __ _ Top. ___ Bottom._ __ _
: Top ___ Bottom __ _ Top ___ Bottom. __ _
: 7. CASINO: Depth Diamete,-
~ Top..s::t__ Bottom,ia_ Ft. 6 1/8
: Top ___ Bottom ___ Ft._ __
; Top ___ Bottom_Ft __ _
Thicknnl/
Weight
....1L
Material
steel
: 8. GROUT: Depth Material
: TopJL__ Bottom~ Ft. Bentonite
: Top.i::l._ Bottom 4$l2 Ft. washed stone
Method
Pumped
poured
: Top ___ Bottom ___ Ft. ____ _
; t. SCREEN: O.pth Diameter Slot Sin
: Top ___ Bottom ___ Ft. __ ln . In. ____ _
: Top ___ Bottom ___ Ft. __ ln . In. ____ _
: Top ___ Bottom ___ Ft __ ln . _ In. ___ _
: 10. SAND/GRAVEL PACK:
; Depth Size Materiel
: Top. ___ Bottom ___ Ft. __ _
: Top Bottom ___ Ft __________ _
: Top. Bottom ___ Ft. __________ _
: 11 . DRILLING LOG
Top Bottom Formation Description
a '-~~::) __ "62 / ... ,.:, ~
---'----
,.~,r ~J ,, /2J ---y
..)
---'.------~/ ___ _
----'-------~----____ / ___ _ ____ / ___ _
---'----
: 12. REMARKS:
: Casil 19 Ren 1ovea
: I 00 HEREBY CEATIFYTHAT THJS Wal WAS CONSTRUCTED IN ACCORDANCE WITH
: ~~~~ ~~Cet:=~~:~:it~~~~DTHAT A COPY OF TI11S
: ,.; • .1.1-1/
RTIFIEO W ELL CONTRAcfoR""' DATE
: Timothy 8 Hamby
; PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality • lnfonnatlon Processing,
1617 Mall Service Center, Ralelgh, NC 27699-161 , Phone ~ [phone]
FormGW-1b
Rev. 2/09
\
NON REsmENTIAL wELL coNsTRucnoN REcoRD
North Carolina Department o fEnvironmcnl and Natural Resources• Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A
1. WELL CONTRACTOR:
Timothy R Hamby
Well Contractor (Individual) Name
Midsouth Geothermal
Well Contractor Company Name
8275 Tournament Dr Suite 1 as
Street Address
Memphis TN
City or Town State
, 901 l 7 48-9095
Area code Phone number
2. WELL INFORMATION:
38125
ZJp Code
WELL CONSTRUCTION PERMIT# WIQ100141 ------------"'..;_.-----------
OTHER ASSOCIATED PERMIT#(ifapl)licable) _______ _
SITE WELL ID #(If applicable) tt ~-~ -+-, ---~--------
3. WELL USE (Check One BoK) Monitoring O Munlclpal/Publlc D
Industrial/Commercial D Agrlcultural O R.eeo11ery □ Injection □
Irrigation□ Other w/ (11st use) Closed loop Geotherra
DATE DRILLED l a. -43-11
4. WELL LOCATION:
1166 Lotla Church Rd
(Street Name. Numberi, Community, SubdMsion, Lot No., Parcel, Zlp Code)
crrv: Franklin couNTY Macon
TOPOGRAPHIC / LAND SETTING; (Clheck appropriate box)
□Slope □Valley \it!=lal □Ridge OC>ther ______ _
LATITUDE ~ ---· OMS OR 3x.xxxxxxxxx OD
LONGITUDE~ ___ • OMS OR 7x,xxxxxxxxx 00
Latitude/longitude source: [);PS Qropographic map
(locetion of well mu11t be .shown on II USGS topo mep endetteched to
this form if not using GPS)
5. FACILFTY (Name of the buslneu where the well ls located.)
Macon Elementary
Facility Name Facillty ID# (If applicable)
1166 Latia Cbuccb Rd
Street Addresa
franklin NC 28734
City or Town State Zip Code
Macao Cauntv Government
Contact Name
Melling Addreu
franklin
City or Town
Area code Phone number
&. WELL DETAILS:
a.. TOTAL DEPTH: q <;' -::/
NC 28143
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES D NO~
c. WATER LEVEL Below Top of Casing: S-0 FT
(Use'+" If Above Top of Casing)
-----------
: d. TOP OF-eAStNG.IS 2 FT. Above Land Surface•
: 'Top of casing terminated at/or below land surface may require
: a variance in accordance with 15A NCAC 2C .0118.
~ •· YIELD <apm>: Jc:. -.) ":> METHoo oF TEsr Blow Down
1 f. DISINFECTION: 'fyp4I HTC Amount 12 OZ
: g. WATER ZONES (depth):
: Top ___ Bottom __ _ Top ___ Bottom __ _
: Top Bottom. __ _ Top ___ Bottom. __ _
:Top Bottom __ _ Top Bottom. __ _
: 7. CASING: Depth Diameter
~ Top~ Bottoni...:o.L Ft. 6 1/8
: Top_ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft. __ _
: 8. GROUT: Depth Material
: TopJL_ Bottom.1!2._ Ft. Bentonjte
Thlcknes■/
Weight Material
steel ....1L
Method
Pumped
~ TopJ:J_ Bottom~ Ft. washed stone poured
: Top ___ Bottom_Ft,, ____ _
: t. SCREEN: Depttl Olamater Slot Size Materiel
: Top ___ Bottom ___ Ft._in. in. ___ _
: Top ___ Bottom ___ Ft.__in. in. ____ _
: Top ___ Bottom ___ Ft. __ ln. In. ___ _
: 10. SANO/GRAVEL PACK:
: O.pth Sin Mate rt al
: Top ___ Bottom ___ Ft. __________ _
: Top Bottom ___ Ft. __________ _
: Top Bottom ___ Ft. ___ ~-------
: 11. DRILLING \.00
: Top Bottom
C) ,_·\~~---
Formation Descnptlon
>" "'lh1 <:) !-.,,,
i::i J w :5 ~ ----'----___ / ___ _
---'----/
---'----___ / ___ _ __ ...;/ ___ _
---'-------'----
: 12, REMARKS:
: Casi119 Removed
: I DO HEREBY CERTIFY THAT THIS waL WM CONSTRIJCTI:O IN ACCORDANCE WITH
i ~~~~;~:~~6~:~~~~THATACOPYOFTHIS
I SIGNATURE OF CERTIFIED WELL CONTRA~ DATE
: Timothy B Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality • lnfonnatlon Processing,
1617 Mall Service Center, Raleigh, NC 27899-161, Phone : [phone]
Form GW-1b
Rev. 2/09
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Dqa1ment ofEnvironment and Natural ~ Division of Waler Quality
WELL CONTRACl'OR CERTIFICATION# 3118-A
1. WELL CONTRACTOR:
Timothy B Hamby
Wei Conlrador (lnclvidual) Name
Midsouth Geothermal
Well Contractor Company Name
8275 Tournament Pc STE s
Street Address
Mem phi s
Clly or T O\llln
c901 >· 748-9095
Ante code Phone runber
2. WELL INFORIIATION:
TN
State
38125
ZlpCOde
WELL CONSTRUCTION PERMITt __ W____,IQ:...::1..:::::0 .... 0_,_14_,_ ____ 1 ___ _
OTHER ASSOCIA. TED PE°'41Tl(ir •PPl::ble)
srra WELL ID~ applicable>.:._ --tl.--:S ~ 3 ·
3. WELL USE (Check One 8o)c) Monttoring D Munidpal/PUblc D
I~□ AgriCIAnlO Recovery □ l~O
1n1gat1onO Olhar J Ctfl. ... > Closed Looo Geotherw
DATE DRJU.ED..:· k..:;J.'-_..\1 ___ _
4 . WELL LOCATION:
11 66 LoUa Church Rd
(StrNt fume, Numoa,s, Community, Subdhllelon, Lat No., Parm!, Zlp Code)
c 1lY: Franklin COUNTY Macon
TOPOGRAPHIC / LAND SETTING: (dleck app,opiilllit 1-)
□Slope □Valley~ □Ridge OOlher. _____ _
LATITUDE 36 _____ • OMS OR 3X.l00000000( 00
LONGITUDE 75 ____ • OMS OR 7x.xxxxxxxxx DD
Lallludellongltude ~; 03PS Qrapograpt,lc map
(location ol wel must be shown on • USGS topo map 1111dattllched to
thJS foml JI not Uling GPS}
5. FACILITY (Name of the buslneu where !he waD Is located.)
Mamo Elemeotrv 5cbool
Facility Name
-1166 t otfa Church Rd
S1reet hidresa
franklin
City or Town
Mamo Co11otv Government
Contact Name
Mailing Address
franklin
C ity or T own
C l Area code~Ph~one--num-~lber-----
e. WELL DETAILS:
a. TOTAL DEPTM :.--'4~5...,0..__ ___ _
Facility IOI (H applicable)
NC 28734
State ZIP Code
NC 28743
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES O NOD
c.. WATER LEVEL Below Top of Ceslng: ..... 6""0..__ __ ----'FT.
(Use•+• If Above Top of C8alng)
----------
: d. 10P OF CASING IS 2 FT. Above lMld St.lface•
.,.op of cas1ng tenninated a11or befow land surface may requre
a vaiance In accordance IM1h 15A NCAC 2C .0118.
: .. YIELD <cnim>: 1 oo METHOD OF lE8T Blow Down ·
~ ,. 01S1NFECT10N: ~ HTC Amount 12oz
: 9. WATER ZONES (depth):
: Top 250 Bottom 254 TOP, ___ Bottom. __ _
:Top ___ Bqttom __ _ Top Bottom. __ _
: Top Bottom. __ _ Top Bottom. __ _
ThlclcnNa/
: 7 . CASING: DepCf'I DlaffNllar w.lght
: Top..±2,__ Bottom 82 Ft. 61/8 ......1.eL
:Top __ eottom. __ Ft. __ _
; Top __ Bottom Ft. __ _
.
: 8. GROUT; Depth Maler1al
: Top_ .. L Boltom_ 3...7: Ft~~~
~ Top_b_BoaDm '-fP't> Ft wui...,i s-1-...
: TOP, __ BollDrn. __ Ft. ____ _
: 9 . SCREEN: D..,ch D..,,.._ Slot Sia
Matar1al
steel
:Top __ Bottom __ Ft __ in. __ In. ___ _
: Top __ BollDrn __ Ft. __ in. __ In, ___ _
:Top __ Botlom. __ Fl __ in. In . ___ _
: 10. SANOIGRAVB. PACK:
: Daplll Slzlt ;TOP. ___ Boltom. __ Fl __________ _
:TOP. ___ Bollom __ Ft __________ _
:TOP.. ___ Bottom. __ Ft.. __________ _
: 11 . ORIWNG LOG
Top
0
77
82
250
254
Bollom
1 77
I 82
/ 250
/ 254
/ 450 ----'-------'-------'----' ---,----
---'----
; 12. REIi.ARKS:
~ C asing ren ,011ed
Formation Desc:ltptlon
Dirt
Granite
Granite
Broken Granite 40ggm
Granite
; I 00 HEREBY CERTIFY THAT THIS WEll WAS COHSTRUCTEO IH ACCORDAHCE WITH
; 1~ NCAC 2C, WEU. CONSTRUCTION STANDARDS.~ THAT A CDP'f OF THIS
: RECOAD HAS BEEN PRO\IIOEOTOnE WELL OWNER.
~ , ~ 12 //r~1 I-~-l l. . .J
: S IGE OF t ERTIRED WELLCONTRAC~ OATE
: Iirootbv B Hamby
: PRINTED NAME OF PERSON CONSTRUCTING TI-IE WEl.L
Su~lt ~th~ 3C> da" of compJ•n to~ OMslo.o~of, W-at~. Qt,~fitV -· lnf0f11'Btlan Pl'OC8S$ktg«
18t..7'ail Service Center, Ralefgh, NC.27899,,161-, Phone : (919} 801~ . -\. ..
FormGW-1b
Rev. 2109
NON RESIDENTIAL WELL coNSTRucnoN RECORD
North Carolina Depar1ment ofF..nviroomeut and Natural Resouroes-Divisloo of Water Quality
WELL CONTRACTOR CERTMCATION # 3118-A
1. WEU. COffTRACTOR:
nmothy B Hamby
Wei Conlraclor (Individual) Nana
Midsouth Geothermal wea Contradol' Company Name
8275 -Toumament Dr STE 5
street Address
Memphis
City or Town
,901 >· 748-9095
Area code Phone lunber
2. WELL INFORMATION:
IN 38125
SlalB Zip Code
WELL CONSTRUCTION PERMITt Wl0100141 -"--"..a..=."'-='=-"---'-'------
OTHER ASSOCIA lED PED.\41Tl("II appic:able). _______ _
SITE WELL ID f{lf lA)llc:atN)..:_ -_-~A~l--~Y~----
3. WEU. USE (Check One Box) Monltol1ng D MunlclpallPubll D
lndU8ftiaUCommen:I O Agl1cutunll D Recovery O lf18Cljon D
1nigallon0 ON' rit' (tit UM} Closed Loop Geothera
DATEDRILLB>_:· . -; l-,t-i..,.l.___
4. WELL LOCATION:
1166 LoHa Church Rd
(Sn« Name, Nuint.n, Community, Sul:ldMtlon, Lot No., P'"'81, Zip Cede)
CITY: FrankJin coUNTY Macon
TOPOGRAPHIC / I.AND SETTING: (chKk ~ box)
□Slope OValey lifFlat □Ridge □Other _____ _
LATITUDE ~ ___ • OMS OR 3X.XX>000000( DO
LONGITUDE 75 _____ • OMS OR 7X.>OOOOQOQ(X DD
Latltudellongll source: 03PS Qropographlc map
(toc.tion olwel mil# be shoWn o, a USGS topo map andtlttached to
this folm ii not Uainf GPSJ
5. FACILITY (Name Of the bUslneu Where lhe well ls localed.)
Maeno fleroaotrv 5rbanl
Facility Name Facility II» (If applicable)
-1166 I otta Church Rd
Street Address
Eraoklio NC 28734
City or Town State Zip Code
Maeno Co11otv Gavemmeot
Contact Name
Malling Address
Eraoklio
City or Town
( ) ________ _
Area code Phone number
8. WELL DETAILS:
&Tm~DEPTH:~4=5~0..._ ___ _
NC 28W
State Zip Code
b. DOES WELL REPl.ACE EXISTING WELL? YES O NO D
c . WATER LEVEL Below Top of casing: _6_0 ____ FT..
(Use -.• If Above Tep of Casing)
----------
: d. TOP OF CASING IS 2 FT. Above land SUrface•
; "Top of casing tem'lila1ed aJ/ol below land surface may reqlint
: a valance In aa:oo!ance wffh 15A NCAC 2C .0118.
~ .. YIELD (gpm>: 1 oo METiiOO OF msT Blow Down
: t . DISINFECTION: -rype HTC Amount 12oz
: g . WATER ZONES (depth):
: Top 250 Bollom 254 Top ___ Bottom. __ _
:Top ___ Bottum __ _ TOP. Bottom __ _
: Top Bottom __ _ Top Bottom. __ _
Tblcknea/
Weight
......1!m._
: 7 . CAS4NG: Depth Dtametlllr
~ Top +2 Bottom Wl?Ft 61/8 . : Top __ Bollom __ Fl __ _
: Top __ Bottom Ft __ _
: 8. GROOT: Depth Mal!!rlal
: Top_·o_Bot!Dm_ Of%_Fl~ -:
~ Top :l J.. Bottom~ Fl u.,,M ¼,,l .S,,..~
:Top __ Boltom ____ Fl _____ _ .
: 9. SCREEH: Depth m.m..r SlatSlm
Malat1al
steel
: Top __ Bottom __ FL __ tn. __ In. ___ _
: TOP. Boltom __ FL __ ln. __ In. ___ _
: Top Bottom __ Ft __ in. In , ___ _
: 10. ~Dt'GRAYEL PACK:
: DepCtl Sia llat8rlal
: Top:-__ Bollom __ Ft ___________ _
: TQP. __ --'Bottom __ Fl ___________ _
;Top ___ BoUom __ FL __________ _
: 11. ORR.UNG LOG
: Top Bottom
0 Ii? ..IL...._t= G5
-Rill 250
250 I 254
254 / 450
I
I
I
I
I
I
: 12. REMARKS:
~ Casing removed
Formation De801ptlon
Dirt
Granite
Granite
Broken Granite 40gpm
Granite
; I DO HEREBV CERT1fY THf.T THIS WEil WAS CONSTRUC'lcO IN ACCORDAHCe Willi
• 15'1 NCAC 2C. 'iNEU. CONSTRUCTION STAHIWUlS, AND THAT A CXJPY OF TI4IS
: RECORD HAS BEEN~ TOTME WELL OWNER
! ...-7 .fi-i I tt/ . ., J .:S-1 :l -1 ~ S1.E CERTIAE8WEL.l.CONfflA~ -UATE
: Timothy B Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Sub~lt ~~)1 30 days of cc;mplettortto~ ,Division ct Wa~. Quality -. lnfonnatlon;Priic:esslng.
1817 Mall ~foe Cenbtr, Raleigh;-NC2769Sl.161, Phone ; (919) 807;QCJO .
FormGW-1b
Rev.2/09
ut
~--~~..,.
;'
<~~!/1111!,i
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department ofEnvimnment and Natmal Resoura:s-Division of Water Quality
"'"•~·
WELL CONTRACfOR CERTIFICATION# 3118-A ----------
1. WELL CONTRACTOR:
Timothy R Hamby
Wei Conl1ador (lndMdual) Name
Midsouth Geothermal
Well Contradllf Col1'4)1111Y Name
6275 Tournament Dr STE 5
street Addl'ela
Memphis
City or Town
< 901 ). 748-9095
Area code Phone number
Z. WELL INFORIIATION:
TN 38125
State Zip Code
WELL CONSTRUCTION PERMIT# Wl0100141 ---'--'----=-~~~-----
OTHER ASSOCIATED PEi.u.tlTl(if 8Jlllllc::abl•). ______ _
SITE WELL ID l(V applic::atlle)~ -_._A_;___:~,.___-~:;__ ___ _
3. WEU. USE (Check One Box) Monitoring O Munidpal/Publlc 0
lndustriallCorrman □ Agric&Alral □ Recovety D 1'19(:llon □
1mgat1on□ other J ~ '1 Closed Loop Geotherw
OATEDRILLED__: 1--,J.')
4-. WELL LOCATlON :
1166 Latia Church Rd
{Street Nam•, Numbln, Cammunlly, Subdivision, Lat No .• Parcel, Zip Code)
c 11Y: Franklin COUNTY Macon
TOPOGRAPHIC J LAND SETTING: (check~ box)
□Slope OValey ilAat ORjdge □Other. _____ _
umTUDE 36 -----· OMS OR 3X.)00000000( DO
LONGITUDE 7.!__ ·---· OMS OR 7x.xxxxxxxxx DD
LatiludellongHude SOl.l"C8: []3PS Qropographlc map
(focalion of wet mus be shown on a USGS topo map andattsched to
thfs form If net usinO GPSJ
s. FACIUTY (Name Of the bUstness where lhe well ls located.)
Maroa Elaroeotcv 5cbaol
Facility Name Facility ID# (If applicable)
...1..166 Lotta Cbuccil 8d
street Address
franklin NC 28734
City or Town state Zip Cade
Maron cm mtv Goveroroeot
ContadName
Malling Address
franklin
City or Town
< ) ________ _
Area code Phone number
6. WELL DETAILS:
a. TOTAi.. DEPllf:._4...,5....,0..._ ___ _
NC 28743
State Zip Code
b.. DOES WEU. REPLACE EXJSTING WELL? YES O NOD
c. WATER LEVEL Below Top of Casing: ~6-Q ____ FT_
(Use•+· if Above Top af Casing)
: d. TOP OF CASING IS 2 FT. AbOve Lni Surface'
-rop af casing temmaled at/or below land su1ace may req\ire
a vatance in ac:i;xxdance ~ 15A NCAC 2C .0118.
: e. YIELD (r,pm): 1 oo METHOD OF TEST Blow Down
: f. 01S1NFECTION: ~ HTC Amount 12oz
: 9-WA11:R ZONES (deplh):
: Top 250 Bottom 254 Top ___ Bottom. __ _
:Top ___ Botlom. __ _ Top Bol!llm __ _
: Top Bottom ____ _ Top Bottom. __ _
Tblckn.al
Wefgflt
~
: 7. CASING: Oeptll Dlernetitr
[ Top~ ~J.~ Ft. 61/8
: Top __ Bottom __ FL __ _
: Top __ Bottom Fl. __ _
: IJ. GROUT: Depth Material
: Top_ (L_ Bottom_ , ,--'i Ft •~~ -;
~ rop..i.L.:)._ Bottom ';Co Ft w ,,+;s4rJ i,-b
: Top __ Bottom. ___ Ft _____ _
Mld&rlal
steel
j I . SCREEN: Depth Dlamtilar Slot Sia llllf8rlal
; Top __ Bottom. ___ Ft __ in. __ In. ___ _
: Top __ Bottom FL __ ln. in.----
: Top __ Bottom __ Ft __ in. In. ___ _
: 10. 8ANDIGRAVB. PACK:
: Depdl Str.a
: Top. ___ BollOrrl. __ Ft ___________ _
:Top. ___ BoUam __ Ft ___________ _
! Top ___ Bottom ___ Fl __________ _
: 11. DRILLING LOG
: Top Bottom
~ 0 J_'f/)_ : _ °t (LL li?-:(,_,1_
: .. f~'-fl:il!
: -·•. ·-'-~--: I : __ -_,--: ____ ,----
: _ ___,I : ____ ,----
: ----'---: ----'---
: 1 Z. REMARKS:
~ Casing removed
Formation Description
_ 5/Jv-ci t:c / At,
_ ~ f &.Is Lee> t ca: 4 s -~..:..:rk.-._ _____ _
:_ ---------
: I DO HEREBY CERTIFY THAT T1-ilS v.EU. WAS CONSTRUCTEO IN ACCORDANCE WITH
: 15'. NCAC2C. WELL CONSTRUCTION STANOAADS, AND THAT A COP( OFnllS
: t2:::::;--~ .J--~ ~ t,-I ;J.. ..J
: RECOADHAS BEEN PRO~TO THE WELL OWNER. 1 ~ s ™RE OF c TiEDWELL CONTRA<!fciR ~ DATE
: Timothy 8 Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within ,3Ct'cf.ays of completion to~ Dlvislon ofWater Q1,1allty • lnfonnation.Processlng,
1617 Mail SeMce,~nter, Raleigh-,.NC 2769~181, Phone : [phone]
FormGW-1b
Rev.2109
..,.Sl"A7t~
d ..,.._..,'°"
il j
\ ,
NON REsmENTIAL WELL coNSTaucnoN REcoRD
North Carolina Dcpertment ofEnvirooment and Natural Resources-Division of Water Quality
....
-~ WELLCONTRACTORCERTIFICATION# 3118-A
1, WEI.L CONTRACTOR:
Timothy R Hamby
We! Conlrador {Individual) Nana
Midsouth Geothermal
Well Contrac:tor c~ Name
8275 Tournament Pc STE 5
Street Address
Memphis
City or Town
< 901 ). 7 48-9095
Alea code PhOne number
2. WELL INFORMATIOH:
TN 38125
State Zip Code
WELL CONSTRUCTION PERMln WIQ100141 --=-.a.=..'-=-'"-'-......_ ____ _
OTHER ASSOCIATl:D PE~IT'Jlf appllcablo)
sm: WELL ID l(Japp11cableJ~/i .... 3 ..... -_k"--------
3. WELL USE (Check One Box) Monitoring □ MunlcipallPubllc D
lndt.lS1rtallCofrw D Agrfct411Jral □ Recove,y D Injection D
tmgat1on□ Other fl{ ot.t. use> Closed Looo Geother11
DATE DRJLJ..ED_: ·; J-C\.:-!1
4. WELL LOCA110N:
1166 Lotla Church Rd
(Street Name, Numberl, Communill', SUbcfMslon, Lat No., Pama!, ZIP Code)
c1TY: Franklin coUNTY Macon
TOPOGRAPHIC / LAND SETTING: (checll .ttppfOPrinl bcJoc)
□Slope □Valley iifFlat □Ridge OOther _____ _
LATlllJOE ~----• OMS OR 3X.XXXXXXXXX 00
LONGITUDE~----• OMS OR 7x.~ DO
Laffludellongil IOURl8: CPPS Qropographlc map
(/Ocatlon of well must be shown on a USGS lopo map an<lettaclled m
Ill/ts form if not using GPS)
5. FACIUTY (Name of the bUsinesa where the well ls localed,)
Macon Elementrv Scbool
Facility Name
1166 I ctla Church Rd
Street Address
Franklin
City or Town
Maron County Government
Contact Name
MalUrg Address
franklin
City or Town
( >~--------Area COde Phone number
t. WEU. DETAILS:
a. TOTAL DEPTH:_4~5~0~----
Facility IDf (If applicable)
NC 28734
State Zip Code
NC 28743
State Zlp Code
b. DOES WELL REPLACE EXISTING WEU? YES □ NOD
c. WATER LEVEL Below Top of casing: _,6...,0...__ ___ .FT.
(Use·+· If Above Top of Casing)
----------
: cL TOP OF CASING IS 2 FT. Above land Surface-
: "Top of casing tennlnn!id atfor below land surface may require
: a variance in aooon:sance With 15A NCAC 2C .0118.
: .. Yta.o (gpm): 1 oo MEntOo oF TEST Blow Dawn
~ f. DISINFECTlON: ~ HTC Amounl 12oz
: g. WATER ZONES (depth):
: Top 250 Bolt0m 254 Top'---Bottom. __ _
:Top ___ Bot!om'---Top Bottom __ _
: Top. ___ Bottom __ _ Top Bottom. __ _
: 7. CASING: Depth Dlam9tltr
~ Top +2 8ottom_L6'l _ Fl 61/8
; Top __ Bollom. __ Ft. __ _
: Top __ Bottom __ Ft __ _
.
Tlllckntillll
We4gbt
_J.88_
Mateltal
steel
: 8. GROUT: Depth Matenal Method
: Top_ LJ_ Bottom_ I~ Fl~-¥-; . Pv W\ p;J
~ Top l'2 '.) 8ot1orn 4&'0 Fl wMW $h,-,.e Povv'c-d
:Top __ Boltom __ R.'-----
: 9. SCREEN: Depth Dtam.t.r SlotSiz:e
: Top. __ Bottom __ Ft __ in. __ In. ___ _
: Tap __ BollDm. __ Ft. __ ln. In. ___ _
: Top __ Bollom __ Ft. __ ln. in. ___ _
: 10. SAND/GRAYll PACK:
: Depth Sim Marfat
;Top Bottom __
:Top BoUom __
:ToP Bottom __
:
: 11. DRILLING LOG
Top Bottom
_ 0_/_j b ...... 0-.._
-1 ~a._!_ Ll.o L_
, I l, 1 __/ _ '-(S'"Q___
-_j_
_/_. ----'----____ / ___ _
----~----
----'-------'·----
; 12. REMARKS:
~ Casing re mo11ed
A.
Fl
Fl
Fonnatton Desalptton
S~v ,1¥.
~-~1U,.. toa< -.e· 1'-+-.t-k'-""----·----
; I DO HERES'( CERTIFY THAT n«S WEU. WAS CONSTRUCT£O IN ACCORDANCE WITH
; 15" NCAC 2C, WB.L CONSTRUCTION STANIWUlS, ANO THAT A Ct:)PV Of Tl-!IS
; RECORD HAS BEEN PRO\lloeD TO THE VtBJ. OWNER.
: •-~-~. -'~ /:.,-I"' •• ~? -.1--.._J
: Sl~RE OF~WELL CONTRACTOR DATE
: Iirootbv B Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit.within 30 dlW"-of completlon to: Division of Water Quality ... lnfonnatton Ptoicessfng ..
1617 Mall Service CG~j Ralefgh,.·NC 27699--16t, Phone: (919} ao7--6300.
'·1
FonnGW-1b
Rev. 2/09
~
NON REs1»ENTIAi WELL. c0Nsmucr10N REcoRD
Nonh Carolina Department of Environment and Natural Resources-Division qfWat~ Quality
WELL CONTRACTOR CER'IIDCATION # 3118-A
1. WEU. CONTRACTOR:
Timothy R Hamby
Well Contractor (lndlvklual} Name
Midsouth Geothermal
Well Contractor Company Nam• a2zs Tournament Pc Suite 1 as
Str•et Addreas
Memphis TN 38125
City or Town State ZlpCod•
c 901 i 7 48-9095
Area code Phone number
2. WELL INFORMATION :
WELL CONSTRUCTION PERMIT# WIQ 100141 --'-"~-'--'--=--~~-----
0 THE R ASSOCIATED PERMIT~i!.!f!>~~le)
SITE WELL 10 #(11 applicable) f\ .) 7 -~~-~------
3, WELL USE (Check One Box) Monitoring □ Munlcfpal/Publlc □
lndustriel/Commerclal □ Agricultural □ RKOverY □ Injection D
Irrigation□ Other!W(listuae) Closed looo Geotherra
DATE DRILLED I a.-/4 .... ,,
4. WELL LOCATION:
1166 Lotla Church Rd
(Street Name. Numbers, Community, SubdlVlsion, Lot No .. Parcel. Zip Code)
ctTY: Franklin COUNTY Macon
TOPOGRAPHIC / LAND SETTING: (cheek appropriate box)
□Slope □Valley iit!"tat □Ridge □Other ______ _
LATITUDE ~ ---· OMS OR 3x.xxxxxxxxx DD
LONGITUDE~• ---· OMS OR 7x.xxxxxxxxx OD
Latltudenongitude source: [):iPS Qropographlc map
(location ofwe/1 must b• shown on• USGS toPo mtp endettached to
this form if not using GPSJ
5.. FACILITY (Name of the business where the well ls located.)
Macon Elementary
Faclllty Name Faculty ID# (tf applicable}
1166 Latia Church Rd
Street Addreaa
Franklin NC 26734
City or Town state Zip Code
Macon Countv Government
Contact Name
Malling Addresa
Ecaoktjn NC ?8743
City or Town State Zlp Code
Area cocle Phone number
8. WELL DETAILS:
a. TOTAL DEPTH: L/ '5 U
1
b. DOES WELL REPLACE EXISTING WELL? YES □ NO r./
c. WATER LEVEL Below Top of Casing: S--0 FT.
(UH•+• If Above Top of Casing)
-----------
: d. TOP OF CASINO IS 2 ~PT. Abo11e.Land Surface•
: •Top of casing terminated at/or belowiand s~rfac:e may require
a variance In accordance with 15A NCAC 2C .0118.
: •. YIELD(gpm): s..::>-,~ METHOD OFTEST Blow Qown
~ f . DISINFECTION:~ HTC Amount 12 az
: g. WATER ZONES (depth):
: Top. ___ Bottom._ __ Top. ___ Bottom __ _
: Top ___ Bottom __ _ Top ___ Bottom __ _
[ Top Bottom, __ _ Top Bottom, __ _
: 7. CASING: Depth Diameter l Top~Bottom~ Ft. 61/8
: Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft. __ _
j s. GROUT: Depth , / I) Material
: Top__Q__ Bottom_/ V'_I_ Ft. Bentonjte
ThlckneH/
Weight
_j_filL
Material
steel
~ Toplk.1_ Bottom~ Ft. washed stone
Method
Pumped
poured
: Top ___ Bottom ___ Ft. ____ _
; 9. SCREEN: Depth Diameter SlotSlzt Mattrlal
: Top ___ Bottom ___ Ft. __ ln. In. ____ _
: Top ___ Bottom ___ Ft. __ ln. in. ____ _
: Top ___ Bottom ___ Ft._ln. __ in. ____ _
: 10. SAND/GRAVEL PACK:
; Depth Material
: Top ___ .Bottom ___ Ft, __ _
: Top Bottom ___ Ft __________ _
: Top Bottom ___ Ft. ___________ _
: 11. DRILLING LOG
Top Bottom
.!)___}-~~<;"_
K.S:_/1~~
J~"1. / y"i o
----'--------'----___ / ___ _
---·'----__ _,/ ___ _
---'-------~----
: 12. REMARKS:
: Casir 19 Re, 11oved
Formation DeserlpH011
~~ d,1
; I 00 HEREBY CERTIFY THAT THIS WELL WAS CONS"TRIJC'TH) IN ACCORDANCE WITH ; ;:~~~ ~~~;r6o;;.r~~~~OTHAT A COPY OF ™16
i ,WfrA. ~ 12-11-11
; SIGTURE OF CERTIFIED WELL CONTRAC~ DATE
: Timothy 8 Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -lnfonnatlon Proce5$lng,
1617 Mall Service Center, Rafelgh, NC 27699-161, Phone: [phone]
Form GW-1b
Rev. 2/09
NON REs1»ENTIAi WELL. coNsmucnoN REcoRD
Nonh Carolina Department ofEnvironment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 31]8.A
1 . WELL CONTRACTOR:
Timothy R Hamby
Well Contractor (Indi vidual) Name
Midso uth Geothe rmal
Well Contractor Company Nam•
8275 Tournament Dr Suite 185
Street Address
Memphi s TN
City or Town State
c 901 l 7 48•9095
Area code Phone number
2, WELL INFORMATION :
38 125
Zip Code
WELL CONSTRUCTION PERMIT# WIQ 10014 1 ..a...,-"=--'-=-=-a'-'---------
OTHER ASSOCIATED PERMIT#(lf appllcable)'---------
SITI: WELl. ID #(If aJ)pllcable),_ .... J\---=3--_~=-------
3. WELL USE (Chedt One Box) Monitoring D Muni cipal/Public D
Industrial/Commercial □ Agricultural □ Recovery □ Injection □
Irrigation □ otharS(U,tu .. ) Closed loco Geotherra
DATE DRILLED / 2.. -I 5--I I
4. WELL LOCATION:
1166 Lotta Church Rd
(Street Name, Numbers, Community, SubCIMsion, Lot No., Parcel, Zip Code)
c1TY: Franklin couNTY Macon
TOPOGRAPHIC / LANO SETTING: (cfleck appn>p!lale box)
□Slope □Valley .tl=lat □Ridge □other ______ _
LATITUDE ~ ___ • OMS OR 3X.XlCXXXXXXX DD
LONGITUDE~ ___ • OMS OR 7X ,)QQOOOOQ(X DO
Latitude/longitude source: CPPS Qropographi c map
(location of well mu:st ti. :shown on • USGS topo map endattach•d to
th/:s form if not u:slnq GPSJ
5. FACILITY (Name of the bu111lnass Whera the well la located.)
Macon ElementaN
Facility Name
1166 Latia Church Rd
Street Address
franklin
C ity or Town
Macon County Government
Contact Name
Malling Address
franklin
City or Town
( ) _________ _
Area code Phone number
6, WELL DETAILS:
a , TOTAL DEPTH: 4 St?
Faclllty 10# (if applicable)
NC 28734
Stlte Zip Code
NC 28743
State Zip Code
b. DOES WELL REPLACE EXISTING WEU.? YES □ NO f¥
c. WATER LEVEL Below Top of Cuing: ~ 6 FT.
(Use "t" If Above Top of Casing)
-----------
: d. TOP OF CASINO IS 2 '"IT Abow Land-Surface• -•
; •Top of casing terminated at/or b61ow ·lend surface may ·require
: a variance in accordance with 15A NCAC 2C .01 18.
~ e. v1ELD (apml: 'I o METHOD OF nsr Blow Down
: r. DISINFECTION: Type HTC Amount 12 QZ
: g. WATER ZONES (depth):
: Top. ___ Bottom __ _ Top ___ Bottom._ __ _
: Top. ___ Bottom __ _ Top Bottom __ _
; Top ___ Bottom __ _ Top Bottom __ _
! 7. CASINO: Depth Dlametar
~ Top_Q_Bottom~Ft. 61/8
: Top ___ Bottom ___ Ft.'----
: Top ___ Bottom ___ Ft. __ _
ThicknHs/
Weight
_.1L
Material
steel
: 8. GROUT: Depth Material
: TopJl_ Bottom.lil Ft. Bentonjte
i Top~ Bottom~ Ft. washed stone
Method
Pumped
poured
: Top ___ Bottom ___ Ft. ____ _
: 9 . SCREEN: Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft. __ l n , In. ___ _
: Top ___ Bottom ___ Ft. __ i n. in. ___ _
: Top ___ Bottom ___ Ft. __ ln. __ in. ____ _
: 10. SAND/GRAVEL PACK:
Depth Size Material
: Top. ___ .Bottorn ___ Ft. __________ _
: Top Botton, ___ Ft. __________ _
: Top Bottom ___ Ft. . -----------
: 11 . DRILLING LOG
Top Bottom
o I t rd Ks-
~ s-,_ ... , t..,.-.,_.z __
I u 2 l_it~si-=o::;.__
---''----___ / ___ _ __ ....,/ ___ _
__ _,I ___ _
---'-------''----___ / ___ _
___ ! ___ _
: 12. REMARKS:
: Casing Removed
FormaUon D••~ptlon
5-v-d y C lo--,
; I 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTR\JCTED IN ACCOROANCE WITH
! ~~~~H~ :e~~ ;==~r=~~O THAT A COPY OF TH IS
~. ,;2.:. /) ~f-c___ . J:J.-/'.>:, JI
: SIGN;ji(jRE OF CERTIFIED W ELl. CONTRAC"fc5R DATE
: Timothy R Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL .
Submit within 30 days of completion to: Division of Water Quality -Information Processing,
1617 Mall Service Center, Ralelgh, NC 27899-181, Phone: [phone]
Form GW-1b
Rev. 2/09
NON REs1»ENTIAL' WELL coNsTRucrmN REcoRD
Nonb Carolina Department ofEnvironment and Natural Resources• Division of Water Qualiry
WELL CONTRACTOR CERTIFICATION# 3 1...1,;i y tl
Well ContracllOr ( ndlvidual) Name I
Tarheet Water Treatment
Well Contractor Company Name
3494 Georg ia RD
Street Addreu
Frankljn NC 28734
City or Town State Zip Code
c 828 i 369-0740
Area code Phone number
2. WELL. INFORMATION:
WELL CONSTRUCTION PERMIT#~W~IQ~1~Q~Q~1~4~1 ____ _
OTHER ASSOC~TED PERMIT#(lf appttcable) _______ _
SITE WELL ID #(If appj/cable)_._{1 ....... / -__._1 __ 4...._ ____ _
3. WELL USE (Check One Box) Monitol1ng □ MunlcipellPubllc □
lndustrial/Commerelal □ Agricultural □ Recovery D Injection □
trng•t10n□ other w 111,t '"e> Clos ed loop Geotherra
DATE DRILLED _______ _
4. WELL LOCATION:
1166 Latia Church Rd
(Street Name, Numbera. Community, Subdivision. Loi No., Parcel, Zip Code)
c1rv: Franklin couNTY Macon
TOPOGRAPHIC / lAND SETTING: (chec.k apPfOPr1&te box)
ostopa □Valley '"l at □Ridge □Other ______ _
K@i!STCO 36_ 1"""1111111 ""111111 1 CL R OR 311:~lt~ cc
~t.'F ISTCD 75 ll\AAA ,!AAI\I\AAAAI CL R OR 7-it~~ cc
Latltude/longittlde source: [)'.,PS QTopographic map
(focetion of well mu&/ be shown on• USGS topo map 1ndatt1C1hed to
thia form if not u4ing GPS)
5 . FACILITY (Name of the bu1lnen where tne well ls located.)
Macon Elementary
facility Name
1166 L atla Church Rd
Street Addreu
Franklin
City or Town
Macon Countv Government
Contact Name
Malllng AddntH
Ecaokllo
City or Town
Area code Phone number
6. WELL DETAILS: •
a. TOTA&. DEPTH:__..3...._½__./..,.)._-_'_
facility ID# (if applicable)
NC 28734
State Zip Code
NC 28743
S tat. Zip Code
b, DOES WELL REPLACE EXISTING WELL? Y ES D ,-,--,.
c. WATERLEVELBelowTopofCaalng: 4L)
(Use·+• if Above Top of Casing)
FT.
: d. TOP OF CASINO IS _____ FT. ~Ve bind Surt,J~•
: 'Top of casing terminated at/or below lal'ld surface may reqtdri
• a variance In accordance with 1 SA NCAC 2C .0118.
: e. YIELD (gpm>: 5o }: METHOD OF TEST Blow Down
~ f. DISINFECTION: ry,,e HTC Amount 12 OZ
: g. WATER ZONES (depth):
~ To p i),3Q Bottom __ _ Top ___ Bottom, __ _
: Top ___ Bottom __ _ Top Bottom __ _
: Top ___ Bottom __ _ Top ___ Bottom ___ _
Thicllnns/
: 7. CASINO: Dtpth Diameter Weight Material
: Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft. __ _
; Top ___ Bottom ___ Ft. ___ _
; 8. GROUT: Depth Material
: TopJL__ Bot;tom~ Ft. Bentonjte
~ Top~ So~ Fl washed stone
Method
Pumped
poured
: Top ___ Bottom ___ Ft. ____ _
; t. SCR EEN: Depth Diameter Slot Sin Material
: Top ___ Bottom ___ Ft. __ in. in. ___ _
: Top ___ Bottom ___ Ft. __ in. in. ____ _
: Top ___ Bottom ___ Ft. __ in. In. ___ _
: 10. SAND/GRAVEL PACK:
: ~¢h S~ Materia4
: Top ___ Bottom ___ FL __ _
; Top ___ Sottom ___ FI. __________ _
: Top Bottom ___ Ft .. __________ _
: 11. DRILLING LOG
Top Bottom
0 1 toD
I -w---o.--,-3......,...,Ar--!'C ..... >
---'----9 r (Le" Fe. ___ , ___ _
----'----___ / ___ _
---'----___ ,/ ___ _ __ _,/ ___ _ __ ... / ___ _
: 12 . REMARKS :
[ Cas ing Re11,oved
Submit within 30 days of completion to: Division of Water Quality • lnfomtatlon Processing,
1617 Mall Service Center, Ralei gh, NC 27699-161 , Phone : [phone]
Form GW-1b
Rav. 1/08
NON REsIDENTIAL 0
WELL coNsTaucTioN REcoRD
North Carolina Departmenl of Environment and Natun1I Resources• Division of Water Quality
WELL CONTRACTOR CERTIFICA'l'ION # 3 L../62 y A
Well Contnleto1' (Individual) Name
Tarheel Water Treatment
Wall Contractof Company Nam•
3494 Georgia RP
Strfft AddrHa
Franklin NC 28734
City or Town State Zip Code
t 828 > 369-07 40
Area ~ Phone number
2. WELL INl'ORMATION:
WELL CONSTRUCTION PERMIT# WIQ1QQ141 ""'-'-'-=...a....:.=..."-'-'--------
OTHER ASSOCIATED PERMIT#(lf applicable ), _______ _
SITE WELL 10 #{If afllllallle) __________ _
3. WEl.L USE (Check One Box) Monitoring D MunicipaVPubtic D
Industrial/Commercial □ Agricultural □ Racovery □ Injection □
ll')'igatlon□ otna,..(list uae) Cl<_:>se d looo Geothe!TII
DATE DRILLED td l-\f> s ,:5 \e..(
4. WELL LOCATION:
1166 Latia Church Rd
(Street Name, Numbera, Community, SubdMeloo. Loi No., Parcel. Zip Code)
c1TY: Franklin couNrv Macon
TOPOGRAPHIC / LANO SETTING: (C'1eck appropriate box)
OS!ot>e □Valley gFlat □Ridge □01her ______ _
K31STCD 36_ 1••••a•M••••"t CL R OR 3,c~)OllC~" CC
KNt.F ISTCO 75 1" .. "cl"""'""""! CL R OR h.~~ CC
Latttude/longItude source: [PPS OT'opogr■ph le map
(locetJon of wall mu~ be sltown on • USGS topo map endettachltd to
this lbrm if not using GPS)
5. FACILITY (Name of the bualneu where t he well I• loeated.)
Macon Elementary
Faellity Name Faeility ID# (If applieable)
1166 Latia Church Rd
S1rfftAddre11
franklin
City or Town
NC 28734
State Zip Code
Macao County Gcvaroroeot
Contact Name
MaitingAddres.
Franklin NC 28743
City or Town State Zip Coda
Area oode Phone n umber
6 . WELL DETAILS: ;'
•• TOTAL DEP'nf:. __ ,_Y.._0 ____ _
b. DOES WEU. REPLACE EXISTING WELL? YES O
c. WATER LEVEL Below Top of Callng: ::t 3
(Usa ·+• If Above Top o f Cuing)
FT.
: d , TOP OF CASINO IS _,_..._~_ FT. Above Land Surface•
: 'Top of easing termi nated al/or below land surface may require
; a va riance In accordance with 15A NCAC 2C .0118.' -.. -
: •• YIELD (gpm): ____ METHOD OF TEST Blow Down
i f, DISINFECTION: Type HTC Amount 12 QZ
: g. W~ER Z ONES (depth):
: Top• Bottom __ _ Top ___ Bottom. __ _
; Top ___ Bottom __ _ T op ___ Bottom. __ _
;Top Bottom. __ _ Top Bottom. __ _
: 7. CASINO: Diameter
:Top __ _
:Top ___ Bo tto~m~~-
: Top___ m ___ Ft.. __ _
: 8. GROUT: Depth Material
~ TopJL_ Bottom 14 0 Ft. Bentonjte
: Top-==-Bottom--==-Ft. washed stoma
; Top ___ Bottom ___ Ft. ____ _
: 9. SCREEN: Depth Dlan,e.te r Slot Sin
Method
Pumped
poured
Material
; Top ___ 8ottom ___ Ft. __ ln. __ i n. ___ _
: Top ___ Bottom ___ Ft. __ in. In. ___ _
: Top ___ Bottom ___ Ft. __ in. in. ____ _
; 10. SAND/GRAVEL PACK:
Depth Size Materlal
: Top ___ aottom ___ Ft. __________ _
; Top. __ __;Bottom ___ Ft. __________ _
: Top. ___ Bottom ___ Ft.. __________ _
: 11 . DRILLING LOG
Top Bottom
Q I $Q
I '
$£.) I /4Q
---'----/ ---,----____ / ___ _ ____ / ___ _
----'----_----' ,.--------
; 12. REMARKS:
: Casit 1g Reniooed
Fonnallon Oeaeription
So /I
UC-reD IN A.CCORDANCE WITH
THAT A COPY OF THIS
l t),r)0-1 /
RAc'fciR DATE
,clM:tf I MS:f.,LLJe
: PRINTED NAME OF PERSON CONSTRUCTING TH E WELL
Submit within 30 days of completion to: Division of Water Quality -lntonnatlon Processing,
1617 Mall Service Center, Raleigh, NC 27699-181 , Phone : (919) 807~300
Form GW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North C11'0lina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3065-A
1. WELL CONTRACTOR:
Roaer L Williams
Weff Contrac:tor {Individual) Name
Tarheel Water Treatment
Well Con1rac:10r Company Name
3494 Georaia RD
StrfftAddntu
FrankJio
City or Town
c 828 1 369-07 40
ma code Phone numbef
2, Wl!LL INFORMATION :
NC 28734
State Zip Code
WELLCONSTRUCTIONPERMIT#~W..:..:.:,IQ~1~0=Q~1~4~1'------
OTHER ASSOCIATED PERM:w~appllcable)
SITE WELL ID #(ii applicable),~/:J......__'J--_/ ______ _
3. WEU. USE (Check One Box) Monitoring □ Munlc!pal/Pubtle □
lndustriel/Commercial □ ""ticultu,.I □ Recovery □ Injection □
Irrigation□ Other rltnst uH> Closed looo GeotheCT:11
DATE DRILLED /-lf-11
,. WELL LOCATION:
1166 Lotta Church Rd
(Street Haine. NtJmbffl. Community, SubdiVisloo. Lot No., Pseel. Zlp Code)
ctlY: Franklin couNTY Macon
TOPOGRAPHIC / LANO SETTING: (chec:lt aPPfl)l)ria1e box)
osiop. □Valley iifflal □Ridge □other-. ______ _
K@,ISTCo 36_ 1••••a"AAAA•••1 CLROR 3k~llJOtl00etl0lcc
KNW:ISTC075 1••••&•""•••11•1 CL ROR h .~ CC
Latitude/1ongltuda source: C)3PS Qropograpt,ic n,ap
(loc.tion of w-'1 mll$f IHI shown on • USGS topo map •ndalt.•ched to
thi& form If not u~ GPS)
S, FACILITY (Name of the buslnes. wh91'8 the well i9 located.)
Maroa Elaroeotarv
Facllfty Name Facility ID# (if applicable)
1166 l ntta Church Rd
Street Addras
Ecaoklio NC 28734
City or Town Stat. Zip Code
Macao Cmmtv Government
Contact Name
Malling AddrMS
Eraoklio
City or Towr,
._ _ _,) .,,,.----,------
Area coda Phone numbef
I . WELL DETAILS: /
a . TOTAL DEPTH : '-{S-{)
NC 28743
Stale Zip Coda
b. DOES WELL REPLACE EXISTING WELL 7 YES O NO r, !~/ c:.. WATER LEVEL Below Top of Caaing: _ _.(dd_""""''----FT.
(UH ..... if Above Top of Casing)
-----------
: d. TOP OF CASING IS O FT. Abow Land Surface•
: •Top of 1:aalng terminated al/0< below land 1urfaee may require
: a variance In ~ with 15A NCAC 2C .0118.
j •. YIELD 111pm>: S METHoo OF TEST Blow Dawn
: f. DISINFECTION: Type HTC Amount 1? oz
: g. WATER ZONES (deptn):
~ Top ).C,(() Bollom J.4/ Top ___ Bottom. __ _
;Top ___ Bottom. __ _ Top ___ Botbn. __ _
: Top Bonorn. __ _ Top Bottom. __ _
Thlckneu/
; 7. CASINO: Depth . / Diameter
j Top~Bottom~Fl __
Weight Matltrfal
; Top __ eottom __ Ft.. __ _
: Top __ Bottom ___ Ft .. __ _
j 8. GROUT: Dep4h q),1 Mai.rial
: Top_L_ Bottom~ Ft. Bentpnite
j Top 't~ Bottom '10 A. wA4,.Jg_.,.,.,
: Top __ Bottom __ Ft .. _____ _
I\Aeltlod
Pumped
: t. SCREEN: Depth Dlamat.r Slot Sin Material
; Top __ Bottom __ Fl __ ln. In. ___ _
: Top __ Bottom __ Fl. __ ln. In. ___ _
: Top __ Botlr:lm ___ R. __ i n. in. ___ _
: 10. SAND/GRAVEL. PACK:
: Depth Sin
; Top ___ Botlom ___ Ft .. __________ _
: Top. ___ Bottom __ Ft .. __________ _
:Top Bottom __ Fl __________ _
: 11, DRILLING LOG
: Top Bottom
~ V I ~')
Ja__l 4£0
I /----
I ,--------____ / ___ _
I ---,----
---'-------·'----
: 12. REMARKS:
: Casing Removed
Fonnalion Descnptlon
s~ J.c..111
; I DO HEREBY CERTIFY THAT THIS WEU. W/4S CO!IISTRUCTB> IN~wml
; 15ANCAC2C, WEU.CONSTR~'TW<T A COPYOF'THIS :=~:: : )-~,IJ.
: SIG/lfATu OFCERTIFIED WELL CONTRAcfoR r tATE
tZIJ.t .. .f'
; PRI UCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality • Information ProcftSlng,
1617 Mall Service Center, Rale-lgh, NC 27699-181, Phone: (919) 807,.300
Form GW-1b
Rev. 1/08
NON &s1»ENTIAL WELL coNsnucrmN REcoRD
Nonh Carolina Deparnncnt of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3065-A
1. WELL CONTRACTOR:
Roger L W illiams
Well Contractor (Individual) Name
Tarheel Water Treatment
Well Contractor Company Name
}494 Georaia RD
Street Addreu
FrankU n
City or Town
< 828 1 369-07 40
Area coda Phone number
2. WELL INFORMATION:
NC 28734
SIN ZJpCode
W E LL CONSTRUCTION PERMIT#._,W'-'-'-=I0"-'1'-"00'-"'-'1'-'4'-'1'-------
OTHER ASSOCIATED PERMIT~~lcable)
SITE WEL L ID #(If appjlcabk!),_. __,_~.....,..2""'2.=-------
3. WELL USE (Chack OM Box) Monitoring O MunlclpaVPublle □
lndi.-1rlal/Commarcial □ Agricultural □ Recovery□ Injection □
Irrigation□ Other J (11st UM) Closed loop Geothen]I
DATE DRILLED /-2 l/, -/J. ..
4. Wl:LL LOCATION:
11 66 Lotta Church R d
(Slnlet Name. Numbers, Community, SUbdMtlon, Lot No .. Plll0el. Lil) Code)
c1TY: Franklin couNrv Macon
TOPOGRAPHIC I LANO SETTING: (dledc ai>PfOl)l1ate box)
□Slope □Valley litRat □Ridge □other ______ _
t<@ISTCD 36_ 1•""•a••u•••A1 CL R OR 3Jt~lUO(~ cc
iq.jt61STCO 75 IAAAA!AAAAAAA•! CL R OR 1',t.'lOC,tJI~ cc
L.atllude/langitude sauraa; [J;PS Ofopogr9Phlc map
(location of wall mu.I be sh<¥Wn on• USGS topo '""" em:t.tt.ched to
!fl/a foml If not using GPS)
5. FACILITY (Name of the buslnaN whara Iha wall la located.)
Maron Elementarv
Facility Name
1166 Lotla Church Rd
Slr..tAddreA
Franklin
City or Town
Maeno County Government
Contact Name
Malllng Addreu
Franklin
City or Town
.___ _ _,) -=----,------
Area code Phone number
'c:-"A I
I. WELL DETAILS: '-/.
a . TOTAL DEPTH·~·-~-~-Lv __ _
Faclltty ID# (if applicable)
NC 28734
Stata Zip Code
NC 28743
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES D
!Al c. WATER LEVEL Balow TOf) of Ca.Ing: _ _.h_..__v ___ FT.
(Use•+• if Abo11e Top of Casing)
-----------
, d . TOP OF CASINO IS O FT. Above Land Surface•
; *Top of casing terminated at/or below !and SU!fac:e may require
: a variance in accotdance with 15A NCAC 2C .0118. . ,,,. ~ e. YIELD (gpm): s METHOD OF TEST Blow Dawn
: ,. DISINFECTION:~ HTC Amount 12 oz
: g. WiTER ZONES (depth):
~ Top 'f o of Bottom Top Bottom_
; Top Bottom Top Bottom
: Top Bottom Top Bottom
Thlckneu/
; 1. CASINO : Def,ttl Dlamatar Waight Material
! Top::t:LBottcm S.2., Fl __
; Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom __ Ft. __ _
Method ; 8. GROUT: Oapth ~, Mal9rial
: Toi:,.JL_Bottom~ Fl. Bentonite
~ Top...a_Botlom~ R. 11,ffW ,5';..,.
~mped
: Top ___ Bottom __ A .. ____ _
: I. SCREEN: Depth Dlamatar Slot Siu Material
; Top __ Bottom __ Ft. __ ln. __ In. ___ _
: Top __ Bottom __ Ft. __ ln . __ In. ___ _
: Top __ Bottam __ Ft __ in, In. ___ _
: 10. SAND/ORAVliL PACK:
: Depth Siu
: Top ___ .Botlom __ Ft __________ _
: Top Bottom __ Fl __ _
: Top Bottom __ Ft __________ _
: 11 . DRIWNGLOG
Top Bottom Fom,atlon Description
I ~1.
I '(£0
5 0-:" 4 ¼'147'
----''----__ .....;/ ___ _
---''-------'----__ .....;/ ___ _
---'----___ /. ___ _
---'----___ / ___ _
: 12. REMARKS:
: Casi, ,g Re,, ,oved
; I 00 HEREBY CERTIFY THAT THIS WEU. WM. CONSTRUCTED IN -'CCOROANCE Wm-I
• 1SA NCAC 2c. weu. CONS'TR\JCTIOtf STANOAROS, N«> THAT A COi"'( OF THIS
; ~ Pl'!OIIIOEO TO THE OWNER.
. " l -2'-1-IJ...
: SIGNAT OF CERTIFIED WELL CONTRA~ DATE
j 0 7 er L, tt/.,1//, i:r,-,r
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit withrn 30 days of completion to: Division of Water Quality -Information Processing,
1117 M■H Service Center, Raleigh, NC 27199-111, Phone : (919) 807~300
FonnGW-1b
Rev. 1108
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natuml Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A
1. WELL CONTRACTOR :
Timoth y R Ham by
Well Contractor (Individual) Name
Mids ou th Geoth erm al
Well Contractor Company Name
827 5 Tourna ment Dr Suite 185
Street Address
Mem phi s TN 38 125
City or Town State Zip Coda
( 901 , 7 48-9095
Area coda Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WIO 100141 ~~~~~------
OTHER ASSOCIATED PERMIT#(lf applicable) _______ _
SITE WELL ID #(lfappllcable).~A~-~1 _________ _
S, WELL USE (Cheek Ona Bo,c) Monitoring D Municipal/Public D
Industrial/Commercial □ Agricultural □ Recovery □ Injection □
Irrigation□ other rl (list UH) Closed looo Geotherrq
DATE DRILLED...,.9'-'-2=9,._,-_,1_.1 ___ _
,. WELL LOCATION:
1166 Latia Church Rd
(streel Name, Numbers, Community, Subdivision , Lot No .. Parcel. Zip Code)
c1TY: Franklin COUNTY Macon
TOPOGRAPHIC/ LANO SETTING: (check appropriate !>ox)
□Slope □Valley (i/Ffel □Ridge □Other ______ _
K@ifSTCO 36_ I AAIIA&A/\AA/11\AA! CL R OR 3JC~>VO(~ cc
KNM"ISTC075 1""""!""""""MI CL ROR 7'Jt~-~ CC
Latitude/longltuda source: [)3PS OT'opographlc map
(location of well must be shown on • USGS topo map andattachlld to
this form If not using GPS)
6. FACILITY (Name of the buslnesa where the well ls located.)
Macon Elementarv
FacllltyName
1166 Latia Church Rd
Street Addrau
Franklin
City or Town
Macon County Government
Contact Name
Malling Address
Franklin
City or Town
( ) _________ _
Area code Phone number
I. WELL DETAILS:
a . TOTAL DEPTH:_4...,5 .... 0 ... ' ____ _
Facility ID# (if applicable)
NC 28734
State Zip Code
NC 28743
State Zip Coda
b. DOES WELL REPLACE EXISTING WELL? YES D NO[:#
c. WATER LEVEL Below Top of Casing: 60 FT.
(Use·+· If Above Top of Casing)
-----------
: d . TOP OF CASINO IS 2 FT. Above Land Surface•
: •Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
: e. v1ELD (gpm>: 40 METHOD oF TEST Blow Down
~ f . DISINFECTION: Type HTC Amount 12 az
; g. WATER ZONES (depth):
: Top 250' Bottom 254' Top ___ Bottom __ _
: Top ___ Bottom __ _ Top Bottom. __ _
: To p ___ Bottom __ _ Top Bottom. __ _
Thickness/
: 7. CASINO: Depth Diameter Waight Material
~ Top....:!:2._ Bottom.....e.z.:_ Ft. 6 1/8 ...JmL steel
: Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft __ _
; 8 . GROUT: Depth Material
: Top....Q__ Bottom...1]__ Ft. Bentonjte
~ Top..12_ Bottom..ASQ_ Ft. washed stone
: Top ___ Bottom ___ Fl ____ _
: 9. SCREEN: Depth Diameter Slot Size
Method
Pumped
poured
Material
: Top ___ Bottom ___ Ft. __ ln. __ In. ____ _
: Top ___ eottom ___ Ft, __ ln, __ in , ___ _
: Top_. __ Bottom ___ Ft,_Jn. in. ____ _
; 10. SAND/GRAVEL PACK:
: Depth Sia Material
: Top ___ Bottom ___ Ft. __________ _
: Top ___ B.ottom ___ Ft. __________ _
: Top ___ S.ottom ___ Ft. __________ _
: 11 . DRILLING LOG
Top Bottom
O /.....,6._.1 __ _
61 , . ....,6=7 __ _
12 1 ..... 2 .... s ... o __
250 /_.2_5..,.4 __
254 /_4=5.._0 __ ____ / ___ _
---''----____ / ___ _
I ---,----____ / ___ _
: 12. REMARKS:
: Casi, 19 Re, r roved
Formation Oascriplion
Oyerburden
Gr anite
Granite
Broken Granite 40 GPM
Granjte
; I 00 111:REB'( CERTIFY THAT THIS WELL WM CONSTRUCTED IN ACCOROANCI: WITH : ::c~~ ~~ =~~r.:~~N:::,o ™AT A COPY OF THIS
~ ~~~ 9-29-11
; SIGNARE OF CERTIFIED WELL CONTRAC~ DATE
: Timothy R Hamby
: PRINTED NAME OF PE RSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -lnfonnatloh Processing,
1617 Mall Service Canter, Ralelgh , NC 27699--181, Phone: [phone]
Form GW-1b
Rav. 1/08
NON REs1»ENTIAL WELL coNsTRucTioN REcoRD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A
1. WELL CONTRACTOR :
Timo thy R Hamby
Well Cohlnletor (lndlvldual) Name
Mid so uth Geothermal
Well Contrector Company Name
8275 Tournament Pc Suite 1 as
Street Address
Memph is TN 381 25
City or Town State Zip Code
1 901 1 7 48-9095
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# ..... W--'--'-'IQ.._1....,0...,Q.._1 .... 4"'""1'------
0THER ASSOCIATED PERMIT#(lfapplicable), _______ _
SITE WELL ID #(If appllcable) A-2 -----~---------
3. WELL USE (Check One Box) Monitoring D Muni cipal/Public □
lnduatrial/Commerelal □ Agricultura l □ RGCOvery □ lnjec1ion □
Irrigation□ Other IW(lfst U18) Closed loop Geotherrb
PATE DRILLE0-=9'--'•2...,8"""-_,_1...,_1 ___ _
,. WELL LOCATION:
1166 LoUa Church Rd
(Street Name. Number&. Community, Subdivision, LOI No., Parcel, Zip Code)
crrv: Franklin coUNTY Macon
TOPOGRAPHIC / LAND SETTING: (check appfOPOate box)
□Slope □Valley ii(Flat □ Ridge □Other ______ _
~ISTCO 36_ I AAM!AIIAAAIIA AJ CL R OR 3J<NIMDC~ cc
KNr.t" ISTCO 75 1"""'!"'"""""1 CL R OR ~.')('JC'JOI~ CC
l..ltltude/longftude source: [)$PS Ol'opographle map
(local/on of well must b• ahown on• USGS topo msp andsttech•d to
th /a form If not uaing GPS)
5. FACILITY (Name of the business where the well ls located,)
Macon Elementary
Facility Name FacTiity 10# (If appllcabla)
1166 Latia Cburcb Rd
Street Addrau
Franklin NC 28734
City or Town State Zip Code
Macon County Government
Contact Name
Mailing Address
Eraokt;n NC 28743
City or Town State Zip Code
( ) ________ _
Area coda Phone number
8. WELL DETAILS:
a, TOTAL DEPTH:._4""5.,.....O_' ____ _
b. DOES WELL REPLACE EXISTING WELL 7 YES D NO rJ/
a. WATER LEVEL Below Top of Casing: 60 FT.
(Use ·+· If Above Top of Casing)
-----------
: d. TOP OF CASINO IS 2 FT. Above Land Surface•
•Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118,
~ e. YIELD (gpm): 40 METHOD OF TEST Blow Down
: f. DISINFECTION: Type HTC Amount 12 OZ
: g. WATER ZONES (depth):
~ Top 250' Bottom 254' Top ___ Bottom, __ _
: Top ___ Bottom._ __ _ Top ___ Bottom~---
: Top Bottom __ _ Top Bottom,_ __ _
: 7. CASINO: Depth Diameter
j Top~ Bottom_e:r__ Ft. 6 1 /8
: Top ___ eottom ___ Ft.. __ _
: Top ___ Bottom ___ Ft.'----
: 8 , GROUT: Oeptt, Material
~ Top_Q_ Bottom..12._, Ft Bentonjte
Thlc:kneH/
Weight
...J.L
Material
steel
: Top...12.__ Bottom~ Ft washed stone
Method
pumped
poured
: TO,:! ___ Bottom ___ Ft. ____ _
: 9. SCREEN: Depth Diameter Slot Size Material
: Top ___ 8ottom ___ Ft. __ ln . in. ___ _
: Top ___ Bottom ___ Ft. __ ln. i n. ___ _
: Top ___ Bottom ___ Ft. __ ln. in. ____ _
: 10. SAN D/GRAVEL PAC K:
: Depth Siu Material
: Top. ___ Bottom ___ Ft. __________ _
: Top ___ Bottom ___ Ft.._ _________ _
: Top Bottom ___ Fl __________ _
: 11 . DRILLING LOG
Top Bottom
o / .... 6 ... 1 __ _
61 '~6~7 __
72 /_.2_5_0 __
250 1_2_5_4 __
254 /_4~50 __ ___ / ___ _ ____ / ___ _
I --------____ / ___ _ ___ ./ ___ _ ___ ./ ___ _
: 12. REMARKS:
~ C as ir 19 Rei 11oved
Formation Description
Overb urden
Granite
Grani te
Broken Granite 40 GPM
Granite
: I 00 HEREBY CERTIFY TliAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
; ~~~C~ ~~ ;~~~~o~rw~~N~DTHAT A COPY OF THIS
: c f ':':2-c · 9-28-11 : ~-n v'JI
; SIGNA RE OF CERTIFIED WELL CONTRAC°"foR' DATE
, . H : Irmothv Bamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Dfvlsjon of Water Quality -Information Processing,
1617 Mall Service Center, Ralelgh, NC 27699-181 , Phone: [phone]
Form GW-1b
Rev, 1108
NON RESIDENTIAL WELL' CONSTRUCTION RECORD
Norili Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A -----------
1 . WELL CONTRACTOR:
Timothy R Hamby
Well Contractor (fndlvldual) Name
Mjdsouth Ge othe rmal
Well Contractor Company Nam•
8275 Tou rn ament Dr Su ite 185
Street Addt9H
Memphis TN 38125
City or Town State Zip Code
1 901 > 7 48-9095
Area coda Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#-'-W~l~0 ..... 1~0 =0 ~14~1~----
0THER ASSOCIATED PERMIT#(lf applicable) _______ _
SITE WELL ID #(If epplicableJ,~A~-~3~---------
3 . WELL USE (Cheek One Box) Monitoring □ Munleipal/Publlc □
lndu11riaUComrnerclal D Agricultorat □ Recovery □ Injection O
Irrigation□ Other !W(llst use) Close d looo Geotherra
DATE DRILLED-"9'-'-2=-7,....-..... 1 ..... 1 ___ _
4, WELL LOCATION:
1166 Latia Church Rd
(Street Name . NUfTlbers , Community, Subdivision, Lot No., Parcel. Zip Code)
ctTY: Franklin COUNTY Macon
TOPOGRAPHIC/ LANO SETTING: (check appropriate box)
□Slope OValtay .{Flat □Ridge □other ______ _
l<@,ISTCD 36_ i"AAl\&AAA AAAAA I CLROR ax~~ cc
l<Nl'.f' ISTCO 75 I ""AA&/\1\1\IIAI\AI\J CL R OR ],t~ cc
Latitude/longitude 1ourea: []3PS Ofopographlc map
(looat(on of we// must be shown on • USGS topo map endettached to
this form if not using GPSJ
5. FACILrrY (Name of the business where the well ls located.)
Macon Elementary
Faellity Nam•
1166 Latia Church Rd
Street Address
franklin
City or Town
Macao Countv Government
Contact Name
Malling AddrHI
Franklin
City or Town
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:_4~5_0_' ____ _
Factlity 10# (if appffeabfe)
NC 28734
Stats Zip Code
NC 28743
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES □ NO r;/
c . WATER LEVEL Below Top of Casing: 60 FT.
(Use •+• If Above Top of Caaing)
: d. TOP OF CASINO IS 2 FT. Above Land Surface•
: •Top of easing terminated aVor below land surfaea may require
; a variance in accordance with 15A NCAC 2C .0118.
: •· YIELD <upm)~ 40 METHOD oF TEST Blew Down
~ f . DISINFECTION: T'ype HTC Amount 12 oz
: g. WATER ZONES (depth):
~ Top 250' Bottom 254' Top. ___ Bottom __ _
: Top ___ Bottom._ __ _ Top ___ Bottom __ _
: Top Bottom __ _ Top Bottom, __ _
; 1. CASINO: Depth Diameter
~ Top...:!:2.._ Bottom...1Z..._ Ft. 6 1/8
: Top ___ Bottom ___ Ft __ _
: Top ___ Bottom ___ Ft. __ _
; 8 . GROUT: Depth Material
~ Top..Q_ Bottom..lL._ Ft. Bentonlte
Thlcknen/
Weight
......18L
Material
steel
: Top.I]_ Bottom_§O_ Ft . washed stone
Method
Pumped
poured
: Top ___ Bottom ___ Ft.. ____ _
j 9. SCREEN: Depth Diameter Slot Sin Meterlal
: Top ___ Bot!om ___ Fl __ in. __ in. ___ _
: Top ___ Bottom ___ Ft. __ ln. __ in. ___ _
: Top ___ Bottom ___ Ft. __ in. in. ____ _
: 10. SAND/GRAVEL PACK:
Depth
; Top Bottom ___
: Top Bottom ___
; Top Bottom ___
: 11 . DRILLING LOG
Top Bottom
Q I 5_5
5.5. I 72.
Z2 I 25Q
250 / 254
2~ I 45_0
I
I
I
I
I
I
: 12. REMARKS:
i Casir 19 Re, 1 ,oved
Ft.
Ft.
Ft.
Size Material
Formation Description
Overburden
Granite
Gr an ite
Broken Granite 40 GPM
Granite
; I DO HEREBY CERTIFY THAT THIS WEU. WAS CONSTRUCTED IN ACCORDANCE. Willi
• 1~A NCAC 2C, WEU. CONSTRUCTION STANOAADS, ANO THAT A COPY OF THIS
; RECORD HAS BEEN PROVIDED TO THE WELL OWNER
:~ R ~ 9-27-11
: SITUREOFCRTIFIEO WELL CONTRAC"TOR DATE
: Timothy B Hamby
: PRINTED NAME OF PERSON CONSTRUCTING Tl-IE WELL
Submit wrthln 30 days of completion to: Division of Water Quality -lntonnatlon Processing,
1617 Mall Service Center, Ralelgh, NC 27699-161, Phone: [phone]
Form GW-1b
Rev. 1108
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources• Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3118-A
1. WELL CONTRACTOR:
Timo th y R Hamb y
Well Contractor (Individual) Name
Midsouth Geothermal
Well Contractor Company Name
8275 Tournament Dr Suite 185
Street Addreu
Memphis TN 38 125
City or Town State Zip Code
< 901 ) 7 48-9095
Area code Pl\011a number
2. WELL INFORMATION :
WELL CONSTRUCTION PERMIT#...,W..:..:.::IQ._1:..::Q::.a:Q'-'1'-4'-'1'------
OTHER ASSOCIATED PERMIT#(if applicable ), _______ _
SIT£ WELL ID #(If apptlcable) . ..,.A..,.---'4,__ ________ _
3-. WELL USE (Check Ona Box) Monitoring □ Municlpat/Publlc D
lndustrial/Commerc:ial □ Agrict1ltural O Recovery □ Injection □
Irrigation□ Other11((1istUN) Closed looo G eothema
DATE DRILLED_9~-2_3_-_.1_.1 ___ _
4. WELL LOCATION:
1166 Latia Church Rd
(Street Name , Numbers . Community, Subdivision, Lot No., Parcel, Zip Code)
c1TY: Franklin couNTY Macon
TOPOGRAPHIC I LAND SETTING: (check approl)flate box)
□Slope □Valley ii(Flat D Ridge □other ______ _
~1$TCO 36_ IAA I\A &lll\111\AA I\II J CLROR 3a:NtJO(~ cc
KN~ISTCO 75 1""111\&AIII\AI\AAAJ CL R OR 7'lf~~ cc
Latltude/longltude source: [):;PS Qropographlc map
(/~lion of wall must b• shown on • USGS topo map andatt.ched to
thla form If not using GPSJ
5. FACILITY (Name of the business where the wall I• loc:ated,)
Macao Elaroantarv
Facillty Nam• Facility 10# (If appllcable)
1166 L otla Cbuccb Rd
Street Address
Franklin NC 28734
City or Town State Zip Code
Macao County Government
Co11tact Name
Malling Addrea■
Franklin NC 28743
City or Town State Zlp Code
Area code Phone number
S. WELL DETAILS:
a. TOTAL DEPTH :...;4""5...,0..._' ____ _
b. DOES WELL REPLACE EXISTING WELL? YES D NO r,
c. WATER LEVEL Below Top of Cas ing: 60 FT.
(Un •+• If Above Top of Casing)
-----------
: d, TOP OF CASINO IS 2 FT. Above Land Surface•
: •Top ot casing terminated at/or below land surface may require
a variance In accordance With 15A NCAC 2C .0118.
: •· v1ELD (gpm1 : 40 METHOD oF TEST Blow Dawn
~ f. DISINFECTION: T~ HTC Amount 12 QZ
: g, WATER ZONES (depth):
~ Top 250' Bottom 254' Top ___ eottom ___ _
: Top ___ Bottom __ _ Top Bottom __ _
: Top Bottom'-----Top Bottom'----
: 7. CASINO: Depth Diameter
~ Top...±2__ Bottom_lZ__ Ft. 6 1/8
: Top ___ Bottom ___ Ft.. __ _
: Top ___ Bottom ___ Ft.. __ _
: 8. GROUT: Depth Mater!al
~ Top.Jl_ Bottom...IL_ Ft. Bentonjte
ThlckneHI
Weight
...1L
Material
steel
: Top..l]__ Bottom~ Fl washed stone
Method
Pumped
poured
: Top ___ Bottom ___ Ft. ____ _
: 9. SCREEN: Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft. __ tn. In . ____ _
: Top ___ Bottom ___ Ft. __ in. in. ____ _
: Top ___ Bottom ___ Ft. __ in. In. ____ _
: 10. SAND/ORAVEL PACK:
: Depth Size Material
; Top ___ Bottom ___ Ft. __________ _
: Top Bottom ___ Ft. __________ _
j Top Bottom ___ Fl __________ _
; 11 . DRILLING LOG
: Top Bottom
0 /_,7..,,5 ____ _
75 /_,TT ... __ _
ZZ ,._,2..,,5..,.0 __
250 /_,2..,5._.4 __
254 /_4...,5.a;O __
---'-------'----
' --'------'----I --------__ ...;/ ___ _
: 12. REMARKS:
~ Casi, 19 Removed
Formation DHcription
Overburden
Gr anite
Granite
Broken Granite 40 GPM
Gr anite
; I 00 HEREBY CERTIFY THAT THIS WEU. WAS CONSTRUCTED IN ACCORDANCE WITH
: 15A NCAC 2C, Wal CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
~ ~IZ_/~ 9-23-11
: SIGNATU RE OF CERTIFIED W ELL CONTRA~ DATE
Iiroathy 8 Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -lntonnatlon Processing,
1617 Mall Service Center, Ralelgh, NC 27-899,.181, Pt,one: [phone]
Form GW-1b
Rev. 1/08
NON REs1DENTIAL WELL coNsraurnoN REcoRD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A -----------
1. WELL CONTRACTOR:
Timothy R Hamby
Well Contractor (Individual) Name
Midsouth Geoth ermal
Wall Contractor Company Name
8275 Tournament Dr Suite 185
Streat Addre111
Memph i s TN 381 25
City or Town State Zlp Code
< 901 l 7 48-9095
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#~W~IQ~1~Q~Q __ 1 __ 4~1~----
0T1-iER ASSOCIATED PERMIT#(lf applicable) _______ _
SITE WELL ID #(if applicablel~A~-~5~---------
3. WELL USE (Cheek One Box) Monitoring O Munlcipal/Publie D
lndustrial/Commerclal □ Agricultural □ Recovery □ Injection □
lrrigatlon□ Other !W(liat use) Closed looo Geotherr11
DATE DRILLED_.9 __ -2=2,.,.-...,1_.1 ___ _
•· WELL LOCATION :
1166 Lotla Church Rd
(Street Name , Numbera, Community, Subdivision, Lot No., Parcel , Zlp Code)
c1TY: Franklin COUNTY Macon
TOPOGRAPHIC / LAND SETTING: (check appropf{a\e boll)
□Slope □Valley ~at □Ridge □other ______ _
K@Sl$TCD 36_ 1MM,tMMM""I CL R OR ax~~ cc
KN~ ISTCD 75 1••AA.t•""···••1 CL R OR 7',t~ cc
Latltudallongltuda source: [);PS Qropographl e map
(local/on of well must be shown on a USGS topo mep andattached to
this form If not using GPS)
5. FACILITY (Name of the businesa where the well 11 located.)
Macao Elementarv
Facility Name Faellity ID# (If appllcab(e)
1166 Lotta Church Rd
Street Addreu
franklin NC 28734
City or Town State Zip Coda
Macon County Government
Contact Name
Mailing Address
Franklin NC 28743
City or Town State Zip Code
Area CO(je Phone number
8. WELL DETAILS:
a. TOTAL DEPTH:_4.,..5...,0..._' ____ _
b. DOES WELL REPLACE EXISTING WELL 7 YES O NO r3/
c. WATER LEVEL Balow Top of Caaing: _6_O _____ FT.
(Usa •+· If Abo11a Top of Casing)
; d . TOP OF CASINO IS 2 FT. Above Land S urtac.•
•Top or ca■lng terminated at/or below land slirface may require
a varlanct in accordance With 15A NCAC 2C .0118.
: e. view <;pm): 40 METHoo oF TEST Blew Dawn
: f. DISINFECTION: Type HTC Amount 12 QZ
: g. WATER ZONES (depth ):
~ Top 250' Bottom 254' Top ___ Bottom. __ _
: Top ___ Bottom __ _ Top Bottom. __ _
: Top ___ Bottom, __ _ Top ___ Bottom __ _
[ 7. CASINO: Depth Diameter
~ Top..&,_Bottom....12:__Ft. 61/8
: Top ___ Botto m ___ Ft.. __ _
: Top ___ Bottom ___ Ft.. __ _
: 8 . GROUT: Depth Material
~ TopJL_ Bottom~ Fl Bentonlte
Thlckneaal
Weight
....wL.
Material
steel
: Top.II._ Bottom~ Ft. washed stone
Method
Pumped
poured
: Top ___ Bottom ___ Ft. ____ _
; I. SCREEN: Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft. __ in. in. ____ _
: Top ___ Bottom ___ Ft. __ in. in. ____ _
: Top ___ Bottom ___ Ft. __ in. In. ____ _
: 10. SANDIORAVEL PACK:
; Depth Size Material
: Top ___ BottOITI ___ Ft.. __________ _
; Top ___ Bottom ___ ft.~--_______ _
: Top ___ Battom_ Fl._ _________ _
: 11. DRILLING LOG
Top Bottom Formation OeseripUon
0 '~7~5 __ Overbu rden
75 l_,7"""7 __ _ Granite
ZZ /_.2..,.5:x0 __ Granite
250 /__.2...,54.._ __ Broken Granite 40 GPM 254 /_4:.,:5:.,:;0 __ Gra nite
----'----' ---,----
---''-------'----____ / ___ _
: 12. REMARKS:
: Cash 19 Ren 1oved
: 100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCOROAN<:f Wrnt
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY Of TH IS
: RECORD HAS BEEN PROY!ffD TO n<E WELL OWNER
: -~ R "-!±_<-9.22.11
; SIGN~RE OF CERTIFIED WELL CONTRAc'\'oR DATE
: Timothy R Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -Information Processing,
1617 Mall Service Center, Ralelgh, NC 27699-161, Phone : [phone]
Form GW•1b
Rev.1/08
'2..3
NON R ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources--Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A
1. W E LL CONTRACTOR:
T imothy R Hamby
Well Contractor (lndlvidual) Name
Midsouth Geothermal
W ell Co ntractor Company Nam•
8275 Tou rn ament Dr Suite 185
Street Addresa
Memphi s TN 38 125
City or Town State Zip Code
< 901 l 7 48-9095
Area coda Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#~W~IQ~1~Q~Q~1~4~1~----
OTHER ASSOCIATl:D PERMIT#{lf applicable). _______ _
SITE WELL ID #(If appllcable)~A~•-"6 '--_______ _
3. WEU. USE (Check Ona Box} Monitoring □ Munlcipal/Publlc D
Industrial/Commercial O Agricultural D Recovery D Injection □
Irrigation □ 01her r,/ (list use) Closed loco Geothe rra
DATE DRILLED...,.9_.-2""0,._•_,.1...,_1 ___ _
4 . WELL LOCATION:
1166 Latia Church Rd
(Street Name, Numbers, Community, Subdivision, Loi No., Parcel. Zip Code)
c 1TY: Franklin couNrv Macon
TOPOGRAPHIC / LAND SETTING: {checlt appropriate bol)
□S lo pe □Valley a"f'lat ORldga □Other ______ _
K@,tSTCD 36_ il\MA.t•AAI\MA•I CLR OR 3K!-JI~ cc
KNMF tsrcD75 i•AAA.tAAAAA>AA! CL ROR 1-it.~ cc
Latitude/longitude 10Urce: [):;PS Qropographic nlap
(locetfon of w.11 must be shown on a USGS topo map andattachad to
this form if not using GPS)
&. FACILITY (Name of tha butinen where the well la located.)
Macon Elementary
Facility Name Facility ID# (If applicable)
1166 L atla Church Rd
Street Addresa
Franklin NC ?8734
City or Town State Zip Coda
Macon County Government
Contact Name
Mailing Address
Ecanklio NC 28743
City or Town State Zip Code
( ) ________ _
Area code Phone number
I . WELL DETAILS:
•• TOTAL DEPTH:,_4=-,oS ... O_' -----
b. DOES WELL REPLACE EXISTING WELL? YES □ NO J:¥
c. WATER LEVEL Below Top of C asing: 60 FT.
(Use •1-• if Above Top of Casing}
-----------
: d. TOP OF CASINO IS 2 FT. Above Land Surfaca•
•Top of casing term inated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
: e. YIELD (gpm): 40 METHOD OF TEST Blow Down
; f. DISINFECTION: Type HTC Amount 12 az
: g. WATER ZONES (depth):
~ Top 250' Bottom 254' Top ___ Bottom __ _
: Top ___ Bottom. __ _ Top Bottom. __ _
: Top ___ Bottom __ _ Top Bottom. __ _
: 7. CASINO : Dapth Diameter
~ Top...±,?__8ottom~Ft. 61/8
: Top ___ Bottom ___ Ft. __ _
; Top ___ Bottom ___ Ft. __ _
' ; 8. GROUT: Depth Matenal
~ Top.Jl.._ Bottom...IZ'..__ Ft. Bentonjte
Thlcknen/
Weight Material
_jJliL. steel
: Top..ZL._Bottom~ Ft. washed stone
Me1hod
Pumped
poured
; Top ___ Bottom ___ Ft. ____ _
; t , SCREEN : Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft. __ ln. in. ____ _
: Top ___ Bottom ___ Ft. __ ln. in. ___ _
: Top ___ Bottom ___ Ft. __ ln. __ In, ____ _
: 10 . SAND/GRAVEL PACK:
: Depth Size Materl1I
: Top ___ .Bottom ___ Ft. __________ _
: Top ____ .Bottom ___ Fl __________ _
j Top ___ .Bottom ___ Ft.. __________ _
: 11. DRILLING LOG
: Top Bottom
0 I 75
_1 ... s.__1_1 .... z'---.. z ... z_ ... 1..,2..,5,..0._ __
250 I 254
254 / 450
---·'---------'-------'-------'--------'---------'----
: 12. REMARKS:
: Casing Re, no"Yed
Formation Description
Overb urden
Granite
Granite
Broken Granite 40 GPM
Gr anite
: I 00 HERESY CERTIFY THAT THIS WELL WAS CONSIBUCTEO IN ACCOROANC£ WITH
; 16A NCAC 2C, WELL CONSTRUCTION STANDAROS, ANO THAT A COPY OF THIS
, RECORD tiAS BEEN PROVIOEO TO THE WEU. OWNER.
: I _, ,c. ;~ 9-2 0-11 : ~ /'I /J I -.
: SIG/IIURE OF CERTIFIED WELL CONTRAefc>R DATE
: Timothy R Hamby
: PRINTED NAME OF PERSON CONSTR UCTIN G THE WELL
Submit within 30 days of completion to: Division of Water Quality. lnfonnatlon Processing,
1817 Mall Service Center, Raleigh, NC 27699-161, Phone: [phone]
Form GW-1b
Rev. 1108
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Wafer Quality
WELL CONTRACTOR CERTIFICATION# 3118~A -----------
1. WELL CONTRACTOR:
Timo thy R Hamby
Well Contractor (lndMdual) Name
Midsouth Geotherma l
W e ll Contractor Company Name
8275 Tournament Dr Suite 1 as
Street Addre.-
M emphis TN 38125
C ity or Town Stale ZlpCode
, 901 l 7 48-9 095
Area oode Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#"_,W'-'-=IQ._1._.0::..::Q._1:.....4:....1,_ ___ _
OTHER ASSOCIATED PERMIT#(if applicable~-------
SITE WELL ID #(If appllcable),..,_A_,_•..,_7 ________ _
3. WELL USE (Check Ona Box} Monitoring D Munlcipal/Pubtlc D
lnduatrlal/Commerelal □ AgrlculllJral □ Recovery o Injection □
Irrigation□ Other ilt'(l~tuff) Closed loco GeotheITII
DATE DRILLED~9~.-2=-O..._-~1~1 ___ _
4. WELL LOCATION:
1166 Lotla Ch urch Rd
(Street Name, Numbers, Community, Subdlvfalon , Lot No., Parcel, Zip Codi)
c1TY: Franklin couNTY Macon
TOPOGRAPHIC / LAND SETTlNG: (clieelt appropriate box)
□Slope □Valley iifl:lat □Ridge □Other ______ _
K@>ISTCD 36_ iAAAA&AAAAAAAA! CL R OR ax~Jt.JO{~ll cc
l<NM= ISTCO 75 IA AAA&AAAAAAhAI CL R OR h~~ cc
Latitudenongitude source: [)3PS Qropographic map
(location of well must ba shown on • USGS topo map endattllcn&d to
this form if not using GPS)
5. FACILITY (Name of Iha business Where the well la located.)
Macon Elementary
Facility Name Facility ID# (If applicable)
1166 Latia Church Rd
Street Addres•
franklin NC 28734
City or Town State Zip Code
Macon County Government
Contact Name
Mailing Address
Franklin NC 28743
City or Towr, State Zip Code
Area code Phone number
8 . WELL DETAILS:
a. TOTAL DEPTH:_4~5_O_' ____ _
b. DOES WELL REPLACE EXISTING WELL? YES O NO r¥
C., WATER LEVEL Below Top of Casing: 60 FT.
(Use •+• If Above Top of Caaing )
: d. TOP OF CASINO 1S -. ____ FT . Above Land Surface•
: 'Top of casing terminated at/or below land eurface may require
: a variance In accordance with 15A NCAC 2C .0118.
: e. YIELD (gpm): 40 METHOD OF TEST Blow Down
! f. DISINFECTION: Type HTC Amount 12 OZ
: g. WATER ZONES (depth ):
: Top 25Q' Bottom 254' Top ___ Bottom~--
:rop. ___ Bottom, __ _ Top ___ Bottom __ _
:Top ___ Bottom __ _ Top ___ Bottam. __ _
: 7. CASINO: Depth Diameter
! Top....!2,_ Bottom..lL_ Ft 6 1/8
: Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft. __ _
; 8, GROUT: Depth Material
~ TopJL_ Bottom....az__ Ft. Bentonite
Thlcknep/
Weight
.....ffi....
Material
steel
: Top_a2_ eottom..A5L Ft. washed stone
Method
Pumped
poured
: Top ___ Bottom ___ Ft. ____ _
: 9. SCREEN: Depth Diameter Slot Slza Material
: Top ___ Bottom ___ Ft. __ tn. ___ in, __ _.__
: Top ___ Bottom ___ Ft __ in. __ in . ___ _
: Top ___ Bottom ___ Ft. __ ln. __ In, ____ _
: 10. SAND/GRAVEL PACK:
Depth Size Material
; Top ___ Bottom ___ Ft. __________ _
: Top __ _.Bottom ___ Ft. __________ _
! Top ___ Bottom ___ Ft. __________ _
: 11. DRILLING LOG
Top Bottom
0 l....,V'-'-----
77 '~2=50~-
250 /_.2...,54=----
254 /_4 ... 5 ... 0 __ ___ / ___ _
---''----__ ....;/ ___ _
----'----____ / ___ _
---''--------'----
: 12, REMARKS:
~ Casi, 19 Re111oved
Formation Description
Overburden
Granite
Broken Granite 40 GP M
Granite
: I 00 HEREBY CERTIFY THAT THIS WEl.l WAfJ CONSTRUCTED IN ACCORDANCE WITH
• 1!A NCAC 2C, WELL CONSTRUCTION STANDARDS, ANO THAT A COPY OF Tl11B
; RECORD HAS BEEN PROVl~_WELL OWNER.
: ·~ r2 /) 9-20-11
: Sl~E OF CERTIFIED WELL CONTRACT5R° DATE
: Timothy R Hamby
; PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -lnfonnatlon Proc:esslng,
1617 Mall Service Center, Raleigh, NC 27699-1 81, Phone : (919) 80Ni300
Form GW•1 b
Rev. 1108
NON RESIDENTIAL WELL CONSTRUCTION RECO RD
North Carolina DepartmentofEnviromne:nt and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A
1. WELL CONTRACTOR:
Tim othy R Ham by
Well Contractor (Individual) Name
M id south Geotherm al
Well Contractor Company Name
8275 Tournament Dr Suite 185
Street Address
Memphjs TN 381 25
City or Town State Zip Code
< 901 l 7 48-9095
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# Wl0100141 ~~~~~------
OTHER ASSOCIATED PERMIT#(if appflcable) _______ _
SITE WELL 10 #{if applicable),~A~·~B~---------
3. WELL USE (Cheek One BoK) Monitoring D Munlcipal/Publlo O
lndustrlal/Cornmercial O Agricultural □ Recovery D Injection D
Irrigation □ Other ~(list use) Closed loop Geotherra
DATE DRILLED...,9:'--'-'15"'"·..,,1 .... 1 ___ _
4. WELL LOCATION:
1166 Lotla Ch urch Rd
(Street Name, Numbera. Community. SubdlVi&lon, Lot No,, Parcel, Zip Code)
CITY; Franklin couNTY Macon
TOPOGRAPHIC I LANO SETTING: (check appropriate box)
□Slope □Valley .ti=lal □Ridge □other ______ _
~CD 36_ IAAAA,tAAAA•••"! CL ROR ax~~)l cc
l<NIVFl$TCD75 1AA••a•••• ... ••1 CLROR h;')MX~ cc
Latitude/longitude source; [)3PS OTopographlc map
(location ofwe// must be shown on• USGS topo map andatt■ched to
this form if not using GPS)
6. FACILITY {Name of Iha bualness where the well ls located,)
Macon Elementary
Facility Name Facility ID# (If applicable)
1166 Latia Church Rd
Street Address
Franklin NC 28734
City or Town State Zip Code
Macon County Government
Contact Name
Malling Address
Ecaoklio
City or Town
( >----,-------Area code Phone number
a. WELL DETAILS:
a. TOTAL DEPTH:._4_5_0~' ____ _
NC 28743
State Zip Code
b. DOES WEL L REPLACE EXISTING WELL? YES D NO~
c. WATER L EVEL Below Top of Casing: 60 FT.
(Use•+• if Above Top of Casing)
-----------
: d. TOP OF CASINO IS 2 FT. Above Land Surface•
: 'Top of casing terminated aVor be low land surface may require
: a variance In acc:ordanca with 15A NCAC 2C .0118.
i e. YIELD (gpm): 40 METHOD OF TEST Blow Down
~ f. DISINFECTION: Type HTC Amount 12 az
: g , WATER ZONES (depth):
: Top 250' Bottom 254' Tcp ___ Bottom __ _
: Top ___ Bottom. __ _ Top ___ Bottom. __ _
: TOP. Bottom ---Top Bottom. __ _
: 7. CASING: Depth Diameter
: Top....:ti...._Botto~Ft. 61/8
: Top ___ Bottom ___ Ft.. __ _
: Top ___ Bottom ___ Ft. __ _
; 8. GROUT; Depth Material
: TopJL__ Bottom~ ft. Bentonjte
Thlcknesa/
Weight
....1eL
Mat.rial
steel
~ Top~ Bottom~ Ft. washed stone
Method
Pumped
poured
; Top ___ Bottom ___ ft.. ____ _
: 9. SCREEN: Depth Diameter Slot SID Material
: Top ___ Bottom ___ Ft __ ln. In. ____ _
: Tep ___ Bottom ___ Ft. __ i n. In. ____ _
: Top ___ Bottom ___ Ft. __ ln. In. ____ _
: 10. SAND/GRAVEL PACK:
; Deplh Siu Material
: Top. ___ Bottom ___ Ft., ___________ _
; Top ___ Bottom ___ Ft.. ___________ _
: Top. ___ Sottom ___ Ft __________ _
; 11. DRILLING LOG
: Top Bottorn
0
80
250
254
I 80
I 250
I 254
I 450
I
I
I
I
I
I ---,----
: 12. REMARKS:
i Casing Re,, 1oved
Formation Description
Overb urden
Granite
Broken Granite 40 GPM
Granite
! I 00 HEREBY CERTIFY THAT IBIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
! 15A NCAC 2C, waL CONSTRUCTION STANDARDS, ANO THAT A COPV OF THIS
• RECORD HAS BEEN PROVIDED TO TliE WELL OWNER.
~ ~/Z 1-~ 9-15-11
; S~E OF CERTIFIED WELL CONTRAC~ DATE
: Timothy R Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit Within 30 days of completion to: Division of Water Quality -lnfonnatlon Processing,
1817 Mall service Center, Raleigh, NC 27699-161, Phone ; (919) 807~300
Form GW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources• Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 31 IB•A
1. WELL CONTRACTOR:
Tim o thy R Hamb v
Well Contractor (Individual) Name
Midsouth Ge oth ermal
Well Contractor Company Name
8275 Tournament Dr Suite 185
Street Address
Memphi s TN 38125
City or Town State Zip Code
< 901 l 748-9095
Area coda Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#__.W--'-'-"10....,1'-"Q'""Q'-'1-'4'""'1 ____ _
OTHER ASSOCIATED PERMIT#(lf eppltcab!e), _______ _
SITE WELL ID #(if appllcabfe)-=B"---'1 ________ _
i. WELL USE (Check One Box) Monitoring D Munielpal/Publlc O
l ndu1trial/Commerclal □ Agricultural □ Recovery □ Injection □
Irrigation□ Other s'(llst use) Closed loop Geotherra
DATE DRILLED 10-12-11
,. WELL LOCATION:
1166 Lotla Church Rd
{Street Name, Numbera, Community, Subdivision. Lot No ., Parcel, Zip Code)
c1TY: Franklin COUNTY Macon
TOPOGRAPHIC I LAND SETTING: (checlc appropnate box)
□Slope □Valley ~lat □Ridge □Other. ______ _
l<@,ISTCO 36_ 1•AA•&AAAAAA••1 CL R OR 3k~)UlJl,C~ cc
~~ISTCD75 1•--•,§AMAMAA! CLROR °])t~ cc
Latitude/longitude source: ()3PS Qropographlc: map
(location of well must be shown on • USGS topo map endettec:hed to
this form if not using GPS)
5. FACILITY (Name of tha business where the well ia localed.)
Macon Elementary
Facility Name Facility 10# (If applicable)
1166 l ctla Church Rd
Street Address
franklin NC 28734
City or Town State ZJp Code
Macon Countv Government
Contact Name
Malling Addra11
Ecaoklin NC 28743
City or Town Stale ZJp Code
Area code Phone number
8. WELL DETAILS:
a. TOTAL DEPTH:,_4......,.5 ... 0_' ____ _
b. DOES WELL REPLACE EXISTING WELL? YES O NO r:./
c. WATER LEVEL Below Top of Casfng : 60 FT.
(Un ·+· if Above Top of casing)
-----------
: d. TOP OF CASING IS 2 FT. Above Land Surface•
: ·Top of casing terminated al/or below land surface may require
: a variance In accordance with 15A NCAC 2C .0118,
: •· YIELD (gpml: 40 METHOD oF n:sT Blow Down
~ f. DISINFECTION: Type HTC Amount 12 OZ
: g. WATER ZONES (depth):
~ Top 250 Bottom 254 Top. ___ Bottom. __ _
: Top ___ Bottom. __ _ Top ___ Bottom __ _
: Top Bottom. __ _ Top Bottom. __ _
ThlckneH/
; 7. CASINO: Depth Diameter Weight Material
j Top_tZ__ Bottom~ Ft. __ _
: Top ___ Bottom_ Ft. __ _
: Top ___ Bottom ___ Ft, __ _
: 8. GROUT: Depth Material
~ Top_Q_ Bottom..19__ Ft. bentonjte
: Top..l,lL_ Bottom~ Ft. washed stone
: Top ___ Bottom ___ Ft. ____ _
Method
pumped
poured
: t . SCREEN: Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft. __ ln. In. ___ _
; Top ___ Bottom ___ Ft. __ ln. __ In . ___ _
: Top ___ Bottom ___ Ft. __ ln, In . ____ _
: 10. SAND/GRAVEL PACK:
Depth Size Matftlal
: Top. ___ Bottom ___ Ft, ___________ _
: Top ___ Bottom ___ Ft.. __________ _
: Top Bottom_ Ft. __ _
: 11 . DRILLING LOG
Top Bottom
0 /_7~0 __
70 /_7.._.5 _____ _
75 , ..... 2 ... 5,...0 __
250 /_.2 ... 5._..4 __
254 /_4=5=0 __
I ---, ,.--------__ _,,! ___ _
I ---,----
: 12. ~E.!'i~K$;
i Casing Re111oved
Formation Description
Di rt
Gra nite
Gra nite
Broken Granite
Granite
: I 00 HEREBY CERTIFY THAT THIS WEl.1. WAS CONSfflUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WEU. CONSTRUCTION STANOARDS, ANO THAT A COP\' OF THIS j R~ HAS BEEN )rOVIDED TO TI1E WEl.1. OWNER.
: t ~ I<' It--"" 10-12-11
: SIG~TURE OF CERTIFIED WELL CONTRACTOR DATE
: Timothy 8 Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -Information Processing,
1817 Mall Service Center, Raleigh, NC 27899-161, Phone: (919) 807~300
Form GW•1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department ofEnvironment 1111d Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A
1. WELL CONTRACTOR:
Timothy R Hamby
Well Contractor (Individual) Name
Mi dsouth Geothermal
Well Contractor Company Name
8275 Tournament or Suite 1 as
Street Addren
Memphi s TN 38 125
City or Town State Zip Coda
1 901 > 7 48-9095
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WIO 100141 """""-'"""-"....a...:'-=--"-'-"-------
OTHER ASSOCIATED PERMIT#{lf applicable), _______ _
SITE W ELL ID #{If appllcable),..,B"'---=2"'-----------
3-. WELL USE (Check One Box) Monitorir,g D Munici pal/Public D
lnduatrial/Commerclal □ Agricultural □ Recovery □ lnjecjlon □
Irrigation□ Other llf(lllt use) Closed looo Geotherra
DATE DRILLED 10-11-1 1
,. WELL LOCATION:
1166 Lotta Church Rd
(Street Name, Numbers. COmmunlty, SUbdivlslon , Lot No., Parcel, Zip Code)
ctTY: Franklin couNrv Macon
TOPOGRAPHIC I LAND SETTING: (Check appropriate box)
□Slope □Valley ltFl•t □Ridge □other ______ _
l<@,ISTCD 36_ 1M•A&MAIIMMI Cl R OR :aJ(~ cc
!<Nll.f 1$TCD 75 i··••au••••Mt CL R OR 7'lt~~ cc
latitude/longitude source: [)3PS Qropographlc map
(local/on of w.11 must be shown on • USGS topo map andattachad to
this form if not using GPS)
IS. FACILITY (Name of th• busi r,ass where the well I• located.)
Macon Elementary
FaclllfyName
1166 Lotla Church Rd
Street Addreaa
Franklin
City or Town
Macon Ccuntv Government
· Contact Name
Mailing Address
Franklin
City or Town
f ) _________ _
Area code Phone number
8. WELL DETAILS:
L TOTAL 0EPTH:-'4""5.....,.O_1 ____ _
Facility ID# (if applicable)
NC 28734
State Zlp Coda
NC 28Z43
State Z ip Code
b. DOES WELL REPLACE EXISTING WELL 7 YES D NO ryl
C . WATER LEVEL Below Top or Casing: 60 FT.
(Use•+• if Above Top of Casing)
-----------
; d. TOP OF CASINO IS 2 FT. Above Land Surface•
"Top of casing termi nated at/or below land surface may require
a variance fn accordance with 15A NCAC 2C .0118.
: e. YIELD (srpmJ: 40 METHoo oF TEST B law Down
~ ,. DISINFECTION: rype HIC Amount 12 az
: g. WATER ZONES (depth):
~ Top 250 Bottom 254 Top ___ Bottom, __ _
: Top, ___ Bottom __ _ Top ___ Bottom, __ _
: Top Bottom. __ _ Top Bottom, __ _
Thickneu/
: 7. CASINO: Depth Diameter
! Top_±,2__ Bottom...lQ_ Ft._ __
Weight Material
: Top ___ Bottom ___ Ft. __ _
; Top ___ Bottom ___ Ft __ _
: 8 , GROUT: Depth Material
~ Top_Q_ aottom..15.._ Ft. bentonjte
: Top_l5__ Bottom~ Ft. washed stone
: Top ___ Bottom ___ Ft.. ____ _
; 9. SCREEN: Depth Diameter Slot Size
Method
pumped
poured
Material
; Top ___ Bottom ___ Ft. __ ln. __ i n , ____ _
: Top ___ Bottom ___ Ft,_in. In. ____ _
j Top ___ Bottom ___ Ft. __ ln . i n. ____ _
: 10. SAND/GRAVEL PACK:
: Dapth Size Material
: Top. ___ Bottom ___ Fl ___________ _
; Top Bottom ___ Ft. ____________ _
: Top Bottom ___ Ft .. __________ _
: 11. DRILLING LOG
: Top Bottom
O I 70
70 I 75
_7~5.___,_ .... 2 .. 5.,.0 __
250 I 254
254 I 450
---·'--------'-------'----/ ---,----
---''----
: 12. REMARKS:
~ C as111g Removed
Fonnatlon Description
Dirt
Gra nite
Granite
Broken Granite
Granite
; I DO HEREBV CERTIFY THAT THIS WEU. WAS CONSTRUCTED IN ACCORDANCE WITH : ~i~~ ~ :~.;~~~c;:.r~=~OTHAT ACOPV OF nus
~ ~ iP J'lh 10-11-11
: ~RE OF CERTIFIED WELL CONTRA~ DATE
: Timothy B Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -lnfonnatlon Processlna,
1617 Mall Service Center, Raleigh, NC 2769&-161, Phone : [phone]
FormGW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Departmenr of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3118-A -----------
1. WELL CONTRACTOR:
Timothy R Ham by
Well Contractor (Individual) Name
Mjdsouth Geot hermal
Well Contractor Company Name
8275 Tournament Pc Suite 185
Street Address
Memphis TN 38125
City or Town State Zip Code
1901 > 7 48-9095
Area code Phone number
2, WEU INFORMATION:
WELL CONSTRUCTION PERMIT#...::W..:..:.,IQ,_1,_0,....0,_1 ..... 4....,1 ______ _
OTHER ASSOCIATED PERMITll(lf applicable)~-------
SITE WELL 10 #(ifappflcable)..;::B_--=3.__ _______ _
3. WELL USE (Check One Box) Monitoring D Munlclpal/Pubtlc D
lnduatrial/Commercial D Agrtcuttural □ Recovery □ Injection □
Irrigation□ Other IW(llst use) Closed loop Geotherra
DATE DRILLED 10-10-11
•· WELL LOCATION:
1166 Latia Church Rd
(Street Name. Numbers , Communlty, Subdivision , Lot No., Paroel, Zip Code)
cITY: Franklin couNTY Maoon
TOPOGRAPHIC / LANO SETTING: (check appropriate box)
□Slope □Valley gFlat □Ridge □Other ______ _
K@,1$Tco JS_ 1•AA •a•11•11AA 11•1 cL R oR JJ11~J1JU1~x cc
KNMFlflTCO 75 111•"•5""""""11"1 CL ROR 7'j~JI~ CC
Latitude/longitude source: [)3PS Of'opographic map
(location of well must be show(! on • USG$ topo m■p ■nd■tt•ched to
this form if not using GPS)
5. FACILITY (Name of the busineaa where the well ls located.)
Macon Elementarv
Faculty Name
1166 Lotla Church Rd
Street Address
Franklin
C ity or Town
Macon Countv Government
Contact Name
M11lilng Addre11
Franklin
City or Town
Area code Phone number
8. WELL DETAILS:
a. TOTALDEPTH:~4~5~0~'-----
Facility 10# (If applicable)
NC 28734
State Zip Code
NC 26743
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES □ NO r¥
c. WATER LEVEL Below Top of Casing: 60 FT.
(Use•+• 1f Above Top of Casing)
: d. TOP OF CASINO IS 2 FT. Above Land Surface•
: "Top of casing terminated at/or below land surface may require
: a variance fn accordance with 15A NCAC 2C .0118.
: e. YIELD fgpm): 40 METHOD OF TEST Blow Down
~ f. DISINFECTION: Type HTC Amount 12 OZ
; g. WATER ZONES (depth):
~ Top 2-50 Bottom 254 Top ___ Bottom. __ _
: Top ___ Bottom, __ _ Top Bottom. __ _
: Top Bottom __ _ Top ___ Bottom, __ _
ThicknHa/
; 7. CASINO: Depth Diameter Waight Materiel
i Top....±2.,___ Bottom..D__ Ft. __ _
; Top ___ Bottom ___ Ft. __ _
; Top ___ Bottom ___ Ft . ._ __
: 8. GROUT: Depth Material
i Top~ Bottom...za__ Ft. bentonjte
: Top-la_ Bottom~ Fl washed stone
Method
pumped
poured
: Top ___ Bottom ___ Ft.._ ___ _
: 9. SCREEN: Depth Diameter Slot Size Material
! Top ___ Bottom ___ Ft. __ ln. in. ____ _
: Top ___ Bottom_Ft. __ ln. in. ___ _
: Top ___ Bottom ___ Ft. __ ln. In. ___ _
: 10. SAND/GRAVEL PACK:
: Depth
: Top Bottom ___
; Top Bottom ___
; Top Bottom ___
; 11. DRILLING LOG
Top Bottom
0 l _.7..,.Q~--
70 '-=7=5~--75 /__.2..,.5...,0 __
250 /_,2,..54...._ __
254 I 450 ----'-------·'--------'--------'----I ---,----
: 12. REMARKS:
: Cas i11g Ren1oved
Size Materiel
Ft.
Ft.
Fl
FormationOe1cnption
Dirt
Granite
Grani te
Broken Granite
Granite
: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTB> IN ACCORDANC£ WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANOAROS, AND TiiAT A COPY OF THIS
: RECORD HAS BEEN PROVIDED TO 'THE WEU. OWNER.
~ ~~ rf"J .,, J/--,--1 0-1 0-11
; S IGNkfURE OF CERTIFIED WELL CONTRAcfcSR DATE
: Iiroctby 8 Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -Information Processing,
1817 Mall Service Center, Raleigh, NC 27699-161, 'Phone: (919) 80T~300
Form GW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A -----------
1. WELL CONTRACTOR:
Timo thy R Ha mby
Well Contractor (Individual) Name
Midsou th Geo thermal
Wall Contraetor Company Name
82 75 To urnament Dr Suite 18 5
Street Address
Memphis TN
City or Town State
1 901 ) 7 48-9095
Area coda Phone number
2. WELL INFORMATION:
38125
Zip Coda
WELL CONSTRUCTION PERMIT#~W_IQ~1_Q~Q~1_4_1 ____ _
OTHER ASSOCIATED PERMIT#{W applicable}, _______ _
SITE WELL 10 #(If appll~ble),..,8:..-4_,_ ________ _
3. WELL USE (Checl< One Box) Monitoring D Municipal/Public D
lndustrtaVCommerelal □ Agricultural □ Recovery □ In/action □
Irrigation□ Other W(llst UMI) Closed loop Geotherre
DATE DRILLED 10-6-11 '-'-'-~-----
<t. WELL LOCATION:
1166 Latia Church Rd
(Street Name. Numbers, Community, Subdivision, Lot No,, Parcel, Zip Coda)
cITY: Franklin COUNTY Macon
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
□Slope □Valley li(Flat □Ridge □Other, ______ _
K@,1$1'CO 38_ IAAAA&AMAAAAAf CL R OR 3kNUtk~ll cc
KNM=tsrco75 l"'""&MIAAM""tCLROR h~cc
Latitude/longitude source: [);PS Dropographlc map
(location of well mu:Jt ti. shown on a USGS topo map andattachttd to
this form If not using GP$}
5. FACILITY (Name ofth• buainesa where the well ls located .)
Macao Elementary
FaeilltyNama
1166 I atla Church Rd
Street Addreaa
franklin
City or Town
Macao County Government
Contact Name
Mailing Addran
Franklin
City or Town
'-----J> ---------Area code Phone number
8 . WELL DETAILS:
a. TOTAL DEPTH:...:4"'5 ... 0.._' ____ _
Facility ID# (If applicable)
NC 28734
State Zip Code
NC 28743
State Zip Coda
b. DOES WELL REPLACE EXJSTINO WELL? YES O NO r,
e. WATER LEVEL Below Top or Casing: 60 FT.
(Use •+• If Above Top of Casing)
; d . TOP OF CASINO IS ? FT. Above Land Surface•
; 'Top of casing terminated at/or below land surface may require
; a variance In aeeordanee with 15A NCAC 2C .0118.
: •. YIELD cupml: 40 METHOD oF TEST Slaw Dawn
~ t. DISINFECTION: Type HTC Amount 12 OZ
; g. WATER ZONES (depth);
~ Top 250 Bottom 254 Top ___ Bottom'----
;Top ___ Bottom __ _ Top ___ Bottom __ _
; Top ___ Bottom, __ _ Top Bottom,_ __ _
Thlck,,.••I
; 1. CASINO: Depth Diameter Waight Material
j Top~ Bottom...lJ_ Ft. __ _
: Top ___ Bottom ___ Ft.. __ _
: Top ___ Bottom ___ Ft. __ _
: 8. GROUT: Depth Material
~ Top_L_ Bottom__zs____ Ft. bentonjte
; Top__zs____ Bottom~ Ft. washed stone
: Top ___ Bottom ___ Ft. ____ _
Method
pumped
poured
; 9. SCREEN: Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft. __ ln . in. ____ _
: Top ___ Bottom_ Ft. __ ln, In, ____ _
: Top ___ Bottom ___ Ft. __ in, in. ___ _
: 10. SANDIORAVEL PACK:
; Depth Size Material
: Top. ___ Bottom ___ Ft.. __________ _
: Top ___ Bottom ___ Ft.. __________ _
: Top. ___ Bottom_ Fl, __________ _
: 11 . DRILLING LOG
Top Bottom Formation Description
O /_7-0 __ Dirt
70 / .... 7~5.__ __
Granite
Broken Granite
75 ,, .... 2_5~0 __
250 /_.2 ... 54....._ __
254 /_4.,.5..,0 __ Gran ite
I ---,----
---''-------''----/ ---,----
: 12. REMARKS:
~ Casi119 Re i 11ovee1
; I DO HEREBY CERTIFY THAT THJS WEU. WAS CONSTRUCTED IN ACCORDANCE WITH
• 10A NCAC 2C, WEU. CONSTRUCTION ST ANDAROS, AN.O THAT A COPY OF THIS
: RECORD HAS BEEN PROVJDED TO THE W ELL OWNER.
~ -!!k..-h u2 .,2-~ 10-6-11
; ~RE OF CERTIFIED WELL CONTRAC"'f'c5R DATE
: Timothy R Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division or Water Quality -Information Processlng1
1617 Mall Service Center, Raleigh, NC 27699-161, Phone: [phone]
Form GW-1b
Rev. 1108
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Caro lina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-.A -----------
1. WELL CONTRACTOR:
Timothy R Hamby
Well Contraetor (lndMdual) Name
Midsouth Geothermal
Well Contractor Company Name
8275 Tournament Dr Suite 185
Street AddreM
Memo~s TN 38125
City or Town State ZlpCoda
c 901 > 7 48-9095
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# Wl0100141 """-'-'-=-'---"'.=...,'-'-'-------
OTHER ASSOCIATED PERMIT#(lf applicable), _______ _
SITE WELL ID #(II appllcabla)_,,B"--""'5'-----------
l. WELL USE (Check One Box) Monitoring D Munlelpal/Publle D
lndustrial/Commerelal □ Agrteultural □ Recovery □ lnje~on □
lmgationo Other W(ll1t use) Closed loco Geotherra
DATE DRILLED~1~Q_-6_-~1~1 ___ _
,. WELL LOCATION:
1166 Latia Church Rd
(Streel Name, Numbers, Community, SubdMslon, LOI No., Parcel, Zip Code)
c1rv: Franklin COUNTY Macon
TOPOGRAPHIC / LANO SETTING; (check appropriate llOX)
□Slope □Valley ~at □Ridge □Other ______ _
~tsrcD 3~ ,••AAa•A•AA ••A, cL R oR aKtitiuoc~• cc
iq,jt.f'ISTCD 75 ,AA••&•AAAAAMI CL R OR h!)(~>t"~ cc
Latitude/longitude sourc;a: [}.PS Dropographlcmap
(location of well mu$/ ba .shown on • USGS topo m•P 11ndattaahod to
this form if not using GPS)
II. FACILITY (Name of the business Where the well ls located.)
Macon Elementary
Facility Name Facility ID# (If applleable)
1166 Lotla Church Rd
Street Addre ..
franklin NC 28734
City or Town State Zip Code
Macon County Government
Contact Name
Mailing Address
Franklin NC 28743
City or Town State Zip Code
Area eoda Phone number
6 . WELL DETAILS:
1. TOTALOEPTH:~4~5_0_1 ____ _
b. ooes WELL REPLACE EXISTING WELL? YES □ NO,;;/
e. WATER LEVEL Below Top of Casing: _,6"'0.._ _____ FT.
(Use '+" If Above Top of Caalng)
: d. TOP OF CASING IS ? FT. Abo'ie Land Surfaoe•
'Top of casing terminated at/or below land surface may require
a variance In aecordanc:e with 15A NCAC 2C .011 8.
~ e. YIELD (gpm): 40 METHOD OF TEST Blow Down
: ,. DISINFECTION: 1YPe HTC Amount 12 az
: g. WATER ZONES (depth):
~ Top 250 Bottom 254 Top ___ Bottom __ _
: Top ___ Bottom. __ _ Top Bottom. __ _
: Top Bottom. __ _ Top Bottom __ _
Thickness/
; 7. CASINO: Depth Diameter Weight Material
~ Top..!2..,_ Bottom..IJ..._ Ft .. __ _
: Top ___ Bottom ___ Ft •. __ _
: Top ___ Bottom ___ Ft •. __ _
: 8. GROUT: Oeplh Material
~ TopJL_ Bottom-28....._ Ft. bentonjte
: Top..za_ Bottom~ Fl washed stone
: Top ___ Bottom ___ Ft ____ _
; 9 . SCREEN: Depth Diameter Slot Size
Method
pumped
poured
: Top ___ Bottom ___ Ft. __ in. in. ___ _
; Top~Bottom ___ Ft._ln. __ in. ____ _
: Top ___ Bottom ___ Ft. __ ln. __ in, ___ _
: 10. SAND/GRAVEL PACK:
; Oepth Size
; Top. ___ Bottom ___ Ft.. __________ _
: Top Bottom ___ Fl. __________ _
: Top Bottom ___ Ft.. __________ _
: 11. DRILLING LOG
: Top Bottom Formation Description
O I 70 Dirt
70 I 75 Granite
_7~5..__/...,2..,5..,,0.__ __ Granite
250 I 254 Broken Granite
254 I 450 Granite
---'----__ _./ ,----__ ....;
---''----/ ---,----
: 12. REMARKS:
~ Casi, 19 Ren 1oved
: I DO HEREBY CERTIFY n;AT THIS WEU WAS CON5mUCT8) IN ACCORDANCE WIT11
• 15A NCAC 2C, WELL CON5mUCTION STANDARDS, ANO THAT A COPY OF THIS
; RECORD HAS BEEN PROVI ED TO THE WELL OWNER
. 10-6-11
WELL CONTRAC~ DATE
: Timothy 8 Hamby
; PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -lntonnatlon Processing,
1817 Mall Service Center, Raleigh, NC 27899•181, Phone: [phone]
Form GW-1b
Rev. 1/08
11
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Narural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A
1 . WELL CONTRACTOR :
Timothy R Hamby
Well Contractor (Individual) Name
Midsouth Ge otherm al
Well Contractor Company Nama
8275 Tournament Dr Suite 185
Street Addreu
M emphjs TN 38125
City or Town Stat• Zip Coda
c 901 > 7 48-9095
Area c;octe Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WfO 100141 ---'--"-'-=--'--'='-"'-''--'-''-------
OTHER ASSOCIATED PERMIT#(if appUcabte), _______ _
SITE WELL ID #{If app/lcable),...:B:c,.--"6=-----------
3 . WELL USE (Check One Box) Monitoring O Municipal/Public D
lnduatrial/Commen:ial □ Agricultural □ Recovery □ Injection □
lnigatlono Other .'111,1 use) Closed looo Geotherra
DATE DRILLED...,1..,,0:-.:•5.._-..,_1__._1 ___ _
4 . WELL LOCATION :
1166 Lotla Church Rd
(Street Name. Numbers. Communit}I. Subdivision. Lot No., Parcel , Zip Code)
c1rv: Franklin couNTY Macon
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
□Slope □Valley ifAat □Ridge □Other ______ _
~CD 36_ 1••••&•• .. •M'"I Cl ROR 3x~x cc
l<N~ISTCD 75 J""AA&M•••M•! CL R OR ]lit.~ cc
Latitude/longitude source: [)3PS 0Topographlc map
(location of w.11 must be $hown on • USGS topo map endettachad to
this form If not using GPSJ
5. FACILrTY (Name of the bu1ine11 whara the well i• located.)
Macon Elameotacv
Facility Name
1166 L aria Ch11rcb Rd
Streat Address
franklin
City or Town
Macon County Government
Contact Name
Malling Address
Franklin
City or Town
Area coda Phone number
8 . WELL DETAILS:
•• TOTAL DEPTH:'-4'-LNS .... 0_' -----
Facility ID# (If applicable)
NC 28734
State Zip Code
NC 28743
State Zip Coda
b. DOES WELL REPLACE EXISTING WELL? YES O NO~
c. WATER LEVEL Below Top of Casing: 60 FT.
(Use •+• if Above Top of Casing)
-----------
: d. TOP OF CASINO IS 2 FT. Above Land Surface•
"Top of caalng terminated at/or below land surface may require
a vanance In accordance with 1 SA NCAC 2C .011 8.
[ •. YIELD (gpm): 4 o METHOD OF T EST Blow Down
: f. DISINFECTION: Type HTC Amount 1 ? OZ
: g. WATER ZONES (depth):
~ Top 250' Bottom 254' Top ___ eottom __ _
: Top ___ Bottom __ _ Top ___ Bottom, __ _
: Top Bottom, __ _ Top Bottom __ _
Thickness/
: 7. CASINO: Depth Diameter Waight Material
steel ~ Top....±2,__Bottom_65,'._Ft. 61/8
: Top ___ Bottom ___ Ft __ _
; Top ___ Bottom ___ F1., __ _
; 8. GROUT : Depth Material
: TopJl__ Bottom..lQ_ Ft. Bentonjte
_J88._
~ Top..lQ_ Botto~ Ft. washed stone
; Top ___ Bottom ___ Ft. ____ _
; I . SCREEN: Depth Diameter Slot Size
Method
Pumped
poured
Material
: Top ___ Bottom ___ Ft, __ ln. __ in. ____ _
: Top ___ Bottom_ Ft._ln. __ in. ____ _
: Top __ ,_ Bottom ___ Ft __ ln. In, ____ _
: 10. SAND/ORAVEL PACK:
: Depttl Siu Material
: Top __ ___,Bottom ___ Ft. __________ _
: Top ___ B.ottom ___ Ft. __________ _
: Top Bottom ___ Ft. __________ _
: 11. DRILLING LOG
Top Bottom
0 /_,6=5'----
65 /....,2=5=0 __
250 /_,2..,5,:;i:4 __
254 /_4..,5 .... 0 __
---'----___ / ___ _ ___ / ___ _
----'----____ / ___ _
I ---,----
: 12. REMARKS: . : --easn 19 Remov ed
Fonnation Oescrtptlon
Overburden
Granite
Broken Granite 40GPM
Granite
: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
; 16A NCAC 2C, WELL CONSTRUCTION STANDARDS, ANO THAT A COPY OF THIS
• R"ECORO HAS BEEN PROVIDB:I TO THE \NEU OWNER
~ -~~~ ~ 14-, 10-5-11
: S IGNATJ:l E OF CERTIFIED WELL CONTRACl'OR DA TE
Timothy B Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE. WELL
Submit within 30 days of completion to: Division of Water Quality. Information Processing,
1617 Mall Service Center,Ralelgh, NC 27699-161, Phone ; [phone]
Form GW-1b
Rev. 1108
72.
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A
1. WELL CONTRACTOR:
Ti mothy R Ha mby
Well Contractor (Individual) Nama
Midsouth Geother mal
Well Contractor Company Name a2zs Tournament Dr Suite 1 as
Street Addreaa
Memp his TN 38 125
City or Town State Zip Coda
c 901 1 748-9095
Area eoda Phone n umber
2 . WELL INFORMATION:
WELL CONSTRUCTION PERMIT#...,W.......,I0.._1--=0=0'-'1--'4'-'1 ____ _
OTHER ASSOC IATED PERMIT#(if appllcabla) _______ _
SITE WELL 10 #(If appllcable)_,,B,.__•...,.7 ..... A_,__ _______ _
3 , WELL USE (Check Ona Box) Monitoring □ Munlclpal/Publlc □
lnduatrtal/Commercial D Agricultural o Recovery □ I njection □
Irrigation□ Other ii'(llst use) Closed loop Geotherra
DATE DRILLED-1=0--3=·~1~1 ___ _
4 . WELL LOCATION:
1166 lotla Church Rd
(street Name, Numbers, Community, Subdivision, LOI No., Parcel, Zip Code)
c1rv: Franklfn couNrv Macon
TOPOGRAPHIC / LANO SETTING: (check appropnale box)
QSlope □Val ley "'"lat □Ridge □Other ______ _
K@>ISTCO 36_ I 1111All &IIIIA I\AIIIIII I CL R OR 3JICt:MJUt~i. cc
KN~ISTco75 1M 11 •a ""1111 •1111111cLROR 7-it.~cc
Latitude,1ongltl.ide sou rce: [):;PS Dropographlc m ap
(location of well must be shown on a USGS tapo map andattachad ID
this form if not ua/ng GPS}
5. FACILITY {Name of the bua inesa where the well is located.)
Macon Elementary
Facility Name
1166 Latta Cht,ccb Rd
Street Address
franklin
City or Town
Macon Cnuntv Government
Contact Name
Maillng Address
Franklin
City or Town
Area code Phone number
8. WELL DETAILS:
a. TOTAL DEPTH :~2 ..... 5""4_' ____ _
Facility ID# (if applicable )
Ne 28734
State Z i p Code
NC 26243
State Zfp Code
b. DOES WELL REPLACE EXISTING WELL? YES D NO r,/
c. WATER LEVEL Below Top of Casing: _,fi.._0..__ ___ ~FT.
(Use •+• If Above Top of Casing)
-----------
; d. TOP OF CASING IS ? FT. Above Land Surface•
, "Top of casing terminated al/or below land surface may require
a variance In accon:lanca with 15A NCAC 2C .0118.
~ ~-YIELD fgpmJ : 40 METHoo oF TEST Blow Down
: ,. DISINFECTION: Type HTC Amount 12 az
: g. WATER ZONES (depth ):
~ Top 250' Bottom 254' Top ___ Bottom __ _
: Top, ___ Bottom __ _ Top Bottom, __ _
: Top Bottom,_ __ Top Bottom __ _
Thickness/
; 1. CASING: Depth Diameter Weight Material
steel ~ Top....±.2_ Bottom~ Ft. 6 1 /8
: Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft. __ _
: 8. GROUT: Depth Material
~ Top_Q__ Bottom_lO_ Ft. Bentonjte
...JmL
: Top_zo_ Bottom~ Ft washed stone
; Top ___ Bottom ___ Ft~----
; 9. SCREEN : Depth Dlam.ter Slot Size
Method
Pumped
poured
Material
: Top ___ Bottom ___ Ft. __ ln . In . ____ _
: Top ___ Bottom ___ Ft. __ ln. __ In . ___ _
: Top ___ Bottom ___ Ft. __ ln . __ In . ___ _
: 10. SANDIORAVEL PACK ;
Depth Material
; Top ___ Bottom ___ Ft. ___________ _
: Top Bottom ___ Ft. ___________ _
j Top Bottom ___ Ft, ___________ _
; 11 . DRILLING LOG
: Top Bottom
O /-'6=5.__ __
65 /_.2..,.5..._0 __
250 /_.2.,.54=----
254 '--------'----___ ./ ___ _ ___ ./ ___ _ ___ ./ ___ _
----'-------'-------'----
: 12. REMARKS:
: Casing Ren ,oved
Formation Description
Overb urden
G ran ite
Broken Granite 40 GPM
; I 00 HEREBY CERTIFY THAT THIS WEll WAS CONSTRUCTED IN ACCORDANCE WITH i ~r~c~ t~ ~Ji6:~~:~~~NE~ THAT A COPY OF THIS
: , ,,., ~ 10-3-11 • ~-,-, ,j,1 I _ _ ,
; SI GNRE OF CERTIFIED WELL CONTRACl'oR DATE
: Timothy R Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -lnfonnatlon Processing,
1617 Mall Service Center, Raleigh, NC 27899-161, Phone: [phone]
Form GW-1b
Rev. 1/08
J 3
NON REsmENTIAL WELL coNsTRucrmN REcoao
North Carolina Dqiartmcnt of Environment and Natural Resomces-Division of Water Quality
WELL CONTRACTOR CERTIFICATJON # 3118-A -----------
1. WELL CONTRACTOR:
Timothy R Hamby
Well Contractor (Individual) Name
Midsouth Geothermal
Well Contractor Company Name
8275 Tournament Pc Suite 1 as
Street Addresa
Memphis TN 38125
City or Town State ZlpCode
< 901 > 7 48-9095
Area eode Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#~W~IQ~1~Q~Q'-1~4~1~----
0THER ASSOCIATED PERMIT#{lf appllcab!e)~-------
SITE WELL 10 #(If appllcableJ,...,,B,::..-...:.7-=B::..._ _______ _
3. WELL USE (Check One Box) Monitoring D Municlpal/Publlc D
lndusttial/Commercial □ Agric:Ultural O Recovery D Injection □
Irrigation□ Other ilf (Ust use) Closed loop Geotherro
DATE DRILI.ED....,1"'"0'--3=-•_,1...,a1 ___ _
4. WELL LOCATION:
1166 Latia Church Rd
(Street Name. Number&. Community, SUbdlVlslon, Loi No., PIIICel, Zip Cede)
c1rv: Franklin COUNTY Macon
TOPOGRAPHIC/ LANO SETTING: (check appropriate box)
□Slope □Valle)' ii{Flat □Ridge □Other ______ _
K@,ISTCD 36_ l''"""!AIIAAAMAI CL R OR 3XNl)U{~]I cc
t<N"61STCD 75 IAAAA&AAAAAAAAI CL R OR 7-)t.~,:~ cc
Latitude/longitude source: [):;PS Qropog,-.phlc map
(locatlon of w.11 must be shown on e USGS topo map endettachad to
this form If not using GPS)
5. FACIUTY (Name of the bu1lnass where the well ls located.)
Macon Elementary
Facility Name
1166 Lotta Church Rd
Street Address
Franklin
City or Town
Macon C01sotv Government
Contact Name
Mailing Address
Ecanktin
City or Town
( ) _________ _
Area code Phone number
t . WELL DETAILS:
a. TOTALDEPTH:_._19 ..... 6_' ____ _
F acility ID# Qf apptlcable)
NC 28734
State Zip Code
NC 28743
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES D NO rJ/
c. WATER LEVEL Below Top of Casing; 60 FT.
(Use•+• if Above Top of Casing)
: d. TOP OF CASINO IS 2 FT. Above Land Surface•
"Top of casing terminated at/or below land surface may require
a variance in ac;c;ordance with 15A NCAC 2C .0116.
l e. YIELD (gpm); 40 METHOD OF TEST Blow Down
: f. DISINFECTION: T~ HTC Amount 1? OZ
: g. WATER ZONES (depth): l Top 250' Bottom 254' Top ___ Bottom._ __
;Top ___ Bottom, __ _ Top ___ Bottom __ _
:Top ___ Bottom. __ _ Top ___ Bottom __ _
; 7. CASING: Depth Diameter
! Top_tL_ Bottom~ Ft. 6 1 /8
: 'rop ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Fl. __ _
; 8. GROUT: Dapth Material l Top_Q__ Bottom..10_ Ft. Bentonjte
Thlcknna/
WelQht
...1L
Material
steel
; Top-1,0_ eottom-1.BL. Ft. washed stone
Method
Pumped
poured
: Top ___ Bottom ___ Ft. ____ _
: 9, SCREEN: Depth Dllmeter Slot Site Material
: Top ___ Bottom ___ A. __ in. in. ____ _
: Top ___ Bottom ___ Ft. __ in. In. ____ _
: Top ___ Bottom ___ Ft._jn. __ In. ____ _
: 10. SAND/GRAVEL PACK:
: Depth Siu Materfal
: Top ___ .Bottom ___ Ft., __________ _
: Top __ ~Bottom ___ Ft __________ _
: Top Bottom ___ Ft. __________ _
: 11. DRILLING LOG
: Top Bottom
0 I 65
--'6 ..... 5.___,/_1=9=6 __
---'-----____ / ___ _ ____ / ___ _
---'~----
----'----___ ./ ___ _ ___ ./ ___ .,----
: 12. REMARKS:
: Casi1 19 Rei 11oved
Formation Descri ptlon
Overburden
Granite
; I DO HEREBY CERTIFY Tl1AT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
j ~i"= ~ :e~;~~~~c;:.r~~~~D THAT A COPY OF TI11S
: -10..3-11 ! TIFIED WELL CONTRA~ DATE
: Timothy B Hamby
; PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: DIVlsion of Water Quality -Information Processing,
1817 Mall Service Center, Raleigh, NC 27699-161, Phone: [phone]
Form GW-1b
Rev. 1/08
NON REsmENTIAL WELL coNsraucTmN REcoRD
Nonh Carolina Department of Environment and Na111ral Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A
1, WELL CONTRACTOR:
Timo thy R Hamby
Well Contractor (lndivldual) Name
Midsouth Geothermal
Wall Contractor Company Name
8275 Tournament Dr Suite 185
Streat Addrau
Memphi s TN 38125
City or Towr, State Zip Coda
1 901 > 7 48--9095
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#...,W-=-=-=1Qe..a1,_,,Q'""Q'-'1'"""4'-'1 ____ _
OTHER ASSOCIATED PERMIT#{if applicable,_ ______ _
SITE WELL ID #(If appjicable),..=B=a..-_,8._ ________ _
$.. WELL USE (Check Ona Box) Monitoring D Municlpal/Publle □
lnduatrial/Commercial □ Agricultural □ Recovery □ lnjeetlon □
Irrigation□ other !f'(lllt use) Closed looo Geotherra
DATE DRILLED_9_-3_O-·_1_1 ___ _
4. WELL LOCATION :
1166 Lotla Church Rd
(Street Name, Numbers, Community, Subdivision, Lot No .• Parcel, Zip Code)
c1TY: Franklin couNTY Macon
TOPOGRAPHIC/ LANO SETTING: (Check appropriate box)
□Stopa □Valley "1"1at □Ridge □other ______ _
K@l!STCO 36_ I MAA&AAAAAAAA( CL R OR 3JC~)OUl(~JC cc
KNM' 1$TCD 75 t"'""&AMA t,AJ\I\J CL R OR 7',t~ cc
Latitude/longitude source: 03PS OTopographlc map
(location of well must b• shown on • USGS topo map andattached to
this form If not using GPS)
5. FACILITY (Name of tha business whara tha wall la located.)
Macon Elementary
Facility Name Facility ID# (If applicable)
1166 Latia Church Rd
Street Address
Franklin NC 28734
City or Town State Zip Coda
Macon County Government
Contact Name
Mailing Address
franklin NC 28743
City or Town State Zip Coda
( ) _________ _
Araa coda Pllona number
8. WELL DETAILS:
a. TOTAL DEP'Tli:._4CL.w5,..0_' ____ _
b. DOES WELL REPLACE EXISTING WELL? YES D NO~
c . WAT'ER LEVEL Below Top of Casing; 60 FT,
(Use •+• If Above Top of Casing)
-----------
: d. TOP OF CASINO IS _... ____ FT. Above Land Surtsce•
: •Top of casing terminated at/or below land surface may requ ire
: a variance In accordance with 15A NCAC 2C .0118.
: e. YIELD (gpm): 40 METHOD OF TEST Blow Down
~ ,. DISINFECTION : rype HTC Amount 12 az
: g. WATER ZONES (depth):
~ Top 250' Bottom 254' Top ___ Bottom. __ _
;Top. ___ Bottom. __ _ Top Bottom. ___ _
: Top. ___ Bottom. __ _ Top ___ Bottom,_ __
: 7. CASINO: Depth Diameter
~ Top-±2,_Bottom_£_,_Ft 61/8
~ Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft.~--
Thickness/
Weight
...J.a8_
l',1aterial
steel
: 8, GROUT: Depth Material Method
i Top.JL_ Bottom...M__ Ft. Bentonjte Pumped
: Top...M__ Bottom~ Ft. washed stone poured
: Top ___ Bottom ___ Ft.. ____ _
; I, SCREEN: Depth Diameter SlotSize Material
: Top ___ Bottom ___ Ft. __ ln. __ In. ____ _
: Top ___ Bottom ___ Ft. __ ln. In. ____ _
: Top ___ Bottom ___ Ft, __ in. __ in , ____ _
: 10. SAND/GRAVEL PACK:
; Depth
: Top ___ .Bottom ___ Ft .'----_______ _
: Top Bottom ___ Ft. __________ _
: Top ___ Bo.ttom ___ Ft. __________ _
: 11. DRILLING LOG
: Top Bottom
0
80
250
254
I 80
I 250
I 254
I 450 ____ / ___ _
----'--------'----____ / ___ _
---'--------'-------·'----
; 12. REMARKS:
~ Ca sit 19 Re, 11oved
Formation De,cription
Overburden
Granite
Broken Granite 40 GPM
Granit e
: I 00 HEREBY CERTIFY THAT THIS weu.. WAS CONSTRUCTED IN ACCORDANCE WITH : ;:ct~c~ -:eeu.. ~~~01:.r~~~~DTHAT A COPY OF TMIS
; / v. 9-30-11
: SI ATURE OF CERTIFIED WELL CONTRAcTOR DATE
~ Timothy B Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -lnfom,atlon Processing,
1817 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1b
Rev. 1108
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment end Natural Resources• Division of Waler Quality
WELL CONTRACTOR CERTIFICATION# 3118-A -----------
1. WELL CONTRACTOR:
Timothy R Hamby
Wall Contractor (Individual) Name
Midsouth Geothermal
Well Contractor Company Name
8275 Tournament Dr Suite 185
Street Address
Memphis TN 38125
City or Town State Zip Code
l 901 l 7 48-9095
Area cod• Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#~W~fQ~1~Q~Q~1~4~1 ____ _
OTHER ASSOCIATED PERMIT#(II applicable) _______ _
Sile WELL ID #{if appl~bie-C ____ -1 __________ _
3. WELL USE (Chec:k One Box) Monitoring O Municipal/Public D
lnduatrtal/Commerclal □ Agricultural □ Recovery □ lnJeotion □
lnigatlon□ other l!f cnst use) Closed looo Geotherra
DATE DRILLED 10-25-11
4. WELL LOCATION:
1166 Latia Church Rd
(Street Name, Numbenl, Community. SubdM&lon, lot No .. Pan:el, Zip Co<le)
c1rv: Franklin COUNTY Macon
TOPOGRAPHIC/ LAND SETTING: (check appn>prtate boll)
□Slope □Valley itAat □Ridge □Other ______ _
K@,ISTCD 36_ ,M••&•••M•••t CL ROR 3JIC~)f.JIO{~ cc
l<Nt51$TCO 75 , .... & .. M••••1 CL ROR ~~~ cc
L atitude/longitude source; [}3PS OTopographlc map
(lo~tlon of well rnu,t be shown on• USGS topo map enriatteched to
this form If not using GPS)
5. FACILITY (Name of the business where the well la located.)
Macon Elemeotacv
Facility Name Facility ID# (if applicable)
1166 Latia Church Rd
Street Addresa
Franklin NC 28734
City or Town State Zip Code
Macon Cauotv Gnvemment
Contact Name
Malling Address
Ecaoklin NC 28743
City or Town Slate Zip Code
Area coda Phone number
S . WELL DETAILS:
a. TOTAL DEPTH:_4~5_0_' ____ _
b. DOES WELL REPLACE EXISTING WELL 7 YES D NO r:f/
o. WATER LEVEL Below Top of Casing; 60 FT.
(Uae •+• if Above Top of Casing)
: d . TOP OF CASINCJ IS 2 FT. Above Land Surface'
"Top of easing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C ,0118,
: ,. v,eLO (gpm): 1 oo METHoo oF TEST Blow □own
~ f. DISINFECTION: ,we HTC Amount 12 oz
: g, WATER ZONES (depth):
; Top 250 Bottom 254 Top ___ Boltom __ _
: Top ___ Bottom __ _ Top Bottom. __ _
; Top Bottom. __ _ Top ___ Boltom. __ _
Thickness/
: 7. CASINO: Depth Diameter Weight Material
steel ~ Top..±2__ Bottom.Jl2.._ Ft. 6 1/8 .....iaa...
: Top ___ Bottom ___ Ft.. __ _
: Top ___ Bottom ___ Ft.. __ _
; 8. GROUT: Cepth Mater/al
~ TopJ)__ Bottom.M._ Fl Bentonjte
: Top..fil._ Bottom...ifilL. Fl washed stone
; Top ___ Bottom ___ Ft ____ _
: 9. SCREEN: Dep"' DJameter Slot Sia
Method
pumped
poured
Material
: Top ___ Bottom ___ Ft. __ in. __ in, ____ _
: Top ___ Bottom ___ Ft. __ in, __ in. ____ _
: Top ___ Bottom ___ Ft. __ ln. In ____ _
: 10. SAND/GRAVEL PACK:
: Depth Size Material
: Top ___ Bottom ___ Ft. __________ _
; Tof:! ___ Bottom_Ft. __________ _
: Top Bottom ___ Ft. __________ _
; 11. DRILLING LOG
Top Bottorn
0 /...,7..._7 __ _
JL_/_,8=2'-----R_/_.2...,5""'0 __
..2.fiL/ .... 2 ... 5....,4 __
..2M_/_4...,.5-0 __
I ---,----___ ./ ___ _
----'-------'----___ / ___ _
: 12. REMARKS :
~ Casing Re,, 1oved
Formatlort Descnptlon
Dirt
Granite
Granite
Broken Granite 40 GPM
Granite
; I 00 HEREBY CERTIFY THAT THIS WEU. WAS CONSTRUCTED IN ACCOROANCE WITH
: i5A NCAC 2C, WELL CONSTRUCTION STANDARDS. ANO THAT A COPY OF THIS
• RECORD HAS BEEN PROVIDED TO "THE WELL OWNER
;~)-A ,'1(
: ~ ,7<.. 1~ 1 0-25-11
: SIGNA1uRE OF CERTIFIED WELL CONTRAC""fOR DATE
: Iiroatbv B Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality • Information Processing,
1617 Mall Service Center, Ratelgh, NC 27699-161, Phone: [phone]
Form GW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A
1. WELL CONTRACTOR:
Timothy R Ham by
Well Contrac:1or (Individual) Name
Mid south Geothermal
Well Contractor Company Name
8275 Tournament Pc Suite 185
Street Address
Memohis TN
City or TO'MI Stale
1 901 > 7 48-9095
Aree eode Phone num ber
2, WELL INFORMATION :
38125
Zip Code
WELL CONSTRUCTION PERMIT#_,W"""-'-'IQ,._1,_,Q=-=Q'-'1'-'4,_,1,_ ___ _
OTHER ASSOCIATED PERMIT#(if applleable), _______ _
SITE WELL ID #(if applicable),""'C:....a-2=-----------
3. WELL USE (Check One Box) Monitoring □ Municipal/Public □
Industrial/Commercial D Agricultural □ Recovery □ Injection □
Irrigation□ other llt'(llst use) Closed loop Geotherra
DATE DRILLED 10-24-11
-'· WELL LOCATION:
1166 Lotla Church Rd
(Street Name, NumbelB, Community, SubdMslorJ , Lot No., Paroel . Zlp Code)
CITY: Franklin couNTI Macon
TOPOGRAPHIC I LAND SETTING: (~eek appropnata bOx)
□Slope □Valley liiFiat □Ridge □other ______ _
K@lfITCD 36_ IAAIIA!IIIIM/11111111 CL R OR 3XNIXJC~)C cc
t<NM=ISTCD 75 IAAAA&AAAAAIIAAf CL ROR ~~~ cc
Latllude/1011gltude source: [PPS OT'opographlc map
(location of well muat ba ahown on a USGS topo map ■ndetteched to
this form if not ua/ng GPS)
II. FACILITY (Name of the buslnen where the well is located.)
Macon Elementary
Facility Name
1166 L otla Church Rd
Street Addresa
franklin
City or Town
Macon Cauotv Government
Co11tac:1 Name
Malling Address
Franklin
City or Town
( ) _________ _
Area code Pho11e 11umbar
6 . WELL DETAILS:
a. TOTAL DEPTH:._4""""5..,.0'-' ____ _
Facility fD# (lf applicable)
NC 28734
state Zip Code
NC 28743
State Zip Code
b, DOES WELL REPLACE EXISTING WELL? YES D NO~
c. WATER LEVEL Below Top of Casing: 60 FT.
(Use••• if Above Top of Casing)
-----------
: d. TOP OF CASING IS 2 FT. Above Land Surface•
: -Top of caslr,g termiriated at/or below land surface may requ ire
: a variance iri accordance with 15A NCAC 2C .0118.
: e. YIELD (gpm): 100 METHOD DF TEST Blow Down
~ f. DISINFECTION: Type HTC Amount 12 CZ
: g, WATER ZONES /depth):
~ Top 250 Bottom 254 Top ___ Bottom. __ _
;Top ___ Bottom __ _ Top ___ Bottom __ _
; Top Bottom. __ _ Top Bottom. __ _
; 1. CASINO: Depth Diameter
~ Top...±2._ Bottom~Ft. 6 1/8
: Top ___ Bottom ___ Fl __ _
: Top ___ Bottom ___ Ft .. ___ _
: 8, GROUT: Depth Material
~ Topj)__ Bottom..,SL_ Fl Bentonite
Thlckr,e•sl
Weight
...JL
M1teriaJ
steel
: Top..8L,_ eottom..A5.Q_ Ft washed stone
Method
pumped
poured
: Top ___ Bottom ___ Fl.. ____ _
: 9. SCREEN: Depth Diameter Slot Size Matertal
: Top ___ Bottom ___ Ft. __ ln, __ In. ____ _
: Top ___ Bottom ___ Ft. __ I11. __ In , ____ _
: Top ___ Bottom ___ Ft. __ ln. 111. ___ _
: 10. SAND/GRAVEL PACK;
: Depth Size MaterlaJ
; Top. ___ Bottom ___ Ft .. ____________ _
; Top ___ Boltom ___ Ft. ___________ ,
: Top. ___ Bottom_ Ft .. ____________ _
: 11. DRILLING LOG
Top Bottom
o ,_n __ _
77 /_8=2 __ _
82 I 250
250 /_.2.,.54...._ __
254 /_4....,50....__ __
I ---,.----____ / ___ _
I
I ---,----
: 12. REMARKS: .
Formatior, Description
Dirt
G ranite
Granite
Broken Granite 40 GPM
Granite
: -jc~ares'T'lil""IQ~R~e""'l""l"'IO""v.,.e"'d-+-------------
: I 00 HERESY CERTIFY THAT THIS WELL. WAS CONS'mUCTl:O IN ACCORl>ANCE WITH
; ~CO~~:-~ ;:Ji:~~~~~~~::' THAT A COPY OF THIS
~ ~~ /<. ~ 10-24-11
: SlGNRE OF CERTIFIED WELL CONTRAc'foR DA1E
. Timothy B Hamby
; 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 27899-161, Phone: [phone]
Fom, GW•1b
Rev. 1108
7
NON RESIDENTIAL WELL CONSTRUCTION RECORD
Notth Carolina Department of Environmenc and Narura! Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A -----------
1. WELL CONTRACTOR :
Timothy R Hamby
Well Contractor (Individual) Name
Midsouth Geothermal
Well Contractor Company Name a2zs Tournament Dr Suite 1 ss
Street Address
Memphis TN 38125
City or Town State Zlp Code
1 901 > 7 48-9095
Area coda Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WIO 100141 .......,,-'-=--'-"-""--'--'-''-------
OTHER ASSOCIATED PERMIT#/lf eppllcable) _______ _
SITE WELL ID #{lfappllcable) ... C=---=3'-----------
3, WELL USE {Checl< One Box) Monitoring D Munlelpal/Publle D
lndu1tr111I/Commereial □ Agricultural □ Recovery □ lnjactlon □
lrrigatlono other m( (llat use) Closed looo Geotherra
DATE DRILLED 10-20-11
4, WELL LOCATION:
1166 Lotla Church Rd
(Slleel Name. Numbers, Community, Subdivision, Lot No .. Paroel, Zip Code)
c1TY: Franklin COUNTY Macon
TOPOGRAPHIC/ LAND SETTING: (cl'leok aPf)IOplfate bO)()
□Slope □Valley ii(Flat □Ridge □Other ______ _
t<@,ISTco 36_ 1.AA,.8 ,. ......... 1 cL R oR aJC~iuu(«~x cc
l(Nll,f=l$TCD 75 l""M&I\IIMAIIMf CL R OR h~~ cc
Latitude/longitude ,ouree: [):;PS OTopographle map
(locel/on of well must be shown on • USGS topo map andattached to
this form If not using GPS)
5, FACILITY (Name of the buslneH where the well is located.)
Macon Elementacv
Faefllty Name
1166 I otla Cbuccb Rd
Streat Address
franklin
City or Town
Macon County Government
Contact Name
Malling Address
Eraoklio
City or Town
._ _ _,) ----------Area code Phone number
e, WELL DETAILS:
•· TOTALDEPTH:~4~5-Q_' ____ _
Faelllty JD# (If applicable)
NC 28734
State Zip Code
NC 28243
Slate Zip Code
b, DOES WELL REPLACE EXISTING WELL? YES □ NO r!/
c. WATl:R LEVEL Below Top of Casing; ~6_0 _____ FT.
(Use••• If Above Top ol Casing)
: d, TOP OF CASING IS 2 FT. Above Land Surface•
: •Top of casing terminated al/or below rand surface may require
: a variance In aCGOrctance with 15A NCAC 2C .0118.
: •· v1eL0 (11pm): 40 METHOD oF TEST Blow Down
~ f . DISINFECTION: Type HTC AmO\lnt 12 OZ
: g. WATER ZONES (depth):
~ Top 250 Bottom 254 Top ___ Bottom ____ _
: Top. ___ Bottom, __ _ Top. ___ Bottom __ _
; Top Bottom __ _ Top Bottom. __ _
! 7. CASING: Depth Diameter
~ Top..±,2__Bottom_..62__Ft. 61/8
: Top ___ Bottom ___ Ft.,_ __
: Top ___ Bottorn ___ Ft.. __ _
; 8. GROUT; Depth Material
j Top.J)_ Bottom....BL_ Fl Bentonjte
Thlc:knes■/
Weight
...J..a8..._
Materl■I
steel
: Top...8.L_ Bottom~ Ft. washed stone
Method
pumped
poured
: Top ___ Bottom ___ Ft.. ____ _
: 9. SCREEN: Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft. __ !n. __ In. ____ _
: Top ___ Bottom ___ Ft. __ ln. In. ____ _
; Top ___ Bottom ___ Ft. __ ln. In . ____ _
: 10, SAND/GRAVEL PACK:
: Depth Size Material
: Top ____ sottom ___ FL. __________ _
: Top Bottom ___ Fl __________ _
[ Top Bottom ___ Ft.. __________ _
: 11. DRILLING LOG
: Top Bottom
~l .... 7 ...... 7 __ _
77 /...,8=2'----82 , ..... 2 .... s_o __
250 /_,2...,5....,4 __
254 /_4=5..,.,0 __
----''-------·'----___ ./ ___ _
----'----___ ./ ,----
----'
; 12. REMARKS:
! Casi119 Removed
Formation Description
o·rt
Granite
Granite
Broken Granjte 40 GPM
Granite
: I DO HEREBY CERTIFY THAT THIS WELL WM CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, ANO THAT A COPY OF THIS
; RECORD HAS BEEN PROVIDED TO THE WELL OWNER
: .~ 10-20-11 ·~~,,,,·
: SIGNURE OF CERTIFIED WELL CONTRAC""fo'R DATE
. Timothy B Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -Information Proce5$lng,
1617 Mall Service Center, Raleigh, NC 27899-181, Phone: [phone]
Form GW•1b
Rev. 1108
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Divis ion of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A -----------
1. WELL CONTRACTOR:
Timothy R Hamby
Well Contractor (Individual) Name
Mjdsouth Geothermal
Well Contractor Company Name
8275 Tourn ament D r Suite 185
Street Address
Memphi s T N 38 125
City Of Town State Zlp Code
< 901 1 7 48-9095
Area coda Phone number
2 . WELL INFORMATION :
WELL CONSTRUCTION PERMIT#..,W ..... f Q=--1 .... 0,...0.._1 __ 4._1 _______ _
OTHER ASSOCIATED PERMIT#(lf applicable ), _______ _
SITE WELL ID #(If a.pplicable).--'C=-4~---------
3. WELL USE (Checi< Ona Box) Monitoring D MU-niclpal/Publlc D
lnduatnal/Commerclal D Agricultura l □ Recovery □ Injection □
Irrigation□ Other ri/(tiat use) Closed loop Geotherrn
DATE DRILLED 10-19-11
4. WELL LOCATION:
1166 Latia Church Rd
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code )
c 1TY: Franklin couNTY Macon
TOPOGRAPHIC / LANO SETTING: (checl( appropriate box)
□Slope □Valley lifFlat □Ridge □Other ______ _
1<@11STCO 36_ 11\1\AA .. A I\A I\AA l\llf CL R OR 3Jttll~X cc
KN~ ISTCD 75 1MM&I\/\I\M /\I\I\! CL R OR 7':it:WJU~ CC
Latitude/longitude sou~: CPPS 0Topographlc map
(location of well must be shown on a USGS topo map andattached to
this form if not using GP$)
5. FACILITY {Name of the bualneq wtiere the w ell is located.)
Macon Elementary
Facility Name Facility I D# (if applicable)
1166 L otla Church Rd
Street Addreu
Ecaoklio NC 28734
City or TOW!l State ZipC~
Macon County Government
Contact Name
Malllng Addreu
Franklin
City or Town
NC 28743
State Zip Code ___ __,) ----------
Area code Phone number
8. WELL DETAILS:
a. TOTAL DEPTH:_4-5_O_' ____ _
b. DOES WELL REPLACE EXISTING WELL? YES D NO 'ii
c , WATER LEVEL Below Top of Caalng: 60 FT.
(Use •+• If Above Top of Casing)
: d. TOP OF CASINO IS 2 FT. Above Land Surface•
: "Top of casing terminated al/or below land surface may requi re
: a variance In accordance With 15A NCAC 2C .01 18.
: e. YIELD (gpm): 40 METHOD OF TEST Blow Down
[ f. DISINFECTION: Type HTC Amount 12 az
: g, WATER ZONES (depth):
~ Top 250 Bottom 254 Top ___ Bottom._ __
: T op ___ Sottom. __ _ Top ___ Bottom. __ _
: Top Bottom __ _ Top Bottom. __ _
: 7. CASINO: Depth Diameter
~ Top..:t.2.__ Bottom.Jl2.._ Ft. 6 1/8
: Top ___ Bottom ___ Ft.. __ _
: Top ___ Bottom ___ Ft.. __ _
: 8. GROUT: Depth Material
~ Top.Jl.._ Bottom_ar._ Ft . Bentonjte
Thickness/
Welgt,t Materiel
steel ~
Method
pumped
: Top....8L_ Bottom.A£)_ Ft . washed stone poured
: Top ___ Bottom ___ Ft.. ____ _
: 9. SCREEN: Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft._in, in. ____ _
: Top ___ Bottom ___ Fl __ ln. In. ____ _
: Top ___ Bottom ___ Ft. __ in. In . ____ _
: 10. SAND/GRAVEL PACK:
; Depth Size Material
: Top. ___ Bottom ___ Ft.. __________ _
; Top ___ Bottom ___ Ft. __________ _
; Top Bottom ___ Ft.. __________ _
: 11. DRILLING LOG
Top Bottom Formation Deacriptlon
O /_7_7 __ Dirt
77 /-'8=2=----Gran ite
82 ,_ .... 2 ... 5..,.0c.....__
250 /_.2_5._.4 __
Granite
Broken Grantte 40 GPM
254 /_4~5-0 __ Gra nite
I ---,----
----'--------'----/ ---/_----
;
: 12. REMARKS:
: C asit 19 Rei 1,ooed
; I DO HEREBY CERTIFY lliAT THIS WELL WAS CONSTRUCTED IN ACCOROANCc WITH
• 1SA NCAC 2C, waL CONSTRUCTION STANDARDS, AND THAT A COPY OF TH IS
; RECORO HAS BE.EN PROVIDED TO THE WELL OWNER
; ~-,0 /I, : =...,......,..""=n~.,...~==~=:---:--::-c:-:-~ 10-19-11
; S~RE OF CERTIFIED WELL CONTRAcfoR DATE
: Tjmothy R Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -tnfonnatlon Processing,
1617 Mall Service Center, Ralelgh, NC 27699-161, Phone : [phone]
Form GW•1b
Rev. 1/08
1'f
NON RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Department of Environment and Natural Resources• Division of Water QuaJity
WELL CONTRACTOR CERTIFICATION# 3118-A
1. WELL CONTRACTOR:
Timothy R Hamby
Wall Contractor (Individual) Name
Midsouth Geothermal
W all Contractor Company Name
8275 Tou rn ame nt Dr Suite 185
Street Address
Memphis TN 38 125
City or Town State Z ip Code
c 901 l 7 48-9095
Area coda Phone number
:Z. WELL INFORMATION:
W ELL CONSTRUCTION PERMIT# WIQ100141 -'-"~---=-=----~------
OTHER ASSOCIATEO PERMIT#(ifapplicable), _______ _
SIT& WELL ID #(11 appUcabte), .... C ... -.... 5.__ _______ _
3. WELL USE (Checl< One Box) Monitoring D Municipal/Public: D
Industrial/Commercial D Agricultural D Recovery □ Injection □
Irrigation □ Other ~<ll•t u .. ) Closed loco Geotherra
DATE DRILLED j 0-1 8-11
,. WELL LOCATION:
1166 Latia Church Rd
(Street Name, Numbers, Community, Subdivision, lot No., Parcel, Zip Code)
c1TY: Franklin COUNTY Macon
TOPOGRAPHIC/ LANO SETTING: (check appropnate box)
□Stopa □Valley gFlat □Ridge o Othar ______ _
~co 36_ 1-"'..,.&"''A"""""J cL ROR 3•~~~~~ cc
1<N~1STcors i"'A"&"""""AA"!CLRoR h~cc
Lalltuda/longttuda source: !J;PS Ofopographic map
(location of well must be shown on a USGS topo map andetteched to
this form if not using GPS)
S-. FACILITY CName of the buainasa wt,ere the well ls located.}
Macon flementarv
FacHlty Name
1166 L atla Cb• 1ccb Rd
Streat Addrau
franklin
City or Town
Macon County Government
Contact Name
Mailing AddrHI
Franklin
City or Town
._ _ _,') ----------Area code Phone number
6 . WELL DETAILS:
a. TOTAL DEPTH:,_4~5 ... 0 .... ' ____ _
FacJllty 10# (if applieabla)
NC 26734
State Zip Code
NC 28743
State Zip Coda
b, DOES WELL REPLACE EXISTING WELL? YES D NO~
c. WAT&R LEVEL Below Top of Caslng: 60 FT.
(Uaa •+• if Above Top of Casing}
-----------
: d . TOP OF CASING IS ? FT. Above Land Surface•
'Top of easing terminated at/or below land surface may requi re
a variance In accordance with 15A NCAC 2C .01 18.
: •· YIELD (gpm): 40 METHOD oF TEST Blow Oawo
~ f , DISINFECTION; ~ HTC Amount 12 oz
: g . WATER ZONES (depth):
~ Top 250 Bottom 254 Top ___ Bottom __ _
;Top. ___ Bottom __ _ Top ___ Bottom. __ _
: Top Bottom __ _ Top Bottom,_ __
Thickness/
; 7 . CASING: Depth Diameter Waight Material
steel ! Top....±2_ Bottom...82._ Ft. 6 1 /8 .....1.8a...
; Top ___ Bottom ___ Ft.. __ _
: Top ___ Bottom ___ Ft. __ _
: 8. GROUT: Oepth Material
~ Top.JL__ Bottom..az._ Ft. Bentonjte
: Top_BL_ Bottom~ Ft. washed stone
: Top ___ Bottom ___ Ft.. ____ _
; 9 . SCREEN: Depth Diameter Slot Size
Met hod
pumped
poured
Material
: Top ___ Bottom ___ Ft. __ in. In. ____ _
: Top ___ Bottom ___ Ft. __ in. In. ___ _
: Top ___ Bottom ___ Ft. __ in. In. ____ _
: 10. SAHD/ORAVEL PACK:
; Deptt\ SIU Material
: Top ___ Bottom ___ Ft. __________ _
: Top ___ Bottorn ___ ft .... ___________ _
; Top Bottom ___ Ft. ---
: 11. DRILLING LOG
Top Bottom Formation De,cnption
0 '~7~7 __ Dirt 77 , __ 8-2 __ _
82 /_.2 ... 5 ... 0 ___ _
Granite
Gr anite 250 ,_2_54 __ _ Broken Granite 40 GPM 254 '~4~50 __ Granite
---·'-------'·----I ---,----
---'·----___ / ___ _
: 12. REMARKS:
' j -1c~ar-=s:-nil'"li1grt-tR+-e"""11,.,,o~vt11e0t1d1"1-------------
: I DO HEREBY CERTIFY THAT THIS WEU. WAS CONSTRUCTED IN ACCORDANCE WIT!i
• 111A NCAC 2C, WELL CONSTRUCTION ST ANOARDS, AND THAT A COPY OF THIS
; RECORD HAS BEEN PROVIDED TO THE WEl.LOWNER.
~ r ~ ll 1+-10.15.11
: S~URE OF CERTIFIED WELL CONTRAC""1'o'R" DAT E
: Timothy 8 Hamby
: PRINTED NAME OF PERSON CONSTRUCTI NG THE W ELL
Submit within 30 days of completion to: Division of Water Quality -Information Processing,
1617 Mall Service Center, Raleigh, NC 27699-181, Phone : (919) 807.f300
Form GW•1b
Rev , 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department 9fEnvironment end Naiural Resources• Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A
1. WELL CONTRACTOR:
Timothy R Hamby
Well Contractor (lndivldual) Name
Midsouth Geothermal
Well Contractor Company Name
8275 Tournament Pr Suite 185
Street Address
Memphis TN
City or Town State
< 901 I 7 48-9095
Area code Phone number
a. WELL INFORMATION:
38125
Zip Coda
WELL CONSTRUCTION PERMIT# W 10100141 ~~~~~~-----
0 THE R ASSOCIATED PERMIT#(lf apPllcable), _______ _
SITE WELL ID #(If appllcabt9)._C~-~6~---------
!. WELL USE (Check One Box) Monitoring □ Munielpal/P\Jblle D
lndustrial/Conimercial □ Agricultural □ Recovery □ Injection □
Irrigation□ Other W(llat use) Closed looo Geotherrp
DATE DRILLED 10-17-11
,, WELL LOCATION:
1166 Lotla Church Rd
(S treet Name, Nornbenl, Community, SubdMslon, Lot No .. Parcel. Zlp Code)
crTY: Franklin couNTY Macon
TOPOGRAPHIC/ LANO SETTING: (clleck appropriate box)
□Slope □Valley i{Flat □Ridge OOth■r ______ _
K@;ISTCO 36_ ,A•••aA•••M••I CL R OR 3Jltl'Joui~ cc
l<N~ISTCD 75 1•"""!AA•u•••I CL ROR ht.~~ CC
Latitude/longitude source: [PPS [Jropographie map
(focation of well mu$t be shown on • USGS topo map andattach~ to
th/$ form if not U$ing GPSJ
5. FACILITY (Name of the bu1inesa where the well 11 located.)
Macon e lementarv
facility Name
1166 I atla Church Rd
Street Address
Franklin
City or Town
Macon Coi,ntv Government
Contact Name
MallingAddrets
Franklin
City or Town
Area coda Phone number
a. WELL DETAILS:
1. TOTAL DEPTH:,_4~5-0_' ____ _
faeiltty ID# (if applicable)
NC 28734
State Zip Coda
NC 28743
State Zip Coda
b . DOES WELL REPLACE EXISTINO WELL 7 YES D NO~
c. WATER LEVEL Below Top of Cating; .. 6..,0..._ ____ FT.
(Use •+• if Above Top ol Casing)
-----------
: d. TOP OF CASINO IS~----FT. Above Land Surfaee•
• -Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
: e . YIEl.D (gpm): 40 METHOD OF TEST Bfgw Down
~ ,. DISINFECTION : Type HTC Amount 12 az
: g. WATER ZONES (depth):
~ Top 250 Bottom 254 Top. ___ Bottom, __ _
; Top ___ Bottom ___ _ Top ___ Bottom __ _
: Top Bottcm ---Top Bottom. __ _
: 7. CASINO : Depth Dlam•ter
; Top..±Z.,_ Bottom....8L.._ Ft. 6 1 /8
; Top ___ Bottom ___ Ft.. __ _
; Top ___ Bottom ___ Ft __ _
: 8. GROUT: Depth Material
: Top.Jl_ Bottom...8Z_ Ft. Bentonjte
Thic:kneas/
Weight
~
Material
steel
: Top....az___ Bottom_A5L Ft. washed stone
Method
pumped
poured
: Top ___ Bottom ___ Ft.. ____ _
; t. SCREEN: Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft. __ ln. In. ___ _
: Top ___ Bottom ___ Ft. __ ln. in. ____ _
: ToP. ___ Bottom ___ Ft. __ in. In . ____ _
: 10. SAND/ORAVEl. PACK:
; Depth Slz• Material
: Top ___ Bottom ___ Fl. __________ _
; Top. ___ Bottom ___ Ft.. __________ _
: Top ___ Bottom ___ Ft .. __________ _
: 11 . DRILLING LOG
Top Bottom
0 I_V~--
77 , __ 82~--
82 1 ... 2 .. s .... o __
250 /_.2...,54"'"---
..2.M_/:-4-5~0 __
-----'----____ / ___ _
I ---,----
----'--------'----
: 12. REMARKS:
: Casi, 19 Rei, roved
Formation Description
Dirt
Granite
Granite
Broken Granite 40 GPM
Granite
; I 00 HERE8Y CERTIFY TtlAT THIS WaL WAS CONSTRUCTED IN ACCORDANCE WITH
! ~~~~:~~~~c;6~~=~~8N~DTHAT A COPY OF THIS
~ :::L~ R ~~ 1 a-1 z-11
: simia'GRE OF CERTIFIED WELL CONTRAefciR""° DATE
: Timothy 8 Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality • Information Proceulng,
1617 Mall Service Center, Raleigh, NC 27699-161 , Phone: [phone]
Form GW-1b
Rell. 1108
'1 \
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 31 18-A
1. WELL CONTRACTOR:
Timoth y R Hamby
Well Contractor (Individual) Name
Midsouth Geothermal
Well Contractor Company Nam,
82 7 5 Tourna me nt Dr Suite 1 as
StrHt Addrn,
Memphi s TN 38 125
City or Town Stat. Zlp Coda
1 901 ) 7 48-9095
Area code Phone number
2. WELL INFORMATION :
WELL CONSTRUCTION PERMIT# Wl0100141 ---'-"'""'-="""-"'.=-a'-'---------
OTHER ASSOCIATED PERMIT#,(11 appllcable)'--------
SITE WELL ID #(If appllcable), .... C ... -'""'7 ___________ _
3. WEU USE !Check One Box) Monitoring D Municlpal/Publlc D
lndusttjal/Commercial □ Agricultural □ RecoV8fY □ Injection □
Irrigation□ other mf (lhst uee) Closed looo Geotherra
DATE DRILLED 10-14-11
4. WELL LOCATION:
1166 Latia Church Rd
(Street Name, Numbel's , Community, Subdivision, Lot No., Parcel , Zip Code)
c1TY: Franklin couNTY Macon
TOPOGRAPHIC I LAND SETTING: (clleck appropriate box)
□Slope □Valley litflat □Ridge □other ______ _
l<@,t5TCD 36_ I•M•a•••••M•11 I CL R OR 3,cNuoo<~ cc
l<NM"' ISTCD 75 1•11AA&A AAIIMM I CL R OR ~!)(,et~ cc
Latltuda/longltude source: Q3PS Qropographlc map
(loc•tion of well must be shown on • USGS topo map andattached to
thi:J ftmn If not using GPS)
II, FACILITY (Name of the buelnese where the well is located.)
Macon flementarv
Facillty Name
1166 Latia Church Rd
Streat Addrau
Franklin
City or Town
Macon County Government
Contact Name
Malling Address
franklin
City or Town
Area code Phone number
8. WELL DETAILS:
■. TOTAL DEPTH:_4~5_0_' ____ _
Facility ID# (If applicable)
NC 28734
State Zip Code
NC 26743
State Zip Code
b. DOES WELL REPLACE EXISTINO WELL 7 YES D NO~
c. WATER LEVEL Below Top of Casing: _6.......,.0 ____ FT.
(Use•+• if Above Top of Casing)
-----------
; d . TOP OF CASINO IS 2 FT, Above Land Surface•
"Top of casing terminated at/or batow land surface may require
a variance In accordance with 15A NCAC 2C .0118.
~ e. YIELD (gpm): 40 METHOD OF TEST Blow Down
: ,. DISINFECTION: Type HTC Amount 12 az
; g. WATER ZONES (depth):
~ Top 250 Bottom 25;4 Top ___ Bottom. __ _
: Top ___ Bottom:---Top ___ Bottom. __ _
: Top ___ Bottom __ _ Top ___ Bottorn._ __
; 1. CASINO: Depth Dlametu
~ Top~Bottom-S2_Ft. 61/8
; Top ___ Bottom ___ Ft.. __ _
: Top ___ Bottom ___ Ft.. __ _
: 8. GROUT: Depth Material
~ Top.JL__ Bottom.JU__ Ft. Bentonjte
Thlcknesll/
Weight Material
steel ~
Method
pumped
: Top~ Bottom....4fill_ Ft. washed stone poured
: Top ___ Bottom ___ Ft. ____ _
: 9. SCREEN: Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft._in. in . ___ _
: Top ___ Bottom ___ Ft. __ ln. in . ___ _
: Top ___ Bottom ___ Ft. __ ln. __ In . ___ _
: 10. SAND/GRAVEL PACK:
: Depth Size Material
: Top ___ .Bottom ___ Ft.. __________ _
: Top ___ Bottom ___ F.._ _________ _
: Top ___ .Bottom ___ Fl'----_______ _
: 11 . DRILLING LOG
Top Bottom Formation Desctiption
0 '~99~--Dirt
90 /__,9...,2,....._ __ Granite
92 /__.2...,5..,.0 __ Granite 250 /....,2.,.5u;4 __ Broken Granite 40 GPM
254 /_4....,5.,.0 __ Grani te
--~'------~'--------'----/ ___ / ___ _
---'----
; 12. REMARKS:
~ Cash 1g Remo ved
; I 00 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
; 10A NCAC 2C, WELL CONSTRUCTION STANDARDS, AHO THAT A COPY OF THIS
• RECORO HAS BEEN PROVIDED TO THE W'Ell OWNER.
~ s~u'1 ~~FIED WELL CONTRAefc>R
10~lti 11
: Timothy R Hamby
; PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completlon to: Division of Water Quality -Information Processing,
1617 Mall Service Center, Raleigh , NC 27699-161, Phone: [phone]
Fom, GW-1b
Rev. 1/08
(;fl.
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department ofEnvironment and Narutal Resources• Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A
1 , WELL CONTRACTOR:
Timothy R Hamby
Well Contractor (Individual) Name
Mid south Geotherm al
Well Contractor Company Name
8275 Tou rn ament Dr Sui te 185
Street Address
Memphis TN 381 25
City or Town State Zip Coda
c 901 l 7 48-9095
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#--..::W...::.:..;::IQ,._.1--=Q=Q_,_14_,_1_.__ ___ _
OTHER ASSOC IATED PERMIT#(if applicable ) _______ _
SITE WELL ID #(If applleable),....=C,._·-=8'----------
3. WELL USE (Check Ona Box) Monitoring □ Municipal/Public □
lnduatrlat/Commarciat D Agrtcultural □ Recovery D Injection D
lnigatk>ri□ other IW(llst UM) Closed loop Geotherra
DATE DRILLED 10-13-11
4. WELL LOCATION:
1166 Lotta Church Rd
(Street Name. Numbers. Community. SubdlVlalon . Loi No~, Parcel, Zip Code)
c 1TY: Franklin COUNTY Macon
TOPOGRAPHIC / LAND SETTING: (check appropriate bo~)
□Slope □Valley ii(Flat □Ridge □other ______ _
K@i!STCD 36_ , .. ••a••M•M"I cLRoR ax~~xx~cc
KNM= tSTCD 75 1••••a 11 " .. ,. .. ,., CL R oR 7'Jt:')(')ett~ cc
Latitude/longitude source: 0:.PS OTopographlc map
(location of well must be shown on • USGS topo map andaltached to
thia form If not uaing GPS)
5. FACILITY (Name of the bu1lneu where the wall is located.)
Macon E!ementarv
Facility Name
1166 Latia Church Rd
Street Address
franklin
City or Town
Macon Cnuntv Government
Contact Name
Malllng Address
franklin
City or Town
Area code Phone n umber
8 . WELL DETAILS:
a. TOTAL DEPTH:._4=--5,..0_' ____ _
Facility ID# (if applicable)
NC 28734
State Zlp Code
NC 28743
State Z ip Coda
b. DOES WELL REPLACE EXISTING WELL? YES □ NO r,
c. WATER LEVEL Balow Top of Casing: ....,6....,0...._ ___ FT.
(Uae •+• if Above Top of Casing)
-----------
: d. TOP OF CASING IS 2 FT. Above Land Surface•
•T9p of casing terminated at/or below !and surface may requi re
a variance In accordance with 15A NCAC 2C .0118.
~ e. YIELD (9pm): 40 METHOD OF TEST Blew Down
: ,. DISINFECTION: Type HTC Amount 12 az
: g. WATER ZONES (depth):
~ Top.250 Bottom 254 Top. ______ Bottom. __ _
: Top ___ Bottom __ _ Top Bottom __ _
: Top Bottom'-----Top Bottom._ __
: 7. CASINO: Depth Diameter
~ Top_:t:2_ Bottom.JM.._ Ft. 6 1/8
: Top ___ Bottom ___ Ft,_. __ _
: Top ___ Bottom ___ Ft.. __ _
: 8. GROUT: Depth Material
~ Top....Q..___ Bottom-99_ Ft. Bentonjte
Thickneaa/
Weight Material
_JM_ steel
: Top...aa__ Botto~ Ft. washad stone
Ma1hod
pumped
poured
: Top ___ Bottom ___ Ft. ____ _
: 9. SCREEN: Depth Diameter Slot Sin Material
: Top ___ Bottom ___ Ft. __ jn . In. ___ _
: Top ___ Bottom ___ Ft. __ l n. In. ___ _
: Top ___ Bottom._ Ft. __ ln. --l (l. ----
: 10. SAND/GRAVEL PACK:
: Depth Size Material
: Top. ___ Bottom ___ Ft., __________ _
: Top. ___ ,Bottom ___ Ft.. __________ _
: Top Bottom ___ Ft. __________ _
: 11 . DRILLING LOG
Top Bott0"1 Fonnatlon Oaacriptlon
0 /_.9..,.0'---Dfrt
90 /...,94 ........ __ Gran ite
94 , ... 2 .... s ... o __ Granite
250 /_.2.,.5....,.4 __ Broken Granite 40 GPM
254 /_45=-"'0 __ G ranite
----''----___ ./ ___ _
---·'-------''--------''----__ ....;/ ___ _
: 12. REMARKS:
: Casi11 g Reil 1oved
: I 00 HEREBY CERTIFY THAT THI S WEU. WAS CONSTRUCTED IN ACCORDANCE Willi
: 15A NCAC 2C. WELL CONSTRUCTION STANOAROS, AND TtiAT A COPY OF THIS
• RECORD HAS BEEN PROVIDED TO THE WELi. OWNER.
;-~ ~ 4 ~ 10-13-11
: ~TURE OF <;IFIED WELL CONTRACTOR DATE
: Jimatby 8 Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Divis ion of Water Quality -Information Processing,
1617 Mall Service Center, Raleigh, NO 27699-161, Phone: (919) 807.f300
Form GW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department ofEovironment and Natural Resources-DMsion of Water Qua)~
WELL CONTRACTOR CERTIFICATION# 3118-A.
1. WELL CONTRACTOR:
Timothv R Hambv
Wei Conlraclor (Individual) Name
Midsouth Geothermal
Wei Contractor Company Name
82 75 Tourn amen t Dr STE 5
Street Address
M e m phis
CltyorTown
< 901 ). 748--9095
Area code Phone number
2. WELL INFORMATION:
T N 38125
State Zip Code
WELL CONSTRUCTION PERMIT•--=W'-'--'-'10=-1-'--'Q=Q=-1.,_4..:..1..:..... ____ _
OTHER ASSOCIATED PE~ITl(lf apPllcable). ______ _
sm: WELL ID #(If appHcable)..:_ ._· ~e'__,({t ____ -.,_,.q...__ __ _
3. WELL USE (Check One Boll) Monitoring O MunlcipallPubllc □
lndustrtallComrner D Agriculural O Recoveiy D Injection D
1n1gation□ Other Fl Qi.t. UM) Closed Looo Geothera
DATE DRllJ.EO_: -~ ... J+-/ __
,. WELL LOCATION:
1166 Latia Church Rd
(Street Name, Numbln, Community, Subdivision, Lat No., Parcal, Zlp Code)
c 1TY: Franklin couNTY Macon
TOPOGRAPHIC I LAND SETTING: (cha appn,pria111t baKJ
□Slope □Valley~ □Ridge □Other. _____ _
LATITUDE 36 ____ • OMS OR 3x xxxxxxxxx oo
LONGITUDE~ ___ ~ OMS OR 7X.)QOOOOOOO( OD
LatitudellonglbJde source; [)3PS Dropographic map
(location of we# must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the bumesa Where the well Is located.)
Macon Eleroeotrv School
Facillty Name
1166 I otla Gbuccb Rd
Street Address
Eraoklio
City or Town
Mamo C01mtv Govemroeot
Contact Name
Maffirig Address
franklin
CttyorTown
( ) ________ _
Area code Phone number
6. WELL DETAILS:
a. TOTAi.DEPTH: ... J.f(S"°
Faclllty IOI Of applicable)
NC 28734
State Zip Code
NC 28743
Stale Zlp Code
b. DOES WELL REPUCE EXISTING WELL? YES D NOD
c. WATERLEVELBelowTopofCaslng: -b(2 FT.
(Use·+· if Above Top of Casing)
----------
: d. TOP OF CASING IS 2 FT. AbcNe. Land Sutface•
: '"Top of casing lem1inafed at/or below land SUlface may requre
: a variance In accontance wtf'I 15A NCAC 2C .0118.
: •· Y1a.o <epm>: 1 oo MEllfOO OF TE8T Blow Dawn
: f. DISINFECTION:~ HTC Amount 12oz
: II• WATER ZONES (deplh):
: T _; Bottom -
~Top~O Bottom~'4
Top ___ Bottom. __ _
Top Bottom. __ _
: Top ___ Bottom. __ _ Top Bottom. __ _
TiilckneNI j 7. CASING: Depth ¥':f Diameter
; Top_-t2_ Bottom illl Fl 61/8
Weight Material
__J_8.8_ steef
:Top __ Bott.om. __ Fl __ _
: Top __ Bottom __ Fl. __ _
: 8 . GROUT: Depth Material
: Top_°CJ_ Bottom_ ~:_FLJL~ ·;
~Top..a_Bottcm~ FL!>,.w't.../~
:Top __ Bottom __ Fl ____ _
: t . SCREEN: Oeplll Dlal'MW Slot Sa
;TOP. __ Bottom __ Fl __ in. __ In. ___ _
: Top __ Bot1om. __ Fl __ in. In. ___ _
: TOP. __ Bottom __ Ft __ in. __ in. ___ _
: 10, SANOIGRAVB. PACK;
: DepCtl s.m Matltrtal
;TOP. ___ Botlom ____ R . __________ _
: Top Bollom Fl __________ _
: TOP. Bottom R __________ _
: 11. ORfLllNGLOG
: Top Bottom
f ., ----
: 12. REMARKS:
~ Casi ng removed
Fonnatlon Descnpllon
: I 00 HERES\' CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
: 15A NCAC2C, WEU. CONSTRUCTIONSTAHOAROS,AHOTHAT A COPV OF THIS
: RECOAO HAS BEEN PROIIIDEO JO THE W£LL OWNER.
~ '~ ;e ✓J/4.-'7 -----~_J
: Sl~RE OF CERTIFIED WELL CON~ DATE
: Timothy B Hamby
; PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit witfitn. 30 -days of completion to: Division of Water Quality • Information Processing.,.
1617 Mail service center,;Ralefgh-, NC 27699-161', Phone : (919) 807"6300.·
FonnGW-1b
Rev. 2109
NON RESIDENTIAL WELL CONSTRUCTION RECORD
Notth Carolina Department of Environment and Natural Re1JOurces-Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3065-A
1. WELL CONTRACTOR:
Roaer L Wil liams
wau Contractor {Individual) Name
Tarheel Water Treatment
Wall Contrac:1Df'Company Name
3494 Georg ia RD
StreatAddrass
Franklin
City or Town
C 828 l 369-07 40
Ar9a code Phone number
:z. WELL INFORMATION:
NC 28734
State Zip Code
WELL CONSTRUCTION PERMIT#...,W_._,_.IQ"""1'""Q'""Q"""1'-4a....;1'--___ _
OTHER ASSOCIATED PERMIT#(IIJ!,P'lcable)
SITE WELL ID #(If applical)ja),_c_~~~<---.... R ______ _
). Wl:LL USE (Check Ona Box) Moni1oring □ Municipal/Public □
lnduatriaVCommarclal □ Agricultural □ Recovery □ Injection □
lrrioation □ Ottier (fiat u .. ) Closed looo Geothe rt'II
DATE DRJLLED,__._O~-,4::.:.........t+--
'-WELL LOCATION:
1166 Lotta Church Rd
(Street Name, Numbeis. Community. SubdM,ion , Lot No., Parcel, Zip Code)
CITY: Franklin couNTY Macon
TOPOGRAPHIC I LANO SETTING: (check appropriate box)
□Slope □Valley .i,:iat o Rldge □~r ______ _
K@ilSTCo 36_ 1••Ma•••A M M ! cL ROR 3Ji:1)U(J(~J1 cc
kN~tSTco 1s 1• .. ••a••••••,,., cL ROR 7-Jt.l)(,c)t-~ cc
Lalltuda/longltude source: [PPS Qropographie map
(toe.lion of _II must be wwn on • USGS topo ""'P endatt.chfld to
th /a form i f not using GPS)
&. FACILITY (Name of the businaM where the well is located.)
Mar.on Elementary
Facility Name Facility ID# (if 1ppllcabl1)
1166 Lotta Church Rd
Street Addntss
f ran kli n NC 28 734
City or Town Stata Zip Code
Macon County Government
Contact Name
Malling Addrass
Eraoklio
CityOl'Town
Area code Phone number
&. Wl:LL. DETAILS: -
•. TOTAL DEPTM:.__,_/...abS _____ _
NC 26743
Stat. Zip Cod•
b , DOES WELL REPLACE EXISTING WELL? YES O NO r¥
c . WATER LEVEL Below Top of Caal r,v: _..z,_c) ___ FT.
(Use •+• if Above Top of Casi ng)
-----------
: d. TOP OF CASINO IS ,2.. FT. Above Land Surface•
: 'Top of casi ng termlnawd •tlor below land surface may require
: a variance in accordance with 1 SA NCAC 2C .0 1 1 &.
: •• YIELD <apm>: / Q C) METHOD oF TEsr Blew Down . .
: t. DISINFECTION: Type HTC Amount 12 QZ
: g, WAT§R ZONES (dep!h~ ~
~ Top /.{pC) Bot1om /~~ Top ___ Bottom __ _
; Top, ___ Bottom __ _ Top ___ Bollom_
; Top Bottom __ _ Top Bottom. __ _
Thicllneu/
: 7, CASINO: Depth Diameter Weight Material
: Top.!.2:.._ Bottom~ Ft. __ _
; Top __ Bottom __ Ft __ _
; Top ___ Bottom __ Ft. __ _
j 8. GROUT: Depth J~O Material
: Top_Q_ Bottom~ Ft. Bentonjte
i Top~ Bottom..lK:_ Ft, "'4{4,J ie,,.
;Top ___ Bottom __ Ft ____ _
: I . SCREEN: Depth Olamem Slot Siu
Method
Pumped
Material
: Top __ Bottom __ Ft. __ ln. __ In. ___ _
: Top ___ Bottom ___ Ft. __ ln . --In. ----
: Top __ Bottotn_Ft __ in , tn . ___ _
: 10. SAND/GRAVEL PACK:
: Depth Size M•t.rial
:Top ___ Sottom __ Ft.. __________ _
;Top ___ Bottom __ Ft __________ _
: Top. ____ Bottom __ f t., __________ _
: 11 . DRILLING LOG
: Top Bottom
0 I q5
,if ~ f~
I -----------·'-------~----
---'-------'-------~----
; 1:z. REMARKS:
~ Casi11 g Ren 1ovec,
; SI
Fonnatlon Dascriptlon
f:;t!f;i~
CONS"l'RUCTE1) IN -'CCOROANCE Wini
ANO THAT A COPY OF THIS
/(J-;J<-{/
~ DATE
1'//~5
E OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -Information Processing,
f617 Mall Servtc. Center, Raleigh, NC 2769&-161, Phone : [phone]
FormGW-11)
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department o f Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3118-A
1. WELL CONTRACTOR :
Tim othy R Hamby
Well Contractor (Individual) Name
Mid south Geotherm al
Wall Contractor Company Name
8275 Tournament Dr Suite 185
Streat Addrau
Memphis TN 38125
City or Town State Zip Code
C 901 l 7 48-9095
Area coda Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# Wl0100141
...a..a..a.=-.a...=.~ ........ ------
OTHER ASSOCIATED PERMIT#(lf app/lcable), _______ _
SITE WELL 10 #(If appllcable) __ ~G....-3....._ ______ _
3 . WELL USE (Check Ona Box) Monitoring □ Munlclpal/Public □
lnduatrial/Commerclal □ Agricultural □ Recovery □ Injection □
lrrigatiort□ other 11i'(l f1t use) Closed looo Geotherra
DATE DRILLED 11 -1 3 -I I
-'• WELL LOCATION:
1166 Latia Church Rd
(Slfeet Name, Numbers, Community, Subdivision. Loi No., Parcel, Zip Code)
c1rv: Franklin COUNTY Macon
TOPOGRAPHIC/ LANO SETTING: (check approprtate bo~)
□slope □Valley -fF11t OR!dge □Other ______ _
LATITUDE ~ ---· OMS OR 3x.xxxxxxxxx OD
LONGITUDE 7!.__ ___ • oMs oR 7x,xxxxxxxxx oo
Latitude/longitude 10urce: [};PS Qropographlc map
(location of well must be irhown on II USGS topo map 11nd11ttached to
this form If not using GPS)
5. FACILITY {Name of the buslneu where the well la located.)
Macao Elementary
Facility Name
1166 Latia Church Rd
Street Addreu
franklin
City or Town
Macon County Government
Contact Name
Malllng Address
Eraoklio
City or Town
'--.,..,> ......,..--------Area code Phone number
ti. WELL DETAILS:
a. TOTAL DEPTH: __ __._f__,6,__0 __
Faoilfty 10# (If applicable)
NC 28734
State Zip Code
NC 28743
State Zip Code
b. DOES WELL RE,PLACE EXISTING WELL? YES D
11. WATER LEVEL Below Top of Casing: ---=-:;.."7cJ ___ _,FT.
(U&e •+• if Above Top of Casing)
-----------
; d. TOP OF CASINO IS ~----FT· Above Land Surface~
•Top of ea1trig terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
: e. YIELD (gpm): 3 0 METHOD OF TEST Blow Down
! f. DISINFECTION: Type HTC Amount 12 OZ
: g, WATER ZONES (depth):
:Top ___ Bottom __ _ Top ___ Bottom, __ _
; Top ___ Bottom __ _ Top ___ Bottom, __ _
; Top ___ Bottom. __ _ Top Bottom __ _
; 1. CASINO: Oepth Diameter
~ Top_Q_ Bottom..1'k.. Ft. 6 1 /8
: Top ___ Bottom ___ Ft. __ _
; Top_ Bottorn_Ft.. __ _
Thickne11/
Weight
_j_8.8_
Material
steel
; 8. GROUT: Depth Material Method
: Top..Q__ Bottom~ Ft. Bentonjte Pumped
~ Toplit!)_ Bottom~ Ft. washed stone poured
: Top ___ Bottom ___ Ft. ____ _
; 9. SCREEN: Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft. __ ln. in. ____ _
; Top ___ Bottom ___ Ft. __ lrt. In . ____ _
: Top ___ Bottom ___ Ft. __ in. __ In . ____ _
: 10. SANDIORAVEL PACK:
; Depth Size Matertal
: Top ___ .Bottom ___ Ft.~--_______ _
: Top Bottom ___ Fl __________ _
: Top Bottom ___ Ft __________ _
: 11 . DRILLING LOG
Top Bottom
(J I
/6 2.../
---'/ ___ _ ___ / ___ _ ___ /. ___ _
___ .! ___ _
---'/ ___ _
-_.....:I /----__ _, ___ / ___ _
---'/ ___ _
: 12. REMARKS:
: Casi119 Re111ooed
; I 00 HEREBY CERTIFY THAT THIS WELi. WAS CONSTRUCTa> IN ACCORDANCE WITH
: 1M NCAC 2C, WELl CONSTRUCTION STANDARDS, mo THAT A COF'V OF THIS
: RECORD HAS BEEN PRO IDEO TO THE WELL OWNER. I
: . £ ,. ;.2-, 3 -1
E OF C TIFIEO WELL CONTRAc'fc5R' DATE
: Iiroctbv B Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality. tnfonnatlon Processing,
1817 Mall Service Center, Raleigh, NC 27899-161, Phone: [phone]
Form GW-1b
Rev. 2/09
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Rc:sources• Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3065-A -
1. WELL CONTRACTOR :
Roger L William s
Well Contractor (lrtdlvtdual) Name
Tarh eel Wate r Treatma nt
Well Contractor Company Name
3494 Geo rgi a Rd
Street Addre11
Franklin
City or Town
r 828 l 369-0740
Area code Phone number
2. WELL INFORMATION:
NC 28 734
State Zip Code
W ELL CONSTRUCTION PERMIT#"-'W.....,_,IO'-'1'-"O'-"O'-'1'-4'-'1'-------
OTHER ASSOCIATED PERM IT#(if appltcable) _______ _
SITE W ELL ID #(II appllcable)_,G=--4-=----------
3. WELL USE (Check One Boxl Monitoring o Munielpal/Publlc □
lnduetrial/Commerelal O Agricultural D Recovery □ Injection □
Irrigation □ Other •<list use) Closed Looo Geotherg
DATE DRILLED~l-2 ..... -7_-~1-1 ___ _
,. WELL LOCATION :
1166 lotla Church Rd
(Street Name, Numbl!ns, Commun ity, SubdM&ion, Lot No., Parcel, Zlp Code)
c1TY: Franklin couNTY Macon
TO POGRAPHIC / LAND SETTING: (check appropnate box)
OSio~ □Valley Q'i:lat □Ridge □Othe r ______ _
K@,1$TCO 3~ 111A••a•AAA AAAAI CL R OR ax~~ cc
t<NM"l$TCD 75 1"•""&""""""'"'1 CL R OR 7'1'~~ CC
Latitude/lo ngitude source: [)3PS Dropographlc map
(location of well must be shown on • USGS topo m•p 1nd11tt11ch11d to
this tbtm if not using GPS)
5. FACILITY (Name of the bu1lnesa wnera the well i1 located.)
Maeoo Elementary School
Facility Name Facility 10# (if applicable)
1166 lctla Church Rd
Street Address
Franklin NC 28734
City or Town State Z ip Code
Macon Countv Government
Contact Name
Mailing Address
Franklin NC 28234
City or Town State Zip Code
( ) ___________ _
Area code Phone number
I. WELL DETAILS:
a. TOTAL DEPTH:_4 .... 5 ... 0 ... ' ____ _
b. DOES WELL REPLACE EXlSTINO WELL? YES D NO~
c. WATER LEVEL Below Top of Casing ; 50 FT,
(Use·+• If Above Top of Casing)
-----------
: cl. TOP OF CASINO IS _____ FT. Above Land Surface•
"Top of c:a1ing terminated at/or below land surface may require
a variance In accordanc:e with 15A NCAC 2C .0 118.
~ •· YIELD 111Pm1: 30 METHOD oF TEST Blow Down
: ,. DISINFECTION: Type HTC Amount 12 az
: g. WATER ZONES (depth):
: Top ___ Bottom_ Top. ___ Bottorn._ __
: Top ___ Bottom.___ Top Bottorn._ __ _
: Top. ___ Bottorn __ _ Top ___ Bottorn, __ _
Tt,ickness/
; 7, CASINO: Depth Diameter Weight Material
j Top....Q..__ Bottom--162..__ Ft.. __ _
: Top ___ Bottom ___ Fl. __ _
; Top ___ Bottom ___ Ft.. __ _
; 8. GROUT: Depth Material
~ Top.Jl__ Bottom...16L_ Ft. bentonjte
: Top-1§L Bottom~ Ft. washed stone
: Top ___ Bottom ___ Ft. ____ _
: 9 . SCREEN : Depth Diameter Slot Si.ze .
Method
pumped
poured
Material
: Top ___ Bottom ___ Ft. __ ln. ln. ___ _
: Top ___ Bottom ___ Ft. __ ln. In. ___ _
: Top ___ Bottom ___ Ft. __ in. In. ____ _
: 10. SAND/GRAVEL PACK:
: Depth Size Material
: Top'---__ Bottom ___ Ft.. __________ _
; Top ___ Bottom ___ Ft. __________ _
; Top ___ .Bottom ___ ft.. __________ _
: 11. DRILLING LOG
Top Bottom
0 /_1=6-2 __
162 /_4=5~0 __
---'----__ _,/ ___ _
----'----_____ / ___ _
----''----___ ./ ___ _
---·'----___ ./ ___ _ ____ / ___ _
: 12. REMARKS :
: Casi1 19 Re111oved
Formation Description
Sand and Clay
Granite 30gpm
.---------------------: I DO HEREBY CERTIFY THAT THIS WEU. W/4S CONSTRUCTEI) IN ACCORDANCE WITH
; 15A ION STANDARDS, ANO THAT A COPY Of THIS
• RE : :--..... : • 12-7-11
; SIGNA E OF C RTIFIED WELL CONTRAC"'foR DATE
: Roger L willlarns
; PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -lntonnatlon Processing,
1617 Mall Service Center, Ralelgh, NC 27699-161, Phone : [phone]
Form GW-1b
Rev . 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3065 .. A
1. WELL CONTRACTOR:
Roaer L Willia ms
Well Contractor (Individual) Nama
Tarhe el Wate r Treatment
Well Contractor Company Name
34 94 Georaja Rd
Street Address
Franklin
City or Town
( 828 l 369-07 40
Area code Phone number
2. WELL INFORMATION:
NC 28734
State Zlp Coda
WELL CONSTRUCTION PERMIT#...:.W..:...:.:10'-'1'-"Q=Q'--'1'--'4'-'1 ____ _
OTHER ASSOCIATED PERMIT#(ifappllceble) _______ _
SITE WELL ID #{lf appllcable),...aG=•....::5:;..._ _______ _
3. WELL USE (Check Ona BoK) Monitoring □ Municipal/Public □
Industrial/Commercial D Agricultural □ Recovery O Injection D
Irrigation□ Other r;/(11,1 uae) Closed Loo o Geothera
DATE DRILLED_,1=2'---5-,._.,1....,.1 ___ _
4, WELL LOCATION:
1166 lotla Church Rd
(Street Name, Number&, Community. Subdivision, Loi No .. Parcel, Zip Code)
c1TY: Franklin couNrv Macon
TOPOGRAPHIC / LAND SETTING: (che<:k appropriate box)
□Slope □Valley '7Flat □Ridge □Other ______ _
K@>ISTCD 36_ 1MA•&•AAAAAI\AI CL ROR 3JC~ll)UO(~ cc
t<1-I~ 1$TCO 75 1""''&"""'11 """1 CL R OR ~.')O~ltXAA~ CC
Latitude/longitude source: [PPS Ol'opographlc map
(/ocetfon of well must be shown on • USGS topo map andattached to
th/a form If not using GPS)
a. FACILITY (Name of the bualnau Where the well Is loca!Bd.)
Macon Elementarv Schoel
Faclllty Name Facility ID# (if applicable)
1166 loUa Church Rd
Street Addren
franklin NC 28734
City or Town Stata Zip Code
Macon Cnuntv Government
Contact Name
Malling Addreas
Franklin NC 28734
City or Town Slate Zip Coda
Area code Phone number
8. WELL DETAILS:
a. TOTALDEPTH:~4_5_0~'-----
b. DOES WELL REPLACE EXISTING WEU? YES D NO(¥
c. WATER LEVEL Below Top of Casing: __.5..,0..._ ____ FT.
(Use •+• If Above Top of Casing)
-----------
: d. TOP OF CASING IS _____ FT. Above Land Surface•
*Top of casing terminated aVor below land surface may require
a variance In accordance wlth 15A NCAC 2-C .0118.
: e. YIELD (apm}: 30 METHoo oF TEST Blow Down
~ ,. DISINFECTION: Type HTC Amount 12 oz
: g. WATER ZONES (daptt,):
:Top ___ Bottom __ _ Top ___ Bottom. __ _
: Top ___ Bottom __ _ Top ___ Bottom __ _
: Top Bottom. ___ _ Top Bottom. __ _
Thleknus/
; 1. CASING: Depth Diameter Weight Material
\ Top~ Bottom-162,_ F.._ __
: Top ___ Bottom ___ Ft._ __
; Top ___ Bottom ___ Ft. __ _
: 8. GROUT: Depth Material
: Top~ Bottom-1.aL_ Ft. bentonjte
~ Top..i§L Bottom~ Ft. washed stone
; Top ___ Bottom ___ Fl ____ _
: 9. SCREEN: Depth Diameter Slot Size
Method
pumped
poured
Material
: Top ___ Bottom ___ Ft. __ ln. __ In. ____ _
: Top ___ Bottom ___ Ft. __ ln. In. ___ _
j Top ___ Bottom ___ Ft. __ ln. In. ____ _
: 10. SANO/GRAVEL PACK:
: Depth Size Material
: Top ___ .Bottom ___ Ft. __________ _
: Top. ___ ,Bottom ___ Ft. __________ _
: Top ___ .Boitom ___ F.._ _________ _
; 11. DRILLING LOG
Top Bottom
0 /_1..,,6=2 __
162 /_4=5=0 __
I --------___ ./ ___ _ ____ / ___ _ ___ / ___ _
---''-------'----___ / ___ _
---'----___ / ___ _
: 12. REMARKS:
i Casi, 19 Rei, 1oved
Formation Description
Sand and Clay
Granite 30 gpm
: I 00 HEREBY CERTIFY lliAT THIS WElL WM CONS7RUCTEO IN ACCORDANCE WITH
• 15AIIICAC 2C EU. CONSTRUC~IOIII St: , AfjQ THAT A COPY OFTiilS
i RECORO ~ ~C TOTH ER.
: ~~~ t-12-5-11
: SltiNA RE OF CERTIFIED WELL CONTRACTOR DATE
: Racer L willieros
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -Information Processing,
1817 Mall Service Center, Raleigh, NC 27899-181, Phone ; (919) 807~300
Form GW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3065-A
1. WELL CONTRACTOR:
Roge r L Willi ams
Wall Contractor (Individual) Name
Tarhe el Water Tre atmant
Wall Contractor Company Name
3494 Georgi a Rd
Street AddrellS
Franklin NC 287 34
City or T O'M'I State Zip Coda
1828 l 369-0740
Ansa code Phone number
2. WELL INFORMATION:
WEJ..L CONSTRUCTION PERMIT# WIO 100141 ..:...:...:.::...a..==-:-'-''-------
OTHER ASSOCIATED PERMIT#(lf applk:able), _______ _
SITE WELL ID #{if appllcable),-'G=--'-6,.,__ ________ _
3. WELL USE (Check One Box) Monitoring D Munlclpal/Public D
lndusbial/Commeroial □ Agricultural D Recovery O Injection D
Irrigation □ other W(ll11 use) Closed Loop Geothera
DATE DRILLED 11-21-11
(. WELL LOCATION:
1166 lotla Church Rd
(Street Name , Numbe11, Community, Subdlvlslon , Lot No., Parcel, Zip Code)
c1rv; Franklin COUNTY Macon
TOPOGRAPHIC / LANO SETTING: (check appropriate box)
□Slope □Valley lit'Ftat □Ridge □Other, ______ _
l<@ltSTCD 38_ 1••••&•AA•AA••1 CL ROR 3JC~)IIJOO(~ cc
KN~ ISTCD 75 , ... ••a•••• .. ••1 CL R OR 7-,e~~ cc
Lalltude/longltude source: ();PS Ofopographle map
(location of well must be shown on • USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of th• bu•inass where the well is localed.)
Macon fleroeotac:v 5cbaol
Facility Name Facility ID# (if applicable)
1166 latla Church Rd
Streat Address
franklin NC 28734
City or To'M'I State Zip Code
Macon County Government
Contact Name
Mailing AddreH
Eraokllo NC 28734
City or Town State Zip Code
1...-_ _,) ---------
Area code Phone number
a. WELL DETAILS:
a . TOTAL DEPTH:_4~5_O_' ____ _
b. DOES WELL REPLACE EXISTING WELL? YES □ NO f¥
c. WATER LEVEL Below Top of Casing: 50 FT.
(Use ••• if Above Top of Casing)
-----------
: d. TOP OF CASING IS _____ FT, AbOVa Land Surface•
; •Top of ca,ing tem,inatad at/or below land surface may require
: a variance In accordance with 15A NCAC 2C .0118.
: e. vrELD 10pm}: 30 METHoa oF TEsT Blow Down
~ ,. DISINFECTION: Type HTC Amount 12 az
: g. WATER ZONES (depth):
: Top. ___ Bottom,. ___ _ Top ___ Bottom, __ _
:Top ___ Bottom __ _ Top ___ Bottom __ _
: Top ___ Bottom. __ _ Top Bottom,...._ __
ThlckneH/
: 7. CASING: Depth Diameter Weight Material
j Top_Q__ Bottom....162_ Ft. __ _
: Top ___ Bottom ___ Ft .. ___ _
; Top ___ Bottom ___ Ft.. __ _
: 8. GROUT: Depth Material
~ Top_Q__ Bottom~ Ft. bentonjte
: Top-1§1._ Bottom..Afill.._ Ft. washed stone
: Top ___ Bottom ___ Ft.. ____ _
: 9. SCREEN: Depth Diameter Slot Size
Method
pumped
poured
Material
; Top ___ Bottom ___ Ft. __ in. in. ____ _
: Top ___ Bottom ___ Ft. __ in .. In. ____ _
: Top ___ Boltom ___ Ft. __ !n. In. ____ _
: 10. SAND/GRAVEL PACK:
: Depth Slz.e Material
: Top ___ Bottom ___ Ft .. ___ _
: Top ___ Bottom ___ Fl. __ _
: Top. ___ ·Sottom ___ Ft.. __________ _
: 11 . DRILLING LOG
: Top Bottom
0 I 162
162 / 450 ,------------'----/ ---,----
--... '-------'----/ ---,----
: 12. REMARKS:
: Casi, ,g Ren roved
Formation Description
s and and Clay
Granite 30gpm
; I 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wm!
: 15A~CAC 2C EU CONSTRUCTION STANDARDS, ANO TH'.T A COPY 01' 'THIS
; RECORD ~ENP~O~
: · p'~ --11-21-11
: SIG NAT(JREOFCE TiFlEOWELLCONTRAc'15R DATE
Racer I williaros
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -tnfonnatlon Processing,
1617 Mall Service Center, Raleigh, NC 27699-181, Phone: (919) 807.f300
FormGW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Narum! Resources• Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3065-A
1. WELL CONTRACTOR:
Roger L Williams
Well Contractor (lndMdual) Nam,
Tarheel Water Treatmant
Well Contractor Company Nam•
3494 Georgia Rd
Streat Addran
F ranklin
City or Town
1 828 l 369-07 40
Area code Phone number
2. WELL INFORMATION :
NC 287 34
State Zip Code
WELL CONSTRUCTION PERMIT# WIQ100141 '-'-'""-=..a..:c=-"--'--'-------
OTHER ASSOCIATED PERMIT#/lf applicable), _______ _
SITE WELL ID #(ff applicable), ... G=-• 7'-----------
3. WELL USE (Checl< One Box) Monitoring □ MuniclpaVPubllc O
lndustnat/Commercial □ Agricultural □ Recovery □ ll!jectlon □
Irrigation□ Other ttf 111,1 use) Closed Looo Geothera
DATE DRILLED 11-22-11
4 . WELL LOCATION :
1166 lotla Church Rd
(Streat Name , Numbers, Community, Subdivision , Lot No., Parcel, Zip Code)
c1TY: Franklin couNTY Macon
TOPOGRAPHIC I LANO SETTING: (cheok appropriate box)
□Slope □Valley ii(Flal □Ridge □Other. ______ _
K@l$TCD 36_ ,••M&AAIIMAA/\I CL ROR 3,c~~l( cc
KN~tsTco 75 111•11•&•11 ••AA•"1 CL ROR 7'9e.~~~ cc
Latitudenongltude soun:e: [):;PS OTopographlc map
(location of well f"()U$I be $hoWn on • USGS topo map andatteched to
th/$ form if not U$/flg GPS)
5, FACILITY (Neme of the busineN where the well 11 located,)
Macon Elementarv School
Fac1l1ty Name Facility 101# (if applicable)
1166 lotl a Church Rd
street Address
franklin NC 28734
City or Town State ZJp Code
Macon Countv Government
Contact Name
Mailing Addre111
Franklin NC 28Z34
City or Town State Zip Code
( ) _________ _
Area code Phone number
8. WELL DETAILS:
a. TOTAL DEPTH:....;4 ...... 5...,Q.._' ____ _
II. DOES WELL REPLACE EXISTING WELL? YES D NO f¥
e . WATER LEVEL Below Top of Casing: 50 FT.
(U&e ·+• i1 Above Top of Casing)
------------
; d. TOP OF CASINO IS -.,....----FT. Above Land Surfac:a•
•Top of casing teimlnated el/or below lend surfece may require
a variance fn accordance with 15A NCAC 2C .0118.
: •• vrELD (gpm): 30 METHOD oF TEST Blew Down
i f. DISINFECTION: Type HTC Amount 12 OZ
: g. WATER ZONES (depth):
: Top ____ Bottom. ___ _ Top ____ Bottom. ___ _
; Top ____ Bottom._ __ _ Top Bottom ___ _
: Top ____ Bottom. ___ _ Top ____ Bottom,_ __ _
ThickneH/
: 7. CASINO: Depth Diameter Weight Materiel
j Top.Jl._ Bottom~ Ft. __ _
: Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft. __ _
: 8. GROUT: Depth Material
~ Top.Jl._ Bottom..1.ZL Ft. bentonjte
: Top..1.ZL Bottom.A®_ Ft. washed stone
: Top ___ Bottom ___ Ft. ____ _
Method
pumped
poured
: 9. SCREEN: Depth Diameter Slot Size Material
; Top ___ Bottom ___ Ft. __ ln. In. ____ _
: Top ___ Bottom ___ Fl __ ln. In . ____ _
: Top ___ Bottom ___ Ft. __ ln. In, ____ _
: 10. SAND/GRAVEL PACK:
: Depth Size Material
; Top. ___ Bottom ___ Ft. ___________ _
: Top. ___ Bottom ___ Ft. ___________ _
: Top. ___ Bottom ___ Ft. ___________ _
: 11. DRILLING LOG
• Top Bottom
O /-'1'-'-72 __
172 /_4=5=0 __ ___ ./ ___ _
-----'----/ ---,----
----'-------''----___ / ___ _
I ------------'----
: 12. REMARKS:
: Casir 1g Re,, 1oved
Formation Oescnption
Sand and Ctay
Granite 30g pm
: I 00 HEREBY CERTIFY THAT THIS WEtl. WAS CONSTRUCTED IN ACCORDANCE WITH
• 1'51' NCAC 2C, WEU. CONSTRUCTION STANDARDS, ANO THAT A COPY OF THIS
j REC~RD EN PRO !j>;DT~ER.
: ~~~~~~~~:,:-:-~~ 11-22-11 : s1GNATEOFCERT1FlEDWEU.CONTRAcTOR DATE
: Racer L williaros
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -Information Processing,
1617 Mall Service Center, Ralelgh, NC 27699-181, Phone : (919) 807~300
Form GW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Nann-al Resources-Divi sion of Water Quality
WELL CONTRACTOR CERTIFICATION# 3065-A
1. WELL CONTRACTOR:
Ro ger L Williams
Well Contractor (Individual) Name
Tarhe el Water Treatmant
Well Conlnlctor Company Name
3494 Geo rgia Rd
Street Addre"
Franklin NC 28734
City or Town State Zip Code
< 828 > 369-07 40
Area coda Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# Wl0100141 '-'-''-'-"'--'-"'-;.=-.'-'--'------
OTHER ASSOCIATED PERMIT#{if applicable) _______ _
SITE WELL ID #(ifappllcable) . ...,G=·...,8"-----------
3, WELL USE (Cheek One Box) Monitoring D MuniclpaVPubllc D
lnduatriaVCommerclal o AgrteuJtural o Recovery □ Injection D
Irrigation □ Other f!l(list use> Closed Looo Geother ■
DATE DRILLED 10 -26-11
4. WELL LOCATION:
1166 lotla Church Rd
(Streel N11me , Numbens, CommU11ity, Subdllllslon, Lot No., Parcel Zip Code)
c1TY: Franklin couNTY Macon
TOPOGRAPHIC / LAND SETTING: (check appropnate box)
□Slope □Valley ii{Flat □Ridge □Other ______ _
K@>ISTCD 36_ 1••••&AAA•MAA! CL R OR 3JCN00(~)1 cc
KN~ISTCD 75 ,•~AA&AIIMMAA! CL ROR 1'll~ cc
l.atitude/longltude source: [)3PS OTopographlc map
(/oa.tion of well must be shown on • USGS topo map 11ndatt11ched to
this form If not using GPS)
5. FACILrTY (Name of the business where the well Is located.)
Macon Elementarv Scbccl
FacTiityName
1166 lctta Church Bci
Streat Addre11
franklin
Ci ty or Town
Macon County Government
Contact Name
Mailing Addreu
Franklin
City or Town
.__ _ _,) ---------
Area code Phone number
8. WELL DETAILS:
•• TOTAL DEPTH :,...;4 .. 5 ... Gw.'-----
Facility ID# (if applicable)
NC 28734
State Zip Code
NC ?8734
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES O NO ri/
c . WATER LEVEL Below Top of Casing: ... 6 ... 0.._ _____ FT.
(Use •+• if Abo11e Top of Casing)
-----------
; d . TOP OF CASINO IS _____ FT. Above Land Surface•
• •Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
: e. YIELD (gpm): 60 METHOD OF TEST Ajr I 1ft
~ r. DISINFECTION: Type HIC Amount 1 /4 Cup
: g. WATER ZONES {depth):
; Top Bottom Top . ___ Bottom._ __ _
: Top Bottom Top ___ Bottom __ _
: Top Bottom Top ___ Bottom,_ __ _
ThickneH/
: 7. CASING: Depth Diameter Weight Material
! Top~ Bottom.....95__ Ft ... ___ _
: Top ___ Bottom ___ Ft.. __ _
: Top ___ Bottom ___ Ft ... ___ _
Method ; 8. GROUT: Depth Materiel
i Top~ Bottom--1.QL Ft. bentonjte pumped
: Top...1.QO._ Bottom..A.5.Q_ Ft. washed stone poured
: Top ___ Bottom ___ Ft.. ____ _
: 9. SCREEN: Depth Diameter Slot Slz-Material
: Top ___ Bottom ___ Ft. __ in. __ In. ____ _
: Top ___ Bottom ___ Ft. __ l n, In. ___ _
: Top ___ Bottom ___ Ft. __ ln . In. ____ _
: 10. SAND/GRAVEL PACK:
: Depth Size Material
;Top. ___ Bottom ___ Ft. __________ _
: Top ___ Bottom ___ Ft __________ _
i Top Bottom ___ Ft. __________ _
: 11 . DRILLING LOG
: . Top Bottom
0 I 95 _9-5 __ ,_1~2=5 __
125 I 450
---'----____ / ___ _
I ---,----___ /. ___ _ ____ / ___ _ ____ / ,--------
; 12. REMARKS:
: Casing Ren ,ooed
Formation Description
Sand and Clay
Loose Granite Gravel
Hard Granite
; I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED l"I ACCORDANCE WITH
• 15A NCAC 2C. WE.LL CONSTRUCTION STANOAAOS, ANO THAT A COPY OF THIS
: RECORD HAS BEEN ~OVIOED TO THE WEU. OWNER
: =~=~==-==-:-~~~=-:-. 10-28-11
; SIGNATURE OF CERTIFIED WELL CONTRAC~ DATE
: Roger L williaros
; PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completlon to: Division of Water Quality -Information Processing,
1617 Mall Service Center, Ralelgh, NC 27899-181, Phone: [phone]
Form GW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3065-A ------------
1. WELL CONTRACTOR :
Roger L Willi ams
Wall Contractor (Individual) Name
Ta rheet Wate r Treatment
Wall Contractor Company Name
34 9 4 Georgia RD
Street Address
Franklin NC 28734
City or Town State Zip Coda
( 828 ) 369-07 40
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WI0 100141 ..a....a=...a...:c..:..-'---'.-'-------
OTHER ASSOCIATED PERMIT#(lf a?l)llcable), _______ _
SITE WELL ID #{If appllcable),...aH .... -__ 1'----------
3. WELL USE (Check Ona Box) Monitoring O MuniclpaVPubllc D
lnduatriaVCommarclaJ □ Agriwltural □ Recovery □ Injection D
Irrigation□ Other llt'u1,tuse) Closed loop Geotherra
DATE DRILLED 11 -17-11
4 . WELL LOCATION:
1166 Latia Church Rd
(Street Name, Numbel'II, Community. SubdMaion. Lot No ., Parcel , Zip Code)
c1TY: Franklin couNTY Macon
TOPOGRAPHIC / LAND SETTING: (Check appropriate boK)
D Slope □Valley lifFlat □Ridge □Other ______ _
1<@1$TCo 36_ 1••••a•••M••"I CL R oR 3Jt~)O{~ cc
KN~ tSTCD 75 1•M•&•••M•••1 CL R OR h~~ cc
Latitudanongituda ■ource: 0:.PS Oopographlc map
(location of wall must ba :shown on a USGS topo map and11tt11ched to
this form if not using GPS)
5. FACILITY (Name of the business where Iha well ia located.)
Macon Elementary
FacUity Name Facllity ID# (if applicable)
1166 Latia Church Rd
Streat Address
franklin NC 28734
City or Town State Zip Code
Macon County Government
Contact Name
Mailing AddreH
franklin
City or Town
Area code Phana number
8. WELL DETAILS:
a. TOTAL DEPTH:-'4_...5 ... 0..._ ___ _
NC
State
b. DOES WELL REPLACE EXISTINO WELL? YES O
28743
Zip Coda
NO ~
e. WATER LEVEL Below Top of Casing: ______ FT.
(Use·+• if Above Top of Casing)
: d. TOP OF CASINQ IS_.,.........,_.,.....FT. Above Land Surface•
: 'Top of casing terminated at/or below land surface may require
: a variance In accoroanca With 15A NCAC 2C .0118.
: •· YIELD (gpm): 30 METHOD OF TEST Blow Down
! f. DISINFECTION: Type HTC Amount 12 OZ
: g. WATER ZONES (depth):
: Top ____ Bottom ___ _ Top ___ Bottom. ___ _
: Top ___ Bottom. __ _ Top ___ BottX>m,_ __ _
: Top Bottom ___ _ Top Bottom. ___ _
ThiekneH/
: 7. CASINO: Depth Diameter Weight Material ! Top_Q__ Bottom.J.62_ Ft. __ _
: Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft.. __ _
: 8. GROUT: Depth Material
j Top..JL__ Bottom....1§Z_ Ft. Benton!te
: Top....1§Z_ Bottom~ Ft. washed stone
: Top ___ Bottom ___ Ft. ____ _
: 9. SCREEN : Depth Diameter Slot Size
Method
Pumped
poured
Material
: Top ___ Bottom ___ Ft. __ ln. In. ____ _
: Top ___ Bottom ___ Ft. __ ln. __ In. ____ _
: Top ___ Bottom ___ Ft._ln, in. ____ _
; 10. SAND/ORAVEL PACK:
; Depth Sin Material
: Top ___ Bottom ___ Ft. __ _
: Top Bottom ___ Ft.. ___________ _
; Top Bottom ___ Ft. ---
: 11. DRILLING LOG
: Top Bottom
_o __ ,_a-2 __ _
_8_2 __ , __ 1=6=2 __
162 I 450
---'----/ ---,
----___ ./ ___ _
---'----/ ---,.----
-----c'----
; 12. REMARKS:
~ Casing Rernoved
Formation Descript1on
Sand Clay
Brol<en Rock
Granite 30 GPM
: I 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
: 1M OTHAT ACOPVOFTHIS
; RE
· ---~:=.:.,!--=-~"'-'=~~= 11-17-11
:SIG ~ DATE
: BaCJec I Williams
; PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -Information Processing,
1617 Mall Service Center, Ralelgh, NC 27899-161, Phone: [phone]
Form GW-1b
R_ev. 1108
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department o f Environment and Natural Resources-Division o t'Water Quality
WELL CONTRACTOR CERTIFICATION# 3065-A
1. WELL CONTRACTOR:
Ro ger L W illi am s
Well Contractor (Individual) Name
Tarheel Water Treatment
Well Contractor Company Name
34 9 4 Georaia R D
Street Address
F r anklin NC 28734
City or Town State Zip Code
, 828 > 369-0740
Area code Pt,one number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#...:.W..:....:..:10 .... 1=-=Q=-=Q=-1-=-4-=-1-=-------
0THER ASSOCIATED PERMIT#(lf applicable ), ________ _
SITE WELL ID #{If applrcable),.._H..,_-..,2~---------
3. WELI. USE (Check One Box) Monitoring □ Municipal/Public:□
Industrial/Commercial □ Agricultural □ Recovery □ Injection □
Irrigation□ Other rr/c11,1 Use) Closed looo Geotherra
DATE DRILLED 11-15-11
•· W&LL LOCATION:
1166 Lotta Church Rd
(Street Name, Numbers:, Community, Subdivision, Lot No., Parcel, Zip Code)
c1TY: Franklin COUNTY Macon
TOPOGRAPHIC I LAND SETTING: (check approp~ete box)
□Slope □Valley ii(Flat □Ridge o Olhet. ______ _
~ISTCD 36_ I""""&""""""""! CL R OR 3J(NU(J(~)( CC
l<NM=i5TCD75 1"11""&""""""""1 CLROR 7-it.~ cc
Latltude/l ongituda source: ()3PS Ofopographic map
(locatfon of we// must be shown on • USGS topo map andattached to
this fonn if not usir,g GPS)
5. FACILITY (Name of the business where Ilia well is located.)
Macao Elementarv
Facility Name
1166 Lotta Church Bci
Street Addres,
Ecaoklio
City or Town
Macon County Government
Contact Name
Mailing Address
Eraoklio
City or Town
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:~4~5_0 ____ _
Facility ID# (!f applicable)
NC 28734
Stete Zip Code
NC 28743
State Zip Coda
b. DOES WELL REPLACE EXISTING W&LL? YES D NO r:;/
c:. WATER LEVEL Below Top of Casing: _______ FT.
(Use "1-" if Above Top cl Casing)
------------
; d , TOP OF CASINO IS -.,....--,.---,.......,.. FT. Above land Surface•
: •Top of casing terminated at/or below land surface may require
: a variance In accordance with 15A NCAC 2C .0118.
: e. YIELD (gpm): 30 METHOD OF TEST Blow Down
j f. DISINFECTION: Type HTC Amount 12 CZ
; g. WATER ZONES (depth):
: Top ____ Bottom. ___ _ Top ____ Bottom _____ _
: Top Bottom ___ _ Top Bottom. ___ _
: Top Bottom ___ _ Top Bottom. ___ _
Thlcknus/
; 7. CASINO: Depth Diameter Weight Material
\ Top.JL_ Bottom....162._ Ft. __ _
: Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft . ._ __
: 8. GROUT: Depth Material
i Top.JL__ Bottom_jfil_ Ft. Bentonjte
: Top_jfil_ Bottom~ Ft. washed stone
: Top ___ Bottom ___ Ft.. ____ _
Method
Pumped
poyred
: 9. SCREEN: Depth Diameter Slot Siz:e Material
: Top ___ Bottom ___ Ft. __ ln. In. ____ _
: Top ___ Bottom ___ Ft. __ tn. In , ____ _
; Top ___ Bottom ___ Ft. __ in. in. ____ _
: 10. SAND/GRAVEL PACK:
; Depth Size Materlal
: Top. ___ Bottom ___ F~--________ _
: Top. ___ Bottom ___ Ft.. ___________ _
: Top. ___ Bottom ___ Ft. ____________ _
: 11 . DRILLING LOG
Top Bottom
0 /_8=2,___ __
82 '.-1~6=2~_ 162 /_4_5_0 __ __ _,/ ___ _ ___ / ___ _
I --------____ / ___ _ ___ / ___ _
I ---,----__ _,/ ___ _
; 12. REMARKS:
l Cas i119 Reriio ved
Formation Description
Sand Clay
Brok en Rock
Granite ao GPM
; I 00 HEREBY C ERTIFY THAT THIS WEU WM CONSTRUCTEO IN ACCORDANCE WITH
• 1l!A NCAC 2C. CONSTRUCTION STANDARDS, AND THAT A COP'( OF 1)1IS
i,• RECORD _. B PROVIC\ED, TO TH ~~
" µ.,/~~ 11-15-11
; SIGNATU E OF CERTIFIED WELL CONTRAefc5R DATE
: Roger L Williams
: PRINTED NAME Of PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -Information Processing,
1817 Mall Service Center, Raleigh, NC 27899·161, Phone: [phone]
Form GW·1b
R•v-1108
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment ond Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3065-A
1. WELL CONTRACTOR:
Roger L William s
Well Contractor (lndfvldual) Name
Tarheel Water Treatment
Well Contractor Company Name
3494 Georgia RD
Street Address
Franklin NC 28734
City or Town State Zip Code
c 828 l 369-07 40
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#_,W~IQ:..1.:..:Q:..:Q:...1.:...4..:..1..:.... ____ _
OTHER ASSOCIATED PERMIT#(lf applioable). ________ _
SITE WELL ID #(If appllcable) . .,,H.,_--=3=-----------
2. WELL USE (Check One Box) Monitoring D MunlclpallPublic □
lndustr!al/Commen:lal □ Agricultural □ Recovery □ Injection □
Irrigation□ Other •c11,1 uae) Closed looo GeotheIT11
DATE DRILLED 11 -10-11
4. WELL LOCATION :
1166 Latia Church Rd
(Street Name, Numbers, CommunllY, Subdivision, Lot No., Parcel , Zip Code)
c1TY: Franklin COUNTY Macon
TOPOGRAPHIC I LAND SETTING: (chedc appropriate box)
□Slope □Valley itffal □Ridge □other ______ _
K@,ISTCO 3t_ 1••••& .... ••••1 CL R OR 3k!'~ CC
KN1'5tSTCo75 l"" .. &•• ...... A•!CLROR h~~cc
Latitude/longitude source: [)3PS Ofopographic map
(location ofwe/1 must be shown on a USGS topo map andatteched to
this form if not using GPS)
5. FACILITY (Name of the business where the well Is located.)
Macon Elementary
Facility Name Facility I0111 (If applicable )
1166 L ctla Church Rd
Str9et Addrese
franklin NC 28734
City or Town State Zip Code
Macon County Government
Contact Name
Malling Addrese
Eraoklio NC 26743
C ity or Town State Zlp Code
Area code Phone number
8. WELL DETAILS:
a. TOTAL 0EPTH:_Af~S_0 ____ _
b. DOES WELL REPLACE EXISTING WELL? YES O NO rJ/
e. WATER LEVEL Below Top of Casing: ______ FT.
(Use •+• if Above Top of Casing)
------------
! d. TOP OF CASINO IS _____ FT. Above Land Surface•
: 'Top of casing terminated at/or below land surface may require
: a variance in accordance With 15A NCAC 2C .0118.
: e. YIELD (gpm): 30 METHOD OF TEST Blow Down
~ f. DISINFECTION: Type HTC Amount 12 oz
; g. WATER ZONES (depth):
: Top ____ Bottom. ___ _ Top ____ Bottom ___ _
: Top Bottom. ___ _ Top Bottom,_ __ _
: Top Bottom. ___ _ Top Bottom. ___ _
ThlckneH/
: 7. CASING: Depth Diameter Weight Material
( Top_Q__ Bottom...1§2-Fl __ _
: Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft.. __ _
: 8. GROUT: Depth Material
i Top_Q__ Bottom...12L._ Ft. Bentonjte
: Top..lfiL Bottom.A5ll.._ Ft. washed stone
: Top ___ Bottom ___ Ft. ____ _
: 9 . SCREEN : Depth Diameter Slot Size
Method
Pumped
poured
Material
: Top ___ Bottom ___ Ft. __ ln. __ \n. ____ _
: Top ___ Bottom ___ Ft. __ ln. __ In. ____ _
: Top ___ Bottom ___ Ft. __ in, In. ____ _
: 10. SAND/GRAVEL PACK:
: Depth Size Material
: Top ___ .Bottom ___ Fl ___ --------
: Top. ___ Bottom ___ Fl ___________ _
j Top ___ Bottom ___ Ft. ___________ _
: 11. DRILLING LOG
: Top Bottom
0 /_.,8..,,2._ __
82 /_1.,...6,_2 __
162 /..;;4;i;,,5""'0 __ ___ ./ ___ _ ___ ./ ___ _ ___ / ___ _
------'--------''----__ ......,/ ___ _ ___ / ___ _ ____ / ___ _
: 12. REMARKS:
i Casi119 Rerrroved
Formation Description
Sand Clay
Broken Rock
Granite 30 GPM
; I DO HEREBY CERTIFY THAT THIS WEll WAS CONSTRUCTED IN ACCORDANCE WITH
; 15A NCAC 2C, WELL CONSTRUCTION ST.ll/OARDS, ANO THAT A COPY OF"TlilS
; RECORD EN AAOVI TO THE E
,r---,,,c..._.,<;..--.._
11-10-11
DATE
: Roger L Williams
; PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -Information Processing,
1817 Mall Service Center, Raleigh, NC 27699,1e1, Phone: (919) 807~300
Form GW•1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Notunll Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3065-A
1. WELL CONTRACTOR:
Roger L William s
Well Contractor (Individual) Name
Tarheel Water Treatment
Well Contractor Company Name
349 4 Georaia RD
Street Address
Frankli n NC 28734
City or Town State Zip Coda
c 828 i 369-07 40
Area code Phone 11\Jmbar
:z. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#~W_IQ~1-Q-Q_1_4~1 ____ _
OTHER ASSOCIATED PERMIT#(it applleable,_ ______ _
SITE WELL ID #(If applicable) H-4 -----------
3. WELL USE (Check One Box) Monitoring D Municlpal/Publlc D
Industrial/Commercial D Agricultural D Recovery D lnjec!lon D
Irrigation □ Other a'(Hstuae) Closed looo Geotherrn
DATE ORIU.ED_.1 ...... 1_-9,._•_.1-'-1 ___ _
,. WELL LOCATION:
1166 Lotla Church Rd
(Street Name, Numbe rs, Community, Subdivision. Lot No., Parcel, liP Code)
c1rv: Franklin COUNTY Macon
TOPOGRAPHIC / LANO SETTING: (check appropoate boK)
□Slope □Valley itF"lal □Ridge □Other ______ _
K@>ISTCD 36_ 1••••a••••AA••1 CL R OR 3Jt\\)U(JU(~" cc
KNl'.f1STCO75 l""""8""""""••1 CL ROR 7'~!lOetJtn~ CC
Latitudel1ongttude source: [)3PS Ol'opographic map
(location ofwe/1 must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the bualnass where the well i• located.)
Macon Elementarv
Facility Name Facility ID# (If applicable)
1155 Lotla Church Rd
Streat Address
franklin NC 28734
City or Town State Zip Coda
Macon County Government
Contact Name
Malllng Address
Franklin NC 28743
City or Town State Zip Coda
____ _,) ---------
Area code Pt,ona number
8. WELL DETAILS:
.a. TOTAL DEPTH :._4.._5.,.__O ____ _
b . DOES WELL REPLACE EXISTING WELL? YES O NO ~
c:. WATER LEVEL Below Top of Casing: ______ .FT.
(Uae •+• if Above Top of Casing)
-----------
; d. TOP OF CASINO IS _____ FT. Above Land Surfaoe•
"Top of casing terminated aVOf balow land surface may require
a variance In accordance with 15A NCAC 2C .0118.
~ •· YIELD (gpm): 30 METHOD oF TEST Blow □awn
: ,. DISINFECTION: Type HTC Amount 12 az
: g. WATER ZONES (depth):
: Top Bottom Top ___ Bottom. __ _
: Top Bottom Top ___ Bottom __ _
: Top Bottom Top ___ Bottom. __ _
Thickneu/
; 1. CASINO : Depth Dlamatar Weight Material
! Top_Q__Bottom~ Ft. __ _
: Top ___ Bottom ___ Ft. __ _
; Top ___ Bottom ___ Ft. __ _
: 8 , GROUT: Depth Material
~ Top__Q___ Bottom--1.il_ A. Bentonjte
: Top~ Bottom~ Ft. washed stone
: Top ___ Bottom ___ Ft.. ____ _
; I. SCREEN: Depth Diam eter Slot Slza
Method
Pumped
poured
Material
: Top ___ Bottom ___ Ft. __ ln. __ in. ___ _
: Top ___ Bottom ___ Ft. __ ln. __ In. ___ _
: Top ___ Bottom ___ Ft. __ ln. __ In . ____ _
: 10. SANO/GRAVEL PACK ;
Depth
; Top Bottom ___ Ft.
: Top Bottom ___ Ft.
: T op Bottom ___ Ft
; 11. DRILLING LOG
Top Bottom Formation Description
Q I ~2 Sa nd C lay
e2 I 1~5 Broken Rock
155 I !150 Granite 30 GPM
I
I
I
I
I
I
I
I
; 12. REMARKS:
j Casil ,g Re, 11ooed
; I 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCOR.CANCE Willi
• 111A NCAC 2C aL CONSTRUCTION ST ARDS, AND THAT A COPY OF THIS j RECfRO EN PRO\11 TOTH~
: d.o. I ~~ 11-9-11
: SIGNAT E OF CERTIFIED WELL CONTRA~ DATE
: Rager L Williams
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL .
Submit within 30 days of completion to: Division of Wate.r Quality -Information Processing,
1617 Mall Service Center, Ralelgh, NC 27699-181, Phone : [phone]
Form GW-1 b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCITON RECORD
Nonh Carolina Department of Environment and Natural Resources• Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2185-A -----------
1. WELL CONTRACTOR:
Stan ley K. Setzer
Well Contractor (Individual) Name
Mid South Geoth erma l
Wall Contractor Company Name
8275 Tourn ament Or ,
Street Addrus
Memphis I n 38125
City or Town State Zip Code
(90 1 > 748-9095
Area coda Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WIQ 100141 ~~~~~~-----
OTHER ASSOCIATED PERMIT#(if ~pllcable) _______ _
SITE WELL 10 #(If applicable) H-5 ~~---------
i . WELL USE (Checl< One Box) Monitoring □ Municipal/Public □
lndusbial/Commerclat □ Agricultural □ Recovery □ Injection □
Irrigation□ other l!f' (list Ula) Closed Looo Geothera
DATE DRILLED_,1...,1_-4_,_-_.1_.1 ___ _
4, WELL LOCATION:
1166 lotla Church Rd
{Street Name. Number&, Community, Subdivilllon, Lot No .. Parcel , Zip Code)
c1rv: Franklin couNrv Macon
TOPOGRAPHIC I LANO SETTING: (c'1eck appropriate box)
□Slope □Valley it'Aat □Ri dge □Other ______ _
LATITUDE ~ ---· OMS OR 3x.xxxxxxxxx OD
LONGITUDE~------' OMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: ():.PS Dropographie map
(/ooa/ion of well must be shown on a USGS topo map andatteched to
thia form If not using GPS)
15. FACILITY (Name of the buslneaa where the well is located.)
Macon Elementary Schoof
Facility Name Facility ID# (if applicable)
1166 latla Church Bd
Strltet Addreu
Franklin NC 28734
City or Town State Zip Code
Macon County Government
Contact Name
Melling Address
Eraoklio NC 26734
City or Town State Zip Code
._ _ _,) ---------
Area coda Phone number
6. WELL DETAILS:
a, TOTAL DEPTH:-'4_..,5...._1.._ ___ _
b. DOES WELL REPLACE EXtSTINO WELL? YES D NO f¥
e. WATER LEVEL Balow Top of Casing: ______ FT.
(Use •+• If Above Top of Casing)
: d. TOP OF CASINO IS Beronved FT. Above Land Surface*
•Top of casing terminated at/or below land surface may require
a vartanca In accordance with 15A NCAC 2C .0118.
! •. YIELD (gpm): _1 ... s .. o __ METHOD OF TEST Air Blow
: f, DISINFECTION: Type Amount ___ _
; g. WATER ZONES (depth):
: Top ___ Bottom~--Top ___ Bottom __ _
: Top ___ Bottom __ _ Top Bottom, __ _
: Top Bottom __ _ Top Bottom __ _
ThlckneH/
: 1. CASINO: D8i>th Diameter Weight Material
steel ~ Top.Jl_ Bottcm.Jl6__ Fl 6 5/8 ...2filL
: Top ___ Bottom ___ Ft. __ _
; Top ___ Bottom ___ Ft. __ _
: 8. GROUT: Depth Material
~ Top.Jl_ Bottom..Jgi_ Ft. Bentonjte
: Top...10.L_ Bottom..ASL_ Ft. washed stone
: Top_ Bottom ___ Ft. ____ _
Method
Pumped
Poured
; 9. SCREEN: Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft. __ ln. in. ____ _
: Top ___ Bottom ___ Ft. __ ln. In. ____ _
: Top ___ Bottom ___ Ft. __ in. in. ____ _
: 10. SAND/QRAVEL PACK:
: Depth Size Material
: Top. ___ .Bottom ___ ~----_______ _
; Top Bottom ___ Ft .. __________ _
: Top Bottom ___ Ft. __________ _
: 11 . DRILLING LOG
: Top Bottom
0 I 20
20 / 65
65 / 92
~9~2....._-'/_1~0 ... 0~--
100 I 142
142 I 150
150 I 280
280 I 320
320 I 451 __ _,! ___ _ __ ...,/ ___ _
: 12, REMARKS:
Formation Oesenptlon
Red Clay
Brown Clay
sandy sou
Sand Rock
Granite
Broken Rock
Granite
Soft Grantte
Granite
: I 00 HERESY 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
~~~~~,c:_.4 11:4-11
: SIG URE OF CERTIFIED WELL CONTRAc'fci'R"° DATE
: Stanley K Setzer
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -lnfonnatlon Processing.
1617 Mall Service Center, Raleigh, NC 27699-161, Phone: [phone]
Fom, GW-1b
Rav. 2/09
NON RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Department ofEnvironment and Natural Resources• Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2185-A
1. WEU. CONTRACTOR:
Stanley K. Setze r
Wefl Contractor (Individual) Name
Mid South Ge othermal
Weil Contractor Company Name
8275 Tournament Dr.
Stl'Vet Address
Memohi s
City or Town
1 901 l 7 48-9095
Area code Phone number
a, WELL INFORMATION:
Tn 38 125
State Zip Code
WELL CONSTRUCTION PERMIT# WIQ 100141 .......,...c.=.--'-=..=..c'---'-----------
OTHER ASSOCIATED PERMIT#{lf applic:able.,_ ______ _
SITE WELL ID fl{lf111ppllcable).~H~-6~A~--------
3. WELL USE (Check One Box) Monitoring □ Munlclpal/Public □
lndu11tri1111/Commercial □ Agricultural □ Recovery □ Injection □
Irrigation□ Other W(lllt u1e) Closed Looo Geothera
DATE DRILLED 10-31 -11
-'· WELL LOCATION:
1166 lotla Church Rd
(Street Name, Numbera , Community, Subdivial011, Lot No .. Parcel, l)p Code)
cITY: Franklin COUNTY Macon
TOPOGRAPHIC / LANO SETTING: (check appropriate box)
□Slope □Valley gl=lat □Ridge □other ______ _
l<@il$TCD 36_ l"M"ll""11 MMAj CL ROR JJ(~~)( cc
KNt.flSTCD 75 1""•"&1\Al\1\1\1\1\1\J CL R OR ]it.~~ cc
Latitude/longitude source: ~PS Oopographie map
(location of wall must be stiown on a USGS topo map and•lt•ched to
this form if not using GPS)
I . FACILITY (Name of the bu,lnen where the well 11 located,)
Macao Elementarv School
Facility NIJ'lla Facility 10# (If applicable)
1166 JotJa Church Bci
Street Address
franklin NC 28734
City or Town State Zlp Code
Macon County Government
Contact Name
Mailing Addras1
Eraoklio
City or Town
Area code Phone numbe r
8, WELL DETAILS:
a. TOTAL DEPTH:._,3..._6 ... 6 ____ _
NC 28734
State Zip Code
b. DOES WELL REPLACE EXISTING WEU? Y ES D NO r,
c, WATER LEVEL Below Top of C11ing: ______ FT.
(Use "+• If Above Top of Casing)
-----------
: d. TOP OF CASINO IS Removed FT. Above Land Surface•
"Top of ca11lng temiinated at/or below land ,urfaca may require
a variance In accordance With 15A NCAC 2C .0118.
~ •• YIELD (gpm): 100+ METHOD OF TEST Ajr Blow
; t. DISINFECTION: Type _____ Amount ____ _
; g. WATER ZONES (depth):
: Top ___ Bottom. __ _ Top ___ Bottom._ __
: Top ___ Bottom __ _ Top ___ Bottom. __ _
: Top Bottom. __ _ Top Bottom. __ _
; 7. CASING: Depth Diameter
Thicknese/
Weight Materiel
steel .j Top~ Bottom_fil_ Ft. 6 5/8
: Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft.. __ _
; 8 , GROUT: Oapth Material
~ Top~ Bottom~ Fl Bentonjte
.....2.filL
: Top~ Bottom....36.§_ Fl Washed stom
: Top ___ Bottom ___ Fl ____ _
: t. SCREEN: Depth Diameter Slot Size
Method
Pumped
Poured
Material
: Top ___ Bottom ___ Fl __ ln. In, ___ _
: Top ___ Bottom ___ Ft. __ ln. __ In . ____ _
: Top ___ Bottom ___ Ft. __ ln. In. ____ _ .
: 10. SAND/GRAVEL PACK :
: Depttl Size Material
: Top ___ Bottom ___ Ft.. ___________ _
:Top ___ Bottom ___ Ft . ._ _________ _
: Top ___ Bottom ___ Ft.. __________ _
: 11 . DRILLING LOG
Top Bottom
O 1..,2 ... 0 _____ _
20 /_7~1~--
70 /_,8.,..5:_ __
85 /_1...,5..,0 __
150 '~1~57~-
157 /_,34 ........ 5 __
345 /_,3..,6..,.6 __
I ---,----
----'--------'----
: 12 . REMARKS:
Formation Description
Red Clay
Brown Clay
sandy sou
Granjte
Broken Grani te
Granite
Granite Gravel
; J 00 HEREBY CERTIFY THAT THIS WEU. WAS CONSTRUCTEO IN ACCORDANCE Wini
• 1M NCAC 2C, WELL CONSTRUCTION STANDARDS. ANO THAT A COPY OF THIS
; RECORD HAS BEEN PROVIOB:> TO THE WELL OWNER.
i f~-fi -1;'• .,· _,~ :z:r.=-10-31-11
: SIGNA URE OF CERTIFIED WELL CONTRA1,;1 OR DATE
: Stanley K Setzer
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality • Information Processing,
1817 Mall Service Center, Raleigh, NC 27699-161 , Phone: (919) 807.f300
FormGW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources. Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 1185-A
1. WELL CONTRACTOR:
Stanley K. Setzer
Well Contractor (lndlVidual) Name
M id South Geothermal
Well Connctor Company Name
82 75 Tourn ament Dr.
Strwet Address
Memph is
City or Town
1901 > 748-9095
Area code Phone number
2. WELL INFORMATION:
In 38 125
state Zip Code
WELL CONSTRUCTION PERMIT# WIQ 100141 -'-"--=--'-=-~--'-'---------
O THE R ASSOCIATED PERMIT#(if applicable) _______ _
SITE WELL ID #{if applicable)~H~-6--=· =B"----------
3. WELL USE (Check Ona BoK) Monitoring □ Municipal/Public □
lndu,trtal/Commerclal □ Agricultural □ Rec;overy □ Injection □
Irrigation□ Other !W(li•t UH) Closed Looo Geothera
DATE DRILLED_.1_.1_-j.,_-__.1 ...... 1 ___ _
4. WELL LOCATION :
1166 lotla Church Rd
(Street f"'ame, Numbe,a, Community. SubdiVlaion, Lot No., Parcel, Zip Code)
c1TY: Franklin couNTY Macon
TOPOGRAPHIC I LAND SETTING: (check appropriate b()x)
□Slope □Valley iii(Ftat ORldga □other ______ _
K@i/STCO 36_ ,.A .. A$AAAAAAAAf CL R OR 3JC!'>fl0(~ cc
1<NM"ISTCD75 IAAAA&AAAAAAAAI CLROR h~~ cc
L-aiitud•llongitude souree: [)3PS Qropographlc map
(location of w•II must~ shown on • USGS lopo map ftlldettach~ to
this form if not using GPSJ
5. FACILITY (Name at the bus lnQ■ Where the well is located.)
Macon Elementarv School
Facility Name Facility ID# (if applicable)
1166 latla Church Rd
Street Address
franklin NC 28734
City or Town State Zip Code
Macon Countv Government
Contact Name
Mailing Addresr;
Ecaoklia NC 28234
City or Town State Zlp Code
Area code Phone number
8 . WELL DETAILS:
a. TOTALDEPTH:.~8_9 _____ _
b, DOES WELL REPLACE EXISTING WELL? YES D NO r.-1
c. WATER LEVEL Below Top at Casing: 70 FT.
(Use •+• If Above Top of Casing)
-----------
: d. TOP OF CASINO IS Removed FT. Above Land Surface·
: •Top of c111,lng terminated at/or below land surface may raqulre
a varlanea In accordance With 1 SA NCAC 2C .0118.
: •. v1ELD (gpm): ____ METHOD o, TEST Air Blow
; f. DISINFECTION: Typ• Amount ____ _
; g. WATER ZONES (depth):
:Top ___ Bottom. __ _ Top ___ Bottom,._ __ _
;Top. ___ Bottom. __ _ Top Bottom __ _
: Top Bottom,._ __ _ Top Bottom,_ __
Thlcknna/
; 7. CASINO: Depth Diameter Weight Material
j Top.JL_ Bottom ___ Ft. 6 5/8 ....250.. steel
: Top ___ Bottom ___ Ft. __ _
; Top ___ Bottom ___ Ft. __ _
: 8. GROUT: Depth Mat■rlal
~ Top.JL_ Bottom-89__ Ft. Bentonjte
Method
Pumped
; Top ___ Bottom ___ Ft.. ____ _
: Top ___ Bottom ___ Ft.. ____ _
; I. SCREEN: Depth Olametar Slot Size Material
: Top ___ Bottom ___ Ft. __ ln. __ in. ____ _
: Tap ___ Bottom ___ Ft. __ ln. __ In. ____ _
j Top ___ Bottom ___ Ft. __ ln. In. ___ _
: 10. SAND/GRAVEL PACK:
: Depth Size Material
: Top ___ Bo.ttom ___ Ft._ _________ _
: Top. ___ .Bottom ___ Ft. __________ _
: Top ___ .Bottom ___ Fl __________ _
: 11 . DRILLING LOG
Top Bottom Formation DescripUon
O /_.2'""0'----Red Clay
20 l_..7...,.0'----Brown Clay
70 '-8~9~--sandy Soil ___ ./ ___ _
----'----___ / ___ _
----'--------'-------'----___ / ___ _ ____ / ___ _
: 12. REMARKS:
: I DO ME.REBY CERTIFY THAT THIS waL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 20, WB.l CONSTRUCTION STANDARDS, ANO THAT A COPY OF THIS
: RECORD HAS BEEN PROVIDED TO Tl-IE wru OWNER.
: i:4
~C....-,K c:;,..../7 11-1-11
: SIGNAi'tJRE OF CEFfi'IREO WELL CONTRA~ DATE
: Staolev K Setzer
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completlon to: Division of Water Quality -Information Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1b
Rev. 1/08
NON REsmENTIAL WELL coNsTRucnoN REcoRD
North Carolina Department ofEnvironment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2185-A
1. WELL CONTRACTOR:
Stanl ey K. Setzer
Well Contractor (Individual) Name
Mid South Geothermal
Wall Contractor Company Name
8275 Tournament Dr.
Streat Addren
Memohis T n 38 125
City or Town State Zip Code
1901 l 748-9095
Area coda Phone number
2, WELL INFORMATION :
WELL CONSTRUCTION PERMIT# WIQ 100141 ~~~~~~------
OTHER ASSOCIATED PERMIT#(if applicable), ________ _
SITE WELL ID #(ii appllcab4e),~H~-~7~A~--------
3. WELL USE (Check One Box) Monitoring □ Munlclpal/Publlc D
Industrial/Commercial □ Agricultural □ Reeovery □ Injection □
Irrigation□ Other W (li1t use) Closed Looo Geothera
DATE DRILLED 10-26-11
4. WELL LOCATION:
1166 lotla Church Rd
(Street Name, Numbers, COmmunity, Subdlviafon, Lot No., Parcel, Zip Code)
c1TY: Franklin couNTY Macon
TOPOGRAPHIC I LAND SETTING; (Check approprtata box)
□Slope □Valley i{Frat □Ri dge □other ______ _
~CD 36_ IAMA&AAAAA'\I\AI CL ROR ax~~ cc
!<N'-f 1$TCD 75 1AAAA&AAAAAAAAI CL R OR ~~lUl(,t')()()(-cc
Latiludellonglt\J de source: Q:;PS OT'opographle map
(location of well mu$t be $hown on a USGS Iopa map endettec:hed lo
th/$ form if not u$/nQ GPS)
I. FACILITY (Name of the business where the well ls located .)
Macon Elementary School
Facility Name Facility ID# (if applicable)
1166 lotla Chmch Rd
Street Address
franklin NC 28734
City or Town State Zip Code
Macon County Government
Contact Name
Mailing Address
Franklin NC 28734
City or Town Stal& Zip Code
Area code Phone number
e. WELL DETAILS:
•· TOTAL DEPTH:, .. 3...,3.,.0...,' ____ _
b. DOES WELL REPLACE EXIS'TINO WELL? YES O NO u/
e. WATER LEVEL Below Top af Casing: -----~fT.
(Use·+· if Above Top of Casing)
------------
: d. TOP OF CASINO IS Removed FT. Above Land Surface•
· •Top of cas ing terminated al/or below l and surface may require
a variance in accordance with 15A NCAC 2C .0118.
: e. YIELD(gpm): ____ ME™ODOFTEST Air Blow
; r. DISINFECTION: Type Amount ____ _
: g, WATER ZONES (depth):
: Top ____ Bottom ___ _ Top ____ Bottom. ___ _
: Top. ____ Bottom ___ _ Top Bottom. ___ _
: Top Bottom ___ _ Top Bottom. ___ _
: 7. CASINO: Depth Diameter
j T0p...o__ Bottom-6a_ Ft 6 5/8
; Top ___ Bottom ___ Ft __ _
: Top ___ Bottom ___ Ft .. __ _
: 8 . GROUT: Oepltl Material
: Top...o__ Bottom_wt_ Ft. bentonite
Thickness/
Waight
~
Material
steel
~ Top...aa.._ Bottom..3J.O_ Ft. washed stone
M•ttiod
pumped
poured
: Top ___ Bottom ___ Ft. ____ _
: 9. SCREEN: Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft. __ ln. ln. ____ _
: Top ___ Bottom ___ Ft. __ in. 1n. ____ _
: Top ___ Bottom ___ A . __ in. In. ____ _
: 10. SAND/ORAVEL PACK:
; Depth Size Material
: Top ___ Bottom ___ FL. __ _
: Top Bottom ___ Ft.. ___________ _
: Top Bottom ___ Ft.. ___________ _
: 11. DRILLING LOG
Top Bottom Formation Description
---'----___ / ___ _
----'----___ / ___ _
I ---,----
/ ---',----
/ ---,.----___ / ___ _
; 12. REMARKS:
: I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WI™
: 151\ NCAC 2C, WELL CONSfflUCTlON STANOAADS, ANO THAT A COPY OF THIS
, RECORD HAS SEEN PROVIDED TO THE WEU. OWNER.
: •t., ), -z : o ... ., -<'. z__ -· 10-26-11
: SIGNATURE OF CERTIFIED WELL CONTRAC"'roR DATE
: Stant ev K Setzer
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality ~ Information Processing,
1817 Mall Service Center, Raleigh, NC 27899-161, Phone: [phone]
Fonn GW-1b
Rev, 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Department of Environment and Natural Resources• Division ofWntcr Qunlity
WELL CONTRACTOR CERTIFICATION# 2 185-A
1. WELL CONTRACTOR;
Stanl ey K. Setzer
Well Contractor (Individual) Name
Mi d Sou th Geot herm al
Well Contractor Company Name
8275 Tourname nt Dr.
Street Address
Memphis
City or Town
, 901 > 7 48-9095
Area coda Phone number
2. WELL INFORMATION :
T n 3812 5
State Zip Code
W l:LL CONSTRUCTION P ERMIT# Wl0100141 -'"-'--'-=-"-=-'""--..:.-..------
0 THE R ASSOCIATED PERMIT#(ifapplicable,_ ______ _
SfTE WELL ID #(if appllcable).-'-H-'-•-'7-=B=-----------
3, WELL use (Check One Sox) Monitoring □ MunlclpalJPubllc o
lnduatrial/Commercfal □ Agricultural □ Recovery □ Injection □
lmgatlono Other LV(llat UH) Closed Looo Geother ■
DATE DRILLED_.1...,1 .... -21-_1'-'1,..._ __ _
4. WELL LOCATION:
1166 lotla Church Rd
(Street Neme, N1Jmbers. Community, Subc!Msion, Lot No .• Parcel, Zip Cade)
c 1TY: Franklin COUNTY Macon
TOPOGRAPHIC / LAND SETTING: (check awroprfsle box)
□Slope □Valley ii'flat □Ridge □Other ______ _
K@/$TCD 36_ 1•• .. ct•AA•AA .. I CL R OR 3JC!')tJUIO(~)f)I cc
KNfvf'ISTCD75 1•A .. ,!M .. •M•I C L ROR ~-'>OClUI~ cc
Lati1ude/longlt1Jde sourai: [J3PS Qropographlc map
(/oc.tlon of well must be :.hown on • LJSGS topo map andattached to
this form if not using GPS)
5, FACILITY (N ame of the b1J1ineas where the well Is located.)
Maron Eleroentarv School
Facility Name
1166 lotla Church Rd
Street Address
franklin
City or Town
Macon County Government
Contact Name
Malling Address
Franklin
City or Town
ma code Phone number
e. WELL DETAILS:
a. TOTAL DEPTH :.__,,.12_0 ____ _
Facility ID# (if applicable )
NC 28734
State Zip Code
NC 28734
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES O NO f¥
c. WATER LEVEL Below Top of Casing: 70 FT.
(Uae "+" if Above Top of Casing)
-----------
; d. TOP OF CASINO IS Removed FT. Above Land Surface•
: •Top of easing terminated at/or below land surface may require
: a variance In accordance with 1 SA NCAC 2C .0118.
: e . YIEL.D (gpm): ----METHOD OF TEST Ajr Blow
: f. DISINFECTION : Type Amount ____ _
: g. WATER ZONES (de pth):
: Top ___ Bottom __ _ Top ___ Bottorn __ _
: Top _____ Bottom __ _ Top Bottom __ _
: Top Bottom __ _ Top Bottom. __ _
Thtckneu/
: 7. CASINO: Depth Di•meter Weight Material
steel ~ Top.JL._ Bottom....aL__ Fl 6 5/8
: Top ___ Bottom ___ Ft.. __ _
; Top ___ Bottom ___ Ft.. __ _
: 8 . GROUT: Depth Material
~ TopJL__ Bottom_BZ__ Fl Bentonite
~
: Top.JU._ Bottom...120_ Ft. washed stone
: Top ___ Bottom ___ Ft. ____ _
; 9. SCREEN: Depth Di.meter S lot Size
Method
Pumped
poured
M•terlal
: To p ___ Bottom ___ Ft. __ in. ln. ____ _
: Top ___ Bottom ___ Ft. __ in. __ ln. ___ _
: Top ___ Bottom ___ Fl __ ln. in. ____ _
: 10. SAHD/ORAVEL PACK:
: Depth Size Material
: Top ___ Bottom ___ Ft. __________ _
; Top ___ .Bottom ___ Ft.. __________ _
: Top ___ .Bottom ___ Fl. __________ _
; 11. DRILLING LOG
Top Bottom
0 /....,2 ... 0....._ __
20 / __ 7 ... 0....._ __
70 /_9~0 __
90 /_1 ... 2 ... 0 __ ___ ./ ___ _
I --------__ -'/ ___ _ ___ / ___ _
---'----___ / ___ _
----'----
: 12. REMARKS:
Formation Description
Red Clay
Brown Clay
sandy Soil
Granite
: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
: 16A NCAO 2C, wru CONSTRUCTION STANDARDS, AND THAT A COPY OF-"!)1IS
; RECORO HAS BEEN PROVIDED TO THE WEU. OWNER.
:/.4 '-i' / L c..__ -· 11-2-11
: SIGN,._l'U RE OF CE RTIFIED WELL CONTRACTOR DATE
: Stanley K Setzer
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit with in 30 days of completion to: Division of Water Quality -Information Proces.slng,
1817 Mall Service Center, Raleigh, NC 27699-181, Phone ; [phone]
Form GW•1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION I# 2185-A. -----------
1. WELL CONTRACTOR:
Sta nley K. Setze r
Well Contractor (lndlvldual) Name
Mi d South Geothe rmal
Wall Contractor Company Name
82 75 Tournament Dr.
Street Addren
Memphis Io 381 25
City or Town State Zip Code
(901 l 748-9095
Area code Phor:,e number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#_,_W..:...:..:::10'-'1""'0=0:....:1'-'4:....:1'-------
0THER ASSOCIATED PERMIT#(lfappllcable) _______ _
SITE WELL 10 #(ii appllcable)..,_H..:..·--=8'----------
3. WELL USE (Check One Box) Monitoring □ Municipal/Public D
l nduelrial/Commerclal □ Agricu ltural □ Recovery □ Injection □
lnigationo Other ilf (t11t UH) Closed Looo Geothera
DATE DRILLED 10-24-11
4. WELL LOCATION:
1166 lotla Church Rd
(Street Name, Numbers, Community, SubdMsion , Lot No., Parcel , Zip Code)
cITY: Franklin COUNTY Macon
TOPOGRAPHIC / LANO SETTING: (check appropriate box)
□Slope □Valle~ .(Flat □Ridge □Other ______ _
K@ISTCO 36_ 1 A•A<&AAA,MAAI CL R OR 3JC~~ cc
t<Nl'vFISTC075 ,AA••&AAAAAAAAI CL ROR 7->t.~ cc
latitude/longitude source: [)3PS Dropographlc map
(location of well must be shown on II USGS topo map andetteched to
this form If not ua/ng GPS)
a. FACILITY (Name of Iha bu1lnBA where the well le located.)
Macon Elementary School
Facility Name
1166 lcUa Church Rd
Streat Addreu
franklin
City or Town
Macon County Government
Contact Name
Malling Address
Ecaoklio
City or Town
Area code Phone number
I. WELL DETAILS:
a. TOTAL DEPTH:,_4_..5..,0..,' ____ _
Facility ID# (ff appllcabla)
NC 28734
State Zip Code
NC 28734
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES D NO~
c. WATER LEVEL Balow Top of Casing: 70 FT.
(Usa •+• If Above Top of Casing)
: d. TOP OF CASINO IS Removed FT. Above Land Surface·
-r op of casing terminated al/or below lend surface may require
a variance In accordance with 15A NCAC 2C .0118.
[ e . YIELD (gpm): _1.._0..,0 ___ METHOD OF TEST Ajr Bfow
: f. DISINFECTION: Type Amount ____ _
: g. WATER ZONES (depth):
~ Top 70 Bottom 450 Top ___ Bottom. __ _
: Top ___ Bottom. __ _ Top Bottom __ _
: Top ___ Bottom. __ _ Top Bottom.._ __ _
Thickness/
: 7. CASINO: Depth Diameter Weight Material
~ Top_Q__ Bottom....a2.__ Ft. 6 5/8 .....2..50_ steel
: Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft. __ _
: 8. GROUT: Depth Material
i Top_Q__ Boltom_BL_ Ft. bentonite
: Top...81__ Bottom~ Ft. washed stone
: Top ___ Bottom ___ Ft.. ____ _
; 9. SCREEN: 0.pth Diameter Slot Size
Method
pumped
poured
Material
: Top ___ Bottom ___ Ft. __ ln. In. ___ _
: Top ___ Bottom ___ Ft. __ ln. __ In. ___ _
: Top ___ Bottom ___ Ft. __ ln. In. ____ _
: 10. SAND/ORAVEL PACK:
: Depth Size Material
: Top ___ Bottom ___ Ft. __________ _
; Top ___ Bottom ___ Ft. __________ _
: Top __ -'Bottom ___ Ft. __________ _
: 11 . DRILLING LOG
Top Bottom
O '~3_0 __ _
30 /...,7..,.8 ____ _
78 /_1._.9 ... 5 __ 19s ,.....;4..,s .. o __
---''-------'-------'-------''----__ _,/ ___ _
----'--------'----
: 12. REMARKS:
Formation Description
Red C!ay
Brown Clay
Mixture of soft and hard granite
Blue granite
~ Hit water with broken ,ock@145' to 155'
: I DO HERESY CERTIFY THAT THIS WEU. WAS CONSTRUCTED IN "CCOROANCE WITH
• 16A NCIIC 20, WEU. CONSTRUCTION STANDARDS, ANO THAT A COPY Of nus
: RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
: ~ 7 ,<'-L, < -10-24-11
: SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
: Stanley K Setzer
; PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -tnronnatlon Processing,
1617 Mall Service Center, Raleigh, NC 27899-161, Phone : (919) B07-6300
Form GW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depanment of Environment and Natural Resour~s-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3065-A
1. WELL CONTRACTOR:
Roger L WIiiiams
Well Contractor (Individual) Name
T arheet Water Treatment
Well Contractor Company Name
3494 Georgia RD
Street Addrtst
Franklin NC 28734
City or Town Slate Zip Code
( 828 I 369-0740
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WIQ 100141 ~~~~~~-----
0 THE R ASSOCIATED PERMIT#(lf applicable), _______ _
SITE WELL ID #{if appllcable),~1--1~A~--------
3, WELL USE (Chac:k One Box) Monitoring D Munlcipal/Publlc O
Industrial/Commercial O Agricultural O Recovery O Injection O
Irrigation □ Other •<list uae) Closed looo Geotherra
DATE DRILLED 11-1 0-11
4. WELL LOCATION:
1166 Lotla Church Rd
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
c1TY: Franklin COUNTY Macon
TOPOGRAPHIC / LANO SETTING: (cheok appropriate bo,c)
□Slope □Valley iirt'lat □Ridge □Other ______ _
~TCD 36_ l""""!IIAMMM( CLROR 3XN4)UO(~ cc
l<Nt.'FISTCD 75 1""'"!"""''"""! CL ROR h~~ CC
Latltudanongltude source: 03PS Of'opographlc: map
(locatlon of well mu1Jt b& 1Jhown on • USGS topo map 11nd11ttached to
thi$ l'onn If not u/Jlng GPS)
5. FACILITY (Name of the bu•lnesa Where the well is located.)
Macon Eleroeotacv
Facility Name Faclllty 10# (If applicable)
1166 Latia Church Rd
Streat Addrese
franklin NC 28734
City or Town State Zip Code
Macon Gcuotv Government
Contact Name
Mailing Address
Ecaoklio
City or Town
( >-,---------Area code Phone number
&. WELL DETAILS:
a. TOTAL DEPTH:._,3"""8""'3...___ ___ _
NC 28743
State Zip Coda
b. DOES WELL REPLACE EXIS11NO WELL? YES O NO ry
o. 'NATER LEVEL Balow Top of Casing: 1"° 0 FT.
(Use•+• If Above Top of Ca ■lng)
-----------
: d. TOP OF CASINO IS _____ FT. Above Land Surface•
: .,.op (I'! casing l!!rmlnated al/or below land surface may r~ulre
: a vartanc:e In accordance with 15A NCAC 2C .0118.
: •• YIELD (gpm): 70 METHOD OF TEST Blow Down
~ f. DISINFECTION: Type HTC Amount 12 OZ
; g. WATER ZONES (depth):
: Top Bottom Top ___ Bottom._ __ _
; Top Bottom Top ___ Bottom. __ _
: Top Bottom Top ___ Bottom __ _
Thlckneu/
: 7, CASINO: Depth Diameter Weight Material
! Top....Q._ Bottom..11.ll_ Ft. __ _
: Top ___ Botlorn_ Ft. __ _
: Top ___ Bottom ___ Ft. __ _
: 8. GROUT: Depth Metartat
~ Top....Q._ Botlom__jjL Fl. Bentonite
: Top...11L Bottom..Jaa_ Fl. washed stone
: Top ___ Bottom ___ Ft. ____ _
: 9. SCREEN: Depth Diameter Slot Siu
Method
Pumped
poured
Material
: Top ___ Bottom ___ Ft. __ ln. __ in. ____ _
: Top ___ Botlom ___ Ft __ in, __ in, ___ _
; Top ___ Bottom ___ Ft. __ ln. __ in. ____ _
: 10. SAND/ORAVEL PACK:
D•pth Siz.e Meteri•I
: Top. ___ Bottom_ Ft. __________ _
: Top ___ Bottom ___ Ft. __________ _
: Top. ___ Bottom_Ft. __________ _
: 11. DRILLING LOG
: Top Bottom
0
82
110
375
I 82
/ 110
I 375
I 383 ____ / ___ ,----
/ ---,.----____ / ___ _
--~'----___ , ___ _
: 12. REMARKS: l Casi119 Removed
Formation Dnc:riplion
Sand Clay
Broken Rock
Granite
Broken rock 70 GPM
: IOOHER THATTHISWELL STRUCTEOINACCORDANCEWlni
• 1tlAN ,ANOTHATACOPVOFTHIS
: RECO ER.
==4µ}1~~~*-~~~;::;: 11-10-11
: SIG N~AcTOR DATE
: Boaec I Williams
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Subrnlt within 30 days of completlon to: Division of Water Quality-lnfonnaUon Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1b
Rev. 1/08
l1
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Naturol Resources-Division of Waler Quality
WELL CONTRACTOR CERTIFICATION I# 3065-A
1 , WELL CONTRACTOR:
R oger L W illiam s
Well Contractor (Individual) Narne
Tarheel Wa te r Tre atment
Well Co111ractor Company Name
3494 Georgia RD
Street Address
Franklin NC 28734
City or Town State Zip Code
< 828 > 369-07 40
Area code Phone number
2. WELL. INFORMATION:
WELL CONSTRUCTION PERMIT# WfO 100141 ·~~~~-'-'-~------
OTHER ASSOCIATED PERMIT#(if applicable)'---------
SITE WELL ID #(JI applicableJ,~l--1~8~---------
J. WELL USE (Check One Box) Monitoring □ MunicipaVPublic □
Industrial/Commercial □ Agricultural □ Recovery □ Injection □
Irrigation□ Other llt'(H1t use) Closed looo Geotherra
DATE DRILLED 11 -1 0-11
,. WELL LOCATION:
1166 Latia Church Rd
(Street Name. Numbers, Community, Subdlvislol'I, Lot No., Parcel, Zip Code)
c11Y: Franklin couNTY Macon
TOPOGRAPHIC I LAND SETTING: (checll appropriate bo~)
□Slope □Valley .{Flat □Ridge □Other ______ _
l<@,ISTCD 36_ IAAAA&11 "'1111 •••1 CL R OR 3JCNO(JOC~ll cc
l<NM'" ISTCD 75 1•"'11 &•11 M 11 • .. , CL R OR 1'lt~'-~ cc
Latitude/longitude aouree: [)JPS Dropographlc; map
(location ofwe/1 must be shown on• USGS topo map endstteof!ed to
this form If not using GPS)
5. FACILITT (Name of the business where the well la located.)
Macon Elementary
Facility Name Facility 10# (If applicable)
1166 I otfa Cbuccb Rd
Streat Address
Franklin NC 28734
City or Town State Zip Coda
Macon County Govemment
C011taet Name
Mailfng Address
Ecaoklio NC 28743
City or Town State Zip Code
Area code Phone number
8. WELL DETAILS:
a. TOTALDEPTH:~6 ....... 7 ____ _
b, DOES WELL REPLACE EXISTING WELL? YES D NO f¥
c. WATER LEVEL Balow Top of Casing: @$# FT.
(Use•+• if Above Top of Casing) I
------------
: d. TOP OF CASINO IS _____ FT. Above Land Surface•
; 'Top of easing terminated at/or below land surface may require
: a variance In accordance with 15A NCAC 2C .0118.
: •· YIELD (gpmt: O METHOD OF TEST Blow Down
~ r. DISINFECTION: Type HTC Amount 12 OZ
: g. WATER ZONES (depU,):
: Top ____ Bottom __ _ Top ___ Bottom._ __ _
; Top Bottom __ _ Top Bottom, ___ _
: Top Bottom, ___ _ Top Bottom, ___ _
ThlckneHI
; 7. CASINO: Depth Diameter Weight Material
\ Top_Q__ Bottom_6L_ Ft., __ _
: Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft., __ _
: 8 . GROUT: Depth Materlal
~ Top_Q__ Bottom-6L,_ Ft. Bentonjte
; Top ___ Bottom ___ Ft .. _____ _
; Top ___ Bottom ___ Ft. ____ _
Method
Pumped
: t . SCREEN: Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft. __ ln. In. ____ _
: Top ___ Bottom ___ Ft. __ ln. In. ____ _
: Top ___ Bottom ___ Ft. __ in. In. ____ _
: 10. SAND/GRAVEL PACK:
: Depth Size Material
: Top, ___ Bottom ___ Ft.. __________ _
: Top ___ Bottom ___ Ft,. ___ ---------
: Top Bottom ___ Ft ________ _ ------
: 11 . DRILLING LOG
: Top Bottom
0 I 67
---'.----____ / ___ _ ____ / ___ _
---'-----/
---·'----/ ---,----
---''----___ / ___ _
: 12. REMARKS:
: Casis 19 Ren,oved
Formation Deacrtptlon
Sand Cla y
: t 00 H£/WIY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A HATA COPY OF 'OilS
; RE
11-10-11
DATE
: Roger L Williams
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit withlo 30 days of completion to: Division of Water Quality -lntonnatlon Processing,
1617 Mall Service Center, Raleigh, NC 27899-161, Phone: [phone]
Form GW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTD'ICA TION # 1185-A
1. WELL CONTRACTOR:
Stanley K. Setzer
Well Contractor (Individual) Name
Mid South Geothermal
Wall Contractor Company Name
8275 Tournament Dr.
Street Address
Memphis Tn 38125
City or Town State Zip Code
< 901 > 7 48-9095
Area c.oda Phone number
2 . WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WIQ100141 ........ .....=....a...=..=-a.-'--'-------
OTHER ASSOCIATED PERMIT#(tr applicable) _______ _
SITE WELL 10 #(ii appUcable)_,_1--"7 _________ _
3. WELL USE (Checl< Ona Box) Monitoring O MunlclpaliPUbllc O
lndu1tr1aVCommareial □ Agricultural □ Recovery □ Injection □
lnrigation□ Other nfc11stusa) Closed Looo Geothera
DATE DRILLED 10-28-11
4 . WELL LOCATION;
1166 lotla Church Rd
(Street Name, Number$, Community, SubdM1ion, Lot No .. Parcel, Zip Code)
c1rv: Franklin couNrv Macon
TOPOGRAPHIC/ LANO SETTING: (cllecl< ■PPIOPriate box)
□Slope □Valley iit!=la1 □Ridge □other ______ _
K@,ISTCO 36_ 11\MA.tAMMAAIIJ CL ROR ax~~ cc
KNll.f"ISTCO 75 1•111111 &1111111111111111 1 CL ROR h.~~ CC
Latl!Ydallongil\4de •ource: [)3PS Qropographlc map
(location of wall must be shown on • USGS topo m11p andattech&d to
thie form if not using GPS)
5. FACILITY (Name of the buaineH where the well is located.)
Mamo Elementarv School
Facility Name
1166 lntla Church Rd
street Address
Eraoklio
City or Town
Macao Cmmtv Government
Cont.ct Name
Malling Addrau
Ecaoklio
City or Town
( \ ________ _
Area ooda Phone number
S. WELL DETAILS:
a. TOTAL DEPTH:_4.,.5,...0..._ ___ _
Facility 10# (if applicable)
NC 28734
State Zip Code
NC 2B734
State Zip Coda
b. DOES WELL REPLACE EXISTING WELL? YES Q NO f3/
c. WATER LEVEL Balow Top of Casing; -----~FT.
(Use •+· If AboVe Top of Casing)
-----------
: d. TOP OF CASING IS Removed FT. Above Land Surface•
•Top of casing terminated-et/or below land surface may require
a variance In accordance With 15A NCAC 2C .0118 .
i e. YIELD (gpm): _.2 ____ METHOD OF TEST Ajr Blow
: f. DISINFECTION: 1VPe Amount ____ _
: g. WATER ZONES (depth):
: Top ___ Bottom. __ _ Top ___ Bottom __ _
;Top ___ Bottom. __ _ Top Bottom __ _
: Top Bottom. __ _ Top Bottom __ _
Thlckneu/
: 1. CASINO: Deptl't Diameter Weight Material
steel ~ Topi__ Bottom--6,Q__ Ft. 6 5/8
: Top ___ Bottom ___ Ft.. __ _
: Top ___ Bottom ___ Ft .. __ _
: 8. GROUT: Oepth Material
~ Top.Jl_ Bottom..l.Q._ Ft. Bentonjte
_.25.Q_
: Top__-m_ Bottom..!5.Q_ Ft. washed stone
: Top ___ Bottom ___ Ft.. ____ _
: t, SCREEN: Depth Diameter Slot Size
Method
Pumped
poured
Material
: Top ___ Bottom ___ Ft ___ in. __ In. ____ _
: Top ___ Bottom.._ __ Ft._ln. __ In. ____ _
: Top ___ B<>ttom_Ft. __ ln. __ In. ____ _
: 10, SAND/GRAVEL PACK:
: Depth Size Material
: Top ____ Sottom_ Ft.. __________ _
: Top. ___ .aottom ___ FL __________ _
j Top ___ Bottom__ Ft. __________ _
: 11. DRILLING LOG
Top Bottom
O 1~2=0 __ _
20 '~6~9 __ _
69 /...,8 .. 2......__ __
82 /_1...,5_2 __
152 '~1=62~-162 /_45....,..0 __ ____ / ___ _
---~----
----'-------'----
: 12. REMARKS:
Formation Oaseliption
Red Clay
Brown Clay
sandy Soil
Granite
Broken Granite
Granite
: I 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 1M NCAC 2C, WELL CONSTRUCTION STANOAROS, ANO TNAT A COPY OF THIS
; RECORO HAS BEEN PROVIDED TO THE WaL OWNER.
: ./L I • : .....---L C......-:Z: .. 10-28-11
: SIGNATURE OF CERTIFIED WELL CONTAA~ DATE
: Stanley K Setzer
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality. lnfonnatlon Processing,
1617 Mall Service Center, Raleigh, NC 27899-181, Phone: [phone]
Form GW-1b
Rev. 1/08
NON RESIDENTIAL ~LL C~NSTRUCTION RECORD
North Carolina Deparunen1 ofEnvirorunenl and Natural Resources• Division of Waler Quality
WELL CONTRACTOR CERTIFICATI ON# 3065-A
1 . WELL CONTRACTOR:
Ro aer L William s
Well Contractor (lndlvldual) Name
Ta rh eel Wa ter Tre at ment
Well Contractor Company Name
3494 Georgi a RD
Street Address
Franklin NC 28734
City or Town State Zip Code
,828 > 369-0740
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WIQ100141 ..;....,...:.=..=..:....,'-'--'--------
0 THE R ASSOCIATED PERMIT#/~ applicable), _______ _
SITE WELL ID ~If appllcable),...,J'--"""1 ________ _
3. WEU. USE (Check One Box) Monitoring O Munlclpal/Publlc O
lnduatrial/Commerc:ial □ Agricultural □ Recovery □ lnjec:tion □
lrr~atlon □ Other l!f wst use) Closed loco Geotherra
DATE DRILLED 11 -11-11
<I. WELL LOCATION:
1166 Lotla Church Rd
(Street Name, Numbe!&, Community, Subdivision . Lot No .. Parcel, Zip Code)
c1TY: Franklin COUNTY Macon
TOPOGRAPHIC / LANO SETTING: (check appropriate box)
□Slope □Valley itflat □Ridge □other ______ _
1<@11STCD 3~ IMAA &AMI/I AM/lf CL R OR gJl(('lfXJ(~" cc
KNM=ISTCO 75 1•11 AA &/I/I/IAAA/III! CL ROR 7'lt.~AA?OOC> cc
Latil\.lda/longltude 50urce: C)3PS [Jfopographlc map
(locatlor, of well mu:,t be shown on • USGS topo map endetteched lo
this form If not using GPS)
Ii, FACILITY (Name oftha buslnes, where the well la located.)
Macon Elementary
Faclilty Name
1166 Latia Church Rd
Street Address
Franklin
City or Town
Macon Gouotv Government
Contact Name
Malling AddreH
Franklin
City or Town
'----') .,,-----------Area code Phone number
8 . WELL DETAILS:
a. TOTAL DEPTH:,_4=--5..,.O'-----
Faclllty 10# (If appli cable)
NC 28734
State Zip Code
NC 28743
State Zip Code
b. DOES WELL REPLACE EXISTING WELL 7 YES O NO f#
c, WATER LEVEL Below Top of Casing: 5 0 FT.
(Use •+· If Above Top of Casing )
-----------
: d. TOP OF CASING IS ______ FT. Above Land Surface•
'Top of casing term inated et/or below land surface meiy require
a variance In accordance wit/\ 1 SA NCAC 2C ,011 B.
: •. YlELO (gpmt: so METHOD oF TEST Blow Pewo
~ f. DISINFECTION: Type HTC Amount 12 az
: g. WATER ZONES (depth):
: Top. ___ Bottom. __ _ Top ___ Bottom, __ _
: Top ___ Bottom __ _ Top ___ Bottom. __ _
: Top ___ Bottom. __ _ TOP. Bottom. __ _
Thickness/
: 7. CASINO: Depth Diameter Weight Material
i Top.JL__ Bottom-11Q_ Ft. __ _
: Top ___ Bottom ___ Ft .. ___ _
: Top ___ Bottom ___ Ft .. ___ _
: B. GROUT; Depth Material
: TopJL_ Bottom~ ft. Benlonjte
: Top..1..1.§._ Bottom...4filL. Ft. washed stone
: Top ___ Bottom ___ Ft.. ____ _
Method
Pumped
poured
: 9 . SCREEN: Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft. __ ln. in. ___ _
;Top ___ Bottom ___ Ft._jn. __ In. ____ _
: Top ___ Bottom ___ Ft. __ ln, In. _____ ,
: 10, SAND/GRAVEL PACK:
: Depth Size Material
: Top. ___ Bottom ___ Ft .. ____________ _
; Top ___ Bottom ___ Ft. ____________ _
: Top. ___ Bottom ___ Ft •. __________ _
: 11 . DRILLING LOG
: Top Bottom
0
67
110
I 67
I 11 0
I 450
I
I
I
I
I
I
I
I
: 12. REMARKS:
: Casi! ,g Re, r ,oved
Formation Description
Sand Clay
Broken Granite
Granite
; 100 HERESY CeRTlFV THAT ffilS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A O THAT A COPY OF ffi!S
: RECO
i , 11-11-11
: SIG TRACTOR DATE
: Roger L Williams
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days-of completion to: Division of Water Quality -lnfonnatlon Processing,
1617 Mall Service Center, Raleigh, NC 27699-181 , Phone: [phone]
Form GW-1b
Rev. 1/08
h5
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Departmenr of Environment and Natural Resources• Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3065-A
1. WELL CONTRACTOR:
Roger L Williams
Well Contractor (Individual) Name
Tarheel Water Treatment
Well Contractor Company Name
3494 Georgia RD
Street Address
Franklin NC 28734
City or Town State Zip Code
< 828 > 369-07 40
Area code Phone r,umber
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#....:.W...:...:.;:I 0""'1""'0:..::Q:..:1'-'4'-'1'------
0THER ASSOCIATED PERMIT#(lf applicable) _______ _
SITE WELL ID #(if appflcable)..,_K-=---=5'-----------
:1.. WELL USE (Check One BoK) Monltollr,g O MUnleipal/Public 0
lndustrial/Commerclal □ Agricultural □ Recovery □ lnJectlon □
Irrigation□ Other llf (1111 use) Closed loop Geotherra
DATE DRILLED~l~1_-8_-~1~1 ___ _
4. WELL LOCATION:
1166 Lotla Church Rd
(Street Name. Numbers, Commu"lty. SubdMslon. Lot No .. Parcel. Zip Code)
c11Y: Franklin couNTV Macon
TOPOGRAPHIC I LAND SETTING: (oheok appropriate box)
□Slope □Valley itFlet □Ridge □other ______ _
K@ilSTCO 36_ 1""••&AA••••""I CL R OR 3kNUOO(~){ CC
l<N'-ftsrCD75 1••••a••,..•AA•1 CL ROR ~~~ cc
Latitude/longitude source: [)3PS OfopographJc map
(locetion of well must be shown on• USGS topo map andattached to
this form If not using GPS)
I. FACILITY (Name of the business where the well ls located.)
Macao Eleroeotarv
Facility Name Facility ID# (If applicable)
1166 Lotta Church Rd
Street Addreaa
Ecaoklio NC 28734
City or Town State , Zip Code
Macon County Gnyemmeot
Contact Name
Malling Address
Eraoklio NC 28743
City or Town State Zip Code
( )-,----,------
Area code Phone number
&. WELL DEtAJLS:
a. TOTALDEPTH:~4~5_0 ____ _
b. DOES WELL REPLACE EXISTING W£LL? YES O NO~
c. WATER LEVEL Below Top of Casing: ______ FT.
(Usa ••• if Above Top of Casing)
-----------
: d. TOP OF CASING IS _____ FT. Above Land Surface•
•Top of casing te1TT1ir,a-tad at/or below land surface may require
a variance in aceordanca with 15A NCAC 2C .0118.
: •• YIELD (gpm): 30 METHOD OF TEST Blow Down
~ f. DISINFECTION: Type HTC Amount 1? OZ
: g. WATER ZONES (depth):
: Top ___ Bottom'----Top'--__ Bottom. __ _
: Top Bottom~---Top Bottom. __ _
: Top Bottom. __ _ Top Bottom __ _
ThlckneN/
; 1. CASINO: D•pth Dlamotor W•lght M1torl1I
I Top_Q___ Bottom...19,L Ft. __ _
: Top ___ Bottom ___ Ft. __ _
: Top ___ Bottom ___ Ft. __ _
; 8, GROUT; Depth Material
~ Top_Q___ Bottom~ Ft. Bentonjte
: Top.2QO_ Bottom~ Ft washed stone
: Top ___ Bottom ___ Ft. ____ _
Method
Pumped
poured
: 9. SCREEN: Depth Dlamete1 Slot SID M■ter111I
: Top ___ Bottom ___ Ft. __ ln. In. ___ _
: Top ___ Bottom ___ Ft __ in. __ in, ____ _
: Top ___ Bottom ___ Ft. __ ln. In. ____ _
: 10,SA.NDIORAVEL PACK:
; Depth Size Material
;Top ___ Bottom ___ Ft. __________ _
: Top Bottom ___ Ft. __________ _
: Top Bottom_Fl'---_______ _
: 11 , DRILLING LOG
Top Bottom
~/~8=2~--
82 /_1_8~5 __
.... 1a5_/_4...,5...,0 __ __ _,/ ___ _ ___ / ___ _
---''----___ / ___ _ __ _./ ___ _ __ _./ ___ _ ___ / ___ _
---'----
: 12. REMARKS:
: Casi11g Rerr,oved
formation Oesqiptlon
Sand Clay
Broken Rock
Granite 30 GPM
: I DO HEREBY CERTIFY Tl-iAT THIS WEU. WAS CONSTRUCTED IN ACCORDANCE WITH
: 15A NCAC 2 CONSTRUCTION ST ANOARDS. AND THAT A COPY OF THIS
• RECORD EN PRO ED TO T.ca::.,,vi;u.,vW ER.
i , d H_ ,-____,,,,-c-_ 11-8-11
: SIGNA RE OF CERTIFIED WELL CONTRACTOR DATE
: Bcaer L Williams
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submtt within 30 days of completion to: Division of Water Quality -Information Processing,
1617 Mall Service Centet, Raleigh, NC 27699-161, Phone: [phone]
Form GW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 306S~A
1. WELL CONTRACTOR:
Roger L Williams
Well Contractor (Individual) Name
Tarheel Water Treatment
Well Contractor Company Name
3494 Georgia RD
Street Address
Franklin NC 28734
City or Town State Zip Code
, 828 > 369-07 40
Area code Phone number
2 . WELL INFORMATION:
WELL CONSTRUCTION PERMIT#~W~I0~1~0~0~1~4~1 ____ _
OTHER ASSOCIATED PERMIT#(if applicable), _______ _
SITE WELL ID #(If appllcable).~K~-~6=A~--------
3. WELL use (Check One Box) Monitoring □ Municipal/Public □
lndu1tl'ial/Commerciai □ Agricultural □ Recovery D lnjeetlon D
Irrigation□ Other "(Ult use) Closed looo Geotherra
DATE DRILLED.....,1_.1-'•3,._•_,,1_._1 ___ _
4. WELL LOCATION:
1166 Lotla Church Rd
(Street Name, Numbers, Community, SubdMslon, Lot No., Parcel, Zip Code)
c1TY: Franklin COUNTY Macon
TOPOGRAPHIC / LANO SETTING: (check approprlale box)
□Slope □Valley iitFlat □Ridge □Other ______ _
K@,1$TCO 3~ I AA AA&A••··•--1 CL R OR 3JC~)tXJ(J(~ll cc
1<N~tsrcD75 1 .. ••a•M• .. ••t CL ROR 7'.it~~ cc
Latitude/longttuda source: [)3PS Qropographlc map
(location of well must ~ shown on • USGS topo map andetteched to
this form If not using GPS)
5. FACILITY (Name of Iha buslneas Where the well ls located.)
Macon E!aroeotacv
Facility Nam. Facility 10# (If applicable)
1166 Lotla Church Rd
Street Address
franklin NC 28734
City or Town State Zip Code
Macon County Government
Contact Name
Mailing Addre11
franklin NC 28743
City or Town Stallt Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:_.2.,.0"'0..__ ___ _
b. DOES WELL REPLACE EXISTJNO WELL? YES □ NO~
c . WATER LEVEL Below Top of Casing: ______ .FT.
(Use ••• if Above Top ot Casing)
-----------
; d. TOP OF CASINB IS _____ FT.Above Land Surface•
: "Top of ca.Ing terminated aVor below land 1wmce may reql.llre
: a variance In accordance with 1SA NCAC 2C. .0118.
: a , YIELD (gpm): 50 METHOD OF TEST Blow Down
j f. DISINFECTION: Type HTC Amount 12 CZ
: g. WATER ZONES (depth):
: Top Bottom Top ___ Bottom __ _
: Top Bottom ___ Bottom __ _ Top
; Top Bottom Top ___ Bottom. __ _
Thicknea•I
; 1, CASINO: Depth Diameter Weight
] Top.Jl_ Bottom...J.§L Ft, __ _
: Top ___ Bottom ___ Fl, __ _
: Top ___ Bottom ___ Ft.. __ _
; 8. GROUT: Depth Material
~ Top.Jl_ Bottom-1.ZQ'._ Ft. Bentonlte
: Top-1.ZQ_ aottom-2.QO_ Ft. washed stone
: Top ___ Bottom ___ Ft. ____ _
Melhod
Pumped
poured
: t . SCREEN : Depth Diameter Slot Size Material
: Top ___ Bottom ___ Ft. __ ln. In. ___ _
: Top ___ Bottom ___ Ft. __ ln. In. ____ _
: Top ___ Bottom ___ Ft. __ in. In . ___ _
: 10. SAND/ORAVEL PACK:
; Depth Siu Material
: Top ____ Bottom ___ Ft._ _________ _
: Top ___ Bottom ___ Ft.. __________ _
; Top ___ Bottom ___ Ft ___________ _
: 1 1. DRILLING LOG
Top Bottom Formation Description
O /....,8=2'-----Sand Clay
82 '~1-=65,.____ Broken Rock
165 1 .... 2 ... 0 ..... 0 __ Loose Gravel so GPM ___ / ___ _ ____ / ___ _
I --------__ ....;/ ___ _
----'--------'-------'--------'----
; 12. REMARKS:
~ Casit,g Re111ooed
; I DO HEREBY CERTIFY THAT THIS W El.L WAS CONSTRUCTED IN ACCORDANCE WITH
• 1M OTHATACOPYOFTHIS
; R
: Roger L Williams
; PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quanty -lnfonnatlon Processing,
1617 Mall Service Center, Raleigh, NC 27899,181, Phone: (919) 807-e300
ForrnGW•1b
Rev. 1/08
N oN REsmENTJAL wntcoNSTRucnoN ucoRO
North Quolina Department of Environment and Narural ~ Division of Water Quality
WELL CONTBACfOR. CERTIFICATION# 3118-A
1. WELL CONTRACTOR:
Timothy R Hamby
Wei Contractor {Individual) Nana
Midsouth Geothermal
Wei Conmlc:tor Company Name
8 275 Tournament Dr STE 5
Street Address
Memphis
City OK Town
,901 ). 74~9095
Area code Phone number
2. WELL INFORIIAnoN:
TN 38125
State Zip Code
WELL CONSTRUCTION PERMITI WIQ100141 ~~~~~-----
OTHER ASSOC IA TED PEOA41T#(lf appllca~~
SITE WELL ID #(If appllGable)~ ·_· .._;)...,___-=4'_1$.__ ___ _
3. VI/ELL USE (Chedt One Box) Monitoring D Municipal/Public 0
lndustriaUCommerda D Agrta.dtural D Recove,y D lnjedion 0
1n1gat1ono ottw J c,w. UN) Qlosed Loop Geothera
DATE DRJU.ED~ 1.-:I0-1 ;t
4. WELL LOCATION:
1166 Lotta Church Rd
(SlrNt Name, Num.,_., Community, SubdivlllDn, Lot No., Pa1011, Zip Code)
cITY: Franklin couNTV Macon
TOPOGRAPHIC I LAND SETTING: (chadl 8l>fll'OPriul 11ml)
□Slope OValay iiFfat □Ridge □other. _____ _
LATITUDE 36 _____ • OMS OR 3X..XXXXXXXXX DO
LONGllVOE 75 -----· OMS OR 7x.xxxxxxxxx DO
ta1ltudellongll source: [J3PS Ofopographlc map
(location of wel must be .shoWn on a USGS topo map enclattac/l#Jd lo
thJs form If not using GPS)
5. FACILITY (Name of toe business where ltle well Is located.)
Macon Eleroeotrv School
Facility Name
. 1166 I ofla Church Rd
Street Address
Eraoklio
City or Town
Macao Cm mtv Gnveroroeot
Contact Name
Matnng Address
Franklin
City or Town
( ) ________ _
Area code Phone number
8. WEU. DETAILS:
L 'TOTAL DEPTH: 4i9::: l.$' Q
Faclllty IOI (If applicable)
NC 28734
State Zip Code
NC 28743
Slate Zlp Code
b. DOESWEU.REPLACEEXIS'TINGWELL? YES □ NOD
c. WATER LEVEL Below Top of Casing: _6_0 ____ FT.
(Use ·+· tr Above Top ~ casing)
----------
: d. TOP OF CASING IS ~ FT. Above Land SUlface•
"Top~ casing ISfmNfed at/Of bekJw land suface may reqan
. a varfance In accordance v.ith 15A NCAC 2C .0118.
~ .. Y1B..D <gpm>: 1 oo 11Ent00 or: TEST Blow Down
: f. DISINFECTION: ~ HTC Amount 12oz
: !J· WATER ZONES (deplh):
; TOI> -Bottom., Top ___ Bottom'---
~ Top ). 4.0 Bottom 2,.Lf J. Top Bottom._ __
;Top ___ Bottom __ _ Top ___ Bottom~--
llltcknael
: 7. CASING: Depth D!amewr W-'aht Mat.rial
: Top__§__ Bottom_.__ R. 61/8 ....11HL. steel
~ Top_Ll__ Bottom_O_Fl __ _
: Top __ Bottom __ Ft. __ _
.
: 8 . GROUT: Depth Material
j Top_. <1.._ Bollom_~_ Ft_fif n~~ -::
Method Pv.,.,,_p"ed_
:Top~_Bottom __ Fl ____ _
: Top __ Botlom. __ Ft. ____ _
: t . SCREEN: Depth D..,,._. Slot Size
: Top __ Bottom __ Fl __ in. --in. ----
: Top __ Bol1Dm __ Fl __ ln. __ In. ___ _
! Top __ Bottom __ Fl __ ln.
: 10. SANDt'GRAVEL PACK:
: Depdl mm
in. ___ _
Mldaltal
: Top. ___ Bottom. __ Ft.. __________ _
: Top Bollom __ Ft. ---: Top Bollom __ Ft .. __________ _
; 11 . DRILLING LOG
Top Bottom Format!On~
. ti. I« -. • I If. . . • ,_ . -,_ a n
: ... ,_
I
0 I J'.) ~A+,col * c14r : ~'.'.) I ~ c'.n::4::".'J ,?i:-£
: I
: I
I
: 12. REMARKS:
: Casing removed
: I DO HEREB'I' CERT1FV THAT THIS 'NEU WAS (X)NSTR\JCTEO IN ACCORDANCE WITH
; 15A NCAC 2C, WB.l. CONSTRtJCTlOH STANWUlS, AHO THAT A C0P'f OF THIS
: RECOAO HAS BEEN PRO\IIDED TO THE WELL OWNER.
: ,~;.:_/ ef< ~ I ~!2-.. I :1.. _J
: SIGNA:JlJRE OF CER~ CONTRACTOR DATE
: :nrootbv B Hamby
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit .withlrt 30Jtayit oi1c(Hitpl~on ,to! Div isl~ .Qf.W8"'r Quality:-•, lnformatlon Ptoceur,nu.
1617 Matl'Servlce CeritllfiRal.,;gtt;-NC 276"-16f, Pho~{ ,(91°9) 807-6300 ..
FormGW-1 b
Rev. 2/09
~ • --' + +
NON RESIDENTIAL ~LL C~NSTRUCTION RECORD
North Carolina Department ofEnvironmer!I end Natural Resources-Divis_ioo of Water Quality
WELL CONTRACTOR CERTIFICATION# 3065-A
1. WELL CONTRACTOR:
Roae r L Williams
Well Contractor (I ndividual) Name
Tarhee l water Treat ment
Well Contractor Company Name
3 4 94 Georgia RD
Street Address
Frankli n NC 28734
City or Town State Zip Code
c 828 > 369-07 40
Area code Phone number
2. WELL INFORMATION :
WELL CONSTRUCTION PERMIT#..:W....:..:.::IQ._1:...;:Q:.;::Q....,1..,..4:....:1 ____ _
OTHER ASSOCIATED PERMIT#(lf applicable) _______ _
SITE WELL 10 #(jf appllcable)..:.K-=--...,,7 _________ _
3. WELL USE {Check One Box) Monitoring □ MunlclpaVPublic; □
lnduatrial/Comrnercial □ Agrfeultural □ Recovery □ lnjeetlon □
Irrigation□ Other fW(llst UH) Closed looo Geotherra
DATE DRILLED 10-31-11
,. WELL LOCATION:
1166 Latia Church Rd
(Street Name, Numbe111. Community, Subdivision, Lot No., Parcel, Zip Code)
c1TY: Franklin c ouNTY Macon
TOPOGRAPHIC / LANO SETTING: (ch eck approPfit1te bo~)
□Slope □Valley ii{Flal □Ridge OOl h er ______ _
K@>tsTCD 36_ 1•••"&""•"••••t CL R OR 3JC~~ll CC
KNPvfts.TCD 75 ,··•"&••MAMAJ CL R OR 1"~JU(,C~ cc
Latitude/longitude souroe: [):;PS Dropographle map
(location of well must be shown on • USGS topo map endatt■ched to
this form if not using GPS)
5. FACILITY (Name of the business where the well i• localed.)
Macon Elaroeotarv
FacilltyNama
1166 Latia Church Rd
Streat Addreu
franklin
City or Town
Macon County Government
Contact Name
Malling Address
Ecaoklio
City or Town
'----'>-:----,-------Area c:ode Phone n umber
I . WELL DETAILS:
a. TOTAL DEPTH:.~4_5_□~----
Faei ltty ID# (if applic;abla)
NC 26734
State Zip Code
NC 28743
State Zlp Code
b. DOES WELL REPLACE EXISTING WELL? YES O NO rJ/
c. WATER LEVEL Below Top of Casing: _____ FT.
(Use•+· If Above Top of Casing)
-----------
, d. TOP OF CASINO IS _____ FT. Above Land Surface'
'Top of ceslng terminated at/or below land surface may requlra
a variance In acoordanee with 15A NCAC 2C .011 8.
~ e. v 1eLD (apm): 50 METHOD o F TEST Blow Down
: f. DISINFECTION: Type HTC Amount 12 az
; g . WATER ZONES (depth):
: Top ___ Bottom __ _ Top ___ Bottom,_ __ _
: Top ___ Bottom __ _ Top Bottom __ _
: Top. ___ Bottom __ _ Top ___ eottom. __ _
: 7. CASINO: Depth Diameter
j Top_L_ Bottom~ Ft. __ _
; Top ___ Bottom ___ Ft.. __ _
; Top ___ Bottom ___ Ft .. __ _
: 8. GROUT: Depth Matertal
~ Top_L_ Bottom-88L_ Ft. Bentonjte
Thickness/
W1tlght Material
Method
pymged
: Top.JlL_ Bottom-4,®_ Ft. washed stone goured
: Top ___ Bottom ___ Ft.. ____ _
: t. SCREEN: Depth Diameter Slot Size Material
: Top ___ Botfom ___ Ft. __ ln. in. ____ _
: Top ___ Bottom ___ Ft. __ ln, In. ____ _
: Top ___ Bottom ___ Ft. __ in. In. ____ _
: 10. SAND/GRAVEL PACK:
; Depth Siu Material
: Top ___ Bottom ___ Ft. __________ _
: Top Bottom_ Ft. __________ _
: Top Bottom ___ Ft.. __ _
; 11. DRILLING LOG
: Top Bottom Fonnation Description
0 I 82 Sand Clay
_8...,2,.___./_,2=0=0 __ water @192 so aom
300 I 450 Grarnte ___ ./ ___ _
---·'----___ ! ___ _
----'--------'--------'-------~----
: 12. REMARKS:
: Casing Re111oved
; I 00 HEREBY CERTIFY THAT THIS wru WAS CON~UCTEO IN ACCORDANCE WITH
• 15AN TliAT ACOP'YOFTHIS
; RE:
10-31-11
OR DATE
: Bcaer L Williams
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -Information Processing,
1817 Mall Service Center, Raleigh, NC 27699-181 , Phone : [phone]
Form GW-1b
Rev. 1/08
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Departmml ofEnvironmenl and Natural Resources• Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3065-A -----------
1 . WELL CONTRACTOR:
Roger L Williams
Wall Conttactor (Individual) Name
Tarheel Water Treatment
Well Contractor Company Name
3494 Georgia RD
Street Addrau
Franklin
City or Town
< 828 l 369-07 40
Area coda Phone number
2. WELL INFORMATION:
NC 28734
State Zip Code
WELL CONSTRUCTION PERMIT# . ...,W~I0,._1...,,0'-"0'-'1'-'4'-'1'--___ _
OTHER ASSOCIATED PERMIT#(lf applicable) _______ _
SITE WEJ.L 10 #(II appllcable), ..... K .... -__.8.__ ________ _
3. Wl:U. USE (Check One Box) Monitoring □ Municipal/Public □
lndu5trial/Commercial □ Agricultural □ Recovery □ Injection □
Irrigation□ Other ff (list use) Closed loco Geotherra
DATE DRIUED 10-27-11
4. WELL LOCATIO~:
1166 Lotla Church Rd
(Street Name, Numbent, Community, SubdlvlsJ011, Lot No .• Paroel. Zip Code)
c1TY: Franklin COUNTY Macon
TOPOGRAPHIC / LANO SETTING: (check appropnate box)
□Slope □Valley ii{Flat □Ridge □Other ______ _
K@ISTCO 36_ 1A•••&AAAMAAA! CL R OR 3JC~JUUU(~ cc
KNM=ISTC075 IAAAA,tAAAI\AAAAI CLROR 7':>t~~ cc
Latitude/longitude source: [):;PS Qropographlc map
(focatlon of waif must be shown on • USGS topo mep endattached to
this form if not using GPSJ
5. FACILllY (Name of the buslne111 Where the well ls located.)
Macon Elementary
Facility Name
1166 Lotla Church Rd
Street Address
Franklin
City or Town
Macon Countv Government
Contact Name
Malling Address
Franklin
City or Town
'---..,.;>...,,..,..--....,....-----Atea code Phone number
I. WELL DETAILS:
•· TOTAL DEPTH:_4~5-0 ____ _
Facility ID# (lf applicable)
NC 28734
State Zip Coda
NC 28743
Stat4 Zip Code
b. DOES WELL REPLACE EXISTINO WELL? YES □ NO G'
o. WATER LEVEL Below Top of Casing: ______ FT.
(Use •+• if Above Top ol Cuing)
: d. TOP OF CASING IS _____ FT. Above Land Surface•
: "Top of ca&ing terminated at/or below land $Urface may ra~ulra
a variance In accordance with 15A NCAC 2C .0118.
: •. YIELD (gpm): ____ METHOD OF TEST Blow Down
~ f. DISINFECTION: Type HTC Amount 12 OZ
: g. WATER ZONES (depth):
: Top Bottom Top ___ Bottom~--
: Top Bottom Top ___ Bottom, __ _
; Top Bottom ___ Bottom. __ _ Top
Thickness/
; 7. CASINO: Depth Diameter Weight Material
j Top_Q__ Bottom~ Ft. __ _
: Top ___ Bottom ___ Ft __ _
: Top ___ Bottom ___ Ft._ __
: 8 . GROUT: Depth Material
l Top_Q__ Bottom....aa.__ Ft. Bentonjte
: Top.Jlil.._ Bottom~ Ft. washed stone
: Top ___ Bottom ___ Ft., ____ _
Method
Pumped
poured
; 9. SCREEN: Depth Diameter Slot Size P,'latetial
: Top ___ Bottom ___ Ft. __ ln. In . ___ _
: Top ___ Bottom ___ Ft. __ ln . i n. ___ _
: Top ___ Bottom ___ Ft. __ in. in. ___ _
: 10. SANDfGRAVEL PACK:
: Depth
; Top ___ Bo.ttom ___ Fl __________ _
: Top ___ B.ottom ___ Fl __________ _
: Top Bottom ___ Fl __________ _
: 11 . DRILLING LOG
: Top Bottom
0 I 84
..... 8:....4.__ __ /_,3..,.0=0 __
300 I 450 __ ...,/ ___ _
----'----___ / ___ _
----'-------'----___ / ___ _ ___ / ___ _
----'----
: 12. REMARKS:
; Casi, 19 Re11,oved
Formation Oeacription
Sand Clay
D
; I DO HEREBY CERTIFY niAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wini
• 15A NCAC 2C. WELL CONSTRUCTION Sl'ANOAROS, ANO THAT A COPY OF nil$
: RECORD HAS BEEN PROVIDED TO THE WELL OWNER
:___________ 10-27-11
: SIGNATURE OF CERTIFIED WELL CONTRAC~ DATE
: Racier L Williams
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: DIVlslon of Water Quality • lnfonnatlon Processing,
1617 Mall Service Center, Ralelgh, NC 27899-1 &1, Phone ; (919) 807 ~300
Form GW-1b
Rev. 1/08
Permit Number WI0100141
Program Category
Ground Water
Permit Type
..
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
FaciJih
FacllityName
Macon County K-4 Elementary School
Location Address
1166 lotla Church Rd
Franklin
Owner
Owner Name
NC
Macon County Government
Dates/Events
28734
Orig Issue
02/28/11
App Received Draft Initiated
02/14/11
Scheduled
Issuance
Central Files: APS_ SWP_
03/03/11
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
Asheville
County
Macon
Facility Contact Affiliation
Owner Type
Government -County
Owner Afflllatlon
Jack Horton
County Manager
5 W Main St
Franklin NC
Publlc Notice Issue
02/28/11
Effective
02/28/11
381250851
28734
Expfration
01/31/16
-'-Rc.;;,e~a.;;;:u.:..:la=te-=--d:;:_:_A.:.:::c..::.;ti-'-v;.::itl;.::ec.:.s _______________ ~R=e=g=ues=t=e=d=/R=e=c=e=iv~e=d~E=v~e=n=ts~----------
Heat Pump Injection RO staff report requested
RO staff report received
Waterbody Name Stream Index Number Current Class
02/18/11
02/24/11
Subbasin
. I•• -~CDE
No rth Carolina Dep artment of En vironm ent an d Natural Reso urces
Beverly Eaves Pe rdue
Governor
Division of Water Quality
Coleen H. Sullins
Director
February 28, 2011
C . Jack Horton, County Manager
Macon County Government
5 W . Main St.
Franklin. NC 28734
Ref: Issuance of Injection Well Permit WI0100141
Issued to Macon County Government
Franklin, Macon County, North Carolina
Dear Mr. Horton:
Dee Freeman
Secretary
In accordance with the application received on February 14, 2011, I am forwarding perntit number WI0100141 for
the construction and operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well system to
be located at Macon County K-4 Elementary School, 1166 Iotla Church Road. Franklin, Macon County, NC 28734.
This pennit shall be effective from the date of issuance until January 31, 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 C(]DStruction records as specified in Part Vll.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 unillterrupted legal use of the injection facility for the stated purpose, you must
submit an application to renew the permit 120 days pnor 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 michael.rof.!ers(ti 1ncdenr.1?ov if you have any questions about your permit.
cc: L andon Davidson, Asheville Regional Of fi ce
WIO 1001 41 Permit F ile
Macon County Environmental Health Dept.
AQUIFER PROTECTION SECTION
163C Mail Serv1et-Center, Raleigh. North Carolina 27699-1636
l ocation: 2728 Capital Boulevard, Raleigh, North ~?Jolim:i 27604
Phone-:.919-733-3221 I fAX 1' 91 9-715-0583: FAX 2: 91 9,715-6048 \ CustomerSer;lre: 1.an-623-6748
Internet ww.v.ncwaterguality,org
"..'toCrtu nm Afflrmallv~ P.c11e>
Best Regards,
/fdtd!.JJ ~...,___,c-. -
'Michael Rogers, P.G. (NC & {L )
One N,.pfthCarolma
;vatttral!!f
NOilTB CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE C ONSTRUCTION AND OPERATION OF A WELL FOR INJEC TION
In accordance with the provis ions of Article 7 , Chapter 87; Article 21, Chapter 143; and other-applicable
Laws, Rules, and Regulations ·
PERMISSION IS HEREBY GRANTED TO
Macon County Govenunent
FOR THE CONSTRUCTION AND OPERATION OF 96 TYPE 5QM 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 Macon County K w4 Elementary School,
1166 Iotla Church Road, Franklin, Macon County, NC 28734, and will be constructed and operated in
accordance with the application received February 14, 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 permit is for Construction and Operation of an inJection well and shall be in compliance with Title 15A of
the North· Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rule~, and
Regulations pertaining to well construction and use.
This_ permit shall be effective, unless revoked, from the date of its issuance until January 31, 2016, and shalJ be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 28th day of February. 2011.
K'coleen H . Sullins, Director
\ Division of Water Quality
By Authority of the Environmental Management Commission.
Perm it #W I0100141 UIC/5QM
ver. 03/2010
Page 1 of 5
PART 1-WELL CONSTR UCTION GENERAL CONDITIONS
l. The Permittee must comply with all condltions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A 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 locat-ed in an area generally subject to flooding. Areas that are generall y
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies , depressions , and
drainage ways.
5. Each injection weJl shall be afforded reasonable protection against damage during construction and use.
PART II -WE LL CONST RUCTION SPECIAL CONDITIONS
1. At least forty-eight (48) hours p rior to constructing system, the Permittee shall notify the Aqmfer
Protection Section's Underground Injection Con trol (UIC) Program Central Office staff, telephone
number [phone] and the Asheville Regional Office Aquifer Protection Section Staff, telephone
number (828 ) 296-4500. ,
2 . The location of each of tfie system manifolds sh all 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 pennanentl y fixed location in accordance with 15A NCAC 2C .0213(g).
PART ill -OPERATION AND USE GENERAL CO NDITIONS
I. This permit is effective onJy 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 trans ferable wi thout prior notice to , and approval by, the Director of the Division of
Water Quality (Director). 1n the event there is a desire for the facility to change ownership, or there is a
name change of the Permitte e, 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 Pem1ittee 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 #WI010014J UIC/SQM
ver. 03/2010
Pag e 2 of 5
PART IV-PERFORMANCE STANDARDS
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 pennit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Pe~ttee 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 b y
the permit.
3 . At least forty-eight (48) hours prior to the initiation o f the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control {Ulq
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 authorized _officer, employee, or representative of fhe 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 term s 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 neces sary and appropriate samples associated with the
injection facility activities.
Permit #WI0100141 UIC/SQM
ver_ 03/2010
Page 3 of 5
PART VII-MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section -U IC Program
DENR -Djvision of Water Quality
] 636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
Asheville Regional Office
2090 US Highway 70
Swannanoa, NC 28778
[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 Asheville Regional Office within 30 days of comp1etion
of well construction. Copies of the GW-1 fonn(s) shall also be given to the Permittee and retained on site
to be made available for inspection.
3 . A copy of the si t e map updated with manifold locations required in Part 11.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Asheville Regional Office within 30
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. T'ne Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence. to the Asheville Regional Office, telephone number [phone]. any of the following :
(A) Any occurrence at the injection facility that resul ts in any unusual operating circumstances:
(B) Any failure due to known· or unknown reasons that renders the facility incapable of proper
j:njection operations, such as mechanical or electrical failur es:
(C) Any loss ofrefrigerant 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 Pennittee.
7. In the event that the permitted facility fails to perform satisfactorily, the Perrnittee shall take such
immediate action as may be required by the Director.
PART V III -PERMIT RENEW AL
In order to continue uninterrupted legal use of the inj ection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expirati on date .
Perm i t #WI0100141 U IC/SQM
ver. 03/2010
Pa ge 4 of 5
PART IX-CHANGE OF WELL STATUS
I. The Permittee shall provide written notification within I 5 days of any change of status of an injecbon
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 Permittee 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 1 SA NCAC 2C .0213(b)(1 ).
Notification shall be submitted to the addresses given in Part VII. l of this pennit.
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 15A NCAC 2C
.0214, including but not limited to, the following:
(A)
(B)
(C)
(D )
(E)
(F)
(G)
All casing and materials inay be removed prior to initiation of abandonment procedures if tbe
Director finds such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
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.
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.
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 exc~eding 10 feet, and grout
injected through the perforations.
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 tenns and conditions
of the permit.
The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(l) with.in 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VIL 1 of this permit.
Permit #WI010014J UIC/SQM
ver. 03/2010
Page 5 of 5
l
]
1
7
j
t
j
7
' l
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
Date: 02/24/2011
To: APS Central Office
Central Office Reviewer: Michael Rogers
Regional Login No: __
· Permittee(a): John C. Williama
Permit No.: WI0100141
County: Macon
Project Name: N. Macon Elem.
L GENERAL INFORMATION
1. This application is (check all that apply): 0 SFR Waste Irrigation System (81 UJC Well(s)
181 New O Renewal
0 Minor Modification O Maj or Modification
D Surface Irrigation O Reuse D Recycle O High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
0 Distribution of Residuals
D Attachment B included
D Surface Disposal
D 503 regulated D 503 exempt
D .Closed-loop Groundwater Remediation D Other lnjection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? (81 Yes or D No.
a. Date of site visit: 02/24/2011
b , Person contacted and contact information: Teny Bell
c. Site visit conducted by: Jonathan Stepp
d. Inspection Report Attached: 181 Yes or O No.
2. Is the following information entered into the BIMS record for this application correct?
D Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For SFR Treatment Facilities:
ll. Location:
b. Dri ving Directions:
c. USGS Quadrangle Map name and numl>er: __
d. Latitude: Longitude: __ Method Usetl (GPS, Google,.M, etc.); __
e. Regulated Activities/ Type of Wa'ltes (e.g., subdivision, food processing, municipal wastewater): __
For UIC Injection Sites:
{If multiple sites either indicate which sites the information applies to. copy and paste a new section into the
document for each site, or attach additional panes for each site)
a. Location(s): Franklin, NC, Macon Co .
b. Driving Directions: See Attached
c. USGS Quadrangle Map name and number: __ ~~
d. Latitude: __ J Longitude: __ Method Used (GPS~ etc.); __
3 s-
0
I 3 ., *' ~ fo )t) r13 ° ,,. -I I
I) :1 'f s I~ 1 w
APS-GPU Regional Staff Report (Sept 09) Page 1 of 6 Pages
1
1
j
1
AQillFER PROTECT~ON SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
IL NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor
modifications, skip to next secJion)
Description of Waste System and Facilities
J. Please attach c-0mpleted rating shee1. Facility Classif'i~tion: __
, Are (he nev.-treatment facilities 11deqtt,\te f~1r the type of waste and displ)S<li system?
0 Yes D Nn O NIA. t l'no, pJeaseexpfain: __
3. Are the new site conditions (soils. topography, depth to water table, etc) ct>nsiste 111 with what was reported by
tl1esoil scientist and/or Professional Eng ineer? D Yes O No D l:-IIA. If no, please explain: __
4. Does the application (rmlps , pl&ns, etc.) represent the actual site (property line-s. wells, su rface drainage)? D
Yes D No ON/A. lfno. please explain: __
5. ls the proposed residual s management plan adequa1e and/or acceptable t<i the Divis ion. 0Yes0No0
N/A. lfno, please explain: __
6 . Are the pmposed applicat ion rates for new sites (hydraulic or nutrie11t) acceptab le?
D Yes D No D NIA . If uo, please explaiu: __
7. Are the new trearment facilities or any new dispo!>al sites located in a I 00-year floodplain?
D Yes D No D N/ A. If yes, please attach a map showing areas of I 00-year noodplain and please explain
and recommend any mitigMive measures/special conditions in Part l V: __
8. Are there ally buff~r wntlicts (new treatment facilities or ne\v disposal s ilcs)? D Yes or O No. If yes, please
attach a map showing ctmflict areas or at1ach any new mHps you have received frt)fl1 the aprlicant to be
incorpornled into the permil : __
Q. ls proposetl 1md/or existing groundwater monitoririg program (number of wells. frequc-ncy of mo1u.tori 11g,
monito r ing parame1ers, etc.) adequate? D Yes D No O N/A. Attach map of existing monitoring well
netwod, if applicab le. In dicate die review and l.!Omp liance boundaries . If No, explnin and recomml!nd any
changes 1o the grotmdwater monitoring program: __
I 0. For r~id.uals, will seasonal or other restrictions be required ? D Yes D No O NIA If yes. attach list of sites
with re.'ltrictions (Certificatio n 11?)
Ill RENEW AL AND MODIFICATION APPLICATIONS {use previous section for new or maior modi(tcaJion
svst.ems)
Description ofWHte System and Facilities
l. Are there appropriately certified OR.Cs for the facilities? 0 Yes m O No.
Operator in Charge: __ Ce1tifkate #: __ _
Back ll p-Operator in CJ1arge: __ Certificate#: __
/\PS-GPU Regional Staff Report (Sept 09) Page~ of 6 Pages
~
I
I
I ;
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONALSTAfFREPORT
2. ls the de-sign, maintenan~ and operation (e.g. adequate. aeration, sludge wasting, sludge storage, efflu.enl
storage, etc) oft.he treatment facilities adequate for the type of waste and dispo6al b')'&tem? D Yes or O No.
Tfno, please explain: __
3. Are the site conditions (soils. topogra1,hy, depth to w11.ter table, etc) maintained appropriately and adequately
assimilating the waste? D Yes or O No. If no, please explain: __
4 . Has t.be site changed in any way that may affect permit (drainage added, new wells inside the compliance
boundary, new development, etc.)? If yes, please explain: __
5. Is the residuals management plan for the facility adequate and/or a.cceptable w the Division?
D Yes orO No. lfno, please explain: __
6. Are the existing application ra1es • (hydrnulic or "utrient) still acceptable? 0 Yes or O No. lf nt\ please
ex.plc1in : __
7. ls the existing grom1dwater mouitorin.g program (nwnbet· of wells, frequency of moni1'orlng, mo nitoring
parameters. etc.) adequate? 0 Yes D No D NIA. Attach map of ~xisting monitoring well network tf
applicable. Indicate the review and comp li ance boundaries. JfNo, explain and recommend any changes to the
groundwarer monitoring program: __
8; Will seasonal or other restrictions be required fol' adde.d sites? D Yes D No O N/ A If yes, attach I ist of sites
with restrictions (Certification B?)
'
9. Are there any buffer oontlicrs (treatment fucilities or disposal sites)? D Yes or D No. If yes, please attach a
1111,p showing oonflkt Meas 01· attach imy new maps you have received from the appticaut to be incorporated
into the permit: _. __
I 0. -l s the description of the faciHties, type and/or volume of waste(s) as wiitten in the existing p em1it correct'? 0
Yes 01· D No. If no. please explain: ___ _
11 . Were monitoring "vells properly construcred mid located? 0 Yes 01· 0 No D N/A . ff 110, plea.~e explain:
12. Has a revi~w of all self-monitoring dotl.l been conducted (GW, NDMR, and NDAR as applicable)'? 0 Yes or
0 No D N/ A. Please sunnnarize a.oy fiJid ings resulting from this review: __ _
13. Checl-nil that. apply: D No compliance issues; D Notice(s) of violation with in the last pe1111it cycle; D
Current enforcement action(s) D Currently under SOC; 0 Currently under JOC: 0 C1,1rrently un der
moratorium. If any items checked. please explain and artuch any documents thnt may help c larify
answer/comments (such a1s NO:V , NOD etc): ____ _
14. Have all compliance dates/conditions in rhe existing permit, (SOC, JOC. etc.) been complied wich '? 0 Yes
D No O Not Determined D N/A .. If no. please explain: __
15. Are there any issues related to compliance/enforcement that should be resolved before isslling this pennit'? 0
Yes or O No D N/A. If yes, please explain: __
APS-OPU Regional Staff~ort (Scpt09) Page 3 of 6 Pages
1
l
1
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
W. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wel1s, in situ remediation injection wells, and heat
pump injectton wells.)
Description of WelJ(s) and Facilities -New, Renewal, and Mod.ifteatio11
l. Type of injection system:
0 Heating/cooling water return flow (SA7)
[81 Close5'-loop beat pump system (SQM/5QW)
□ In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (SL/''Non-Discharge")
0 Other (Specify: ___)
2. Does system use same well for water source and injection? 0 Yes l'8'J No
3. Are there any potential pollution sources that may affect injection? 0 Yes l'8'J No
What is/are the pollution source(s)? . What is the distance of the injection well(s) from the pollution
source(s)? ft.
4. What js the minimum distance of proposed injection wells from the property boundary? __ ..::ft;.
5. Quality of drainage at site: t8] Good D Adequate D Poor
6. Flooding potential of site: [81 Low O Moderate O High
7. ror groundwawr remediation systems, is the propose d and/or exi~ting gl'o und watcr monitoring pmgram ·
(nu mber of wel ls, frequency of monitoring, monitoring p,H"ameters, etc.) adequate? 0 Yes D No . Attu.ch
map of existing moniLOriug well network. if <1pplicable. If Nu, explu:i:n and recomme11d any changes to the:
groundwat1;1r mon itoring pro gram: __
8. Does the map presented represent the actual site (property lines, wells, surface drainage)?~ Yes or O No. lf
.oo or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
lnjection Well Permit Renewal and Modification Only:
I. f-\>r heat pump systems, are there any ,tbnormalities in heat purn p M i,uection w~II operatio11 (e.g. tw·bid wt1tc r,
l(,'ti lure to t1!isimilate i11jected lluicJ, poor-heating,'cooling)'?
D Ye~ 0 No. ·1rves. exp lain :
2.. f.()r clo~ed-loop heat pump systems, has system l ost p ress ure or required make-up lluid since perm it issuance
or last inspection'? 0 Yes O No. If Yes. explnin:
J. Fo r renewal or modification of groundwater remediation permits (of anv type). wi ll
contimi ed/additionalhnodifted injections have an adverse impact on migration of the plume or mana!lement of
the contaminniion incideul'? D Yes O No. lfves, explain:
APS-GPU Regional Staff Report (Sept 09) Page 4 of 6 Pages
.J
I
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AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
4. Drilling Co11tractor: NAme: __
Address:
NC Certification nu mber: __
S. Complete 1md attach NEW Injection Farility Inspection Repol't, If ftJ)J>llcable
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional nmative regarding your review of the Application:
2. Attach new ln}tctlon FacJlity lnspecdo11 Form, if applicable
3. Do you foresee any problems with issuance/renewal of this permit? D Yes f.81 No. If yes, please explain
briefly. __ .
4. List any item·s that'you would like APS Central Office to obtain through an additional information request
Make sure that you provide-a reason for each item:
Item Reason
.
5. List specific Pemiit conditions that you recommend to be removed from the permit when issued . Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
APS-GPU Regional Staff Report (Sept 09) Page 5 of 6 Pages
j
AQUIFER PROTECTION SECTION -GROUNDWATER PROTECTION UNIT
REGIONAL STAFF REPORT
7. Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft perm.it by regional office; D Issue upon receipt of needed additional infonuation; [8]
Issue; D Deny. If deny, please state reasons: __
8. SignatureofreportPreparer~-~
Signature of APS regional supervisor: ;.:;_ ;;. = ~
Date:
VL ADDITIONAL INFORMATION AND SITE MAP (Sketch of site showing house and waste irrigation
system, spra v or drip field, location of well(s), and/or other relevant information-SHOWNORTH ARROW)
See Pennit App .
APS-GPU Regional Staff Report (Sept 09) Page 6 of 6 Pages
.
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Driving Directions from 2090 Us 70 Hwy, Swannanoa, North Carolina to 1166 Jotla Church Rd, ... Page 1 of 1
mapquest· ma
Trip to:
1166 lotla Church Rd
Franklin, NC 28734-6542
79.48 mllea
1 hour 38 minutes
Notes
I ----· -
I Meet with Terry BeU at 10:30am
I 828-731-1234
2090 Us 70 Hwy
Swannanoa, NC 28778-8211
' '
as.
Mlln Per
Section
Mllea
Driven
• 1. Start out going WEST on US-70 I BL.ACK MOUNTAIN HWY toward NEW SALEM • Go 2.4 Ml
RD .
2.4ml
•• • • ·-· --, .......... ·-• -· ·--·-·--... -••• ' • _,.. ....... , .... , • .,_,. • -, ......... -♦-• ,. ,-.. --··· ··-: "'" .... t , ••
2. Turn LEFT onto PORTER COVE RD. . 1 Go 0.1 Ml ·2.5mi
,.
■
PORTER COVE RD Is Just past BURLESON RD
.. ,, ........ ,, -·-··---··"·· .................... ,_,,,., ... ,.,_,_ .. _..,..__.,_,_
3. Merge onto l-40 W toward 1-26 / ASHEVILLE.
4, Merge onto US-74 Wvla EXIT 27 toward US-18 /CLYDE/ US-23/WAYNESVILLE /
MAGGIE VALLEY/ FRANKLIN/ MURPHY/ ATLANTA.
5. Merge onto US-23 SI US-74 Wvla EXIT_ 107 towa~ E JONES COVE.
6. Merge onto US -23 S / US-441 S via EXIT 81 toward DILLSBORO I FRANKLIN/
ATLANTA.
7. Take the US-441-BR ramp toward FRANKLIN .
0. 4 miles past HUNTERS TRL .
8. Turn SLIGHT RIGHT onto E MAIN ST I US-441-BR W.
9. Turn RIGHT onto HARRISON AVE/ NC-28. Continue to follow NC-28,
NC-28 isjust past MACON AVE .
10. Tum LEFT onto IOTLA CHURCH RD.
fOTLA CHURCH'RD Is 0.2 miles past PARRISH LN
,'
11. Turn RIGHT to stay on lOTLA CHURCH RD.
12. 1168 IOTLA CHURCH RD is on the LEFT.
Your destination is Just past \I\OODHAVEN DR
If you reach MCCALL CIR you'Ve gom about 0. 1 rrilles too 'far
1166 lotla Church Rd
Franklin, NC 28734-6542
Total Travel Estimate: 79.46 miles -about 1 hour 36 minutes
~LdgJm; a:sen,ed Use subjec;t to uoensetC~
Go 27.4MI
Go 1,4MI
Go25.0 Ml
Go 16.9 Ml
Go 0.1 Ml
'Go 1.5MI
Go3.5MI
29.9 rnl
31 .3 ml
•· ., ., ·-
[56.3ml
i
I
..... ,,_ ., -
73.2mi
73.3ml
74 .8ml
78.3ml
L .. ···-··· ....... J.. ····-
Go 0 .4 Ml i 78.7 mi
Go0.8Ml 79.5ml
79.5ml
79.6ml 79.S ml
Dlrectior,s and maps are Informational only. We make no w■mint!ea on the accuracy of their content. road conditions or rcute usability or expeditiousness. You
asaume an risk of uae, MapQueet and \ti suppliers shall not be Uable to you for any losa or delay 1'$1\Jltlng from your use of MapQue1t. Your uae or MapQuest muns
you ag_ree to our Terms of Ve
http://www.mapquest.com/print?a=app.core.ce366ad5670033efa3a20796 2/23/2011
Rogers, .Michael
From:
Sent :
To:
Cc:
Subject:
Attachments:
Michael,
Stepp , Jonathan
Thursday, February 24, 2011 4 :23 PM
Rogers, Michael
Davidson, Landon
WI0100141
Wt0100141.pdf; WI0100141-001 ,pdf
Please find the regional staff report attached.
Thanks,
Jonathan
Jonathan Stepp-Jonatha-n.Ste pp@ ncdenr.gov
North Ca rolina Dept. of Environment and Natural Resources
Asheville Regional Office
Divisi on of Water Quality -Aquifer Protection Section
2090 U .S. 70 Highway
Swannano,a, NC 28778
Tel: [phone]
Fax : [phone]
' Notice: E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and
therefore may be disclosed to third parties.
1
AVA
NCDENR
North Carolina Department of Envi ronment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
February 16, 2011
C. Jack Horton, County Manager
Macon County Government
5 West Main Street
Franklin, NC 28734
Subject: Acknowledgement of Application No. WIOI00141
Iotla Church Road
Injection Mixed Fluid GSHP Well System (SQM)
Macon
Dear Mr. Horton:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on February 14, 2011. This application package has been assigned the number listed above and will be reviewed
by Michael Rogers.
The.eviewerwill perform 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 addilional infonnation requests.
Please be aware that the Division's Regional Office, copied below, ·must provide recommendat ions 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. ·
If you 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,
o~~.~
for Debra J. Watts
Supervisor
cc: Asheville Regional Office, Aquifer Protection Section
MidSouth Geothennll1 LLC (Janice Scott -8i75 Tournament Drive, Ste 185, Memphis, TN 38125 )
Permit Application File WIO 10014 l
AQUIFER PROTECTION SECTION
1636 Mall Service Center,,Raleig h, North Calt>lina 27599-1636
Location· 2728 Capital Boulevard, Raleigh , North Carolina 27604
Phone : [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 I CustomerSm,ce: 1.STT-623-6748
Internet: www .ncwaterguality.org
An Equ.1 upportuniiy \ Affirmallve Aot100 Employei
rforth Carolina
;Natural~i;
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTH.EkMAL BEAT PUMP SYSTEM FOR:
TYPE SOM WELL{S)
_x ___ New Permit Application OR ____ Renewal (check one)
DATE: __ __,l=0/2=6=--__ _, 2010_
PERMIT NO. \fgL Q~ 0 0 ~ 4 ) (leave blank if NEW petmit application)
A. PROPERTY OWNER(S)/APPLICANT(S)
List each PrQperty Owner listed on property deed (if owned by ~ business or government agenoJ. state name of
entity and a representativ~ w/authority for signature): _ __..!;M~a~c:!!'on.!..:C,,..,02un~ty'-L.!,,G..,,O'~ve.,..mu:e,..n ______ _
(I) Mailing Address: __ ..:::5_,W"-'es,,,,t.e..:M=ain~Str"'"'e=ec:..t _______________ _
City: Franklin State: NC Zip Code: 28734 County:---'-'M=ac=o=n.,__ ___ _
Home/Office Tele No.: .....;8,<,:2,.,,,8·..:::3..!.,49"-·=20=0=0 _____ _,,C=e,_,_ll ....,N=o·=-=-: __ ..,__,n/=a _____ _
EMAIL Address:. ____ ~n/=a~-----,,-k~ ..... o_,~L..,-
l., :r.o.ru
(2) Physical Address of Site (if different than above): _l,...,1=66.=.=Lo=tl=a'"""C=h=ur=ch=R=o=ad~-------
City: Franklin State:~ Zip Code: 28734 County: """M=a=co=n __ _
Home/Office Tele No.: ----------~C=e=ll~N=o~·=----------
EMAIL Address:. ______________ _
AUTHORIZED AGENT OF OWNER, IF ANY (if the Pennit Applicant does not own the subject property,
attach a letter from th:i?operty owner_wthorizing Agent to install and operate UlC well)
Company Name: /!la.ui tl Lg U rt ±v
Contact Person: J a.ck H~ rf-.o~ r EMAIL Address: j ho rba @ mo..cc. n fl(_,,. crq
Address: s We.~ I J r ()),,,, C, -Ire~ 1--.J
City: 1-r a. ri k. i' (J State/V C. Zip Code: .;i. f 7 3 f County: ~--t--~"----'----
Office Tele No.: 8' do-8 -34C,.-;;._o ~2 Cell No .:
Website Address of Company! if any: _____________ _
STATUS OF APPLICANT
Private: Federal:
State: Municipal:~
GPU/UIC SQM Well Permit Application (Revised 7/2008)
Commercial:
Native American Lands:_._
~ ... .:. DI OENR I DV
Aqu fP.r P ot ct n Se 1!>
FEB 14 2011
Page 1
D. WELL DRil..LER INFORMATION
Company Name : ______ M~i=d~So~u=th~G_eo~th_e~rm~al~L=L=C _____________________ _
Well Drilling Contractor's Name: ___ T=ar=h=e=e"-1 W=at=er.,_T=rea=tm=en""'t"--, I=n=c·=/Mi=· c=h=ae=l=M-=c=C=lur=e _____ _
NC Contractor Certification No.: __ __._N'""C:....-3::....4=2,._,_4~-A.,__ ________________ _
Contact Person,.,_: =Jan=ice=-'=S:.=c=ott=---------=E=MAIL==-=-A=d=dr=e=ss=:J,:,js""c=ott@m==id=s,,.ou=th=ge=o=therm===al=·=co=mee:-__
Address: __ ..,,,8,..2.,,.,75:c..T_.__o,.,u,...ma=m...,en=t D=r.__,S""te"---"-'18"'°5'---------------------
City: Mem phis Zip Code: 38125 County: --=Sh=e=lb...,.y _______ _
.Office Tele No.: ___ 9~0_1-~7~48~·~90=9 ...... 5 _______ Fax No·.: ___,_9 ____ 0~1-~74~8~-9~0~97 __________ _
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: ___ M=i=d><eSo=u::.::th"'-'G=eo=th""e"'-rmal='-L-'='LL""'C=-------------------
Contact Person . .,_: =Jan=.:ice"""--"S'-"'co=tt=----------10~"'-'MA""""'IL,=.,.A...,d,..,,d...,re.,.ss=:~js""c:x.ott@=.,,.m'-"id=s,.,.o=uth=ge=o=th=e=nn=al=·=co=m=-
Address ; . 8275 Tournament Dr. Ste 185
City: Mem phis Zip Code: 38 125 County: ---'S=h=e=lb..,_y _______ _
Office Tele No.: ...,9'""'0=1--'-7~48=-·"-'90=9-=-5 _______ Fax No.: _,9'""0-=-1--'-7""'"'48"-·"'"'90=9-'-7 _______ _
F, INJECTION PROCEDURE (briefly describe how the mjection well(s) will be used)
G. WELL CONSTRUCTION DATA (Skip to Section H if this ls a Permit RENEW AL)
(l) Proposed date to be constructed: L{-1-{/ Number of borings: 9 U
Approximate depth of each boring (feet): ry51_) {
(2) Chemical additives to be used in closed-loop system (only those chemicals indicated have been approved):
___ R-22 --~propylene glycol --)Cethanol ________ other {other additives will
need prior approval by NCDENR before use)
(3) Type of tubing to be used .(copper, PVC, etc): fl:8PEC o·,ou
(4) Well casing. Is the well(s) cased? (check either (a.) YES .2! (b.) b {etow)
(a) YES ___ if yes, then provide casing information such as ~ (steel, PVC, plastic, etc.), diameter,
depth. and extent of casing appearing above ground~ _______________ _
(b) NO
(S) Grout (material surrounding well c~~ri~
(a) Grout type: Cement __ , Bentonite . Other (specify) -------
(b) Grout depth of tubing (reference to land surface): from a to VS(] (feet)
JfweU has casing, indicate grout depth: from ___ to ____ (feet)
H. 1NJECTION-RELA TED EQUIPMENT
Attach 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 supplementary
infonnation.
GPU/UIC .SQM Well Pmnit Appli~tion (Revised 7/2008) Pagel
L LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a site map (can be drawn) showing: buildings, property lines. surface water bodies, potential sources
of groundwater contamination and the orientation of and distances Qetween the proposed well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
geothermal heatpu~p well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
J . POTABLE WATER WELL(S)
Are there any potable water well(s) on the subject property or adjacent properties? __ YES X-No
If Yes, than indicate location on attached map(s).
K. CERTIFICATION
Note: This Pennit Application must be signed by each person apJ>earing on the recorded legal property deed.
"I hereby certify, under penalty of law, that 1 have personally examined and am familiar with the information
submitted in this document and all .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 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, mai · repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the prov cification and conditions of the Permit."
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UICProgram
REC EJVED I DEN I Dv\'O
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC SQM Well Pennit Application (Revised 7/2008)
Aqu .... r ~!lnll'll!l'IIVI
FEB 14 2011
Page3
..........
♦S&ME Boring tocatlon Plan
Macon County K-4 School
S&MEJobNo.1411-07-111
!
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·· .. "
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Date: 10/9/07
Figure No: 1,
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