WI0400102_GEO THERMAL_20120517

Beverly Eaves Perdue
Governor
AVA--
NCDENR-
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild,P ;-E.
Director
May 17, 2012
Richard and Colleen Fain
700 Arvida Parkway
Miami, FL 33156
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0400102
Dear Mr. and Mrs. Fain:
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.or g/web/wq/aps.
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: [phone] \ FAX: [phone]
Internet: www.ncwaterquality.org
An Equal Opportunity \ Affirmative Action Employer
One North Carolina
JVaturall!f
NON ONRFsSIDE+NTIAL WELL CONSTRUCTION RECORD
NvtlF tyeiaiirta Doparlment o("Environttlent and Natural Resource- Division of Water Quality
WELL CONTRACTOR CERTIIPICATION t 5 )
f. WELL CONTRACTOR:
.E k.-L3 CYA 0\ \ 1`5
Wolf contra for (lndivfttual) Na
Yadkin Wall Company, inc.
Well Contractor ComPiTVAYoMbItf i}.7ttil Iv Ili Road
STREET ADDRESS ;;amptonvllle, NC 27020
City or Town State
(33t,)- 17/47." 4
Zfp Code
17/I
Area coda- Phony number
2. WELL INFORMATION:
SITE WELL ID Ppm opptIoabre) 4t '- J -
. WELL CONSTRUCTION PERMT1W(If appllaab4)
OTHER ASSOCIATED FERMI TEft appllcablo)
S. WELL LISE (CitackApplicable Box) MonitoringC1
IndusOtaf/CammercialCI AadGuIWra10 RecoveryU
Irs1galloril Othaitr °latuse) n Jf/-L.v
_Al "• 4r-L.. i e11
•
Man1cdpatrFobflcl7
Inca aril_
#.-/ ((•
71
DATE DRILLED 0• 1'7 . 6
PM0
LJGI $torsI f r,I
TIME COMPLETED AMD
_
4. WELL LOCATION:
CITY: Pa /o to+ tt c COUNTY
//IOa
5-7 i � Zoe. c4,p F'Wy
(SIraot Herne, Numbers. Community, BubdM+ION Log No,, Noll, Zip Code)
T POORAPHICI LAND SETTING:
lope U Valley 0 Flat 0 RMdga t] Diher
(check apprapdata bek}
DvnTUDE
May be in desotcs,
minutes, saontla or
3n a decimal Fermat
LONGITUDE
_ T
LatitudcRong[tudo souroa: 0 PPS 0 Topographic map
(lose Won of well mini bo shown on a USOS fop° map end
°reached la this tan fl not using 42PS)
5. FACILITY -tie,. name urea min In re v,a We ri located. I
FACILITY 1D ORapplloabro) D? C f #-1
NAME OF FACILITY /4•1 /..4 et d2 i tA.-
STREET ADDRFS- 5-0 / 6'J F * ..4.e +. r2' / „,
0 GJ II' LA120 SQL C •
Cllybr Town ) Stole Zip Code
CONTACT PERSON /tr.. .
MAILING ADDRESS
Lrr City or Tom Slate
(, .2.P .)- Z -4t 4r41
Zip Cods S'Cz
z
YESl7 NO)'
FT.
Ronae2�D5'
Area coda - Rona number
5, WELL DETAILS: •
a. TOTAL DEPTH: 300
b. DOES WELL REPLACE EXISTINQ WELL?
c. WATER LEVEL Below Tap of Casing:
. (Use ++' If Above Top of Caaing)
d, TOP OF CASINO 18 FT. AISOve Land Surface
'Top of casing larmtnatad at/or below lend surface may require
a violence 1n acccmdence Will taA NCAC 20.0119,
e. YIELD Wpm):I�G. METHOD OF TEST
t. DISINFECTION: Type rR`- 7, Arnount %c1yr
g. WATER ZONES (depth):
From- To From To
Rom To From To
From To Frvrri _ _ To
7. CASIN0: Depth Dlamefor ztslcknauMlelghl Material
From To Ft.
From To FL
_ ,
Frog; To -Ft
I. GROUT: Depth Material Method
From 0 To 300 Ft ,?urn.(]
From To Ft
From To Ft.
9. SCREEN: Depth Diameter Mal Size Malarial
From To Ft. In, In,
„
Frans _ _ To R. in.
_In.
From To FI. In. In.
Ia. aANDrGRAVEL PACK:
Depth Sire Malarial
From To Ft.
From To FL
Fran, To Ft.
4t.DRlLLINO LOa
From Formafo D icriipp On
a �. rf 4+ii�as�{�
am' ryi ! fin,
qr - .]c-er-
12. REMARit81
1 CO HERM CERTIFY THAT Traa W U WAS COrr9TAVOTER INACC0ROANce WITH
SaA !CAC 2C, WELL corral RUCTION ST KIARU4, AND TWIT A CCAY 0 F 7111B
REtx7ROHAS BEE RQVIDEOTOTNEW E
8 TURE ERTWF1E0 WFLL G NTRACTOR DATE
6c )61A.L1 `ki r'1C71
PRINTED NAfd6&OF PERSON CONSTRUCTING THE WELL
Submit the original to the Dlvlslan of Water quality within 30 days, Alin: Information Mgt.,
1 E117 Mali Service Center-- Raleigh, NO 2T609-1817 Phone No. [phone] ext dee.
Form GW-1b
Rev.12107

NON RESIDENTIAL WELL CON$TRi/CTICN RECORD
North Carolina Dapaztment oftavirorameni and Natural Resources-,Dlvislun of Wafer quality
WELL CONTRACTOR CERTIFICATION iJ v 7?
1, WELL CONTRACTOR:
rYIA
Welt contreUar (individual) Nome
Yadkin
t}��Well Company, lc.
Well Contractor Cem3i FRBQrlli.lill /V; es Floe—
S7REEETADPRESS Hamptonviiie, NC 27020
City or Town Slate Zip Code
Area code- Phone number
9, WELL INFQRMATIOH:
SITE WELL ID fgr appikabre) 114 s 7,47..)
. WELL CONSTRUCTION PERMET#(RspplIoabiey J' ¥OF/C12.
OTHER ASSOCIATED PERMIT IRK applicable)
3, WELL USE (CheckApplios$le Box) MonliortngE} MtlniclpaWublla[f
Induatrlel/Commeretain AgrlcuturelD Re-•veryi3 tri.Jecilorn
IrrigatIonl Olhe4' (Ifuse - • r,►'
DATE DRILLED /71}}st "' / C7IS'
TIME COMPLETED AMO PMU
4. WELL LCC TERN: �(,
CITY: to L.,r° �_ COUNT' ( 4 Ls1 u, r+�
(Street Hared, Numbers, Community, aubdrislan, tot No.. Faroe],,Rp way
•T POGRAPHIC / LAND SETTING:
tops i] Valley t] Flat 13 Ridge n Other
(check appropriate box) May be la degret',
LATITUDEminutes, seconds or
Ina &alma3 f¢rras'
LONGITUDE
Latltude&longltude sollrcc: fI CfPS D Topographio map
Afocettoh of wallmue, he shown on a t)SCS tops rump and
attached fo this lbml it not using (3Psj
b, FACIL{TY•I. via rams asse anNnesswhere Shame Ionsred.
FACILITY ID Alf applicable] X C�
NAME OF FACILITY if/cc c-+eta r:,lw
STREET ADDRESS _ $'7 / j5fa /. r 1 r +- 5if
r37 C.
a 20 Gtcr • 7
City or Town J Slate Zip Coda
CONTACT PERSON jlr� .
MAILING ADDRESS
r 4-7--
�i:°' City arTown �7 State Zip Code Scc
Area codo - Phofle number
e, WELL DETAIL I: r
a. TOTAL DEPTH: .c.30 a
b. DOE3 WELL REPLACE EXISTING WELL? YESE1 NOX
o. WATER LEVEL Below Too of Dosing: FT.
, (Use'+' irAb(We Tap of Caelrlg)
d. TOP OF CASING IS _ FT. Above Land Surface'
'Top of casing teiminalod alfor belay/tend surface may require
a valiance In acoorence Kith 16A NCAC 2C.0118.
.. YIELD (gpm): �- METHOD OF TEST
f. DISINFECTION: Type Amount �e ear
g, WATER 2DHE8 (depth):
From To
From-- To
From----- To -
7. CASING; Depth
From To -
Fron(___.,__ To
From To
Dia Mots ThkenesaMetpht Material
From _ __ To . Ft,
From_ _ _ To - FL_ ___ __
Front To Ft.
O. QROLIT, Depth
From D To ed4 Ft,
Frorn To FL
From To Ft.
9.8CREENi Depth
Meterlal
Diameter
Front To FL In.
From TO FL ln.
Frain ,To Ft. In,
10. SAND/GRAVEL PACK:
Depth Size Malarial
From, To Fl
Frorn To FL
From _ _ To FI,
Slot Siza
In.
In.
in.
11.DRILLUNG LO4
Forlrtatlan eecripl[o )
r P- ji covt o ha•i [tic iC
From
Moth (xi
Material
12. RE MARKS:
rci 'camfiLrewre`
I IJU 34PAEeY GERTIPY THAT3raa WELL WAS CONSTRUCTED IHACCORDANCE WITH
'CAW -ACM Watt, CONSTRUO OH STANDARDS. RHO THAT A CO PY OF TF$
RECORD VAS BEE PROYiD€DTo 7Haa Via Mf
id �/ i)—r Vedg
TUR F CERTIFIED WELL CONTRACTOR DATE
—To ot.l L-\) kkii
PRINTED NAME OF PERSON CONSTRUCTiNO THE WELL
Submit the original to the Division of Water Quality within 30 days, Attn: inforrnatlan Mgt,
1817 Mell Service Center --Raleigh, NC 2780 9.1847 Phone No. [phone] ext 68B.
--fs4G4`4ia tie s!xi,r`i e'del L — Our d
FormcWtb
Rev.1 ua7

NON RESI1fl NTL L WELL CONSTRUCTION RECORD
Noith aroilaaDeparimentofTnvtianmont and Natant Resources-Divisia:I of Water Qua/Ity
WELL cormuCTQR CERTI[FICAT ON # ? Y
1, WELL CONTRACTOR;
r -u� Gk trr
Wel(Contractor (Individual) NarnaL
Yadkin Well Company, tin.
Well Contractor CvmPelainHalFlNUliia FlO&
STREET ADDRESS 'Hamp#onvllle, NC 27020
City or Town Maio Zip Codo
(3. e/a/P.-cf41d
Area Phone nUmbar
2. WELL INFDSMATION:
SITE WELL ID Cif apptl abta) ! K = r% j/r3
- WELL CONSTRUCTION P RMfTIIQr appitcabtn)1O Veld -AO
OTHER ASSOCIATED PERMITs(IF appllcabie)
3, WELL Ube (Check Applicable Box Monitoring[] MUnldpaVPublic0
lnduatdellf;ommerchIO Vied relO RecovoryD Injector
IutgatiorL OtheAro gist use) �[.. �.r 1' U73T
RATS DRILLED " t r 00 7
T1MEiCOMPL7 rgp 7 - Uf) A) D
4.WELL LOC TlON;
CITY to w ptpz, fro Gt( COUNTY uut:i
(Stine[ Name, Numbers, Community, SvbdMeb , Lot No., Parcel, zip Coda)
�TQ POOftAPHIC.!LAND BETTING:
Slope a VaItey r3 Flat a Rldpe 4 Other _
(shark ape ropdeie box) May beta degrees,
LATITUDE minutes, aecon& or
—' Ina &dmal !moat
LONGITUDE
Latttudc/long[tudo source; A OPS t7 Topogcaph10 map
(location a! wail must be shown an a USGS tope mop and
a:footled to fhls torn fftrot using GPS)
G. f ACILIIY- is u*name ago boobs+
FACILITY ID #{if appIlcabte)
NAME OF FACILITY
the wig k aaa [ad
CSC
Fi[ r r !'jr I61*
STREET ADDRESS re? l
Clfyhr7
I'� aws: w r X I'll)
&r} [ C
State
CONTACT PERSON fr��
MAILING ADDRESS
2ip Coda
rt City or Town Stela
Area code . Phone number
Z1p Code 5-aes-
B, WELL DETAILS; 1 o
B. TOTAL DEPTF(t
b. DDE8 WELL REPLACE EXISTING WELL? VERB HOo
c. WATER LEVEL Beim Top of Can FT.
(Use '+' II Above Top of Geeing)
7
,-,r✓ UoT.{rA
Sularn t the original to the Qlvlafon of Water Quality within 30 days, Attn: info► radon Mgt.,
1617 Mall Senile° Center Raleigh, NC 2799-1617 Phone No, (919) 733.7Q18 ext 688.
/J-rf cr c4`4,4z cf Lf` e es-'1't7 az LF rf C- 'Wry
d. TOP OF CASING Is FT. Above Land Sorrow'
'Top of easing terminaled aLor below land aurfaoe may require
a variance In accordance with 1 BA NOAC 2C .0118.
a. YIELD Wpm):a METHOD OF TESTrwif
f. DISINFECTION: Type r {irk` Amount Luf)r
g. WATER ZONES (depth):
From- 1516 To 2' ( From To
Frorrl To From . To
Fieru _ _-To Frarn To
7.OAeIt1O: Depth Diameter TAleirneaaeWatght Material
From To Fr -
From
From To Fi,T
B. GROUT; Depth
From 6 _To 30c Ft /[.4mil
From To Ft.
Front To F!.
Materiel
tI, SCRIM Depth
Mottled
alamelar Slot title Material
From To Ft. in. In.
Front,,To FL ln. En.
From To Fit _In. In,
13. SAN DJGRAVEL PACK
Depth Stza Material
From To _ FL
From TO .- FL
Frot[__,To Ft.
11.ORILLUHG LOG
From
o--
12. REMARKS:
FormRllon l7AecrlptIon
G T
MC'� II ''f`�[J # k
1 EX) rilAE9Y CERTIFY THAT Ills WELL WAa OQtiSTRU0TeoiNACOORDA CE RIR
!EA NG,O20.WELL CQNSt1W0TlorterMWJU .AHOTHATA COPY DFTH1e
RECORD K .B E EEF P ROHOEl7 TO THE YrELL wine%
St[3NATUREOF CERTIFIED WELL CONTRACTOR DATE
Ni I [ �'a't _ VL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-ib
Rev.12J07

NON RESIDENVAL WELL CONSTRUCTION RECORD
North Carolina Department of BovIroaullmt and Natural Resources-17)Ivisly la. of Water QL Iity
WELL CONTRACTOR CERTIFICATION # 5 7 )-
1. WELL CONTRACTOR:
Well Contr or (Individual) IVn
Yad In iVei1 Company, #no.
Well Contractor ComiilrrifIRr 1ptLsl r load
BTREETADDREaS 'Hamptonville, NC 27020
City or Town Stets Zip Code
(31J ! 6"A r 4 4 d
Nee code- Phone number
2, WELL INF,RMATlONt.
SITE WELL ID or applkabte) d44 47.
WELL CONSTRUCTION PERMIT#(H eppticeMo ij//s1 V!ad
OTHER ASSOCIATED PEwar #(t( applicable)
3, WELL U8E (Check ApptIoabie [3oX) MortItoring❑ Munldpat1Pvbllct
mdustristreurnmeroloIEI Agri cujiur8ID RecoveryU aorta,
Irrtgolive Othe t use)j /n cr1 a (G am, ¢r. � ■
u.,
DATE DRILLED
�)'I I-0 6 I
11ME COMPLETED AMQ PMI]
4. WELL LOC TION,
C 1 Y: Flo
��Wrl s-�/ fpo at- COUNTY 4 /414 orI
fi-
lreal Harm
Nurnberg, �Covet/ay. -iforLol Na., pem1.I}p Code)
YQPOGRAFRIC ! LAND SETTING:
•$lope Q Valley D Flat Q Ridge to Other
(shook eppropriete hex) ?d4y be in Cortices,
LAT1TU DE nth liseconds or
Ina decimal forme
LONGITUDE
Latitude/longitude souse, 0 OPS 0 Topographic map
((moa[lmn of wen meat be shown on o VS08 (apa map and
affocned to ails roar} It not usrng OPS)
6. FACILITY -le vacam wVt. aue;naustibm!iele ►71elxered.
�7 f
FACILITY ID Cif applfeeble.) LY S A4(
NAME OF FACILITY le/ad A. Ezie
! ,1 h-
STREET ADDRESS ,_,,r�1 _,S4,1�� r^—L�,
r�� Town
) SI
Glly r o5m Slate Zip Cana
CONTACT PERSON r- /re
MAILING ADDRESS
Lir, City or Tawn State 2Ip Coda $ apa.4
�- Y5-- ,ff 4/4 e2 e
Area code - Phone number
B. WELL DETAILS:
e. TOTAL DEPTH:
b. DOES WELL REPLAOE EXISTING WELL? YE813 NO Y
a. WATER LEVEL DslewTop of Cs sing: FT.
. (Use'+' irAbove Top or Casing)
d, TOP OF CASINO IS FT. Above Land Surface
`Top of castor/ lermincried mdorbelow rend surface rimy require
a ',redone In accord once vdth i6A NGAC 20 .O11 B.
•
a. YIELD (gpm): I/L' METHOD OF TEST Oil. rtA...
f. DISINFEDT1OH:Type it/ 7, Amount r�u�,r
g. WATSRZON88 (depth);
From To From , To
From To Fronk To
Prone, To Nam Tc
7. CAGING: Depth Dletrseter Thlr3messoWerghs Maled&
From. To FL
Fromm, To FI,
From, To FL
S.4ROUTt Depth Material
RIM .6 Ta c" Ft.,
Fromm _ To FL
Fram TO Ft.
Method
9. 8CREENs Depth Diameter Stet Site Material
From To F!, In. in.
Front Tv FL ,In. _ 1n.
From To FI. In. In.
10, 8AND!GRAVEL PACK:
Depth airs Material
Front . To Ft
Erotic. Tc Ft.
From To FL____
i 1.DRiLLIR() LOG
From
-e
i2. REMARKS:
formation scription
40., rdCivon:4-4
IDOFilnTETYCERTIFYTHATTr4BWELL WAS OQ 7RUOTEDrkACLOft6NrCeLNT1{
tea HCCc 2C,MIL CONSTRUCT ION a?AHLZARDS. AriD 7sIAT A CO Fry Or SIaS
RECORD 12AB EA et MAI OE D ra THE WEE. trivJJ E
&/
TUREyr. CERTIFIEp WELL CONTRACTOR
,Q-y9.Qg
DATE
PRINTED NAME or: PERSON CONSTRUCTING THE WELL
Submit the origin} to the Division of Water Quality within 30 Heys. Attn: Information Mgt.,
1647 Mall Service Center- Raleigh, NC 276 9.1017 Phonapo. (619) 733 7O15 ext 688.
4-rf & 4-4tct Cl e 4-'1/7 d� c[ v► D e
Form GW-1 b
Rev.12107

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department Of Bel lronmant and Natural Resauioes- Dtv talon or Water Quality
WELL CONTRACTOR CERTIFICATION # 5 n) )-
1. W.L.!'ICONTRACTOR:
LJ [110\\is
Wall Contrattor (IndlvtdUe Name,
YadRirtoff company, inc.
WsII Contractor comPiti tanWaI tip IL11)v I o-floacd
STREET ADDRESS }ampfanve, NO 27020
City or Town Sista
� a.3� � :a4'j
A1teTA - Phone number
s. WELL INPQRMAT!ON:
SITE WELL ID iC(1! oppileab/s) 14 j 7 7S
WELL CONSTRUCTION PERMIT#{tr applIcabta) W/d N4a1/►4-
OTHER ASSOCIATED PERMIT NO applicable)
3. WELL USE (Check Applicable Box) MonlloringU MunlcipaVPub1100
fnduatriallCommerrlai0 Agritil VraiEl Rec vvery0 In)ediorf
krigalfcra Maier Met u5) h �i1,tro or")-
DATE DRILLED 0- 1 D I
TIME COMPLETED AND FMEJ
4, WELL LO4 TfON1
CITY /o w rti 1- P9 _de COUNTY
5 2/ ►-0-+10
{streai NBme, Numbers, Community, 6ebetvialon, Lel?1a„ Perim, 74 Code)
•T POQRAPHIC/LAND BETTING:
lope it Valley El Flat 0 Fdrign Olhnr
(check appropriate box)
LATITUDE
LONGITUDE
Letitudellongltude sourac: 0 OPS Iz Topographlo map
rf 4ansche n hiss Tom of t be veiny Ci 5)on a DS Iopa map and
Zip Code
Mey bale dcgew,
minutia, woanda or
in a doofinel tbrrnet
6, rACILITT-Is menerrwarrabuaJrsase+t+ersIhowa71s'acted.
FACILITY ID 17(If sppllcabl2) f� D� C_ r -S
NAME OF FACILITY
STREET ADDRESS
�I3 y4•r rt eti -
Clty or Town )I S,[ata Zip Code
!
CONTACT PERSON /ram
MAILING ADDRESS
LIt City or Town State
q
Area code • Phone number
Zip Coda 5 aft",
gz
1, WELL DETAILB: 1
n. TOTAL DEPTH: �
b. DOES WELL REPLACIT EXISTlNO WELL? YESC NO)
e. WATER LEVEL Below Top of Dosing: _ FT.
, (Lisa +• Ir above 'lop of Cuing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of eating terminated aIfor below land surface may require
avariencoInUtterance Hilh 15AHCAC2C,t}1la,
o. YIELD Wpm): Iel METHOD OF TEST (V r,j,
I. DISINFECTION: Typo XI 7, Amount
g, WATER ZONES (depth);
Fro rn TO From , To
ROM TO From To
Front To From To
7. CASINO: Depth Diameter ThkknesaM'etitht Materiel
From To _-
Fro nl _ To Ft
From To Fi.
B.OROUT! Depth
From c To 3-
Ft.
Prom To Ft
From To Ft,
9. SCREEN: Depth Diameter
Msterlat
Method
Slat Size Mated&
Frair_ To Ft. In, In.
From _ To Ft. In. in.
From To Ft. In, in.
le. SAND1ORAVPL PACI[t
Depth Eke Materiel
From To FL
Frorn_ To - FL
from Ta FI.
11.DRILLING LOG
Prom r rrns3a acrintls�n o{ L. f el
t2 REMARKS:
IX) HMV OERTTKT HAT MS WELL WAS COtorrnu TEO tN ADCARDANCI: WTH
1 W HOAG 2C, W E t. CONS"(R WTTOHOTAHWRDS, AND THA/ ACOPY OP THIS
RECORD IASSEEriArCVIDEOTOmeWELL !en.
r G
RE 0fs RTIFiED WELL CONTRACTOR DATE
Ci « v t �s
PRINTED HAM OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water quality within 30 days. Attn: information Mgt,
1617 Mull Service Center -Raleigh, NC 276 9.1617 Phone No, (919) T33 7015 ext 56E,
4-1- 5" - cer`4,71 t•a1/ a2 t i - D w4 O
Form GW-lb
Rev.12107
k.
S

NON RRS DENTJAL WELL CONSTRUCTION RECORD
-North Carolina Department oFenvlroomcnt end Natural Rciources- Divisio}n, or Water Quality
WELL CONTRACTOR CRTI}7ICATION At3 c i 4
1.WELL CONTRACTOR:
614V'e
Well Contractor (Individual) Naroo
Yadkin Well Company, inc.
Waft contractor Com7t 1aulptJ lviii@ Hoad
STREET ADDRESS Hamptvnvilie, NC 27020
Oily or Town f `State
( j- �n rf 4Y4'4 ji
Area Cade- Phone number
2. WELL IHP9RMATlON:
SITE WELL ID ;TV apgtaabts) 44 . = ?'�
WELL CONSLRUCTiON PERMIT#(?! appticrbre) Wla HaO /D I.
OTHER ASSOCIATED PERMIT►0(1f applicable)
3. WELL USE (Check Applicable Box) Monlioring0 MunidpeVPubllcp
Industriel&Commerclatl] Aga Cv1lural0 Reroveryf lrriecllorfl
IrrlgaVorO Olhe ' (tfstuse)
DATE DRILLED 16
TIME COMPLETED,
h. WELL LOCATION:
CITY: to L It r- Po Gk COUNTY t:rJJ ?
fir- r p ,
teirse! Norse, Numben, Community, SubdMalan. Lot No,, PsrC71, rip Coda)
T PQGRAPHIC 1 LAND SETTING:
• lope ci Valley 0 Flat 0 Ridge D Other r _.
(check sppttYpirate box)
LATITUDE
LONGITUDE
Latitude/longitude. source: El OPS a Tvpograt hlo map
(/oceleon of weft must be shown one USGS lope neap end
affaehedto lies form 1►not wing OPS)
Zip Code
hri
Ama P j-
Maybe {h degzecs,
rnlnutcs, seconds or
Ir a decimal format
FACILITY• rs u+e rarer orris ws:nsu w ere lh6 WO Lr taptvd.
FACILITY 1U 1r(Irappitaabfe) S 1
NAME OF FACILITY g/ - 60
STREET ADDRESS _ ��l otS°''/,,ce/r 1 r g- vi.
AIFiI,
Lzlrkla fff f'L�• f
City Or Town J Slate Zip Code
CONTACT PERSON I
MAILING ADDRESS
Ltert, City or Town State zlp Codo $nth
(tip ).29z�—�Lrrf4 0�g
Area code - Phone number
9. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YEW] NO `
a. WATER LEVEL Below Tap of Cooing. FT.
(Use'+' if Above Top at Dating)
Submit the arig!ne st oche Division of Water Quality within 30 days. Attn: information Mgt,
1617 Mall Service Confer - Raleigh, NO 276 9-1917 Phone No. [phone] ext 656.
4 rr e•-?.`a11cl ra1,7 ir7 eirti - 0 .14,. ce
a. TOP OF CASING IS FT. Above Land Surraca'
'Top of easing terminated eUor below land surface may require
violence In er.cardenat} with 16A NOAC 20 .0118.
r. YIELD (9pm): II I,IMOD OFTt:8T
f. DISINFECTION: Type AI fir' Amount
g. WATER IONEE (depth):
From To From To
From To From To
From. To From To
7. CASING: Depth Dlantotor InlomaslY'. ah% Materiel
Front ,ii To — Ft. - �~
From_ To FL
From To Ft,
8.4ROUT: Depth Material
Float 6 TO3GO F! -
From - To Ft.,
From To FL
9. SCREEN: 0aplh
Method
Diameter Slot Sire Material
From To Ff. Jn, In.
Front To Fi. it . In.
Fron To FI. in. In,
19. SANDJGRAVEL PACK:
Depth $ire Material
Front --- To Ft,` _.
Front, To . - Ft.
From To Ft
MIMING LOG
From o
4
12. REMARKS:
Formation 0(18cl-4110n
CIA C,e) j c t,"ol
i11,,..d font •f-r
I DD RERE8Y CERTIFY THAT TNiS WE IL WAe CORM ROOTED IN ACCORDARO � WITH
16A NCAO 2C. WW. CT: M111 c no I ewlvlp.kP . AND Y-HAT A COPY OF VAS
RECont rime EHEl I3OVI ATOThe WELL OWNI.P..
SIGNATURE OF CERTIFIEDWELL CONTRACTOR DATE
1-V1 t- 4,2
PRINTED E OF PER8OH CONSTRUCTING THE WELL
Form GW-1b
Rev. f 2J07

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of8nvtronment and Natural Rosouroas- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 5 dt
1. WALL CONTRACTOR:
Wail Contract r {1rldlHdua Nar
Yadkin Well Company, inc.
Well Contractor ComOdrl ridarFlPtlfi 106- Hoa&"
STREET ADDRESS-amptonvllle, NO 27020
City or Town Stele Zip Code
e�• 47_61.r.lief4e
a Phone number
7. WELL INF9 U,TATIOH:
SITE WELL ID efeappllaable) ITS 4q c- 2 79
WELL CONSTRUCTION PER MIT#¢1rpFlleeble) Ya1AeEG L-
OTHER ASSOCIATED PERMIT #0 applicable)
&.WELL USE (Check Applicable Boa) MonRortng f MunlcipaVPublIctl
1nduairlalICommarcial0 AgricuyIrreiO Recoverytl In)oottonC
trrlgaUorO Othe l5tuse) 6.1440 4,1", ..r' �■ uAf
DATE DRILLED / •) 3�
TIME COMPLETED AMI7 PMC1
4, WELL. LOWION:
CITY: A to 4-'3 :t n P ? aeCOUNTY ¢ 4 r4/ c4.
(StscatN�� 1 r�Ab('Mklal,Let Xo.,Plea 1, bp Cade)
T P:OGRAPHIC / LAND SETTING:
• tope 0 Valley LI Flat Ci Rldo a LI Other
[e$eck ■pprcprrate box)
LATITUDE
LONGITUDE
Latltudc/1❑ngituda souran: 0 GPS 0 TopogsaphLo trap
{location of wall must be shown on a LJSOB tops map and
attached to this Iomi II not using LIPS}
Mey be in degrams,
minutes, raow,di 0-
in a dolmas formal
a. FAGILtTY is 'mixer* or:he 1:0.4514ia w e the WO l; loam,
FACILITY ID #(if applicable) ff d? x }r'
NAME OF FACILITY /et c f /<;
STREET -ADDRESS s0 / 6/ f /( .I r r a ' /134
1 .4 r t 4e lei 4 C. '
City Gor Town) Stele zip Coda
CONTACT PERSON
MAILING ADDRESS
- Oily or Town Slain Zip Cade SCL�I-L
-). Z g' 5-- 1 ' ` 4 2f•aF574c-
- to
tee coda- Phone number
8, WELL DETAILS: a!
a. TOTAL DEPTH:
6
b. DOES WELL REPLACE EXISTING WELL? YESO N{i '
o. WATER LEVEL Below Top of Cooing. fT.
(Use -+• If Above Top of Cooing)
d. TOP OF CASING 18 FT, Above Land Surface'
'Top of ening Laminated ever below fand wrist* may require
a variance In marance 1Mth 15A NCAC 2C .411B,
e. YIELD Wpm):METHOD of TEeT a/r,, s,.s-T,
f. D1SD1FEicTIONI Typo M f�/ Amount f ue f
g, WATER ZONES (depth):
From To From _ To_
From To From To
From To From To
7. CASINO; Depth Diameter Thiduleaaftnipbt Meterlal
From To FI,
From TO FL
From To Ft.
8. GROUT: Depth
Depth /Animist
From e) ToL366 Ft
From To Ft
From To Ft
5. SCREEN: Depth Diameter Slot Size IAMarl al
From To F. In. in.
From To Ft .Irl, in.
From To FI. In, in,
ID. SAND!QRAVEL PACK:
Depth Size Material
Fro To Ft.
Fron To, Ft.
From To _Ff.
11,DR/LLINa LOGI
12. REMARKS:
1 cad °
f ei- ?}
Method
f1r
I bd liElre CERTIFY THAT T,ne WELL WAS CQNSTllLIM° tri ACCORTmCC WOH
18A tiC O 2C. Witt CONEOWUC1ION erAnomea. Ago i HAT A COPY OF Tine
Rt'GO yRo'YllwTOTHE
9.J.G lRTURE < CERTIFIED WELL. CONTRACTOR DATE
PRINTED NAM OF PERSON CONSTRUCTING THE WELL
Submit the Original to the DtvlsiOn of Weiler Quality within 30 days. Attn: Information Mgt.,
1617 Mall Sorvlco Center— Raleigh, NC 2789•1617 Phone No. [phone] ext 588.
14-rs o- co`ai cf e o /7 .� sf - D w/ce
Form OWlb
Rev.12/O7

NO, O,N R.ESID.ENTM W , COantUCoQlkulECO ]-
Natth Carolina Departwcnt o£I3avIrcrimsnt end Natural Resources- Division of Wafer Quality
WELL CONTRACTOR CERTIFICATION if 3 5~ 1
I. WELL CO i (R' "1-0 V
I�wAI If �, ,r -t-
Well Contractor (individual) Name
Yadkin Well Company, inc,
well Contactor ComPattisrhiat IrpEuf pas need
STREET ADDRESS Hariiptonvrile, NC 27020
City or Town Siete
1{tr, h{ 6
LA..-
Zip Cods
9 7 g)
Phone number
2. WELL INFQRMATTON1
SITE WELL IO fctappllc Ne) 0----
. WELL CONSTRUCTION PERMIT#I(If appiiabte)
OTHER ASSOCIATED PERMIT 1(Ir applies bte)
S. WELL USE (Check Applicable Box) Manitwring
lndua lal/CommercieiU Agr1a1 ureII1 RecoveryU
Irrigatiori3 011ie j4` (list use) e a
JV /It V AQ/ cf./-
i Munldpet1PublIon
tnjedion0
f !r[�,_...( � uA�
DATE DRILLED fa —a, w,2C1o4
PM
_4l telt /I try
TIME COMPLE1 U ,? . 0 U AMO
4, WELL LOG TION:
CITY: A to W 43 i??v ae CCUH1Y
!/
(street' Name, Humbare, Commurllpl, Bubdtvtste , Lot No., Parcel, ifp Coda]
T POGRAPHIC f LAND SETTING:
lope 0 Wiley fl Flat ❑ Ridge (1 Other
(shack appropriate boxy
LATITUDE
May be !odorous.
scs.
mirrutrs, seconds or
in a etch al forma
LONGITUDE
Latitude/longitude source: 0 OP5 U Topographic Map
(location of wag must be shown art a USG/Slap map Aad
attached to fls harm 11 net using GP. )
C.PRO}LtTY-$sel. now ofelstosrnaaaw thaw 3mew.
FACILITY TO It(if applicable) - S 8
NAME OF FACILITY 414 X .s 1.J .r h�
I ,p
STREET ADDRESS l% / /'� (-1 1 f re ► /1 ' i,
City 6r Town Slats Sip Code
CONTACT PERSON / /ir[� ,
MAILING ADDRESS
4* Clly or Town State
rf � }-2 -fl?q
Zip Codo ,fr..tti
s,- 1z
YEW N91'
FT.
Area code • Phone number
O. Wrxf.t. DETAILS;
S. TOTAL DEPTH;
b. DOES WELL REPLACE EXISTING WELL?
a. WATER LEVEL L Below Top ❑! CatIng:
Nee.4' IrAbova Top of Casing)
d. TOP OF CASING 18 FT. Above Land Surface.
*Top of ea 'Mg terminated aVor bsiawls nd autism may require
a varlance to accor1d nee K1th ICA NCAC 2C .0116.
e. YIELD (gpm): 72 METHOD OF TE81" G j.. r..
D181NFECTION: Type j/i/i` Amount
WATER ZONES (depth):
From TO From To,
From To Frorrt Tc
From To From To
7. CARING; Depth Dla motor ThkkrumsAs'e:pht Material
g•
Frorfl r _ _ To FL
From_ , To _Ft
From To FL�
S.ORLIInt Depth Malerfal
From 0 Te JOO Ft
From_ __ _To Ft.
From_ To__ Ft.
Method
9, BCflEEN: Depth Diameter Slot Bin IAalerlel
Frort Y_ To Ft, In. In.
From__ _ ___ To FE. In. In. -
From To FL fn. In.
10. SAWDIGRAVEL PACK:
Depth Size Malarial
Frarn To FI.
From To . FI
From To Ft,
11.DRILLING L1X
From o
--
1 2. REMARKS:
Formation DeAoriptfon
t �
ul'�6/)S r r�"loi4e/ fc,
co-ed rat,
I eo Heaurr Ce RIIFY TlhAT MS WELL WAS CoiarRUOT ED lt: ACCORDANCE WITH
FE1 NOW 20, WELL Corl&tRLI Tr on STANDARDS, ARO THAT Amp.. oe nee
RECO T1�THE rR _r14`,66.7,r, E I d 3 `U
SIGNATURE OF CERTIFIED WILL CONTRACTOR DATE
MJ (+at% CO. V'L
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
of 1of,(1A
Submit the original to the Division of Water quality within 30 days. Mtn; Inforrnatlon Mgt.,
16117 Mall ServIoe Center- /fRaleigh, NC 276 9•1817 Phone No, ($19} 733-7016 ext 66B.
f -; 6- e-cLR.W Cr Ct e ev trs.y e'l efti L " D Alit S
Form GW-lb
Rev.1 TJo7

OYRES AAIMAL WELL cons cnorq RECORD
t+Torth Molina Department of tiovironmlent and Natural Resouroas- DIv1eloo of Water Quality
WELL CONTRACTOR mum CATION # '?' 1
1. WELL CONTRACTOR'
�Vl i !#v(t 4 cvt
Walt Contractor (Individual) Na
Yadkin Well Company. no.
Welt Contractor CorrtiAWArkdaiti kn lwitiv f 1o&1
STREET ADDRESS Harn(7tonviile, NC 27020
City Or Town State
?3,l• Y -4/e-14
Zip Code
7 ?
Area coda- Phone number
2. WELL 1HFQt:k1.TAT1ONl
SITE WELL ID }rp( epplrceWte) ,44
• WELL CONSTRUCTION PERM1TNat applicable)
OTHER ASSOCIATED PERMIT Sic I applicable)
3. WELL USE (Check AppllCable BOX) MoRllortngf
IndueldertCommarc.JalO Agrlcul ra&D RecoveryD
IrrlgatlarO Othaiirr tat U16) e f-Xr
Lei." C -/ O : d
MlrntdpatIPubllcD
lnleaiiori:)
ern---_( / 0
„
•
.
DATE DRILLED 3 1 _ eo ?
1
I'
PMtr
a i r., j a
TIME COMPLETED 7 : U 0 min
4. WELL LOC TON:
CITY: Is I0 W .t (` COUNTY
/
($treat Name. Numbers, Community. aubdhMdfoh, Lot No., Parcel, Decode)
AP°GRAPHIC / AND SETTING:
lope 0 Vettey 0 Flat i3 Ridge U O1ho r
(oheckappreciate box)
IAT1TUQE
Mqy be in degzoW.
mfnutcs, amorrds Qt.
a dcolmet fbrmak
LONGITUDEIn
Latitude/longitude source: 11 OPS 13 Topographic map
(lonallon of well must ba shown on a USG& repo map and
attached la this Form If not vents GFS)
0. FACILITY -Is uha rwttiafOlt bulimia tome+lhewroalo fed-
FACILITY ID#(Ifeppllcable)
!x)C -3-NAME
/
OF FACILITY 'L %1C4"``
STREET ADDRESS x
cortbs. 1c l�C-•
ORy dr TTown I State Zip Code
ERSON / .
CONTACT PC
MAILING ADDRESS
Lit City or Town Stale
code- P `n
Zip Code I [c{ft
2 �DG' L
YESa NO)`
FT.
mber1�'
Area number
a. WELL DETAILS: Q� 4
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL?
a. WATER LEVEL below Top of Cooing:.
(Use'+' If Above Top of Caalog)
d. TOP OP CASINO IS FT. Above Lend Surface`
'Top of casing terminated atior balawiand aurtace may require
a variance In ern ee�aa wlRI f5ANCAC 2C .011B.
e. YIELD (gm):i r METHOD OF TEST et/
f. DISINFECTION: Type i �d' Arnaunt �f
g, WATER ZONES (depth):
From , To From To
Frain To From To
From _ To From To
7. CACHO: Depth Diameter Thi isnewi.vefght Meteriol
From _To
Front To FL
From To, FL
6. GROUT: Depth Material Method
From Ta .3 Gb FL 104-1• tt..,
From To FL 'r
From To Ft.
SCREEN: Depth
Diameter Slot Size i.ialedat
From To FL in. In,
From To FL_ In. In.
From To Ft s -_ In. In.
10, SAHDIGRAVEL PACK':
Depth Size Material
Front_To Fi.
Nola To _ Ft.
FronT To Ft.
11.0RILLIM LOO
From yo Formation DeacrIptton
a.r 11
�tl"1 C rJ n( r Ci 6 t
(4') eel G f 4 Fl f f e
12. REMARKBr
T 00 HEREBY cat/!Fr THAT -rem WELL WAS CONETRUr [D IN ACCORDAHCEYRTH
1 HA NCAO2C,YfetLeOn3TRUCTION OTAND.ARDS,AND 7NAT A COPY OF Tf{!8
RECORD HAS eQEPROVIDED 7t1r:lYELLCI�INER. " 21 —
0? •
DATE
SIGNATURE OF CERTIFIED WELL CONTRACTOR
U/I rt
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ne( V�Lt (1
Submitthe orlg.�nal to tno DIviston of Water Quality within 30 days. Attn: Information Mgt.
1617 Mail service Center- Raleigh, NC 276 84E17 Phone No, [phone] ext EEB.
e- c`4,, rJ d e a./.y afref R11. e
Form OW -lb
Rov.12!07

NONRESIDENTIAL WELT. CONSTRUCTION RECORD
North COMMIS DapMtznc st of Eovimnment and Natural Ramos- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 5 7).
1. WELL CONTRACTOR:
70e1L () PA0\VI
Wolf Contractr (individual) Name.
VVell Company, inc.
Well Contractor ComilIzi rMafT1PtUlIvtll9 -load
STREET ADDRESS ramptonvlll$, NC 27020
City or Town j Slots
(33 �ra /-�)- 40 4
Zip Code
7 g0
Area coda- Phane number
2, WELL INP,O>{ RATION:
SITE WELL ID ■{If rpplkahte) 144
. WELL CONSTRUCTION PERMITIkd applImblo}
OTHER ASSOCIATED PERMIT Of appllcabio)
3. WELL USE (Check Applicable Box) MonitaringO
Industrleitcommerdatn ABrlsajt rain Eta
'Moiled:I MO,} 9�jj:sl� use) 6../.4
1v IQ 4'010140L
MunldpstrPubilc0
veryp injecllori}
e (.ln...., /..
7)
DATE: DRILLED 1 "?C.1 • 6b'
?MO
w%J ' Li t.ra r,..
TIME COMPLETES] AMU
d, WELL LOC T1ON:
CITY: Ar `o c•' rl (Po ateCOUNTY
�
52 / rI < .6., E—r..-/
(Street Hama Numbers, Community. subdMrlol,, Lot No., Penal, lip Code)
APOGRAPHIG l LAMD SETTING:
lope 0 Valley 0 Fiat 0 Rldpa t Other
(check appropriate Los)
LAT{TUDE
May be. In &grass,
reroutes, woods or
to a deotmnt fprTI t
LONGITUDE
_
Latitude/1041 edo souroe: a OPS 1] Topographio map
(locallon of wall must be shown on a JSOS ropo rep end
srinched to this farm If nor using OPS)
6. FACILITY- Is the nerve of Ms !van$ 4 1M ki1 le !Darted
FACILITY ID s(If appllcabia) C. S P' /d
NAME OF FACILITY ,L /ii et it
!l[
STREET ADDRESS e r s-
,gip
li 4(
City7rTovn ) late Zip Code
CONTACT PERSON / /. .,
MAILING ADDRESS
4,1�r► City or Town State
($ZU ). 295-,9V `€‘4 b'2.v-
Zip Code rehlrw
5'4
YESO Nii:Ar
T.
Area code • Phone number
I, WELL DETAIL; ,
a. TOTAL DEPTH: 366
b. DOES WELL REPLACE EXIST1HO WELL?
o. WATirR LEVEL Below Top of Ceslne:
(Use +' If Above Top of Casing)
d. TOP OF CASINO'S FT. Above Land Surface'
Top of casing lermInated alloy below land surface may requlra
s vallanee In accordance with 16A NCAC 2C .011 A.
tr. YIELD (ppm): 1 METHOD OF TEST iv)...
f. DISINFECTTONi Type t1 ref( Amowst______�r
g. WATER ZONES (depth):
From To From To
From To, From To,
From To From - To
7. CA91HO: Depth Minister ThiatnaaENM ht Mnterio!
Frora___To Fl.
From To Ft._
From___'__ To Ft.
S. OROUTt Depth M Iorlsl Method
From, O To 36oFl 4414-
5/0
From To f.
From To FL
9. SCREEN; Depth Dlameler Slat Sizo Material
From To FL in, to.
From _To FLJn. In.
Frorn To FL In, in.
13. SANDIORAVEL PACK:
Dapih Size Meterlal
Front To _ FL
Frorn To - Ft.
From To Ft.
11.DRILL IRO Lac3
From t Formatia sect Uon
rd-
12. REMARKS;
t no Km EBY OS/STIPY THATTHIS WELL WAS OC{NST WOTEP 1irA0CCRMOfi WITH
1&A NCAC 20. Ness eoN sT R#A: rtOR STANDARDS, APO THAT A COPY OF IN1B
etES? PROVIDED TOMEWELL ER.
ATUR CERTIFIED WELL CONTRACTOR DATE
1A.) CV\ Its
PRINTED NAIlE ❑F PERSON CONSTRUCTING THE WELL
Submit the original to tha Division of Water Quality within 30 daya. Attn: information Mg&,
1617 Mall 3errrlee Center -- Ralalgh, HC 2769.1617 Phone No. (19) 733.7015 axt B68.
14-rf c-ctco' cc, dee 4.Y/7 v7 rf D 'W.rd
Form GW-1 b
Rov.i7J07
P4.

NON ON RESIDENTIAL Wi,LL CONSTRUCTION RECORD
North Caro]Ina Department of Environment and Nalurai Reaouroe DDivlslonroof Water Quclfly
WELL CONTRACTOR CERTIltxCA.TION ) 4
1. WELL CONTRACTOR:
AA f [4-di E c,vti
Well Contractor (IndlvtdUal Name.
Yadkin Vela Company, Inc.
mu Contractor COrriMA AM IOU! Ivtlltr Road
STREET ADDRESS Hamptofivllle NC 27020
City or Town Stale ZIp Code
Aloe code- Phone number
2. WELL INFC(7MATIOH:.
81TE WELLID ii(ltapplfeabts) A44.7= 7 1'/
. WELL CONSTRUCTION PERMtTNQI appileabie) Hibl'M i L',—
OTHER ASSOCIATED PERMIT (If oppllcable)
3. WELL USE (Check Applicable Oo%) Manitorkkgt3 MunrdpeVPubil
industrielvCemmerclela Agricul ral0 Recovery3 inieGtion0
irtlgaUorO Otha f pistusa „ -e a �G,....( + op -
DATE
DRILLED_ 4 `)--- 2-6 0
TIMECOHPLEIVO S. , 00 AM PMtji"
4, WELL 1.00 TION1
CITY: t/o Lo rt ay Po Get' COUNTY 644 hfrrt'�
(Street Noma, Numbers, Demrnvntly, Subdhiskl4, Le! Ile., Piro , lip Code)
POGRAPHIC!LJ DSETTING:
tope d Valley 0 Fiat 0 Rldga I
(check appropriate boxy
LATITUDE
LONGITUDE
Latitude/longitude souroe: D GPS 0 Tvpagraphio map
(ooatten of wed mud ba shown on it L►SGS fopo map and
attached to !his farm rfnof °slag OPS)
May beindegrime,
minutes, seconds or
in ze chim& forme!
Other
S, FACILITY•rsthe hams athsha/nets Oars uwe ro Focetea.
/
FACILITY ID #pf applicable) r' r GY C S /I
NAME OF FAGlL1TY r . 4��' Q t h
STREET ADDRESS , 2,� 4/4
a ‘ ,p •
CityOr 7ow�r1 r �� r S Ste u G Tip Cade
CONTACT PERSON ��.� .
MAILING ADDRESS
L•1r City or Town &into zip Coda $ a!s-.
Area code • Phone number
O. WELL DETAILS:
a. TOTAL DEPTH:
do
b, DOES WELL REPLACE EXISTING WELL? YESIO N0 '
e. WATER LEVEL Below Top of Cesing: FT.
(Use if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top etoesing termlReled atlorbelow land surface may require
a variance Ina eoort ce vAlh 16A NCAC 20 .01 i8.
e. YIELD (gpm): I METHOD OF TEST��
f. DISINFECTION; Type if ArdOUrrt r-uepf
g, WATER ZONES (depth):
Frain To From , To,
From To From To
From , To From, To
7. CASING Depth Die mator ThIttlneae4Weivht Material
From J To Ft,
From To _ Ft._
From 'co FL_
8. GROUT: Depth Malarial
From 0 Tc,36 , FL,
Fmm, To Ft
From_ _ _ Ta Ft,
9.8CREEH: Depth
Method
Diameter BIoI Size Malarial
From • To FL In. in.
Fro MTo FL In. in.
Fron To, FI. ,Jn. , In.
ID_ SANDIORAVE L PAC Kt
Depth 81ze Materiel
From To FI,
From To , Ft
From To Ft.
11.DRILLrNO LOG
From To
12. REMARKS:
Formation Description
[fin Curt 5r,146 're/ r - c.
(3l crt -t-41i -r
r pbin:nESYGfRTIFY THAr TNI8 VreU. WAS Pominticreo rii Accon W,NC6wYTH
1dAHCAC20,YYELtCONs RUCTt0ASrA}rQ+.ROS.ANDTHATA CQF'Yonto a
moon ttRS a Eel pnoviozoTOTrte WELL M 1 i:R.
q 11,f 3`•. E. 6! `O
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
i +ciA
PRINTED NAME OIL PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 3D days. Attn: Information Mgt.,
1617 Mall Servloe Canter -- Raleigh, NC 27$ d}-isi7 phone No. (919) 733-701 a ext 668.
C- c� Ott e 4.4,r7 vl (f. - p vie
Farm GWib
Rev.121o7

X ON RESIDENTIAL WELL, CONSTR1C lON RECORD
North Carolina Department of Environment and Natural Resources. DivIsIon of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 7 " f
1. WELL CONTRACTOR:
We Contractor (Individual. Nametlr C.
Yadl�ln Dell Company,
Wall Contractor CvmOtttilde lrrk afl1ptui 1vrlk fb&.
STREET ADDRESS IrlaMPtOrIVIIIS, NO 27020
Clgr or Town State
Area coda• Phone number
2. WELL INFDRMATtON'
SITE WELL ID OQrnppuesuo .44 i% - d F .
WELL CONSTRUCTION PERM1T#Ql ■pptkable)Waged 1_ e 4—
OTHER ASSOCIATED PERMIT#(II appllcabia)
3. WELL USE (Check Applicable Sox) Monitoringp Munldpat&Ptrbilct)
fnduatrIal/Commsrc 9FO Agrfcu ura[p Rs veryfl In;ectorsn
frrtflalforE Otht3' gist use) p {! �.� ,.� ii 4J
DATE DRILLED r i 0q I
T1HE COMPLETED ) (.k) AME3 F
4. WELL LOCATION'
CITY: tis t' it r"1 j a arc' COiJNTY to y na
Zip Code
(Stma1 Hama. Waters, Community, Sut+drvrrkh, Lot No., Parcel, Tip Coda)
TOPOGRAPHIC/UM SETTING:
Mope 0 Vitally 0 Flat O Ridge 13 Older
I (check:ppmptteto oil
LATITUDE
LONdITULE
Latitude/longitude source: 0 OPS ❑-Topographic snap
(location ofwall moat 1)a shown one USGS fop* map end
of/ached to this form 1f not tieing GPS)
May be in degreas,
Mao las, aaondr or
n1 n dolma' format
6. FACILITY- re me name dose waneea when trt6WM Tf rotated.
FACILITY 1D #(Irappllcebl) C s # /2—.
NAME OF FACILITY��^rC!^. �c 4 j4 rt h.
? STREET ADDRESS co/ /5..*.I r H r.t+ i,
City, r akvn ) Stela Zip Cade
CONTACT PERSON■�, .
MAILING ADDRESS
City or Town State
( � � a- Z 95—, 4?e
Area code - Phone number
a, WELL DETAILS:
a. TOTAL, DEPTH:
b. DOES WELL REPLACE EXISTING WELL?
a. WATER LEVEL Below Top or Casing:
(Use'+• If Above Top of Casing)
Zip Coda Stcfil
62s
YEen NO ?'
FT.
Submit the or Dina' to the Division of Water Qulallty within 30 days. Attn: Information Mgt,
1817 Mall Service Cantor — Ralolgh, NC 278 9.1817 Phons No. (910 7334016 ext 668.
4,—rf - BLS el de e �.,r`7 ' oeff y ` k7 w.'d
d. TOP OF CASING 18 Y FT. Abova Lend Surface'
'Top aiming terminated aLF r below land surface may require
a variance In aecolnonoo vNlh 15A NCAC 20 .0118,
o. YIELD (opm): �f_ METHOD ar TEST
f, D18INFECT1oNt Type U rr,, Amount [z
g. WATER ZONES (depth):
From To
From To
From To
T. CASINO: Depth
From_ To__ _
From To.
From To.
Diameter ThftrvlaaaNsbyhl Material
Fr❑m ; To '— Ft,
--
Freak To_ FL
From______ To FL
D. GROUT: Depth Materiel Method
From To FL "u'1.''.
Fmm_To F• .
From To Ft
S, SCREEN: Depth DIaMeter Bfat Size Materiel
From _ To FL In. 19.
From To , Ft`_In, 1n
From To Ft. In. In.
to, BANDJt MVEL PACK:
Depth 84xe Malaita!
Froth ^,To FL
From To - FL
From To Ft
11.AR1LL1NO LOG
From To Formation Dascrtptfon
40 • L{/1or3 Sry fr +rt
rd O i (o
t2. REMARKS:
1 DO HEREBY CUM FY TRAI THIS WELL WAR CONSTRUCTED IN AMOR mace VYFr1S
SSA TIC.AO24.wELLDOH8TRUOTIOU STANDARDS, AND THAT A COPY OF THIS
RECORD KA8 a EE!{ PROVIDED TO Tile WELL OWNER_
` 51 E. 6 f -- E —69
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Ali I' n E Cckt�c
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Fawn GW-lb
Rov.12101

NON RE.SIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depertmont otteVltvument and Natufnl Re oases- Division of Writer Quelfty
WELL CONTRACTOR CERTtPICATION # ' 5 `7 L
-r.
1. WELL CONTRACTOR:
SAL k-t1l'1°\IZS
Well Contras ar (Individual) Nome Well Company, Mu,
well caahactor ComjialArklarr 1 PIO 1 Idle Fload
STREETACDRES8 Hamptonvil le, NC 27020
City or TTovm �j/"T 4lSiete
24 ( )- Cad:-/-/. 6
Zip Code
7g3
,
Noe code- Phone number
2, WELL INF9 lMATtt H: A ^J�--
sire WELL 1D #t1f app1Y.abte} 44
• WELL CONSTRUCTION FERMI -MN apPiicableVeld
OTHER ASSOCIATED PERMIT#(lf applicable)
3, WELL USE (ChechApplicable Box) MonlladngO
lnduatrfal1Comrnercle1a A ricul ra10 Recovery'
Irrigation:I Cthe let Lao) �
DATE DRILLED 10,-36— 4
►do le �.
MunldpdWublIcD
In)ecrior�
� Ur.,, __ � _ +
PM0
fiel wd sr.
LIMB. COMPLETED AMO
4. WELL Lot: 11ON:
CF1Yr AIt tk_ COUNTY
(Street Nemo, Number', Common*, Subarlsrah, L91 ko„ Neal, llo Cede]
irOGRAPHIC / LAND SETT]NG:
pe l] Valley R Flat (IRidge El Other
(check spprvprlelo box)
IATITIJOE
May be In depseaf.
minuur, seconds or
hr a declnlal format
LONGITUDE
^
Latl[udoliongitudosource: fl OP 0 Thpooplt{omap
Vocetron of well must be shown on a tISGS tope map and
attached to this form if not using GM
6. FACILITY to rite Tarns e4 ere WNnessr,rwe insvree re tasttd,
FACILITY IDg(irapplicable) e C(f % 3
NAME OF FACILITY ( /// jilt A..
STREET AOQRESSJ- / / c� �r1.
,
/34 l
�C1 own Simla 74 Cade
CONTACT PERSON / jtr6 .
MAILING ADDRESS
L.rre��A Clly ()If Town Slate}
tf - 2 Y a--i f `e e �-2.
Zip Code
r $
y_ )5 4S
061 Z
YESii NO T`
FT.
Area code - Phone number
s. WELL DETAILS: t
a. TOTAL DEPTH: .3i U
b, ❑OES WELL REPLACE EXISTING WELL?
o. WATER LEVEL BoIowTop of Cueing:
(Use'+' If Above Top of Caaing)
d, TOP OF CASING IB FT. Above Lend Surfric6'
'Top of casing terminated slier below land surface may require
a variance do acootdence with 1 BA NCAC 2C .0118,
o. YIELD (ppm); METHOD OF TEST
'
1. o181NFEOnoNlTypo Y9' Amount ° fl
tt, WATER ZONES (depth):
From, _ To. Frain .To
From To Frorn _ - To,
From To From To
7. CASINO; Depth Diameter "mkaueasine Ight Msleire I
From To Ft.
Frorq To Ft
From To Ft.
3. GROUT: Depth Malarial
From C ,To ?0OFt.
Fmm To FI,
From To Ft.
S. SCREEN: Depth Newsier Blot Size Material
From To Ft., -_ In. In.
From To Ft In. In.
Frorq To Ft., In, In.
10. $ANR=RRAVE:L PACE
Ooptrt site Weds)
From To FL_
Frain Ta PL
Front, To FL.
1 1.DRILLtNG LOG
From 1°azsA,°on „kip
0
7 CstOs
Method
la, REMAF KB;
r CO HEREBY CERTIFY THAT THIS WELL WAS COdreT RUCTSO IN A000ROlU1C a WTI m!
16! UC O 20. WELL cOH3 UO7:ON srmorwOS. AHD/HATA COPY OF 1H1
DE 1PROY10ROTOTH!! LTA
Alt/RE +d�F CERTIFIE WELL CONTRACTOR DATE
PRINTED NAM OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality 'within 30 days. Attn: Information Mgt.,
1611 Mail Sorvloe Center — Rafelgh, NC 27899.18i7' Phone No. [phone] ext 668.
!Y`rr `61.1 EdtJU" {�e 4A'ff7 92 — } 4444
Form GW-1 b
Rev.12/07
13

.NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Oapertment of Bnvtmument and Natural Resources, � Division of Wetar Quality
WELL CONTRACTOR CERTIFICATION # 5- P
1. WELL CONTRACTOR;
Mr
j i +oi E O[(r t
Welt Contractor (Individual) Ne
Yadkin"Wefi Company, inc,
Well ContraClot Com >aAtir Iia iip{Qr 1vilia Fiead
STREET ADDRESS :HamptOnvilI9, NO 27020
City or Town Stale
i?,31• 47G2'rid' 4
Zip Code
7 P'
Area code- Phone number
2. W LL EHFDRMATION:
$ITE WELL iD NOAppt!cable) /44 X2-
• WELL CONSTRUCTION PERMIT#F(Mr apAlest4ey14f1O
OTHER ASSOCIATED PERMIT'1(iI applicable]
3. WELL UBE (Check Applicable Bok) Monitoringr)
rndustrfeilCammercial❑ Agricul urala Recoveryd''
irrfg91Ioril Oche let use)n ti%.�j
GYD 4 /a:,F.--
.
Munldpala:ubll ]
Iniecilo
�r�. / op
-
DATE DRILLED -..�� -
Pic(
1
)4 jcird .,
TIME COMPLETED - 0 U AMO
4, WELL LQC TTCN:
CiTY: rr o w rt rl', r COUNTY
_S" I /I sr./c4_T Pr—y
(Street Hama, Numbers, Community, gubdlvisin , Lot No., Nice?, 7!p Cods)
T POGRApt1IC / LAND SETTING:
• lope p Wiley 0 Net a Ridge 0 Other
(r h * appropdalC box)
LATITUDE
May be in degrees,
minutes, seconds or
in a decimal comet
L0NOITUDE
_ —
Latitude/longitude source: n GPs D Topographic, map
(laeation at wail nwaf be shown aria USG3 iapo neap and
attached fa Oils tam ',not using OF$)
6. FACILITY. n sui na w d Ni w+rRau ...dull 1hewetl Il finned. �,, C(
FACILITY ID Kg appllcabrro) ce ff- f `T
NAME OF FACILITY /etc iii 4 r--ee /,t ►._
STREET ADDRESS $o / /5'6= !_!f Ae r r r kJ
0/ t GLc. -
Oily r am Isle 71p Coda
CONTACT PERSON / /tl• .
MAILING ADDRESS
Litr CityorTown�State
� • Zy5-1 l4' 4 23'2.
Zip Code SCE
y- 1is--
O a l Z
.
YESO NO '
.'r.
Area code • Phone number
6, WELL. DETAILS; ` 1y
B. TOTAL DEPTH:
b. DOl?8 WELL REPLACE EXISTING WELL?
c. WATER LEVEL Salem Top of Casing:
- (use `a." 1rAbove Top al Casing)
d. TOP OF CASINO is FT. Above Land Surfs Ob.
Top pleasing ierminalad atier below land surface may require
a variance to accoMee with 10A NCAC 2C .011 a.
e. YISLD (q pm): OF TESTTA/
f. DISINFECTION: Typo ji, 7, Amount
g, WATER ZONEs (trepthj:
From To !"ram To
From To From To
From To Frorrz_� To
7. CAsING1 Depth Diameter ThkivrssedWileht Materiel
From To r Ft. --
From To Ftti
From To ,-FL
a. GROUT: Depthr� Metarlat Method
From D To 3o) Ft / .4Iy'
From ,To Ft
Frarq .To F.
V. SCREEN: Depth Diameter Slot Stze Materiel
From _To Ft. In. In.
From To FL In. In.
From To Ft. In. rn.
la. SANDJORAVEL PACK:
Depth Size Materiel
Froth To Fr.
From To FL
Front To FI.
.DRILLING LQO
Fronn
o Formation Do9criptlon
r :r
CIO):Ace fib( r c
5 - ./I r1'1 .t er--!a A i t
12. REMARKS:
I DO rtetteBYCf]IT1'e'MAT Ttas WELL WAa 0.O1i8TRUQTED 1I1ACOORCA1Ci WITH
1 AHCAO20,WELLCON STRUCTTON SrANWRDS,M B]THATACOPY OF THIS
RECORD WS9EE.1PROVIDE°TOME Mil OWNER.
fr. C f 2730-��
SIGN RE OP CERTIFIED WELL CONTRACTOR DATE
r 4,1 CGt -t
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
' J.irT�� a �!n
Submit the or nab
gto the Division of Water Quality within 30 days, Attn: Information Mgt„
1817 Mall Service Center-- Raleigh, NC 77890.1617 Phone No. [phone] ex# 688,
Form GW lb
Rev.12107

NON ONRESIDENT.IA.L WELL CONSTRUCTION RECORD
Notiil Carolina Department of eVironment end Ntltural Resouroos• DIvialon or Water Quality
WELL CONTRACTOR CERTL LC/tT1ON 0 3 5'4
4, WELL CONTRACTOR:
Well Contractor (Indlvldtre Name_
Yadkin ell Company, Inc.
Wolf ConbentorCornUaldar htri llutiville Plead
STREET ADDRESS ' amptofVllle, NC 27020
City or Town state 23p Coda
134 . / iel4i
Araa code- Phone number
2, WELL 1HFDSMATION:
SITE WELL 10 Vappikettel '4 e �S
WELL CONSTRUCTION PERMITh(1f opplkabte) W/4.04,dr2
OTHER ASSOCIATED PERMITapplicable)
3. WELL USE {Cher* Applicab}e Box) Monttor1ngri Murtldpal/Publlc°
IndusirteltCommarclefa Agrlcul relp Recovery'} 1njectforCf
lydgatlorO Other Gist use} ' a. Gl[�y/� [r f /
DATE DRILLED I 06 ci
TIME COMPLETED a. • /) 6 A>i❑ P
4. Wa:LL 4.00 71ON:
CITY: /d W �� r» f 'Zk COUNTY A ' 6Z ct7, G '
(8 m t?arrm, Numbers, Community, 8ubdhieh!, tot No., Farcef, AI Code)
TOPOGRAPHIC PHIC / LAND SETTING:
§lope D Va}!sy O Fiat El fildge f7 Other
(checl4 eppr„prleta box) May be In degrexs.
LATITUDE ERN les, seconds or
inadeaimidtarmac
LONGITUDE
Lauttudc/Iongttudo source: 0 COPS i} TopagraphIo map
(loGalion o1 well mtidt be ehDR; on a USG& tapo map and
effechodlo fhb farm Ifnaf wing GP$)
s, FAOIL(YY•ti the twee orthe botnsssv,twsJthirvng fe Napes.
FACILITY fD tx(Irapplicable) /� GY (X
NAME OF FACILITY eftCr^ [•r,
STREET ADDRESS Si] / # 4C* e H Y ` 4,/,
13,;GI riIn+
Cityr Town ) 1a4e Zip Cade
CON TACT PERSON
MAILING ADDRESS
L,ree . City or Town Stale
4'41 1- Z/S--LCir
Area code - Phone number
Zip Code 5'04-k.�
,& 57Ij c
O. WELL DETAILS:
a. TOTAL DEPTH: 3 0 V
b. DOES WELL REPLACE F.XIWTlNU WELL? YESU N9
e. WATER. LEVEL fBIow Top or Casing: FT
{Use'+" I! Abova Top of Casing)
d. TOP OF cps [IN 4 !8 FT. Above Lend Surface'
'Top of cuing terminated allor below land surface may require
a vattence In accgrda ca with 15A NCAC 2C .Di i0.
a YIELD Wpm): + METHOD +a TESL
i, D1S]nFECT1UH: Type 4 2ft
r''F'br
Amount
g, WATER ZONES (depth),
F vm To From To
From To From To
From_ To Front To
7, CASING; Depth Diameter ThletuseaadWolght Hated
From To
From To FL
From _Ta Ft. _,
8, GROUT: Depth-7 Meath! Molhod
From D To 5VO FL f44.0,14
Horn._To F! I
From To , Ft.
S. SCREEN; Depth DIeMoler Slot Size Matedat
From To FL fn.
From To FI.
From To FI, In.
10. SAND/GRAVEL PACK
Depth
Sri° Malarial
Frorrt_____To
From To . FL
From To Ft. _
11.DRILLIHO Leta
From To Formation Description
12. REMARKS;
r DDiteritoY CERTIFY THATTI S WELL WA8 CptiSTRUCTEO kNADOORGANCE YY4TH
16ANcA02C, WELL CONSTRUCTION STANDARDS, ANT) THAT A COPY OF'THIS
DECM 103SEEt PROVlOE0T4T e1NELI.OWNER.
�k tf s (41
• SIGNA�71UJRErOF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING 711E WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1817 Mali Sorvioe Center Raleigh, NC 278?9.1617 Phone No. t919) 733-7018 ext 688.
4--Gi�i.�Cry GT`/a aAd/e7 v7 del D iet•ed
Form GW-1 b
Rev.12/O7

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North CarolinaDeparlmeft ofRnvlrotimcnt andNalumi Resource-Divlafon of Water QualiV
WELL CONTRACTOR CERTIFICATION fi 4J
1. WELL. CONTRACTOR:
-
L g t ' `ok`3
_
Welt Contra or (individual) Na a � G
Yadkin VVo1I Company,
Wela contraclor DorrlitiRerattfripitn sviIIk3 i=3e&d
STREET ADD RESS HamptOnVIlie, NC 27020
City or Town State
>< 33 l• 4 !- 4'4a
Zip Dodo
( IS yfr
Arve code- Phone number
2. WELL INF9 .MATIOtlr a
SITE WELL 1D Npf applicable) 44
nT
- WELL CONSTRUCTION PERMITIF{irspplicab[ay
❑THER ASSOCIATED PERMIT. NU appilceble)
3, WELL USE (Check Applicable BOX) Monlio1fl
IndustriallCommarclalD Agrlcultura1R R`ecovery0
trs1pal[orf Olhe� Qletuse) 6- h.J/4
1VIOme/ G £
D Munldpa&I ublIcD
lejeetor31
rPin... �i
r f
DATE DRILLED_/»t3 fr ds
!!
FMD
We r r'i`4/ n1
TIME COMPLETED AMC:
4.WELL LOC TION:
CITY: Ala w Ft(F ck COUNTY
✓
S?Ierr 4,-,.-,
{Street Rama, Numbers, Cern money, SubdMMisioh, Lv1 No., Fircal, zip Code)
TOPOGRAPHIC! LAND SETTING:
lope 0 Valley n Flat 0 Ridge 0 Other
pack swop/tatobony
LATITUDE
_
May baindrWei,
minutes, sxmxt& or
Ina &armd form
LONGITUDE
LatitudctI.ongltudo source: 0 GPS C Topographlo map
[lcootron of well mutt be shown an a CJSL3S Iopa map and
attached fo firs foml !tacit uarng OPSj
6,FACILITY-it th. neplt,Wlinsurtneralhewelleiccgoi.
FACILITY ID SWRppllcabtn) T f
NAME OF FACILITY ' r .r h.STREETADDRESB
rf / t5 r.`r A e >- 19' /2(,/,
6-1 r` ecti G r- -
...._.. ,2
City or i own )I 5lalo 2Jp Code
CONTACT PERSON 1— jtr r, .
MAILING ADDRESS
Lei Clty or TOwrt �y State
t Z )• 2y1`-6 `'q
Zip Coda 5�i�r-,
'z —" C—
0 t. 9 L
YESD NO, '
FT.
AN a come • Reno number
6. WELL DETAIL®: i
a. TOTAL DEPTH:
is, DOES WELL REPLACE EXISTltl° WELL?
a. WATER LEVEL Below Top Of Casing:
. Oise '4' If Above Top et Casing)
d. TOP OP OASfHG IS FT. Above Lend Surface'
'Top of cluing terminated allorbelow tend nuders may require
a variance In aecordenoe with 10A NCAG 2C .0118.
e. YIELD (gpm): 2- METHOD OF TE T
f. DISINFECTIONiType h( rji Amount /,s.)/
g. WATER ZONES (depth),
From TO From TO
From To , From To
Prom__ To From TO
7. CASINO: Depth otometor ThIciumerWeIght Material
Fro al_r_ To F1,
From To Ft.
From To Ft.
8, GROUT: Depth Metertsl Method
From 0 To ,3ci o F — /r frirrit
From To Ft
From To Ft,
S. SCREEN: Depth Dlentela► Slot Size Mater1a1
From To Fl, in. tn.
Float TO FL In. !rt.
From To Fl. tn. in.
10, SANDIEIRAVEL PACK:
Depth Size Meterlel
Fmrn Tn F.
From To . Ft.
From To Ft.
11.DRILLIHO LOC
From
v � ;
12. R. MAR191
Formally s an
Oleo/& k
I e0 HERESY CUM PY TIiA'rThaE Witt Wl,B OO OTRUOTEo TrrAMOR MOM S VITH
I M CAC 2C.11EiL colt $TAUCri 0m srmom co. Ana THAT A COPY OF ma
REO=I1b 1 IA$ OEM FRQVipl:TO rpm weu.
FCERTFIEOWELL, ONTRACTOR DATE. .
4L-1U.) V 10cs
PRINTED NAM OF PERSON CQNSTRUCTINC3 THE WELL
Submit the original to the Dlvision of Water Duality within 30 days. Attn: Information Mgt.,
1017 Mail Service Center - Raleigh, NC 27899.1817 Phone No. [phone] ext 688.
4-ff & 4.6'41 icy ere t 41 /7 aX frt ` D 4C+rrd
Form QW-lb
Rov,12l47

NON RESIDENTIAL WALL CONSTJWcriON RECORD
Noah Carolina Dopariment of1nvironmcnt end Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # DL 5
1. WELL CONTRACTOR;
Weil Contractor (Indivfdua Name
Yadkin Well Company, Inc.
Woo Contractor ComOir1ir nktiarT1PtU1 iviiie (load
STREET ADDREas Hamptonviiie, NC 27020
City orr/Town
� S[llaatt`e
Area °ode• Phone number
2.WELL INF9RMAilONt J�
SITE WELL ID iforepposaws) 7 h"
WELL CONSTRUCTION PERMITW f applicable) 1V ihsd iG.'I---
OTHER ASSOCIATED PERMIT ;TV apafloat le)
3. WELL USE (ChecicApplicable Box) Montforinal MtrntctpaVPubllca
TnduslrtellCorrrnterclern Agracnf uralD R velyi] .Inject: riJi
TrrlgaUDr i Otho' (list use) &. ' a r 4.rn.. e ' e m
DATE DRILLED �J'O q I
TIME COMPLETED AKICi PM❑
4. WELL LOC T1ON:
CITY: A /o t,a rt � &ad__ COUNTY WO m/ �.
Zip Code
(Street Name, Number+, Community, SubdMsie. , Lot Ha, pima], 7Jp Cods)
APOGRAPlitO 1 LAND SETTING:
ivpe C VeIley t3 Flat C Ridge D Other-
tehoa appropriate tox] Hey ba In dogmas.
LATITUDE minute.% 5,x001I1 a
Ina decimal fbrmet
LONGITUDE
Latitude/longitude source: t] OFS C Tnpngraphia map
pace iron or wall must be shown on a t1SOS lop° map aril
attached I'd nits fame lino! using OM)
3. FACILITY- eale aerneareatwun.s+++nere wentriacated.
FACILITY ID Cif appllCablo)
NAME OF FACILITY /,et i 4 r-2-17 !•
STREET ADDRESS
,V//
59I 4fkIe s?' Ai
City r own Jute Zip Cade
CONTACT PERSON Z. f rL
MAILING ADDRESS
L e&_ City or Town pState Zip Code 5041-,
Area coda - Phone number Q g L
B, WELL DETAILS:
a. TOTAL DEPTH: r j 106 I
b. DOES WILL REPLACE EXISTING WELL? YESC NOX
el. WATER LEVEL Seiow Top of Casing: FT.
. (Use "+"If Above Top of Casing)
d. TOP OF CASINO IS FT. Above Land Surface'
`Top of caafng terminated silk► below le nd surface may ►equlre
a vs dance In accordance with 16A NCAC 20 .011S.
e. YIELD (Wpm); t NIET1IOD OF TEST pt,+fr p
I. DISINFECTION: Typo X/ 7, Amount %(4.-e4pr
g. WATER ZONES (depth):
From 'To From To
From To From To
From To From ,To, ,
7. CASINO: Depth Dfarneter ThloceassiWAIht Material
From , _Tv Ft.
From To i=t_
Frain , Tv Ft.
8. GROUT: Depth Malarial Method
From To t36` Ft �eiL�rs fJ
From . To Ft A i
Pmm To FL
S. SCREEN: Depth Diameter Slot Sim Malarial
From To FL_ in. In
From_ To FL_fn. In.
From To Pt. in. In.
I O. BAHRAVEL PACK
Depth Size Material
From To FL_____
From To FL
Frorsl To FI.
11.DRILLING LOG
From
a--
12. REMARKS:
r6„f t d-' S,lF iGCPS5a } 1s`Q4trikrc4
& W- G tery . i{�
I DO HEREBY cen13F! /11ATTHIS WELL. WAS coos -minnow Accorom Ct? watt
f M NOW TC, W t. COHSTRUcInori 8TA iC,AXO4, Alto THAT A COPY OF MO
CCO JI 11+4 8 t p r RO N CED 7p 71 e. �ft.
z7r %-1-oP.-
RE 0VCERTIFII:DWELL
I ONTRACTOR DAZE'.
lei- L?J P' 4) L5
PRINTED NAM OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1917 Matt Service Center - Raleigh, NC 278 9-1817 Phone No, (919) 7334016 ext as.
AL-rf GcAivit of c a.i frig tz eft( rr 0 'Wr c
Form r3W-lb
Ray.121p7

NON ON RUIDENTL41 WELL CONSTRUCTION RECORD
No-A-CarolinaDe artennt o£Bnvlmarraent anti Natural R,eanurces- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # P 5 7)
't.WELL CONTRACTOR: �
Oc�'L L1J ' r l LS 1
ell Contra for (individual) Newt inc.Yad Cin well Company,
WO CantractorCertlPEWkakd ID p LUEIVitiv r}¢o
STREET ADDRESS Hamet0nviils, NO 27020
City vrTown Slate ZZp Code
(? 3 ). TWO- 27'Z'4
Area code, Phone ntm1ber
2, WELL INF9RMATIONt
SiTf3 WELL JO 11(st appltoswel fFF-4 �7= fST
'
WE}.L CONSTRUCTION PERM1T#{sr app3icebla) IJJ0516'4 / G S--
OTHER ASSOCIATED PERMIT IT (I f applicable)
3. WELL USN (Cheek Applicable Box) Monlrosingf MvnldpaVPubllcti
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IrdgetlorD Othe4' (IIst uise) .n °.�. � y In. .+r ,• eyif
DATE DRILLED �) Oa'
TIME COMPLETED AMO PMD
4. WELL LOCATION:
CITY: ro V'it o GG -, coUu1Y u./.�.
(Street Name, Numhara, Coirmunfty, eubdIvii IX tot No., Pa roil, zip OCtda)
TNPDC3RAPHIC / LAND SETTING:
ape 0 Valley 0 Flat d Ridge iJ
(cheek sppropitala boo
LATITUDE
LONQn1J E
Latitudeliorlgltudo source: to 0PS p Topographic map
(loaaflan of wen must ba shown an a t/SGS fops map end
attached to ihls farm ?Mot uslrip GPS)
May bo In dearer-,
minutes, seconds or
In a deaisle; former
Other
6. FACILITY -it tru rwna orals Wrtnnaa wave IAs w 1 h fixated.
FACILITY ID Oat spa lcaWe)
NAME: OF FACILITY
STREET ADDRESS
41,
Cf r own Sleto
CONTACT PERSON 4 /e4. .
MAILING ADDRESS _
Zip Code
Orrea_ City or Tom Stet° Zip Code serf`
( � ). 275"--Y Lp`le`l S'- ' S
Area coda . Phone number p 6 g Z
6. WELL DETAILS:
a. TOTAL. DEPTH:
30
b. DOES WELL REPLACE EXISTING WELL.? YES17 N9AY
a. WATER LEVEL Below Top of Caging; FT.
. (use '+' I Above Top of Cuing)
a. TOF OF GAS/NO IS FT. Above Land Surface"
"Top of casing terminated RVor balm land surface may sequin)
a vs (fence In accordance wf Ih 16A NCAC ZC .0116.
o. Y1ELD;gum): 1 METHOD OF TEt3T �, w"
t. DISINFECTION: Type r4` Q Amount/
g. WATE R ZONES (depth):
From TO From TO
From Tv From Tv
From To From To
7. CASINO: Depth piemster Thldmass+Wolghl Welter
From _To Ft.
From __ To Ft�^
From To FL
9. GROUT: Depth Dated!!
From 6 . To 3o6r Ft
Front, To Ft.
From To FL
9. SCREEN; Depth Diameter
From To Ft: in.
From To
From To Ft, in.
10. SAHD!ORAVEL PACK;
Depth eke Material
From To Fl.
From To, . FL
From To FL
%DRILLING LOG
> ;nix,T9
12, REMARKS:
Slot Size
In.
1n.
Method
Material
FotTnBiinrlvicripil0
100 HEREBY CF_Jtrtn.MAT 71-as wrai WAe occaxhumED iN ACCORDANC6lrA7rt
takmoo 2C,wEt,4o1sTRucnoN swarms. AND THAT COPY OF TM
FEE ►1•• BE riPRpvioeoTOTHE W1:LL ER.
!r ��,:%�� 1 -?- D$
+�ATJREc'GCRTIFIED WELL CONTRACTOR DAT
;ram)) (/,.) trio 1 l is
PRINTED NW.iEOF PERSON CONSTRUCTING THE WELL
Rcc
Submit the original to the Division of Water Quality within 30 days, Attu! information Mgt,
1817 Mail Service Center Raleigh, NC 276 9.1617 Phone ND. [phone] ext 898.
/4-rf a cif/7 eff(%r D 40. e/ -
Form GW1 b
Rev,12107

Permit Number WI0400102
Central Files: APS SWP
12/16/08
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michaei.rogers
Permitted Flow
Facility
Facility Name
Richard and -Colleen Fain SFR
Location Address
571 Blackberry Rd
Boone NC 28607
Owner
Status
Active
Project Type
New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Lela Price
571 Blackberry Rd
Boone
NC 28607
Major/Minor Region
Minor Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Name
Richard
Dates/Events
orlg Issue
12/16/08
D Fain
App Received
11/18/08
Regulated Activities
Heat Pump Injection
Outfall NULL
Graft Initiated
Scheduled
Issuance
Owner Type
Individual
Owner Affiliation
Richard Fain
571 Blackberry Rd
Boone
NC 28607
Public Notice Issue Effective
12/16/08 12/16/08
Requested(Received Events
Region comments on draft requested
Region comments on draft received
Expl ration
11/30/13
1210110E
12/11/08
Waterbody Name Stream Index Number Current Class Subbasln

Permit Number W10400102
Central Files: APS SWP
12/11/08
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Permitted Flow
ar lire
Status Project Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Lela Price
571 Blackberry Rd
Boone
NC 28607
Facility Name
Richard and Colleen Fain SFR
Location Address
571 Blackberry Rd
Boone NC 28607
Major/Minor Region
Minor Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Name
Richard
❑ Fain
Owner Type
Individual
Owner Affiliation
Richard Fain
571 Blackberry Rd
Boone
NC 28607
Scheduled
Orig issue App Received Draft Initlated issuance
11 118/08
f.�' 15,ctivities
Heat Pump Injection
Public Notice Is
10)
Effective
RwnI:iPste!!Rer eivPdF,vP.if5
Region comments on draft requested
Region comments on draft received
12/01/08
12/11/08
Waterbody Name
Stream Index Number Current Class Subbasln

o uvNIF�
O' G
Cr}. 7
f'
Michael F. Easley, Governor
William G. Ross Jr„ Secretary
North Carolina Department of Environment and Natural Resources
Col een H. Sullins, Director
Division of Water Quality
December 16, 2008
Richard and Colleen Fain
571 Blackberry Road
Boone, NC 28607
Re: Issuance of Injection Well Permit
Permit No. WI0400IO2
Issued to Richard and Colleen Fain
Dear Mr. and Mrs. Fain:
In accordance with your application received November 18, 2008, I am forwarding Permit No.
W10400102 for the operation of a vertical closed -loop geothermal mixed -fluid heat pump
injection well system to be located at 571 Blackberry Road. Boone, Watauga County, NC 28607.
This permit shall be effective from the date of issuance until November 30, 2013, and shall be
subject to the conditions and limitations stated therein.
Please pay special attention to the bolded language in the permit. In addition, please
submit copies of the Well Construction Completion form (GW-1) and site map after
construction as required in Part I paragraphs 8 and 9.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit
an application to renew the permit three months prior to its expiration date. As indicated in the
permit, this permit is not transferable to any person without prior notice to, and approval by, the
Director of the Division of Water Quality. If you have any questions regarding your permit or
the Underground Injection Control Program please call me at [phone].
Michael Rogers, Envzra en#al Specialist
cc: Sherri Knight — W-SRO
Central Office File — WI0400102
Leia Wynn — ARCS Construction Services
Vaughn Brown — Yadkin Well Co., Inc.
Andy B]ethen — Appalachian District Health Dept.
Attachment(s)
N9nr Carolina
7vaturally
Aquifer Protection Section 1636 Mail Service Center Raleigh. NC 27699-1636 Telephone: [phone]
Internet: htij /Iwww,ncwaterqualitv.or 2728 Capital Boulevard Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
An Equal Opportunity/Affirmative Action Employer-- 50% Recycled/10% Post Consumer Paper Customer Service: [phone]

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21. Chapter 143, and
other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Richard and Colleen Fain
FOR THE CONSTRUCTION AND OPERATION OF 18 TYPE 5QM INJECTION WELLS,
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 571 Blackberry Road. Boone, Watauga County, NC 28607, and will be constructed
and operated in accordance with the application dated November 18, 2008, 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 only, and does not waive any provisions of the
Water Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an
injection well shall be in compliance with Title 15A North Carolina Administrative Code 2C
.0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well construction and
use.
This permit shall be effective, unless revoked, from the date of its issuance until November 30.
2013, and shall be subject to the specified conditions and limitations set forth in Parts I through
X hereof.
Permit issued this the f day of2008.
.L
VColeen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0400102 Page 2

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. T.he Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (I SA NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94 ..
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that
are generally subject to flooding include those with concave slope, alluvial or colluvial
soils, gullies, depressions, and drainage ways.
5. Each injection well shall be secured to reasonably insure against unauthorized access and
use. Each well shall be permanently.labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during
construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate
according to 2C .0213(g).
8. A completed Well Con$,truction Record (Form GW-1) must be submitted for each injection
well to:
Aquifer Protection Section -UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section -Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
GW-1 s must be submitted within 30 days of completion of well construction. Copies of
the GW-1 form(s) shall be retained on-site and available for inspection.
9. Well construction-records must also be submitted for the existing water supply wells on-
site as well as· a site map showing any water supply wells on adjacent properties as
specified in NCAC .021 l(d)(l)(D).
Permit No. WI0400102 Page3
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight ( 48) hours prior to constructing each injection well, the Permittee shall
notify the Aquifer Protection Section-Underground Injection Control (UIC), Central Office
staff, telephone number [phone] and the Winston-Salem Regional Office,
telephone number (336) 771 :..5000.
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to
change ownership, or there is a name change of the Permittee, a formal permit amendment
request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of
complying with any and all statutes, rules, regulations, or ordinances, which may be
imposed by other local, state, and federal agencies, which have jurisdiction. Furthermore,
the issuance of this permit does not imply that all regulatory requirements have been met.
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, which will render it unsatisfactory for normal use. In
the event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility.
2. The Permittee shall be required to comply with the· terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface or groundwater 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.
Permit No. WI0400102 Page4
2. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical · alterations or additions in the permitted facility or activity
not specifically authorized by the permit.
3. At least forty-eight ( 48) hours prior· to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Aquifer Protection Section-
Underground Injection Control (UIC), Central Office staff, telephone number (919) 715-
6166 and the Winston-Salem Regional Office, 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 the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place
on or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained
under the terms and conditions of this permit, and may obtain samples of groundwater,
surface water, or injection fluids.
2. Department representatives shall have· reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. 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.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first
knowledge of the occurrence, to the Winston-Salem Regional Office, telephone number
[phone], any of the following:
(A) Any occurrence at the injection facility, which results in any unusual
operating circumstances;
(B) Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
failures.
3. 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
Permit No. WI0400102 Page 5
the Director, the relevant and correct facts or information shall be promptly submitted to
the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
PART VIII-PERMIT RENEWAL
The Pennittee shall, at least 90 days prior to the expiration of this permit, request an
extension.
PART IX-CHANGE OF WELL STATUS
1. The Pennittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinued use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to be used for any purpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Pennittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but notlimited to the following:
(A) All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination of an underground
source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe, which extends to the bottom of the
well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have
not been removed, the casing shall be perforated opposite the gravel pack,
at intervals not exceeding 10 feet, and grout injected through the
perforations.
Permit No. WI0400102 Page 6
(F) In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids into or between underground
sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30)
as specified in ISA NCAC 2C .0213(h)(l) within 30 days of completion
of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-VIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X -OPERATION AND USE SPECIAL CONDITIONS
None.
Permit No. WI0400102 Page 7
State of North Carolina Oc. \NAT-,51
Department of Environment � 0C.
and Natural Resources & r i 1 !r'1 r
Division of Water Quality
Michael F. Easley, Governor
William G. Ross Jr., Secretary
Coleen H. Sullins, Director
Division of Water Quality
Aquifer Protection Section
Location: 2728 Capital Blvd.
Raleigh. NC 27604
Mailing Address: 1636 Mail Service Center
Raleigh. N.C. 27699-1636
FAX: [phone]
[phone]
Date: f a/%7a51
FAX TO: �.
REF:
FAX NUMBER:
FROM: /0_ l-o�
i PHONE:
NO. OF PAGES INCLUDING THIS SHEET:

DATE,TIME
FAX NO./NAME
DURATION
PAGE(S)
RESULT
MODE
TRANSMISSION VERIFICATION REPORT
12/15 17:22
913364684048
00:02:25
09
DK
STANDARD
ECM
TIME 12/15/2008 17:25
NAME NCDE&NR/WATER QUAL
FAX [phone]
TEL [phone]
Re: UIC ,permit App WI0400102 (Richard Fain)
1 ofl
Subject: R.e: UIC permit App WI0400102 (Richard Fain)
From: Stephen Berry <Stephen . [e-mail]>
Date: Thu, 11 Dec 2008 12:46:32 -0500
To: Michael Rogers <[e-mail]>
Mr. Rogers,
I have spoken with Sherri regarding a pre-permit site inspection. She has requested that the
permit be issued and that-! schedule a site inspection sometime during the construction.
I have contacted the driller (David Brown, Yadkin Well) and let him know of our plans. I have
requested that he contact me sometime before the system is completed (wells are drilled).
Sorry for the delayed response ... I was hoping the Holiday Season would bring respite, quite the
contrary.
Happy Holidays,
Stephen Berry
NC DENR
Winston-Salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
Stephen Berry <Step [e-mail]"'>
Environmental Senior Technician
Division of Water Quality, Aquifer Protection Section
NCDENR
12/11/2008 12:58 PM
State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
Michael F. Easley, Governor
William G. Ross Jr., Secretary
Coleen H. Sullins, Director
GF W A
Division of Water Quality
Aquifer Protection Section
Location: 2728 Capital Blvd.
Raleigh, NC 27604
Mailing Address: 1636 Mail Service Center
Raleigh. N.C. 27699-1636
FAX: [phone]
[phone]
FAX TO:
REF:
Date:
A. gam/--,
FAX NUMBER:
FROM: p1
PHONE:
NO. OF PAGES INCLUDING THIS SHEET:
?4" 6-‘r4-4 +I (A)/k4 "'oar
Se'S-70. 1.‘DsT ee}r. 4-4,Le"-)
ch4- / 70 tc ok' cee eze—
CA4liet>15k C;r` (L4k)it •
0.4

UIC permit App .WI0400102 (Richard Fain)
1 of 1
Subject: UIC permit App WI0400102 (Richard Fain)
From: Michael Rogers <[e-mail]>
Date: Mon, 01 Dec 2008 15:15:11 -0500
To: Sherri Knight <[e-mail]>
CC: [e-mail]
Sherri-
We got an App in for a SQM mixed fluid well 11/18 located on the Parkway in
Boone, NC. It was processed and logged into BIMS and given to me on Wed,
11/26 the day before Thanksgiving. The architect and the driller called today·
asking on the status of the permit and that they will have a rig on-site this week
or next. I told him there was no way we could issue a permit this week and that
you haven't gotten a package yet to decide if you wanted to conduct an
inspection.
To help him expedite, I told him to get a copy of the App to you overnight or
hand deliver as the site maps/plans are the size of my desk. It is for a huge house.
Therefore, be on look out (BOLO) for this package as it will be arriving. Also,
Chris Brantley with the App Dist HD asked to be in the loop for geothermal wells
in his district (Alleghany, Ashe, and Watauga Counties).
In the meantime, I will fax every thing except the site plans.
Thanks
Mike R.
12/1/2008 3:22 PM
'NA
Michael F. Easley, Governor
Wilhiam G. Ross Jr., Secretary
North Carolina Department of Environment and Nature! Resources
Coieen H. Sullins Director
Division of Water Quality
November 26, 2008
Richard Fain
Colleen Fain
571 Blackberry Road
Boone, NC 28607
Subject; Acknowledgement of Application No. WI0400102
Richard Fain & Colleen Fain - SFR
Injection Mixed Fluid GSHP Well System (5QM)
Watauga
Dear Mr. & Mrs. Fain:
■
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit
application and supporting materials on November ] 8, 2008. This application package has been assigned the number
listed above and will be reviewed by Michael Rogers.
The reviewer will 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 additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final
action by the Division. Please also note a 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
michael.rogersia�ncmail.net. If the reviewer is unavailable, you may leave a message, and they will respond
promptly. Also note that the Division has reorganized. To review our new organizational chart, go to
__h'ti :L/h2a.enr.state.nccus/documents/dwL, or�2chartndf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS
PROJECT.
Sincerely,
Lt 6,xi/L
for Debra J. Watts
Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
Lela Price (ARCS - 571 Blackberry Rd, Boone NC 28607)
Permit Application File W10400102
Aquifer Protection Section 1636 Mail Service Center
Internet www,ncwaterauaiity,orq
Location: 2728 Capital Boulevard
An Equal Opportunity/Affirmative Action Employer- 50% Recycled110% Post Consumer Paper
NQCaro ina
Naturally
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: 1919j 715.0588
Fax 2; [phone]
Customer Service: [phone]

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL BEAT PUMP SYSTEM FOR:
TYPE SOM WELL {S}
___ New Permit Applieation OR ____ Renewal (cheek one)
DATE: ooroace-~ • 20.lltL
PERMIT NO. _______ 0eave blank if NEW pennit application)
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): __.t2:..___._\f±\~~ ...... E:t?----'PL-·__.t'-LA....;.:.l.,_N'---_______ _
C. Q~E;N ) · fN N
( 1) Mailing Address: 011 2,L-Mrf:2Q-f-':! {½?AD
City: ~bNB: State: ~ Zip Code: 1J;{eo 1 County: WAJAV ~ A
Home/Office Tele No.: f31..-B · 1}f!z · BCJ 14 Cell No.: B~~ · 221 · 4 o~;,
EMAIL Address: _____________ _
(2) Physical Address of Site (if different than above): ~11 BU¥?¥:~'( f:P •
City: ~ N Fi State: & Zip Code: :z@.loD1 County: ',('J/;TAV~ f"
Home/Office Tele No.: #JU, · Z.~9· ~4'1 Cell No.:~• 922· jOf22
EMAIL Address: _____________ _
B. AUTHORIZED AGENT OF OWNER, IP ANY (if the Pennit Applicant does not own the subject property,
attach a letter ftom the property owner authorizing Agent to install and operate UIC well)
c.
Company Name: AF--f,'i, tot:¥7w-yefloN ~ l~~
Contact Person: ~lA r:t:::<NN fP1C..B EMAIL Address: \V,:it;e.@Avc.~wa.t,oV\11
Address: '711 BL-{\C,V:~P:< P.P ·
City: !>oQNe: State:~ Zip Code: Vbfl 01
Office Tele No.: to1-fb · 7---1 '2 · f/f 11
Website Address of Company, if any: WWW, 4t"'2tfVl. UVVI
STATUS OF APPLICANT
Private: .x_ Federal: Commercial:
County: Wl,TAV~e-
Cell No.:~-fjC?'Z.·'JQli2
State: Municipal: _ Native American Lands:
OPU/UIC SQM Well Pennit Application (Revised 7/2008) RECElVED / DEN~ I DWQ p 1 AquifP''"' . , ,, ---..-.ion aac
NOV ~ b ""~~6
D.
E.
F.
G.
WELLDRil.LER INFORMATION
CompanyName: YbPt\N ~Q..-L-vO. (N~-
Well Drilling Contractor's Name: • ~"' ... VAVq~fJ ~P.~N
NC Contractor Certification No.: ---=~;...!l__..'3--11L-------------------~
EMAIL Address: rJ WV1V'!tlle ~td . jlle.+ Contact Person:\Jt\V~ttN *""N
Address: l1D'b ~N:1P[oN\JlU£., f<i\ P
City: f¼t.MPt•tNIY& Zip Code: 1101-0 Coumy: ....... 't ...... ~ __ \ti--'-"--N _______ _
Office Tele No.: 600 · 2'f:0 · ~!>'ii Cell No.: 3?h · 1lt 1 · ~l14
HEAT PUMP CONTRACTOR INFORMATION (if different tbaa driller)
Company Name:UfJ>G-IAI&Q t\f>;nNf\ ~ NV-: ~ND[TtoNLNf1 > (Nv•
Contact Person: PfNlP &\,pot\Et£ EMAIL Address:~fMa.W&~Hfi.oqfall) t\f.AT. t.of-"\
Address: po~ 2d1 /?,it P?fN0tJ?:> f-Ni.. 1
City: N9SH W\~@-o Zip Code: 1tt,e;4 County: ----~-\k\'%'? _________ _
Office Tele No.:~· (e(il · JOl"l-Cell No.: ?nv· '(t;1 ·Vl'.?lf
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
1~~ ~ Y:!lV--P& vsa? Bf: t: ?UX;Jb ,,.ooe ~EP1WIM/sk lNbff\U.,M1 oN • ft.-VlP 1rau ... 1.-&-\{W)&JqE: t.oNTINvou~'--Y
l~\o;: lk\E'P;W\F.P flflE:/>d::!P "Si Jk Moffiff.1!: m"lfEPNYH Ofll'i: r&-ttt Ab A l;\Q.r ~~~ ·Tlt5 ~ LDOP~
1/'1\~\.. tor-\~ 1\7 U\e ~ffl"Ge > ~ ,._, P,. f-'V+JlfOl.-0 ~Q tol'lt,af;q V\/li,. 1°P""l'll' f't?\N~ \t-llt> 't\W p.e~~t... T\il~
f\&~itc'l\f~mfl'y\~1u~Tif 1~~~1~1>=tHWlW\~o ~0 ~N '"'f0 1\\~ ~-
( 1) Proposed date to be constructed: H~ 'l0012> Number of borings: _(_f; __ _
Approximate depth of each boring (feet):_229~_' ____ _
(2) Chemical additives to be used in closed-loop system (only those chemicals indicated have been approved):
___ R-22 '/. propylene glycol __ ethanol _______ other (other additives will
need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC. etc): ..... f\J____,._,.&..._ ___________ _
(4) Well casing. Is the well(s) cased? (check either (a.) YES![ (b.) NO below)
(a) YES ___ if yes, then provide casing infonnation such as~ (steel, PVC, plastic, etc.), diameter,
depth., and~ of casing appearing above ground: ______________ _
(b) NO .......,'A_
(S) Grout (material su1TOunding well casing and/or piping):
(a) Orout type: Cement__ Bentonite .£ Other (specify) ______ _
(b) Orout depth of tubing (reference to land surface): from ~' to -~-'_(feet)
If well has casing, indicate grout depth: from ___ to ___ (feet)
H. INJECTION .. RELATED 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 manufacturer7 S brochure may provide supplementary
information.
OPU/lJIC ,QM Well Pennit Application (.Revised 7/2008) Page2
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 Ines, surface water bodies, potential sources
of groundwater contamination and the orientation of and distances between 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 heat pump 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 wells) on the subject property or adjacent properties? / YES NO
If Yes, than indicate location on attached map(s).
K. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the recorded legal property deed.
•'1 hereby certify, under penalty of law, that I 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.
1 am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conditions of the Permit."
Signature of Property Owner/Applicant
1.r ryryw/
Print or Type Pull Name
Signature of PropertyOrvner/A
ppltcartt
eo,\ -p,c
Print or Type Full Name
[gnat re A u orized Agent, if any
i.IG v Vt'{tt N
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
[]liC Prograrn
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
CP1J(U1C 5QM well Permit Application (Revised 7/2008)
RECEIVED 1 DEM 1 DIMQ
Aquifer --41art
NOV 16 606
Pagel

AR
CS
Architectural Construction Services
TO North Corolina DENR-DWQ
Aquifer Protection Section
TEL [phone]
FAX
RECEIVED/ ❑ENR ! Dj
Aquifer Pralurtiv+,- ran
NOV 18 2008
FROM
DATE
NO. OF PAGES
TRANSMITTAL NO.
PROJECT/JOB NO.
RE
TRANSMITTAL
Lela Wynn Price
November 14. 2008
(see below)
9062
Geothermal Permit App.
To Whom It May Concern:
In application for permit to construct and use a well for injection with a geothermal heat
pump system for TYPE 5QM WELLS for a private residence at 571 Blackberry, Boone,
NC 28607, please find the following enclosed;
(1) Geothermal Permit Application (original copy to follow immediately)
(1) Authorization Letter
(1) Geothermal Riser Diagram
(2) Site Utility Plan
(2) Site Plan
Please do not hesitate to contact me with any questions.
Regards,
Leia WynI4 Price
1 pricearescrn.com
828 295.8949 (office)
828.552.9053 (cell)
6ioctbs-rry Rcl.. Foono. Norm Carciiirlo 2,8607 TEL 820 :295 8'?4' FAX : 8389

North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
To Whom It May Concern:
I, Richard Fain, being the owner of 571 Blackberry Rd., Boone, NC, do hereby authorize
ARCS Construction Seivices to act as an Agent on my behalf to oversee the installation
and operation of all the components of a completely functioning closed--loop geothermal
heat pump system.
Thank you,
/4:VI!
Richard Fain
RECEIVED/ DENR / DWQ
Aquifer Prot1:1r.tittn ~or,tion
NOV l t, 2008
AR
CS
Architectural Construction Services
RECEIVED r DENR I DWQ
AQUIFER PRf1TF[:W)N iFCTION
DEC 022008
'--C 2
TRANSMITTAL
TO North Carolina DENR-DWQ FROM Lela Wynn Price
Aquifer Protection Section DATE
NO. OF PAGES 2 (Including cover sheet)
TRANSMITTAL NO.
TEL PROJECT/JOB NO. 9062
FAX RE
To Whom It May Concern:
Enclosed is the original copy of the Richard & Colleen Fain Permit Application for an
injection well with a I^ermal heat pump system for Type 5QM Wells at 571
Blackberry Road, Boone, NC 28607. A copy of the application and all supporting
documents has already been received by your department. Please contact me if you have
any questions.
Thank you,
Lela Wynn Price
828.295.8949 (office)
828.552.9053 (cell)
r I lirl . b+irry fZ i.. Boole, N')rih Co-ai t• 2&! TEL u28 295 F'ie" :'Ai s:: ?95 83 9 • .. �s .rn.: �*t

RECEIVED 1 DEWR / DWO
NORTH CAAOLiNA AQUIFFR•P141)1€f:Tl[lNSH,T1ON
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDE tla5 0 2 200g
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 50M WELL(S)
New Permit Application OR Renewal (check one)
DATE: DG'-D 1F - }' o 20 p&
PERMIT NO.
(leave blank if NEW permit application)
A_ PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): VV-1P'PQ
Got— N t-P+(N
ti i] Mailing Address: r2Z I :: rP -3-Y P°AO
City: eoOtt: State: N !V Zip Code: 2— Cr el County: LNINTAul pt
Home/Office Tele No.: jai?) - Zit Ri • M4'1 Cell No.: vc
EMAIL Address: 4 pvi t4 Qy 44 GyVI . Gv rvt
(2) Physical Address of Site (if differentthan above):. `II Dt.134Y-i3EP-¢`1f 1--O •
City: N F State: jG Zip Code: 14, 42 Di County: INtesittUtt f�
Home/Office Tele No.: ei Z 2..1 ' e6149 Cell No.: •_95Z .109
EMAIL Address:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Perrnit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate U1C well)
Company Name: 4 L9r41kATI e1`I A.' tG•ES
Contact Person: J, .tA \ y N N flItCog EMAIL Address: 1 rr iG e. (9 AY GrGvvI.6o M
Address: 1'il etW\611-1ILP
City: DNIr State: NG, Zip Code: 'yrbC O1 County: 1Nis+rAUl
Office Tele No.: t2- •e142 Cell No.: f;2fi • gi7e,3
Website Address of Company, if any: y 4W. G[YCSGi' i.t4W
C. STATUS OF APPLICANT
Private: X Federal: Commercial:
State: Municipal: Native American Lands:
GPU/UIC 5QM Well Permit Application (Revised 7/2008) Page 1

E.
F.
WELL DRILLER INFORMATION
co.mpanyName: YAP't:l-N ~~ vtl, trJi •
Well OrillingConttactot'sName~ -~~~ \IA\tq~N ~P,O~N
RECEIVED/ DENR / OWQ
AQUIFF.R'PROTl?.CTION SECTION
DECO 2 2008
NC Contractor Cerdtication N.o .. : _____.:::t::...,,!· l~q1....1'-------------------.-------,-,-----.---
EMAILAddres&: jM k-in ~I ~-rJtd , Vie-+ Contact Petson: \JAv41ttN ~w N
Addr~ss: -t1 oto ~N::1PteN\JlU&: p-q\t>
City: ~eN:ilw& Zip dQde: 11 P1.-0 Cpunty: .....:'(:.,e...:..~~·\t-1.L...=..;N:.;_-______ _
Office Tele No.: 8()0· Uf0 · ~~ Cell No.: ?@ · 1ilt 1 · ~l14-
BEAT PUMP CONTRACTOR INFQRMATION Ot dtff~re•t t ... ._ dtlll~:t)
CQmp~y ~~~ &6QaAtW HFAUN 4, ~ f\l'&: t()}sl ptnoN tNti 1 (Nb~ .
-Contac.t P~rson; ~l•D .. ~pPt\et:te . . EMAIL Address:prJiptaiJ,1£.J;f)~ t\fhl-~
Address: ·eo ~ 71 [?lt-± ?f)'N 0(J?S A'lt, .. ~ I ~
City: Nt9:\ Wt~~ ZipCode: ·zM1 C<>untr;-. ..!._W .:.Llk:¥?:::..1..· __;;___:;:_S _______ _
Offi¢e Te.le No~: ~-.(e,(ll· J ol~ Cell No.:@•, j§1 ~tlt¼j
INJECTION PROCEDURE ;(briefly describe how the injection we11(s) will be us~d)
w~ W~l,.,lJ. ~\L,L-~ \/@ '£!p, f. &\..,IIS~ voP ~r,onp,t-,\~I,, (,-.,&,f e,«..og],tJ f WIP .... \IA,, t-t(l.(.v c>.~ t.Mlf'IV..V~"'( ~~11::>E!
n\t-!'"eP P\Pt ~ \I~ @ t\bQ.Pffl:-00::,Pfl?'.NYP:': of ti. ~ca-rtt 1$ b l:'Q.r: e't@rl'c~-~ ~lttn .. ot~ \rl\L.t.'"
u,t,\f; "tO 1'rtJ ~~ I,~ ~ ,,._ ~lf'~ f"NP ~"'at """ 1t'-'4"~ f'\itl"I~ lNtcP nu:; P«,ltt,\.l&e. '{\\\I:.
0, "1Wi~t~NS~~l'¥.l1\~~~~ii'J~~~tlf"a'E~MUf ,.~ ~v-v;~ ~
(l) Proposed date to be constructed: 1:4~ ;l.OOt-· Nwpber Qf boring$:: __.('--"'-f;~• __ _
Appr(),omate deptli ·ofeachboring(feet):_. 29..c..;.· .. ~.;()~'-----
(2) Chemical ~ditiv~s ·to be used in ctosed~loop system (only those chemicals indicated have bee.n approved):
______ tt~22 '/.: .propylene glycol .. ethanol _ other(<>th¢t ,additives wm
need prior approval by ·NcDENR ~fore use)
(3) Typ¢ ofttibing t(>. ~e used (copper, PVC, ,etc): _._f\J_...;.--. ·L>,ve..;...· .. · ___________ _
(4) W~l:~ing. Js th~ well(s) ¢ased? (check eitlwr (a) YES or(p..) NO below}
(~) YES ~--if yes, then provide easing inform~dc;m such as •.~ (s~eel, PVC~ plasd~, et¢.), diathetet,
•·~. and extent of casing appe~ri'ngabove gr0und~ ______________ _
'(b) NO ..r,...;;.$_
(S) Grout (material S'1rrounding well casing and/or p_iping}! ·
.(a) Or<Mty~:: •Cement__ Bent9nite.X,. Othet(spec.ify) ______ _
. , a ..... '· . (b) Qt()utdepth of tubing (reference to land surface): from .1«> to -----'-7----'---_ (feet)
lfweU has. easins, ·indicate grouideptht irom --~ to ____ (f~t)
JI. INJECl'ION~RELATED EQUlPM:ENT
Attach a diagram · showing the engineering· btyout or Pr<>})Osed tnodifi<:adon o'f the injection ~q~ipment at1d ex-terior
piping/tubing associated · with the lnjectio1'1 operation. -The :rtianufacturer"s bl'()<:hure may provide supplem~ntary
information.
.QPU/UIC .'5QM Well P.eramt Applieation {Revised 7/2,008) Page2
RECEIVED / DENR / DWQ
Ao0FizPIZATMTICINWTION
DEC 0 2 2008
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(l) 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 between 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 heat pump 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 NO
If Yes, than indicate location on attached map(s).
K. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the recorded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this 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.
1 am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. I agree to construct, operate, maintain. repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conditions of the Permit."
Signature of Property Owner/Applicant
. r
Print or Type Full Name
Signature of Property owner/Applicant
ev`\ Q x- ;• c :—
Print or Type Full Name
ignat re ` Au orixed Agent, if arty
L�iF• W�r�N}a�
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone (9I9) 715-6935
GPUIUIC 5QM Well Permit Application (Revised moos) Page 3

North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
To Whom It May Concern:
I, Richard Fain, being the owner of 571 Blackberry Rd., Boone, NC, do hereby authorize
ARCS Construction Services to act as an Agent on my behalf to oversee the installation
and operation of all the components of a completely functioning closed-loop geothermal
heat pump system.
Thank you,
Richard Fain
T.Q. ROOF FLOG 3
T.O.5.BLOC 3
-r 13'-1O
ZONE A
ZONE 0
ZONE C
rlrrrr
.1117-rr-
MECH RM 3
OUTSIDE INSIDE
GEOTHERMAL MANIFOLD
VAULT 4'
2
F
x" 1
- - -
2
(6) WELLS PER ZONE -
1" SDR PIPING FROM
EACH WELL CONNECTS TO
2" BRANCH LINE
3LOW1 N C ROCK RESIDENCE
571 BLACKBERRY ROAD
11.07.2008
NOT TO SCALE
GP-l.�
GP 2
MAIN LINE INTO HOUSE
T.O.S. GRN ROOF
4' + 14'-5 1; 2
4"
T.O.S. GAME RM
+2'-5T
T.O.S. POOL
4
1 1/4' -� 1
1 t/4"
MECH RM 1
<•
-1-
MECH RM 2
RECEIVED / DENR / DWQ
Aquifer Protection Section
NOV 18 2008