WQ0020881_Regional Office Historical File Pre 2018 (2)

Pat McCrory
Governor
TT
.� ►r.
NCDENR
North Carolina Department of Environment and Natural Resources
May 15, 2015
Lake Norman State Park
159 Inland Sea Lane
Troutman, North Carolina 28166
Attention: Greg Schneider, Acting Park Superintendant
Dear Mr. Church:
Donald van der Vaart
Secretary
Subject: Surface Irrigation Permit Inspection Report
Permit No. WQ0020881
Lake Norman Swim Beach and Family Campground
Iredell County
Enclosed you will find the report for the compliance inspection that was conducted on April 28th, 2015
for the referenced facility's treatment and disposal system. The inspection included a review of:
records, two pump stations, the residuals processing and storage areas and the application sites.
I would like to thank Dena Myers, Matthew Cartner, Shane Felts and Daniel Baumgardner for their
time during the inspection.
The facility storage and application fields appeared well maintained at the time of inspection. There
are a couple of points worth nothing for continued program compliance:
• A couple of data questions were discussed during our meeting or in subsequent email. Most
questions have already been addressed; however, the 12 month floating totals will be
addressed starting with the next NDAR.
• A visual alarm was out at the Swim Beach pump station and was to be repaired.
This permit is currently in the renewal process with Central Office staff in Raleigh. Please contact
troy. doby(o-)-ncdenr.gov with questions about the renewal.
The attached report should be self-explanatory; however, should you have questions, please contact
me by phone [phone]) or email (maria.schutte(@-ncdenr.gov).
Sincerely,
Maria Schutte, Environmental Specialist
Mooresville Regional Office
Water Quality Regional Operations Section
Division of Water Resources, NCDENR
Attachment(s): WQ00020881 Inspection Report
CC: Dena Myers, Statesville Analytical (Email)
Matthew Cartner, LA-ORC (Email)
Mooresville Regional Office
610 East Center Avenue, Suite 301, Mooresville, North Carolina 28115
Phone: [phone] Fax: [phone] / Customer Service 1-877-623-6748
Intemet,, www.ncdenr..goy „

State of North Carolina
Department of Environment
and Natural Resources
Division of Water Resources
Pat McCrory, Governor
Donald van der Vaart, Secretary
A&4;1 a )
NCDENR
NON -DISCHARGE COMPLIANCE INSPECTION
GENERAL INFORMATION
City/Town/Owner: NCDENR DIV of Parks & Recreation County: Iredell
Permit No.: W00020881 Issued: 9/12/2008
Permittee Contact: Jarid Church Telephone No.: 704-528-6350 Cell No
Expiration: 9/3 0/2015
.: 704-881-1680
ORC Name: Matthew Cartner Cert #SI 995910 Telephone No.: 704-880-4373
Email: [e-mail]
B/U ORC Name: Dennis Gryder Cert# SI 989073 Telephone No.: 704-902-0427
Reason for Inspection
X ROUTINE COMPLAINT FOLLOW-UP OTHER
Type of inspection
Collection System X Spray Irrigation Sludge Other
Inspection Date(s): April 28, 2015
Inspection Summary: (additional comments may be included on attached pales)
This inspection was conducted in conjunction with the permit renewal, and included pump stations,
residuals processing, storage, end -use and a records review. The treatment and irrigation systems appeared
to be operating properly and the disposal fields appeared to be in excellent condition, at the time of
inspection.
A visible alarm at the Swim Beach pump station was inoperable and to be repaired.
The MRO had a couple of data related questions which were either addressed at the meeting or via follow-
up email.
Please note:
• This permit is currently in the renewal process with Central Office permitting staff in Raleigh.
Please contact trov.dobvnncdenr.gov with permit renewal questions.
• , The MRO should be informed of any changes to the contact information noted above. .
Is a follow-up inspection necessary _yes . X no
Inspector(s): Maria Schulte - Environmental Specialist
Telephone No.: 704-663-1699 Fax No.: 704-663-6040
Date of Inspection: April e8t', 2015

Surface Irrigation Inspection
WQ0020881 Lake Norman State Park - Iredell County
pg. 2
Type
Activated Sludge Spray, low rate
Activated Sludge Drip, low rate
.X_ Lagoon Spray, Low Rate
Lagoon Drip, Low Rate
Treatment
Y Are treatment facilities consistent with those outlined in the current permit.
Y Do all treatment units appear to be operational. If no, note below.
Influent Pump Station
Y All pumps present, operational Bypass structure present
Bar. screen, maintained Free of excessive debris
Bars evenly spaced Bars excessively corroded
Back-up power Duringpower outages the State Park will close — there is no back-up power.
Flow Measurement — Influent - NA — influent to the plant is calculated monthly by runtimes from the two
pump stations.
Is flowmeter calibrated annually?
Is flowmeter operating properly?
Does flowmeter operate continuously?
Does flowmeter record flow?
Does flowmeter appear to monitor accurately?
Flow Measurement — Water -Use Records
Y Is water use metered?
Y Are the daily average values properly calculated?
Disinfection
Y Is the system working? Y Is the system properly maintained?
Tablets Gas X Liquid UV
If tablets, proper size? Present in Cylinder(s)?
Y If gas/liquid, does cylinder/tank storage seem safe?
If bulbs, are replacement bulbs on hand?
Y Is contact.chamber free of sludge, solids and growth?
Flow Measurement — Effluent
Y Is the flowmeter calibrated annually?
Y Is the flowmeter operating properly?
Y 'Does the flowmeter monitor continuously?
Y Does the flowmeter appear to monitor accurately?
Effluent Storage
X LAGOON SEPTIC TANK(s) ABOVE GROUND TANK OTHER
Number of months storage — 1.4 Spill control plan on site
Above ground tank Aerated Mixed
In ground tank Aerated Mixed

'Surface Irrigation Inspection
WQ0020881 Lake Norman State Park - Iredell County
pg. 3
Storage Lagoon
Check any/all that apply
Y Influent structure (free of obstructions)
N Banks/berms (are there signs of seepage, overtopping, down cutting or erosion)
N Vegetation (is there excessive vegetation on the lagoon bank
Y Liner (if visible, is it intact)
NA Baffles/curtains (in need of repair)
Y Freeboard (>2 feet from overtopping)
Y Staff gauge (clearly marked)
N Evidence of overflow (vegetation discolored or laying downibroken)
N Unusual color (very black, textile colors)
N Foam (are antifoam agents used)
Y Floating mats (sludge, plants, inorganics) — duckweed present
NE Excessive solids buildup (from bottom)
Y Aerators/mixers operational (if present),— not running at the time of inspection
Y Effluent structure (free- of obstructions, easily accessible)
Residuals
storage/treatment Y - 780, 000 gal. treatment and storage lagoon.
Comment: Tank residuals are removed when pump stations are serviced by a septyge contractor (Lentz).
Disposal (final end use)
Y Is the application equipment present and operational?
N Is application equipment in need repair?
*N Spray heads calibrated this past year? * Maintained but not calibrated with bucket, etc. Per
conversation past ORC did a calibration within the past permit cycle. The spray quipment was running at
the time of this visit and appeared to produce an even application throughout both zones.
Y Are cover crops the type specified in permit? Permit is not specific just states suitable vegetative cover.
N Is cover crop in need of improvement?
N Signs of runoff? N Signs of ponding? N Signs of drift?
Y Are buffers adequate?
Y Is the acreage specified in the permit being utilized?
N Are there any limiting slopes in disposal fields?
Y Are restrictions for use of these areas specified? Entire area is,fenced.
Y Is permit being followed?
Y Is site access restricted in accordance with permit?
Recordkeepinjj
Y Is permit available upon request?
Y Are flow rates less than permitted flow?
Y Are monitoring reports present: NDMR Y NDAR . Y
Y Are operational logs present? Y Complete?
Y Are lab sheets available for review?
Y Do lab sheets support data represented on NDMR or NDAR?
Y Are all samples analyzed for the required parameters?
Y Is field parameter certification required?
NA Are there any 2L GW quality violations? Groundwater monitoring is not required
N Are annual soil reports available? Recent sampling was conducted in April and results not vet available.
Y Is the operation and maintenance manual present? Complete?
N Has DWR received any complaints regarding the facility in the last 12 months?

Compliance Inspection Report
Permit: WQ0020881 Effective: 09/12/08 Expiration: 09/30/15 Owner: NC DENR Division of Parks and Recreation
SOC: Effective: Expiration: Facility: Lake Norman State Park Swim Beach
County: Iredell 137 Shortleaf Ln
Region: Mooresville
Statesville NC 28677
Contact Person: G Robert Graham Title: Phone: [phone]
Directions to Facility: -
From the intersection of Perth Rd (1303) and State Park Rd., travel southwest 4.4 miles past the park entrance and the boat
landing. The WWT system and spray fileds are located on the right side of State Park Rd.
System Classifications: SI,
Primary ORC: Certification: Phone:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Inspection Date: 04/28/2015
Primary Inspector: Maria Schutte
Secondary Inspector(s):
Entry Time: 10:OOAM
Reason for Inspection: Routine
Permit Inspection Type: Wastewater Irrigation
Facility Status: Compliant ❑ Not Compliant
Question Areas:
Exit Time: 02:OOPM
Phone: [phone]
Inspection Type: Compliance Evaluation
Treatment Flow Measurement -Effluent Treatment Flow Measurement -Influent
Treatment Flow Measurement -Water Treatment
Use Records
Treatment Filters Record Keeping
Treatment Sludge Storage/Treatmeht End Use -Irrigation
Treatment Disinfection Treatment Flow Measurement
Storage Standby Power
(See attachment summary)
Miscellaneous Questions
,M' fireatment Barscreen
Treatment Lagoons
Treatment Influent Pump Station
Treatment Return pumps
Page: 1

Permit: WQ0020881 Owner - Facility: NC DENR Division of Parks and Recreation
Inspection Date: 04/28/2015 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
Page: 2

Permit: WQ0020881 Owner - Facility: NC DENR Division of Parks and Recreation
Inspection Date: 04/28/2015 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Type
Infiltration System
Reuse (Quality)
Single Family Spray, LR
Activated Sludge Spray, LR
Activated Sludge Spray, HR
Recycle/Reuse
Activated Sludge Drip, LR
Single Family Drip
Lagoon Spray, LR
Treatment
Are Treatment facilities consistent with those outlined in the current permit?
Do all treatment units appear to be operational? (if no, note below.)
Comment:
Treatment Influent Pump Station
Is the pump station free of bypass lines or structures?
Is the general housekeeping acceptable?
Are all pumps present?
Are all pumps operable?
Are floats/controls operable?
Are audio and visual alarms available?
Are audio and visual alarms operational?
# Are SCADA/Telemetry alarms required?
Are SCADA/Telemetry available?
Are SCADA/Telemetry operational?
Comment:
Treatment Flow Measurement -Influent
Is flowmeter calibrated annually?
Is flowmeter operating properly?
Does flowmeter monitor continuously?
Does flowmeter record flow?
Does flowmeter appear to monitor accurately?
Comment:
Treatment Flow Measurement -Water Use Records
Yes No NA NE
El
El
Yes No NA NE
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑
Yes No NA NE
❑ ❑ ❑ ❑
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❑ ❑ ❑ ❑
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑
b�r�'rPi ❑ ❑ ❑ ❑
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Yes No NA NE
ca"o( bwl cQ ❑ ❑ ❑ ❑
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❑ 000
t Yes No NA NE
f Page: 3
1?�4 5'

Permit: WO0020881 Owner - Facility: NC DENR Division of Parks and Recreation
Inspection Date: 04/28/2015 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Is water use metered? ❑ ❑ ❑ ❑
Are the daily average values properly calculated? /` ❑ ❑ ❑ ❑
a
Comment: �
Treatment Flow Measurement -Effluent S ( r
14�/'� Yes No NA NE
Is flowmeter calibrated annually? � l' ❑ ❑ ❑ ❑
Is flowmeter operating properly? ^�(� f l �/ V / ❑ ❑ ❑ ❑
Does flowmeter monitor continuously? �r / l� S �?�/Z/C'C / ❑ ❑ ❑ ❑
Does flowmeter record flow? ❑ ❑ ❑ ❑
Does flowmeter appear to monitor accurately? ❑ ❑ ❑ ❑
Comment:i
Standby Power Yes No NA NE
Is automatically activated standby power available? ❑ ❑ ❑ ❑
Is generator tested weekly by interrupting primary power source? ❑ ❑ ❑ ❑
Is generator operable? ❑ ❑ ❑ ❑
Does generator have adequate fuel? ❑ ❑ ❑ ❑
Comment:
Treatment Barscreen
Yes No NA NE
Is it free of excessive debris? ❑ ❑ ❑ ❑
Is disposal of screenings in compliance? ❑ ❑ ❑ ❑
Are the bars spaced properly? ❑ ❑ ❑ ❑
Is the unit in good condition? ❑ ❑ ❑ ❑
Comment:
Treatment Return pumps Yes No NA NE
Are they in place? ❑ ❑ ❑ ❑
Are they operational? ❑ ❑ ❑ ❑
Comment:
Treatment Filters Yes No NA NE
Is the filter media present? ❑ ❑ ❑ ❑
Is the filter media the correct size and type? ❑ ❑ ❑ ❑
Is the'air scour operational? ❑ ❑ ❑ ❑
Is the scouring acceptable? ❑ ❑ ❑ ❑
Is the clear well free of excessive solids? ❑ ❑ ❑ ❑
Is the mud well free of excessive solids and filter media? ❑ ❑ ❑ ❑
Does backwashing frequency appear adequate? ❑ ❑ ❑ ❑
Comment:
Page: 4

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Permit: WQ0020881 Owner - Facility: NC DENR Division of Parks and Recreation
Inspection Date: 04/28/2015 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Treatment Sludge Storaae/Treatment
Yes No NA NE
Is the aeration operational? ❑ -❑ ❑ ❑
Is the aeration pattern even? ❑ ❑ ❑ ❑
If required, are Sanitary "Ts" present in tankage? ❑ ❑ ❑ ❑
Comment:
Treatment Disinfection
Yes No NA NE
Is the system working?
GRS
❑ ❑ ❑ ❑
Do the fecal coliform results indicate proper disinfection?
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❑ ❑ ❑ ❑
Is there adequate detention time (-30 minutes)?
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❑ ❑ ❑ ❑
Is the system properly maintained?
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If gas, does the cylinder storage appear safe?
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❑ ❑ ❑ ❑
Is the fan in the chlorine feed room and storage area operable?
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Is the chlorinator accessible.
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❑ ❑❑❑
If tablets, are tablets present?
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❑ ❑ ❑ ❑
Are the tablets the proper size and type?
❑ ❑ ❑ ❑
Is contact chamber free of sludge, solids, and growth? ,
❑ ❑ ❑ ❑
If UV, are extra UV bulbs available?
❑ ❑ ❑ ❑
If UV, is the UV intensity adequate?
❑ ❑ ❑ ❑
# Is it a dual feed system?
❑ ❑ ❑ ❑
Does the Stationary Source have more than 2500 Ibs of Chlorine (CAS No. 7782-50-5)?
❑ ❑ ❑ ❑
If yes, then is there a Risk Management Plan on site?
❑ ❑ ❑ ❑
If yes, then what is the EPA twelve digit ID Number? (1000-
)
If yes, then when was the RMP last updated?
Comment:
Record Keeping Yes No NA NE
Is a copy of current permit available? qq ❑ ❑ ❑ ❑
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Are monitoring reports present: NDMR? / ❑ ❑ ❑ ❑
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NDAR? di-14-
❑ ❑ ❑ ❑
Are flow rates less than of permitted flow?�
Are flow rates less than of permitted flow? ❑ ❑ ❑ ❑
Are application rates adhered to? "" �� ❑ ❑ ❑ ❑
Is GW monitoring being conducted, if required (GW-59s submitted)? ; ❑ ❑ ❑ ❑
Are all samples analyzed for all required parameters? ❑ ❑ ❑ ❑
Are there any 2L GW quality violations? ❑ ❑ ❑ ❑
Is GW-59A certification form completed for facility? ❑ ❑ ❑ ❑
Page: 5

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Pump Station Inspection Checklist
Name
Address
Housekeeping
Secure
Accessible lS�
Identification Signage
Inspection Schedule Daily Ceekly
Wet Well — Floats
Free .of debris �,U
High water float
Telemetry
Audio -Visual
1"
SCADA
Alarm system tested for communications
Emergency power Gener or
Fuel tank
Testing schedule
Bypass pumping configured
Overflow piping
Manhole upstream
Inspection Logs
0
No of Pumps
Operational 1
2` j
Capacity of each (gpm)
1 -
2
Runtime hour meter reading average
2
#I
Portable Quick -connect
Gallons per hour usage rate
Automatic
Left
Onsite

Name
Address
Housekeeping
Secure y�
Accessible �t.Q
Identification Signage
Inspection Schedule
Pump Station ffuspcctaonn Checklist
No of Pumps 1��xIG�''''''�
Operational 1
2
Daily eekly
Capacity of each (gpm)
1
2
Runtime hour meter reading average
1
2
Wet Well — Floats
Free -of debris
High water float
Telemetry' /
Audio -Visual Q
S CADA
Alarm system tested for/communications X/�
Emergency power CGenerato Portable Quick -connect
Fuel tank Gallons er hour usa e rate
Testing schedule
Bypass pumping configured
Overflow piping
Manhole upstream
Inspection Logs
p g
Automatic
C �b�� oof
Onsite

k ..l
Water Resources
Environmental Quality
Lake Norman State Park Swim Beach
159 Inland Sea Lane
Troutman, North Carolina 28166
Attention: Greg Schneider, Park Superintendent
Dear Mr. Schneider,
November 7, 2017
RE: Surface irrigation Permit
Inspection Report
Permit WQ0020881
Iredell County
ff� R� EOOPER
_ L L�L Governor
_: r
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Interim Director
Enclosed you will find the report for the compliance inspection that was conducted on October 26, 2017 for the
referenced facility's treatment and disposal system. The inspection included a review of: records, two pump
stations, the residuals processing'and storage areas and the application sites. The facility storage and application
fields. appeared well maintained at the time of inspection. I would like to thank Matthew Church, Dena Myers and
Matthew Cartner for their time during the inspection.
A general measurement of the throw of the sprinkler heads was performed to assess coverage being applied to the
dedicated spray fields. Although it appears that the irrigation spray heads have experienced some reduction of
throw, the system is still in compliance with the permit. The irrigation spray heads should be checked on a regular
basis for wear to maintain optimum surface area coverage.
The following link has forms for changing ORC's. Please complete the forms as necessary and return it to our Non -
Discharge permitting group.
https://files.nc.gov/ncdeg/Water%20illuality/Operator Certification Files/WW Files/ORC Designation Form Filla
ble.pdf
Should you have any questions, please contact Edward Watson at [phone] ext. 2198, or by email at
[e-mail].
Sincerely,,
Edward Watson, Hydrogeologist
Mooresville. Regional Office
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ
Attachment(s): WQ00020881 Inspection Report
CC: Dena Myers, Statesville Analytical (Email)
Matthew Cartner, LA-ORC (Email)
State of North Carolina I Environmental Quality I Water Resources I Water Quality Regional Operations
Mooresville Regional Office 1610 East Center Avenue, Suite 3011 Mooresville, North Carolina 28115
704-663-1699

Compliance Inspection Report
Permit: WQ0020881 Effective: 10/01/15 Expiration: 09/30/20 Owner: NC Department of Natural and Cultural
Resources
SOC: Effective: Expiration: Facility: Lake Norman State Park Swim Beach
County: Iredell 759 State Park Rd
Region: Mooresville
Statesville NC 28677
Contact Person: Greg Schneider Title: Phone: [phone]
Directions to Facility:
From the intersection of Perth Rd (1303) and State Park Rd., travel southwest 4.4 miles past the park entrance and the boat
landing. The WWT system and spray fileds are located on the right side of State Park Rd.
System Classifications: SI,
Primary ORC: Matthew Bryan Cartner Certification: 995910 Phone: [phone]
Secondary ORC(s): -
On -Site Representative(s):
Related Permits:
Inspection Date: 10/26/2017 Entry Time: 09:45AM
Primary Inspector: Edward Watson
Secondary Inspector(s):
Reason for Inspection: Routine
Permit Inspection Type: Wastewater Irrigation
Facility Status: Compliant Not Compliant
Question Areas:
Exit Time: 11:15AM
Phone:
Inspection Type: Compliance Evaluation
Treatment Flow Measurement -Effluent Treatment Flow Measurement -Influent Miscellaneous Questions
Treatment Flow Measurement -Water Treatment Record Keeping
Use Records
Treatment Lagoons End Use -Irrigation Treatment Influent Pump Station
Treatment Disinfection Treatment Flow Measurement
(See attachment summary)
Page: 1

Permit W00020881 Owner - Facility: NC Department of Natural and Cultural Resources
Inspection Date: 10/26/2017 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
On October 26, 2017, a compliance evaluation was performed by the MRO for non -discharge permit WQ0020881 at Lake
Norman State Park Swim Beach. All items of concern from the September 2016 inspection have been observed to have
been corrected. The NDMR records have been kept current since the last site visit.
As mentioned during the site vist, I have reviewed the systems' original irrigation design. The spray irrigation system
employs a Senniger Model 4023-1.75 inch - M-12 spray head which has a design pressure of 45 PSI. The spray head has a
maximum discharge of 6.76. GPM. The original irrtigation system was designed for a 100-ft. diameter spray area. Based
on the rough measurement made during the site visit, it appears that the irrigation spray heads has experienced a 10%
reduction of throw. The irrigation spray heads should be checked on a regular basis for wear to maintain optimum surface
area coverage. The reduction can be accounted for as normal wear.
With the change of system service from Statesville Analytical to AQUA -Trot, the permittee is notified of their responsibility to
update the RIMS system with the new contact information.
Overall, the site was in good operating condition.
No ponding or runn-off was observed after treated wastwater application.
Page: 2

Permit: WQ0020881 Owner - Facility: NC Department of Natural and Cultural Resources
Inspection Date: 10/26/2017 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Type
Reuse (Quality)
Infiltration System
Single Family Spray, LR
Activated Sludge Spray, LR
Activated Sludge Spray, HR
Recycle/Reuse
Activated Sludge Drip, LR
Single Family Drip
Lagoon Spray, LR
Yes No NA NE
Treatment
Yes No NA NE
Are Treatment facilities consistent with those outlined in the current permit? ❑ ❑ ❑
--Do-all-treatment-units--appear-to be -operational? -(if no, note below.)
❑ ❑ ❑
Comment: Treatment system and wet wells were viewed during the site visit. Alarms were tested and are
operational.
Treatment Influent Pump Station
Yes No NA NE
Is the pump station free of bypass lines or structures?
0 ❑ ❑ ❑
Is the general housekeeping acceptable?
❑ ❑ ❑
Are all pumps present?
M ❑ ❑ ❑
Are all pumps operable?
❑ ❑ ❑
Are floats/controls operable?
M ❑ ❑ ❑
Are audio and visual alarms available?
M ❑ ❑ ❑
Are audio and visual alarms operational?
❑ ❑
# Are SCADA/Telemetry alarms required?
❑ ❑
Are SCADA/Telemetry available?
❑ ❑ ❑
Are SCADA/Telemetry operational?
❑ ❑ 0 ❑
Comment: The system does not have SCADA telemetary. There is no back up power supply
to the
. treatment_ system. Procedure for the loss of power is to evacuate the park.
Lift station lights have been replaced since the previous site visit.
Treatment Flow Measurement -Influent
Yes No NA NE
Is flowmeter calibrated annually?
M❑ ❑ ❑
Is flowmeter operating properly?
0❑ ❑ ❑
Does flowmeter monitor continuously?
0 ❑ ❑ ❑
Does flowmeter record flow?
M ❑ ❑ ❑
Page: 3

k
Permit W00020881 Owner - Facility: NC Department of Natural and Cultural Resources
Inspection Date: 10/28/2017 Inspection Type: Compliance Evaluation Reason for Visit: 'Routine
Does flowmeter appear to monitor accurately? 0 ❑ ❑ ❑
Comment: There was a light laver of solids present in the influent well However, no solids were visible iri
the effluent well. Flow records were reviewed and appear to be in working order. The meter is
continuously working.
Treatment Flow Measurement -Water Use Records Yes No NA NE
Is water use metered? E❑ ❑ ❑
Are the daily average values properly calculated? 0 ❑ ❑ ❑
Comment: This system is applying treated wastewater within the parameters of the permit The cover crop
is planted pine trees. The spray system was operated to be able to observe the throw of the
sprinkler heads. No wastewater was applied outside of the compliance boundary. The system
currently applies 15.00 GPD of residuals to the application fields
Treatment Flow Measurement -Effluent Yes No NA NE
Is flowmeter calibrated annually? E ❑ ❑ ❑
Is flowmeter operating properly? 0❑ ❑ ❑
Does -flowmeter monitor continuou_sly? _
Does flowmeter record flow? E ❑ ❑ ❑
Does flowmeter appear to monitor accurately? ■ ❑ ❑ ❑
Comment: Flow meter calibration records were reviewed and the flow meter displayed a current calibration
sticker. - -
Treatment Disinfection
Is the system working?
Do the fecal coliform.results indicate proper disinfection?
Is there adequate detention time (-30 minutes)?
Is the system properly maintained?
If gas, does the cylinder storage appear safe?
Is the fan in the chlorine feed room and storage area operable?
Is the chlorinator accessible?
If tablets, are tablets present?
Are the tablets the proper size and type?
Is contact chamber free of sludge, solids, and growth?
If UV, are extra UV bulbs available?
If UV, is the UV intensity adequate?
# Is it a dual feed system?
Does the Stationary Source have more than 2500 Ibs of Chlorine (CAS No. 7782-50-5)?
If yes, then is there a Risk Management Plan on site?
If yes, then what is the EPA twelve digit ID Number? (1000 _)
If yes, then when was the RMP last updated?
Yes No NA NE
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Page: 4

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Permit: WO0020881 Owner - Facility: NC Department of Natural and Cultural Resources
Inspection Date: 10/26/2017 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Acceptable color M ❑ ❑, ❑
Floating mats 0 ❑ ❑ ❑
Excessive solids buildup ❑ M ❑ ❑
Aerators/mixers ❑ ❑ ❑
Effluent structure ❑ ❑ ❑
Lagoon cover ❑ M ❑ ❑
Page: 7

Pat McCrory
Governor
4*2
NCDENR
North Carolina Department of Environment and Natural
May 15, 2015
Lake Norman State Park
159 Inland Sea Lane
Troutman, North Carolina 28166
Attention: Jarid Church, Acting Park Superintend
Dear Mr. Church:
fyl=.2:3
Resources
Donald van der Vaart
Secretary
Subject: Surface Irrigation Permit Inspection Report
Permit No. W00020881
Lake Norman Swim Beach and Family Campground
Iredell County
Enclosed you will find the report for the compliance inspection that was conducted on April 28th, 2015
for the referenced facility's treatment and disposal system. The inspection included a review of:
records, two pump stations, the residuals processing and storage areas and the application sites.
I would like to thank Dena Myers, Matthew Cartner, Shane Felts and Daniel Baumgardner for their
time during the inspection.
The facility storage and application fields appeared well maintained at the time of inspection. There
are a couple of points worth nothing for continued program compliance:
o A couple of data questions were discussed during our meeting or in subsequent email. Most
questions have already been addressed; however, the 12 month floating totals will be
addressed starting with the next NDAR.
• A visual alarm was out at the Swim Beach pump station and was to be repaired.
This permit is currently in the renewal process with Central Office staff in Raleigh. Please contact
troy. dobV(a)-ncdenr.gov with questions about the renewal.
The attached report should be self-explanatory; however, should you have questions, please contact
me by phone [phone]) or email (maria.schutteancdenr.gov).
Sincerely, >
Maria Schutte, Environm ntal Specialist
Mooresville Regional Office
Water Quality Regional Operations Section
Division of Water Resources, NCDENR
Attachment(s): WQ00020881 Inspection Report
CC: Dena Myers, Statesville Analytical (Email)
Matthew Cartner, LA-ORC (Email)
Mooresville Regional Office
610 East Center Avenue, Suite 301, Mooresville, North Carolina 28115
Phone: [phone] / Fax: [phone] / Customer Service 1-877-623-6748
Internet: www.ncdenr.aov

State of North Carolina
Department of Environment
and Natural Resources
Division of Water Resources
Pat McCrory, Governor
Donald van der Vaart, Secretary
4JO
NCDENR
NON -DISCHARGE COMPLIANCE INSPECTION
GENERAL INFORMATION
City/Town/Owner: NCDENR DIV of Parks & Recreation County: Iredell
Permit No.: WQ0020881 Issued: 9/12/2008 Expiration: 9/30/2015
Permittee Contact: Jarid Church Telephone No.: 704-528-6350 Cell No.: 704-881-1680
ORC Name: Matthew Cartner Cert #SI 995910 Telephone No.: 704-880-4373
Email: mcartnergiss.kl2.nc.us
B/U ORC Name: Dennis Grvder Cert # SI 989073 Telephone No.: 704-902-0427
Reason for Inspection
X ROUTINE COMPLAINT FOLLOW-UP OTHER
Type of inspection
Collection System X Spray Irrigation Sludge Other
Inspection Date(s):. April 28, 2015
Inspection Summary: (additional comments may be included on attached pages)
This inspection was conducted in conjunction with the permit renewal, and included pump stations,
residuals processing, storage, end -use and a records review. The treatment and irrigation systems appeared
to be operating properly and the disposal fields appeared to be in excellent condition, at the time of
inspection.
A visible alarm at the Swim Beach pump station was inoperable and to be repaired.
The MRO had a couple of data related questions which were either addressed at the meeting or via follow-
up email.
Please note:
• This .permit is currently in the renewal process with Central Office permitting staff in Raleigh.
Please contact trov.doby6ncdenr.$tov with permit renewal questions.
• The MRO should be informed of any changes to the contact information noted above.
Is a follow-up inspection necessary _yes X no
Inspector(s): Maria Schulte - Environmental Specialist
Telephone No.: 704-663-1699 Fax No.: 704-663-6040
Date of Inspection: April e8', 2015

Surface Irrigation Inspection pg. 2
WQ0020881 Lake Norman State Park - Iredell County
Type
Activated Sludge Spray, low rate
Activated Sludge Drip, low rate
X Lagoon Spray, Low Rate
Lagoon Drip, Low Rate
Treatment
Y Are treatment facilities consistent with those outlined in the current permit.
Y Do all treatment units appear to be operational. If no, note below.
Influent Pumn Station
Y All pumps present, operational Bypass structure present
Bar screen, maintained Free of excessive debris
Bars evenly spaced Bars excessively corroded
Back-up power During power outages the State Park will close — there is no back-up power.
Flow Measurement — Influent - NA — influent to the plant is calculated monthly runtimes from the two
pump stations.
Is flowmeter calibrated annually?
Is flowmeter operating properly?
Does flowmeter operate continuously?
Does flowmeter record flow?
Does flowmeter appear to monitor accurately?
Flow Measurement — Water -Use Records
Y Is water use metered?
Y Are the daily average values properly calculated?
Disinfection
Y Is the system working? Y Is the system properly maintained?
Tablets Gas X Liquid UV
If tablets, proper size? Present in Cylinder(s)?
Y If gas/liquid, does cylinder/tank storage seem safe?
If bulbs, are replacement bulbs on hand?
Y Is contact chamber free of sludge, solids and growth?
Flow Measurement — Effluent
Y Is the flowmeter calibrated annually?
Y Is the flowmeter operating properly?
Y Does the flowmeter monitor continuously?
Y Does the flowmeter appear to monitor accurately?
Effluent Storage
X LAGOON SEPTIC TANK(s) _ ABOVE GROUND TANK OTHER
Number of months storage — 1.4 Spill control plan on site
Above ground tank Aerated Mixed
In ground tank Aerated Mixed

Surface Irrigation Inspection pg. 3
WQ0020881 Lake Norman State Park - Iredell County
Storage Lagoon
Check any/all that apply,
Y Influent structure (free of obstructions)
N Banks/berms (are there signs of seepage, overtopping, down cutting or erosion)
N Vegetation (is there excessive vegetation on the lagoon bank
Y Liner (if visible, is it intact)
NA Baffles/curtains (in need of repair)
Y Freeboard (>2 feet from overtopping)
Y Staff gauge (clearly marked)
N Evidence of overflow (vegetation discolored or laying downibroken)
N Unusual color (very black, textile colors)
N Foam (are antifoam agents used)
Y Floating mats (sludge, plants, inorganics) — duckweed present
NE Excessive solids buildup (from bottom)
Y Aerators/mixers operational (if present) — not running at the time of inspection
Y Effluent structure (free of obstructions, easily accessible)
Residuals
storage/treatment Y - 780, 000 gal. treatment and storage lagoon.
Comment: Tank residuals are removed when pump stations are serviced by a septage contractor (Lentz)
Disposal (final end use)
Y Is the application equipment present and operational?
N Is application equipment in need repair?
*N Spray heads calibrated this past year? * Maintained but not calibrated with bucket, etc. Per
conversation past ORC did a calibration within the past permit cycle. The spray equipment was running at
the time of this visit and appeared to produce an even application throughout both zones.
Y Are cover crops the type specified in permit? Permit is not species just states suitable vegetative cover.
N Is cover crop in need of improvement?
N Signs of runoff? N Signs of ponding? N Signs of drift?
Y Are buffers adequate?
Y Is the acreage specified in the permit being utilized?
N Are there any limiting slopes in disposal fields?
Y Are restrictions for use of these areas specified? Entire area is fenced.
Y Is permit being followed?
Y Is site access restricted in accordance with permit?
Recordkeeping
Y Is permit available upon request?
Y Are flow rates less than permitted flow?
Y Are monitoring reports present: NDMR Y NDAR Y
Y Are operational logs present? Y Complete?
Y Are lab sheets available for review?
Y Do lab sheets support data represented on NDMR or NDAR?
Y Are all samples analyzed for the required parameters?
Y Is field parameter certification required?
NA Are there any 21, GW quality violations? Groundwater monitoring is not required
N Are annual soil reports available? Recent sampling was conducted in April and results not vet available.
Y Is the operation and maintenance manual present? Complete?
N Has DWR received any complaints regarding the facility in the last 12 months?

NCDENRFrLE
North Carolina Department of Environment and Natural Resources
Pat McCrory Donald van der Vaart
Governor Secretary
April 21,-2015
W Barry McKinnon, Director of Public Utilities
Town of Mooresville
P.O. Box 878
Mooresville, NC 28115
Subject: Acknowledgement of Receipt of the 2014 Annual Report
Town of Mooresville - Permit No.: WQ0014136
Land Application of Residuals
Iredell County
Dear Mr. McKinnon:
The Mooresville Regional Office (MRO) received and reviewed the 2014 Annual Report for the
above permit. The report reflects there was no land application conducted in 2014.
The MRO plans to conduct a facility inspection within the calendar year; however, should you have
questions before then, I may be reached by phone at [phone] or email
(maria.schuttea-ncdenr.gov).
Sincerely,
di
Maria Schutte, Environmental Specialist
Mooresville Regional Office
Water Quality Regional Operations Section
Division of Water Resources, NCDENR
CC: John Ritchie, RR-WWTP ORC (email)
Bill Bourke, RR-WWTP (email)
Ed Hardee, LAU Compliance, CO -Raleigh (email)
Mooresville Regional Office
610 East Center Avenue, Suite 301, Mooresville, North Carolina 28115
Phone: [phone] / Fax: [phone] Customer Service:1-877-623-6748
Internet: www.ncdenr.gov
\ An Equal opportunity 1 Affirmative Action Employer — Made in part by recycled paper

Compliance Inspection Report
Permit: WO0020881 Effective: 09/12/08 Expiration: 09/30/15 Owner: NC DENR Division of Parks and Recreation
SOC: Effective: Expiration: Facility: Lake Norman State Park Swim Beach
County: Iredell 137 Shortleaf Ln
Region: Mooresville
Statesville NC 28677
Contact Person: G Robert Graham Title: Phone: [phone]
Directions to Facility:
From the intersection of Perth Rd (1303) and State Park Rd., travel southwest 4.4 miles past the park entrance and the boat landing.
The WWT system apd spray filed. are located on the right side of State Park Rd.
System Classifications:
Primary ORC: Harry Withers Myers Certification: 986154 Phone: [phone]
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Inspection Date: 05/24/2013 Entry Time: 02:00 PM Exit Time: 03:00 PM
Primary Inspector: Margaret A Finley Phone: [phone]
Secondary Inspector(s): = 4' t fit. Ext.2183
Reason for Inspection: Routine .
Permit Inspection Type: Wastewater Irrigation
Facility Status: ❑ Compliant Q Not Compliant
Question Areas:
■ Treatment Flow ■ Treatment Flow
Measurement -Effluent Measurement -Influent
Treatment Record Keeping
■ Treatment Influent Pump ■ Treatment Disinfection
Station
Standby Power
(See attachment summary)
Inspection Type: Compliance Evaluation
Miscellaneous Questions Treatment Flow
Measurement -Water Use
Records
Treatment Lagoons End Use -Irrigation
■ Treatment Flow ■ Storage
Measurement
Page: 1

Permit: WQ0020881 Owner - Facility: NC DENR Division of Parks and Recreation
Inspection Date: 05/24/2013 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
Page: 2

Permit: WQ0020881 Owner - Facility: NC DENR Division of Parks and Recreation
Inspection Date: 05/24/2013 Inspection Type: Compliance Evaluation
Type
Reuse (Quality)
Infiltration System
Single Family Spray, LR
Activated Sludge Spray, LR
Activated Sludge Drip, LR
Activated Sludge Spray, HR
Recycle/Reuse
Single Family Drip
Lagoon Spray, LR
Treatment
Are Treatment facilities consistent with those outlined in the current permit?
Do all treatment units appear to be operational? (if no, note below.)
Comment:
Treatment Influent Pump Station
Is the pump station free of bypass lines or structures?
Is the general housekeeping acceptable?
Are all pumps present?
Are all pumps operable?
Are floats/controls operable?
Are audio and visual alarms available?
Are audio and visual alarms operational?
# Are SCADA/Telemetry alarms required?
J
Are SCADA/Telemetry available?
Are SCADA/Telemetry operational?
Comment:
Treatment Flow Measurement -Influent
Is flowmeter calibrated annually?
Is flowmeter operating properly?
Does flowmeter monitor continuously?
Reason for Visit: Routine
Yes No NA NE
n
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Yes No NA NE
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No
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Page: 3

Permit: WQ0020881 Owner - Facility: NC DENR Division of Parks and Recreation
Inspection Date: 05/24/2013 Inspection Type: Compliance Evaluation
Does flowmeter record flow?
Does flowmeter appear to monitor accurately?
Comment:
Treatment Flow Measurement -Water Use Records
Is water use metered?
Are the daily average values properly calculated?
Comment:
Treatment Flow Measurement -Effluent
Is flowmeter calibrated annually?
Is flowmeter operating properly?
Does flowmeter monitor continuously?
Does flowmeter record flow?
Does flowmeter appear to monitor accurately?
Comment:
Standby Power
Is automatically activated standby power available?
Is generator tested weekly by interrupting primary power source?
Is generator operable?
Does generator have adequate fuel?
Comment:
Treatment Disinfection
Is the system working?
Do the fecal coliform results indicate proper disinfection?
Is there adequate detention time (>=30 minutes)?
Is the system properly maintained?
If gas, does the cylinder storage appear safe?
Is the fan in the chlorine feed room and storage area operable?
Is the chlorinator accessible?
If tablets, are tablets present?
Are the tablets the proper size and type?
Reason for Visit: Routine
n❑n❑
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No
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nnnn
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No
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Page: 4

Permit: WQ0020881 Owner - Facility: NC DENR Division of Parks and Recreation
Inspection Date: 05/24/2013 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Is contact chamber free of sludge, solids, and growth?
If UV, are extra UV bulbs available?
If UV, is the UV intensity adequate?
# Is it a dual feed system?
Does the Stationary Source have more than 2500 Ibs of Chlorine (CAS No. 7782-50-5)?
If yes, then is there a Risk Management Plan on site?
If yes, then what is the EPA twelve digit ID Number? (1000- - )
If yes, then when was the RMP last updated?
Comment:
Record,Keeping
Is a copy of current permit available?
Are monitoring reports present: NDMR?
N DAR?
Are flow rates less than of permitted flow?
Are flow rates less than of permitted flow?
Are application rates adhered to?
Is GW monitoring being conducted, if required (GW-59s submitted)?
Are all samples analyzed for all required parameters?
Are there any 2L GW quality violations?
Is GW-59A certification form completed for facility?
Is effluent sampled for same parameters as GW?
Do effluent concentrations exceed GW standards?
Are annual soil reports available?
# Are PAN records required?
# Did last soil report indicate a need for lime?
If so, has it been applied?
Are operational logs present?
Are lab sheets available for review?
Do lab sheets support data reported on NDMR?
Do lab sheets support data reported on GW-59s?
Yes No NA NE
(pool]
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Page: 5

Permit: WQ0020881 Owner - Facility: NC DENR Division of Parks and Recreation
Inspection Date: 05/24/2013 Inspection Type: Compliance Evaluation
Reason for Visit:
Routine
Are Operational and Maintenance records present?
n
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Were Operational and Maintenance records complete?
n
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Has permittee been free of public complaints in last 12 months?
21100
Is a copy of the SOC readily available?
nni9❑
No treatment units bypassed since last inspection?
fl
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Comment:
End Use -Irrigation
Are buffers adequate?
Is the cover crop type specified in permit?
Is the crop cover acceptable?
Is the site condition adequate?
Is the site free of runoff / ponding?
Is the acreage specified in the permit being utilized?
Is the application equipment present?
Is the application equipment operational?
Is the disposal field free of limiting slopes?
Is access restricted and/or signs posted during active site use?
Are any supply wells within the CB?
Are any supply wells within 250' of the CB?
How close is the closest water supply well?
Is municipal water available in the area?
# Info only: Does the permit call for monitoring wells?
Are GW monitoring wells located properly w/ respect to RIB and CB?
Are GW monitoring wells properly constructed, including screened interval?
Are monitoring wells damaged?
Comment:
Yes No NA NE
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Beverly Eaves Perdue
Governor
Aja
FILE
NC®ENR
.North Carolina Department of Environment and Natural Resources
Coleen H. Sullins
Division of Water Quality
Lake Norman State Park
159 Inland Sea Lane
Troutman, North Carolina 28166
Attention: Casey Rhinehardt, Park Superindentant
Dear Mr.Rhinehardt:
Dee Freeman
Secretary
July 6, 2012
RE: Surface Irrigation Inspection Report
Permit No. WQ00020881
Facility: Lake Norman Swim Beach & Family Campground
Iredell County, N.C.
Enclosed you will find the report for the annual compliance inspection that I conducted on June 25, 2012.
The treatment and disposal system appears to be in compliance with your permit. During the inspection we
discussed the need to remove solids from the septic tank. This may be scheduled along with your next
routine pump cleanout. I have also enclosed an ORC designation form, as you have recently changed OR
and Back-up personnel. Please note the form should be sent (via fax or mail) to both the Certification
Commission in Raleigh and the Mooresville Regional Office.
The report should be self-explanatory but should you have any questions, please feel free to call me at
704/235-2184. As a reminder, your permit was extended and now it will expire on September 30, 2015.
Sincerely
% ,a
Maria Schutte
Environmental Senior Technician
Enclosures: Inspection Report
ORC Designation Form
CC: Harry Myers, ORC, Statesville, NC (email)
Iredell Co. Health Dept. (email)
One
NorthCarohna
Division of Water Quality / Aquifer Protection Section / Mooresville Regional Office Phone: [phone] Fax: [phone] �'JatUrally
610 East Center Avenue, Suite 301, Mooresville, NC 28115 Customer Service 1-877-623-6748 Internet: www.ncwaterquality.org �/ V 6 l[

State -'of `N'64 Carolina
Department of Environment
and Natural Resources
Division of Water Quality
Beverly Eaves Purdue, Governor
Dee Freeman, Secretary
Coleen H. Sullins, Director
0 1 9W'J
NCDENR
NON -DISCHARGE COMPLIANCE INSPECTION
SURFACE IRRIGATION
GENERAL INFORMATION
Owner: NC Div. of Parks & Recreation County: Iredell
Permit # WQ0020881 Project Name: Lake Norman SP Swim Beach
& Family Campground
Issuance Date: 9/12/08 Expiration Date: 9/30/15
Permittee Contact: Casey Rhinehardt Telephone No.: 704/528-6350
ORC Name: Harry Myers Cert #S1986154 Telephone No.: 704/881-1680
Email address: [e-mail]
Backup ORC Name: Tim Smith Cert #S1989774
Reason for Inspection
X ROUTINE COMPLAINT FOLLOW-UP Facility Start-up
Inspection Summary: (additional comments may be included on attached pages)
The irrigation fields are well maintained, record keeping. is in order and treatment system
appears to be operating in accordance with the permit. The MRO recommends the effluent
septic tank be pumped for solids removal during the next scheduled grinder pump clean -
out. Also, submit an updated ORC designation form as both ORC and back-up have
recently changed.
Is a follow-up inspection necessary yes X no
Inspector Name/Title: Maria Schutte, Environmental Senior Technician
Tel. No. 704/235-2184 Fax No. 704/663-6040
Date of Inspection: 6/25/12

Surface Irrigation
Permit #WQ0020881
Type
Activated Sludge Spray, low rate
Activated Sludge Drip, low rate
X Lagoon Spray, Low Rate
Lagoon Drip, Low Rate
Treatment
Y Are treatment facilities consistent with those outlined in the current permit.
Y Do all treatment units appear to be operational. If no, note below.
Influent pump station
Y All pumps present, operational
Bar screen, maintained
Bars evenly spaced
Back-up power
Flow Measurement - Influent
Y Is flowmeter calibrated annually?
Y Is flowmeter operating properly?
Y Does flowmeter operate continuously?
Y Does flowmeter record flow?
Y Does flowmeter appear to monitor accurately?
Bypass structure present
Free of excessive debris
Bars excessively corroded
Flow Measurement - Water -Use Records
Y Is water use metered?
Y Are the daily average values properly calculated?
Disinfection
Y Is the system working? Y Is the system properly maintained?
Tablets Gas X Liquid, UV
If tablets, proper size? Present in Cylinder(s)?
Y If gas/liquid, does cylinder/tank storage seem safe?
If bulbs, are replacement bulbs on hand?
Y Is contact chamber free of sludge, solids and growth?
Comments:
Flow Measurement - Effluent
Y Is the flowmeter calibrated annually?
Y Is the flowmeter operating properly?
Y Does the flowmeter monitor continuously?
Y Does the flowmeter appear to monitor accurately?
Effluent Storage
X LAGOON SEPTIC TANK(s) ABOVE GROUND TANK OTHER
Number of months storage - 1.4 Spill control plan on site
Above ground tank Aerated Mixed
In ground tank Aerated . Mixed
Page 2

Beverly Eaves Perdue
Governor.
NCDENR
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins
Division of Water Quality
Lake Norman State Park
159 Inland Sea Lane
Troutman, North Carolina 28166
Attention: Casey Rhinehardt, Park Superindentant
Dear Mr.Rhinehardt:
Dee Freeman
Secretary
July 6, 2012
RE: Surface Irrigation Inspection Report
Permit No. WQ00020881
Facility: Lake Norman Swim Beach & Family Campground
Iredell County, N.C.
Enclosed you will find the report for the annual compliance inspection that I conducted on June 25, 2012.
The treatment and disposal system appears to be in compliance with your permit. Durinq the inspection we
discussed the need to remove solids from the septic tank. This may be scheduled along with vour next
routine pump cleanout. / have also enclosed an ORC designation form, as you have recently changed OR
and Back-up personnel. Please note the form should be sent (via fax or mail) to both the Certification
Commission in Raleigh and the Mooresville Regional Office.
The report should be self-explanatory but should you have any questions, please feel free to call me at
704/235-2184. As a reminder, your permit was extended and now it will expire on September 30, 2015.
Sincerer
Vdo
Maria Schutte
Environmental Senior Technician
Enclosures: Inspection Report
ORC Designation Form
CC: Harry Myers, ORC, Statesville, NC (email)
Iredell Co. Health Dept. (email)
Division of Water Quality / Aquifer Protection Section / Mooresville Regional Office Phone: [phone] Fax: [phone] NOTt11CaT011lla
610 East Center Avenue, Suite 301, Mooresville, NC 28115 Customer Service 1-877-623-6748 Internet: www.ncwaterquality.org �aturaljrr

State of North Carolina
Department of Environment
and. Natural Resources
Division of Water Quality
Beverly Eaves Purdue, Governor
Dee Freeman, Secretary
Coleen H. Sullins, Director
A6T'1?W'J
IT
4
NCDENR
NON -DISCHARGE COMPLIANCE INSPECTION
SURFACE IRRIGATION
GENERAL INFORMATION
Owner: NC Div. of Parks & Recreation County: Iredell
Permit # WQ0020881 Project Name: Lake Norman SP Swim Beach
& Family Campground
Issuance Date: 9/12/08 Expiration Date: 9/30/15
Permittee Contact: Casey Rhinehardt Telephone No.: 704/528-6350
ORC Name: Harry Myers Cert #S1986154 Telephone No.: 704/881-1680
Email address: [e-mail]
Backup ORC Name: Tim Smith Cert #S1989774
Reason for Inspection
X ROUTINE COMPLAINT FOLLOW-UP Facility Start-up
Inspection Summary. (additional comments may be included on attached pages)
The irrigation fields are well maintained, record keeping is in order and treatment system
appears to be operating in accordance with the permit. The MRO recommends the effluent
septic tank be pumped for solids removal during the next scheduled grinder pump clean -
out. Also, submit an updated ORC designation form as both ORC and back-up have
recently changed.
Is a follow-up inspection necessary yes X no
Inspector Name/Title: Maria Schutte, Environmental Senior Technician
Tel. No. 704/235-2184 Fax No. 704/663-6040
Date of Inspection: 6/25/12

Surface Irrigation
Permit #W00020881
Tvpe
Activated Sludge Spray, low rate
Activated Sludge Drip, low rate
X Lagoon Spray, Low Rate
Lagoon Drip, Low Rate
Treatment
Y Are treatment facilities consistent with those outlined in the current permit.
Y Do all treatment units appear to be operational. If no, note below.
Influent pump station
Y All pumps present, operational
Bar screen, maintained
Bars evenly spaced
Back-up power
Flow Measurement - Influent
Y Is flowmeter calibrated annually?
Y Is flowmeter operating properly?
Y Does flowmeter operate continuously?
Y Does flowmeter record flow?
Y Does flowmeter appear to monitor accurately?
Bypass structure present
Free of excessive debris
Bars excessively corroded
Flow Measurement - Water -Use Records
Y Is water use metered?
Y Are the daily average values properly calculated?
Disinfection
Y Is the system working? Y Is the system properly maintained?
Tablets Gas X Liquid UV
If tablets, proper size? Present in Cylinder(s)?
Y If gas/liquid, does cylinder/tank storage seem safe?
If bulbs, are replacement bulbs on hand?
Y Is contact chamber free of sludge, solids and growth?
Comments:
Flow Measurement - Effluent
Y Is the flowmeter calibrated annually?
Y Is the flowmeter operating properly?
Y Does the flowmeter monitor continuously?
Y Does the flowmeter appear to monitor accurately?
Effluent Storaae
X LAGOON SEPTIC TANK(s) ABOVE GROUND TANK OTHER
Number of months storage - 1.4 Spill control plan on site
Above ground tank Aerated Mixed
In ground tank Aerated Mixed
Page 2

Surface Irrigation Page 3
Permit #WQ0020881
Storage Lagoon
Check any/all that apply
Y Influent structure (free of obstructions) Influent well in need of solids removal,
N Banks/berms (are there signs of seepage, overtopping, down cutting or erosion)
N Vegetation (is there excessive vegetation on the lagoon bank
Y Liner if visible, is it intact)
NA Baffles/curtains (in need of repair)
Y Freeboard (>2 feet from overtopping)
Y Staff gauge (clearly marked)
N Evidence of overflow (vegetation discolored or laying down/broken)
N Unusual color (very black, textile colors)
NA Foam (are antifoam agents used)
Y Floating mats (sludge, plants, inorganics)
N Excessive solids buildup (from bottom)
Y Aerators/mixers operational (if present)
Y Effluent structure (free of obstructions, easily accessible)
Disposal (final end use)
Y Is the application equipment present and operational?
N Is application equipment in need repair?
NE Spray heads calibrated this past year?
* Y Are cover crops the type specified in permit? * Permit states a cover crop, but is not
specific.
N Is cover crop in need of improvement?
N Signs of runoff? N Signs of ponding? N Signs of drift?
Y Are buffers adequate?
Y Is the acreage specified in the permit being utilized?
N Are there any limiting slopes in disposal fields?
Y Are restrictions for use of these areas specified? Entire area is fenced.
Y Is permit being followed?
Y Is site access restricted in, accordance with permit?
Recordkeeping
Y Is permit available upon request?
Y Are flow rates less than permitted flow?
Y Are monitoring reports present: NDMR _ NDAR
Y Are operational logs present? Y Complete?
Y Are lab sheets available for review?
NE Do lab sheets support data represented on NDMR or NDAR?
Y Are all samples analyzed for the required parameters?
Y Is field parameter certification required?
NA Are there any 2L GW quality violations? Groundwater Monitoring Not Required
Y Are annual soil reports available?
Y Is the operation and maintenance manual present? Complete?
N Has DWQ received any complaints regarding the facility in the last 12 months?

Beverly Eaves Perdue
Governor
ti
CA1
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins
Division of Water Quality
Lake Norman State Park
159 Inland Sea Lane
Troutman, North Carolina 28166
Attention: Casey Rhinehardt, Park Superindentant
Dear Mr.Rhinehardt:
Dee Freeman
Secretary
July 15, 2011
RE: Surface Irrigation Inspection Report
Permit No. W000020881
Facility: Lake Norman Swim Beach & Family Campground
Iredell County, N.C.
This letter is in response to my phone conversation with Wayne Crenshaw on July 15, 2011. 1 have
reviewed our files and found I erroneously pulled the sampling requirements from an older permit. Mr.
Crenshaw is correct in his assessment. Your current permit requires four sampling events per year to be
conducted in March, June, September and December.
I am sending this letter as a record for your files. I apologize for any inconvenience this may have caused.
Should you have any questions, please feel free to call me at 704/235-2184.
Sincerely,
Maria Schutte
Environmental Senior Technician
Enclosure: Inspection Report
Cc: Iredell Co. Health Dept.
Nne
orthCarolina
Division of Water Quality / Aquifer Protection Section / Mooresville Regional Office Phone: [phone] Fax: [phone] J,1�1
610 East Center Avenue, Suite 301, Mooresville, NC 28115 Customer Service 1-877-623-6748 Internet: www.ncwaterquality.org E/q�P,d ,11

S�
0PD
CCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Division of Water Quality Secretary
June 20, 2011
Lake Norman State Park
159 Inland Sea Lane
Troutman, North Carolina 28166
Attention: Casey Rhinehardt, Park Superindentant
RE: Surface Irrigation Inspection Report
Permit No. WQ00020881
Facility: Lake Norman Swim Beach & Family Campground
Iredell County, N.C.
Dear Mr.Rhinehardt:
Enclosed you will find the report for the annual compliance inspection that I conducted on June 16, 2011.
The treatment and disposal system appears to be in comliance with your permit. I discussed the permit
effluent sampling schedule with Mr. Crenshaw. He has already submitted data for March 2011 and should
schedule the remaining 2011 sampling events for July and November, in accordance with the specifications
of the permit (Condition 111.3).
The report should be self-explanatory but should you have any questions, please feel free to call m _
704/235-2184. As a reminder, your permit was extended and now it will expire on September 30, 2014.
Sincerely,
Maria Schutte
Environmental Senior Technician
Enclosure: Inspection Report
Cc: Iredell Co. Health Dept.
One
NorthCarohna
Division of Water Quality / Aquifer Protection Section / Mooresville Regional Office Phone: [phone] Fax: [phone] Naturally
610 East Center Avenue, Suite 301, Mooresville, NC 28115 Customer Service 1-877-623-6748 Internet: www.ncwaterquality.org (/ V

rr.
State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
Beverly Eaves Purdue, Governor
Dee Freeman, Secretary
Coleen H. Sullins, Director
NCDENR
NON -DISCHARGE COMPLIANCE INSPECTION
SURFACE IRRIGATION
GENERAL INFORMATION
Owner: NC Div. of Parks & Recreation County: Iredell
Permit # W00020881 Project Name: Lake Norman SP Swim Beach
& Family Campground
Issuance Date: 9/12/08 Expiration Date: 9/30/14
Permittee Contact: Casey Rhinehardt Telephone No.: 704/528-6350
ORC Name: Wayne Crensha ert #S1986154 Telephone No.: 704/881-1680
Email address: [e-mail] -',) (
a
Backup ORC Name: Tim Smith Cert #S1989774
Reason for Inspection
X ROUTINE COMPLAINT FOLLOW-UP Facility Start-up
Inspection Summary. (additional comments may be included on attached pages)
The treatment system appears to be operating satisfactorily. The irrigation fields are well
groomed and in good condition. Recordkeeping was well organized and complete. All effluent
monitoring analyses were conducted during the past year, however the schedule noted in the
permit was not followed exactly. Please NOTE: Effluent monitoring analyses are to be
conducted in March, July and November and reports submitted on or before the last day
of the following month.
Is a follow-up inspection necessary yes X no
Inspector Name/Title: Maria Schutte, Environmental Senior Technician
Tel. No. 704/235-2184 Fax No. 704/663-6040
Date of Inspection: 6/16/11

.r
Surface Irrigation
Permit #WQ0020881
Type
Activated Sludge Spray, low rate
Activated Sludge Drip, low rate
X Lagoon Spray, Low Rate
Lagoon Drip, Low Rate
Treatment
Y Are treatment facilities consistent with those outlined in the current permit.
Y Do all treatment units appear to be operational. If no, note below.
Influent pump station
Y All pumps present, operational
Bar screen, maintained
Bars evenly spaced
Back-up power
Flow Measurement - Influent
Y Is flowmeter calibrated annually?
Y Is flowmeter operating properly?
Y Does flowmeter operate continuously?
Y Does flowmeter record flow?
Y Does flowmeter appear to monitor accurately?
Bypass structure present
Free of excessive debris
Bars excessively corroded
Flow Measurement — Water -Use Records
Y Is water use metered?
Are the daily average values properly calculated?
Disinfection
Y Is the system working? Y Is the system properly maintained?
Tablets Gas X Liquid UV
If tablets, proper size? Present in Cylinder(s)?
Y If gas/liquid, does cylinder/tank storage seem safe?
If bulbs, are replacement bulbs on hand?
NE Is contact chamber free of sludge, solids and growth?
Comments:
Flow Measurement — Effluent
Y Is the flowmeter calibrated annually?
Y Is the flowmeter operating properly?
Y Does the flowmeter monitor continuously?
Y Does the flowmeter appear to monitor accurately?
Effluent Storacie
Page 2
X LAGOON SEPTIC TANK(s) ABOVE GROUND TANK OTHER
Number of months storage Spill control plan on site
Above ground tank Aerated Mixed
In ground tank Aerated Mixed

Surface Irrigation
Permit #WQ0020881
Page 3
Storage Lagoon
Check any/all that apply
Y Influent structure (free of obstructions)
N Banks/berms (are there signs of seepage, overtopping, down cutting or erosion)
N Vegetation (is there excessive vegetation on the lagoon bank
Y Liner (if visible, is it intact)
NA Baffles/curtains (in need of repair)
Y Freeboard (>2 feet from overtopping)
Y Staff gauge (clearly marked)
N Evidence of overflow (vegetation discolored or laying down/broken)
N Unusual color (very black, textile colors)
NA Foam (are antifoam agents used)
Y Floating mats (sludge, plants, inorganics)
N Excessive solids buildup (from bottom)
Y Aerators/mixers operational (if present)
Y Effluent structure (free of obstructions, easily accessible)
Disposal (final end use)
Y Is the application equipment present and operational?
N Is application equipment in need repair?
NE Spray heads calibrated this past year?
N Are cover crops the type specified in permit?
N Is cover crop in need of improvement?
N Signs of runoff? N Signs of ponding? N Signs of drift?
Y Are buffers adequate?
Y Is the acreage specified in the permit being utilized?
N Are there any limiting slopes in disposal fields?
NE Are restrictions for use of these areas specified? Entire area is fenced.
Y Is permit being followed?
Y Is site access restricted in accordance with permit?
Recordkeeping
Y Is permit available upon request?
Y Are flow rates less than permitted flow?
Y Are monitoring reports present: NDMR _ NDAR
Y Are operational logs present? Y Complete?
Y Are lab sheets available for review?
NE Do lab sheets support data represented on NDMR or NDAR?
Y Are all samples analyzed for the required parameters?
Y Is field parameter certification required?
NA Are there any 2L GW quality violations? Groundwater Monitoring Not Required
Y Are annual soil reports available?
Y Is the operation and maintenance manual present? Complete?
N Has DWQ received any complaints regarding the facility in the last 12 months?

08:42 3369573985
2 15:06 7045285623
STONE MOUNTAIN STATE
WEST AISTP.ICT OFFICE
PAGE 01
PAGE 02
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by the WawrPntluti"C •••••••••••••••••.-,•••••••••••
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Directions to Julia's Talley House Restaurant
305 North Main Street, Troutman, NC 28166 - [phone]
20.3 mi — about 41 mins
Save trees. Go green!
Download Google Maps on your
phone atgooglexom/gmm DODO
I

610 E Center Ave, Mooresville, NC 28115
T
1. Head west on E Center Ave toward E Statesville Ave
go 0.6 mi
About 1 min
total 0.6 mi
2. Turn left onto S Main St
go 397 ft
total 0.7 mi
3. Turn right onto W McLelland Ave
go 0.9 mi
About 2 mins
total 1.6 mi
4. Continue straight to stay on W McLelland Ave
go 167 ft
total 1.6 mi
5. Turn left onto E Plaza Dr
go 0.4 mi
About 2 mins
total 2.1 mi
6. Take the US-21 N ramp
go 384 ft
total 2.1 mi
7. Merge onto Westfield Dr
go 295 ft
total 2.2 mi
21
8. Take the ramp onto US-21 N/Charlotte Hwy
go 1.9 mi
About 2 mins
total 4.1 mi
9. Turn left onto Cornelius Rd
go 2.4 mi
About 5 mins
total 6.5 mi
10. Turn right onto Judas Rd
go 1.2 mi
About 2 mins
total 7.7 mi
11. Turn right onto Perth Rd
go 3.0 mi
About 6 mins
total 10.7 mi
12. Sharp left onto State Park Rd
go 3.6 mi
About 7 mins
total 14.4 mi
4
13. Turn left onto Inland Sea Ln
go 0.2 mi
About 1 min
total 14.5 mi
14. Take the 1st right to stay on Inland Sea Ln
go 285 ft
total 14.6 mi
Total: 14.6 mi - about 29 mins
Inland Sea Ln
total 0.0 mi
15. Head north on Inland Sea Ln
go 285 ft
total 285 ft
16. Turn left to stay on Inland Sea Ln
go 0.2 mi
total 0.2 mi
17. Turn right onto State Park Rd
go 3.6 mi
About 7 mins
total 3.8 mi
18. Slight left onto Perth Rd
go 0.7 mi
About 1 min
total 4.6 mi
19. Continue onto Wagner St
go 0.8 mi
About 1 min
total 5.4 mi
20. Turn left onto S Main St
go 0.3 mi
total 5.7 mi
About 1 min

Total: 5.7 mi — about 12 mins
Aft'Julia's Talley House Restaurant
If 305 North Main Street, Troutman,, NC 28166 (704) 528 6 962
These directions are for planning purposes only. You may find that construction projects, traffic, weather, or other events may cause
conditions to differ from the map results, and you should plan your route accordingly. You must obey all signs or notices regarding your route.
Map data ©2011 Google
Directions w eren't right? Please find your route on maps.google. corn and click "Report a problem" at the bottom left.
ell
i
�Q

Beverly Eaves Perdue
Governor
WA
NCDENR
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins
Division of Water Quality
Lake Norman State Park
159 Inland Sea Lane
Troutman, North Carolina 28166
Attention: Casey Rhinehardt, Park Superindentant
Dear Mr.Rhinehardt:
Dee Freeman
Secretary
June 7, 2010
RE: Surface Irrigation Inspection Report
Permit No. WQ00020881
Facility: Lake Norman Swim Beach & Family Campground
Iredell County, N.C.
Enclosed you will find the report for the annual compliance inspection that I conducted on May 28, 2010.
The treatment and disposal system appears to be in comliance with your permit. The report should be
self-explanatory but should you have any questions, please feel free to call me at 704/235-2183.
As a result of passage of Session Law 2009-406, the expiration of your permit has been extended until
September 30, 2014. Please submit a renewal application to the division at least six months prior to that
date.
Sincerely,
Peggy Finley
Environmental Specialist
Enclosure: Inspection Report
Cc: Iredell Co. Health Dept.
MAF/Lake Norman SP inspection rpt 5-28-10
One
NoAhCaroli
Division of Water Quality !Aquifer Protection Section / Mooresville Regional office Phone: [phone] Fax: [phone] %��at�ra!!
610 East Center Avenue, Suite 301, Mooresville, NC 28115 Customer Service 1-877-623 6748 Internet: www.ncwaterquality.org U

State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
Beverly Eaves Purdue, Governor
Dee Freeman, Secretary
Coleen H. Sullins, Director
AIT-190%
NCDENR
NON -DISCHARGE COMPLIANCE INSPECTION
SURFACE IRRIGATION
GENERAL INFORMATION
Owner: NC Div. of Parks & Recreation County: Iredell
Permit # WQ0020881 Project Name: Lake Norman SP Swim Beach
& Family Campground
Issuance Date: 9/12/08 Expiration Date: 9/30/14
Permittee Contact: Casey Rhinehardt Telephone No.: 704/528-6350
ORC Name:Wayne Crenshaw Cert #S1986154 Telephone No.: 704/881-1680
Email address: [e-mail]
Backup ORC Name: Tim Smith Cert #S1989774
Reason for Inspection
X ROUTINE COMPLAINT FOLLOW-UP Facility Start-up
Inspection Summary. (additional comments may be included on attached pages)
The treatment system appears to be operating satisfactorily. The irrigation fields are well
groomed and in good condition. Recordkeeping was well organized and complete.
Is a follow-up inspection necessary yes X no
Inspector Name/Title: Peggy Finley, Environmental Specialist
Tel. No. 704/235-2183 Fax No. 704/663-6040
Date of Inspection: 5/28/10

,If
Surface Irrigation Page 3
Permit #WQ0020881
Effluent Storage
X LAGOON SEPTIC TANK(s) ABOVE GROUND TANK OTHER
Number of months storage Spill control plan on site
Above ground tank Aerated Mixed
In ground tank Aerated Mixed
Storage Lagoon
Check any/all that apply
Y Influent structure (free of obstructions)
N Banks/berms (are there signs of seepage, overtopping, down cutting or erosion)
_N_ Vegetation (is there excessive vegetation on the lagoon bank
Y Liner (if visible, is it intact)
Baffles/curtains (in need of repair)
Y Freeboard (>2 feet from overtopping)
_Y_ Staff gauge ( clearly marked)
_N_Evidence of overflow (vegetation discolored or laying down/broken)
—N—Unusual color (very black, textile colors)
Foam (are antifoam agents used)
—Y—Floating mats (sludge, plants, inorganics)
_N_ Excessive solids buildup (from bottom)
Y Aerators/mixers operational (if present)
Y Effluent structure (free of obstructions, easily accessible)
Residuals NA
Disposal (final end use)
Y Is the application equipment present and operational?
_N_ Is application equipment in need repair?
Spray heads calibrated this past year?
_N_ Are cover crops the type specified in permit?
_N_ Is cover crop in need of improvement?
_N_ Signs of runoff? —N_ Signs of ponding? _N_ Signs of drift?
Y Are buffers adequate?
Y Is the acreage specified in the permit being utilized?
N Are there any limiting slopes in disposal fields?
_ Are restrictions for use of these areas specified?
Y Is permit being followed?
Y Is site access restricted in accordance with permit?

Beverly Eaves Perdue
Governor
NCENR
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins
Division of Water Quality
Lake Norman State Park
159 Inland Sea Lane
Troutman, North Carolina 28166
Attention: Casey Rhinehardt, Park Superintendent
Dear Mr. Rhinehardt:
Dee Freeman
Secretary
May 5, 2009
RE: Surface Irrigation Inspection Report
Permit No. WQOO20881
Facility: Lake Norman SP Swim Beach
And Campground
Iredell County, N.C.
Enclosed you will find the report for the annual compliance inspection that I conducted on April 27, 2009.
The facility is in compliance with the referenced permit.
The report should be self-explanatory but feel free to contact me if you should have any questions. My
telephone number is 704/235-2183. Please note my new email address: [e-mail].
Sincerely,
PeZrinley
Environmental Specialist
Enclosure: Inspection Report
Cc: Harry Myers, 291 Elmwood St., Statesville 28625 w/ enclosure
MAF/surface irrigation/ Lake Norman SP inspection rpt 4-27-09
Nne
orthCarolii
Division of Water Quality / Aquifer Protection Section / Mooresville Regional Office Phone: [phone] Fax: [phone] JQ�u1,R //t
610 East Center Avenue, Suite 301, Mooresville, NC 28115 Customer Service 1-877-623-6748 Internet: www.ncwaterquality.org !/ Y l61

��:�.�R � �, �.� �
��
�� �� �� �

North Carolina
GROUNDWATER FIELD/LAB FORM Department of Environment and Natural Resources
DIVISION OF WATER QUALITY -GROUNDWATER SECTION
Location code W10300045-EFF SAMPLE TYPE SAMPLE PRIORITY
County_Rowan I9 Water X Routine Lab Number
Quad No Serial No. El soil El Emergency Date Received Time:
9•
Lat. Lon El Other Rec'd By: From:Bus, Courier, Hand Del.,
❑ Chain of Custody Other:
Report To: ARO, FRO, RO� RRO, WaRO, WiRO, Data Entry By: Ck:
WSRO, Kinston FO, Fed. Trust, Central Off., Other: Date Reported:
Shipped by: Bus,`ourie� Hand Del., Other: Purpose: UIC System Inspection
Collector(s): Maria Schutte / Andrew Pitner Date: 10/13/2010 Time Baseline; Complaint, Compliance, LUST, Pesticide Study, Federal Trust, Other:
FIELD ANALYSES Owner: Catawba College (circle one)
pH 400 Spec. Cond.94 at 25°C Location or Site: 2300 W. Innes Street, Salisbury
Temp.lo °C Odor Description of sampling point: Effluent
Appearance
Field Analysis By: Maria Schutte
LABORATORY ANALYSES
BOD 310 mg/L
COD High 340 mg/L
COD Low 335 mg/L
X
Coliform: MF Fecal 31616 /100ml
X
Coliform: MF Total 31504 /100ml
TOC 680 mg/L
Turbidity 76 NTU
Residue, Total Suspended 530 mg/L
pH 403 units
Alkalinity to pH 4.5 410 mg/L
Alkalinity to pH 8.3 415 mg/L
Carbonate 445 mg/L
Bicarbonate 440 mg/L
Carbon dioxide 405 mg/L
X
Chloride 940 mg/L
Chromium: Hex 1032 ug/L
Color: True 80 CU
Cyanide 720 mg/L
Lab Comments
_ Sampling Method: Pump Sample Interval
_ Remarks -
(Pumping Bailer. a c.
(Pumping time, air temp., etc.)
X
Diss. Solids 70300
mg/L
X
Ag-Silver 46566
ug/L
X
Fluoride 951
mg/L
X
AI -Aluminum 46557
u /L
X
Hardness: Total 900
mg/L
X
As -Arsenic 46551
u /L
Hardness (non-carb) 902
mg/L
X
Ba-Barium 46558
u /L
Phenols 32730
ug/I
X
Ca -Calcium 46552
mg/L
Specific Cond. 95
pMhos/cm
X
Cd-Cadmium 46559
u /L
X
Sulfate 945
mg/L
X
Cr-Chromium 46559
u /L
Sulfide 745
mg/L
X
Cu-Copper 46562
u /L
X
Fe -Iron 46563
u /L
Oil and Grease
mg/L
Hg-Mercury 71900
u /L
X
K-Potassium 46555
m /L
X
Mg -Magnesium 46554
m /L
X
Mn-Manganese 46565
u /L
NH3 as N 610
mg/L
X
Na-Sodium 46556
m /L
TKN as N 625
mg/L
X
Ni-Nickel
u /L
NOZ + NO3 as N 630
mg/L
X
Pb-Lead 46564
u /L
P: Total as P 665
mg/L
X
Se -Selenium
u /L
X
Nitrate (NO3 as N) 620
mg/L
X
Zn-Zinc 46567
u /L
X
Nitrite (NO2 as N) 615
mg/L
GW-54 REV. 7/03 For Dissolved Analysis -submit filtered sample and write "DIS" in block.
Or ano hos horus Pesticides
Nitrogen Pesticides
Acid Herbicides
PCBs
Semivolatile Organics
TPH-Diesel Range
Volatile Organics(VOA bottle
TPH-Gasoline Range
TPH-BTEX Gasoline Range
LAB USE ONLY
Temperature on arrival (°C):

A
State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
Beverly Eaves Purdue, Governor
Dee Freeman, Secretary
Coleen H. Sullins, Director
16?7?W,J
IT
A&4V*J�
NCDENR
NON -DISCHARGE COMPLIANCE INSPECTION
SURFACE IRRIGATION
GENERAL INFORMATION
Owner: NCDENR, Div. of Parks & Rec. County: Iredell
Permit # WQ0020881 Project Name: Lake Norman State Park
Issuance Date: 9/12/08 Expiration Date: 9/30/11
Permittee Contact: Casey Rhinehardt Telephone No.: 704/528-6350
ORC Name: Harry Myers Cert #S1986154 Telephone No.: 704/880-1084
Email address:
Backup ORC Name: Wayne Crenshaw Cert #S1991559 Telephone No.: 704/528-6350
Reason for Inspection
X ROUTINE COMPLAINT FOLLOW-UP Facility Start-up
Inspection Summary: (additional comments may be included on attached pages)
The pump station for the campground is now on-line. The wastewater treatment system
appears to be operating well. The irrigation fields are in good condition. Record keeping is
in good order. Park employee Chris Dockery will be attending spray operator's school in
May.
Is a follow-up inspection necessary yes X no
Inspector Name/Title: Peggy Finley, Environmental Specialist
Tel. No. 7041235-2183 Fax No. 704/663-6040
Date of Inspection: 4/27/09

i
Surface Irrigation
Permit #W00020881
Type
Activated Sludge Spray, low rate
Activated Sludge Drip, low rate
X Lagoon Spray, Low Rate
Lagoon Drip, Low Rate
Treatment
Y Are treatment facilities consistent with those outlined in the current permit.
Y Do all treatment units appear to be operational. If no, note below.
Influent pump stations
Y All pumps present, operational
Bar screen, maintained
Bars evenly spaced
—Y—Back-up power
_N_Bypass structure present
Free of excessive debris
Bars excessively corroded
Flow Measurement — Influent
_Y_ Is flowmeter calibrated annually?
_ Y _ Is flowmeter operating properly?
Y Does flowmeter operate continuously?
_ Y _ Does flowmeter record flow?
Y Does flowmeter appear to monitor accurately?
Flow Measurement — Water -Use Records
Y Is water use metered?
Are the daily average values properly calculated?
Page 2
Treatment and Storage Lagoon
Check any/all that apply
Y Influent structure (free of obstructions)
N Banks/berms (are there signs of seepage, overtopping, down cutting or erosion)
_N_ Vegetation (is there excessive vegetation on the lagoon bank
_Y_ Liner (if visible, is it intact)
NA Baffles/curtains (in need of repair)
Y Freeboard (>2 feet from overtopping)
—Y—Staff gauge (clearly marked)
_N Evidence of overflow (vegetation discolored or laying down/broken)
_N Unusual color (very black, textile colors)
N Foam (are antifoam agents used)
_N Floating mats (sludge, plants, inorganics)
_N_ Excessive solids buildup (from bottom)
Y Aerators/mixers operational (if present)
Y Effluent structure (free of obstructions, easily accessible)

0
Surface Irrigation
Permit ##WQ0020881
Page 3
Disinfection
_Y_ Is the system working? Y_ Is the system properly maintained?
Tablets Gas X Liquid _Y_ UV
If tablets, proper size? Present in Cylinder(s)?
If gas/liquid, does cylinder/tank storage seem safe?
If bulbs, are replacement bulbs on hand?
Is contact chamber free of sludge, solids and growth?
Flow Measurement — Effluent
Is the flowmeter calibrated annually?
_ Y_ Is the flowmeter operating properly?
_Y Does the flowmeter monitor continuously?
Y Does the flowmeter appear to monitor accurately?
Residuals NA
storage/treatment
Disposal (final end use)
Y Is the application equipment present and operational?
--N_ Is application equipment in need repair?
Y Spray heads calibrated this past year?
N Are cover crops the type specified in permit?
_N_ Is cover crop in need of improvement?
_N Signs of runoff?
_N_ Signs of ponding?
_N_ Signs of drift?
Y Are buffers adequate?
Y Is the acreage specified in the permit being utilized?
N Are there any limiting slopes in disposal fields?
Are restrictions for use of these areas specified?
Y Is permit being followed?
Y Is site access restricted in accordance with permit?
Groundwater Monitoring
_N_ Does the permit require monitoring wells? If so,
are the monitoring wells properly installed according to the permit?
are the wells properly identified?
are the wells damaged?

a
Surface Irrigation
Permit #WQ0020881
Page 4
Recordkeeping
Y Is permit available upon request?
Y Are flow rates less than permitted flow?
Y Are monitoring reports present: NDMR _ NDAR
Y Are operational logs present? _ Complete?
Y Are lab sheets available for review?
Y Do lab sheets support data represented on NDMR or NDAR?
Y Are all samples analyzed for the required parameters?
_Y_ Is field parameter certification required?
_N_ Are there any 2L GW quality violations?
Are annual soil reports available?
Y Is the operation and maintenance manual present? Complete?
N Has DWQ received any complaints regarding the facility in the last 12 months?
Comment: Soil samples were collected on the day of the inspection.

F WATF Micnaei r. tasiey, vovernor
R ( William G. Ross Jr., Secretary
�O� QG p North Carolina Department of Environment and Natural Resources
,3 r Coleen H. Sullins, Director
Division of Water Quality
O 'C
AQUIFER PROTECTION SECTION
July 8, 2008
Lake Norman State Park
159 Inland Sea Lane
Troutman, North Carolina 28166
Attention: Casey Rhinehardt, Park Superintendant
RE: Surface Irrigation Inspection Report
Permit No. WQ0020991
Facility: Swim Area Bath house
Iredell County, N.C.
Dear Mr. Rhinehardt:
Enclosed you will find the report for the annual compliance inspection that I conducted on July 2, 2008.
Based on that inspection, your facility appears to be in compliance with the referenced permit. The
report should be self-explanatory but do not hesitate to call me if you should have any questions.
Sincerely,
Peggy Finley
Environmental Specialist
Enclosure: Inspection Report
Cc: Harry Myers 291 Elmwood St., Statesville 28625 w/enclosure
MAF/Lake Norman SP inspection rpt 7-08
NorthCarol:
Division of Water Quality / Aquifer Protection Section / Mooresville Regional Office Phone: [phone] Fax: [phone]�Futa/t
610 East Center Avenue, Suite 301, Mooresville, NC 28115 Customer Service 1-877-623-6748 Internet: www.ncwaterquality.org �/ V ` l

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
NCDENR
NON -DISCHARGE COMPLIANCE INSPECTION
SURFACE IRRIGATION
GENERAL INFORMATION
City/Town/Owner: NC Div. of Parks & Rec.
Permit # WQ0020881
Issuance Date: 10/25/06
Permittee Contact: Casey Rhinehardt
ORC Name: Harry W. Myers Cert #S1986154
Backup ORC: David Fesperman Cert#S114852
County: Iredell
Project Name: Lake Norman SP
Swim Area Bath House
Expiration Date: 9/30/11
Telephone No.: 704/528-6350
Telephone No.: 704/880-1084
Telephone No.: 800/438-0551
Reason for Inspection
X ROUTINE COMPLAINT FOLLOW-UP OTHER
Inspection Summary. (additional comments may be included on attached pages)
The treatment system is in good operating order and the lagoon is in good condition. A
permit modification request is presently. under review to add the wastewater stream from the
family campground to this facility. Control of grassy vegetation in the spray field corridors has
improved. Records are in good order and compliance monitoring is complete.
Is a follow-up inspection necessary yes X no
Inspector Name/Title: Peggy Finley, Environmental Specialist
Tel. No. 704/235-2183 Fax No. 704/663-6040
Date of Inspection: 7/2/08

Permit #WQ0020881 Page 2
Type
Activated Sludge Spray, low rate
Activated Sludge Drip, low rate
X_ Lagoon Spray, Low Rate
Lagoon Drip, Low Rate
Treatment
Y Are treatment facilities consistent with those outlined in the current permit.
Y Do all treatment units appear to be operational. If no, note below.
Treatment and Storage Lagoon
Y Influent structure (free of obstructions)
N Banks/berms (are there signs of seepage, overtopping, down cutting or erosion)
_N_ Vegetation (is there excessive vegetation on the lagoon bank
_Y_ Liner (if visible, is it intact)
_N Baffles/curtains (in need of repair)
Y Freeboard (>2 feet from overtopping)
—Y—Staff gauge ( clearly marked)
_N_ Evidence of overflow (vegetation discolored or laying down/broken)
_N Unusual color (very black, textile colors)
N Foam (are antifoam agents used)
Y*_Floating mats (sludge, plants, inorganics)
_N_ Excessive solids buildup (from bottom)
Y Aerators/mixers operational (if present)
Y Effluent structure (free of obstructions, easily accessible)
Comment: * Duckweed is still present but is very thin. It appears to pose no problem to the
operation of the lagoon. The depth of bottom solids is to be measured shortly.
Influent pump station
Y All pumps present, operational
NA Bar screen, maintained
_NA_ Bars evenly spaced
_Y_ _Back-up power
_N_Bypass structure present
_NA Free of excessive debris
_NA Bars excessively corroded
Flow Measurement — Influent
Y_ Is flowmeter calibrated annually?
_Y_ Is flowmeter operating properly?
_Y_ Does flowmeter operate continuously?
Y_ Does flowmeter record flow?
Y Does flowmeter appear to monitor accurately?
Flow Measurement — Water -Use Records
Y_ Is water use metered?
— Are the daily average values properly calculated?

Permit#WQ0020881
Disinfection
page 3
_Y_ Is the system working? _Y_ Is the system properly maintained?
Tablets Gas _X_ Liquid UV
If tablets, proper size? Present in Cylinder(s)?
Y_ If gas/liquid, does cylinder/tank storage seem safe?
If bulbs, are replacement bulbs on hand?
_Y Is contact chamber free of sludge, solids and growth?
Flow Measurement — Effluent
_Y_ Is the flowmeter calibrated annually?
_Y_ Is the flowmeter operating properly?
Y Does the flowmeter monitor continuously?
Y_ Does the flowmeter appear to monitor accurately?
Effluent Storage
X LAGOON SEPTIC TANK(s) ABOVE GROUND TANK OTHER
Number of months storage_1.4 Spill control plan on site
Above ground tank Aerated Mixed
In ground tank Aerated Mixed
Drying beds Concrete storage pad
Residuals N/A
storage/treatment (if storage is greater than 24 months, Surface Disposal permit?)
Disposal (final end use)
Y Is the application equipment present and operational?
—_N_ Is application equipment in need repair?
_N Spray heads calibrated this past year?
_ N_ Are cover crops the type specified in permit?
_N_ Is cover crop in need of improvement?
_N_ Signs of ponding?
Comments: Control of the grassy vegetation in spray corridors is improved.
Y Is the acreage specified in the permit being utilized?
N Are there any limiting slopes in disposal fields?
NA Are restrictions for use of these areas specified?
Y Is permit being followed?
N Is there evidence of runoff or drift?
Y Is site access restricted in accordance with permit?

Permit #WQ0020881
Recordkeeping
Y Is permit available upon request?
Y Are flow rates less than permitted flow?
Y Are monitoring, reports present: NDMR _ NDAR
Y Are operational logs present? _Y_ Complete?
Y Are lab sheets available for review?
Y Do lab sheets support data represented on NDMR or NDAR?
Y Are all samples analyzed for the required parameters?
NA Are there any 2L GW quality violations?
* Are annual soil reports available?
_N_ Did the last report indicate a need for lime? Was it applied?
Y Is the operation and maintenance manual present? Complete?
N Has DWQ received any complaints regarding the facility in the last 12 months?
Comment: *Samples have been sent to NCDA. Results are not yet back.
Groundwater Monitoring NA
Does the permit require monitoring wells? If so,
are the monitoring wells properly installed according to the permit?
are the wells properly identified?
are the wells damaged?
Page 4

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
a Division of Water Quality
AQUIFER PROTECTION SECTION
June 26, 2007
Lake Norman State Park
159 Inland Sea Lane
Troutman, North Carolina 28166
Attention: Casey Rhinehardt, Park Superintendant
RE: Surface Irrigation Inspection Report
Permit No. WQ00209" E Of
Facility: Swim Area Bath house
Iredell County, N.C.
Dear Mr. Rhinehardt:
Enclosed you will find the report for the annual compliance inspection that I conducted on March 16,
2007. Based on that inspection, your facility appears to be in compliance with -the referenced permit.
The report should be self-explanatory but do not hesitate to call me if you should have any questions.
Sincerely,
Peg i7ne y
Environmental Specialist
Enclosure: Inspection Report 6-22-07
Cc: Harry Myers 291 Elmwood St., Statesville 28625
MAF/surface irrigation/ Lake Norman SP inspection rpt 6-07
One
Division of Water Quality / Aquifer Protection Section / Mooresville Regional Office Phone: [phone] Fax: (704). 663-6040 N�OithCaTolh
610 East Center Avenue, Suite 301, Mooresville, NC 28115 Customer Service 1-877-623-6748 Internet: www.ncwaterquality.org l� Yahmal i,

F
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
e��
NCDENR
NON -DISCHARGE COMPLIANCE INSPECTION
SURFACE IRRIGATION
GENERAL INFORMATION
City/Town/Owner: NC Div. of Parks & Rec
Permit # WQ0020881
Issuance Date: 10/25/06
Permittee Contact: Casey Rhinehardt
ORC Name: Harry W. Myers Cert #S1986154
Backup ORC: David Fesperman Cert #S114852
County: Iredell
Project Name: Lake Norman SP
Swim Area Bath House
Expiration Date: 9/30/11
Telephone No.: 704/528-6350
Telephone No.: 704/880-1084
Telephone No.:. 800/438-0551.
Reason for Inspection
X - ROUTINE COMPLAINT FOLLOW-UP OTHER
Inspection Summary: (additional comments may be included on attached pages)
The system consists of an influent pump station with dual grinder pumps, a 15,000-gallon
septic tank, an aerated treatment and storage lagoon, liquid chlorine disinfection with contact
chamber, an irrigation pump station, and two 1.715 acre irrigation zones.
The treatment system is in good operating order and the lagoon is in good condition. The
spray fields are generally in good condition. However, the grassy vegetation in the spray
corridor needs trimming. Records are in good order and compliance monitoring is complete.
Is a follow-up inspection necessary yes X no
Inspector Name/Title: Peggy Finley, Environmental Specialist
Tel. No. 704/235-2183 Fax No. 704/663-6040
Date of Inspection: 6/22/07

46
Permit #WQ0020881 Page. 2
Type
Activated Sludge Spray, low rate
Activated Sludge Drip, low rate
_X_ Lagoon Spray, Low Rate
Lagoon Drip, Low Rate
Treatment
Y Are treatment facilities consistent with those outlined in the current permit.
Y Do all treatment units appear to be operational. If no, note below.
Treatment and Storage Lagoon
Y Influent structure (free of obstructions)
N Banks/berms (are there signs of seepage, overtopping, down cutting or erosion)
_N_ Vegetation (is there excessive vegetation on the lagoon bank
_Y_ Liner (if visible, is it intact)
_N Baffles/curtains (in need of repair)
Y Freeboard (>2 feet from overtopping)
—Y—Staff gauge ( clearly marked)
_N_ Evidence of overflow (vegetation discolored or laying" down/broken)
_N Unusual color (very black, textile colors)
N Foam (are antifoam agents used)
Y Floating mats (sludge, plants, inorganics)
N Excessive solids buildup (from bottom)
Y Aerators/mixers operational (if present)
Y Effluent structure (free of obstructions, easily accessible)
Comment: Duckweed covers much of pond surface.
Influent pump station
Y All pumps present, operational
NA Bar screen, maintained
_NA_ Bars evenly spaced
Back-up power
—N—Bypass structure present
_NA Free of excessive debris
_NA Bars excessively corroded
Flow Measurement — Influent
_Y_ Is flowmeter calibrated annually?
_Y_ Is flowmeter operating properly?
_Y_ Does flowmeter operate continuously?
Y Does flowmeter record flow?
Y Does flowmeter appear to monitor accurately?
Flow Measurement — Water -Use Records
Is water use metered?
Are the daily average values properly calculated?

Permit #WQ0020881
page 3
Disinfection
Y Is the system working? _Y_ Is the system properly maintained?
Tablets Gas _X_ Liquid UV
If tablets, proper size? Present in Cylinder(s)?
Y If gas/liquid, does cylinder/tank storage seem safe?
If bulbs, are replacement bulbs on hand?
Y Is contact chamber free of sludge, solids and growth?
Flow Measurement — Effluent
Y Is the flowmeter calibrated annually?
_Y_ Is the flowmeter operating properly?
Y Does the flowmeter monitor continuously?
Y Does the flowmeter appear to monitor accurately?
Effluent Storaae
X LAGOON SEPTIC TANK(s) ABOVE GROUND TANK OTHER
Number of months storage_1.4 Spill control plan on site
Above ground tank Aerated Mixed
In ground tank Aerated Mixed
Drying beds Concrete storage pad
Residuals N/A
storage/treatment (if storage is greater than 24 months, Surface Disposal permit?)
Comment: No substantial residuals generated so far.
Disposal (final end use)
Y Is the application equipment present and operational?
N_ Is application equipment in need repair?
—N Spray heads calibrated this past year?
_ N_ Are cover crops the type specified in permit?
_N_ Is cover crop in need of improvement?
_N_ Signs of ponding?
Comments: Grassy vegetation in spray corridor needs to be trimmed back.
Y Is the acreage specified in the permit being utilized?
N Are there any limiting slopes in disposal fields?
NA Are restrictions for use of these areas specified?
Y Is permit being followed?
N Is there evidence of runoff or drift?
Y Is site access restricted in accordance with permit?

Permit #WQ0020881
Recordkeeping
Y Is permit available upon request?
Y Are flow rates less than permitted flow?
Y Are monitoring reports present: NDMR _ NDAR
_ Y Are operational logs present? _YComplete?
Y Are lab sheets available for review?
Y Do lab sheets support data represented on NDMR or NDAR?
Y Are all samples analyzed for the required parameters?
NA Are there any 2L GW quality violations?
Y Are annual soil reports available?
_N_ Did the last report indicate a need for lime? Was it applied?
Y Is the operation and maintenance manual present? Complete?
N Has DWQ received any complaints regarding the facility in the last 12 months?
Groundwater Monitoring NA
Does the permit require monitoring wells? If so,
are the monitoring wells properly installed according to the permit?
are the wells properly identified?
are the wells damaged?
Page 4

IN
State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
Michael F. Easley, Governor
William G. Ross, Jr., Secretary
Alan W. Klimek, P.E., Director
NCDENR-
NON -DISCHARGE COMPLIANCE INSPECTION
r`FAIPPAl IA11=09Md T1(1N
City/Town/Owner: NC Div. of Parks & Rec.
Permit # WQ 0020881
Issuance Date: 6/10/02
Permittee Contact: Casey Rhinehardt
ORC Name: Harry Myers S1986154
Backup ORC Name: K. Smith
Reason for Inspection
X ROUTINE _
Type of inspection
Collection System
County: Iredell
Project: Lake Norman State Park
Expiration Date: 5/31/07
Telephone No. 704/528-6350::
Telephone No. 704/880-10844.:.
Telephone No.704/528-6350
COMPLAINT FOLLOW-UP
X Spray Irrigation Sludge
Inspection Summary. (additional comments may be included on attached pages)
The treatment system appears to be operating properly. The spray fields are in good
condition.
Is a follow-up inspection necessary yes X no
Inspector Name/Title Peggy Finley, Hydro Tech II
Tel. No. 704/235-2183 Fax No. 704/663-6040
Date of Inspection: 6/21/06

Spray Irrigation
Permit #WQ0020881
Type
Activated Sludge Spray, low rate
Activated Sludge Spray, high rate
Activated Sludge Drip, low rate
X Lagoon Spray, low rate
Reuse (Golf Courses)
Recycle /Reuse
Single Family Spray, low rate
Single Family Drip
Infiltration System
Page 2
Treatment
Y Are treatment facilities consistent with those outlined in the current permit.
Y Do all treatment units appear to be operational. If no, note below.
List any action items necessary for each unit.
Comments:
Lagoons
Primary (check any/all that apply)
Y Influent structure (free of obstructions)
N Banks/berms (are there signs of seepage, overtopping, down cutting or erosion)
_N_ Vegetation (is there excessive vegetation on the lagoon bank
Y Liner (if visible, is it intact)
_NA Baffles/curtains (in need of repair)
Y Freeboard (>2 feet from overtopping)
-- _ --- _Y Staff gauge ( clearly marked)
_N Evidence of overflow (vegetation discolored or laying down/broken)
N Unusual color (very black, textile colors)
N Foam (are antifoam agents used)
_Y Floating mats (sludge, plants, inorganics)
_N Excessive solids buildup (from bottom)
Y Aerators/mixers operational (if present)
Y Effluent structure (free of obstructions, easily accessible)
Comments: Duckweed covers pond surface.

Spray Irrigation
Permit #WQ 0020881
Influent pump station
Y all pumps present, operational
Bar screen, maintained
Bars evenly spaced
Back-up power
Comment:
Aeration Basin
aeration pattern even across surface of unit
easily accessed
Comment:
Clarifiers N/A
weirs level
Comment:
Return Pumps NIA
in place
scum rack operational
operational
Bypass structure present
Free of excessive debris
Bars excessively corroded
easily accessible
Page .3
Filters N/A
media present air scour operational clear well free of solids
Residuals N/A
storage/treatment ( if storage is greater than 24 months, Surface Disposal permit?)
Comment:
"- Disinfection
_Y_ Is the system working? _Y_ Is the system properly maintained?
Tablets Gas _X Liquid UV
If tablets, proper size? Present in Cylinder(s)?
If. gas, does cylinder storage seem safe?
If bulbs, are replacement bulbs on hand?
Y Is contact chamber free of sludge, solids and growth?
Effluent Storage
X LAGOON SEPTIC TANK(s) ABOVE GROUND TANK OTHER
Number of months storage_1.45 Spill control plan on site
Above ground tank Aerated - Mixed

Spray Irrigation Page 4
Permit #WQ0020881
Lagoon Lined ?
In ground tank Aerated Mixed
Drying beds Concrete storage pad
Comment:
Disposal (final end use)
Y Is the application equipment present and operational?
N_ Is application equipment in need repair?
Y Are cover crops the type specified in permit?
_N_ Is cover crop in need of improvement?
_N_ Signs of runoff?
_N_ Signs of ponding?
Y Are buffers adequate?
Y Is the acreage specified in the permit being utilized?
N Are there any limiting slopes in disposal fields?
NA Are restrictions for use of these areas specified?
Y Is permit being followed?
N Is there evidence of runoff or drift?
Y Is site access restricted in accordance with permit?
Comments:
Recordkeeping
Y Is permit available upon request?
Y Are flow rates less than permitted flow?
Y Are monitoring reports present: NDMR X NDAR _X_
Y Are operational logs present? Y_ Complete?
Y Are lab sheets available for review?
Y Do lab sheets support data represented on NDMR or. NDAR?
_Y_ Are all samples analyzed for the required parameters?
_N_ Are monitoring wells called for in the existing permit?
If so, are there any 2L GW quality violations?
Y Are annual soil reports available?
N Did the last report indicate a need for lime? Was it applied?
Y Is the operation and maintenance manual present? Y_Complete?
N Has DWQ received any complaints regarding the facility in the last 12 months?
Comment:

OF WATLc9
�o� pG
� r
O `C
r
Lake Norman State Park
159 Inland Sea
Troutman, North Carolina 28166
Attention: Casey Rhinehardt, Park Superintendent
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality-'
RE: Spray Irrigation Inspection Report
Permit No. WQ20881
Iredell County, N.C.
Dear Mr. Rhinehardt:
Thank you and your staff for taking the time to meet with me last week. Enclosed you will find the report
for the inspection that I conducted on June 20. The treatment and disposal system appears tob.eln
working order. There are no compliance issues at this time.
Sincerely,
Peggy Finley
Hydrogeological Technician
Enclosure: Inspection Report
MAF/lake norman sp 06 inspection & cover Itr
one NCarolii
Division of Water Quality / Aquifer Protection Section / Mooresville Regional Office Phone: [phone] Fax: [phone]
610 East Center Avenue, Suite 301, Mooresville, NC 28115 Internet: www.ncwaterquality.org u

Subject: Re: Nov 19th Meeting
From: [e-mail]
Date: Mon, 15 Nov 2004 10:00:15 -0500
To: "Ellen Human" <[e-mail]>
Hey Ellen,
Just take Hwy 150 West to Bluefield Road intersection (where Starbucks, Walgreens,
CVS and Duckworth's Gas Station are). Take a right onto Bluefield (past Target
and all that mess)and follow it until it ends at Cornelius Rd. Take a left
onto Cornelius and then about 1 mile on the right take a right onto Judas
Rd. When Judas ends at Perth Rd, take a right and go about 3-4 miles, you'll
see a sign on your right for the park and take a left onto State Park Road.
Follow this into the park and follow the signs to the park office where we'll
meet you.
Casey
-- Original Message --
Date: Mon, 08 Nov 2004 08:33:22 -0500
From: Ellen Huffman <[e-mail]>
To: [e-mail]
Subject: Re: Nov 19th Meeting
Yes, I can meet on Friday Nov. 19th. Please send me directions.
Thanks!
Ellen
[e-mail] wrote:
Hey Ellen,
Are you able to meet with the Lake Norman State Park staff at 9 am on Nov.19th
to look at the spray irrigation system?
Thanks,
Casey
Ellen Huffman
Environmental Specialist II
North Carolina Dept. of Environment & Natural Resources
Div. of Water Quality
919 N. Main St.
Mooresville, NC 28115
Ph: 704.663.1699 Fax: [phone]
i of 1 11/19/2004 7:46 AM

North Carolina
Department of Environment and Natural Resources
Water Pollution Control System Operator Certification Commission
Michael F. Easley, Governor /
William G. Ross Jr., Secretary
Coleen H. Sullins, Chairman
July 16, 2002
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
Philip K McKnelly
DENR - Division of Parks and Recreation
1615 Mail Service Center
Raleigh NC 27699-1615
Subject: Classification of Water Pollution Control Systems
Facility: Lake Norman State Park Swim Beach Spray Facility
Permit #: WQ0020881
County: Iredell
Dear Dr. McKnelly:
A��
NCDENR
JUL 1 9 2002
The Water Pollution Control System Operators Certification Commission adopted 15A NCAC 8C .0800, Classification
of Spray Irrigation Systems, effective July 1, 1993. In order to ensure the proper operation and maintenance of these
systems, this Rule requires that all facilities permitted for the spray irrigation of wastewater be classified as spray
imgation systems. As required by 15A NCAC 8G .0202(b) and the subject permit, a certified operator and back-up
operator of the appropriate type must be designated for each classified system.
The Water Pollution Control System Operators Certification Commission hereby classifies the subject facility as a
Spray Irrigation System effective today, July 16, 2002. Your system requires an Operator in Responsible Charge
(ORC) and back-up operator who hold valid spray irrigation certificates.
The ORC and back-up operator must be designated 60 days prior to the introduction of waste into your system. If you
have already obtained an ORC and back-up operator, please complete and return the enclosed designation form to this
office by August 31, 2002. If you have not yet obtained an ORC and back-up operator, please notifiy this office, in
writing, of a date when you anticipate you will designate the ORC and back-up for your facility. Please note that
failure to designate a properly certified ORC and back-up operator 60 days prior to the introducaiton of waste into the
facility is a violation of the permit issued for this system and Rule 15A NCAC .0302(b).
A Spray Irrigation System Operators Training School is planned for October 7 through 10, 2002, at the McKimmon
Center in Raleigh. You can register for this traning school by calling Joni Tanner at 919-513-1678 or by going on-line
at http://www.soil.ncsu.edu/swetc/Iandapi)school2/landal)l).htm. The first certification examination offered after
the training school will be December 12, 2002.
1618 Mail Service Center, Raleigh, North Carolina 27699-1618
Phone: 919 — 733-0026 \ FAX: 919 — 733-1338
AN EQUAL OPPORTUNITY \ AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLED / 10% POST CONSUMER PAPER

Philip K McKnelly
July 11, 2002
Paae Two
If you need assistance or have any questions concerning this requirement or the upcoming training school, please call
Beth Buffington at 919-733-0026, extension 313.
Sincerely,
/1 I
6-
Hope Walters, Supervisor
Technical Assistance and Certification Unit
Enclosure
CC: TAC Facility_Fi1es _
pro sv FnRer-ion-al-0f€ c_e'
Non -Discharge Enforcement/Compliance Unit
Central Files

North Carolina Department of Environmental Quality —1 Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number—W10300409
1. Permit Information
Mark W. Ehrman., P.E.
Permittee
. Marathon Charlotte East Terminal
Facility Name . -
7401 Old Mount Holly Road., Mecklenburg
County., Charlotte,N`C 2F214
Facility Address (include County)
2. Injection Contractor Information
Margaret.Ness / AECOM
Injection Contractor/ Company Name
Street Address— I 600-Perinieter Park Dr., #400
___Morrisville NC 27560
. City State Zip Code
(_919) _461-1423
Area code — Phone number
3. Well Information
Number of wells used.for injection 4
Well IDs MW2 1. N/IW5 I., MW65. and MW48—
Were any new wells installed during this injection
event?
F-1 Yes No
If yes. , please provide the following information:
Number of Monitoring Wells - NA
Number of Injection Wells NA
Type of Well Installed (Check applicable type):
F-1 Bored ❑ Drilled El Direct -Push
❑ Hand -Augured F-1 Other (specify) ____—
Please include a copy qJ'the 0V-1 f orinfor each
well installed.
Were any wells abandoned during this injection
event?
D Yes No
If Ives, please provide the following information:
Number of Monitoring Wells NA
Number of lqiection Wells NA
Please-inclutle a copy of the GW-30for each well
abantloned.
4. injectant Information
_—O-Sox "socks"
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration — 15 lbs/ 100 lb O-Sox
If the In. lectant is diluted please indicate the source
dilution fluid.
Total Volume Injected (gal)-3 O-Sox socks 11well—
VOIL111le Injected per well (gal)_1.75 lb
material/sock 3 socks = 5,25 lb/well (4 wells)_
S. Injection History
Injection date(s)—De6eniber 30,2019
Injection number (e.­. 3 of 5)___2nd of TBD
Is this the last injection at this site?
EJ Yes El No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN T14E PERMIT.
y-,
SIGNATURE OF INJECTION C ., 0 .. N _F1;L_,1,C'rOR'_1 4 kD
Submit the original. of this form to the Division of Water Resources within 30 days of injection. Form UIC-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No..919-807-6464
I Rev. 3-1-2016

WA7-,- Michael F. Easley, Governor
William G. Ross Jr., Secretary
Cq 7 North Carolina Department of Environment and Natural Resources
© W i ek, P.E. Director
D 1 1 of Water Quality
October 25, 2006
William Rhinehart, Jr. — Park Superintendent
NCDENR (Division of Parks & Recreation)
159 Inland Sea Lane
Troutman, NC 28166
Dear Mr. Rhinehart:
OCT 3 1
Subject: Permit No. WQ0020881
Lake Norman State Park Swim
Beach
Wastewater Surface Irrigation
Iredell County
In accordance with your permit renewal request received September 25, 2006, we are forwarding
herewith Permit No. WQ0020881, dated October 25, 2006, to the North Carolina Division of Parks and
Recreation for the continued operation of the subject wastewater treatment and surface irrigation
facilities.
This permit shall be effective from the date of issuance until September 30, 2011, shall void
Permit No. WQ0020881 issued June 19, 2002, and shall be subject to the conditions and limitations as
specified therein. Please pay particular attention to the monitoring requirements in this permit. Failure to
establish an adequate system for collecting and maintaining the required operational information will
result in future compliance problems.
This permit approves the continued operation of the subject wastewater, treatment and spray
irrigation facilities for another five-year cycle. However, please take the time to review this permit
thoroughly as some of the conditions contained therein may have been added or changed since the last
issuance of this permit. Of special interest are the following:
Condition III.3. — Please note that total phosphorous, TKN, and NO2-NO3 have been
added to the effluent monitoring parameters.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the
right to request an adjudicatory hearing upon written request within thirty (30) days following receipt of
this permit. This request must be in the form of a written petition, conforming to Chapter 150B of the
North Carolina General Statutes, and filed with the Office of Administrative Hearings, 6714 Mail Service
Center, Raleigh, NC 27699-6714. Unless such demands are made this permit shall be final and binding.
NorthCarolina
Naturally
North Carolina Division of Water Quality 1636 Mail Service Center Raleigh, NC 27699-1636 Phone [phone] Customer Service
Internet: www.ncwaterquality.org 2728 Capital Boulevard Raleigh, NC 27604 FAX [phone]
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper

If you need additional information concerning this matter, please contact Matthew Fleahman at
(919)7157617:3.
4.
Sincere ,
{;i
flan W. Klimek, P.E.
cc: Iredell County Health Department
�a, es G e `�ic�"a�l •� �uce � ,fd r � - n
Te—ch—nical Assistance and Certification Unit
APS Central Files
LAU Files
2

FA
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH
SURFACE IRRIGATION SYSTEM PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
North Carolina Division of Parks & Recreation
Iredell County
FOR THE
continued operation of a spray irrigation treatment and disposal facility approved to accept 15,000 GPD
of wastewater (monthly average) during April through October and 3,500 GPD of wastewater (monthly
average) during November through March and consisting of a 78 GPM influent pump station with dual
grinder pumps, a 15,000 gallon septic tank with effluent filters, an aerated 780,000 gallon treatment and
storage lagoon to provide 10 days of treatment and 42 days of storage at maximum design flow with two
3HP aerators, chlorine disinfection in a 8,112 gallon chlorine contact chamber, a ' 135 GPM irrigation
pump station, and a solid set irrigation system to irrigate two 1.715 acre irrigation zones: Zone A and
Zone B , to serve Lake Norman State Park Swim Beach, with no discharge of wastes to the surface
waters, pursuant to the application received September 25, 2006, and in conformity with the project plan,
specifications, and other supporting data subsequently filed and approved by the Department of
Environment and Natural Resources and considered a part of this permit.
This permit shall be effective from the date of issuance until September 30, 2011, shall void Permit No.
WQ0020881 issued June 19, 2002, and shall be subject to the following specified conditions and
limitations:
I. PERFORMANCE STANDARDS
1. The surface irrigation facilities shall be effectively maintained and operated at all times so that there
is no discharge to the surface waters, nor any contamination of ground waters, which will render them
unsatisfactory for normal -use. In the event that the facilities fail to perform satisfactorily, including
the creation of nuisance conditions or failure of the irrigation area to adequately assimilate the
wastewater, the Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality, such as the construction of additional or replacement
wastewater treatment and disposal facilities.
2. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface
or groundwaters resulting from the operation of this facility.
3. The residuals generated from these treatment facilities must be disposed in accordance with General
Statute 143-215.1 and in a manner approved by the Division.

9
4. Diversion or bypassing of the untreated wastewater from the treatment facilities is prohibited.
5. The following buffers shall be maintained:
a) 400 feet between wetted area and any residence or places of public assembly under separate
ownership,
b) 150 feet between wetted area and property lines,
c) 100 feet between wetted area and wells,
d) 100 feet between wetted area and drainage ways or surface water bodies,
e) 50 feet between wetted area and public right of ways,
f) 100 feet between treatment/storage units and any wells, and
g) 50 feet between treatment units and property lines.
H. OPERATION AND MAINTENANCE REQUIREMENTS
1. The facilities shall be properly maintained and operated at all times.
2. Upon classification of the wastewater treatment and irrigation facilities by the Water Pollution
Control System Operators Certification Commission (WPCSOCC), the Permittee shall designate and
employ a certified operator to be in responsible charge (ORC) and one or more certified operator(s) to
be back-up ORC(s) of the facilities in accordance with 15A NCAC 8G .0201. The ORC shall visit
the facilities in accordance with 15A NCAC 8G .0204 or as specified in this permit and shall comply
with all other conditions specified in these rules.
3. A suitable year round vegetative cover shall be maintained.
4. Irrigation shall not be performed during inclement weather or when the ground is in a condition that
will cause runoff.
5. Adequate measures shall be taken to prevent wastewater runoff from the irrigation field.
6. The facilities shall be effectively maintained and operated as a non -discharge system to prevent the
discharge of any wastewater resulting from the operation of this facility.
7. The application rate shall not exceed a cumulative loading of 30.16 inches over any twelve (12)
month period at an instantaneous application rate not to exceed 0.4 inches per hour.
8. No type of wastewater other than that from Lake Norman State Park Swim Beach shall be irrigated
onto the irrigation area.
9. No traffic or equipment shall be allowed on the disposal area except while installation occurs or while
normal maintenance is being performed.
10. Public access to the land application sites shall be controlled during active site use. Such controls
may include the posting of signs showing the activities being conducted at each site.
11. Freeboard in the lagoon shall not be less than two feet at any time.
12. If not already installed, a waste -level gauge, to monitor waste levels in the storage pond, shall be
installed within 60 days of issuance of this permit. This gauge shall have readily visible permanent
markings indicating the maximum liquid level at the top of the temporary liquid storage volume,
minimum liquid level at the bottom of the temporary liquid storage volume, and top of the dam
elevations. Caution must be taken not to damage the integrity of the liner when installing the gauge.
2

13. A protective vegetative cover shall be established and maintained on all earthen basin embankments
(outside toe of embankment to maximum pumping elevation), berms, pipe runs, erosion control areas,
and surface water diversions. Trees, shrubs, and other woody vegetation shall not be allowed to grow
on the earthen basin dikes or embankments. Earthen basin embankment areas shall be kept mowed or
otherwise controlled and accessible.
M. MONITORING AND REPORTING REQUIREMENTS
Any monitoring (including groundwater, surface water, soil or plant tissue analyses) deemed
necessary by the Division to insure surface and ground water protection will be established and an
acceptable sampling reporting schedule shall be followed. .
2. Influent flow shall be continuously monitored and daily flow values shall be reported on, Form
NDMR.
The Permittee shall install an appropriate flow measurement device consistent with approved
engineering and scientific practices to ensure the accuracy and reliability of influent flow
measurement. Flow measurement devices selected shall be capable of measuring flows with a
maximum deviation of less than 10 percent from true flow, accurately calibrated at a minimum of
once per year, and maintained to ensure that the accuracy of the measurements is consistent with the
accepted capability of that type of device. The Permittee shall keep records of flow measurement
device calibration on file for a period of at least three years. At a minimum, data to be included in
this documentation shall be:
a. Date of flow measurement device calibration
b. Name of person performing calibration
c. Percent from true flow
3. The effluent from the subject facilities shall be monitored by the Permittee at the point following
chlorination and prior to irrigation every March, July and November for the following parameters:
BOD5
TSS
NO2-NO3
Fecal Coliform
NH3 as N
TKN
pH
Total Phosphorous
4. The Permittee tracking the amount of wastewater disposed shall maintain adequate records. These
records shall include, but are not necessarily limited to, the following information:
a. Date of irrigation,
b. Volume of wastewater irrigated,
c. Field irrigated,
d. Length of time field is irrigated,
e. Continuous weekly, monthly, and year-to-date hydraulic (inches/acre) loadings for each field,
f. Weather conditions, and
g. Maintenance of cover crops.
5. Freeboard in the lagoon shall be recorded weekly.
6. Three (3) copies of all monitoring data [as specified in Conditions 111(2) and I11(3)] on Form NDMR-
1 and three (3) copies of all operation and disposal records [as specified in Conditions III(4) and
III(5)] on Form NDAR-1 shall be submitted on or before the last day of the following month. All
information shall be submitted to the following address:
Division of Water Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
3

7. An annual representative soils analysis (Standard Soil Fertility Analysis) shall be conducted on each
irrigation field and the results maintained on file by the Permittee for a minimum of five years. The
Standard Soil Fertility Analysis shall include, but. is not necessarily limited to, the following
parameters:
Acidity
Manganese
Potassium
Calcium
Percent Humic Matter
Sodium
Copper
pH
Zinc
Magnesium
Base Saturation (by calculation)
Phosphorus
Cation Exchange Capacity
Exchangeable Sodium Percentage
8. Noncompliance Notification:
The Permittee shall report by telephone to the Mooresville Regional Office, telephone number (704)
663-1699, as soon as possible, but in no case more than 24 hours or on the next working day
following the occurrence or first knowledge of the occurrence of any of the following:
a. Any occurrence at the wastewater treatment facility which results in the treatment of significant
amounts of wastes which are abnormal in quantity or characteristic, such as the dumping of the
contents of a sludge digester; the known passage of a slug of hazardous substance through the
facility; or any other unusual circumstances.
b. Any process unit failure, due to known or unknown reasons, that render the facility incapable of
adequate wastewater treatment such as mechanical or electrical failures of pumps, aerators,
compressors, etc.
c. Any failure of a pumping station, sewer line, or treatment facility resulting in a by-pass directly to
receiving waters without treatment of all or any portion of the influent to such station or facility.
d. Any time that self -monitoring information indicates that the facility has gone out of compliance
with its permit limitations.
Occurrences outside normal business hours may also be reported to the Division's Emergency
Response personnel at telephone number [phone], [phone], or [phone].
Persons reporting such occurrences by telephone shall also file a written report in letter form within
five (5) days following first knowledge of the occurrence. This report must outline the actions taken
or proposed to be taken to ensure that the problem does not recur.
IV. GROUNDWATER REQUIREMENTS
1. The COMPLIANCE BOUNDARY for the disposal system is specified by regulations in 15A NCAC
2L, Groundwater Classifications and Standards. The Compliance Boundary is for the disposal system
constructed after December 31, 1983 is established at either (1) 250 feet from the waste disposal area,
or (2) 50 feet within the property boundary, whichever is closest to the waste disposal area. An
exceedance of Groundwater Quality Standards at or beyond the Compliance Boundary is subject to
immediate remediation action in addition to the penalty provisions applicable under General Statute
143-215.6A(a)(1).
2. In accordance with 15A NCAC 2L, a REVIEW BOUNDARY is established around the disposal
systems midway between the Compliance Boundary and the perimeter of the waste disposal area.
Any exceedance of standards at the Review Boundary shall require remediation action on the part of
the Permittee.
4

! 3. Waste application activities shall not occur when the vertical separation between depth of application
and the water table is at less than one (1) foot. Verification of the water table elevation may be
confirmed by water level readings obtained from auger borings(s), which should be done within 24
hours, prior to application of wastewater. Any open borings must be properly filled with native soil,
prior to application to decrease the chance of any waste contaminating the groundwater.
4. The lagoon shall have a liner of natural material at least one foot in thickness, having a hydraulic
conductivity of no greater than 1 x 10-6 cm/sec after compaction, or a synthetic liner of sufficient
thickness to exhibit structural integrity and an effective hydraulic conductivity of no greater than that
of the natural material liner according to 15A NCAC 02T .0505(g).
V. INSPECTIONS
1. Adequate inspection, maintenance, and cleaning shall be provided by the Permittee to insure proper
operation of the subject facilities.
2. The Permittee or his designee shall inspect the wastewater treatment and disposal facilities to prevent
malfunctions and deterioration, operator errors and discharges which may cause or lead to the release
of wastes to the environment, a threat to human health, or a nuisance. The Permittee shall keep an
inspection log or summary including at least the date and time of inspection, observations made, and
any maintenance, repairs, or corrective actions taken by the Permittee. This log of inspections shall
be maintained by the Permittee for a period of three years from the date of the inspection and shall be
made available upon request to the Division or other permitting authority.
3. Any duly authorized officer, employee, or representative of the Division may, upon presentation of
credentials, enter and inspect any property, premises or place on or related to the disposal site or
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 leachate.
VI. GENERAL, CONDITIONS
This permit shall become voidable unless the facilities are constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
2. This permit is effective only with respect to the nature and volume of wastes described in the
application and other supporting data.
3. This permit is not transferable. In the event there is a desire for the facilities to change ownership, or
there is a name change of the Permittee, a formal permit request must be submitted to the Division
accompanied by an application fee, documentation from the parties involved, and other supporting
materials as may be appropriate. The approval of this request will be considered on its merits and
may or may not be approved.
4. Failure to abide by the conditions and limitations contained in this permit may subject the Permittee
to an enforcement action by the Division in accordance with North Carolina General Statute 143-
215.6A to 143-215.,6C.
The issuance of this permit does not exempt the Permittee from complying with any and all statutes,
rules, regulations, or ordinances which may be imposed by other government agencies (local, state,
and federal) which have jurisdiction, including but not limited to applicable river buffer rules in 15A
NCAC 2B .0200, erosion and sedimentation control requirements in 15A NCAC Chapter 4 and under
the Division's General Permit NCGO10000, and any requirements pertaining to wetlands under 15A
NCAC 2B .0200 and 2H .0500.
6. The Permittee shall retain a set of approved plans and specifications for the life of the project.

7. The Permittee must pay the annual administering and compliance fee within thirty (30) days after
being billed by the Division. Failure to pay the fee accordingly may cause the Division to initiate
action to revoke this permit as specified by 15A NCAC 02T .0105(e).
8. The Permittee, at least six (6) months prior to the expiration of this permit, shall request its extension.
Upon receipt of the request, the Commission will review the adequacy of the facilities described
therein, and if warranted, will extend the permit for such period of time and under such conditions
and limitations as it may deem appropriate.
Permit issued this t 25"' day of October 2006
NORTH C OLINA E ONMENTAL MANAGEMENT COMMISSION
-14Alan W. Klimek, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission
Permit Number WQ0020881

North Carolina Department of Environmental Quality
Division of Water Resources
Water Quality Section
NON -DISCHARGE COMPLIANCE INSPECTION REPORT
CLASS B RESIDUALS LAND APPLICATION
General Information
Facility Name: Lake Norman Swim Beach
Permit No.: W00020881
Owner: NC Dept of Natural & Cultural Resources
Plant ORC Name:
LA ORC / Contract Company: Matt
Other Contact(s):
Facility Location (address, gps or directions):
County: Iredell County_
Permit Issuance Date: _
Permit Expiration Date:
Telephone No.:704-_
Telephone No.:
Telephone No.:
Reason for Inspection
® ROUTINE ❑ FOLLOW-UP ❑ COMPLAINT ❑ PERMITTING ❑ Other:
Comments (attach additional pages as necessary)
Is a follow-up inspection necessary? ❑ Yes ® No
Primary Inspector: Edward Watson
Secondary Inspector:
Date of Inspection: October 25, 2017 Entry Time: 10:00 AM_ Exit Time:

Non -Discharge Compliance Inspection Report
Residuals Generating Facility
Was the residuals. generating facility inspected? ® Yes ❑ No
Residuals Storage:
Describe storage:_Lagoon storage
Number of days/weeks/months of storage:
Residuals Sampling:
Is sampling adequate and representative?
Describe Sampling:
Y
®
N
❑
NA
❑
NE
❑
Transport Vehicle:
Y
N
NA
NE
Is transport occurring at time of inspection?
❑
❑
®
❑
Are necessary records (i.e. permit & spill plan) present in vehicle? ID of observed vehicle(s):
❑
❑
®
❑
Record Keeping and Reporting Information:
Y
N
NA
NE
Is current permit and prior annual reports available upon request?
®
❑
❑
❑
Has the facility been free of public complaints for the last 12 months?
®
❑
❑
❑
TCLP analysis conducted and results available? Frequency? ❑ 1/yr or ❑ 1/permit cycle
❑
❑
❑
❑
Residuals metals and nutrient analysis conducted? Frequency? 1/YR.(See permit for frequency)
®
❑
❑
❑
Nutrient and metals loading calculations? (to determine most limiting parameter)
®
❑
❑
❑
Do lab sheets support data reported on Residuals Analysis Summary?
®
❑
❑
❑
Are PAN balance records available and within permit limits?
®
❑
❑
❑
Are there nutrient (crop) removal practices in place?
❑
❑
❑
❑
Are hauling records available? (gal and/or tons hauled during calendar year to date)
❑
❑
®
❑
Are field loading records available?
®
❑
❑
❑
Are field inspections conducted and are records available?
®
❑
❑
❑
Are soil sample results available?
❑
❑
❑
❑
Did soil results call for lime amendment? If so, are there records of application?
❑
❑
❑
❑
Soil results indicate that Cu & Zn indices are <3,000 (ideally <2, 000)?
❑
❑
❑
❑
Soil results indicate Na <0.5 meq/100 cm', and Exchangeable Sodium Percentage (ESP) <15%?
❑
❑
❑
❑
Does the permit require groundwater monitoring?
❑
❑
Are groundwater lab results present?
❑
❑
❑
❑
There are no 21, GW standard violations indicated in the lab results?
❑
®
❑
❑
Pathogen and Vector Attraction Reduction Records
Pathogen Reduction:
Which Alternative was used to demonstrate compliance?
❑ Alternative 1 Fecal Coliform Density
❑ Alternative 2 Process to Significantly Reduce Pathogens (5 options)
❑ Alternative 3 Use of Equivalent to RSRP (Not commonly used- See White House Manual)
If Alternative 2 was used, select which Option was utilized and complete the section below
❑ Option 1 - Aerobic Digestion
Y
N
NA
NE
Are logs present showing time and temperature?
❑
❑
❑
❑
Was the time & temp. between 40 days at 68°F (20°C) and 60 days at 590 F (150C)?
❑
❑
❑
❑
❑ Option 2 - Air Drying
❑ Option 3 - Anaerobic Digestion
Are logs present showing time and temperature?
❑
❑
❑
❑
Was the time & temp. between 15 days at 95' F — 131' F (35°-55° C) and
60 days at >68' F (20' C)?
❑
❑
❑
❑
❑ Option 4 — Composting (Not commonly used - See White House Manual)
❑ Option 5 - Lime Stabilization
Are logs present showing time and temperature?
❑
❑
❑
❑
Was the pH raised to >12 after two hrs of contact?
❑
❑
❑
❑
Was the temperature corrected to 25' C (77' F) (by calculation, NOT auto correct)?
❑
❑
❑
❑
Page 2 of 5

Non -Discharge Compliance Inspection Report
Vector Attraction Reduction:
Select which Option was used to demonstrate compliance and complete answer associated questions.
❑ Option 1 - 38% Volatile Solids Reduction
Y
N
NA
NE
Are lab results and calculations present?
❑
❑
❑
❑
Was the reduction on volatile solids (not total solids)?
❑
❑
❑
❑
Were samples collected at correct locations?
❑
❑
❑
❑
(beginning of digestion process & before land application)
Was there a >3 8% reduction?
❑
❑
❑
❑
❑ Option 2 - 40-Day Bench Scale Test
Y
N
NA
NE
Were residuals from anaerobic digestion?
❑
❑
❑
❑
Are lab results and calculations present?
❑
❑
❑
❑
Was the test anaerobically digested in lab, and test run for 40 days?
❑
❑
❑
❑
Was the test done between 30°C (86°F) and 37°C (997)?
❑
❑
❑
❑
Was the reduction of on volatile solids (not total solids)?
❑
❑
❑
❑
Was the reduction less than 17%?
❑
❑
❑
❑
❑ Option 3 - 30-Day Bench Scale Test
Y
N
NA
NE
Were residuals from aerobic digestion?
❑
❑
❑
❑
Are lab results and calculations present?
❑
❑
❑
❑
Were residuals 2% or less total solids?
❑
❑
❑
❑
If not 2% total solids, was the test ran on a sample diluted to 2%
with unchlorinated effluent?
❑
❑
❑
❑
Was the test run for 30 days?
❑
❑
❑
❑
Was the test done at 20°C (68°F)?
❑
❑
❑
❑
Was the reduction of on volatile solids (not total solids)?
❑
❑
❑
❑
Was the reduction less than 15%?
❑
❑
❑
❑
❑ Option 4 - Specific Oxygen Uptake Rate (SOUR Test)
Y
N
NA
NE
Were residuals form aerobic digestion?
❑
❑
❑
❑
Were residuals <2% total solids (dry weight basis) (not diluted)?
❑
❑
❑
❑
Was the test done between 10°C (507) and 30°C (867)?
❑
❑
❑
❑
Was the temperature corrected to 20°C (68°F)?
❑
❑
❑
❑
Was the sampling holding time <2 hours?
❑
❑
❑
❑
Was the test started within 15 minutes of sampling or aeration maintained?
❑
❑
❑
❑
Was the SOUR equal to or less than 1.5 mg of oxygen per hour per gram of
total residual solids (dry weight basis)?
❑
❑
❑
❑
❑ Option 5 - 14-Day Aerobic Process
Y
N
NA
NE
Were the residuals from aerobic digestion?
❑
❑
❑
❑
Was the average residuals temperature higher than 45°C (113°F)?
❑
❑
❑
❑
Were the residuals treated for 14 days and temperature maintained higher
than 40°C (104°F) for the 14-day period?
❑
❑
❑
❑
❑ Option 6 = Alkaline Stabilization
Y
N
NA
NE
Was the pH of the residuals raised to >12 and maintained for two hours
without addition of more alkali?
❑
❑
❑
❑
Did the pH of residuals remain at > 11.5 an additional twenty-two hours
without the addition of more alkali?
❑
❑
❑
❑
Was the pH corrected to 25°C (77°F) (by calculation, NOT auto correct)?
❑
❑
❑
❑
❑ Option 7 - Drying of Stabilized Residuals
Y
N
NA
NE
The residuals do not contain unstabilized residuals?
❑
❑
❑
❑
Were the residuals mixed with any other materials?
❑
❑
❑
❑
Were the residuals dried >75% total solids?
❑
❑
❑
❑
❑ Option 8 - Drying of Unstabilized Residuals
Y
N
NA
NE
Were the residuals mixed with any other materials?
❑
❑
❑
❑
Were the residuals dried >90% total solids?
❑
❑
❑
❑
Page 3 of 5

Non -Discharge Compliance Inspection Report
❑ Option 9/10 — Injection/ Incorporation of Residuals (Not commonly used - See White House Manual)
Land Application Site(s)
Were application site(s) inspected? If so, please list Site ID(s) below. ❑ Yes ❑ No
Annlication Site ID(s):
Is application occurring at the time of inspection? If no, note the date of the last event: ❑ Yes ❑ No
Weather Conditions:
® Sunny ❑ Partly Cloudy ❑ Cloudy ❑ Overcast ❑ Stormy
❑ Windy (wind direction: ❑ Breeze ❑ Calm
❑ No Precipitation ❑ Drizzle ❑ Rain ❑ Cloudburst (If applicable, precipitation measurement:_
Is there a rain gauge onsite? ® Yes ❑ No
Weather Notes (i.e. Significant Changes, Forecasts, etc):
Temp. (° F): ❑ <32 ❑ 32 — 40 ❑ 40 — 60 ❑ 60 — 80 ❑ >80
Was the Division notified of the application event(s)? ® Yes
Permit and Spill Plan onsite during application? ❑ Yes ❑ No
Application Observations: [Type of application: ❑ Liquid ❑ Cake
❑ No
❑ Other,
Page 4 of 5

Non -Discharge Compliance Inspection Report
Application Site —Field ID(s):
Intended Crop: PAN Requirement: Ibs/ac
Application Rate (gallons/acre):
Nutrient Content:
Application occurring at time of visit: ❑ Yes ❑ No
Application Method: ❑ Surface ❑ Incorp/Injection
Incorporation/Injection during visit: ❑ Yes ❑ No ❑ N/A
Vegetative Buffer description: ❑None ❑Grass ❑Crop ❑ Shrub
❑Tree ❑ Other
Current Field Conditions:
® Bare ❑ Stubble ❑ Planted (cro ® Pasture
Soil Condition:
❑ Dry ❑ Moist ❑ Wet ❑ Saturated
❑ Not -Frozen ❑ Frost ❑ Frozen ❑ Snow -Covered
Slope: ❑ 0-3% ❑ 3-6% ❑ 6-10% ❑ 10-18% ❑ >18%
Odor: ❑ None ❑ Mild ❑ Moderate ❑ Strong
Vectors: ❑ None ❑ Few ❑ Many ❑ Excessive
Application Site —Field ID(s):_
Intended Crop:
Application Rate (gallons/acre):
Nutrient Content:
PAN Requirement: lbs/ac
Application occurring at time of visit: ❑ Yes ❑ No
Application Method: ❑ Surface ❑ Incorp/Injection
Incorporation/Injection during visit: ❑ Yes ® No ❑ N/A
Vegetative Buffer description: ❑None ❑Grass ❑Crop ❑ Shrub
❑Tree ❑ Other
Current Field Conditions:
❑ Bare ❑ Stubble ❑ Planted (crops ® Pasture
Soil Condition:
❑ Dry ❑ Moist ❑ Wet ❑ Saturated
❑ Not -Frozen ❑ Frost ❑ Frozen ❑ Snow -Covered
Slope: ® 0-3% ❑ 3-6% ❑ 6-10% ❑ 10-18% ❑ >18%
Odor: ❑ None ❑ Mild ❑ Moderate ❑ Strong
Vectors: ❑ None ❑ Few ❑ Many ❑ Excessive
Application Details:
Y
N
NA NE
Application Details:
Y
N
NA NE
Application areas clearly marked?
®
❑
❑
❑
Application areas clearly marked?
❑
❑
❑
❑
Application within authorized area?
®
❑
❑
❑
Application within authorized area?
❑
❑
❑
❑
Application method appropriate?
®
❑
❑
❑
Application method appropriate?
❑
❑
❑
❑
Application is even (no ponding)?
❑
❑
❑
❑
Application is even (no ponding)?
❑
❑
❑
❑
Sufficient setbacks from wells/residences?
❑
❑
❑
❑
Sufficient setbacks from wells/residences?
❑
❑
❑
❑
Sufficient setbacks from surface waters?
❑
❑
❑
❑
Sufficient setbacks from surface waters?
❑
❑
❑
❑
Slopes >10% avoided (Surface App.) ?
®
❑
❑
❑
Slopes >10% avoided (Surface App.) ?
❑
❑.
❑
❑
Slopes >18% avoided (Incorp/Inject) ?
®
❑
❑
❑
Slopes >18% avoided (Incorp/Inject) ?
❑
❑
❑
❑
Incorp./Injection within time -frame?
❑
❑
®
❑
Incorp./Injection within time -frame?
❑
❑
❑
❑
Biosolids visible on surface?
❑
®
❑
❑
Biosolids visible on surface?
❑
❑
❑
❑
Site Restrictions
Y
N
NA
NE
Site Restrictions
Y
N
NA
NE
Public access is restricted / Signage present?
®
❑
❑
❑
Public access is restricted / Signage present?
❑
❑
❑
❑
Grazing restrictions are met?
❑
❑
®
❑
Grazing restrictions are met?
❑
❑
❑
❑
Transfer of biosolids is in permitted area?
❑
❑
❑
❑
Transfer of biosolids is in permitted area?
❑
❑
❑
❑
No evidence of shallow GW?
❑
❑
❑
❑
No evidence of shallow GW?
❑
❑
❑
❑
Sufficient timing for harvest restrictions?
❑
❑
®
❑
Sufficient timing for harvest restrictions?
❑
❑
❑
❑
Off Site Transport
Y
N
NA
NE
Off Site Transport
Y
N
NA
NE
Tracking is prevented?
❑
❑
®
❑
Tracking is prevented?
❑
❑
❑
❑
Biosolids run-off is prevented?
❑
❑.
®
❑
Biosolids run-off is prevented?
❑
❑
❑
❑
Windblown biosolids prevented?
❑
❑
®
❑
Windblown biosolids prevented?
❑
❑
❑
❑
Vegetative buffers exist?
❑
❑
®❑
Vegetative buffers exist?
❑
❑
❑
❑
Page 5 of 5

Compliance Inspection Report
Permit:• W�'0020881 Effective: 10/01/15 Expiration: 09/30/20 Owner : NC Department of Natural and Cultural
Resources
SOC: Effective: Expiration: Facility: Lake Norma ;State Pzark Swim Beach
County: Iredell 7L59 State Park Rd
Region: Mooresville
Statesville NC 28677
Contact Person: Greg Schneider Title: Phone: [phone]
Directions to Facility:
From the intersection of Perth Rd (1303) and State Park Rd., travel southwest 4.4 miles past the park entrance and the boat
landing. The WWT system and spray fileds are located on the right side of State Park Rd.
System Classifications: SI,
Primary ORC: Matthew Bryan Cartner Certification: 995910 Phone: [phone]
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Inspection Date: 09/07/2016 Entry Time: 10:OOAM
Primary Inspector: Edward Watson
Secondary Inspector(s):
Maria Schutte
Reason for Inspection: Routine
Permit Inspection Type: Wastewater Irrigation
Facility Status: ❑ Compliant Not Compliant
Question Areas:
Exit Time: 11:30AM
Phone:
Inspection Type: Compliance Evaluation
Treatment Flow Measurement -Effluent Treatment Flow Measurement -Influent Miscellaneous Questions
Treatment Flow Measurement -Water Treatment Record Keeping
Use Records
Treatment Lagoons End Use -Irrigation Treatment Influent Pump Station
Treatment Flow Measurement Storage Standby Power
(See attachment summary)
Page: 1

Permit: W00020881 Owner - Facility: NC Department of Natural and Cultural Resources
Inspection Date: 09/07/2016 Inspection Type : Compliance Evaluation Reason for Visit: Routine
Inspection Summary
On September 7, 2016,staff from the Mooresville Regional Office (MRO) of the Division of Water Resources (DWR) inspected
the Wastewater Irrigation Permit for the Lake Norman State Park Swim Beach under permit WQ0020881. This was an
annual compliance inspection for the facility. Prior to the inspection, notification was provided to the facilty operator that a
Notice Of Violation (NOV) was going to be issued because permit requirements were not met regarding timely submittals of
NDAR and NDMR forms. There was confusion as to who had signature authority to be able to sign off on the NDAR and
NDMR permit required forms.
As the previuos ORC had passed -away, information had not been clearly conveyed to the new supervisor on what was
required to be submitted regarding permit requirements and the due dates. The MRO will issue an NOV without the issuing
enforcement with the understanding that in future,the required forms are be submitted in a timely manner. The MRO has
also sent a name change form to the permitee so the past ORC's name can be removed from the permit and new names be
adding having signature authority.
Overall, the site was in the operating condition. The treatment system was reviewed and the sprayer heads were tested with
regards to operational condition. At the time of the inspection, the treatment unit was operating properly and flow meters
were calibrated.
During the inspection, the pump stations were also reviewed and the alarm light at lift station 1 needs to have the bulb
replaced in the alarm light.
Page: 2

Permit: WQ0020881
Inspection Date: 09/07/2016
Owner - Facility: NC Department of Natural and Cultural Resources
Inspection Type--. Compliance Evaluation Reason for Visit: Routine
Type
Yes No NA NE
Single Family Spray, LR
❑
Infiltration System
❑
Reuse (Quality)
❑
Activated Sludge Spray, HR
❑
Activated Sludge Spray, LR
❑
Recycle/Reuse
❑
Activated Sludge Drip, LR
❑
Single Family Drip
❑
Lagoon Spray, LR
Treatment Yes No NA NE
Are Treatment facilities consistent with those outlined in the current permit? 0 ❑ ❑ ❑
Do all treatment units appear to be operational? (if no, note below.) M ❑ ❑ ❑
Comment: The system is treated using ligiud chlorine which is dispensed automatically to the lagoon.
Treatment Influent Pump Station
Yes No NA NE
Is the pump station free of bypass lines or structures?
❑ ❑ ❑
Is the general housekeeping acceptable?
❑ ❑ ❑
Are all pumps present?
M ❑ ❑ ❑
Are all pumps operable?
0 ❑ ❑ ❑
Are floats/controls operable?
0 ❑ ❑ ❑
Are audio and visual alarms available?
0 ❑ ❑ ❑
Are audio and visual alarms operational?
❑ 0 ❑ ❑
# Are SCADA/Telemetry alarms required?
❑ ❑ 0 ❑
Are SCADA/Telemetry available?
❑ ❑ 0 ❑
Are SCADA/Telemetry operational?
❑ ❑ 0 ❑
Comment: Lift station alarms are working. During
the inspection, the alarms were tested at both lift stations.
The light at Lift Station 1 needs to have the bulb replaced.
Treatment Flow Measurement -Influent Yes No NA NE
Is flowmeter calibrated annually? M ❑ ❑ ❑
Is flowmeter operating properly? 0 ❑ ❑ ❑
Does flowmeter monitor continuously? 0 ❑ ❑ ❑
Does flowmeter record flow? ■ ❑ ❑ ❑
Does flowmeter appear to monitor accurately? 0 ❑ ❑ ❑
Comment: The flow meters were calibrated and labeled with the calibration date. The meters are
conituously working and flow meter records were available to be reviewed.
Page: 3

Permit: W00020881 Owner - Facility: NC Department of Natural and Cultural Resources
Inspection Date: 09/07/2016 Inspection Type : Compliance Evaluation Reason for Visit: Routine
Treatment Flow Measurement -Water Use Records Yes No NA NE
Is water use metered? M ❑ ❑ ❑
Are the daily average values properly calculated? 0 ❑ ❑ ❑
Comment: The treatment system is a 40 gallon liquid chlorine dispenser tank that is feed through an
automatic feed system Records were able to be reviewed of the dispensing rate for the
treatment system.
Treatment Flow Measurement -Effluent
Yes No NA NE
Is flowmeter calibrated annually?
0
❑ ❑ ❑ .
Is flowmeter operating properly?
❑ ❑ ❑
Does flowmeter monitor continuously?
0
❑ ❑ ❑
Does flowmeter record flow?
0
❑ ❑ ❑
Does flowmeter appear to monitor accurately?
M
❑ ❑ ❑
Comment: Flow meter is calibrated and the calibration ticket was dated February
2016. The ticket was
present on the flow meter.
Standby Power
Is automatically activated standby power available?
Is generator tested weekly by interrupting primary power source?
Is generator operable?
Yes No NA NE
❑0❑❑
❑0❑❑
❑■❑❑
Does generator have adequate fuel? ❑ M ❑ ❑
Comment: The park procedure for power failure is to evacuate the park Therfore back-up power is -not
available.
Record Keeping
Yes No NA NE
Is a copy of current permit available?
0
❑ ❑ ❑
Are monitoring reports present: NDMR?
❑
■ ❑ ❑
NDAR?
❑
0 ❑ ❑
Are flow rates less than of permitted flow?
M
❑ ❑ ❑
Are flow rates less than of permitted flow?
M
❑ ❑ ❑
Are application rates adhered to?
M
❑ ❑ ❑
Is GW monitoring being conducted, if required (GW-59s submitted)?
❑
❑ 0 ❑
Are all samples analyzed for all required parameters?
❑
❑ 0 ❑
Are there any 2L GW quality violations?
❑
❑ M ❑
Is GW-59A certification form completed for facility?
❑
❑ 0 ❑
Is effluent sampled for same parameters as GW?
M
❑ ❑ ❑
Do effluent concentrations exceed GW standards?
❑
0 ❑ ❑
Are annual soil reports available?
M
❑ ❑ ❑
# Are PAN records required?
❑
❑ ❑
Page: 4

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Permit: WQ0020881 Owner - Facility: NC Department of Natural and Cultural Resources
Inspection Date: 09/07/2016 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Are monitoring wells damaged? ❑ ❑ i ❑
Comment: The system does not required GW monitoring and no MWs are present for this site.
01 - Lake Norman State Par
Treatment Lagoons
Yes No NA NE
Lagoon Type
Aerated
Primary/Secondary
Primary
Influent structure
M ❑ ❑ ❑
Banks/berms (seepage and erosion)
M ❑ ❑ ❑
Vegetation (excessive vegetation on banks/berms)
■ ❑ ❑ ❑
Liner
0 ❑ ❑ ❑
Liner Type
Apron, synthetic
Baffles/curtains
❑ ❑ ❑ M
Freeboard Marker
0 ❑ ❑ ❑
Required freeboard
2
Feet
Actual freeboard
2.5
Feet
Are increments clearly marked on gauge at adequate intervals?
M ❑ ❑ ❑
Has the water level gauge been surveyed w/ respect to lowest point on dike? wall?
❑ ❑ ❑ M
No Evidence of overflow
❑ M ❑ ❑
Acceptable color
❑ ❑ ❑
Floating mats
❑ 0 ❑ ❑
Excessive solids buildup
❑ 0 ❑ ❑
Aerators/mixers ❑ ❑ ❑
Effluent structure ❑ ❑ ❑
Lagoon cover ❑ 0 ❑ ❑
Page: 6

Compliance Inspection Report
Permit: WQ0020881 Effective: 10/01/15 Expiration: 09/30/20 Owner: NC Department of Natural and Cultural
Resources
SOC:. Effective: Expiration: Facility: Lake Norman State Park Swim Beach
County: Iredell 759 State Park Rd
Region: Mooresville
Statesville NC 28677
Contact Person: Greg Schneider Title: Phone: [phone]
Directions to Facility:
From the intersection of Perth Rd (1303) and State Park Rd., travel southwest 4.4 miles past the park entrance and the boat
landing. The WWT system and spray fileds are located on the right side of State Park Rd.
System Classifications: SI,
Primary ORC: Matthew Bryan Cartner Certification: 995910 Phone: [phone]
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Inspection Date: 09/07/2016 EntryTime: 10:OOAM
Primary Inspector: Edward Watson
Secondary Inspector(s):
Maria Schutte
Reason for Inspection: Routine
Permit Inspection Type: Wastewater Irrigation
Facility Status: Compliant Not Compliant
Question Areas:
Exit Time: 11:30AM
Phone:
Inspection Type: Compliance Evaluation
Treatment Flow Measurement -Effluent Treatment Flow Measurement -Influent
Treatment Flow Measurement -Water Treatment
Use Records
Treatment Lagoons End Use -Irrigation
Treatment Flow Measurement Storage
(See attachment summary)
Miscellaneous Questions
Record Keeping
Treatment Influent Pump Station
Standby Power
Page: 1

Permit: WQ0020881 Owner - Facility: NC Department of Natural and Cultural Resources
Inspection Date: 09/07/2016 Inspection Type : Compliance Evaluation Reason for Visit: Routine
Inspection Summary
On September 7, 2016,staff from the Mooresville Regional Office (MRO) of the Division of Water Resources (DWR) inspected
the Wastewater Irrigation Permit for the Lake Norman State Park Swim Beach under permit WQ0020881. This was an
annual compliance inspection for the facility. Prior to the inspection, notification was provided to the facilty operator that a
Notice Of Violation (NOV) was going to beissued because permit requirements were not met regarding timely submittals of
NDAR and NDMR forms. There was confusion as to who had signature authority to be able to sign off on the NDAR and
NDMR permit required forms.
As the previuos ORC had passed -away, information had not been clearly conveyed to the new supervisor on what was
required to be submitted regarding permit requirements and the due dates. The MRO will issue an NOV without the issuing
enforcement with the understanding that in future,the required forms are be submitted in a timely manner. The MRO has
also sent a name change form to the permitee so the past ORC's name can be removed from the permit and new names be
adding having signature authority.
Overall, the site was in the operating condition. The treatment system was reviewed and the sprayer heads were tested with
regards to operational condition. At the time of the inspection, the treatment unit was operating properly and flow meters
were calibrated.
During the inspection, the pump stations were also reviewed and the alarm light at lift station 1 needs to have the bulb
replaced in the alarm light.
Page: 2

Permit: WQ0020881
Inspection Date: 09/07/2016 .
Owner - Facility: NC Department of Natural and Cultural Resources
Inspection Type : Compliance Evaluation Reason for Visit: Routine
Type
Yes No NA NE
Single Family Spray, LR
❑
Infiltration System
❑
Reuse (Quality)
❑
Activated Sludge Spray, HR
❑
Activated Sludge Spray, LR
❑
Recycle/Reuse
❑
Activated Sludge Drip, LR
❑
Single Family Drip
❑
Lagoon Spray, LR
M
Treatment Yes No NA NE
Are Treatment facilities consistent with those outlined in the current permit? 0 ❑ ❑ ❑
Do all treatment units appear to be operational? (if no, note below.) M ❑ ❑ ❑
Comment: The system is treated using ligiud chlorine which is dispensed automatically to the lagoon.
Treatment Influent Pump Station
Yes No NA NE
Is the pump station free of bypass lines or structures?
0 ❑ ❑ ❑
Is the general housekeeping acceptable?
M ❑ ❑ ❑
Are all pumps present?
0 ❑ ❑ ❑
Are all pumps operable?
0 ❑ ❑ ❑
Are floats/controls operable?
0 ❑ ❑ ❑
Are' audio and visual alarms available?
M ❑ ❑ ❑
Are audio and visual alarms operational?
❑ 0 ❑ ❑
# Are SCADA/Telemetry alarms required?
❑ ❑ 0 ❑
Are SCADA/Telemetry available? •
❑ ❑ M ❑
Are SCADA/Telemetry operational?
❑ ❑ 0 ❑
Comment: Lift station alarms are working. During
the inspection, the alarms were tested at both lift stations.
The light at Lift Station 1 needs to have the bulb replaced.
Treatment Flow Measurement -Influent Yes No NA NE
Is flowmeter calibrated annually? i ❑ ❑ ❑
Is flowmeter operating properly? 0 ❑ ❑ ❑
Does flowmeter monitor continuously? 0 ❑ ❑ ❑
Does flowmeter record flow? M ❑ ❑ ❑
Does flowmeter appear to monitor accurately? M ❑ ❑ ❑
Comment: The flow meters were calibrated and labeled with the calibration date. The meters are
conituously working and flow meter records were available to be reviewed.
Page: 3

Permit: WQ0020881 Owner - Facility: NC Department of Natural and Cultural Resources
Inspection Date: 09/07/2016 Inspection Type : Compliance Evaluation Reason for Visit: Routine
Treatment Flow Measurement -Water Use Records Yes No NA NE
Is water use metered? 0 ❑ ❑ ❑
Are the daily average values properly calculated? 0 ❑ ❑ ❑
Comment: The treatment system is a 40 gallon liquid chlorine dispenser tank that is feed through an
automatic feed system. Records were able to be reviewed of the dispensing rate for the
treatment system.
Treatment Flow Measurement -Effluent Yes No NA NE
Is flowmeter calibrated annually? 0 ❑ ❑ ❑
Is flowmeter operating properly? 0 ❑ ❑ ❑
Does flowmeter monitor continuously? 0 ❑ ❑ ❑
Does flowmeter record flow? 0 ❑ ❑ ❑
Does flowmeter appear to monitor accurately? M ❑ ❑ ❑
Comment: Flow meter is calibrated and the calibration ticket was dated February 2016. The ticket was
present on the flow meter.
Standby Power
Is automatically activated standby power available?
Is generator tested weekly by interrupting primary power source?
Is generator operable?
Yes No NA NE
❑ M ❑ ❑
❑ M 110
❑■❑❑
Does generator have adequate fuel? ❑ 0 ❑ ❑
Comment: The park procedure for power failure is to evacuate the park. Therfore, back-up power is not
available.
Record Keeping
Yes No NA NE
Is a copy of current permit available?
0 ❑ ❑ ❑
Are monitoring reports present: NDMR?
❑ 0 ❑ ❑
NDAR?
❑ ■ ❑ ❑
Are flow rates less than of permitted flow?
0 ❑ ❑ ❑
Are flow rates less than of permitted flow?
■ ❑ ❑ ❑
Are application rates adhered to?
M ❑ ❑ ❑
Is GW monitoring being conducted, if required (GW-59s submitted)?
❑ ❑ 0 ❑
Are all samples analyzed for all required parameters?
❑ ❑ M ❑
Are there any 2L GW quality violations?
❑ ❑ 0 ❑
Is GW-59A certification form completed for facility?
❑ ❑ M ❑
Is effluent sampled for same parameters as GW?
0 ❑ ❑ ❑
Do effluent concentrations exceed GW standards?
❑ 0 ❑ ❑
Are annual soil reports available?
M ❑ ❑ ❑
# Are PAN records required?
❑ ❑ ❑
Page: 4

Permit: W00020881 Owner - Facility: NC Department of Natural and Cultural Resources
Inspection Date: 09/07/2016 Inspection Type : Compliance Evaluation Reason for Visit: Routine
# Did last soil report indicate a need for lime?
If so, has it been applied?
Are operational logs present?
Are lab sheets available for review?
Do lab sheets support data reported on NDMR?
Do lab sheets support data reported on GW-59s?
Are Operational and Maintenance records present?
Were Operational and Maintenance records complete?
Has permittee been free of public complaints in last 12 months?
Is a copy of the SOC readily available?
No treatment units bypassed since last inspection?
• ❑ ❑ ❑
• ❑ ❑ ❑
❑ ❑ ® ❑
❑ ❑ ❑
■❑❑❑
■❑❑❑
❑ ❑ ❑
❑■❑❑
Comment: The NDMR and NDAR records were present and availble for review during the site visit. There
was some confusion recently causing a delay in the submittal of the NDAR's and NDMR's to the
regional office and therefore these form were submitted past their due dates. The confusion has
been sorted out and future forms will be subitted by the due dates. Due to circumstances,
NDAR's and NDMR's were not submitted for a period of six (6) months. This results in a
reporting violation However, no enforcement action will be generated due to the circumstances.
Soil adat indicates low pH Lime may need to be applied to raise pH level.
To assist with resolving this issue a name change form has been sent to the permitee to add
and remove names for signature authority.
End Use -Irrigation
Yes No NA NE
Are buffers adequate?
i ❑ ❑ ❑
Is the cover crop type specified in permit?
❑ ❑ ❑
Is the crop cover acceptable?
❑ ❑ ❑
Is the site condition adequate?
. ❑ ❑ ❑
Is the site free of runoff / ponding?
❑ ❑ ❑
Is the acreage specified in the permit being utilized?
❑ ❑ ❑
Is the application equipment present?
❑ ❑ •❑
Is the application equipment operational?
❑ ❑ ❑
Is the disposal field free of limiting slopes?
0 ❑ ❑ ❑
Is access restricted and/or signs posted during active site use?
0 ❑ ❑ ❑
Are any supply wells within the CB?
❑ E ❑ ❑
Are any supply wells within 250' of the CB?
❑ E ❑ ❑
How close is the closest water supply well?
❑ ❑ ❑
Is municipal water available in the area?
❑ ❑ ❑
# Info only: Does the permit call for monitoring wells?
❑ ! ❑ ❑
Are GW monitoring wells located properly w/ respect to RB and CB?
❑ ❑ 0 ❑
Are GW monitoring wells properly constructed, including screened interval?
❑ ❑ 0 ❑
Page: 5

Permit: W00020881 Owner - Facility: NC Department of Natural and Cultural Resources
Inspection Date: 09/07/2016 Inspection Type : Compliance Evaluation Reason for Visit: Routine
Are monitoring wells damaged? ❑ ❑ 0 ❑
Comment: The system does not required GW monitoring and no MW's are present -for this site.
01 - Lake Norman State Par
Treatment Lagoons
Vies No NA NE
Lagoon Type
Aerated
Primary/Secondary
Primary
Influent structure
E ❑ ❑ ❑
Banks/berms (seepage and erosion)
i ❑ ❑ ❑
Vegetation (excessive vegetation on banks/berms)
N ❑ ❑ ❑
Liner
■ ❑ ❑ ❑
Liner Type
Apron, synthetic
Baffles/curtains
❑ ❑ ❑ E
Freeboard Marker
0 ❑ ❑ ❑
Required freeboard
2
Feet
Actual freeboard
2.5
Feet
Are increments clearly marked on gauge at adequate intervals?
E ❑ ❑ ❑
Has the water level gauge been surveyed w/ respect to lowest point on dike? wall?
❑ ❑ ❑
No Evidence of overflow
❑ ❑ ❑
Acceptable color
❑ ❑ ❑
Floating mats
❑E ❑ ❑
Excessive solids buildup
❑E ❑ ❑
Aerators/mixers E ❑ ❑ ❑
Effluent structure ❑ ❑ ❑
Lagoon cover ❑ E ❑ ❑
Page: 6

`
�
Central Files: Ape— ovvP___
OO/2O/11
Permit Number W10300176
Permit Tracking Slip
Program Category
Status
Project Type
Ground Water
Active
New Project
��
Permit Type�
i
Version
Permit Classification
Injection \Water Only GSHPWell System
(5QVV)
i.00
Individual
Primary Reviewer
{
Permit Contact Affiliation
miohao|.rogena
David J.Brown
Coastal SVVRule
1908 Homptonvi||a
don 2 ^ cu//
Hamptonvi||e
NC 27020
Permitted Flow
I
Facilinr
Facility Name N
Major/Minor
Lake Norman State Park
Minor
Location Address
County
159 Inland Sea Ln
)nadeU
Troutman
Owner Name
NCOENRDivision ofParks and Recreation
Facility Contact Affiliation
Government - State
Owner
Owner Affiliation
Erin Lawrence
Engineering Supervisor
1615 Mail Service Ctr
Raleigh NC 276901615
Scheduled
O,igbsun App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
00/28/11 06/24/11 06/28/11 05/28/11
Activities
Heat PUMP Injection
OutfaU NULL
vvote,unuvmame Stream Index Number Current Class muuuosin

Beverly Eaves Perdue
Governor
mr
MCDENR
North Carolina Department of Environment and Natural
Division c
Colee
NC DENR Division of Parks and Recreation
Attn: Erin Lawrence, P.E., Head, Engineering Program
1615 Mail Service Center
Raleigh, NC 27699-1615
C
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0300176
Lake Norman State Park
159 Inland Sea Lane
Troutman, NC 28166
Dear Erin:
Resources
Dee Freeman
Secretary
On June 24, 2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-oniv
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified'in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the lredeU County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Roeersk—uncdenr.aov if you have any questions.
Sincerely, L
fbr Debra Watts
Supervisor
cc: Mooresville Regional Office - APS
APS Central Files - Permit No. W.10300176
lredell County Health Dept.
Yadkin Well Company (David Brown)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwateraualitv.org
An Equal Opportunity', Affirmative Action Employer
t Jit�
Igor"ll(C'at-01ina
6�

I
c ? NOg,OLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTTFICgXT ION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
Tom,
In Accordance With the Provisions of 15A NCAC 02C .0200 `y
LO8k�f-LOOT' WATER -ONLY GEOTHERMAL INJECTION WELLS �
r
�`C-'
wells circulate potable water only as part of a geothermal heating and cooling system.
�he_e
a�..Thg ; )Is are "permitted by rule" and do not require an individual permit when they are constructed in
° �cor ance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
-
Print or Type Information and Mail to the Address on the Last Page.
DATE: June 23 2011 PERMIT NO. _r M� 7 : (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence Business/Organization
Government: State X Municipal County Federal
B. WELL OWNER — For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
NC DENR Division of Parks and Recreation
Mailing Address: 1615 Mail Service Center
City: Raleigh State: NC Zip Code:27699-1615 County: Wake
Day Tele No.: [phone] Cell No.:[phone]
EMAIL Address: erin.lawrence(F ncdenr.gov Fax No.:[phone]
C. LOCATION OF WELL SITE —Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 4720-56-9709 County: Iredell
(2) Physical Address (if different than mailing address): Lake Norman State Park
159 Inland Sea Lane
City: Troutman State: NC Zip Code: 28166
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: David Brown
NC Well Drilling Contractor Certification No.: NC 2195A
Company Name: Yadkin Well Company
Contact Person: David Brown EMAIL Address: [e-mail]
Address: 1908 Hamptonville Rd
City: Hamptonville Zip Code: 27020 State: NC County: Yadkin
Office Tele No.: [phone] Cell No.: [phone]_ Fax No.: [phone]
GPU/UIC 5QW Notification (Revised 3/18/2011)
Page I

E.
F.
HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: to be determined
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.:
WELL CONSTRUCTION DATA
Fax No.:
(1) Number of borings to be constructed*: one Depth of each boring (feet): 450
* If existing water supply wells will be used then provide the information in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc): PVC
(3) Well casing. -If the well(s) will use casing then provide the type (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground: 6" steel depth to be determined 24" above grade
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement IBentonite** X Other (specify)
**By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(1)(A), which requires a cernent type grout.
(b) Grout depth of tubing (reference to land surface): from 0 to 450 (feet)
If well has casing, indicate grout depth: from to (feet)
G. WELL LOCATIONS — Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1)
(2)
Attach a site -specific map showing the locations of the following:
* Proposed injection wells
* Surface water bodies
* Buildings
* Water supply wells
* Property boundaries
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
Existing or potential sources of groundwater contamination
Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures call be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a `layer' can be selected showing topographic contours or
elevation data.
GPU/UIC 5QW Notification (Revised 3/18/2011) Page 2

H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the property deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that 1 have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if.applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit." -^
Signatur f Property Owner/Applicant
Fa, FD i' Deip,' DIA10- Erin Lawrence P.E.
Aqgier FrOti'-Ors Sedlon
Print or Type Full Name
JUN $ 4 N11
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notification (Revised 3/18/201 1) Page 3

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DATE: June 23, 2011 RECEIVED 1 DENR I DWG
Aquifer Protection Scr.{ior?
PROJECT: J1ffI
Project Description: Lake Norman State Park: Visitor Center and West District OfF 2011
Notification of Intent to Construct or Operate Injection Wells
Budget Code: 40916 Fund: 4K77 SCO ID#: 09-08107-01
TO: Mr. Michael Rogers
DWQ — Aquifer Protection Section
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
FROM: Jennifer Goss, OAIV
Phone#: [phone]
e-Mail: [e-mail]
WE TRANSMIT:
x herewith ❑ under separate cover ❑ in accordance with your request
FOR YOUR:
X use
X execution processing
❑
❑ review & comment
❑
X forwarding
❑10
THE FOLLOWING:
X Notification of Intent
❑ Design Amendment No.
❑ Samples
. n Informal Contract
❑ Letter of Agreement
❑ Submittals
❑ Drawings
❑ Shop Drawing Prints
Ci Product Literature
❑ As Builts
❑ Shop Drawing Repros
C; Design Contract
#Contents
Description
1
Signed Notification of Intent to Construct or Operate Injection Well at Lake Norman
State Park for the Visitor Center and West District Office project.
COMMENTS
Copy to: Lance White, Project Manager
h - + Erin Lawrence, P.E., Head, Engineering Program

GEC -THERMAL WEILL CONSTRUCTION RECORD
OI
1 V ®NRESIDENML wuLL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality l
� E, LL CONTRACTOR CERTIFICATION #
-1-WEILL G&NTRACTOR:
'j
Well Contract r (Individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREETADDRESS 1908 HAMPTONVILLE ROAD
HAMP T ONVILLE NC 27020
City or Town State Zip Code
3( 36 )-468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ifapplicable)lir
WELL CONSTRUCTION PERMIT#(if applicable) C L i- v C.i. i '7
OTHER ASSOCIATED PERMIT *(if applicable)
3. WELL USE (Check Applicable BDx) Monitoring❑ Municipal/Public❑
Industriai/Commercial❑ Agricultural❑ Recovery❑ Injection[]
Irrigatioril Oth - list use) (71 porn Td=) ('nn"i b nran
DATE DRILLED /0- 3
TIME COMPLETED 5-",go AM❑ P-NAM
4. WELL LOCATION:
CITY: IC LI ' COUNTY
759 S 4-evVc fal-k P,,�
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
•ry � May be in degrees,
LATITUDE �J/ S ^ ��. 36 9' minutes, seconds or
LONGITUDE 0� in a decimal format
Latitude/longitude source: gGPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form ifnot using'GPS)
5. FACILITY- Is the name or the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY I+r-Q, iV,: Vj-,-Q,, .S-44- Pl.,, (.
STREET ADDRESS
SL- . �GrclQ
trD,.t'�itnrl,ti
�P✓
.
City or Town
Slate
Zip Code
CONTACT PERSON_Rick,lr•b
S kcfk
Seotg
MAILING ADDRESS
00121rl7C ,j ((�
hd C; ,-P,) V tbI
v
2 ( t -7
City or Town
State
Zip Code
170 � - 6G3, I.X-9
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:O�
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOD'
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface*
Top of casing terminated al/or below land surface may require
a variance in accordance With 15A NCAC 2C .0118.
e. YIELD (gpm): 6-0 METHOD OFTESTAIR PUMP
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth):-e-Pff�
From To 0 7 m To
From To A t' yrom To
From To From To
7. CASING: Depth Diameter ThicknessANeight Material
From To Ft.
From To Ft.
From To Ft.
8. GROUT: Depth Material Method
From �(QQ To 0 F-t. BenonztPu no
From To Ft.
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. " in. _tn. , r
10. SANDIGRAVEL PACK:
Depth -Size _ Material
From To Ft. t I
�t
From l To Fl, r U LL 1 f1
From To Ft, t
11.1DRILLING LOG
From To , Formation -Description. ;:;:c
, � avn6 .JC..V i�Viv
SIZE OFF'r.,,,...,
BIT SERIAL NO:
12. REMARKS:
Bores Deptl, ( '/GO
of looms der Bore ! B )
Ida a_.. of loops ( %rr 51)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN ROVIDED TO THE WELL 0 JE
1_2 0
P-111TUREP CERTIFIED WELL CONTRACTOR DATE
�)0dw C,J"ell)ile.-i
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water -Quality within 30 days. Attn: Informatlon Mgt., Form GW-ib
1617 Mall Selvlce Center- Ralelgh, NC 27699.1617 Phone No. [phone] ext 668, Rev,12107
DATE SITE VISITED: BY: PERIAIT: YES NO

Builders
Name-.
SO(&
k.'s,6vt
Address.-
tot) 6,0.�
-?2-L6_
U(.
Phone Number: Pcc",A -rl-loll 70 � -'7 717 - 03 to
'r L i j (Ay
6,3'..'TO

ON ESYDEN�f .l(AL WELL CONSTRUCT ION RE, CORD A
North Carolina Departnidnt of Environment and Natural Resources- Division of Water Quality
WELL CONTIUCTOR CER711FICATION ## D 'S-T),-A
-1,WEL4-- C-GWTRACTOR:
Well Contra .orgdividual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREETADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town State Zip Code
3( 36 )_468-4440
Area code- Phone number
2. WELL INFORMATION: � � ��
SITE WELL ID #(ifapplicable)
WELL CONSTRUCTION PERMITit(if applicable) Q
OTHER ASSOCIATED PERMIT i#(if applicable)
3. WELL USE (Check Applicable Box) Monitoring[] MunicipallPublic❑
IndustriallCommercial❑ Agricultural❑ Recoveryl7 Injection❑
Irrigatior[I Othefi *'(listuse)
DATE DRILLED
TIME COMPLETED 30 AM❑ PM
4. WELL LOCATION:F
CITY: dre7 s t't 3ya COUNTY •R� 4✓` t-
75 't,yk U •�
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC I LAND SETTING:
❑ Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
. (check appropriate box) May be in degrees,
LATITUDE -3 ;3 Y o, 36 � minutes, seconds or
in a decimm al foiat
LONGITUDE A- ssP %
Latitude/longitude source: BOPS ❑ Topographic map
(location of well must 6e shown on a USGS topo map and
attached to this form if not using'GPS)
5. FACILITY- Is the name or the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY
S-41117- 01,118
STREET ADDRESS
$-s4QC9�Li° �'�
lYda9 if
Y If0'1-6116A ,
Bi g
City or Town
Stale
Zip Code
CONTACT PERSON
Pmr- +Ld,
��= d�
MAILING ADDRESS°
I
2 i 7
A,, C've'p el 9d
r if
City or Town
Stale
Zip Code
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ N00:7:
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface*
`Top of casing terminated allor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST AIR PUMP
If. DISINFECTION: Type HTH Amount ee4
• 6
g. WATER ZONES (depth):
From i To (7? From To
From To From To
From To From To
7. CASING: Depth Diameter ThicknessWeight Material
From _ To Ft. —
Fr ornTo Ft. —
Fro mTo Ft.
8. GROUT: Depth Material Method
From�co To () Ft. IBenL-) n t?i. -f)
From To Ft.
From To Ft.
9. SCREEN: Depth
Diameter Slot Size Material
From To
Ft. in. in.
From To
Ft. v in: - _._-.__.. in.i
From To
in.;
i in.......
F'ti
. ._ .. ..
10. SANDIGRAVEL PACK: ;
Depth
;'Size Material
From To
Ft. _
From To
Ft
From Tc
Ft. s
'91.DRILLING LOG
Fromm
-Forrriation-De'scription-"
—()
SIZE OFF
BIT SERIAL NO:
12. REMARKS:
Bores ( 1 DeIAI-t
of 3oobs per Bore � )
E i ? of lQOns L.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
REqQBqHAS BEEN PROVIDED TO THE WELLOWNER.
SpqATUWOF CERTIFIED WELL CONTRACTOR DATE
nvG t4 [) 'VIdac�
P�INTE17 *ME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water -Quality within 30 days. Attn: Information Mgt., Form GW--lb
1617 Mail Service Centel- Ralelgb, NG 27699.1617 Phone No. [phone] ext 668, Rev.12107
DATE SITE VISITED: BY: PERMIT: YES NO

Duil.ders
Naimeg—
co
A d d r e s s
Li
Q
I Phone Number., 31--3 7
lk �� e,( F-'-9
Mle- CC, L- -f
63SO
116A

GEOTHERMAL VVEL•IL• CONSTRUCTION ION RECORD
-
,'`.`s
'; `®1� ES�If�EIVT� WELL CONSTRUCTION RECORD
L 2-
North Carolina Departmdai of Environment and Natural Resources- Division of'Vatcr Quality
WELL CONTRACTOR CERTIFICATION -9 a 56W-�
-1•.WELL C,"TRACTOR: /�
-� Ocl � W 11` f 1--, 1, Y, 17Y
WeTI Contrac r (Individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREETADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town State Zip Code
3( 36 )-468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) f�
WELL CONSTRUCTION PERMIT#(if applicable) LL) „R: i✓ .S`, ( 5
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring[] Municipal/Public❑
Industrial/Commercial❑ Agricultural❑ RecoveryO lnjectiono
Irrigation0 Olh (listuse) rlogpr�' T,pr,t-3 rr-nTlnpr(rr
DATE DRILLED
TIME COMPLETED 3'•'1fo AM❑ PMgR-
4. WELL LOCATION: f y
CITY: D,"l n COUNTY
*7S-9 s -6k IOUl,-k
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
M . � 3.� May be in degrees,
LATITUDE 3 S �� • 71 minutes, seconds or
LONGITUDE 0
j �6 in a decimal Fonuat
Latitude/longitude source: 5GPS 0 Topographic map
(location of well must be shown on a USGS.topo map and
attached to this form if not using"GPS)
S. FACILITY- Is the name or the business where the yell is located.
FACILITY ID #(if applicable)
NAME OF FACILITY �.4� %t a. lLio✓ 1 +�+,+ S- d� ��� �C/e'J L
STREET ADDRESS-n(Gln� SSG �t/cu
f t/1,4A W, 4f��
City or Town Stale Zip Code
CONTACT PERSON Riickorb S n,Tf/S'ccli�e
MAILING ADDRESS
City or Town State Zip Code
Area code - Phone number
G. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES0 NOOK
c. WATER LEVEL Below Top of Casing: FT.
(Use "+'= if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface,
"Top of casing terminated allor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): _357 METHOD OFTESTAIR PUMP
f. DISINFECTION: Type HTH Amount � e__
g. WATERZONES(depth): LCD ,n'_ b'
From r V To 3-41 6iti To
From 3 TAIT- E T- �zrip — To
From To Ffom To
7. CASING: Depth Diameter ThicknesslWeight Material
From To Ft.
From To Ft.
From To Ft.
8. GROUT: Depth Material Method
From 00 To 0 Ft. Pen.oni b Pump
From To Ft.
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From To- Ft. in. in.
From To Ft. in. in.
From To Ft.. - in. , — —�
10. SANDIG RAVE L PACK: ;
Depth '�iz�e -- ._ Material
i I
From To Ft. , ,
From -To- Ft._J ! -
From To Ft.
11.DRILLING LOG i�..=L I- t' i ",t-
From_T Fo'[mationDescrlption : _i-i_
2jo
krt,,l v c ri,.
SIZE OFF
BIT SERIAL NO:
12. REMARKS:
Bores ( /S_ ) Depti-i
,t of l000s der Bbre ( 9 )
Dia. of looPS ( 11, 56
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 20, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO TIE W L HWNER. �� ` q (3
�ZD]�(/ll! A
S ATUR F CERTIFIED WELL CONTRACTOR DATE
3Q d
-PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water -Quality within 30 days. Attn: Information Mgt., Form GW-lb
1617 Mall Service Center- Raleigh, NC 27699.1617 Phone No. [phone] oxt 668, Rev.12107
DATE SITE VISITED:
PERIv1IT: YES NO

Builders
Name-
Address.-
19D. o" 05
-Z
X
U Aj c
Phone Number.-. -LI-toY 70 � - *777 - 0-7,17
6 eovj-( 14-
o, T, � vx)
10
rtla)
A I
(f 9CAAC C(I'L-c
e-A
17

GEO-THERMAL WELL CONSTRUCTION REGORD
�i SIATF .
1 VONRESIDENll ML WELL CONSTRUCTION RECORD
North Carolina Deparhndnf of Environment and Natural Resources- Division of"Water Quality
WELL CONTRACTOR CERTIFICATION 9 � ��� >-� r
-1•, WELL G&NTRACTOR:
Well Conlrac oror (individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREETADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town State Zip Code
3( 36 )-468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ifapplicable),trxy
d' .w
WELL CONSTRUCTION PERMIT#t(ifapplicable)adli �Ile�
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring[] Municipal/Public❑
Indus trial/Commercial❑ Agricultural❑ Recovery❑ injectionD
Irrigation[] Olhe (list use) ("Zpgp'a T,onr) (,eoThir-rma
DATE DRILLED 1 0- f-I R j
TIME COMPLETED T. 30 AM❑ PM@�
4. WELL LOCATION: g /
CITY: /0 LJ ph COUNTY (raC' Vl
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
(check appropriate box) May be in degrees,
LATITUDE minutes, seconds or
w c� in a decimal fom�al
LONGITUDE O 4"J ��3 ,La 7e
Latitude/longitude source: KGPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using'GPS)
5. FACILITY- Is the name of the business where the vrell is located,
FACILITY ID #(if applicable)
NAME OF FACILITY S.il---i koi,,k
STREET ADDRESS d n+crn� 5��lrcig
CilyorTown r� Stale Zip Code
CONTACT PERSON_ Ckavb S kl-fdf Wb� ,AiQ 814
MAILING ADDRESS �� Ac,)�C h
City or Town State Zip Code
cam— 6 G —� , 1, C .3
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: Q
b. DOES WELL REPLACE EXISTING WELL? YESD NOD
<�
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface°
`Top of casing lermil- ted aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm):_ 20 _METHOD OFTESTAIRPUMP
f. DISINFECTION: Type HTH Amour,
g. WATER ZONES (depth): do
FromP1 0 To Pq3 From To
From To From To
From To From To
7. CASING: Depth Diameter Thickness/Weight Material
From To Ft.
From To Fl.
From To Ft.
8. GROUT: Depth Material Method
From To 0 F-t._aen.oni-L P11m�
From To Ft. T
From To Ft.
9. SCREEN: Depth
Diameter Slot Size Material
From To
Ft. in. in.
From To
Ft. __.in._ _. _ in_
From To
Ft. in., m-' '
1�
10. SANDIGRAVEL PACK:
Depth
•. 'Size ' Material
From To
Ft.
LJI�
I: L"
From To
FL' _ F
From To
Ft..
11.DRILLING LOG
From T9
Formation Des�Llplfon"
n —57
n i I -
��'�
nn,r<.,-,ne 70n��6Ce_thlr?�f�1�.
SIZE OFF
BIT SERIAL NO:
12. REMARKS:
Bores ( /S- Depth ( 1/O0
of looks per Bore ( 8 )
Dia e of loops / ur !)
I DO HEREBY CERTIFY THAT THIS WELL W�TRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOR 6E�PROVIDEDTOTHE WE OWNER. y Gf
S TURE F CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water -Quality within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mail Service Center- Raleigh, NC 27699.1617 Phone No. [phone] eXt 668, Rev.12107
DATE SITE VISITED: BY: PERMIT: YES NO

v
91,E
Cvia C
N-d
REP
/- f ZQ .6 t L. - h Ot f POV3�-7,"J2-w --:caciu-Tn-r-,T euouia
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g ssaapp-t'T
F-I ll-f:�
SaO-PTTng

01�
GED-THERMAL WELL CONSTRUCTION RECORD
TF
N®Nlilt.lESIDENTML WELL CONSTRUCTION RECORD
North Carolina Depattmdnf of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # �:`..
—1,WE1J_ GJ5'-AITRACTOR:
�1nd!:::� 0 ',1J
Well Contra for (Individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREETADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or -Town State Zip Code
3( 36 )-468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)���"
WELL CONSTRUCTION PERMIT±t(if applicable) fi;J .Q G 3 Q C i d C
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring[] Municipal/Public[]
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection[]
IrrigaliorU Othe(listuse) ('1(�ca� Tnnt) C"�n i'1nc�rTO
DATE DRILLED /0- f -Q
TIME COMPLETED 7: 3 o AM❑ PM€ -
4. WELL LOCATION: �
CITY: /O cl.� W , COUNTY Elva& t /Vl
7,5-9 S' r k 0AaYk ('�2
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC I LAND SETTING:
❑ Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
d U May be in degrees,
LATITUDE 3 S Y�. 3�a t minutes, seconds or
in a decimal format
LONGITUDE 0 ID ,��i� �.S
Latitude/longitude source: SOPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using-GPS)
5. FACILITY- Is the name of the business where the yell is located.
FACILITY ID #(if applicable)
NAME OF FACILITY 19061,l-c
STREET ADDRESS d n�Gln� ,S<'-� _rycu Q
(V"ex� .�
City or Town Stale Zip Code
CONTACT PERSON Rickor--S S ,,, f /SZGl 0_1," g
MAILING ADDRESS �� 4-2,c�.K (C� rlf ct
KGC�-C') AIC DWI
City or Town State Zip Code
Area code - Phone number
G. WELL DETAILS:
a. TOTAL DEPTH: boa
b. DOES WELL REPLACE EXISTING WELLY YES❑ NOWT
c. WATER LEVEL Belove Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
`Top of casing terminated @Uor below land surface may require
a variance in accordance With 15A NCAC 26.0118.
e. YIELD (gpm): RO METHOD OF TESTAIR�- PUMP
f. DISINFECTION: Type HTH Amount /%
g. WATER ZONES (depth):
Fromll-0 To15-5� From To
From173 To / �0:_From To
From Y&O To Q r m v To
7. CASING: Depth Diameter ThicknessAVeight Material
From To Ft.
From To Fl.
From To Ft.
8. GROUT: Depth Material Method
From jaQ To Ft. Be -non i'Lb Pllmp
From To Ft.
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. -
From To Ft. in.!
10. SANDIGRAVEL PACK:
Depth Siie. ` : Material
From To FL
From To FL
From To Ft.
11.1DRILLING LOG
From _T Formation Description- --__�-- -
T-1- "V 60
' V IVI
SIZE OFF
BIT SERIAL NO:
12. REMARKS:
Bores ( /,.5'^ ) Deptli (BOO )
i of looms per Bore { 9 D
Di_a, of looips
I Do HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STP,NDARDS, AND THAT A COPY OF THIS
REC HASBEENPROVIDED TOTHE WELL OWNER.
ATLTR05F CERTIFIED WELL CONTRACTOR DATE
"PRINTED NAVE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water -Quality within 30 days. AUn: Information Mgt., Form GW-ib
1617 Mail Service Center- Raleigh, NC 27699.1617 Phone No. (919) 733.7a15 ext 668, Rev,12107
DATE SITE VISITED: BY:
PERMIT: YES NO

Builders
Name-.
S
d dress e
Pa a
Phone Number; Oc e",,i 1-6o,14 Za � — .7 -7 F - 0Z S
At,
( -35-0
- O-f
'rLi1. (d6,--t
11

GEC —THERMAL V IJE)LIL .CONSTRUCTION RECORD
1 V ONJ11?LE'SIDENTML WE, LL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of tiVater Quality
WE, LL, CONTRACTOR CFRTIFICA.TION # � � 1� _
-1• 11VELL C£"TRACTOR:
Well Contractor individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREETADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town Slate Zip Code
3( 36 )-468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ifapplicable)�
WELL CONSTRUCTION PERMIT#(itapplicable) LU r— 0 _S r.� 1 "t
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring[] Municipal/PublicD
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection[]
Irrigatiorp Olhe,0 (list use) -(-I C)gpf Txnh--,) Gen^lnp-rma
DATE DRILLED-�'d-B�
TIME COMPLETED e�f)� AM❑ PVIR
4. WELL LOCATION:
I
CITY: iO LL r lR vt COUNTY 1r4 Z_ bi
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC I LAND SETTING:
❑ Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
May be in degrees,
LATITUDE 3 ,5 . 7 minutes, seconds or
LONGITUDE in a decimal fom,al
Latitude/longitude source: gGPS ❑ Topographic map
(location of well must be shoran on a USGS topo map and
attached to this form if not using'GPS)
5. FACI LITY- Is the name of the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITYL—A KQ, Nc,✓'f-vr1 S44e, r,,I G
STREET ADDRESS �-n(CIn� S�Lc �ticLy
City or Town Slate Zip�C/ode
CONTACT PERSON RL-kJ►^b S e��Glil�Q�
MAILINGADDRESS'�� /,2,o?{ (�
K6 chC i Et/7�4RJL ((
City or Town State Zip Code
Area code - Phone number
WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOQ
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
`Top Df casing terminated al/or below land surface may require
a variance in accordance With 15A NCAC 2C .0118.
e. YIELD (gpm):-4>METHOD OFTESTAIR PUMP
f. DISINFECTION: Type HTH Amount �� ✓
g. WATER ZONES (depth): $LEA
From 13 f To / �� ®frf To
From ;?5*0 To Fro sic To —
Fro mTo From To
7. CASING: Depth Diameter ThicknessNveight Material
From To Ft.
From To Ft.
From To Ft.
8. GROUT: Depth Material Method
From Q© To n Ft. Benoni,he pt to
From To Ft.
From To Ft.
9. SCREEN: Depth Diameter. Slot Size Material
From
To
FL
From
To
Ft.
i , , •.1 in
!I in:,
From
To
Ft.
; in:
10. SAND/GRAVEL PACK:
Depth
'Size
h9aierial
From
To
Ft.
From
To
FL
l
I
From
To
Ft.
'+`..T IIY_
11 DRILLING LOG.'
From To,
Formation Description
0 _ 5a
61—1%
f E`u ,9_
• / 1 •'}
Mtn 1!Nn
SIZE OFF
BIT SERIAL NO:
12. REMARKS:
Bores ( 45- ) Deloth ( 1/0O )
of lootos per Bore ( A )
Di a.of. loops ( % r Si)"
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECO BE PROVIDED TO THEV�' L WtJER.
SI URE f6F CERTIIF,/IIED WELL CONTRACTOR DATE
�� e,r. `/JUII,,T
PRINTED NME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water -Quality within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mail Service Center- Raleigh, NO 27699.1617 Phone No. [phone] ext 668. Rev.12107
DATE SITE VISITED: BY: PERNIIT: YES NO

Builders
Nave-.
SodkIzvA,
Address:
PD, 6w . -j
-? 2-
L
Phone NJumber.,-.Pcc",A f6oll 70 � - *7 7 7 - 02',y 7
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GEO-THERMAL vvELL CONSTRUCTION RECORD
F- ' ;� ` 1 V ®N1RES1DENTL4L W14 LL CONSTRUCTION RECORD
o North Carolina Department of Environment and Natural Resources- Division of Water Quality
:yea_ �. r
Z WE, L L CONTRACTOR CERTXFXCATEON # � S 7,
-1 WJ -LL CGITRACTOR: pp IIII
)Idn �A,! ➢�' e1 t N r
We I Contrac r (Individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREETADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town State Zip Code
3( 36 )-468-4440
Area code- Phone number
2. WELL INFORMATION: j/ J} q
SITE WELL ID ir(ifapplicable) '— Q
WELL CONSTRUCTION PERMIT#(ir applicable) iP.� .r- C . , O
OTHER ASSOCIATED PERMIT#(if applicable)
3. WELL USE (Check Applicable Box) Monitoring1] Municipal/Public❑
Industrial/Commercial❑ Agricultural❑ Recovery❑ lnjec(ion❑
Irrigatiorfl Olhe (list use) r"ln�pr� T,r?n-) ('r�nr'lzr?rPic�
DATE DRILLED /0 --po1 0 -13
"'b. TIME COMPLETED Doi AM❑ P40--
4. WELL LOCATION:
CITY: IllOt��It�Gt� COUNTY r-t-eAg-(A
7S9 real-k R,;
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
May be in degrees,
LATITUDE , 1 O. -� ��� minutes, seconds or
LONGITUDE 0 iJ" .�, �? in a decimal forniat
Latitude/longitude source: KGPS ❑ Topographic map
(location ofwell must be shown on a USGS topo map and
attached to this form if not using'GPS)
5. FACILITY- Is the name or the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY . �ke. /UcsY, Pcr�.k
STREETADDRESS .6 n(C;rn� Sc'Gs �fr6L,
City or Town Slate 01Zip Code
CONTACT PERSON ReGkvrb S vJ S�ctY^Q 6rtit
MAILING ADDRESS N�?C
li9 ct^t )VAt� - AAG yk ((7
City or Town Stale Zip Code
t70�)-6C IS63
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:Q
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOOT
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
`Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm):-1 _5— METHOD OF TESTAIR PUMP
f. DISINFECTION: Type HTH Amount
g, WATER ZONES (depth):
From 162 S- To ®&7 7rom To
From • Tokb® c FrImFaTo
From To From To
7. CASING: Depth Diameter ThicknessANeight Material
From To Ft.
From To Ft.
From To Ft.
8. GROUT: Depth Material Method
From To 0 Ft. Benoni-L-e Pt�no
From To Ft.
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From
To
Ft.
in.,
in.
From
To
Ft.
in.
in. � r
From
To
Ft.
in.
I
in.
10. SANDIGRAVEL PACK:
`
Depth
Size
Material
From
To
Ft.
DE C
From
To
Ft.
From
To
Ft.
11.DRILLING LOG
From To
Formation Description
S'
nin`i i E f2
�,n Sri I If )IU
SIZE OFF
BIT SERIAL NO:
12. REMARKS:
Bores ( /Y ) Dept!--: ( "c3O )
of loops.per Bore ( 9 )
Dia - of looios ( 7`r Sb�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOJM.HAS BEEN PROVIDED TO THE Vil( LL OWNER.
!'4� lied®-v�?
FIED 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,, Form GW-1b
H 17 Mall Service Center- Raleigh, NC 27699.16V Phone No. (9i9) 733-70i5 ext 668, Rev.12/07
DATE SITE VISITED: BY: PERMIT: YES NO

Builders Namte2
Collj-h-"L-S
,�Lddress.- Pb Co
i -Z2-(C
1'Aooj1-cZuj'(jAo
jj(.
Ph.one Number c Aoll 1 -7 -77 - 0
M
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GEO-THERMAL WALL CONSTRUCTION ION RECORD
�,-12, - VON-RESIDENTM-L NVELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
-1rWELL GO-NT•RACTOR:
=Oc��j W PIQ1�.r�y
Well Contract r (Individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREETADDRESS 1908 HAM PTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town Slate Zip Code
3( 36 }-468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ifapplicable) � �- 5- 2
WELL CONSTRUCTION PERMIT#(if applicable) W -Z o s' CG c, 1 •7 C
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring[] Municipal/Public]
Industrial/Commercial❑ Agricultural❑ Recovery❑ lnjectiohO
Irrigationl7 Othe�l (list use) � gPrn T,nnr) (Zr-nTlip ma
DATE DRILLED
TIME COMPLETED AM❑ PMEP
4. WELL LOCATION: 12
CITY: /0 0- at v% COUNTY E-1-4 . Vr
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
May be in degrees,
LATITUDE 3 S ., �0. 3 7� minutes, seconds or
LONGITUDE � 0' ( in a decimal format
Latitude/longitude source: gGPS ❑ Topographic map
(location of well must be shown on a USGS fopo map and
attached to this form ff not using'GPS)
5. FACILITY -is the name of the business where lhewell is located.
FACILITY ID #(if applicable)
NAME OF FACILITY. kQ, /Joylga++ •S•44e. GEC,,k
STREET ADDRESS f rZ,Icf, 1-t,
"City orTown State r Zip Code
CONTACT PERSON ACfcko b S
MAILING ADDRESS 41�0)c
City or Town Stale Zip Code
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:®
b. DOES WELL *REPLACE EXISTING WELL? YES❑ NOQr
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
t
d. TOP OF CASING IS FT. Above Land Surface*
`Top of casing terminated 2U6r below land surface may require
a variance in accordance With 15A NCAC 2C .0118.
e. YIELD (gpm):�METHOD OP TESTAIR PUMP
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth):
s"o.
From/25' To ( Frfrm To
FromP5,T To e1&6 -.91 rdm To
From To From To
7. CASING: Depth Diameter ThicknessNVeight Material
From To Ft.
From To Ft.
From To Ft.
S. GROUT: Depth Material Method
From 00 To(_Ft. BenonitA Pump
From To Ft.
From To Ft.
9. SCREEN: Depth
Diameter Slot Size Material
From To
Ft. in, in.
From To
Ft. in. in.
From To—
Ft. - tn...._.__-�-in.- - � �--_ -_
10. SAN DIG RAVEL PACK:
- I im L.,
Depth
Size •t==-Material"" -- j-
From To
Ft.
From To
Ft. ! ? n
I
From To
Ft.
11.DRILLING LOG
I_- ...__-..,,- -, -- -_.-.-
From To
Form atipobscriptlon
SIZE OF -` - Jtt,I ION
BIT SERIAL NO: cQ0lIhi ' f Intl•
12. REMARKS:
Bores ( 13 D Depth ( 1/00 }
it of looms per Bore ( e )
Di a of loops ( 1" S6ti
I DO HEREBY CERTIFY THAT THIS WALL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOR EN P OVIDED TO THE WELLA0W
(mac%
SI URE OCOERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water -Quality within 30 days. Attn: Information Mgt.,
16W Mall Service Center- Raleigh, NG 27699.1617 Phone No. [phone] oxt 668,
Form GW-ib
Rev.12107
DATE SITE VISITED:
BY: PERMIT: YES NO

Builders
IPanee
L-S
Phone 7,.iumber . 0,c e",vk fAol1 70 � - 7 717- 0Z S 7
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6 3`�-v
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GEO-THERMAL V VEILL• CONSTRUCTION RECORD
•ivcs
NON ®N1t1+`ESIDENT14L NvELL CONSTRUCTION RECOR D
North Carolina Departmdnf of Environment and Natural Resources- Division of Water Quality
��^' • WELL CONTRACTOR CERTIFICATION 4 �� %�A
—1.rW.ELL GcDsNTRACTOR:
We Conlract (Individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREETADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town Slate Zip Code
3( 36 )-468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT#(ifapplicable)i X
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring❑ Municipal/Public[]
Industrial/Commercial❑ Agricultural0 Recovery❑ Injection[]
Irrigation[] Olh (listuse) C1�dcF,� Te=) Ma
DATE DRILLED / 0 --�I q —{,
TIME COMPLETED Y - d✓ AM❑ P &
4. WELL LOCATION: r
CITY: TfIOL\,� va COUNTY E(ra�2(A
'75-9 S' G­k eavk (.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley. ❑ Flat 'D Ridge ❑ Other
(check appropriate box)
�, v May be in degrees,
LATITUDE S/ 1 �P J c,,f minutes, seconds or
LONGITUDE 0 U 1�5 _�' in a decimal format
0
Latitude/longitude source: gGPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using'GPS)
5. FACILITY- Is the name or the business where the well is located.
FACILITY ID #(if applicable) ++
NAME OF FACILITY "Kam /Jo: ,j­y- 'S.4.,T ioyvk
STREET ADDRESS '—n(CtA� S'
TV'0J-k"a, .4i ,
City orTown I Stale Zip Code
CONTACTPERSON Rickorb S c,- fIS4oCi>\Q,K"
MAILING ADDRESS PO (12113!rC-
l�(; uNe) m)Lt�' &-
CilyorTown Stale Zip Code
( 7()Y- I563
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:®
b. DOES WELL REPLACE EXISTING WELLY YES❑ NOIJ;
o, WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
"Top of casing terminaled aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm):5'METHOD OF TEST AIR PUMP
f. DISINFECTION: Type HTH Amount A�e
g, WATER ZONES (depth):
From_5 P%To From To
From To From To
From To From To
7. CASING: Depth Diameter Thickness/Weight Material
From To Ft.
From To Ft.
From To Ft.
S. GROUT: Depth Material Method
From `rQ() To 0 Ft. B en.on.i Le P umi:i
From To Ft.
From -To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From
To
Ft.
in. in.
From
To
Ft.
-in: - --" `in:`=
a
From
To
Ft.
in., ifl. lr_'_ !! 1
10. SAND/GRAVEL PACK:
Depth Size Material i
From To FL !" C. 1 r r na i
From To Ft.
From To Ft.
11.DRILLING LOG
From To Formation Description
0
SIZE OFF
BIT SERIAL NO:
12. REMARKS:
Bores ( is ) Depti-i ( '000 )
11 w of looms pbr Bore ( A )
Dia of loops ( %`r s P
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECO EEN PROVIDED TO THE WELL O.
SI�URE 5ff CERTIFIED WELL CONTRACTOR DATE
-.a C".) I , • W 'r1' 1011,a-y
PRINTED NAME"DF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water -Quality within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mall Service Center- Raleigh, NG 27699.16W Phone No. (919) 733-70115 DA 568, Rev.12/07
DATE SITE VISITED: BY: PERIAIT: YES NO

"P guilders
Name-
�kddress:
Pa
Phone Njumber.- Pcc",, i 1-6tall 70 �- -7 -7 7 - 0,7 J
gmi
A I c
r's

0,
CEO -THERMAL VVEILL -CONSTRUCTION RECORD
�SI'ATF„' .
,� ON itECOILD
- �:., e;
y =��j ; ' -
u 'I L o North Carolina Deparhndnt of Environment and Natural Resources- Division of 'Alater Quality
'K 4--- .
WELL CONTRACTOR CERTIFICATION # F71 -A
-1rWEL1 C.CVTRACTOR:
Well Contractor (Individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREETADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town State Zip Code
3( 36 )-468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT;ftf pa plicable) G 1 0 G C:; Y -d'
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring[] Municipal/Public❑
Indus trial/Commercial❑ Agricultural❑ Recovery❑ Injection❑
Irrigatioril OthgdOlist use) r°l n�r-%r3 T.nnr) Q--r) T Jn PrIIia
DATE DRILLED
TIME COMPLETEDAM❑ Ph'E
d. WELL LOCATION:
CITY: III toLkf nNgvi COUNTY
7S`�
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
May be in degrees,
LATITUDE/ 3,72 minutes, seconds or
LONGITUDE 0 rl' ,�, `•S in a decimal format
Latitude/longitude source: gGPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using,GPS)
5. FACILITY- Is the name or the business where the well is located.
FACILITY ID #(if applicable) Nf.:�, 'NAME OF FACILITY�KQ, S.-64e, P,-,,, .
STREET ADDRESS 8-nlCon� Si°Cs (1cu d
City or Town II Stale / Zip Code
pS.A CONTACT PERSON oc�6 S ,,ff S60-ke- �
MAILING ADDRESS
/ii 0-ejyjtt,�,
City or Town Slate Zip Code
(7o� UG 3, /SSG3
Area code - Phone number
G. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YESO NOUE
c. WATER LEVEL Below Top of Casing: FT t
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
`Top of casing terminated allor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): IS— METHOD OF TESTAIR PUMP
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth): ��pr�
From t5"6-To .�& 6 F om To
From 36 To 3&P O-Ma-rn@" To
From To From To
7. CASING: Depth Diameter ThicknessiWeight Material
From To Ft.
From To Fl.
From To Ft.
8. GROUT: Depth
Material
Method
From -00 To 0
Ft. Penonz-L-e
PUMm D
From To
Ft.
From To
Ft.
9. SCREEN: Depth
Diameter
Slot Size
Material
From —To —Ft.
—in.
in.
From To
Ft.
in:, --
in::' -
From To
Ft.
' is
in. ! `
�— is � I•_
in. +
10. SAND/GRAVEL PACK:
Depth
Size Material
From To
FL
l Cr
I
From —To —
From —To—
Ft.
11.DRILLING LOG
From To Formation Description -
() S-7 c n i l
fL
SIZE OFF
BIT SERIAL NO:
12. REMARKS:
Bores ( /S- ) Deptla ( 1/00 )
;r of loos per Bore ( 9 )
Di a of looms if I( S6°
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
C7),HAS EENPROM DEDTOTHE IA' OWNER. 57,1
TU OF ERTIFIED WELL CONTRACTOR DATE
piV)16
'PRINTED N OF RERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water -Quality within 30 days, Attn: Information Mgt., Form GW-1b
1617 Mall Service Center- Ralelgh, NC 27699.1617 Phone No. [phone] ext 668, Rev.12107
DATE SITE VISITED:
M.
PERMIT: YES NO

Builders
Narne�iS���
�ed��
���
���a's
!ddresse
b- Cqq
i ����
�LIuD�/'r
awl 1�FC ULi
P one Njumber o RLC1—arrk 1-
1`olll 70 � - 7 17 - O `yam
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GEO-THERMAL V VE'LL CONSTRUCTION RECORD
�i SI;971'
1 �®N1C4�-�,��.�l�NlT'.l L WELL CONSTRUCTION RECORD
:l
o North Carolina Deparhnant of Environment and Natural Resources- Division of Water Qualify. + T
WELL CONTRACTOR CERTIFICATION 4 f'o � �a
-1rWEL G"TRACTOR:
+, W m o� tl U-37
Well Contra for (Individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREETADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town Slate Zip Code
336 )-468-4440
Area code- Phone number
2. WELL INFORMATION: /� j/'
SITE WELL ID#(ifapplicable) o'r19 • ® 51Z,5
WELL CONSTRUCTION PERMITfl(if applicable) 0.)
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL• USE (Check Applicable Box) Monitoring❑ Municipal/Public[]
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection❑
Irrigatioril Olhea(k- (list use)
--(-IO-p,7'- Td=) (,r-n^innr( a
DATE DRILLED
TIME COMPLETED AM❑ PMW
4. WELL LOCATION: tW
4
CITY: I ilO EJ M;sQ^ COUNTY EIr��°-
'75-9 9'teL- e_ fal k rib2
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
(check appropriate box) May be in degrees,
LATITUDE J{ +, J 0, . Zr minutes, seconds or
LONGITUDE O ,5+� `�,� in a decimal format
Latitude/longitude source: IgGPS ❑ Topographic map
(location of well must be shown on a USGS fopo map and
attached to this form if not using'GPS)
5. FACILITY- Is the name of the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY -Aa, fu,,,✓n,on -a-
S-4- �e.&--k
STREETADDRESS Z-,Iq,� si Ccy 11"
k "
City or Town Stale Zip Code
CONTACTPERSON Rie-6rb S k.,_Xf.1/S4 '�AQ.IrIkt,
MAILING ADDRESS �� 131,rj�c
City or Town Slate Zip Code
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: i Y�
b. DOES WELL REPLACE EXISTING WELL? YESO NOP
c. WATER LEVEL Below Top of Casing: FT, t`
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
`Top of casing terminated 21.1 below land surface may require
a variance in accordance with 15A NCAC 2C .011 a.
e. YIELD(gpm):dQ—METHODOFTESTAIRPUMP
f. DISINFECTION: Type HTH Amount
g. WATERZONES(depth):
® ® c�
From 111 To /'F��rgr _ To
From 3�1� To 315- G Filth v To
From To From To
7. CASING: Depth Diameter Thickness/WeighL Material
From To Ft.
From To Ft.
From To Ft.
S. GROUT: Depth Material Method
From To_Ft. Ben.onite Pumio
From To Ft.
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in.
From To Ft. in'--:,, !In,. I ' :'t
! ' I
10. SAND/GRAVEL PACK:
Depth size. Material
t
From To Ft.. n` 1 i 0 I; j
;
From —To —
From Ft.
—To—
11.DRILLING LOG
From To Formation Description`
SIZE OFF
BIT SERIAL NO:
12. REMARKS:
Bores ( /S_ ) Depth ( 1/00
;r of loolbs jper Bore ( I 1
Dias Of lQo70S ( �tr Si d
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDA14CE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECO SAS BEEN PROVIDED TO THE WELL OWNER.
S TURVIF CERTIFIED WELL CONTRACTOR DATE
)047 !A Jul f a
PRINTED NAWE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water -Quality Within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mail Service Center- Raleigh, NC 27699.1617 'Phone No. (919) 733-7N5 ext 668. Rev.12/07
DATE SITE VISITED:
BY: PERIVIIT: YES NO

Builders Name-, SO A-kp't'A.
Address-. Pb Uk-,3 :2-(C 4,)C,
Phone Numper z Pcc", k -flia.14 70 V- -7 717 - 0 Z j 7
At !j .9 CAL, � C CC, L -(
3 To

GEO-THERMAL VVELLCONSTRUCTION RECORD
1 V ®NJll ESIDENTML WELL CONSTRUCTION RECORD
North Carolina Departmdnf of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # � � ? � /g 1 � `J U
--1,-W8L-L C"TRACTOR:
a -I L, V,l
Weil onlraclor ($dividual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREETADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town State Zip Code
3( 36 )-468-4440
Area code- Phone number
2. WELL INFORMATION: �[
SITE WELL ID #(if applicable) 44Z m
WELL CONSTRUCTION PERMIT#(if applicable)
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring1] Municipal/Public❑
Indus trial/Commercial❑ Agricultural❑ Recovery[] Injection❑
Irrigation0 Othe (list use) rj ncarn T n(,T) C pn^i-i p ma
DATE DRILLED / 0-. /7-/_? L
TIME COMPLETED ��- AM❑ PM&
4. WELL LOCATION:
CITY: O LJ i1 va COUNTY
)i6'
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
•y ., May be in degrees,
LATITUDE 3 Yam. minutes, seconds or
LONGITUDE 'IS
in a decimal Connat
Latitude/longitude source:. gGPS ❑ Topographic map
(location of well must 6e shown on a USGS fopo map and
attached to this form if not using'GPS)
S. FACILITY- Is the name or the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY 6Ko, &44e-✓r(oa k
STREET ADDRESS-n(Crn� S�'Cs v rc o d
City or Town Slate Zip Code
CONTACT PERSONS�
_ lick i- S i;�J c� eNf4,
MAILING ADDRESS
li?VC (( i
City or Town Slate Zip Code
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:O�
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOM
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
`Top of casing lerminaled atfor below land surface may require
a variance in accordance With 15A NCAC 26.0118.
e. YIELD (gpm): `,)-0 METHOD OF TEST AIR PUMP
f. DISINFECTION: Type HTH Amount ��
g. WATER ZONES (depth):
From To Fro To -
Fro rn To From To
From To From To
7. CASING: Depth Diameter Thickness/Weight Material
From To Ft.
From To Ft.
From To Ft.
8. GROUT: Depth
Material Method
From 00 To 0
Ft. P,en.onZ'L-e Puma
From To
Ft.
From To
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
From To
Ft.
in. in.
From To
Ft.
in._ . in.
From To
Ft.
in. , f,,.in.i;=' II 'llf? f
10. SANDIGRAVEL PACK:
Depth
Size Material
From To
Ft.
n
From To
FL
From To
Ft.
11.DRILLING LOG
From To
Formation Description
®
r'
-.
®- zlo-or
N\ i V i 3 j
rUh
,!nq. Inl
SIZE OFF
BIT SERIAL NO:
12. REMARKS:
Bores ( /S ) Del-ti; ( 1/00
6, of looios per Bore If 1 )
Dl a of loops ( C 06
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 20, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD H EEN PR VIDED TO THE VVELL OW ER.
do
SIG _RE OF ERTIFIED WELL CONTRACTOR DATE
PRINTED NAMQ'OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water -Quality within 30 days, Attn:Information Mgt., Form GW-1b
1617 Mall Service Center- Ralelgh, NC 27699.1617 Phone No, [phone] eut 668. Rev.12/07
DATE SITE VISITED: BY: PERMIT: YES NO

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1 V ©NRE'SIDENT14L w�J L L CONSTRUCTION RECORD
o` North Carolina Departmdnf of Environment and Natural Resources- Division of Water Quality
WE, LI., CONTRACTOR CERTIFICATION # Q� 5 7 �1- 4
G"TRACTOR:
�a,tt��rii �..'�i ��rliGtl.�t�
Well Conlraclor Individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREETADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town State Zip Code
3( 36 )_ 468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) AZX141>
WELL CONSTRUCTION PERMIT,t(if applicable) %j 6 .�(7 t)
OTHER ASSOCIATED PERMIT ##(if applicable)
3. WELL USE (Check Applicable Box) Monitoring[] Municipal/Publicl]
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection[]
Irrigatioril Oth11(list use) C11 ngpr:' T poy) Cyr-o -iorma
DATE DRILLED 0`'j• A 0 - ii 3
TIME COMPLETED AM❑ PATE
4. WELL LOCATION: ��ii /I
CITY: O Lt,.� ^ COUNTY F—Pe'� � A
75-9 S J'pai-k ru,
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Cade)
TOPOGRAPHIC I LAND SETTING:
❑ Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
-y �, � Maybe in degrees,
J LATITUDE / •� �U. 37 minutes, seconds or
tb
LONGITUDE -, cj S-0 in a decimal formal
Latitude/longitude source: BOPS ❑ Topographic map
(location ofwell must be shown on a USGS topo map and
attached to this form ifnot using'GPS)
S. FACILITY- Is the name or the business where the well is located,
FACILITY ID #(if applicable) NAME OF FACILITY _� Q. � W Wtnr, S.44e, Pce k
STREETADDRESS
1
City or Town II State Zip Code
CONTACT PERSON RICkor S k- 1r1. S6-AQ'V-14
MAILING ADDRESS i0o Al 0K
7
City or Town State Zip Code
c 70 Y- )- 6 G 3, I-s 6 3
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 0©
b. DOES WELL REPLACE EXISTING WELLY YES❑ NOpr
o. WATER LEVEL Below Top of C2sing: FT 1;
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
`Top of Casing terminated allor below land surface may require
a variance in accordance With 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD oFTEST—AIR PUMP--
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth):
From 9'52 To `� From To
From To From To
From To From To
7. CASING: Depth Diameter ThicknessNVeight Material
From To Ft.
From To FL.
From To Ft.
8. GROUT: Depth Material Method
From Tom_ Ft. BenonZ•Le P i rmo
From To Ft.
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft,
From To Ft. in. In:: ;
•,
C)
10. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To FL
From To Ft.
11.DRILLING LOG
From To Formation Description
o
fvnv e or11�
' ^•na0�1=S�lAll^ t lktjl
SIZE OFF
BIT SERIAL NO:
12. REMARKS:
Bores ( 13— ) Deptl__
of look - per Bore ( P )
Dla., of loops f %�r Siff•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD AS BEEN PROVIDED TO THE WEL-OWNER.
,SOKATUR ' F CERTIFIED WELL CONTRACTOR DATE
oo rr p r A
d
"PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water -Quality Within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mail Service Center- Raleigh, NG 27699.1617 Phone No. (919) 733-701I5 0Xt 668, Rev.12107
DATE SITE VISITED:
BY: PER ,11T: YES NO

Dui lders
Names
SO
address -.
Phone Number g Rce"t-i f 1-toll 70 J6 - *7 -7,7 - 00,1
'r L, J. 015'.7
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GEE —THERMAL VVELL -CONSTRUCTION RECORD
1 V ONRESIDENTML NVE, LL CONSTRUCTION RECORD
North Carolina Departmdnf of Environment and Natural Resources- Division of Water Quality
NVELL CONTRACTOR CERTIFICATION # . .'
-1 VV8U- GG`NT•FiACTOR:
Q�Q ff ^�
t !�_ l bn1 e 1'
Well ConlraVor (Individual) Name
YADKIN WELL COMPANY, INC.
Well Contractor Company Name
STREETADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town State Zip Code
336 )-468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #0fapplicable)
WELL CONSTRUCTION PERMIT#(if applicable) OU .d 6 -A G i•- i '7�
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) Monitoring[] Municipal/Public❑
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection[]
Irrigation0 Othg�( (list use) C'lpgprq Tnnn C tin T'1tc�r d
DATE DRILLED /.d'��qqA�-
TIME COMPLETED `�,' 3Q AM❑ PMFJ'
4. WELL LOCATION: CITY: I • ~O (. 't va COUNTY lr�� biq
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC I LAID SETTING:
❑ Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
••� �, v May be in degrees,
LATITUDE -3am. r�� minutes, seconds or
�{ U in a decimal format
LONGITUDE
Latitude/longitude source: gGPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using'GPS)
5. FACILITY- Is the name of the business where the yell is located,
FACILITY ID #(if applicable)
NAME OF FACILITY
6KQ, {l oy ),m, SJI;4e� foc&k
STREET ADDRESS
zllfcln� ,SL.ra T-VIL
l V'y.A6'0'-
k l�'
City or Town
Slate ZiCode
CONTACT PERSON
G t ,4 S kJ 06�*Aowm'
-11
�n)C
MAILING ADDRESS
MA';,C)V;tt. -
IVC ��d i i
City or Town
Stale Zip Code
( 70 - �G3- IS63
Area code - Phone number
B. WELL DETAILS:
a. TOTAL DEPTH:®
b. DOES WELL REPLACE EXISTING WELL? YES❑ N=
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
-IL a + r
d. TOP OF CASING IS FT. Above Land Surface'
`Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): C,'' METHOD OF TEST AIR
s PUMP
f. DISINFECTION. Type HTH Amount d ��
g. WATER ZONES (depth): ��p
From To j P �r` F Qom To
From Q 70~ To/ 1 FA7mTo
From To From To
7. CASING: Depth Diameter ThicknesslWeight Material
From To Ft.
From To Ft.
From To Ft.
8. GROUT: Depth Material Method
From 0® To 0 rt. t3enonit� Pum—r)
From To Ft.
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From To
Ft.
in. in.
From To
Ft.
in.
From To—
Ft.
in. in! G;
3
10. SANDIGRAVEL PACK:
Depth
Size Material
1' '
;j
From To
Ft.
From To
FL
From To
Ft.
I
11.DRILLING LOG
From To
Formation Description ---•—
=
-
�`t
y
d
- ..any.,,; l-t;l-Ir-)h1
SIZE OFF` ` ')nn pq, IiUi; I IPrih
BIT SERIAL NO:
12. REMARKS:
Bores ( /S- ) Denti= ( Oo )
of looks per Bore ! Q )
Dia., of loops f far
I DO HEREBY CERTIFY THAT THIS WELL bVAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE VYEL PER.
/01 .017
S ATUFMOOF CERTIFIED WELL CONTRACTOR DATE
•..� c'`���� �'sG.10 )Ili"� �; tl � ; `�`
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water -Quality within 30 days. Attn: Information Mgt., Form GW-1b
16W Mail Service Center-- Raleigh, NC 27699.1617 Phone No. [phone] oxt 568, Rev.12107
DATE SITE VISITED: BY: PERMIT: YES NO

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.d sr 4�a GE® -THERMAL WELL .CONSTRUCTION RECORD
~ ON �,�I�E I -AL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
�VELL CONTRACTOR CERTIFICATION 4
1. WELL CONTRACTOR:
Well Conlract (Individual) Name
Ya kin well C oMrz anv Inc
Well Contractor Company Name
STREET ADDRESS 'f 9()R Harz t-nntri l l e EM9
Hamptonville, NC 27020
City or Town Slate Zip Coda
336 - 468-4440
Area code- Phone number
2. WELL INFORMATION:
S ITE WELL iD 11(lt applicable.,
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(If applicable) 0 -a 092 C-11 •
WELL USE (Check Applicable Box) Monitoring ❑ MunicipaVPublic ❑
industrial/Commercial ❑ Agricultural ❑ Recovery [I Injection O
Irrigation[] Olher,2C- (list use) C'-Yi' S L1 Q,0-' Leir,
DATE DRILLED-������
TIME COMPLETED____. " AM ❑ PM-Lz'
3, WELL LOCATION:
CITY: fd� �-.�rL COUNTY.�c11r�� f
S-Aae, t1g11J 1 s?
(Street Name, Numbers, Community, Sdbdmscon, Lot No., Parcel, Zfp Code)
TOPOGRAPHIC / LAND SETTING:
[Slope E3Valley ❑Flat ❑Ridge ❑ Other
(check appropriate box)
LATITUDE 3 ' ' .7 ,�^ May bcindegrecs,
minutes, seconds or ,
LONGITUDE w G �.9: 7• 6 Ina decimal format
Latitude/longitude source: jgrPS ❑Topographic map
(location of we9 must be shown on a USGS logo map and
atteched fo ihis form ifnof using GPS)
4. FACILITY- is the namo of ft business where the eU is located,
FACILITY 1&4(ftpplicable)
NAME OF FACILITY
STREET ADDRESS
City or Town Stale // `Zip Code
CONTACT PERSON " c ?t4( -41,- o 1C:•-6
MAILING ADDRESS
City or Town Slate Zip Coda
}J�9_ )_ 2 2Y" 9 0_16 Fora
Area code- Phone number �j9 4e ) 5�,`
5. WELL DETAILS:
a, TOTAL DEPTH: 7s .
b, DOES WELL REPLACE EXISTING WELL? YES ❑ NO 2C
c. WATER LEVEL Belorl Top of Casing:
(Use `+' if Above Top of Casing)
L
-----'----�'—C-�l't, L
d, TOP OF CASINO IS FT. Above Land Surface"
'Top of casing terminated atlor below land surface may require.. —
a variance in accordance with 15A NCAC 2C .0118,
[7t; ltt.
o. YIELD (gpm): L METHOD OF TEST L__
f. DiSiNFECTION:Type H� Amount
g. WATER ZONES (depth): -4 P41"
From To P�� � To
Toarri�_To
- From T To � ' From To
6. CASING: Thickness/
Depth Diameter Weight Material
From r To s
From o Ft.
From Ta Ft.�
7. GROUi, Deplh Material Method
From YMU To 1 FL���? 'ns AlC..'Y'ln
Fro•rt To Ft.
From To Ft.
a. SCREEN: Depth Diameter SMSize Material
From To
FI.
in.
In.
From To
Ft.
In.
in.
From To
Ft.
in.
in.
9. SANDiGRAVEL PACK:
, Depth • -•.- ""
""
Size
Material
From To
Ft.
From TD
Ft.
From To
Fi.
% DRILLING LOG
From To
De
C) -_ 653-7
,pFormation
`jf . as JA S"-.
ti�Zoac��s
_
11,JEMARKS:
SFP it
1 W HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCEWiiH:
ISA NCAC 2C, WELL CONSTRUCTM STANDARDS, AND THAT A COPY OF T141S
,A666 BEE PRWIDEDTOTHE f:t ER
��;
ofdUTUR®r CERTIFIED WEE
WELL CONTRACTOR DAT
=0clL.,f -Lk; Md99 a�
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days, Attn: Information Mgt.,
1617 Mall Service Center— Raleigh, NO 27699.1617 P one No,'(919) 733-7G15 axt 5G8.
Date site visited: ���?� - 1 by Permit required- des No
Form GW-lb
Rev. 7105
FA
2 7 2011' } 9
J
.lifer iO�r?';ilCi�
ft•r&°„ e E
�..

-4
MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
' Coleen �(. Sullins Dee Freeman
Governor Director Secretary
6/28/2011
NC DENR Division of Parks and Recreation
Attn: Erin Lawrence, P.E., Head, Engineering Program
1615 Mail Service Center
Raleigh, NC 27699-1615
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0300176
Lake Norman State Park
159 inland Sea Lane
Troutman, NC 28166
Dear Erin:
On June 24, 2011, the Aquifer Protection Section (APB) received notification of your intent to construct a closed -loop water -only
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
individual permit is not required for the construction and opefation of this type of geothermal injection well system as long as the
following conditions are met:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Iredell County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties. .
Please contact Mike Rogers at [phone] or Michael.RoUers(a,Incdenr.izov if you have any questions.
Sincere
for Debra Watts
supervisor
SE
cc: l ioores,nIle Reo onal Office- APS
APS Central Files - Permit No. V110300176 4err;,atio� PrO ;&s5irec '•r"t
Iredell County Health Dept. v Q1'
Yadkin Well Company (David Brown)
AQUIFER PROTECTION SECTION
1636 Mail Semite Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604 Gr�e
Phone: 919-73J 3221 \ FAX 1: 919-115 588: FAX 2: 919-715-6048 \ customer Service: 1„77ti23'oI18 T4�1 Rib 11 p j A
�' 'zJ f e
Internet w%% netvateroualitv.org Ti � �`�fi E E7F
r t ,kUftt 6, r
An Equal Opportunity 1 Affirmative Adion Employer

GEO-THERMAL WELL CONSTRUCTION RECORD
NON RESIDE1 TML WE, L L CONSTRUCTION RECORD
North Carolina Departmdni of Environment and Natural Resources- Division of Water Quality
- WEL,L, CONTRACTOR CERTIFICATION P S-7,- —
-TWELL CCITRACTOR:
Well Conlracto (Individual) Name
YADKIN WELL COMPANY, INC.
Well Cdntractor Company Name
STREETADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City orTown State Zip Code
1336 )-468-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) 41 % �- � •
WELL CONSTRUCTION PERMIT#(if applicable) vld = 0 5 G d 'r
OTHER ASSOCIATED PERMIT#(if applicable)
3. WELL USE (Check Applicable 136x) Monitoring[] Municipal/Publicn
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection[]
Irrigatior[I Othqd1<101stuse) (-lncarI T.rxjr) (,'Pr)mi T-iP ma
DATE DRILLED_ --(/
TIME COMPLETED AM❑ FIFE'
4. WELL LOCATION: /
CITY:. Tflo c'J Ll COUNTY T—I-P-8- P. Vi
759 S' eL'k eat-k r,,,�
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
(check appropriate box) May be in degrees,
LATITUDE 3 ,, d �U, minutes, seconds or
LONGITUDE 0 CIS 2 in a decimal fomtat
Latitude/longitude source: 513PS ❑ Topographic map
(location of well must 6a shown on a USGS fopo map and
attached to this form if not using-GPS)
5. FACILITY- Is the name of the businass where the Weil is located.
FACILITY ID #(if applicable)
NAME OF FACILITY �x �i @� IJ,7, '1s,,6r, 'S.-kete. PC/vLG
STREETADDRESS ZJc?n� S�Ca l/uJ�
1
Iva A-ftol
CityorTown State Zip Code
CONTACT PERSON �COckat•b ,i jc l /SaclT' ertq,
MAILING ADDREADDRESS"P'3 A0)�c (�Lt
6CI-(,)tt ttg
City orTown Slate Zip Code
Area code - Phone number
6. WELL DETAILS:
a: TOTAL DEPTH: &c)
b. DOES WELL REPLACE EXISTING WELL? YES[] NOUt
c. WATER LEVEL Below Top of Casing: FT. L,
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface -
°Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 26.011 a.
e. YIELD (gpm):4_ METHOD OF TESTAIR PUMP
f. DISINFECTION. Type HTH Amount -//5- E
g. WATER ZONES (depth). -
From PY 7 To J ,FIlom To
From C'rr To-?1)-C Fr6m To
From To From To
7. CASING: Depth Diameter ThicknessNVeight Material
From To
Ft.
From To
Ft.
From To
Ft.
S. GROUT: Depth
Material Method
From Q© To 0
r-t._Renoni-Le Pllm
From To
Ft. {
From To
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
From
To Ft.
In. in,
From
To
Ft.
in. in
,,In.
From
To
Ft.
in.
10. SAND/GRAVEL PACK:
Depth
Size Material
From
To
Ft.
From
To
Ft.
From
To
Ft.
-
11.DRILLING LOG
jf
From To
Formation Description
—0 �
n i
1
p�°�
�t
JCr
V ) �ni7
SIZE OFF
BIT SERIAL NO:
12. REMARKS:
Bores ( /Y y Depti' ( boo )
; of looms per Bore ( 1 )
Dia of loons (I"
I DO HEREBY CERTIFY THAT THIS WELL bVAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 20, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEr PROVIDED TO THE "'ELL M
v/J �> /0- -=!•sue
S ATUR C RTIFIED ELL CONTRACTOR DATE
�s•�z�•� lt� �� � Q �o
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water -Quality within 30 days, Attn: information Mgt., Form GW-ib
16i7 Mail Service Center- Ralelgb, NC 27699.16i7 Prone No. (9i9) 733-7015 ex-t 668, Rev.12/07
DATE SITE VISITED:
PERIv1IT: YES NO

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759 State Park Rd, Troutman, NC 28166 to 159 Inland Sea Ln, Statesville, NC 28677 - G... Page 2 of 2
Driving directions to 169 Inland Sea Ln, Statesville, NC 28677
759 State Park Rd
Troutman, NC 28166
1. Head west on State Park Rd toward Wildlife Rd
2. Turn left onto Inland Sea Ln
Destination will be on the right
159 Inland Sea Ln
Statesville, NC 28677
These directions are for planning purposes only. You may find that construction projects, traffic, weather, or other events may cause
conditions to differ from the map results, and you should plan your route accordingly. You must obey all signs or notices regarding your n
Map data 02013 Google
https://maps.google.com/maps?q=159+inland+sea+lane+troutman+nc+28166&ie=UTF-8... 9/20/2013

NC to Lake Norman State Park Directions - MapQuest
R TRIP TO:
irman State Park
20.7 MI R
.r.el Cost: $1.39
Trip time based on traffic conditions as of 12:46 PM on October 25, 2017. Current Traffic: Light
-------------------------------------------------- ____------------------------
_____________________
It1. Start out going northeast on Campground Rd toward Bellwood Ln.
a�'
_-Theft-2:58miles------------- ____---------------- _----- I --------- -._----------
T2. Campground Rd becomes Slanting Bridge Rd.
Then-2.32miles------------ _--- ____ ---- ______________.
3. Turn right onto E NC 150 Hwy/NC-150. Continue to follow NC-150.
NC-150 is 0.2 miles past Mocassin Dr.
If you reach Adeline Ln you've gone about 0.2 miles too far.
-------- Then-5,9&lmiles-_. --------------------------------------- '--------------------
--2-.58-total miles
_______ __________4.89-total miles
------------ 10,81-total miles
4. Turn left onto Perth Rd.
Perth Rd is 0.3 miles past Barington Dr.
If you reach Byers Village Dr you've gone about 0.1 miles too far.
___.____Then-5:09mites------------------------- ___----------------------------------------------------------- 18..7-9-totalmiles
5. Turn sharp left onto Stale Park Rd.
ki State Park Rd is 0.3 miles past Menster Dr. '
If you reach Spicewood Cir you've gone about 0.1 miles too far.
-------- Then-3,65miles--------------
------------- -________________20,44-total miles
` 6. Turn left onto Inland Sea Dr.
If you reach Saint Johns Rd you've gone about 0.2 miles too far. -
__Then-0,23milas------------------- ____________________.__.._.._..._--------------------------------- .20,57-total,Mae&
7. Lake Norman State Park, 159 Inland Sea Dr, Troutman, NC, 159 INLAND SEA
O DR.
Your destination is just past Duke Power Cir.
If you are on Inland Sea Dr and reach State Park Rd you've gone about 0.2 miles
too far.
_____-__._-______________________________-___-_____-___--__.________._______-___--_--___-__________________._____________.___._
use of directions and maps, is subject to our Terms of use. we don't guarantee accuracy, route conditions or usability. You assume all risk of use.
Page 1 of 2
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NC to Lake Norman State Park Directions - MapQuest
Page 2 of 2
Book a hotel tonight and h Car trouble mid -trip?
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Aooresville, NC 610 E Center Ave to Lake Norman State Park Directions - MapQuest
YOUR TRIP TO:C
Lake Norman State Park
1 HR 10 MIN I 42.2 MI JR
Est. fuel cost: $2.74
Trip time based on traffic conditions as of 11:49 AM on October 24, 2017. Current Traffic: Moderate
___ ........ _------------------------------------------------------------------- _____----- ______ ----- ___
1. Start out going west on E Center Ave toward Cedar St.
un
-Then-0,59-miles___ --------- _---------- __________________________ _____---------
2. Turn left onto S Main SYNC-152.
S Main St is just past S Church St.
If you are on W Center Ave and reach N Broad St you've gone a little too far.
.___.___Fhen-0:o8,miles........................___________-____..___....__..._.....--_-____.___-__.____----._6.67-totat miles
3. Take the 1st right onto W McLelland Ave.
If you reach E Catawba Ave you've gone about 0.2 miles too far.
----------------------- __..__.____..__.________. 1,63-total miles
4. Turn left onto E Plaza Or/NC-150. Continue to follow NC-150.
Then-&19miles-------------------------------------------- _____-______.____________..___.______--__9,8240tal.miles
O5. 8320 NC HIGHWAY 150 E is on the right.
Your destination is just past NC-150.
If you reach Marshall Rd you've gone a little too far. -
fs Marshall Steam Station
This leg of your trip is:
15 minutes • 9.82 miles
-------- Start of next- leg of foule----------------------------- ---.... ---- ____.________________.
6. Start out going southwest on NC Highway 150 E/NC-150 toward Marshall Rd.
Continue to follow NC-150.
______-_-Then-6-38miles-------- _-------- ___---------------------------------------- --- ------
.__.
7. Turn left onto N Highway, l6/NC-16 Bus.
N Highway 16 is 0.1 miles past Bud Rd.
If you reach E Maiden Rd you've gone about 0.1 miles too far.
Then-2-79-miles----------------- __--- _--------------------------- '____.____.-______-_.____
O8. Welcome to DENVER, NC.
Your destination is 0.2 miles past Pleasantview Trl.
If you reach Saint James Church Rd you've gone a little too far.
Denver, NC
This leg of your trip is:
12 minutes • 9.16 miles
-------- Start of next4eg .ro Trlof-route_______________--- _---- _____--- _______________________._______
9.. Start out going northwest on N Highway 16/NC-16 Bus toward Pleasantview
--------T.hen-2,79 miles -------------------------------------- __________________..___._._.__-___.
10. Turn right onto E NC 150 Hwy/NC-150. Continue to follow NC-150.
NC-150 is 0.3 miles past Hicks Dr.
If you reach Bos Dr you've gone about 0.4 miles too far.
..------ Then- 10.64- miles --------------------- ___--- _------------------------ —-------------------
----- 4&..20-total miles
48,96-total miles
------ 29.7-7-total miles
32-.30-total miles
Page 1 of 2
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Mooresville, NC 610 E Center Ave to Lake Norman State Park Directions - MapQuest
11. Turn left onto Perth Rd.
Perth Rd is 0.3 miles past Barington Dr.
If you reach Byers Village Or you've gone about 0-1 miles too far.
___-____-Then-5:99-m8es-------------- _______-------------------------------------------------------- ______--- 3&.29-totaFrniles
12. Turn sharp left onto Stale Park Rd.
State Park Rd is 0.3 miles past Menster Dr.
If you reach Spicewood Cir you've gone about 0.1 miles too far.
---------------- _______-------------- _... __--- --_•--------- ..-_._._-.-_.-------- '---- 44-.94-totalmi7es
13. Turn left onto Inland Sea Dr.
If you reach Saint Johns Rd you've gone about 0.2 miles too far.
---- Then-0,234miies----------------- __________________
14. Lake Norman State Park, 159 Inland Sea Or, Troutman, NC, 159 INLAND
SEA DR.
Your destination is lust past Duke Power Cir.
If you are on Inland Sea Or and reach State Park Rd you've gone about 0.2 miles
too far.
Lake Norman State Park
This leg of your trip is:
33 minutes - 23.19 miles
------------------------------ ---_.._..__--._..._._.._--.-_----_-------------------------- '-___-----------•---------------------
Use of directions and maps is subject to our Terms of Use. We don t guarantee accuracy, route conditions or usability. You assume all risk of use.
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(1-877-577-5766) Assistance is here:
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LAKE NORMAN
STATE PARK
LEGEND
Bathhouse
Bike Trail -----------
Boat Ramp.
® Rental
Park Boundary
® Community Building
8 Dragonfly Trail
Family Camping
Fishing
Group Camping
® Hiking Trail -------------•
EaS� Mom= Road
©
Hospital-911
Parking
Park Gate
©
Visitor Center
®
Public Phone
Picnic Shelter
Picnicking
aRanger
Residence
®
Restrooms
Paved Road
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Swimming
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0.8 miles Easy
White Q
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0.25 miles Easy
Paved Path
Lake Shore Trail
Q
5.0 miles (from trailhead) Moderate
White
6.3 miles (from trailhead & doing an
Red Q
out -and -back on the Group Camp Spur)
2.6 miles (traveling north from trailhead
Red Q
then using Short Turn Trail)
3.2 miles (traveling south from trailhead
Red Q
then using Short Turn Trail
Itusi Trail
30.5 miles
Blue Q
The 30.5 Itusi Trail is comprised of the following loops:
Hawk Loop 3.0 miles
Hicks Creek Loop 1.0 mile -
Norwood Creek Loop 2.5 miles
Monbo Loop '6.25 miles
Laurel Loop 9.75 miles
Wildlife Loop 4.25 miles
Fallstown Loop 1.25 miles
Fox Loop 2.5 miles
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GPS: 35.672548,-80.932500
Lake Norman State Park is located in Iredell County and is 10
miles south of Statesville and 32 miles north of Charlotte. Reach
the park by taking exit 42 off 1-77 and following the signs.
Park Information
Park Hours:
North Carolina State Parks are open every day, with the exception
of Christmas Day. Park hours vary with the seasons.
Please visit the North Carolina State Park website or contact the
park office for the most current information about seasonal hours,
activities, alerts, camping fees, programs, rules and weather.
Contact Information:
Lake Norman State Park
N.C. Division of
759 State Park Road
Parks and Recreation
Troutman, NC 28166
Dept. of Natural and
Office: 704-528-6350
Cultural Resources
[e-mail]
1615 Mail Service Center
www.ncparks.gov
Raleigh, NC 27699-1615
919-707-9300
Welcome!
At Lake Norman State Park, fun is just a matter of scale. On one hand,
there's the largest man-made lake in the state, Lake Norman. When
filled to capacity, its surface area is 32,510 acres with a shoreline of 520
miles and a main channel 34 miles in length —thus its nickname, the
"Inland Sea."Thirteen miles of the shoreline are in the state park, which
provides boating access.
On another hand, the park boasts the 33-acre Park Lake where fishing
and boating are enjoyed. And, with hiking and biking trails, picnic areas,
interpretive programs and campgrounds, there's more to Lake Norman
State Park than water.
We're Social
® www.ncparks.gov
ODWhen you have finished with this publication, help saveourearth
a, by sharing it with a friend, returning it to the park or recycling it.
Pat McCrory
Governor
Susan Kluttz
Secretary
Natural and 20,000 copies of this public document were
Cultural Resources printed at a cost of51,229.31or$0.06per copy. 01/16
History Highlights
The area surrounding the Catawba River is rich in history. Artifacts in-
cluding pottery shards, flint chips and arrowheads, as well as burial sites
near the river, indicate the presence of American Indians long before
European settlement.
In 1600, the Catawba Indians had an estimated population of 5,000 but
their number steadily declined due to disease and warfare with Iroquoian
tribes. By 1760, the tribe was reduced to 60 fighting men. In 1762, the
Catawbas left the area and moved south.
In the mid-18th century, Fort Dobbs was built to protect area settlers
during the French and Indian War. Daniel Boone helped to defend this
fort against the Cherokees. During the Revolutionary War, Lord Cornwallis
set up a camp in the area and a skirmish was fought at Cowans Ford,
an area now covered by Lake Norman.
Lake Norman was created from 1959 to 1964 when Duke Energy built the
Cowans Ford Dam across the Catawba River to generate electrical energy.
The creation of the lake led to further industrialization of Mecklenburg
County, helping establish Charlotte as a major trade center.
The park was formed in September 1962, when Duke Energy donated
1,328 acres of land on the northeastern shore of Lake Norman for a
state park.
On the Water
Boating: Pedal boats, kayaks, canoes, and paddle boards may be rented
for use on the Park Lake. Contact the Visitor Center for days and hours
of operation. Privately owned boats and watercraft may access Lake
Norman from the boat launch area located at the south end of the park.
Use of the boat launch area is free.
Fishing: Popular game fish in Lake Norman include crappie, bluegill
and yellow perch, as well as striped, largemouth and spotted bass. The
smaller Park Lake also has some choice fishing spots. Regulations of the
N.C. Wildlife Resources Commission apply for both lakes.
Swimming: A lakefront swimming area and beach is located at the
end of State Park Road. It is open daily from 10 a.m. until 6 p.m. April
through October. A modest fee is charged when lifeguards are employed.
Hiking Trails
Alder Trail: Begin this easy 0.8-mile loop near the Visitor Center.
The trail goes through the Peninsula picnic area, circles the peninsula
between Norwood and Hicks creeks and then skirts the edge of Lake
Norman. Take a short side -path to the dam and view the spillway and
gates that control Park Lake's water level.
Dragonfly TraiL 0.25 mile ADA accessible paved path from the Visitors
Center to a scenic overlook on Lake Norman. Numerous nature exhibits
are found along the pathway.
Lake Shore Trail: The trailhead for this moderate 5-mile trail is lo-
cated near the Cove picnic area, off of Shortleaf Drive. The trail follows
the lakeshore, passes by the family campground and swimming area
and returns to the trailhead. Take the Short Turn Trail to roughly cut
the distance in half. To add another 1.3 miles, do an out -and -back on
the Group Camp Spur Trail.
Mountain Biking
Itusi Trail: (pronounced "ee-too-see") The trailhead is located near the
Visitor Center. The 30.5 mile long trail is primarily used by mountain bik-
ers but hikers are also welcome. Hikers must yield to the bikers however.
This trail will be closed to all users whenever the trail is too wet from
precipitation. Contact the park for trail conditions prior to arrival. This
trail closes one hour before regular park closing time.
Flora and Fauna
All of the fields cultivated for the past three centuries have been re-
forested by pines through natural succession and intentional planting.
Today, the park is comprised of a mix of pine and hardwood forests.
Due to severe storms and infestation by southern pine beetles, the pine
forest exists as smaller pockets surrounded by a forest of hardwoods.
Hickories, sweet gum, red maple, dogwood and oaks are the prevalent
species. Mountain laurel, wild hydrangea, box elder, strawberry bush,
other small trees and shrubs comprise the understory.
Stream banks are dominated by sweet gum, ironwood and river birch,
while beech may be found in the coves. Alder and willow thickets grow
along the lake's edge, as well as marsh grasses, rushes and sedges.
Though most of the park's animal species are rarely seen, at least 35 spe-
cies of mammals have been found in the area around the park. Upland
communities are home to the Virginia -opossum, eastern cottontail, gray
squirrel, bobcat, coyote, red and gray foxes, white-tailed deer, eastern
mole and several species of shrews and mice. Muskrat and raccoon may
be seen in the marshes along the creeks and lake.
Amphibians and reptiles are abundant and diverse at Lake Norman.
Frogs, turtles and water snakes inhabit wetlands along the creeks and
the perimeter of the lake. Most of the snakes found in the park are
harmless and seldom seen. However, the venomous copperhead lives
in the park. Hikers should exercise caution.
Birdlife in the park is typical of the Carolina piedmont. Wild turkey, pine
warblers, blue jays, American goldfinches and bobwhites make their
homes in the uplands. During spring and fall migrations, a diversity of
warblers pass through the area. In the summer, species like the ruby -
throated hummingbird, indigo bunting and yellow -throated warbler
breed here. Red-tailed and broad -winged hawks are common and osprey
also may be seen near Lake Norman.
The waters of Lake Norman attract a variety of waterfowl. Mallards,
wood ducks, teal, hooded mergansers and other ducks, as well as geese,
may be seen during certain seasons. Wading birds, including great blue
herons, green -backed herons and egrets, may be encountered along
lake shallows during the summer.
Camping
Family Tent/Trailer Camping: Tent pads, picnic tables and grills
are available at 32 sites for a fee. Occupancy is limited to one family or
six people per site.
Group Tent Camping: Walk-in group campsites may be reserved by
organized groups for a fee. Campers without reservations must confirm
site availability with park staff before occupying a site. No less than
seven or more than 25 people are permitted on each site. Drinking
water and restrooms are available nearby. Picnic tables and a fire ring
are provided at each site.
Community. Building
A community building located near the group camping area may be
rented for events. The facility has a large meeting room, kitchen facili-
ties, restrooms and a fireplace. The building may be occupied between
8 a.m. and one hour before closing. Contact the park office to reserve
the facility.
Make a reservation online
at ncparks.gov or call
1-877-7-CAMP-NC
(1-877-722-6762)
Nature's Classroom
Rangers hold regularly scheduled educational and interpretive programs
about Lake Norman State Park. Contact the park office to arrange a
special exploration of the park for your group or class.
Educational materials about Lake Norman State Park have been developed
for grades 4-6 and are correlated to North Carolina's competency -based
curriculum in science, social studies, mathematics and English/language
arts.The Lake Norman program introduces students to aquatic organisms.
The program also focuses on water quality and resource management,
demonstrating how watersheds should be managed to maintain healthy
aquatic ecosystems and drinking water.
Picnicking
The Pier picnic area, one of three in the park, is located next to the
swimming area. The Cove picnic area is located off o(Shortleaf Drive.
The Peninsula picnic area is located near the Visitor Center. Picnic tables
and grills are scattered throughout the woods at all three areas. Picnic
shelters are available at the two latter areas and they may be reserved
for a fee. Restrooms are also provided at each area.
Rules & Regulations
Make your visit a safe and rewarding experience. Some of our regulations
are posted for the protection of our visitors and our park. A complete
list is available at the park office.
■ The possession or consumption of alcoholic beverages is prohibited.
■ The removal of any plant, animal, rock or artifact is prohibited.
■ Pets must be on an attended leash no longer than six feet. Pets are not
allowed in buildings or the swimming area.
■ Allstate parks are wildlife preserves. Hunting and trapping are not permitted.
■ Please throw trash in proper receptacles. State law requires aluminum
cans and plastic bottles to be placed in recycling containers.
■ Fireworks are not permitted.
■ Firearms and other weapons are prohibited except that those with a
proper permit may possess a concealed handgun in permitted areas and
under the requirements of North Carolina G.S.14-415.11. All firearms and
weapons are prohibited in visitor centers and park offices.
■ North Carolina motor vehicle and traffic laws apply in the park.
■ Camping is allowed in designated areas by permit only.
■ As a courtesy to other campers, observe the posted campground quiet
hours.
■ Cooking fires are permitted only in designated areas.
■ Obey all boating and fishing regulations of the North Carolina Wildlife
Resources Commission.
See the Division's website for a full listing of Rules and Regulations at
www.ncparks.gov
For Your Safety
To prevent accidents, please remember these safety tips.
■ Do not swim alone.
■ Dueto underwater hazards and irregular water depths, swimming outside
the designated swim area is not recommended.
■ Remember that you may be boating in unfamiliar waters; exercise cau-
tious seamanship. Do not water ski in boat -launching and mooring areas.
■ Be aware of approaching storms and seek appropriate shelter.
■ Take a vested interest in your safety. Wear a life vest when in or near
the water.
■ Be careful with fires when cooking or camping.
Contact park staff for other safety tips or for an explanation of park rules.