WI0300187_Regional Office Historical File Pre 2018

North Carolina D partment of Environment and Natural Resources-. Div
WELL CONTRACTOR CERTIFICATION # 3309-A
1. WELL CONTRACTOR:
Nathaniel Burt
Well Contactor (Individual) Name
MIUSOUTH GEOTHERMAL
Well Contactor r Company Name
8275 TOURNAMENT DRIVE SU TE 185
Street Address
MEMPHI S
City or Town
748-9995..
Phone number
FORMATION:
WELL CONSTRUCTION PERMITS I 0 7
OTHER ASSOCIATED PERMITI1(1 appre)
SITE WELL ID Sipe appecatrre) F5
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public L7
IndustriallCommercial D Agricultural 0 Recovery G Injection L2
Irrigation0 Other tI((Ilst use) E THERM
DATE DRILLED 2-1-12
4. WELL LOCATION:
C
,d e tin
T
C3 Stole Valley
LATITUDE 36
TN 38125
State Zip Code
'_
LONGITUDE 75 " ISMS OR 7x,
Latitudellongitude source: [ PS EjTopographic map
(location p1 well must be shown o' a USGS hypo map andaltached to
this form if not using GPS)
FACILITY (Name of the business where the well is located.)
CMPD-Stetlle Crp�k
Facility Name Facility ID* (if applicable)
72,2J WWsstinntnnha ttse RIvl
Street Address
or Town
of Cham!eftet,
f .)
Area code Phone number
6. WELL DETAILS:
a, TOTAL DEPTH:
b. DOES WELL REPLACE ED(1S
92
LL7 YES I] NO El
c. WATER LEVEL Below Top of Casing, 20
(Use " " if Above Top of Casing)
FT.
in 3 Ctays o f completion to: Division of Wal
�e Cartier, Weigh, NC 27699-161, Phone : (91
NONRESIDENTIAL W LCONST t,C'I'ION RECORD
n of Water Quality
Of
40 1101
c1. TOP OF CASING is lfa FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm):. 200 METHOD OF TEST Air Blown.
f. DISINFECTION: Type
g. WATERZONES (depth)
Top 209 Bottom 203 * Top
Top. Bottom Top
Top --. Bottom Top
Amount
Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top +1 Bottom 20 .. FL
Top Bottom Ft.
Top Bottom Ft.
8, GROUT: Depth Material
TopQ_ Bottom 450 Ft. Therm -Ex,_ I
Top Bottom Ft,
Top n n, Bottom FL,
Pump
g, SCREEN: Depth Diameter Eilctt Stoat Malarial
Top Bottom FL in. in.
Top Bottom Ft, Irt. in.
Top Bottom Ft In. in.
t13_ SANitIGRAVEL PACK:
Depth Size Material
Top Bottom Ft,,
Top Bottom. Ft.
Top _ ._Bottom ,.
11, ORILLTNG LOG
Top notion
APR 2O2(€
Formation Description
0 i 25 Oat too soil
28 12QQ
304. / 20,3
203 ,/ 450..
f
granite
'(ricred 9rEl
granite
Quality - Information Processing,
807-6300
Form GW-lb
Rev. 2/09

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department et Environment and Natural Resources- Division ofMfr"ater Quality
WELL CONTRACTOR CERTIFICATION # 3309-A
1. WELL CONTRACTOR:
NatKaniel Burt
Well Contractor (Individual) Name
MIF OUTH EQTE MAC.._
Waft Contractor Company Name
827 LTQURNAMENT DRIVE ..SUITE ,185
Street Address
MEMPHIS TN
City or Town
(901 ) .748-9Q95
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT*WV10300187
State
OTHER ASSOCIATED PERMIT#l+(if eppeeetie)
SITE WELL ID 4kif npP)�
3. WELL USE (Check One Box) Monitoring I0 Municipal/Public 0
hndestriatlrorrai to ai C Agricutturai 0 Recovery Li Injection ❑
lnlgation❑ Other I((8at use) GEOTHERMAL
DATE iRIU-E0 2-1-12
4. WELL LOCATION:
2227 WVestinatonhot a Blvd
(Street Name, Numbers, Community, Subdivision, Lot No.„ PQM* Zip Code)
cITY: Charolette COUNTY Mecklinbura
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
❑ Slope O Valley g'Fiat LI Ridge 0 Other
KOKTCD 38 i,^n^&,nhn.,n"nl CL R OR aXexxltx186001 CC
t( t&%ICC75 inn"8nnnnnnAAl CL ROR 7'7tlet:I" `7!'lthktOt CC
Latitude/longitude source: D3PS 070PograPhic map
(location of well mustbe shown on a USGS topo map srietsttached to
this farm if not using GPS)
5. FACILITY (Name of tfhe business where the well is located.)
CI IP©-Steele Creek
Facility Name
22271V eetrinatnnhoi Ise RI
Street Address
Charnlette
City or Town
City of Ch rctietta
Contact Name
Facility ID* Of applicable)
NC 7P7-1
State Zip Code
Malling Address
City or Town zip Code
( )
Area code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 450
b.. DOES WELL REPLACE EX It WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing:, 20
(Use +' tf Above Top of Casing)
.FT
4 5 2 .1
d. TOP OF CASING IS nla FT. Above Land Surface'
-Top of casing terminated attor below land surface may require
a variance In accordance with 15A NCAC 2C ,0118.
(flpm): 200
METHOD OF TESTjr B
f. f tSINFECT1ON: Type_ Amount
g. WATER ZONES (depth),
Top 200 Bottom 203 Top
Top Bottom Top
Top Bottorn Top
7. CASING: Depth
Top +1, Bottom 25 Ft
Top BottomFt.,
Top Bottom Ft,
8, GROUT: Depth Material
Top 9 Bottom 40. Ft Therms -Ex
Top_ , Bottom Ft
Tap Bottotn Ft.
own
Method
Fas{tve
Pump
1iw SCREEN: Depth Diameter Slot Size Material
Top Bottom.. Ft. in. iah,
Top Bottom Ft. In.
Top Both Ft.
in.
10. SANIi/GRAVEL PACK:
Depth Size tl�rfal
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
R,d /28,.
28 /.200
200, 1 203.
213 ... / 45Q
Submit ern t1 stays of completion to: Division of Water Quality - Inft
1617 Mail stale i Center, Raleigh, NC 27699-161, Phone : [phone]
4PR p 0 2UP
Form GW-lb
Rev. 1/08

NON RESIDENTIAL V LL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3309-A
1. WELL CONTRACTOR;
Nathaniel Burt.
Well Contractor (Individual)
et
MEMPHI$ TN '5
City or Town State
(901 748-9095
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT* W10 1 &7
OTHER ASSOCIATED PERMIT*(it appiesbie)„„
SITE WELL ID *Of eppli able) C6
3. WELL USE (Check One Box) Monitoring D Munir IIPubiic G
Industrial/Commercial 0 Agricultural 0 Recovery is Injection [�l
irrigation Li Other Me(erst Ise) GBOTHl✓RINAI_
DATE DRILLED 1/13/12. w .
4. WELL LOCATION:.
2227 Westir►atonlhous Blvd
(Street. Name" Numbers, Community,Subdivision, Lot Na„ Pelt- l ,Zip Code)
CITY: Chgrolette COUNTY Mecklinburg
TOPOGRAPHIC / LAND SETTING: (check puce box)
QSlope DVatley (Fiat 0Ridge E=7Other
LATITUDE 36 " " DMS OR 3x.�xxx?t3Ci DD
LONGITUDE 75 ° " DMS OR 7'x.7xxxxXxx. DD
Latitude/longitude source. CGPS DTopograph maP
(location et woit must be shown an a USGS topo map andattached to
this firm if not using GPS)
5. FACILITY (Name of the business where the well is located.)
City or' Town
NC
State Zip Code
Area code Phone number
11. WELL DETAILS:
a. TOTAL DEPTH:ASO
b. DOES WELL REPLACE EXISTING WELL? YES C) NO [/
c. WATER LEVEL Below Top of Casing: 20 FT.
(Use "+" if Above Top of Casing)
d, TOP OF CASING 18 fllfs FT. Above Lard Surface'
'Top of casing terminated or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD 161Pm). 180 _
METHOD OF TEST Air MOW'
fw DISFNFECTIONt Type Amount
g, WATER ZONES (depth):
Top 2Q4 Bottom 2(3_ Top
Top Bottomm Top
Top_ Bottom Top
7. CASING: Depth Diameter
Top. + . Bottom 30 Ff.
Top Bottom Ft.
Top Bottom Ft.
8 GROUT Depth
Material Method
Top ..0. Bottom Ft. Therm -Ex , Po i1(Ye
Top Bottom Ft._
Top . Bottom
8. SCREEN: Depth �n
Top Bottom Ft.
Top Bottom Ft.
Tope Bottom Ft,
14. SAND?GRAVEL PACK;
Depth Size
Top Bcnl .__ FL.
Top Bottom Ft,
Top Bottom Ft,
11, DRILLING LOG
Top Bottom
11 REMARKS:
Mataurtal
R" 2017
'OE
Formation Description
OF PER Sf)1'+l CQ " RI CTING T
Ipletion to: Divisi n of Water InfonnaUon PI
h, NC 27699-161, Phone : [phone]
Form GW-1b
Rev. 2/09

NON RESIDENTIAL WELxL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1. WELL CONTRACTOR:
Neste Burt
Wed Contractor (tndtvtdual) Name
$Quthern Well Drillina
Well Contractor Company Name
1530 Beaver Darn RSt
Street Address
Creedrnoor NC ?7522
City or Town State Zip Code
(_919 ) 603-7165
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT
OTHER ASSOCIATED PERMIT4(it a
SITE WELL ID /kif appiicabie) E 1
3. WELL USE (Check One Box) Monitoring 10 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery p In ion Cl
Irrigationo Other IOW use) W
DATE DRILLED 12105/11
4. WELL LOCATION:
2227 Westinatan House Blvd
um
CITY: Charlotte
ry, N'ca� Fari Zip Cade
COUNTY Meolcllnbt
TOPOGRAPHIC / LAND SETTING: tthedc appfopri
D Skope [::'IValeey J` Iat ['°Ridge `:I Other
LATITUDE 36 " DMS OR 3X.xxxX Xxx CD
LONGITUDE 75 a " DMS OR 7x x xXXxa€ 1t DD
Latitude/longitude source. 3PS D'jTopographic map
(belabor; of well must be shown on a USES fop° map anda/t tk
this form if not using GPS)
S. FACILITY (Name of the business where the well
CMPO-St :el. Creek
Facility Name
2'227 Westi ntonhouse. Blvd
Street Address
Charlotte
City or Town
City of Charlotte
Contact Name
ted.)
b
zi
7
Mailing Address
City or Town
(.... )
Area code Phone number
6, WELL DETAILS!
a. TOTAL DEPTH: 450
Zlro Code
b. DOES WELL REPLACE EXISTING WELL? YES fl NO :1
c. WATER LEVEL z slow Top of Casing; 20 FT,
(Use "+* if Above Top of Casing)
309-A
d. TOP OF CASING IS LI� FT Above Land ;rrfa
*Top of casing temnlbelow land surface may require
a variance in accordance with 15A NCAC 2C .0118,.
a. YIELD (gpm); 4 METHOD OF TEST Blow, down
f, DtSttNFECTI©N: Type htf . Amount 1207
g. WATER ZONES (depth):
Top 200 Bottom 203 Top Bottom ..
Top Botttom Top Bottom
Top Bottom Top Bottom
Thickness'
7. CA tri .: Depth Diameter Weight Material
Too 1 Bottom 30 Ft, 0114 t6$, LlelV
Top Bottom Ft.
Top _ Bottom Ft
8. GROUT, Depth Material
Top Q Bottom 451 Ft. Htc geothQrm
Top Bottom Ft,
Top Bottomu Ft.
9, SCREEN. Depth Diameter Slot Size
Top Bottom Ft. in. In.
Top Bottom Ft in, in.
Top Bottom Ft, in. in.
Materiel
10. SAND/GRAVEL PACK:
Depth Size Material
Top_ Bottom Ft.
Top ..Bottom FL
Top Bottom Ft.
I. DRILLING LOG
Top Bottom
0 /2
28 / 200
200 / 203
203
12. REMARKS:
Formation Description
ay top sQi(Granite
.
granite
VME
fr; c(yreci granite 30ppm
lie
00 HERESY CERTIFY THAT TH S W'ELR. WAS C'0 4STr UCTED IN A
iSANCAC'e WELL f NSTRUCTICN bATLaS#NOTHAT V�
REC0 eEE OVsE9 TOT
SI N »,TURF 0
RTIFIED WELL CON
COROANCE T
Y OF THIS
12105/11
OR DATE
PRINTED NAME OF PERSON CONSTRUCTING TFIE WEl
Submit with iili ; i days of completion tca* Division of Water Quality - Infonnatican Processing,
1617 Mall Serv➢ce center, Raleigh, NC 27699461, Phone : (919i 807-6300
Form GW1b
Rev, 2/09

(Street Name, Numbers,
CITY: CharQlette
ov ESIDENTIAL WELL CONSTR ICTIoN RECORD
North Carolina Department of Environment. and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3309-A
1. WELL CONTRACTOR:
Nathniaj Burt
Well Contractor (Individual) Name
MIP$OUTH GEOTHERMAL
Well Contractor Company Name
8275 'TOURNAMENT DRf VE
Street Address
MEMPHIS
City or Town
(9Q 1 ) 748-9Q95
Area code Phone number
2. WELL INFORMATION:
TE1
TN
State
WELL CONSTRUCTION PERMIT* WI 87
OTHER ASSOCIATED PERMIT4(4apprrese*_ w „
SITE, WELL ID Mdf applicable A-
3„ WELL USE (Check One Box) Monlioring 0 Municipal/Public E
IndustrsaUCommerraal 0 Apncarltural Ll Recovery 0 injection 0
Inigation0 Other tp((ilst use) GEOTHERMAL
DATE DRILLED 1-31-12
4. WELL LOCATION;
2227 Weatingto house Iv•
on, Lot No., Pam, Grp Code)
NTY Meck inburq
2
TOPOGRAPtftC / LAND SETT!t
D Slope 0 Valley laAFlal 0 Ridge I©
MIS OR 3x
LATITUDE 36
opolite box)
LONGITUDE " DMS OR 7x
Latitude/longitude source: C3 PS Oropographic map
(location of well must be shown on a USGS toper rnap and
this Awn, if not using GPS)
5. FACILITY (Name of the business where the well is located)
CMPQ-Stelae it ek
Facility Name
7227 tAfestinatnnhoijciA Rtuci
Street Address
CharOIFItte
City ar Town
CAN of CJwol't tte
Contact Narne
NC,
State Z
DD
ling Address
City or T
a. TOTAL DEPTtiz 350
b. DOES WELL REPLACE EXISTING
c, WATER LEVEL Below Top of Casing; .'
(Use '+' If Above Top of Casing)
NC=
State Zi
YESE' NOD
FT
d. TOP OF CASING IS
"Top of casing
avariance Ina
e. YIELD (ppm). 200
FT. Above Land Surfed,'
r below Land surface may require
15A NCAC 2C ,pt 18.
METh OD OF TEST Air Blown
f. DISINFECTION: Type
g. WATER ZONES (depth)
Top, 200 .._.... Bottom_ 203
Amount
Top
Top ttam Top
Top BottomTop
pth
Top +1 3.
Top Bottom
Top Bottom
Ft.
Ft.
Ft.,
8. GROUT, Depth M
Top 0 Bottom 350 Ft, The
Top Bn Ft.
Top Botlorn Ft
11. DRILLING LOG
Top Bottom
Q J 28
28 1 200
200 1203}.
203 f 354
Positiye
Pump
Formation DesctiptioV
slat top soil
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
2017
E
Form GW-lb
Rev. 2/09

NON RESIDENTIAL WELL CONSTRUCT ON RIC0�at
North Carolina Deparunent of Environment and Natural Resources Division of Water Quality
W ELL CONTRACTOR CERTIFICATION # 3309 A
1. WELL CONTRACTOR:
Nathaniel Quirt
Welt Contactor (Individual) Name
MD8OUTFI_GEQTFIERMAI,
Well Contractor Company Name
PHIS
IS
Town
T 185
TN 3812
State Zip Code
/ 9Q 1 ) 748-9095
Area code Phone number
2. WELL FORMATION:
WELL CONSTRUCTION PERMITS WI0304187
OTHER ASSOCIATED PERMrTil(tr apt iicahte)
SITE WELL ID #(K aypucabie) E3
3. WELL USE (Check One Box) Monitoring f7 Municipal/Public 0
Industrial/CommercialD Agricultural 0 Recovery C7 Infection l
InigatianD Other 8((iist use) GEOTHERMAL
DATE DRILLED 12/19/11
4. WELL LOCATION:
2227 Westinaton HQU
(Street Name, Numbers, 7nbrYaarni
CITY. tt
TOPOGI
rlSI
LATITUDE 36 "D is O?R x.xxxxxxxxX DE?
LONGITUDE 75 " DMS OR 73tXXXX XXSCX DD
Latitudebngitude source: BPS ('fcrpographfc map
Watson of wok must be shown on a USGS toop map andattached to
this form if not using GPS)
FACILITY (Name of the business where the welt is located)
T
Phone n
NC
State Zip
6. WELL DETAILS:
a. TOTAL DEPTH: 450
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 51(
c. WATER LEVEL Below Top of Casing: 20 FTa
(Use "+" if Above Top of Casing)
METhtOD OF TEST Air Blown
f. DISINFECTION: Type Amount
. WATER ZONES (depth),
Top 200 .. Bottom 203 Top Bottom
Top_ Bottom Top Bottom
Top Bottom_ Top Bottom
Thickness/
Diameter Weight Material
Top_+1 Bottom 23 FL
Top Bottom Ft,
Top Bottom P Ft,
TOP OF CASING IS _ nita FT. Above land Surface'
`Top of casing terminated aVor below and surface may require
a variance in acco dance with 15A NCAC 2C ,0118.
a. YIELD (ten): _ 10._
7. CASING: Depth
8. GROUT Depth
Material
Top 0 eotfom 450 Ft. Therm -Ex
Top Bottom Ft,
Top Bottom Ft.
9. SCREEN: Depth Diameter
Top Bottom Ft .k
Top Bottom Ft. it
Top Bottom Ft. it
10. SAND/GRAVEL PACK:
Depth
Top Bottom Ft
Top Bottom Ft.
Top Bottom Ft,
11, DRILLING LOG
Top Bottom
.9 f_28..
28 t� 200
20& / 450
Sire
Slot Size
In.
in.
in.
Method
Material
Material
APR 20 47
Foarrrration Description
clay toiZ sail Granite
granite
20Q / 203 fractured acre
granite — u
T RE e CERTIFIED WELL C
Submit within 30 days of completion to: Division of Water Quality
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : (919} 807-6300
fhr.
E OF PERSON CONSTR TING THE WELL
Form GW.1b
Rev. 2/p9

NONR'ESIDLNTIAL WEL .,CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
3+9-A
WELL CONTRACTOR CERTIFICATION t
1. WELL CONTRACTOR:
Natbniel Burt
Well Contractor (individual) Name
MIDSOUTH GEOTHERMAL.
Well Contraicior Company Name
8275 TOURNAMENT DRIVE SUITE 185
Street Address
MEMPHIS
City or Town
( 901 ) 748-9095
Area code Phone number
2. WELL IHFORttIATION
WELL CONSTRUCTION PERMIT
_____ TN 38125
State Zip Code
Wi03+187
OTHER ASSOCIATED PERMIT*(I<spoiiebto)
SITE WELL ID ;r(if sprrl +a) .Q_.
3. WELL USE (Check One Box) Monitoring 0 Municipat+Public l;l
InduslriagCormrrwarr aI C7 Agricultural © Recovery L7 injection U
Irrigatfonrj Other fi(Iist use) GEOTHERMAL
DATE DRULLED1-3Q- 1 2 -
4. WELL LOCATION:
Z227 \Ngstinatanhqupe IBI d
(Street Name, Numbers, Community, Subdivision, L t4Cr. PSI,.
Code)
CITY. Charotette courm Meciclinbura
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
o Slope D Watley kittlat o Ridge 0 Other
LATITUDE 36 ' _.. " DMS OR 3x,XxiStl x DI)
LONGITUDE 75 " DMS OR 7X.XXXXXXXXX DO
L.abtudellonjftude source: BPS [Topographic map
(location of web must be shown on a USGS topo rnap andattacdad to
this farm if not using GPS)
5. FACILrrY (Name of the business where the well is located.)
CMPD-SjefklA Crl I k
Facility Name
Facility lfxlr (if applicable)
ChRST1tEtne.
City or Town
tv of Char€le tg
Contact Name
Maainq Address
NC 2a217
State Zip Code
City orT
C. ),
Area code I�rte rht
L. WELL DETAILS:
a. TOTAL DEPTH: 4.50
b. DOES WELL REPLACE EXISTI
c WATER LEVEL Below Top of Casing: 20
( '4" if Above Top of Caring)
State Zip Code
U. YES CI NO of
FT.
Submit within 30 days of completion to Division 0f1
1617 Mali Service Center, Raleigh, NC 27699-161, Phone
403314.E
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/ below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gem). _ 200
METHOD OF TEST Air Blown
f. DISINFECTION: Type Amount
u. WATER ZONES (depth)
Top 200 Bottom 203 Top
Top Bottom Top
Top.r. Bottom Top
7. CASING: Depth Dtarrtar
Top +1 Bottom 25 Ft
Top__ Bottom Ft.
Top ... Bottom Ft.
8, GROUT. Depth Material Method
Top I,) Bottom Fe PQsitiv'e
Top Bottom Ft.�
Top Bottom_
9. SCREEN: Depth
Top Bottom
Top
Top
11. DRILLING LOG
Top Bottom
0 x(3
28 12QQ
200 1 203
203 1450
f
Pu p
Diameter Skit Size ttMatsrtal
Ft. in, br.
Ft In.
FL trr. in_
tl
L•dat ct.Qil.
_aranite
fractured graniantet
granite
Rtt�(TE) (FL+ E OF PERSON COTIipIG THE
Quality -
807-630t)
n P
il,
Forrn GW-lb
Rev. 2/09

ing Directions from 16104 Black
mapquest.
uest
Trip to:
227 Westinghouse Blvd
Charlotte, NC 28273-6209
33.52 miles
43 minutes
ii11s :Dr, Midland, North Caroline 2 1 %7 to 2 V stinghouse... Page 1 of 2
Notes
14. 8200 ARROWRIDGE BLVD STE C is on the right.
your destination Oast past iertowneatn tat
It you roach the end {.tArto tinotge Bled you've,gb e s , i>, 0 2 maos too lei
A to B Travel Estimate. 30,61 mi - about 37 minutes
B to C Travel Estimate: 2.91 mi - about 5 minutes
227 Westinghouse Blvd
Charlotte, NC 28273-6209
2,9 mi
301.8 mi
http://A.mapquest.cont/print?a= app.core.e43150b4 1e453f7c6203a62 12/6/2911

Driving Directions from 16104 131ackl err = l-tills Dr. Midland, North Carolina 28107 to 227 r'estint house.... Page 2 of a
Total Travel Estimate: 33.52 miles about 43 minutes
02011 MapQuest, Inc. Use of direct¢ons and maps is subject to the MapQuest Terms of Use. We zc ke no guarantee of the accuracy of their content, road conditions or
route usabifity. You assume a4I risk of use, Vein T`er s of use
http:/!w
est.com!print?a=app.core.e43150451 e453t""'r c620 3a62 12/6/201.1.

To: Pitner, Andrew
Subject: RE: City Geothermal Well Site
Thanks Andrew, l`Il head down there this morning and take a look.
Sincerely,
Mecklenburg County LUESA
Groundwater & Wastewater Services
700 N. Tryon Street, Suite 205
Charlotte, NC 28202
704-336-5454
htlplrGrounriwgtercharrneckor9
From: Pitner, Andrew[mailto:andrew.pitner@ncdenrgov]
Sent: Wednesday, November 30, 2011 2:57 PM
To: Pitner, Andrew; Tyndall, Dennis
Cc: Corbitt, Lisa
Subject: RE: City Geothermal Well Site
Sorry, here's the attachm n't. The address is noted as 2227 Westinghouse,
A
From: Pitner, Andrew
Sent: Wednesday, Novem
To: Tyndall, Dennis'
Cc: 'Corbitt, Lisa'
Subject: FW: City Geoth
30, 2011 2:48 PM
al Well Site
Hi Dennis,
I spoke with Lisa a bit about this geothermal site earlier and she said she was going to mention i to you and maybe have
you swing by. Some additional info about the nearby UST sites is presented below. rm also attaching our notification
documents that provide a bit more on the geothermal installation (key thing to note is thirty-seven 450' deep boreholes
with HDPE pipe proposed to be fully grouted over the whole length), If you make it by, please let me know as I'd be
curious about what you see, Thanks,
Andrew
From: Bowser, Daniel P
Sent: Wednesday, November 30, 2011 1:54 PM
To: Pitner, Andrew
Subject: City Geothermal Well Site
The Handy Pantry 62 site has not been worked on in some time, latest groundwater data is from 1995. While
GW flow is towards the site I doubt the subject site has been impacted, unless a new undocumented release
has occurred.
The Exxon site is similar, low levels of petroleum contaminates. They encountered Rock at 14 feet, deep well
is ND. Data from 1999.

W10300187
City of Charlotte 5QW - S Tr oniWestinghouse
CO Copyright 2008 ESRI
Ivor
n quaiity an commi meet

Central Files: APS SWP®..
11/22/11
Per ntt Number V11►10
B7
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (50W)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
F agility
Facility Name
City of Charlotte - Westinghouse Blvd
Location Address
2227 Westinghouse Blvd
Charlotte
Owner
Owner Name
City of Charlotte
Dates/Events
NC 28217
Scheduled
Orig Issue App Received Draft Initiated Issuance
11 /22/11 10/28/11
ulate Activities
Heat Pump IntecGQn
Outfafl
Waterbody Name
Status
Active
Project Type
New Project
Version Permit Classification
too Individual
Permit Contact Affiliation
Janice Scott
8275 Toumament Dr
Memphis
TN 381250851
Major/Minor Region
Minor Mooresville
County
Mecklenburg
Facllity Contact Affiliation
Owner Type
Government - Municipal
Owner Affiliation
Michelle Haas
600 E 4th St
Charlotte
Public Notice Issue
NC
Effective
11 /22111 11/22/11
28202
Expiration
Stream Index Number Current Class Subbasin

No
eveves Perdue
Governor
Charlotte. NC:` 2) 20'
arolin
Depa.
NCDENR
t of Environment and Natura
'vision of Water Quality
r H Sullins
DIreoto`
Subject: Ackno ; ledgement oflntent to Construct Type 5Q Injection \\
Pertn,it No. Wltl cl(01,
Westin«hous= L- ule\arc w'tarla tt . 181 C w '
Dear Ms. Haas:
Resources
On October 28. 201 . the Aquifer Protection Section (APS) received notfficanon of your intent to construct a closed -loop ! Ater Qttl\.'
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 construe ion and operation of this type of` geothetrnal injection w=e11 system as long as the
following conditions are met:
1. The injection well system contains only potable water,
?. The injection well system is constructed in accordance with well construction standards specified in. North
Carolina Administrative Code "Title 15A Section 2C Subchapter :021 , and
The required notification form and associated maps have been completely and accurately Submitted.
Failure to comply'writh all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code 'Title 15A Section 2C Subchapter .0 1.1(u (2 . Additionally, you should contact the Mecklenburg 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 (919) 15-6166 or (\I l ¢nael.l4
cc: .MooresvilL Regional Office - APS
APS Central Files - Permit No. MO 001 i
Mecklenburg Count Health Dept,
Mictionth C;ie:otherma Janice Scott
ne' . -3
interne,: w_r wcteran,St3ilV,or
zs:5 n .-lnrµ.cak if you have any
u
ns,

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of I5A NCAC 02C .0200
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed in
accordance 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: 10/12 , 2011 PERMIT NO. \.K. C'OCD 1' 1 (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence Business/Organization
Government: State Municipal x 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:
City of Charlotte
Mailing Address: 600 East Fourth Street
City: Charlotte State: NC Zip Code: 28202 County: Mecklenburg
Day Tele No.:
704-336-3654 (Michelle Haas) CeII No.:
EMAIL Address: [e-mail] Fax No.:
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) ParceI Identification Number (PIN) of well site: County: Mecklenburg
(2) Physical Address (if different than mailing address): 2227 Westinghouse Blvd.
City: Charlotte State: NC Zip Code: 28217
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Tim Hamby
NC Well Drilling Contractor Certification No.:
Company Name: Midsouth Geothermal
Contact Person: Janice Scott
Address: 8275 Tournament Drive, Ste. 185
NC-3 I 18A
EMAIL Address:[e-mail]
City: Memphis Zip Code: 38125 State: TN County: Shelby
Office Tele No.: 901-748-9095
GPUIUIC 5QW Notification (Revised 3/18/20I 1)
Cell No.: _
RECEIVED / DENR 1 DVV�I
Aquifer Protection Section
OCT 28 201E
Fax No.: 901-748-9097
Page 1

HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company ° 'Name:_
Contact Person:
Address
City.
Office Fele No.:
Zip Code:
Cell No.:
LL CONSTRUCTION DATA
MAIL Address:
County:. m�
Fax No.:
1) Number of borings to be constructed*: 37 Depth of each boring ('feet : 450
If existing water supply wells will be used then provide the arz arrraatiot? rrt Uem (4) below.
of tubing to be used (steel. PVC, etc). HINT pe_
ca ing. If the ‘vell(s) will use casing theta pro isle t1 e type (steel, PVC, etc.), cliarrteter, d ,
and extent of casing appearing above ground: None
(4) Grout (.material surrounding well easing and/or piping):
(a) Grout type: Cement Bentonite** x Paler (specify
"* By selecting bentonite grout, a rraraanee is hereby .requested tag 15A .t' `CAC 2C .U213(d)(I)t,A} c, 'e-quires a cement type grout.
(fib) Grout depth of tubing (reference to land surface): from tl to 450(feet)
If well has easing, indicate grout depth: from
feet)
G. WELL LOCATIONS — Maps must he scaled or otherwise accurately indicate distances and orientations of
features located within WOO feet of the injection well(s). babel all features clearly and include a north arrow.
Attach a site -specific map showing; the locations of the following:
* Proposed injection wells
* Buildings * Property boundaries
* Surface water bodies * Water supply wells
* 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 !!vile 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 lutes !arid structures can be
obtained and downloaded from ,the applicable county GIS website. Typically, the properly 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. ,'Ilia, a 'laver' can be selected showing topographic contours or
elevation data.

1
y _
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:
I. 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 I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. 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."
4 ,rei f, /
Signature of Property Owner/Applicant
h4 olIlt . f-f5
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type FuII Name
Signature of Authorized Agent, if any
Print or Type FulI Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED / DENR / DWQ
Aquifer Protection Section
OCT 28 2011
OPU/UIC 5QW Notification (Revised 3/15/2011) Page 3

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