WI0500443_GEO THERMAL_20111027

Permit Number
Program Category
Ground Water
Permit Type
Wl0500443 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Frederick May Woodward SFR
Location Address
4500 Revere Dr
Raleigh
Owner
Owner Name
Frederick
Dates/Events
NC 27609
May Woodward
Scheduled
Orig Issue App Received Draft Initiated Issuance
10/27/11 10/26/11
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NUL
Central Files: APS_ SWP_
10/27/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Frederick May Woodward
Owner
4713 Little Falls Dr
Raleigh
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Frederick May Woodward
Owner
4713 Little Falls Dr
Raleigh
NC
NC
Public Notice Issue
10/27/11
Effective
10/27/11
27609
27609
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
ArA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
10/27/2011
Frederick May Woodward
Tracey Hill Woodward
4713 Little Falls Dr.
Raleigh, NC 27609
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W 10500443
4500 Revere Dr.
Raleigh, NC 27609
Dear Mr. Woodward:
On 10/26/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -mil.
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,
?. 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 Wake County I-lealth
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 1l ichael.Roeersia. ncdenr.gov if you have any questions.
cc: Raleigh Regional Office - APS
APS Centres Files - Permi: No. WI0500443
Wake County Health Dept.
Harry Lechworth (N.W_ Poole Well & Pump Co., 3500 Rolesville Rd., Wendell, NC 27591)
Andy Smart (Bowman Mechanical Services Inc., 145 Technical Ct., Garner, NC 27529)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh. North Carolina 27599-1838
Location, 2728 Capital Boulevard. Raresgh, North Carolina27604
Phone- 919-73'3.32211 FAX 1: 919.715.0588: FAX 2: 918-715-6R48 l Customer Service: 1.877.623-e748
Internet: www.ncwalerquaIity.ore
Arr Equal ppinrlvnily 1 Aflinnative Atiioa Employer
One
NortCa o ina
Naturally

10/25/2011 07:39 9197799294 RECEIVED/ DENR / owa PAGE 01/05
Aquifer Protection Section
DATE:
A.
OCT 28_ 2011 vJllfiXJL/1'?)
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 1 SA NCAC 02C .0200
CLOSED-LOOP WATER-ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothexmal heating and cooling system_
These wells ate "permitted by rule" and do not require an individual pennit when they are constructed in
ac~ance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction. z Print o,-Type l'!ftmnatmff ~d Mail to tho Addrn, on the Lost Pag,
liO /1.-,: 'I 1·/ -~ . 20_ PERMIT NO. ________ (to be filled in by DWQ)
STATUS OF WELL OWNER (choose one)
Non-Government: Individual Residence _X_ Business/Organization __
Government State Municipal__ County_~ Federal_
B. WELL OWNER -For individual residences , list each owner on property deed. For all others, 5tate name of
entity fill4 name of person delegated authority to sign on behalf of the business or agency:
Frederick May Woodward. Tracey Hill Woodw:a,m
Mailing Addres~: 4 713 Little Falls Dr. Ba,l ei G?.h 2760 9
City: Raleigh State:~ Zip Code: 27609 County: Wake
Day Tele No.: (919) 80 0-9570 Cell No.:
EMAIL Address: finwoodward @earthHnk .net f ax No.:
C. LOCATION OF WELL SITE -Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) ofwell site: 17067 15940 County: Wake
(2) Physical Address (if different than mailing addre:;:;): ..,_,45=0=0_,,_R=e"""'vc,,,._re=-=Dr.,_ __ ~----
City: Raleigh State: NC Zip Code: --=2~76~0~9 _____ _
D. WELL DRU,LER INFORMATION
Well Drilling Contractor's Name: N.W . Poole Well & Pump CQ
NC Well Drilling Contractor Certification No.: 2833 A or 2514A
Company Name: N.W. Pool e Well /fl, Pump Co
Contact Person: Harty L echworth
Address: 3500 Rolesville Rd
EMAIL Add re ss: Lechwo:rth@NWPoo lewcJJ.com
City: Wendell Zip Code: 27521 State: ~NC=--_County: Wake
Office Tele No .: [phone] Cell No.: fax No.: [phone]
GPU/UIC 5QW Notification (Revised 3/lS/201 l) Page 1
10/26/2011 07:39 9197799294 RECEIVED/ DENR / DWQ
Aquifer Protection Section
OCT 28 2011
E. HEAT PUMP CONTRACTOR lNFORMA TION (if different than driller)
Company Name:~.B owman Mechanical Service s Inc.
PAGE 02/05
Contact Person: A,yjy 5~u.r f: EMA IL A ddress: bowrnanmechanical @bellsouth .net
Address: 145 Techn ica l Court
City: Gam er Zip Code: 27529 State: NC County: ~
Office Tele No.: [phone] Cell No.: ________ Fax No_: [phone]
F, WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: __ 2 __ ~ Depth of each boring (feet): ___ 188~----
* If existing water supply wells will be used then provide the informcition in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc):. liQeB
(3) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, etc.), diameter. depth,
and extent of casing appearing above ground: --~------________ _
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite*"' X Other (specify)---.,.-,--,------
"'"' By selecting ~Jltonite g,out, , variance is hc:rcby requested tQ 15A NCAC 2C .0213(d)(l)(A), which requires a cement ty~ grout.
(b) Grout depth of tubing (reference to land surface): from SE to 188 (feet)
lf 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 weU(s). Label all features clearl y an d include a north arrow.
(1) 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
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicatei:. the
facility's location and the map name .
NOTE: In most case;,, tUI aerial photograph of the property parcel showing pr<>perty lines and structure$ ca,i be
obtained and d<>wnloaded .from the applicable coufl.ty GTS website. Typically, the property can be searched by
owner na,;r.e. or addres$. The location of tJr.e wells in relation to prQperty boundaries, houses, septic tanks; otlu.r
wells, ete. can tJr.e11. be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
eleva'li.on data.
GPU/UTC 5QW Notification (Revised 3/18/201 I) Page2
10/26/2011 07:39 9197799294
PAGE 03/05
RECEIVED / DENR 1 CWO
Aquifer Protect;on Sectran
OCT 9g 201!
H. CERTIFICATION (to be signed as required below of 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 genenrt partner or the proprietor, respectively;
3. for a municipality or a sate, federal, or other public ageoey: bit either a principal executive
officer or inking publicly elected official;
4, for all othrs' by the well owner CtiligkinetinLitgArstinSilitleagin the property deed).
If an authorized agent is signing on behalf of the appliemit, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf,
"I hereby redly, wider penalty of law, that 1 have personally examined and am familiar with die information
submitted in this document and all attachments thereto and that, based an my 'toquity of those individuals
immediately responsible for obtaining aaid information, I believe that the infonxiation is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Signature of Property Owner(Appl
to F am
t14/1111
#t'CL,Ctf-aN
Signatrrr of Property Owner/Applicant
f ac. E. �'4 ; u u tA! as kTd,Pet
Pri.at or Type f all Name
Signature ofAutitonxed Agent, if nary
Print or Type Full Name
Submit the complete application package to:
UWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-I636
Telephone [phone]
OP[]ILi1C 3QW Notification (8cvisvd 3I1a12011)
3
noir

10/26/2011 07:39 9197799294
PAGE 04/05
0 25 50
100 Feet
PIN 1706715840
Real Earle ID 0033518
r
AAap Nam 170620
Owner
WOODWARD,
FREDERICK MAY
WOODWARD,
TRACEY HRI.
Mailing Address 1
4713 LITTLE FALLS
DR
Mailing Address 2
RALEIGH NG
27609-5885
Mailing Address a
Deed eat* 14325
Deed Page 1164
Deaf1 Dale 4/15/2011
Deeded A0reaae 0.54
Assessed Building 580,480.00
Value
A seteed Land Value 8190,000.00
Total Assessed Value 1200,480 00
Billing Clem INDIVIDUAL
Property dewlption L0139 LAKEMGNT
SE1
Heated Area
id03
Site Address
City
4Goo REVERE OR
Raleigh
Townuhip
Year BlAiil
RA-EIGH
1966
Total Sale Price 5135,000.00
Sale Date 4/15/2011
Type end Use Single Family
Design Style C4nventIonat
Land Class
RESIDENCE-c 10
ACRES -HOME SITE
Old Parcel Number 408-00000.0028
RECEIVED 1 DENR / p1N4
Aquifer Protection Section
OCT 26 2011
WAKE
COUNTY
N UU. It L4vouk4

10/26/2011 07:39
9197759294
PAGE 05/05
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1880 Peel
PJN '7C/671%5940
P.f.,lite. if)
Moe Name
Owner
rio:r35 !E.
170820
WOODWARD,
FREDERICK MAY
WOODWARD,
TRAcEY HILL
Mailing At VSS 1
Addres4 2
Ackkoas 3
ved Book
4713 LITTLE FALLS
DR
RALEIGH NC
27803-5935
14325
Deed Pape
1184
Deed Date
4/15/201
Deeded ACeeage
0.64
Assessed Building ,880,484.00
Value
Asseesed Land ValLeri S120,000.00
TO121 Alarmed Val. $200,4i1L1,00
ilIIng DEass
I ND IVI DU AL
Property DeerAption Loin LAICWORT
SE1
Heat.0 Ana
8Itf2f morass
1403
4500 REVER,E DR
CrEY
Raleigh
Township
RALEIGH
Year Built
1908
1.0018.1 Safe Price
Sate Dale
$135,000.00
4/15/B011
Type and Lisa
Singe Family
Del* Style
Cenventonal
Land Mau
RESIDENCE-c 10
AGRES-HOME SITE
Oicl Pain?! hhimber 408-o0000-002t
RECEtVEu f DENR uvut.t
Aquifer Protection Section
OCT 26 2011
iglillim
WAKE
COUNTY

DATE:
A.
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of I SA 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.
L Pdnt o, Type lnformatfon ond M<UI to the Address on the Last Page
liO J~)i II 1·/ · . , 20__ PERMIT NO. ________ (to be filled m by DWQ)
STATUS OF WELL OWNER ( choose one)
Non-Government: Individual Residence X Business/Organization __
Government: State 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:
Frederick May Woodward. Tracev Hill Woodward
Mailing Address: 4713 Little Falls Dr. Ralei gh 27609
City: Raleigh State: NC Zip Code: 27609 County: Wake
Day Tele No.: {919) 800-9570 Cell No.:
EMAIL Address: fmwoodward@ earthlink.net Fax No.:
C. LOCATION OF WELL SITE-Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 1706715940 County: Wake
(2) Physical Address (if different than mailing address): ~45~0~0~R=e~v~er=e~D~r _______ _
City: Raleigh State: NC Zip Code: ~2 _76~0~9 _____ _
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: N.W. Poole Well & Pump Co
NC Well Drilling Contractor Certification No.: 2833A or 2514A
Company Name: N.W. Poole Well & Pum p Co
Contact Person: H arry Lechworth EMAIL Address: Lechworth@ NWPoolewell.com
Address: 3500 Rolesville Rd REG_EIVED / DENR / DWQ
Aquifer Protection Section
OCT 2 7 2011
City: Wendell Zip Code: 27591 State: N"----'-=C'--_ County: Wake
Office Tele No.: [phone] Cell No.: Fax No.: {919) 266-7507
GPU/UIC 5QW Notification (Revised 3/18/2011) Page 1
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Mechanical Services Inc.
Contact Person: .S d"'\&v-EMAIL Address: bowmanmechanical bellsouth.net
Address: 145 Technical Court
City: Gamer Zip Code: 27529 State: NC County: Wake
Office Tele No.: [phone] Cell No.: ________ Fax No.: (919 ) 779-9294
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: 2 ___ Depth of each boring (feet): __ 188 ____ _
* 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): HDPE
(3) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, etc.), diameter. depth,
and extent of casing appearing above ground: _________________ _
( 4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite** X Other (specify) _______ _
** By selecting bentonite grout, a variance is hereby requested to ISA NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from Sfc to __..1-8-S __ (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 clearl y and include a north arrow.
(1) 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
(2) 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 can 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) Page2
A. CERTIFICATION (to be signed as required below or by that person's authorized agent)
l 5A 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 tneans ail.pecsons listed on the 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 al! attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. 1 am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Signature of Property Owner/Applibant
1� LJ"4 eAj1(44
f;r0 or `type Fall ame y
tiPo J'
Sire of Property Owner/Applicant
rdc.G 4-t ir?t U J 06 11.vaf C1
Print or Type Full Name
Signature of A uthorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-11636
Telephone [phone]
GPUIUIC 5QW Notification (Revised 3/18/20I i )
RECEIVED 1 DENI DWQ
Aquifer Prntactior Section
OCT 2 7 2011
3
hoof

0
25
50
100 Feet
Field
Value
PIN
1706715940
Real Estate ID
0033518
Map Name
170620
Owner
WOODWARD,
FREDERICK MAY
WOODWARD,
TRACEY HILL
Mailing Address 1
4713 LITTLE FALLS
DR
Mailing Address 2
RALEIGH NC
27609-5985
Mailing Address 3
Deed Book
14325
Deed Page
1104
Deed Date
4/15/2011
Deeded Acreage
0.54
Assessed Building
680,480.00
Value
Assessed Land Value
$120,000.00
Total Assessed Value
$200,480.00
Billing Class
INDIVIDUAL
r
Property Description
L0139 LAKEMONT
SE1
lleated Area
1403
Site Address
4500 REVERE DR
City
Raleigh
Township
RALEIGH
Year Built
1966
Total Sale Price
$135,000.00
Sale Date
411512011
Type and Use
Single Family
Design Style
Conventional
Land Class
RESIDENCE-‹ 10
ACRES -HOME SITE
Old Parcel Number
408-00000-0028
WAKE
COUNTY
NU&III LMIUL INA

Carroll
Middle
School
0 400 800
1600 Feet
Field
Value
PIN
1706715940
Real Estate ID
0033518
Map Name
170620
Owner
WOODWARD,
FREDERICK MAY
WOODWARD,
TRACEY HILL
Mailing Address 1
4713 LITTLE FALLS
DR
Mailing Address 2
RALEIGH NC
27609.5985
Mailing Address 3
Deed Book
14325
Deed Page
1184
Deed Date
4/15/2011
Deeded Acreage
0.54
Assessed BulIding
$80,480.00
Value
Assessed Land Value
$120,000.00
Total Assessed Value
$200,480.00
Billing Class
INDIVIDUAL
Property Description
L0139 LAKEMONT
SE1
Heated Area
1403
Site Address
4500 REVERE DR
City
Raleigh
Township
RALEIGH
Year Built
1966
Total Sale Price
$135,000.00
Sale Date
4/15/2011
Type and Use
Single Famiiy
Design Style
Conventional
Land Class
RESIDENCE-< 10
ACRES -HOME SITE
Old Parcel Number
408-00000.0028
WAKE
COUNTY
NUA I H i. A NLIL I N/.

NORTH CAR.01 INA DEPARTMENT OF ENN, IRONMEN'I AND NA IL RA RLSOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 1 5A NCAC 02C .0200
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
fl}ese walls 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 ptirmit when they are constructed in
accordance with this rule:, oi' 15A 7CAC 02C .O200 and titik Ntio[ice is subniitted prior to construction,
Print ur Tire h fnr►rtation and .flail 140 Iij. , tclell ss urn ihw Losr Page.
DATE: 20 PERMIT NO.
ito be filled it by DWQ}
A. STATUS OF WELL OWNER teboose one
Non-Crt>!i'mnient. lndi'. i,lual Residence N 13u7iness'Organicatiun _
Government:
Stare Vlunicipai Count) Federal
B. WFI.L OWNER — For individual reidences. liti► .:ach n nt'r on property deed. I or a;l others. state name of
entity and name of person delegale�1 authority to sign on behalf of the business or agency
;.edrrick Ma. Woodward. trace. Hill \V ioJw.ird
Mailing Address: 4713 Little Falls Dr. Rarei.li 27609
City: Raleigh State: IBC tip Code: 27609 County : Wake
Day Tele No.: 019) 800-9570 Cell No.:
1:1vIAIL Address: fin woodward'dearth! ink_net Fax Na,:
LOCATION OF WELL SITE. — W1),.ro the injection ►+e!I; are pliysicalI) located:
Parcel Identification Number (PIN) of well site: l 067 ,5c1-k[1_ County: WaL
(21 Physical Address (if different than mailing address): 45UtlRevere Dr
City Raleigh State: NC Zip Code- 27609
D. WELL DRILLER INFORMATION
Well Drillini [ nntravor's Ttar:te: N.W. Pnnle 1k 42,11 Pump Cn
NC Well Drilling Contractor C'ertificalion Flo.: 2833.N or 2514A
Company Marne:: N _W. Poole Well & Pump Co
Contact Person: I-larry Lechworth EMAIL Address: I echwarth it NWPooIewell.eon
Address: 1500 Rc7lesvrlle Rd
City t Wendell _ tip ('ode: 275911 State: NC Count): Wa•
Office Tcle No.: (9 i 9 266-922 3 Ceti No.: EaxNo,_ (9191266-7507
GP( -1:1C .QW Nnlili67:fnion (Revised 3 1Rl2t1t 1) rap: I

F. HEAT PUMP (`(EVI'R.A(" 1'OR I\FoRm.1 rIo\ than driller)
(-t.Inprirn Name: Bo‘‘. man \techanical Sonic[,. inc.
ont.:ci Person: it i'MMAILA ddress; htniinainnechanicatellsoutli.nel
Address: 1-15 technical Court
City. Owner hip Code: 27529 State:: NC' County': Wake
ltrie. tr 19 -5v •.: 1-,,\ \i+_: j19j'7' -9'_94
E. WELL CONSTRUCTION DATA
l ; ? Number of htirinv_, to he ccni-ltuctect*: Depth of e.ich boring t feet]:_ __-188
-
4 if t.'.11%t/n ; i+.'flc S1111 !r�' N►i�t' UM' 1Yr.11[11. tlli' irnji mullnn !i1 iti2111 !1 h.'l(iii .
i2 1 %pe ol'tubing to he ii ed t steel_ P C. etc): 1 I[]H[_
;1 14.1I casinL. 11 the nt..ilts n ill use c,isuiv. then pi IJe t1it; thpe ]steel. PVC:'. etc.]_ diameter. depth.
;il tl �''. wilt t+1::t�in_ :il]n�:1C113ti ahovi:
r a i (iroul (litittcri..iell easing and or piping):
) I'row t> p.: Cement TM_ Bentonite** Y Other- tspecif' 1 _
Itl ti.!C1111:_ tw1lttllittt: wrialk. I♦ hl:rLh' rsytle kIJ ti { 1 '~a .-.C_(' .I12I.11.iii i It Nhich re,isimp: 11:01163rtt 10.1)t_W}tit
11,; t r -c■i.t tl.. p'h o'' • Ihing t referenec to land -ttr•facc t: from SA: to 188 tteed
I t %'ell 11.1, e.lsl'12. indicate grow. depth: trttrn
.0 ifeet!
1 LL I:Ot'A 1'1O - Maps nisi t h: scaled o1' uiher'ti tie ac urakkli indicate distances and orientations 01
t:attirLs located Z tt.'ct ";thin 1(IIl0 t'et1 tH.11ti injection uellts1. Label all feature,, clear]► and include a north array►►.
titiuelf a :ite-•pi.. i i1; :nap .110►'. ina T h.: 01th tallt�►► ink:
Proposed injection ►►efts ' Buildings * I'ropert, boundaries
• Sar_ace ‘'ate.- htrcli.. - Water Sapp]! ',.Its
Nvrtic ta111‘, .Irlci ;ati,c�ciwle'l 51i•1 rrigation site, ti:tain fields. or repair area:-
" or potential sources eft' Lvtliinit«at.r contamination
1-, 1[l.ich .i tilpilgraphie map of the area emending 1.4 mile troll, the inje%:;io11 ncti,itt that irulicaios the
I.It ilit'.', location and the map name.
\Il !'!_'; In now rr,.►L.►, an ue'irrl photograph of the pr►,pertt' parcel showing property fires and structures can he
obtained and downloaded from the applic able county GIS 1vehsire. 71pic'a!11•, the property can he searched b1'
owner nu►►re• or address. Th[- locution of the weil► in relation to property boundaries, ]nurses, septic tanA►, other
wells, etc. can then he drawn in by ]runt]. Also, Ir 'how' Can he selected .,rowing topographic contours or
elevation dom.
II'I i it e41'. \ilit:auun 1 fete be i 1 2011 r ['ape 2

H. CERTIFICATION (to b..> signed as required helow or by that person's auth.Jrized agent)
l SA 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 partner.,hip or sole proprietorship: by a general partner or the proprietor, respe-ctivel};
3. for a municipality or a &tate, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by th~ well o\+ner (whi,;h means ail pt;rsons listed vn the prnperty deed).
If an authorized agent is signing on behalf of the applicant, then supply a Jetter signed by the
applicant that names and auth.orizes 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 thtJreto and that, ha~ on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the infonnation 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 i:i accordance with the approved specifications and conditions of
.-he Pennit."
--~--L _W ~ Signature of Property ~crZ~.ppil ant
u e }.,u: ;cl h(L!i"' lJ c4 JtA.l yj
Print or Type Full Frwne / --~· ---~~~r::¾=±pplicant --
Tr.-.. '-{:cf l-l-7lt 'vJ o<>~w~J
Print or TypeJull 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]
GPll/UIC 5QW Notificaliun (Rcvis.:d 3/18/7011)
Fmk!
Vahu
p::,;
17:167i5`40
HI Esl•sle I❑
Cv33518
Map Nam.?
170620
[r'rrflcr
NOOUWAr,b,
f•RE'I)E- lCr. VIA'r
WOOD WAr-;D
4Ar:1.-', I- IL
J
Ma ra r+,:ldress 1
471 a LL; FALL'S
FALL
uR
!A.;. , fi.trf:,_:,r:
1 ALFIS•1H h::
27609-5965
i. ,:fetes:;3
u =iP SQok
14325
:lees Wage.
'AB.:
:14:ec aalc
4 15 20' -
•ec st d A:.• ..
G 5-1
A5srs5 F. iic•-r,
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$80 - .0 ..)
Assus:zek:._sr.dValue
5120.00000
Total Assossc•d value
5�00.460 I)ti
B,: rn1,i Class
DIV:CUAI.
PrLpl:l:y Et*e",01i1I
1_0139 LAKEP,S(;'NT
EI
.. .:ad Ore
5+}i. Aderei .
+$C6 =,F='lr •_ ': F
C :ti
cir.:eLq-
cvr .51!`•
FiALE•CH
Year ii.[1l•
196e.
'ola Sale 5.,ee
5135.(10U Oil
5111. pate
4152!J1
Tvpc z11p use
5 rplc Fa'- !•
ACPL- ' OME S+Tr"
O1r. .1-Yt1 A.:„mh. r
4:1$.f1f4Ui1,' 0.,.''
I
COW
WAKE
( 0tlti l•Y

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/
/
H,00 Feet
Rl::DfcRICK MAY
WOODWARD
.,.RACFY -IILL
. r -:..~
408-00000 0028
WAKf
COUNTY