WI0600069_GEO THERMAL_20110310

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2818-A
1. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (Individual} Name
Go! Green Drilli na, Inc.
Well Contractor Company Name
61 05 Rest Home Rd .
Street Address
Claremont NC 28610
CityorTown State Zip Code
< 828 > 367-1293
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#_.W ........ I0._.6 ... 0....,Q...,Q...,6_9 ______ _
OTHER ASSOCIATED PERMIT#(if applicable).....,1'"""1'""0'""0~7~8~----
SITE WELL ID #(if applicable),....:G=L-_1.,__ _______ _
3. WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 2/15/2011
TIME COMPLETED..,.5=:0..._0..__ ____ AMO PM r/
4. WELL LOCATION:
c1TY: West End couNTY Moore
210 Beth's Point 27376
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC/ LAND SETTING: (check appropriate box)
litSlope □Valley □Flat □Ridge □Other ______ _
LATITUDE 35 • 16 ' 34.7600 "OMS OR 3x.xxxxxxxxx DO
LONGITUDE?!,__•~ 32.0600 • OMS OR 7x.xxxxxxxxx DD
Latitudenongitude source: lilbPS Dropographic map
(location of well must be shown on a USGS topo map andattached to
tflis form If not using GPS)
5. WEl,.L OWNER
Jam es & Sh aron Lasswell
owner Name
210 Beth's Point
Street Address
West End NC 2 7376
City or Town State Zip COde
(910 > 673-1929
Area code Phone number
6. WELL DETAILS:
a. TOTALDEPTH:,~9-Q-' ____ _
b. DOES WELL REPLACE EXISTING WELL 7 YES D NO~
c. WATERLEVELBelowTopofCasing: N/A FT.
(Use "+" if Above Top of Casing}
d. TOP OF CASING IS N/A 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): N/A METHOD OF TEST~N=/.~A~--
f. DISINFECTION: Type N/A Amount ~N=/~A~--
-----------
g. WATER ZONES (depth):
Top NIA Bottom_N_IA __ Top ___ Bottom __ _
Top ___ Bottom, __ _ Top Bottom __ _
Top Bottom, __ _ Top Bottom __ _
Thickness{
7: CASING: Depth Diameter
'..;...;;;--'-_Ft.NIA
Weight Material
Bottom NIA NIA NIA Top NIA ----
Top Bottom , ___ Ft., __ _
Top Bottom , ___ Ft.. __ _
8. GROUT: Depth Material
Top O Bottom,....:9 .... 0 __ Ft. Bentonite
Top ___ Bottom, ___ Ft. ____ _
Top Bottom Ft.~----
Method
Tremie
9. SCREEN: Depth Diameter Slot Size Material
Top N/A Bottom N/A Ft.~ln. N/A in. -'--'N;;.;./A-'-----
Top ___ Bottom ___ Ft. __ in. in. ___ _
Top Bottom Ft. __ in. in. ___ _
10. SAND/GRAVEL PACK:
Depth Size Material
Top N/A Bottom N/A FL NIA NIA --------Top ___ .Bottom, ___ Ft., __________ _
Top Bottom Ft. __________ _
11. DRILLING LOG
Top Bottom o 1 .... a __ _
8 /...;.1=2 __ _
12 /...;.1..;;..6 __ _
16 /-,;4..,,.5 __ _
45 /65 65 ,...,,.9..,,...0 __ _
90 / --------'-------'--------'----____ 1 ___ _
____ I ___ _ ____ / ___ _
----'----
12. REMARKS:
Mailed 2/28/2011
Formation Description
Sand
Sticky White Clay
Larg e Peebles
Gray Clay
Red Clay (Hard )
Red Weathered Clay w/Rock
Rock
;,.;, •.: .d~'
MAR 1 6 2011
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 HAS BEEN
PROVIDED TO THE WELL OWNER. ? ~e~~~ 212812011
Sl d°NATURE OF CERTIFIED WELL CONTRACTOR DATE
Randall E. Cutter
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -lnfonnation Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: [phone]
Form GW-1a
Rev. 2/09
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818-A
1. WELL CONTRACTOR:
Randall E. Cutter
Weil Contractor (Individual) Name
Go! Green Drillino. Inc.
Well Contractor Company Name
6105 Rest Home Rd.
Street Address
Claremont NC 28610
City or Town
8?8) 367-1293
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10600069
State Zip Code
OTHER ASSOCIATED PERM1T#{irapplicable) 110079
SITE WELL ID #(ifapplicable) GL-2
3. WELL USE (Check Applicable Box): Residential Water Supply El
DATE DRILLED 2/11 /201 1
TIME COMPLETED 4:00 AM ❑ PM ail
4. WELL LOCATION:
CITY: West End couNrY Moore
210 Beth's Point 27376
(Street Name, Numbers. Community, Sut:division, Lot No., Paroei, Zip Code)
TOPOGRAPHIC 1 LAND SETTING: (check appropriate box)
I tStope ❑Valley ❑Fiat ❑Ridge ❑Other
LATITUDE 35 ° 18 ' 34.8100 " DMS OR 3xxdoctxxxx DD
LONGITUDE 79 _' 35 ' 31.8000 " DMS OR 7X.XXXKXXKXX DD
Latitudellongitude source- IWPS [Topographic map
(location of well must be shown on a tJSGS kopo map andattached to
this form if not using GPS)
5, WELL OWNER
James & Sharon Lasswell
Owner Name
210 Beth's Point
Street Address
WestEnd NC 27376,
City or Town State Zip Code
1910 y 673-1929
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 90'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO of
c. WATER LEVEL Below Top of Casing: N/A FT
(Use "+" if Above Tap of Casing)
d. TOP OF CASING IS NIA. 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 (gprrt): NIA METHOD OF TEST N/A
g. WATER ZONES (depth):
Top NIA
Top
Top
7. CASING: Depth
Bottom N/A Top Bottom
Bottom Top _ Bottom
Bottom Top Bottom
Thickness/
Diameter Weight Material
Top N/A Bottom N/A Et N/A N/A N/A
Top Bottom Ft.
Top Bottom Ft.
8_ GROUT: Depth Material Method
Top 0 Bottom 90 Ft, Bentonite Tremie
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top N/A Bottom NM Ft,NJA in. N/A in. N/A
Top Bottom Ft. in. in.
Top Bottom Ftin. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top NA Bottom NIA Ft. NIA N/A
Top Bottom Ft.
Top Bottom Ft.
11. DR}LLING LOG
'fop Bottom
0 /8
8 112
12 /14
14 152
52 170
70 /80
80 185
85 190
1
1
1
1
12. REMARKS:
Mailed 2/28/2011
Formation Description
Sand
Sticky White Clay
Large Pebbles
Gray Clay
Red Clay
Red Ciy w1 Rock
Red Weathered Clay w/Rock
Rock
DIN :� �S !1 Urm:t
'^emu
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 HAS BEEN
PROVIDEDJO THE LLLOOWNER.
vie el 2/28/2011
SIGP' ATURE OF CERTIFIED WELL CONTRACTOR DATE
Randall E. Cutter
f. DISINFECTION: Type N/A Amount N/A
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mall Service Center. Raleigh. NC 27699-161. Phone - 19191 807-6300
Form GW-la
Rev. 1/08

R ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818-A
1. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (Individual) Name
Gol Green Drilling : Inc,
Well Contractor Company Name
6105 Rest Home Rd.
Street Address
Claremont NC 28610
City or Town
8{ 28 } 367-1293
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WIO600O69
State Zip Code
OTHER ASSOCIATED PERMIT#(if appllcabte) 110081
SITE WELL ID #(ir applicable) GL-3
3. WELL USE (Check Applicable Boxy:
DATE DRILLED 2/10/2011
TIME COMPLETED 12:30
Residential Water Supply ❑
AM PM la(
4. WELL LOCATION:
CITY: West End COUNTY Moore
210 Beth's Point 27376
(Street Name, Numbers, Community, Subdivision. Lot No., Parcel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING: (check appropriate box)
'Slope ❑Valley ❑ Flat ❑Ridge El Other
LATITUDE 35 ' 16 ' 34.7853 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 79 35 ' 31,7000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: gbPS (]topographic map
(location of well must be shown on a USGS topo rnap andattached to
this form if no/ using GPS)
5. WELL OWNER
James & Sharon Lasswell
Owner Name
210 Beth's Point
Street Address
West End
City or Town
(910 ) 673-1929
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTfi: 90'
NC 27376
Slate Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO t f
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING 1S N/A 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 (gpnt); NIA METHOD OF TEST N/A
f. DISINFECTION: TypeNIA Amount NIA
g. WATER ZONES (depth):
Top N/A Bottom N/A
Top Bottom
Top Bottom
7. CASING: Depth
Top NIA Bottom NIA
Top Bottom
Top Bottom
6. GROUT: Depth
Top 0 Bottom 90
3 .812
Top Bottom
Top Bottom
Top Bottom
Thickness/
Diameter Weight Material
Ft. NIA N/A NIA
Ft.
Ft.
Material
Ft, Berttonite
Top Bottom Ft.
Top - Bottom Ft_
9. SCREEN: Depth
Top NIA Bottom N/A
Tap Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth
Top N/A Bottom NIA
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
0 /12
12 /17
17
45
80
85
90
145
180
/85
/ 90
J
I
I
I
/
1
1
I
12. REMARKS:
Malted 2/2BI2011
Method
Tremie
Diameter Slot Size Material
Ft.N/A in. N/A in. N/A
Ft. in. in.
Ft. in. in.
Size Material
Ft. N/A N/A
Ft. -
Ft. -
Formation Description
Sand
Sticky White Clay
Gray Clay
Red Clay
Red Clay w/Rock
Red Weathered Clay w/Rock
Rock
MAR 1 0 7 fl1'(
!r}yOrnT ti:.k;
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 HAS BEEN
PROVIDED TO THE WELL OWNER.
f c•-7:6--1 •
GNATURE OF CERTIFIED WELL CONTRACTOR
Randall E. Culler
2128/2011
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -
ie.,7 as..a Cnr+.:rn C:antpr Raleigh. NC 27699-1E1, Phone : [phone]
Information Processing,
Form GW-t a
Rev. 1/08

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818-A
1. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (Individual) Name
Go! Green Drilling. Inc.
Weil Contractor Company Name
6105 Rest Horne Rd.
Street Address
Claremont
City or Town
(828 ) 367-1293
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10600069
NC 28610
State Zip Code
OTHER ASSOCIATED PERMIT#f(it applicable) 110082
SITE WELL ID #(it applicable) GL" 4
3. WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 2/14/2011
TIME COMPLETED 4:30 AM © PM Li
4. WELL LOCATION:
CITY: West End couuTY Moore
210 Beth' Point 27376
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
VSlope C]Valiey ❑Flat C7 Ridge DOther
LATITUDE 35 " 76 34.7600 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 79 a 35 3s.53oa " DMS OR 7x.XXxxxx000c ❑O
Latitude/longitude source: FloPS [Topographic map
(location of well must be shown on a IJSGS topo map anda#ached to
this fora 1f not using GPS)
5. WELL OWNER
James & Sharon Lasswell
Owner Name
210 Beth's Point
Street Address
West End
City or Town
c910 j 673-1929
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 90'
NC 27376
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO igr
c. WATER LEVEL Beicw Top of Casing: N/A FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING I5 N/A FT. Above Land Surface'
`Top of casing terminated at/or below farad surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): NIA METHOD OF TEST N/A
g. WATER ZONES (depth):
Top N/A Bottom N/A Top Bottom
Top _ _ Bottom- _-f Top Bottarn
Top Bottom
7. CASING: Depth
Top N/A Bottom NIA
Top Bottom„,
Top Bottom
B. GROUT: Depth
Top 0 Bottom 90
Top
Top
Top Bottom
Thickness/
Diameter Weight Material
Ft. N/A N/A N/A
Ft.
Ft.
Mate rial
Ft. Bentonite
Bottom Ft
BottomFt.
9. SCREEN: Depth
Top NIA
Top Bottom
Top Bottom
Method
Tremie
Diameter Slot Size Material
Bottom N/A Ft.NIA in. N/A in. N/A
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top NIA Bottom NIA Ft. NIA N/A
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Tap Bottom
0 /12
12 1117
17 145
45 180
80 /85
85 /90
90 1
1
1
I
1
1
I
12. REMARKS:
Mailed 2/28/2011
Formation Description
Sand
Sticky -White-Clay
Gray Clay
Red Clay
Red Clay w/Rock
Red Weathered Clay w/Rock
Rock
VAR 1 0 zun
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH ISA NCAC 2C, WELL CONSTRUCTION
STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN
PROVI0 D TO THE WELL OWNER.
S GNATURE OF CERTIFIED WELL CONTRACTOR
Randall E, Cutter
2/28/2011
DATE
f. DISINFECTION: Type N/A Amount N/A
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
4AI7 rule;t Rork/Jr.. r'c+ntPr Ratpitsh. NC 276g9-161. Phone : f9191807-6300
Form GW-la
Rev. 1108

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818-A
1. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (Individual) Name
Go! Green Drillina. Inc.
Well Contractor Company Name
6105 Rest Home Rd.
Street Address
Claremont NC 28610
City or Town
( 828 j 367-1293
Area code Phone number
2. WELL IISFQRNIAT1ON;
WELL CONSTRUCTION PERMET# W10600069
State Zip Code
OTHER ASSOCIATED PERMIT#(itapplicable) 110083
SITE WELL ID #Elf applicable) G L_5
3. WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 2/16/2011
TIME COMPLETED 1:00 AM p PM N(
4. WELL LOCATION:
CITY: West End COUNTY Moore
210 Beth's Point 27376
(Street Name, Numbers. Community, Subdivision, Lot No.. Parcel, Zip Cade)
TOPOGRAPHIC / LAND SETTING: (check apprepnete box)
10Slope DValley ❑Flat ❑Ridge ❑Other
LATITUDE 35 - 16 • 34.7760 ^ DMS OR 3x_xxxxxxxxx DD
LONGITUDE 79 -35 31.15oo " DMS OR 7X.7DC OODOC?OC DD
Lafitude/1ong"rtude source- liCPS °Topographic map
(location of well must be shown on a USGS fop° map andattached to
this form iif not using GPS)
5. WELL OWNER
James 8: Sharon Lasswei!
Owner Name
210 Beth's Point
Street Address
West Enc#
City or Town
(910 ) 673-1929
Area code Phone number
NC 27376
State Zip Cade
6. WELL DETAILS;
a. TOTAL DEPTH: 90'
b. DOES WELL REPLACE EXISTING WELL? YES L NO
c. WATER LEVEL Below Top of Casing: N/A _ _FT.
(Use "+" if Above Too of Casing)
d. TOP OF CASING IS NIA FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NGAC 2C .011S,
4. YIELD (g}tm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top NIA Bottom NIA Top
Top Bottom Top
Top Bottom Top_
7. CASING; Depth
Top NIA Bottom N/A Ft NIA
Top Bottom Ft.
Top Bottom Ft.
6. GROUT: Depth
Top 0 Bottom 90
Material
FL Bentonite
3 .1814
__ Bottom
Bottom
Bottom
Thickness/
Diameter Weight Material
NIA NIA
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top N/A Bottom N/A
Top Bottom
Top Bottom
Method
Tremie
Diameter Slot Size Materiat
Ft.N/A in. N/A in. N/A
Ft. In. in.
Pt. in. in.
JO. SAND/GRAVEL PACK:
Depth Size
Top NIA Bottom NIA Ft. N/A
Top _ Bottom Ft.
Material
NIA
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 112
12 117
17 /45
45 / 80
80 / 85
85 190
90 1
/
1
Sand
Formation Description
Sticky White Clay
Gray Clay
Red Clay
Red Clay wlRock
Red Weathered Clay wlRock
Rock
UT, -1--tt
:3 r'Y051-731i
12. REMARKS: }�Z=
Maiied_2128I2011
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 HAS BEEN
PROMO TO THE WELL OWNER.
SrGIVATURL C]F CERTIFIED W LE L CO
2/28/201 T
CTOEt DATE
Rat da!1 E. Cuitr r
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 a
Rev. 2/09

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818 A
1. WELL CONTRACTOR:
Randall E. Cutter
Weil Contractor (Individual) Name
Go! Green Drilling Inc.
Well Contractor Company Name
6105 Rest Horne Rd.
Street Address
Claremont NC 28610
City or Town State Zip Code
r 828 1 367-1293
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10600069
OTHER ASSOCIATED PERMIT#{'dapplicable) 110084
SITE WELL ID *or applicable) GL-6
3. WELL USE (Cheat Applicable Box): Residential Water Supply ❑
DATE DRILLED 2116/2011
TIME COMPLETED 5:00 AM o PM 131
4. WELL LOCATION:
CITY: West End
210 Beth's Point 27376
COUNTY Moore
(Street Name, Numbers, Community, Subdivision. Lot Na. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
GIStope (Valley ❑Flat (Ridge ID Other
LATITUDE 35 • 16 • 34-neo " DMS OR 3x.100000o00C DD
LONGITUDE 79 o 35 • 31.1soe " DMS OR 7X.Xtxxxxxxx DD
Latitude/tongilude source: 3PS Cropographtc map
(location of well must be shown on a USGS topo ►nap andattached to
this fotrn if not using GPS)
5. WELL OWNER
James & Sharon Lassweli
Owner Name
210 Beth's Point
Street Address
West End NC 27376
City or Town State Zip Code
(910 ) 673-1929
Area code Phone number
6. WELL DETAILS:
a. TOTAI. DEPTH: 90'
b. DOES WELL REPLACE EXISTING WELL? YES © NO gr
c. WATER LEVEL. Below Top of Casing: N/A FT.
(Use "+` if Above Top of Casing)
d. TOP OF CASING IS N/A FT. Above Land Surface`
`Top of casing terminated at/or below land surface may require
a valiance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST NIA
f. DISINFECTION: Type N/A Amount NIA
g. WATER ZONES (depth):
Top N1A Bottom NIA Top Bottom
Top Bottom_ _ _ Top - Bottom
Top Bottom Top_ _ _ Bottom
7. CASING: Depth Diameter
Top N/A Bottom N/A Ft. NIA
Top Bottom Fi
Top Bottom FL
8. GROUT: Depth Material
Top 0 Bottom 90 Ft. Bentonite
1Z
Thickness/
Weight Material
N/A N/A
Top Bottom Ft.
Top Bottom FL
Method
Tremie
9. SCREEN: Depth Diameter Slot Size Material
Tap NIA Bottom NIA FLN/A in. N/A In. N/A
Top Bottom Ft
Top Bottom Ft.
in. In.
in. In.
10. SAND/GRAVEL PACK:
Depth Size
Top N1A Bottom NIA Ft. NIA
Top Bottom Ft.
Top Bottom
11. DRILLING LOG
Top Bottom
0 /12
12 /17
17 145
45 /80
80 /85
85 /90
90 /
1
1
1
I
i
I
Ft
Material
NIA
Formation Description
Sand
Sticky White Clay
Gray Clay
Red Clay
Red Clay wlRock
Red Weathered Clay w/Rock
Rock
MAR 1 0 in
12. REMARKS:
Mauled 2/28/2011 =1'1fI;i1 rotlor: PtC,r; S5S1+ig
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 HAS BEEN
PR060 TO THE ELL 0
",
P.ts.c eI � - 2I281207 t
NATURE OFCERTIFIED II CONTRACTOR DATE
Randal! E. Cutter
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 a
Rev. 2109

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment andNatural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818-4
1. WELL CONTRACTOR:
Randall E. Cutter
Weil Contractor (Individual) Name
Go! Green Drilling, Inc.
Well Contractor Company Name
6105 Rest Home Rd.
Street Address
Cieremont
City or Town
828 } 367-1293
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10600069
NC 2$610
State Zip Code
OTHER ASSOCIATED PERMIT#(if appiireble) 110104
SITE WELL ID Cif applicable) GL-7
3. WELL USE (Chuck Applicable Box): Residential Water Supply ❑
DATE DRILLED 2/17/2011
TIME COMPLETED 1:00 AM Ip PM 1V
4. WELL LOCATION:
CITY: West End couwTY Moore
21 ❑ Beth's Point 2737E
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Gude}
TOPOGRAPHIC l LAND SETTING: (check appropriate pox)
6JSiope ❑Valley CIFIat ❑Ridge °Other
LATITUDE 35 16 ' 34.7800 „ DMS OR 3x.nocoo om DD
LONGITUDE 79 ^ 35 30.9700 ^ DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: If PS Drop:graphic map
(location of well must be shown on a IJSGS topo map andattached to
this form if not using GAS)
5. WELL OWNER
James & Sharon Lasswell
Owner Name
210 Beth's Point
Street Address
West End
City or Town
( 10) 673-1929
Area code Phone number
G. WELL DETAILS:
a. TOTAL DEPTH: 90'
NC 2737f.
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES p NO pf
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use +" if Above Top of Casing)
d. TOP OF CASING IS N/A 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): NIA METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount Nth
g. WATER ZONES (depth):
Top NIA Bottom N/A
Top Bottom _ __
Top Bottom _
Top_
Top_
Top- -
7. CASING: depth Diameter
Top N/A Bottom NIA Ft. N/A N/A N/A
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 90
Material
Ft. Bentonite
Top Bottom Ft.
Top Bottom FL
9. SCREEN_ Depth
Top NIA Bottom NIA
Top Bottom
Top Bottom
Bottom__
Bottom.. _
Bottom _
Thtcknessl
Weight Material
Method
Tremie
Diameter Slot Size Material
Ft.NIA in. N/A in. N/A
Ft. In. in.
Ft. to.
10. SANDIGRAVEL PACK:
Depth Size
Tap NIA Bottom WA Ft. N/A
Top Bottom FL
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 112
12 /17
17 /45
45 180
80 185
85 /90
90 /
1
1
I
12. REMARKS:
Mailed 2/28/2011
Sand
Material
N/A
Formation Description
Sticky White Clay
Gray Clay
Red Clay
Red Clay w(Rocic
Red Weathered Clay w/Rock
Rock
AK.l� �fi
•
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 HAS BEEN
PROVIDES TO THE WELL OWNER.
/bt 128120 f 1
SI TURE"DF CERTIFIED WELL CO TRACTOR DATE
Randall E. Cutter
PRINTED NAME OF PERSON.CQNSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Information Processing,
Form GW-la
Rev. 2/08

.RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment aria Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818-A
1. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (Individual) Name
Go! Green Drillino. Inc.
Well Contractor Company Name
6105 Rest Horne Rd.
Street Address
Claremont NC 28610
City or Town State Zip Code
( 828) 367-1293
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT* WI0600069
OTHER ASSOCIATED PERMITe(irapplicable) 110105
SITE WELL ID Ai( applicable) GL-8
3. WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 2/17/2011
TIME COMPLETED 5:30 AM L7 PM El
4. WELL LOCATION:
CITY: West End COUNTY Moore
210 Beth's Point 27376
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, ZIp Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
6i'Stope ❑Valley ❑Flat DRidge ❑Other
LATITUDE 35 16 • 34.1300 • DMS OR 3x.xxxi000nxx DD
LONGITUDE 79 " 35 ' 301900 DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: 190PS Dropographic map
(location of well must be shown on a USGS top° map aodattached to
this form if not using GPS)
6. WELL OWNER
James & Sharon Lassweil
Owner Name
210 Beth's Point
Street Address
West End
City or Town
( 910 ) 673-1929
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 90'
NC 27376
State Zip Code
b- DOES WELL REPLACE EXISTING WELL? YES ❑ NO 14
c. WATER LEVEL Below Top of Casing: N/A FT,
(else "+^ if Above Top of Casing)
d. TOP OF CASING IS N/A 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): N/A METHOD OF TEST NSA
f. DISINFECTION: Type N/A Amount NA
g, WATER ZONES (depth):
Top NIA Bottom NIA Top- _ _. Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
Top N/A Bottom N/A
Top Bottom
Top Bottom
Thickness/
Diameter Weight Material
Ft. N/A N/A NIA
EL
FL _
B. GROUT: Deplh Material Method
Top 0 Bottom 90 Ft Bentonite Tremie
Tc
Top
p Bottom FL
Bottom Ft.
9. SCREEN: Depth
Top NIA Bottom NIA
Top Bottom
Top Bottom
Diameter Slot Size Material
Ft.N/A in. N/A in. N/A
Ft. in, In.
Ft. in. In.
10. SAND/GRAVEL PACK:
Depth Size Material
Top N/A Bottom NIA Ft, N/A NIA
Top Bottom Ft.
Top Bottom Ft
11. DRILLING LOG
Top Bottom
0 112
12 /15
15 I47
47 165
65 180
80 /90
Sand
Formation Description
Sticky White Clay
Gray Clay
Red Clay
Red Clay w/Rock
Red Weathered Clay wlRock
90 / Rock
1
1
1
1
1
1
12. REMARKS:
Mailed 2/28/2011
11/r4R 1 0 2/111
=rrrnrls. e . r
I DD HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROM TO THE WELL OVIINER.
ux-
NATUR
2/28/2011
OF CERTIFIED WELL CONTRACTOR DATE
Randal! E. Cutter
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699.161, Phone : [phone]
Form GW-1 a
Rev. 2109

Ar
1. WELL CONTRACTOR:
Randall E. Cutter
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818-A
Well Contractor (Individual) Name
Go! Green Crillinn. Inc.
Well Contractor Company Name
6105 Rest Hame Rd.
Street Address
Claremont NC 28610
City or Town
826) 367-1293
State Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10600069
OTHER ASSOCIATED PERMIT#01 applicable) 110106
SITE WELL ID #[irappitcable) GL-9
3. WELL USE (Check Applicable Box): Residential Water Supply L
DATE DRILLED 2/18/201 1
TIME COMPLETED 5:30 AM ❑ PM 211
4. WELL LOCATION:
CITY: West End couu r Moore
210 Beth's Point 27376
(Street Name, Numbers, Community. Subdivision, Lot No„ Parcel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING: (check appropriate box)
'Scope oValley ❑Flat ❑Ridge ❑Other
LATITUDE 35 ° 16 34.9666 " DMS OR 3x.moaco xxx DD
LONGITUDE 79 ° 35 ' 39-8000 " DMS OR 7x.xxxxxx txx DD
Latitude/longitude source: IRt PS ETopographic map
(locaffon of well must be shown on e USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
James & Sharon Lasswell
Owner Name
210 Beth's Point
Street Address
West End
City or Town
(910 ) 673-1929
Area code Phone number
6. WELL DETAILS:
8. TOTAL DEPTH: 90'
NC 27376
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO IRr
c. WATER LEVEL Belmar Top of Casing: N/A FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS N/A 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 (gprn): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A _ Amount NIA
3
g. WATER ZONES (depth).
Top MA_ _ Bottom N/A _ Top Bottom
Top Bottom_ Top _ Bottom
Tap_ Bottom
Tap Bottom_
Thickness/
7. CASING: Depth Diameter Weight Material
Top NIA bottom N/A Ft, N/A N/A N/A
Top_ Bottom Ft.
Top Bottom Ft,
8. GROUT: Depth Material Method
Top 0 Bottom 90 Ft. Bentonite Tremie
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top N/A Bottom N/A R N/A in. N/A fn. N/A
Top
Top
Bottom Ft. in. 1n.
Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Sire Material
Top N/A Bottom N/A Ft. N/A N/A
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 112
12 115
15 /47
47 /65
65 /T4
70 /80
80 /90
1
1
I
1
1
1
1
12. REMARKS:
Mailed 2/28/2011
Formation Description
Sand
Sticky White Clay
Gray Clay
Red Clay
Red Clay w1Rock
Red Weathered Clay wfRock
Rock
AR ]. 0 7Qfi
111-?L1Grl iJ,v'= `�5::: Uri/
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 HAS BEEN
PROVIDE PTO THE WELL OWNER.
0NTR7[CTOR DATE
Randall E. Cutter
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2109

James & Sharon Lasswell
210 Beth's Point
West End, NC 27376
HVAC Contractor: Sunbelt Mechanical
GPS coordinates for Geothermal Loops
GL-1 35° 16' 34.76" N 79° 35' 32.06" w
GL-2 35° 16' 34.81" N 79° 35' 31.80"W
GL-3 35° 16' 34.76" N 79° 35' 31.70"W
GL-4 35° 16' 34.76" N 79° 35' 31.53" w
GL-5 35° 16' 34.77" N 79° 35' 31.33"W
GL-6 35° 16' 34.78" N 79° 35' 31.15"W
GL-7 35° 16' 34. 76" N 79° 35' 30.97" w
GL-8 35° 16' 34.73" N 79° 35' 30. 79" w
GL-9 35° 16' 34.59" N 79° 35' 30.80" w
See Map for corresponding coordinates
-,? 't~
iqg, Inc.
JJriYing
~ r
M.L\R I O 2011
!nforrn".:.~tk-1n Process¼s'1fJ Uni·•
DV'!C."'\/30G
6105 Rest Home Rd.~ Claremont NC 28610 ~ [phone]~ Cell# 828-228-1695
15.0'
i
15.01
L.
rui-15.O'
Q GL-8 G3 GL-9
V GL-7
IF--- ' GL-6
15.0'
15.0'
O GL-5
GL-- 4
15.0'
j_WGL-3
15.0'
i
L GL-2
15.0'
GL-1
. --- 25.0'
25.0'
Septic ]gain
Field
North
James & Sharon Lasswell
210 Beth's Point
West End, NC 27376
House
r
- Garage Door

Perm it Number
Program Category
Ground Water
Permit Type
WI0600069 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
James & Sharon Lassell SFR
Location Address
21 O Beth's Point
West End
Owner
Owner Name
James
Dates/Events
NC 27376
Lasswell
Orig Issue
01/13/11
App Received Draft Initiated
12/15/10
Re a ulated Activities
Heat Pump Inj ection
Outfall ~-; 11 I
Scheduled
Issuance
Central Files: APS_ SWP_
01/13/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Randall Cutter
6105 Rest Home Rd
Claremont NC
Major/Minor
Minor
Region
Fayetteville
County
Moore
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
James Lasswell
PO Box 716
West End
Public Notice Issue
01/13/11
NC
Effective
01/13/11
28610
27376
Expiration
Waterbody Name Stream Index Number Current Cl ass Subbasin
SA
NCD EN R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
James Lasswell
Sharon Lasswell
PO Box 716
West End_ NC 27376
Coleen H. Sullins
Director
1/13/2011
Subject: Acknowledgement oflntent to Construct Type SQW Injection Well System
Permit No. Wl0600069
210 Beth's Point, West End, NC 27376
Dear Mr. & Mrs. Lasswell:
Dee Freeman
Secretar y
On 12/15/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
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 we11 '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 a~sociated 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 .021 l(uX2). Additionally, you should contact the Moore 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.Ro !!ersi@ncdenr.!!OV if you have any questions.
Sincerely,
fo,~~
cc: Fayetteville Regional Office -APS
APS Central Files -Permit No . WI0600069
Moore County Health Dept.
Supervisor
Go! Green Drilling, Inc (Randall Cu.tter -6105 Rest Home Road., Claremont. NC 28610)
Sunbelt Mechanical (Chuck Ferrell -707 South Pinehurst Street, Aberdeen, NC 28315)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh , North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588: FAX 2: 919-715-6048 \ Customer Service : 1-877-623-6748
Internet: www.ncwaterguality.org
11,o Equal Opportunity\ Affirmative Action Employ er
Nonel C 1· ort1 aroma
/Vat11ral/!f
12/1442010 3:53 PM FROM: Fax Go! {ireen DriMing, Inc. To: 919715058B PAGE: 001 OF 006
Go! Green Drilling, inc.
6105 Rest Home Rd.
Claremont, NC 28610
urgent
facsimile
To. <9197150588>
Fax Number: 9197150588
From: Randall E. Cutter
Fax Number: 828-367-1293
Business Phone: [phone]
Home Phone: o
r*1
Pages: 6
❑ate/77me: 12/14/2010 3:53:24 PM
Subject: Lasswell-itent a
Lasswell 5QW "Intent to Contruct"

12/14f2010 3:53 PM FROM: Fax Go! Qreen Dril1ing, Inc. TO: 9197150588 PAGE: 002 OF 006
Please replace the orignal copy faxed in by Lothridge Plumbing.
Incorrect data in Section C. Well Driller Info & G. Well Construction Data
Please email a copy of the "Acknowledgement of Intent'' to [e-mail]
Thanks, .
Randall E. Cutter CWD/PI
Page 1 of 1
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12/14/ 010 3:53 PM FROM: Fam Go: Green Drilling, Inc. TO: 91971.50588 PAGE: 003 OF 006
: .;NC o • OKTH CAROLINA
DEPAR T.OF.ENVU>� t 4TAM NATU n Ottimets
NOTIlltAT1ON pF.1111TEi T TQ t'ONSTR ;CT A CLokii4b0P GEOTHERMAL
WATER-Q.NLY INJECT1ONW.EL,L.SYSTEM.
TYPE SOW 11.5k
i' Actordand With the Piaeicfsuisis:D NCAC That' r$A:113C.0110
Final root iot and ;writ &i tri&* tt rive the ►ir ',Lpaije.
DATE: No:Atrbet:13,. 2•10
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loop •cli COMirnirli$ 4404i1s3t stick as R-4 or dtlict- lordit 'r tfersion imhibit r3)
PROPEL' OWNEINSAPPLI.Willp
i„+stmo Pr•ope1,1310 r liked cn Input de d (it ovx fled b; a business or garcaumcnt agency, stsrre:name of:
wily and a rrplacniatli' w( utbalri for;sjgtftal ure): JasncUAsset- L Shan Fr Lasswct!
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atgicitS law from the-prvpoi} owtottsoriziag•A c tl to install and °perm 111C well) ._n
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12/14/20lb 3:46 PM FROM: Fax Go! GLeen Drzlling. Inc. TO: 9197150588 PAGE: 004 OF 006
?4 MILL DRILLER INFORMATION
y Name: G4 Groom ()Mine. i rec.
i1V i Iiri/lar 'sName: Rid I. Cutter
NC Contraulaitleitifteakieit 21 A
Ott Pao% Randall OM' EMAIL Ad : randy@giriifi + coni
6191 R©st.Hoaq 141.
C32y• Coral erc6ft 70CA60a.
s-a'in#r'Ws •2152-. i` 2..IMK a 74z_'!iQd.l 1.00
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12114,i2010 3:46 PM FROM: Fax Go! Green Drilling, Inc. TO: 9197150588 PAGE; 001 OF 006
■
s
Go! Green Drilling, Inc. •
6105 Rest Home Rd.
Claremont, NC 28610
urgent
facsimile
To: <9197150588>
Fax Number: 9197150588
From:
Fax Number:
Business Phone:
Home Phone:
Pages:
Dateinme:
Subject:
Randall E. Cutter
828-367-1293
828-228-1695
6
12/14/2010 3:46:09 PM
Laswell Intent to Drill (50W)
_e:11S1Le)
Lasswell 5QW "Intent to Contruct Closed Loop (5 pages)

12/14/2010 3:46 PM mom; Fax Go! Green Drilling, Inc. TO: 9197150588 PAGE: 002 OF 006
Please replace the earlier copy faxed to you from Lothridge Plumbing.
Incorrect data in Sections C. Well Driller Information & Section G. Well Construction ❑ata.
Please submit a copy of the "Aoknowledement of intent' to my email address: randy(Dgogreendrilling.com
Thanks,
Randall E. Cutter CWa/PI
mhtml:mid://00000000/ 12/14/2010

/2/2010 3:45 PM FRom: Fax Co! Green Drilling, Inc. TO: 9197150588 PAGE: 003 OF 006
010..
IkK/F4TH CAROLNA.
OEPARTMENT 0 F.ENYIRONMENTAN NATURAL..REIMOES
_NOTIFICATION OP INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WEL L swam
TYPE SOW iv1rti(s1
ACCOgLitiCa i ite Pioi i$ions rot NeAC Tirta- 1 KIMONO
Pn�f4Jrft OA' ii'quireti itridttuatiinut ihelinekottg
DATE; Dom Oat I „ 261 0_
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12/14/2010 3:53 PM FROM: Fax Go! Grben Drilling, Inc. TO; 9197150588 PAGE: 004 OF ODE
C, WELL .DRZLI.Rt INFORMATION
Coulpany Nam: Go Gs= Clnaiins. inc
Well DTI lier4eoradoe s Name:
]+[ Contractoi ,CettiVeation No,: 28124
Coosa Person. Pauxialituttet EMAIL Address: randy y FVC ! _.•.._
Ate: 1 .#40,,RAL
COY` filarquogu:C 10 County:
!NAT MEP CONTkAC f OR INFORMATION • {if diarist Haan &ditto
Company Naaie:, :Sts,nbXlt MechanicalContact Person:Churkarrell EWA, Ad:
Address: 7th. J Pinehnist Street-
ip Cade: 1
Caw T ,: - 4i+ C iH ..
Anicipat-w-�_ N.akive Americaniands
F. perwrilON €biiow. 40coio-#6* otc . *stiori rvel s).0 be
WELL ON DATA _
(1)Proposed .dadeio.be.etwediucted:. ASAP' .... Niamb* #'bcciags:. 6
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(P.Typo of to:to:mod 0.0ppez, v ►, cot) _Jut
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MARC SIQW NotificiiimoelateafRaMMR6W200131
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12/14:2010 3:53 PM FROM: Fax Go! aceen Oriiling, Inc. TO: 9197150588 PAGE: 005 OF 006
I 944 7
L tAICATION OV VELEM
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Dec 14.10 01:28a Lothridge Plumbing 3363572951
P.1
25 Years of Quality Service
Cam
Dear Sir or Madam,
Lothridge Plumbing, Inc.
To :
Company : _NCDENR
Sent By : _Tina Yates
Date : _December 14, 2010
Time :
# of pages including cover : 5 pages
919 715 0588
Cover sheet only :
Following is a Type 5QW Well application for processing. Thank you for your
attention to this matter.
Sincerely,
Tina ates
Comptroller
PO Box 249
Linwood, NC 27299
Phone: [phone]
Fax: [phone]
Email: loth ridge©m i n d spring.corn
rrl
4
•
q:
•

Dec 14. 10 0.8:29a Lothridge Plumbing 3363572951 p.2
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 50W WELL(S)
In Accordance With the Provisions ofNCAC Title 15A 02C1400
Print or type the required information mrd,rnaii to addreis on the hack page.
D4TE: Deeember 13, 2010_
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in '
continuous piping that completely isolate the fiuid from the environment (i.e.
closed -loop)?
Yes _X_ Continue completing this form.
No Do Not complete this form- Complete either UIC applicatiA fob for installing
either a 5A7 well (open -loop well injecting potable water into the aquifer) sir'a 5(gOvelf(Olinciilk
loop well containing additives such as R-22, ethanol, or odic( antifreeze or cv;a ,sion.inr ikit .
A. PROPERTY O I NER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a bnsaness or government agency, 6t4
entity and a representative wlauthority for signature): dames Ljssweli_ 5haro-
(1) Mailing Address: PO Box 716
City: West End State: NC_ Zip Code:. 7376 Co
Home/Offcc Tele No.: 910 673 1929 Cell 14o.:
Email Address: Web
(2) Physical Address of Well Site (if different than above): I0Beth's Point
narae
Wpst End State: _NC Zip Code: 27376 County: Mdore; .
Ho ne!Of Tele No.: 910 673 1929 !`el? iy: .
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Appicant d; s not own the subjeci;taraperty,
attach a letter from the property owner authorizing Agent to install tid c erateUIC well)
Company Name:
Contact Person: EMA,". Address:
Address:
City: State: Zip Code: County
. -
Office Tele No.: Cell No.: •
Website Address of Company, if any:
•a+

Dec 14 10 Pe:29a Lothridge Plumbing,
C. WELL DRILLER INFORMATION
Company Name: Innovative Environmental Dililline
Well Driller Contractor's Name: Randall E Cutter
3363572951
NC Contractor Certification No.: 2818-A
Contact Person: Randall Cutter
Address: 6105 Rest Home Road
EMAIL Address: randviargngreendrillinn.c;om
City: ClaremonttNC Zip Code: 22610
Office Tele No.: 828 228 1695 Cell No.: 828 228 1695
County: Catawaba
r•
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Sunbelt Mechanical
Contact Person: Chuck Ferrell EMAIL Address: — —
Address: 707 South Pinehurst Street
City: Aberdeen. NC Zip Code: 28315 County:
Office Tele No.: 910-944-2044 Cell No.:
E. STATUS OF APPLICANT
Private: X Federal:
Star: Municipal:
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed loop water only for heat pump
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: Number of borings: 2
Approximate depth of each boring (feet): 425
(2) Type of tubing to be used (copper, PVC, etc): HDPE
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: galvanized steel black steel _plastic other (specify)
Casing depth: From to feet (reference to land surface)
Casing extends to above ground inches
(b) No _X__
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite X_ Other (specify)
(b) Grout placement: Pumping Pressure Other
(c)
Grout depth of tubing (reference to land surface): from _425_ to _4_ (feet)
If well has casing, indicate grout depth: front to
(feet)
_x

Dec 14 10 OS:29a
Lothridge plumping
33635'72951
1. LOCATION OF 'WELL(S)
Attach two copies of amps showing the following loft:U i iuu
{l) include a site map (can be drawn) showing bu Wings, property lines. surl°sce wa
of groundwrter conzminatiOn and the orientation of aid distances between the
existing well(e) or waste disposal facilities such as septic tams or drat, fields
geothermal !neat pump well system. Label ail features dearly and '
bdiea, potsi saunas
*elks). and • any.
wiihisr 100p feet ofttie
f zl Include a topographic map of the area extending ogee mile front the property boo, • 'es end
indicate the facility's loca le° and Inc map mane,
1. IPOTABL! WATER WELL(S)
Are them any ptwbio water weL'is) on the subject property or adjseetlt prapvssies? :• _� 1
if Yes, than indicate locative on attached maple).
X, CERTIFICATION
Note: This Permit Application nasal be
bereby certify, raider penalty of law,
submitted in this dccurneii and in teat
immediately respor:'sibk for obtaining Jain
1 am aware that tltrx+e art significant peer
False Infarnudion. i agree to construct. o
all reisted appurtenances in acawdarn:e yr
tigurd by each persara appear -tag ea the rake
that 1 hive personally exarained and Ian
rchmenls theme and Ili, based on my i
J afasmadam, I believe that the infbrmatlon is
hies, including the possrinllty of tins and inn
taate. maintain, repair. and if applicable. anand
Ih the approved a ifkatioos and eanditions of
logd lane
with the
of Most
accurate sa
astt,ft
the inject
a Pu:rmrt."
1,41 1
:cunt
Prise or Ty
t ` e orProperty pp m
f
Pnri or Type Full Mande
Signature of Aathorsted Agana. if tome
Print or Type Full ?~hate
Meese mum two copies of'the completed Application pactayge to:
North Carolina DENR DWQ
Aquifer Protection Section
UIC ProZtam
1636 Mail Sereke Center
Raleigh. NC 27699-1636
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