WI0600166_GEO THERMAL_20151221

·w ATER QUALITY 'REGIONAL OPERATIONS SECTIQtL,. ,-
APPLICATION REVIEW RE Q UEST FORM -,:::<~~:.:·,,.
Date: Decem ber 2 , 201 5
To :. Belinda Henson -Tre nt Allen
From: Michael Rogers, WQROS-Animal Feeding Operations and Groundwater Protection Branch
A.
B.
C.
D.
Telephone: [phone] Fax: (919 ) 807-6 4 96 E-Mail: Michae1.Roge;[e-mail]
Permit Number: Wl0600166
Applicant: Scott C ol e
Facility Name:
Application:
Permit Type:
Project Type: .NEW Projecr
E. Comments/Other Information:
D I would like to accompany you on a site visit.
Attached, you will find all infonnation submitted in support of the above-referenced application for your
review, comment, and/or action . Within 30 calendar days, please return a com pleted W OROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate C\!ntral Office Groundwater Protection Branch contact person
listed above. _/ /) _ _
RO-WOROSReviewer: VJ 1--(~~ Date: 12/t,,/;.!(
COMMENTS:
NOTES :
FORM : WQROS-ARR ver. 092614 Page l of l
WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
Date: 12/15/15
To: Michael Rogers
Central Office Reviewer
Permit No. WI0600166
County: Scotland
Permittee/Applicant: Scott Cole
Facility Name: Cole Residence 11320 Loch Lomond Dr.
I. GENERAL INFORMATION
1. This application is (check all that apply): [8J New O Renewal
0 Minor Modification D Major Modification
a. Date of Inspection: 12/10/15
b. Person contacted and contact information: Scott Cole
c. Site visit conducted by: Jim Barber
d. Inspection Report Printed from BIMS attached: IZ! Yes O No.
e. Physical Address of Site including zip code: 11320 Loch Lomond Drive. Laurinburg NC 28352
f. Driving Directions if rural site and/or no physical address: __
g. Latitude: 34.689137 Longitude: -79.520684 (in jection well)
h. Latitude: 34.688974 Longitude: -79.520649 (water su pp ly well)
Source of Lat/Long & accuracy (i.e., Google Earth, GPS, etc: Goo gle Earth
II. DESCRIPTION OF INJECTION WELL (S ) AND FACILITY
1. Type of injection system:
IZI Geothermal Heating/Cooling Water Return
D In situ Groundwater Remediation
D Non-Discharge Groundwater Remediation
D Other (Specify: _ ___,_)
2. For Geothermal Water Return Well(s) only
a. For existing geothermal system:
RECE\\JEDIDENRIDWR
DEC 21 20'5
rty Regions\ W~~~~~~ris section
Were samples collected from Influent/Effluent sampling ports? 0 Yes [8J No.
Provide well construction information from well tag: See attached GW-1 for the su pp ly well and
in jection well.
b. Does existing or proposed system use same well for water source and injection? 0 Yes [8J No
If No, please provide source/supply well construction info (i.e., depth, date drilled, well contractor,
etc.) and attached map and sketch location of supply well in relation to injection well and any other
features in Section IV of this Staff Report.
3. Are there any potential pollution sources that may affect injection? D Yes C8J No
What is/are the pollution source(s)? _________________________ _
What is the distance of the injection well(s) from the pollution source(s)? ___________ _
4. What is the minimum distance of proposed injection wells from the property boundary? l![
5. Quality of drainage at site: IZ! Good D Adequate O Poor
6. Flooding potential of site: IZ! Low O Moderate D High
Rev. 6/1/2015 Page I
WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
7 . For Groundwater Remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. If No,
attach map of existing monitoring weII network if applicable and recommend any changes to the groundwater-
monitoring program.
8. Does the map included in the Application reasonably represent the actual site (property lines, wells, surface
drainage)?~ Yes D No. If No, or no map, please attach a sketch of the site. Show property boundaries,
buildings, weils, potential pollution sources, roads, approximate scale, and north arrow.
9. For Non-Discharge groundwater remediation systems only:
a. Are the treatment facilities adequate for the type of waste and disposal system? D Yes D No D N/A.
If no, please explain: __
b. Are the site conditions (soils, topography, depth to water table, etc.) consistent with what was reported by
the soil scientist and/or Professional Engineer? D Yes D No D N/A. If no, please explain: __
III. EVALUATION AND RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? D Yes ~ No. If yes, explain. __
2. List any items that you would like WQROS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
3. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
4. Recommendation
D Deny. If Deny, please state reasons:
D Hold pending receipt and review of additional information by regional office
D Issue upon receipt of needed additional information
lz;l Issue
5 . Signature of report preparer(s): 6i ~ ~~
Signature ofWQROS Regional Supervisor: ~ ~ ~f/l-.-:: fo{2., BeLJJJPAr-/1-f/tl>ON
Rev. 6/1/2015 Page 2
WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
IT! ADDMONAL REGIONAL STAFF RMEW COMMENTSIATTACHMENTS (ANeeded)
A_site visit was made on 10 December 2015 to verity well locations for the proposed geothermal injection
s` stem for the residence at 11320 Loch Lomond Drive.
Both the water supph well and injection well have been installed b� the same driller. Both wells are 10' from
all adjacent properiv lines. The water supple well is approximately 50' from the corner of the residence and the
injection well is apmoximately 30' from the residence. Both wells are tagged with the appropriate well tag late
indicating the depth of well, case d rAh and screen interval (see attached GW-1 well construction records for
each well). The injection well and water aupply wall are approximately 60' apart. The injection well is
approximately 75' from the septic leach field located in the front yard of the residence.
The residence and neighborhood is served by municipal water and the water supply well is to be used for the
Geothermal s% stem only at this time. Future use of the water suRnlN well for yard irrigation may take place,
depending on well yield and geothermal system demand.
Based on the depth of each well and the approximate site, elevation of 195 msl at the residence Sand the well -I
description provided for the water supply well); both appear to be constructed and screened in the surficial,
unconfined agu�fer abave_the Black Creek confining unit ( see attached maps with staff report �. Based on other
injection wells installed in Scotland County over the past five,years: shallow injection wells screened in the
unconfined shallow sand aquifer accept the discharge water reasonably well. with ve►)� little if an, overflow.
Most iniection wells are constructed with a [train pipe and foot valve, extended down into the well to the screen
level to utilize the by draulic head_ created in. the drain p pe to oyereome an% hydraulic head in the water table.
if for some reason the current injection s. stern proposed one well doesn't accept the volume of water
discharged: there is additional space on the pLo erg to allow far additional injection wells. Also. the
neigborhood strects_arcpav_ed with curb &gotten• and have stormwater collection drains. Worst case.
dischars,e water could be directed to the street and manap-ed within the stormwater system.
Rev. 61112015 Page 3

Permit: WI0600166
SOC:
County: Scotland
Region: Fayetteville
Effective:
Effective:
Contact Person: Christopher Scott Cole
Directions to Facility:
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
24 hour contact name
On-site representative
Related Permits:
Inspection Date: 12/10/2015
Primary Inspector: Jim Barber
Secondary lnspector(s):
Reason for Inspection: Routine
Com pliance Ins pection Re port
Expiration:
Expiration:
Title:
Certification:
Christopher Scott Cole
Christopher Scott Cole
Owner : Christopher Scott Cole
Facility: Christopher and Jennifer Cole SFR
11320 Loch Lomond Dr
Laurinburg NC 28352
Phone: [phone]
Phone:
910-280-1497
910-280-1497
Entry Time: 08:30AM Exit Time: 09:30AM
Phone: [phone]
Inspection Type: Reconnaissance
Permit Inspection Type: Injection Heating/Cooling Water Return Well
Facility Status: ■ Compliant D Not Compliant
Question Areas:
■ Wells
(See attachment summary)
Page: 1
Pennit: WI0600166
Inspection Date: 12/10/2015
Inspection Summary:
Owner -Facility: Christopher Scott Cole
Inspection Type : Reconnaissance Reason for Visit: Routine
Site is suitable for the operation of the proposed geothermal injection well. Setbacks from building foundations (on-site and
adjacent residences) are greater than 25' for the supply well and proposed injection well.
No apparent sources of contamination noted during site visit. No above ground heating oil tanks present or backyard/shade
tree mechanic garages.
Page: 2
Permit: WI0600166
Inspection Date: 12/10/2015
BIMS044470
Location
Distance from septic tank & drainfield (feet)
Distance from other waste disposal/collection
Comment
Owner -Facility: Christopher Scott Cole
Inspection Type : Reconnaissance
(feet)
Adjacent residences have septic systems in front yards, same as Cole residence
Distance from other pollution source (feet)
Comment
No sourves of contamination noted or observed. Residential neighborhood.
Is well location subject to flooding?
Minimum distance to property boundary (ft)
Reason for Visit: Routine
Yes No NA NE
75
75
100
□■□□
10
Comment: The area of the residence is at an a po roximatel elevation of 195' msl (accordin g to to po ma p)
and the nearest surve yed flood plain is to the east alon g Gum Swam p Creek. The 100 year
flood plain for Gum Swam p Creek ran ges from 154 to 156 msl ad j acent to the nei ghborhood and
Scotch Meadows golf course (see ma ps attached with staff re port)_
Grout Yes No NA NE
Type Concrete Grout
Thickness 20
Depth
Comment:
ID Plate
(Decimal range, e,g_ 15.5 to 25.5 fl)
ID Plate present & properly completed?
Well Contractor indicated on ID Plate?
Comment:
o
20
Yes No NA NE
■□□□
■□□□
Page: 3
�yd
'r 1
' Y REMENIML WELL RECORD
Nam Carrot ofEnvm t and bFwu[al Rm Dnmm °f Waaa Qm ity
WELT: CONTRACTOR CERTIFICATION # 3561 A
Chad Deese _
Well Cantracior (lnnf AdLij Nerne m
Deese Well Driliina _-
WeAt Caroadar Cor["M Narne
19886 Indian reservation rd_
street Addnx6
Wagram NC 28396
city or Town same zip Code
910 3fi 7
Area code Phone number
2. WELL tlrlFOIwATIDN:
WELL CONSTRUCTION PERNHT-# Y 1
OTHER ASSOCIATED PEf2tNaTtt(tr,$ppt�le]
SITE WELL ID i!(i[ epprra63a)
3. WELL USE (CheckA " Banc;: Reaklers6al Waret Stippry t�
{LATE DRUM)
�! � �] �
TIME COMPLETED AM © PM 9
g. WATER 2XINES (der):
Top— — Bottom�
Top- 8d0 orn
Tap Balsam I '_
Top Baum
Top eattarn
Top Bottom
Thic 1
7_ No:
Tnp
Deplh
gottam LFt..
Oiartae� r� d7
I
Tap
Sottnrrl
FL
Tap
Sonora,
Ft
-
S- GROUT:
6
DepM
, ird
Material , Method
Top
Bottom
Ft.
--
Tap
Bottom
FL
Top
l amwn
fv _
s.
To P�
Oepth
8ati°mY
x Slot size
FL_'±_en. _[ ?] aa- _
Material
r ' � --
Top
Bottom
Fl- In in,
-
Top
Bottom
Ft- in. in-
_
4. WELL LOCAT 10. SAtrtiYORAVEL PACK
Dem size
CITY: = i+A�'�'�I f1t 'C'•, CO[3NW 7c L' �i r' TopBotfoum fi
+7L l! �_ r• f 1{ q! �� yl Tap Ba3lotn FL
(Street Nance NunlaeasC =xnwrity, Srrocii . i.d i3a, PWRA Z[pCnde] Top Beitom Ft_
TOPOGRAPHIC 1 LAND SETTING: (dwek aippmprwle hmc)
pS}ape OValtey El"at pRidge ❑Other
LATITUDE 36 �,;� ' DMS OR 3xao00oaO= DD
LONGITUDE 7-5 _ " DMS OR 7)-XD Ogt M DD
L aa.�e„ngitr,. sotrow. c]3PS' OrapograThiC map
#vcsforr oaf wW mast ba WTo1YR on a (=S lopc map aadatlached to
OWs form ifnottWFM GPS3
5. M L11fI0EER
r e.clr
Name
Straet Aj
CRy at Town _ _ state 7p Code
Arm code Pit M rl wbu
6. WELL DETPALS-
a TOTAL. DEM: _
Ib� 00 WELL RE3 iACf E1tl5'F UG WELL? YES 0 mo f2r
c- YYATER aLOfEl_ Below Top of Casing- �_• _ FT.
[lice'+' iF A6vve Top of Casing}
d. TOP OF CAGMG IS FT. Above Land Sra&ce`
'Top of casng terminated aNar below land surface may mcWwe
a variance in accordannewiie t5A HCAC X _0118._
- 214.
�,` '1 !
VV3LD (gprn)METHOD CW TEST f 10 "&' -
F DISMIFMTK*L Type Arnwu �i i - "
11. DRILLING LOG
°R r
= I
1
Material
Formation Descriphon
12- REMARKS.-
i DO HERESY CERTIFY THAT 'f HIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TQ THE WELL OV1 NER-
SIGNATLI E Tl D WELL CONTRACTOR M =DPI
PRINTED) NAME OF PERSON CONSTRUCTING THE WELL

WELL CONSTRUCTION RECORD
This form can be usod fur single or multiple wells
1. Well Contractnf ln1'ormation: tJ,q rA ·1Jet :fL
Well Conttactor Name
·~5 ~ l -{\-
NC Well Contractor Certification Number
lk..e..--s s: ~.~.~~ I)('i \ \11~
CompanyNarlle
2. Well Construction Permit#:
list all applicobl• ><~I conslr"ction pem,it., (i.<1 County, ~~ate, Var/anco, e.c.)
3 . Well Use (cbeckwell use):
Water Supply Well:
□Agricultural □MunicipaVPublic
□Geothermal . (Heating/Cooling Supply) □Residential Water Supply (single)
OindusrriaVCommercial □Residential Water Supply (shared)
□Irri ~ation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquirer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test OStonnwater Drainage
□Experiinental .Tecbnology □Subsidence Control
□Tracer ~thermal (Closed Loop)
thermal (Heatin g/C ooling Return) □Other(exo lain under#21 Remarks)
4. Date Well(s) Completed: 11 /, 5
S. Well Location:
I
-Stc l -r-t0 \ e..
Facility/Ow= Name Facility ID# (if applicable)
\ I '?J l o l p e -~, LL\'V\c.,.,c\ :J><.
Physical Address, City, -end Zip
')c• '1 ~L1"'-d
County Parcel Identification .No. (l'IN)
Sb. Latitude and. Longitude in degrees/minutes/seconds or decimal deg~:
(if well field, one lat/long is S\lfficient)
~h\., \p ~ q '2/51 N -119 , 5 7 I :") 7-C
6. Is (are) the well(s): Z anent
7. ls this a repair to an existing well:
or □Temporary
OVe5 or~
w
If this tr a repair, fill au/ kl1own well con.,1ructi<m llifi,1111a1/o11 and e.rp/0/11 The n1:A11re of 1he
rcpair untkr 1111 ram am .,a·liun vr an th~ buck of lflls form.
8. Number of wells constructed: _____ .__~----
For mu/tiplt! injt:c:1ion ur non--warer 1mpply 'tt-ttll.x ONLY with the: ~-flmt constrHCtian, yuu can
submil one.form.
9. Total well depth below land surface: --:--:-=-c-:Lj~'CJ-,--,-_______ (.ft.)
for multiple well.~ list all depth, if different (exumplu-3@J/)O · and l@I 00')
''] 10.. Static water level below top of ca~lng: ----'----+-------(ft.)
(f water level is a/,ow, casfng, use "+ ''
11 .. Borehole diam~ter: lp (In.} { ·
1
\
12. Well construction method: --,,--'=1--t_•·+~<~=r_:b.~· ---i\--...,cc-lv_\~1.,~1-d...,kJ_
(i.e. auger, rotary, cable, direct push. etc:)
13. FOR WATER SUPPLY WELLS ON.LY:
.1311. Yield (gpm) ________ Method o(t)!St: _______ _
ror Internal Use ONLY:
14. WATER ZONES
FROM TO DESCRIPTION
ft. rt. /1/ /.It
ft. ft. ' r
IS. Ol1TER CASING (for n,ulti-c,ised wells) QR LINER fif a 1111UcQbl~I
FROM I TO DLa\.\lETER I THICKNESS I MATERIAL
i) ft. 2 ('\ ft. to in. S,L, '-16 'fVC .
16. JNNEJl. C \SING OR TUBL'\G i2collier.mal closc,Hoon)
FROM TO DIAMETER THICKNESS MATERIAL c, ft. i t> ft. I Y-z_ ln. Sc.1-i 4D A: c;
ft. rt. ln.
17,SCREF.~
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
l o ft. yo ft. \o in. 2C Se.,t 4 0
ft:. rt. in.
18.GROUT
'FROM TO MATERIAL EMPLACEMENT MF.TROD & AMOUNT
C ft. 20 ft. C.e .w.,.r,J· l> ✓
ft. ft.
ft. ft.
19, SAND/GRAVEL PACK (lfap11li~oble 1
FROM TO MATEIUA.L E.'1.PLACEM.£."''T M£nl0.0
,JI.tis ft. ,J/A rt. --ft. ft.
20. DRILLING.LOG (attach additionul sheets if necessanl
FR0\1 I TO DESCRIPTJON (i:oJor. bardaeu. 50illrock·,\'P•• u·11.UJ m,e, etc.)
I) ft. I 'I ft. lc'i' 6,;i ·vr.vK ')
ft. I rt. -
1 ft. I ,s ft. C,~o..i l~ ( w~,,te..1
n. n.
16 ft. ,r;rt. 5r.1 .vl ( ,,,. r:i; , w1 u Lle. ) -ft. rt.
fl. ft.
21.REMARKS
22. Certill1.J) _r.~,?, . ~~:J 2 /
Signature of Certified Well Contractor
,,,, I ,~I ''1 ~
By signing thL, form, 1 hereby certify thul the well(:,) wm-(were) <'Unstnr,'led In uccordo11ce
with /SA NC.AC 02C .0/00 r,r /SA NCAC (12C .02110 Well Con.,1n1ction S1amlard., and tlu,t a
oop)• nf rhn record ha., heQn pro•lded 10 the well owner.
23. Site diagram or additional well details:
You may use ihe back of this page to provide ttdditional well site details or well
construction details. You may also attach additional pages if necessary.
24 , Submittal lnstructions:
24a. For All Wells: Submit this form v,,jthin 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, For lniection Wells: In addition. to sending the fonn to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to. the following:
Division of Water Quality, Underground Injection Conll'ol Program,
1636 l\1ail Service Center, Rillelgb, NC 27699-1636
24c. fur Wpter Supply & Geothermpl WelJs: In addition to sending the form to
the address(es) above, also submit one copy of this fonn within 30 days of
Amount·• completion of well construction to the county health department of the county Lt::3::b.:._:D::i:si:u:fec=ti:::o:n:..:ty::p~e:':..=======:...._.:::=:::::.:========:l where cnnstructed.
FormGW.J North Carolina Department of Environment and Natural Resources -Division of Water Quality Revi,ed Jan. 2013
I\CME Mapper 2.1 -4.0 km NE of McColl SC
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Property Record Card
A;
Deed
Parcel Number.
040197 15021
No Tax Record Match:
Owner Name 1:
COLE CHRISTOPHER SCOTT
Owner Name 2:
COLE JENNIFER SELLERS
Mail Address 1:
Mail Address 2:
11320 LOCH LOMOND DRIVE
Physical Address;
11320 LOCH LOMOND DR
GIS Data Acres:
0.746
Tax Data and Land Unit
1
Tax Data and Land Unit
Type: LT
Legal Description:
#21 SEC 6 SCOTCH MEADOWS
Mail City.
LAURiNBURG
!Nail State:
NC
Mail zip:
283520000
land Value:
24000
Building Value:
273140
Deferred Value:
0
Elderly Exemption:
Total Value:
0
Market Value:
298200
Deed Doc.:
WD
Deed Book:
00950
Deed Page:
D061
Deed Date:
20041129
Stamps;
0
School Tax
SCH
County Tax:
C
Fire Tax:
FIRE
City Code:
Parcel Update.
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Property Record Card
0^
Deed
Parcel Number.
040197 15021
No Tax Record Match:
Owner Name 1-
�-
COLE CHRISTOPHER
SCOTT
Owner Name 2:
CO LE JENNIFER
SELLERS
tt
Mail Address 1:
Mail Address 2:
11320 LOCH LOMOND DRIVE
Physical Address:
It
11320 LOCH
LOMOND OR
,
GIS Data Acres:
0.746
y
Tax Data and Land Unit
1
Tax Data and Land Unit Type:
LT
` l
Legal Description:
421 SEC 6 SCOTCH MEADOWS
Mail City.
LAURINBURG
Mail State:
NC
Mail zip:
2835200DO
Land Value:
24000
Building Value:
273140
Deferred Value:
0
Elderly Exemption:
Total Value:
0
Market Value:
298200
Deed Doc.:
WD
Deed Book:
D0950
Deed Page:
0061
04019 i f 006
Deed Date:
20041129
Stamps:
0
School Tax:
SCH
County Tax:
C
Fire Tax
FIRE
City Cade:
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12/15/201 f

L' -L" shown on plate 13
M-M', N-N', N'-N", P-P', and R-R'
shown on plate 14
Permit Number
Program Category
Ground Water
Permit Type
WI0600166
Injection Heating/Cooling. Water Return Well
Primary Reviewer
michael.rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
Christopher Scott Cole and Jennifer S. Cole SFR
Location Address
11320 Loch Lomond Dr
Laurinburg NC
Owner
Owner Name
Christopher Scott
Dates/Events
Orig Issue
12/29/2015
App Received
11/17/2015
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
28352
Cole
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
12/29/2015
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Christopher Scott Cole
11320 Loch Lomond Dr
Laurinburg
Region
Fayetteville
County
Scotland
NC
Issue
12/29/2015
Effective
12/29/2015
28352
Expiration
11/30/2020
Requested /Received Events
Additional information requested
Additional information received
RO staff report requested
RO staff report received
Streamlndex Number Current Class
11/20/15
12/2/15
12/2/15
12/16/15
Subbasin
WuterResources
ENWRONMENTAL OUALITY
December 29, 2015
Christopher Scott Cole and Jennifer S- Cole
11320 Loch Lomond Drive
Laurinburg, NC 28352
Re: Issuance of Injection Well Permit
Permit No. W10600166
Geothermal Heating/Cooling Water Return Well
Scotland County
Dear Mr, and Mrs. Cole_
PAT M.CCRORY
Govemor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
0irerfor
In accordance with your permit application received November 17, 2015, and additional information
received December 2, 201.5,1 am forwarding Permit No- 1WI0600166 for the construction and
operation of geothermal heating/cooling water return well(s) located at the above referenced address.
This permit shall be effective from date of issuance until November 30, 2020, and shall be subject to
the conditions and dmitations stated therein.
Please Note:
• Please contact the Fayetteville Regional Office (FRO) of the Division of Water Resources
(910-433-3300) within 30 days after the geothermal well becomes operational to arrange
to -.collect samples from the influent and effluent sampling ports. Laboratory analytical
results will then be forwarded to you when it becomes available.
Also, please send copies of the Well Construction. Record (GW-1) to the FRO and to my
attention in the Central Office in Raleigh within 30 days after constructed (addresses are
available on attached permit).
In. order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days prior to its expiration date. As indicated in the permit, this
permit is not transferab] e to any person without prior notice to, and approval by, the Director of the
Division of Water Resources- If you have any questions regarding your permit or the Underground
Injection Control Program please call me at [phone].
Sialc ofNorih Ca+ohna I Fn vironm enial QkwGh• I Waltf Re9'%zccs
161 I. Mail scmue Center I Raleirk North Camlina 176W-1 611
919 707 9000

Best Regards,
~a,--
Michael Rogers, P.G. (NC & FL)
Underground Injection Control (UIC) Manager -Hydrogeologist
Division of Water Resources, NCDENR
Water Quality Regional Operations Section
cc: Belinda Henson & Jim Barber, Fayetteville Regional Office
Central Office File, WI0600166
Scotland County Environmental Health Department
Page 2 of2
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH, NORTH CAROLINA
PERMIT FOR THE USE OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 97; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Christopher Scott Cole and Jennifer S. Cole
FOR THE CONSTRUCTION AND OPERATION OF i GEOTHERMAL HEATING/COOLING WATER
RETURN WELL(S), defined in Title 15A North Carolina Administrative Code 02C .0224(a), which will he used
for the injection of heat pump effluent. The injection well(s) located at 11320 Loch Lomond Drive, Laurinburg,
Scotland County, NC 28352 will be constructed and operated in accordance with the application submitted
November 17, 2015, and conformity with the specifications and supporting data received December 2, 2015. all
of which are filed with the Department of Environmental [duality and are considered a part of this permit.
This permit is for construction and operation of an injection well shall be in compliance with Title 15A North
Carolina Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until November 30, 2020, and shall
be subject to the specified conditions and limitations set forth in this pennit.
Permit issued this the 29th day of December 2015.
�or S. Jay Zimmerman, P.G.
Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Permit 4WW600156 U1C15A7 [age 2 cif 5
Ver. 1111512015

PART I -PERMIT GENERAL CONDITIONS
1. The Permittee shall comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is grounds
for enforcement action as provided for in N.C.G.S. 87-94
2. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data [15A NCAC 02C .021 l(a)).
3. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data [ISA NCAC 02C .0211(1)].
4. This permit is not transferable without prior notice and approval. In the event there is a desire for the facility
to change ownership, or there is a name change of the Permittee, a formal permit amendment request must
be submitted, including any supporting materials as may be appropriate, at least 30 days prior to the date of
the change [15A NCAC 02C .021 l(q)].
5. The issuance of this pennit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met [ISA NCAC 02C .0203].
PART II -WELL CONSTRUCTION GENERAL CONDITIONS
1. The well supplying water for the geothermal heating and cooling system shall be constructed in accordance
with the requirements of rule 15A NCAC 02C .0107 except as required in Item #2 below.
2. Any injection well shall be constructed in accordance with the requirements of rule 15A NCAC 02C .0107
except that the entire length of the casing shall be grouted in such a way that there is no interconnection of
aquifers or zones having differences in water quality that would result in degradation of any aquifer or zone.
For screened wells, grout shall be emplaced from the top of the gravel pack to the land surface. For open-
end wells,.the casing shall be grouted from the bottom of the casing to the land surface [15A NCAC 02C
. 0224( d)(2),(3)].
3. Bentonite grout shall not be used to seal any water-bearing zone with a chloride concentration equal to or
greater than 1,500 milligrams per liter. In areas where elevated chloride levels are known to exist or are
probable, such as coastal areas, chloride levels shall be verified in the field to detem1ine existing conditions.
[15A NCAC .0225(g)(8)].
4. The injection well system shall be constructed such that a sampling tap or other collection equipment
approved by the Director provides a functional source of water when the system is operational. Such
equipment shall provide the means to collect a water sample immediately after emerging from the water
supply well and immediately prior to injection into the return well [ISA NCAC 02C .0224(d)(4)].
5. Each well shall be secured to reasonably insure against unauthorized access and use and shall be sealed
with a watertight cap or well seal as defined in G.S. 87-85(16).
6. Each well shall have permanently affixed an identification plate [15A NCAC 02C .0l07G)(2)].
Permit #WJ0600166 UJC/5A7
ver. 11 /15/2015
Page 2 of 5
7. A completed Well Construction Record (Form GW-1) shall be submitted as described in Part VI.5 of this
permit.
PART III -WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing each injection well, the Permittee shall notify the
Underground Injection Control (UIC) Central Office staff, telephone number 919-807-6496 and the
Fayetteville Regional Office Staff, telephone number 910-433-3300. [ISA NCAC 02C .021l(k)].
2. Within 30 days of injection well completion/operation, the Permittee shall contact the Fayetteville Regional
Office Staff in order to have samples collected at the source well and injection well. [ISA NCAC 02C
.021 l(k)]
PART IV -OPERATION AND USE CONDITIONS
1. The Permittee shall comply with the conditions of this permit and properly operate and maintain the
injection facility in compliance with the conditions of this permit and the rules of 15A NCAC 02C .0200,
even if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02C .021 l(j)].
2. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface water
or groundwater resulting from the operation of this facility. In the .event that the facility fails to perform
satisfactorily, including the creation of nuisance conditions or failure of the injection zone to adequately
assimilate the injected fluid, the Permittee shall take immediate corrective actions that may be required,
such as the repair, modification, or abandonment of the injection facility [ISA NCAC 02C .0206].
PART V -INSPECTIONS [15A NCAC 02C .021 l(k)]
1. Any duly authorized officer, employee, or representative of the Division of Water Resources (DWR) may,
upon presentation of credentials, enter and inspect any property, premises, or place on or related to the
injection facility at any reasonable time for the purpose of determining compliance with this pennit, may
inspect or copy any records that must be maintained under the terms and conditions of this permit, and may
obtain samples of groundwater, surface water, or injection fluids.
2. DWR representatives shall have reasonable access for purposes of inspection, observation, and sampling
associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary samples of the injection facility's activities.
PART VI -MONITORING AND REPORTING REQUIREMENTS
1. Records of well construction, repair, or abandonment shall be submitted within 30 days of completion of
such activities. Copies of such records shall be retained on-site and available for inspection [15A NCAC
02C .0224(f)(2), ( 4)].
2. Monitoring of any well may be required to ensure protection of the groundwater resources of the State and
compliance v.rith the groundwater quality standards specified in 15A NCAC 02L [15A NCAC 02C
.0224(f)(l )].
Pennit #Wl0600166 UlC/5A7
ver. 11/15/2015
Page 3 of 5
3 . The Permittee shall report any monitoring or other information that indicates noncompliance with a specific
permit condition, that a contaminant may cause a violation of applicable groundwater quality standards, or
that a malfunction of the injection system may cause the injected fluids to migrate outside the approved
injection zone or area. As specified in rule 15A NCAC 02C .021 l(r), noncompliance notification shall be
as follows:
(A) Oral notification shall be given within 24 hours of the occurrence, or first knowledge of the
occurrence, to the Fayetteville Regional Office, telephone number 910-433-3300.
(B) Written notification shall be made within five days of the occurrence and submitted to the addresses
in Item #5 below.
(C) The written notification shall contain a description of the noncompliance and its cause; the period of
noncompliance, including dates and times; if the noncompliance has not been corrected, the
anticipated time it is expected to continue; and any steps taken or planned to reduce, eliminate, and
prevent reoccurrence of the noncompliance.
4. The Permittee shall record the number and location of the wells with the register of deeds in the county in
which the facility is located. (15A NCAC 02C .0224(f)(3)].
5. All forms, reports , or monitoring results required by this permit shall be submitted to:
UIC Program Staff
Division of Water Resources
1636 Mail Service Center
Raleigh , NC 27699-1636
and
Water Quality Regional Operations Section
DWR Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301
PART VII ~PERMIT RENEWAL (15A NCAC 02C .0224(c)]
As required by rule an application for permit renewal shall be made at least 120 days prior to the expiration
date of the permit. This permit condition does not apply if the Pennittee chooses to discontinue operation
of the well for injection of effluent from the geothermal heating and cooling system associated with this
pennit.
Permit #Wl060U 166 UJC/5A7
ver. 11/15/2015
Page 4 of5
PART VIII -CHANGE OF WELL STATUS (I SA NCAC 02C .0240)
1. Procedures for temporarily or permanently abandoning a well are the same as those specified in rule 15A
NCAC 02C .0113. While some of those criteria are given below, the Permittee bears the responsibility of
complying with all applicable regulatory requirements.
2. If a well will no longer be used for any purpose, then it should be permanently abandoned according to rule
ISA NCAC 02C .0113(b) in order to prevent the well from deteriorating and acting as a source or conduit
of contamination, which is prohibited by General Statute 87-88(c).
3. If a well is taken completely out of service temporarily, the Permittee shall install a water-tight cap or well
seal that cannot be removed without the use of hand or power tools.
4. When injection operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall permanently abandon that injection well in accordance with the procedures specified in 15A
NCAC 02C .0113(b), which include, but are not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected prior to sealing in accordance with rule ISA
NCAC 02C .011 l(b)(l)(A),(B), and (C).
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In those cases when a subsurface cavity has been created as a result of the injection
operations, each well shall be abandoned in such a manner that will prevent the movement
of fluids into or between underground sources of drinking water.
(F) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0224(£)(4) within 30 days of completion of abandonment.
5. The written documentation required in Part VIII (4)(F) shall be submitted to the addresses specified in
Part VI.5 above.
Pennit #Wl0600 J 66 UJCi5A7
ver. J 1/JS/2015
Page 5 of 5
Re"rIaI�/ r
.WATER QtJ--ALTTY'RF.G1O.NkL OPERATIONS SEC
APPL` CATION REIVIEW REQUEST FORM
Date,.
Tc;: Belint!_i Hetisun. I:-ew :fillet=
Front; Michael Rcgcn-±. u'QROS — Anilaai Feeding Operations and Groundwater I'rorectioll B avji�h
Telephone: [phone],406 FcL : '9 i 9 j 8D7-a4ciu` E- lutl- Michact- Rage�a Ci--lcdem .-Ro
A- Permit'Pia mbei-.- W10600166
B. Apliumir SeUtt
C. Facility Name;
�� r4iilelCl�l�Cl:
Permil Tl.pN: Grothermal Hcatinu..Coolingr tl' icet Return Well
Prajetf
E. Con] nitwisiother].nfurmation-
J 1 Nvould like cc, uccaltlpank VOU On a site visii.
Attached. you «'iII find all inforlllatILI11 SObiniaed in suppoil of the above -referenced appIication i-or vour
review. coatlmat. andior €lcrion. \ itllin 30 caiendor days. please return a completed )L(c RC7S Stay.
Repo rt,
WIle II t (!u receixc this rcqucsi 16orri1. 1)icast o, nie your n Dime acid dates in 131e spaces below- make a copy cif'
this Shut- and retIim it to Ilic appropriate ceiltrai ()thee Grou11dw ow. Frotecticli 81-131c11 ,_can€ac! person..
listen above.
RO-'W()ROS Reviewer-: _ U J �/ Dalc:
COMMENTS:
1 NOTE&

WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
Date: 12/15/15
To: Michael Rogers
Central Office Reviewer
Permit No. WI0600166
County: Scotland
Permittce/Applicant: Scott Cole
Facility Name: Cole Residence 11320 Loch Lomond Dr.
I. GENERAL INFORMATION
1. This application is (check all that apply): 0 New O Renewal
D Minor Modification O Major Modification
a. Date oflnspection: 12/10/15
b. Person contacted and contact information: Scott Cole
c. Site visit conducted by: Jim Barber
d. Inspection Report Printed from BIMS attached: 0 Yes D No.
e. Physical Address of Site including zip code: 11320 Loch Lomond Drive. Laurinburg NC 28352
f Driving Directions if rural site and/or no physical address: __
g. Latitude: 34 .689137 Longitude: -79.520684 <in jection wel l)
h. Latitude: 34.688974 Longitude: -79.520649 water su mly well)
Source of Lat/Long & accuracy (i.e., Google Ea1ih, GPS, etc: Google Earth
ll. DESCRIPTION OF INJECTION WEL L(S ) AND "FACILITY
l . Type of injection system:
0 Geothermal Heating/Cooling Water Return
0 In situ Groundwater Remediation
0 Non-Discharge Groundwater Remediation
0 Other (Specify:__j
2. For Geothermal Water Return Well(s) only
a. For existing geothermal system:
Were samples collected from Influent/Effluent sampling ports? D Yes 0 No.
Provide well construction information from well tag: See attached GW-1 for the su ppl I well and
in jection well.
b . Does existing or proposed system use same ·well for water source and injection? D Yes 0 No
If No, please provide source/supply \Veil construction info (i.e., depth, date drilled, well contractor,
etc.) and attached map and sketch location of supply well in relation to i,~ection well and any other
features in Section /Vofthis Staff Repo,1 .
3 . Are there any potential pollution sources that may affect injection? D Yes [8J No
What is/are the pollution source(s)? _____ _ ------------------
What is the distance of the injection well(s) from the pollution source(s)? _____________ _
4 . What is the minimum distance of proposed injection wells from the property bouncfary? lQ_'_
5. Quality of drainage at site : [8J Good D Adequate O Poor
6 . Flooding potential of sile: [8J Low
Rev. 6/l /2015
D Moderate O High
Pagel
WQROS REGIONAL ~TAFF REPORT FOR
UIC Program Support
7. For Groundwater Remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. If No,
attach map of existing monitoring well network if applicable and recommend any changes to the groundwater-
monitoring program.
8. Does the map included in the Application reasonably i'epresent the actual site (prope11y lines, wells, surface
drainage)? IX! Yes D No. IfNo, or no map, please attach a sketch of the site. Show prope11:y boundaries,
buildings, welis, potential pollution sources, roads, approximate scale, and north arrow.
9. For Non-Discharge groundwater remediation systems only:
a. Are the treatment facilities adequate for the type of waste and disposal system? D Yes D No D N/A.
If no, please explain: __
b. Are the site conditions (soils, topography, depth to water_ table, etc.) consistent with what was repo1ied by
the soil scientist and/or Professional Engineer? D Yes D No ON/A. If no, please explain: __
III. EVALUATION AND RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? D Yes IX! No. If yes, explain. __
2. List any items that you would like WQR0S Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason 1--------------------+I---------
3. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
--
Condition Reason --
--
4. Recommendation
D Deny. lf Deny, please state reasons:
D Hold pending receipt and review of additio1ial information by regional office
0 Issue upon receipt of needed additional information
IZJ Issue
5. Signature ofreport preparer(s): ____ dJ Jr-.., ~\~
--·
Signature of WQR0S Regional Supervisor: CfJ ti' ~]SJ, f/l.,-:: f:or7.---]e U µ P~ #E.1-J >ON
Rev_ 6/1/2015 Page2
WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
Dater
IV ADDITIONAL - REGIONAL STAT'F EVIEW COMMENTSIATTACHMENTS Uf Needed)
A site visit was made on 10 December 2.015 to verif► well locations for the proposed geothermal injection
s► stein for the residence at 11320 Loch Lomond Drive.
Both the water _sup )lvwell and infection well have been installed by the some driller, Both wells are 10' frotrt
ail adiacent pronerty lines. The water supply well is approximately 517' from the corner of the 'residence and the
infection well is approximately 30' from the residence. Botli wells are iageed witlt the appropriate well task plate
indicating the depth of well, case depth and screen -interval_(see attached GW=I well construction records for
each tire!!).The iil4ectiun. ive]i and tivatcr sunp
jN, well arc approximately 60' apart, The infection well is
apf+roximate1Y 75' front the sen[i� leach field located in the front yard ofthe residence.
The residence and nei Itg borhoQd is served hI water and the water suppIv well is to be used for the
geothermal swstem onl"t ibis time._Future use of the water sul!lal.,:►Yelffor yard irrigation mad take place.
dependigpn ►velllield and geothe-mal_s}stem demand.
Based on the depth of each well and the-ML)Yoxiinete site elevation of_195 n3sl at the residence i and the well to,
description p3_ovidt d far tine water sup 31v well ; bath appear to be constntcle . and screened ut the s irfici_al,
unconfined ayuifea above the BIack Creek confining unit fsee attached malls with staff'reevrjt . Based oil other
t eGtion wells installed in Scotland County over the ast five yearsr. shadow injection_wells screened in the
unconfined shallow .sand aquifer accept the discharge water reasonabl►we11, wilh }fiery little if arty Pyerflow-
Most infection ►►+ells are constructed with a drail3 aiQe and fool valve, extended down into the well to the screen
level to utifia_e the h►+drattlic head created in the drain -pine to overcome ain' lwdraulic head in the water table.
If for some reason the cturent indo t-ion system proposed I one we111 doesn't accept the volume of water
dischareed: there is -add itiona I s pace on the Pro ivny_to allow for additional injection wells. Also the
nejt_,rliM_rljoodstreets areved with curb & putter and have stotinwater collection drains. Worst case-
d ischaMq water cottId be directed to the street and inan aped within the stormwater system.
Re► . b f 10-it 15 Page 3

Permit: WI0600166
SOC:
County: Scotland
Region: Fayetteville
Effective:
Effective:
Contact Person: Christopher Scott Cole
Directions to Facility:
System Classifications:
Primary ORC:
Secondary ORC(s):
On-Site Representative(s):
24 hour contact name
On-site representative
Related Permits:
Inspection Date: 12/1012015
Primary Inspector: Jim Barber
Secondary lnspector(s):
Reason for Inspection: Routine
Com pliance Ins p ection Re port
Expiration:
Expiration:
Title:
Certification:
Christopher Scott Cole
Christopher Scott Cole
Owner : Christopher Scott Cole
Faclllty: Christopher anct Jennifer Cole SFR
11320 Loch Lomond Dr
Laurinburg NC 28352·
Phone: [phone]
Phone:
910-280-1497
910-280-1497
Entry Time: 08:30AM Exit Time: 09:30AM
Phone: [phone]
Inspection Type: Reconnaissance
Permit Inspection Type: Injection Healing/Cooling Water Relurn Well
Facility Status: ■ Compliant 0 Not Compliant
Question Areas:
■ Wells
(See attachment summary)
Page: 1
Permit: W10600166
Inspection Date: 12/10/2015
Inspection Summary:
Owner. Facility: Christopher Scott Cole
inspection Type : Reconnaissance Reason for Visit: Routine
Site is suitable for the operation of the proposed geothermal injection well. Setbacks from building foundations (on-site and
adjacent residences) are greater than 25' for the supply well and proposed injection well.
No apparent sources of contamination noted during site visit. No above ground heating oil tanks present or backyard/shade
tree mechanic garages.
Page: 2
Permit: Wl0600166.
Inspection Date: 12/10/2015
BIMS044470
Location
Distance from septic tank & drainfield (feet)
Distance from other waste disposal/collection
Comment
Owner • Facility: Christopher Scott Cole
Inspection Type: Reconnaissance
(feet)
Adjacent residences have septic systems in front yards, same as Cole residence
Distance from other pollution source (feet)
Comment
No sourves of contamination noted or observed. Residential neighborhood.
Is well location subject to flooding?
Minimum distance to property boundary (ft)
Reason for Visit: Routine
Yes No NA NE
75
75
100
□■□□
10
Comment: The area of the residence is at an a pp roximate! elevation of 195' msl (accordin g to to po ma p)
and the nearest surve yed flood olain is to the east alon g Gum Swam p Creek. The 100 year
flood plain for Gum Swam p Creek ran ges from 154 to 156 ms ! ad jacen t to the neighborhood and
Scotch Meadows golf course (see ma ps attached with staff re port).
Type
Thickness
Depth
Comment:
ID Plate
(Decimal range, e.g. 15.5 to 25.5 fl)
ID Plate present & properly completed?
Well Contractor indicated on ID Plate?
Comment:
Yes No NA NE
Concrete Grout
20
0
20
Yes No NA NE
■□□□
■□□□
Page: 3
fir_ T RESMEN77A I WELL CONSsTRUCHON ICORD
NOfItt C.w0hMDCPffofFuyw0nmmt wdxant R=Imes- DTnmmi of Wamr gym.
WELL coNTRAcToR CERTmcATiON # 3562-A
1. WEIi coN'CRAcTop_
Chad Deese
Well CAQrftebr (kXkviduai) Name
Deese Wei10niilna
Wei? Canbac9or Company Norm
190
6 indiart-reseryatign rd.
Street Address
WaqL-!�rTl - - NC_--28396
City or Town State Zap Cope
t 910 a 369-2607
Area code Phone number
2. WMLL INFORMATION:
WELL COMST RUCTION PERIAlTO AI
OTHER ASSOCIATED PERMITI1<(l wAftbie)_
SATE WELL 10 t1(T, appGrable)._ SQL
3. WELL USE (Check k tica Bax): Residential Water Supply g
DATE DRILLED 1 f ko/ P
nmr- cxwPLETED 1,AM ❑ PM Uj i
4. WELL LOCA `l JrI r11
C1TY. l�}uC V{, IArC'C, CCUNTY 17 ! ii�ji `
(Straet Nana. Nunbom Corrmuniy. Subd4retciorr, W No., Para3. Zrp Ccde)
TOPOGRAPHIC 1 LAND SETTING-, (c "apluoWsde bore)
C)SbPe O vaHeY ❑ RBI ©Ridge ❑ Doter
LATiTIIDE 36 ' oms OR 3x.xoD 7A)(x% DD
LONGITUDE 76 . WS; OR 7x-xxx) oovc DD
LaQtdeflor4*ude sacvice- LOPS [QTopographlcmap
{MCation of we9 must be stm are a USGS typo reap aWatMched In
Mis forme if not using GPS]
ti. WELL OWNER e LG { �- �1 f� r_i ` L i�i F1 i f C r (;q
Clymer Narn& r
Slrret Ajdrrss
City or Tower �J _ 3t2te Zip Code
li
Area cue Phone nuwnbar
6. WELL DETAILS- Cr
a. TOTAL DEPTH•
g. WATER ZDNES (de )-
To¢ I Boz-ro r J _ Top ESrrawr
Tnp ff Baltnm _ _ _ Top_ Bots—
lop lv Bottom _ Top Both.
Thidalessl
7_ G: DiarrK�er VIF�td l
Top Bodurn Ft.,
Tap Bottom FI.
Tap PDftrrt Ft
S- GROUT: Depth Mabuial �1 Uethad
f�1� ,v
Top 13o11om Lf Ft. ClI
T❑p Bottbm Ft
Top sowm PL
S. Sc": Depth Slot Size _Ma*Aal
Top�Flti-,-!' FL in. -Lj5— in.
Top Bottom FL In. in. ,
Top Bottom Ft. in. In.
16. SAND GRAVEL PACK:
Deptn .SIZE
Tog Bottom R= _
Top Bottom FL _
• Top mttom FL _
11. DRILLING LOG
P
- 1
r
1
Lu
_ 1
1
U. DOES ► ELL i2LP E E)OS TWG WELL? YES O NO L2r
c_ WATER L FVUL Below 74p of Casing- e?� fT_
(Use `+' it Move 'Fop of Camp}
d. TOP OF CASING IS _ FT. Above Land Surface'
'Top of casing terrrinatM alkx below land surface may require =
a va:anoo in ao=wdonce with 115A NCAC 2C .-011 a_
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l DO HEREBY CERTIFY THAT THIS WELL WAS CON STRLICTF.n IN
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STANDARDS, AND THAT COPY OF THIS RECORD 14AS BEEF'
PROVIDED Tq THE WELL OWNER_
SIGNATURE OFdRTIf FDWELL CONTRACTOR 'DATr
PRINTED NAME Or PERSON CONSTRUCTsiiG T1iE V5 ELL --

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24. Sohank tsl I usi r u r lion v:
9. Tom well depth beWw land %,arNer: 1 b_ 4r4) 24n. For All ►gRs. Submit this form within 30 days o!' campletion of well
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11 BorehoPC cleAM tor: {! (ur) 241). For Iniestion Wills: in additirm io scoding the form to the address in 24n
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(i.e_ nuWr. a,tary, cable, dirxet push etc.)
Division nr Wattr QoirHk', ilgdergronnd injection Cwrrrol Program,
13. FOR WAi'Kk 5tlf'P1,Y Wei, Ls ONLY., 163r .Alvil Servire C:eattr, Raleigh, i1C 27693-1636
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w_ where constructed.
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1132D LOCH LOMOND DRIVE
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a
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WE)
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00950
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20041129
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C
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COLE CHRISTOPHER SCOTT
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COLE JENNIFFR SELLERS
t 340
Mail Address 1:
Mail Address 2:
11320 LOCH LOMOND DRIVE
Physical Address:
11320 LOCH LOMOND DR
at.tlpo!
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0.746
Tax Data and Land Unit
1
Tax Data and Land Unit Type: LT
r
Legal Description:
0215EC 6 SCOTCH MEADOWS
Mail City:
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Mail Zip:
23352MOO
Land Value-
24000
Building Value:
273140
Deferred Vahie:
0
Elderly Exemption.
Total Value:
0
Market Value:
298200
Deed Doc-:
WD
Deed Book:
00950
Deed Page:
0061
040107 Zt W
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20041129
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a
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J /
L' -L" shown on plate 13
M -M', N -N1, N' -N", P -P', and R -R'
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r i
1-
Rogers, Michael
From: Barber, Jim
Sent:
To:
Wednesday, December 16, 2015 12:12 PM
Rogers, Michael
Subject: Scott Cole residence WI0600166
Attachments: Scott Cole residence WI0600166 .pdf; Scott Cole residence WI0600166 geologic cross
section.pdf
Mike;
Attached is the staff report and supporting documentation/maps for the injection well application for Scott Cole in
Laurinburg, Scotland county. The hard copy will be in the courier this evening.
I also received a emailed copy of the proposed injection well project in Raeford, Hoke county for the Aaron Malcolm
residence from Bill's Well Drilling. I plan to visit the property on Monday 21 December. I understand from folks at Bill's
Well Drilling (who prepared the application) that they were submitting a revised map or well diagram.
I will be out of the office tomorrow and Friday. If all goes well I will email the staff report to your attention on Monday
the 2l5t.
Jim Barber
Environmental Engineer
NCDENR-DWR-APS
Fayetteville Regional Office
910-433-3340 voice
910-486-0707 fax
jim.barber@ ncdenr.g ov
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and
may be disclosed to third parties .
./;_ Go Green! Print this email only when necessary. Thank you for helping NCDENR be environmentally responsible.
*******************
1
Ro gers, Michael
From:
Sent:
To:
Chad Deese <[e-mail]>
Wednesday, December 02, 2015 10:27 AM
Scott Cole; Rogers, Michael
Subject:
Attachments:
RE: Cole Geothermal Well Permit WI0600166
GW1.pdf
Here goes the GW-1 form. There is only 1 injection well. The injection well is at least 50 feet from the supply
well. The injection well is 75 feet away from the septic tank. The bottom casing is 30 feet and the bottom
bentonite seal I'd 20 feet.
Sent from Yahoo Mail on Android
On Wed, Dec 2, 2015 at 9:07 AM, Scott Cole
<[e-mail]> wrote:
Did you get Mr. Rogers what he needed?
C. Scott Cole. PE LEED AP
NABCEP™ Certified PY Installer
Vice President
Manager of Commercial and Solar Division
Simmons Heating-Cooling-Electrical, Inc.
11 780 McColl Road
Laurinburg, NC 28352
p: 910.276.2791
f: 888.400.1990
From: Chad Deese [mailto:[e-mail]]
Sent: Tuesday, December 01, 2015 7:52 AM
To: Scott Cole
Subject: RE: Cole Geothermal Well Pern1it \!./10600166
Mr. Cole, is this for Scott's well? I'm still planning to meet with you today around lunch time. I've had a busy
start to this week do to my vacation last ,veek. Sorry for foe inconvenience.
1
Chad Deese
Sent from Yahoo Mail on Android
On Tue, Dec 1, 2015 at 7:45 AM, Scott Cole
<[e-mail]> wrote:
Attached is the new signature page.
Chad, ,ve really need to hear from you so ·we can move this along.
Thanks
C. Scott Cole. PE LEED AP
NABCEPTM Certified PV Installer
Vice President
Manager of Commercial and Solar Division
Simmons Heating-Cooling-Electrical, Inc.
11780 McColl Road
Larninburg. NC 283 52
p: 910.276.2791
f: 888.400.1990
From: Rogers, Michael [mailto:michael.rogers(?ncdenr.govJ
Sent: Monday. November :30.2015 l: 15 Pl\1
To: Scoti Cole
Cc: Chad Deese (deesewelldrillingw,vahoo.com)
SubJect: RE: Cole Geothermal \Veil Pennir Vv'l0600166
Can you scan and send a revised signature page as an at1achment in reply to this email''
2
From: Scott Cole [mailto:[e-mail]]
Sent: Monday, November 30, 2015 11:38 AM
To: Rogers, Michael <[e-mail]>
Cc: Chad Deese ([e-mail]) <[e-mail]>
Subject: RE: Cole Geothem1al Well Pennit WI0600166
The well is 29' from the house. I just went and measured it.
The rest Chad will have to help us with. Chad, I think y'all located the septic, so we need that distance and the
other questions below answered. Thanks
C. Scott Cole, PE LEED AP
NABCEPTM Certified P\l Installer
Vice President
Manager of Commercial and Solar Division
Simmons Heating-Cooling-Electrical, Inc.
11 780 McColl Road
Laurinburg, NC 28352
p: 910.276.2791
f: 888.400.1990
From: Rogers, Michael [mailto:[e-mail]]
Sent: Monday, November 30. 2015 10:54 AM
To: Scott Cole
Cc: Chad Deese ([e-mail])
Subject: RE: Cole Geothennal Well Pennit W10600166
OK, thanks. l '11 wait on the additional info. Please get it to me by 12:00 Wed so I can forward the package to
the regional office to request a staff report (1 am going on funeral leave Thurs and Friday). ,1\lso. the inj ,vell
needs 10 be at least 25' away from the house. If it will be less than that distance, you v,,j]l need to request a
variance from the RO
3
From: Scott Cole [mailto:[e-mail]]
Sent: Monday, November 23, 2015 3:23 PM
To: Rogers, Michael <[e-mail]>
Cc: Chad Deese ([e-mail]) <[e-mail]>
Subject: RE: Cole Geothennal Well Pem1it
There is only one injection well. The map shov-,'S the supply well as the other welL which is 50 feet (plan south)
from the injection well.
The injection well is approx. 25' from the house. I think Chad located the septic tank. so he will have to tell
you that distance.
Chad. please provide the other info Mr. Rogers is requesting.
On the flov,.·s.
10 GP\1
Assuming a run time of 1500 hours per year, that is a bit over 4 hours per da:i. v,foch is 2,500 gallons per day
average.
Injection pressure will be approximately 35-40 PSI
Injection temp \cVill be approximately 50 degress in January and approx. 75 degrees July .
\.Ve are married. so I will get you a new signature page.
Thanks for your help.
C. Scott Cole, PE LEED AP
NABCEP1 M Certified PV Installer
Vice President
Manager of Commercial and Solar Division
Simmons Heating-Cooling-Electrical, Inc.
11780 McColl Road
Laurinburg, NC 28352
p: 910.276.2791
f: 888.400.1990
From: Rogers, Michael [ mailto:[e-mail]]
Sent: Friday, November 20, 2015 5 :24 PM
To: Scott Cole
Cc: Chad Deese (deesewelldrilling@yahoo .com)
Subject: Cole Geothermal Well Pern1it
Scott-
We received the geothermal well pennit application for the above project. Thank you . However. we need some
additional infonnation/clarification for the following:
• The app indicates there are 2 proposed inj wells but the map shows 1.
• What is the separation distance for the inj well(s) and the house, and septic tank field/system?
• Please clarify the depths of the bottom of casing , and bottom of bentonite seal/top of sand pack.
• Please provide the GW-1 for the existing well If not available, please provide well construction
info including date drilled, depth , and well casing and grout info. Also , will this be the supply well?
• If you are married both persons appearing on the property deed need to sign the app.
5
• What will be the estimated average:
o daily injection volume-
o injection pressure-
o temperature for January and July-
For the info above I can put on the app and initial. However, please send back in reply to this email a revised
signature page if applicable.
Thanks.
i\1ichael Rogers, P.G. (NC & FL)
llnderground Injection Control (UIC) Program Manager -Hydrogeologist
NCDEQ-DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh. NC 27699
Direct No. 919-807-6406
httn://11 ortal.ncdem.ondv,.,eb/wq /a ps/£w Qro/re portirn2:-forms
jV()IE· Per Execuzive Order Nu. 150. all e-mails sent to and.fom this account are subject to the North
Carolina Public Records Lmv and may be disclosed to third parties.
6
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQ UEST FORM
Date: December 2, 2015
To: Belinda Henson -Trent Allen
From: Michael Rogers, WQROS -Animal Feeding Operations and Groundwater Protection Branch
Teleplione: 919-807-6406 Fax: [phone] E-Mail: [e-mail]
A. Permit Number: WI0600166
B. Applicant: Scott Cole
C. Facilin • Name:
D. Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: l\TEW Project
E. Comments/Other Information:
D I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action . Within 30 calendar days, please return a completed W QROS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROS Reviewer: Date: -------------------------
COMMENTS:
NOTES:
FORM: WQROS-ARR ver. 092614 Page I of l
P A'.T MCCRORY
Governor
DONALD R. VAN DER VAART
Secretory
Water Resources
ENVIRONMENTAL QUALITY S. JAY ZIMMERMAN
December 2, 2015
Christopher Scott and Jennifer Cole
11320 Loch Lomond Drive
Laurinburg, NC 28352
RE: Acknowledgement of Application No. WI0600166
Geothennal Heating/Cooling Water Return Well
Scotland County
Dear Mr. and Mrs. Cole:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
pennit application and supporting documentation received on November 17, 2015, and additional
infonnation oh December 2, 2015. Your application package has been assigned the number listed
above, and the primary reviewer is Michael Rogers.
Central and Fayetteville Regional Office staff will ·perform a detailed review of the
provided application, and may contact you with a request for additional infonnation. To ensure
maximum efficiency in processing permit applications, the Water Quality Regional Operations
Section (WQROS) requests your assistance in providing a timely and complete response to any
additional information requests.
Please note that processing standard review pennit applications may take as long as 60 to
90 days after receipt of a complete application. If you have any-questions, please contact
Michael Rogers at [phone] [e-mail].
cc: Fayetteville Regional Office, WQROS
Permit File WI 0600166
)~~~
fr Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch
Division of Water Resources
State ofNor1h Carolina I Environmental Quality I Water Resources
J 611 Mail service Center I Raleigh , North Carolina 27699-161 J
919 707 90(10
Director
NORTH CAROUNA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATFON FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .02?4
GEOTHERMAL HEATING/COOLING WATER RETURN WELLS
These wells inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
(check one) _ZNew Application Renewal* Modification
* For renewals complete Parts A-D and L the signature page.
Print or 1�pe Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: /0 zz , 24 1 S
PERMrf NO. W f C9 G p Q I (leave blank if New Application)
A. STATUS OF APPLICANT (choose one) '
Non -Government: Individual Residence
B.
C.
D.
Government: State Municipal
BusineWOrganixation
County Federal
WELL OWNERIPERAUT APPLICANT - For individual residences, list owners) on property deed. For all
others, list name of entityand name of person delegated authority to sign on behalf of the business or agency: _
[ _ t4ILI sntr P,__; S C o TT -Co Lie - -
Mailing Address: 1132 o 4,acjt L&S-L-si ob TNm-
City: LAw1Z j -a13 u tX & -- State: L zip code: :Z�3� _ County: SCv F4Awp
Day Tele No.: 1/0 -4 d - 102 CellNo.:_ ��y�•�Pa �1
EMAIL Address: See.7F_C64 1F rCM&AG. r0141 Fax No.:
WELL OPERATOR (if different from well owner) - For individual residences, list owner(s) on property
deed. For all others, list name of entity and name of person delegated authority to sign on behalf of the
business or agency: iV ,
Mailing Address:
city:
_ T State: Zip Code: County:
Day Tele No.: Cell No.;
EMAIL Address: Fax No.:
LOCATION OF WELL SITE - Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: UVD! 9 7I56 --- _County: <eOMAP P
(2) Physical Address (if different than mailing address): j/"y_��a4r4lL
City- State: NC Zip Code:

E. WELL DRILLER INFORR7ATI
Well Drilling Contractor's Name: Vie,
NC Well Drilling Contractor Certification No.
Company Name: ,CCS r £� K-k f 1 — 0
F001
1
Contact Person: L V Rd I f e Nt
Address: (1 M XJ, 4V
A I ;
EMAIL, Address: Q►E�i� .�d ��� , pQ
City: k)W ft+yL Zip Code: �_ State: yi & County: �1
Office Tele No.: �llt 4 y - Z �� Cei i No_: 110 �f 7 �ra3 Fax No.: T1 Q S
F. RVAC CONTRACTOR INFORMATION (if different than driller) j
HVAC Contractor's Name: t*if�Co�•+s _ iw3 S doe.�� �_ ^G?] T. ,je
NC HVAC Contractor License No.:
Company Name: Si ,F Ow+a J.S _
Contact Person: <",o 7! 4 G 1 EMAIL Address: S6•y
Address:- /% 1;1�10 41c�
City: eN$ LLS & _ Zip Code:,ta2- State:►"u County:
Office Tele No.: Iza ".x2 7 .*CZeli No.: .9I41 - -2P0 — i Vf a Fax No.: '4 If P
G. WELL USE Will the injection well(s) also be used as the supply welI(s) for the following?
(1) The injection operation? YES NO
(2) Personal consumption? YES NO _
H. WELL CONSTRUCTION REQUIREMENTS — As specified in 15A NCAC 02C .0224� d F;
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
(2) if a separate well is used to inject the treat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
(a) For screen and gravel -packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.

L WELL CONSTRUCTION SPECIFICATIONS
(1)
(2)
Specify the number and type of wells to be us~r the geothermal heating/cooling system:
J *EXISTING WELLS _L ____ .PROPOSED WELLS
* For existing wells, please attach a copy of t fieWell Construction Record (Form GW-1) if available.
Attach a schematic diagram of each water supply and injection well serving the geothennal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b)
(c)
(d)
(e)
(f)
(g)
Well casing and screen type,.thickness, and diameter
Casing depth below land surface
Casing height "stickup" above land surface
Grout material(s) surrounding casing and depth below land surface
Not~: bentonite grouts are prohibited for sealing water-bearing zones with 1500
mg/L chloride or greater per 15A NC4C 02C .0107(0(8 )
Length of well screen or open borehole and depth below land surface
Length of sand or gravel packing around well screen and depth below land surface
J. OPERATING DATA
(1)
(2)
(3)
(4)
Injection Rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
Average (daily) / 0 gallons per minute (gpm).
~ ~ Average ( daily))SO iJ gallons per day (gpd). ~
Average (daily)~'{o pounds/square inch (psi).
Average (January) <D ° F, Average (July)~-° F.
K. SITE MAP-As specified in ISA NCAC 02C .0224(b){4), attach a site-specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map
shall include the fol1owing:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in I SA NCAC 02C .0 l 07 ( a )(2 ) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
NOTE: In most cases an aerial photograp/1 of O,e property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, tire property can be searched by .
owner name or address. The location of O,e wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn In by hand. Also, a •tayer' can be selected sliowing topographic contours or
elevation data.
L. C-TR1HICA FJON (to be signed as required below or by that person-s autfioriz&d ag_-fiti
15A NCAC 02C_.021 �'e, requires'rhat all permit applications shall be sime-d As follows-
1. for a corporation. by a responsible corpon5de officer;
1. for a partnership or sole proprietorship, by a general partner or the prapristor, =espe4ti'rely,
3. for a municipality or a state, federal, car other public agency. by either a principal exec�a6ve
officer or ,ranking publicly elected official-,
A. sfor all oibers: by the well owner (pemn(s) listed an the property deed).
If an authorized agent 6 signing on hehalf at the applicant, then Supply a letter signed by the
applicant that names and authorize their agent to sign this applications on their behalL
" I hereby certify, under penalty of law, drat l have personally examined and am familiar with the informatson
submirted in this docurnerd and all attachments therew and that, based on my inquiry of those individuals
immediately responsible for obtaining said ird'ormaFion, I believe that the tnforrnation is true, accurate and
complete, l am aware that there are significant penalties, including the possibility of fines and imprisorunerrt
for subrnitting false information. I agree to construct operate, maintain, repair, and if applicable, abandon the
Wection well and all related appurtenances in accordance with the approved spec:r_fseaiions and conditions of
the Permit,"
Signature of Property Owner/Applicant
Print or type Fall Name
Signature of Authorized Agent if any
Print or Type Full Name
Submit two copies of the completed application package to:
Underground Injection Control Program
NC Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]

L. CERTMCATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .021.1 + e + requires that ail 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 (person(s) listed on the property deed).
rf an authorized agent is signing on behalf of the applicant, then snpply a letter signed by the
applicant that names and authorizer their agent to sign this application on their behalf
"I hereby certify, under penalty of law, that 1 have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my: inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. 1 am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, reoir, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Si tore of Property O.WiflerlApplicant
Print or Type Full Name
Signature �f Property Owner/Applicant
Print of Type Fult�4ame
Signature of Authorized A:g=rt, if any
Print or Type Full Name
Submit two copies of the completed application package to:
[lnderground Injection Control Program
NC Division of Wafter Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]%
r

l .and
Re
Lai
GEOTHERMAL HEATINGICOOLING WELL CONSTRUCTION DETAIL
Choose applicable Injection Well design and check the appropriate boxes. Fill in depths and details of well construction on
the blank liwes provided Use additional sheets as needed
❑ en -Hole Well Design
Proposed El Existing
❑ Injection; ❑ Supply;
❑ Dual Purpose
Scerred Well Design
oposed Existing
Injection; [I Supply;
❑ Dual Purpose
urfac
(FL)
cord Depths Below
id Surface as Lines
Provided
Return or Supply Line
Casing
Grout
Record Depths 11
Land Surface an
Provided
WELL DETAYLS
Casing Material: �k, 5d ,
Casing Diameter (in.):
Casing Thickness (in..): 5
Grant Type: &— tan I L
(cement, beutanite, or mix)
Screen Material: P x,
Screen Slot Size (in.): S D
Sand/Gravel Pack
Material: _
(Ft.]
Bentonite Seal
(ifpmseni)
Bedrock
Sand/Gravel Pack
Open Note
Screen
r
►
/L-
f
(Ft)
etvw
Lines
VQ
(PL)
(Ft)

xa'.s.sorrt
r E IU N7'1A� W19LL CMSTS.UMOW REM"
wn.L CONTRACTOR C&R.TfflCATIQN # 3562 A
t. VWIML CO>S nww.Tm
Chad Deese.
Well Contractor (ICI} Name
Deese wefi Driff na
VVeIE (:amactor company Name,
19886 ind_iari_reservafilm fd.
Sbeet Ad&ess-
Waaram NC 28396
City or Torun Sly zip code
910 3 260i
Area code Phww rwrtoer
2. WELL INFURMATIOW
WELL CDiJ.STRIJCTtOH PERIrUT4
OTfiER ASSOCIATED PERMIT7f(rf /} i�
S>f1RIt W1fELL ID #(K» s bw) ! '
3. WELL USE (Check A U +BOX): Residential Water Supply I1
DATE DRILLED 1177, }, L; `7 �
TIME COMPLETED �" W AM ❑ PM [�f
� L � - -- —
T 8aflnrn Top_. Bottom
Tap Bottom Tap _ Bottom
Top Soitorn Top Be tam
Top=Depth—� �� Thkkneesi
>� mFt-�"04- a C� :
Tap Ek ttnm f
Top Bottom FL
8. GROUT: De" � Mate" Melftod
Top V Bonam - FL it i,
Tap Bottom Ft
- Tap aottnsn PL
9. SCPJPk Depth Slat Size matedid
Top- w Bo'tfom R. fa in_
Top Wftm ft tn_
Top fiatfarr: Ft. in.
4- VVFLL I.00ATH31 - ] 16. SAND"O RAVEL PACX-
iF I 1J—If Depth Size
CITY: ��};i ,r ��,j[ "I� S _ COUNTY .)'-^ U � l d dap Hat6orrt FL
i �]I yl] _Q�k "• C. � U - r _ Tap Bunorr� Ft
-
(Streat Han^ mmbe m Qw"PiN4. saawiqke, Lot ND, Parnet, %oeae) Top Bolo" ft _
TOPOGRAPHC 1 LAND SE-MOG: appmpriala hex)
©slope OValley DRat DRidge ©Gtkrer
LATITUDE A6 _' " (WS IDIR 37L.lQDD00[)dd[ DD
LONGITUDE 7-5 - " Dma OR 7x.x*oc>ao= m
Lauit-Ielbrgdtde -xvza-: D33PS pr'opoorapt& mP
poca an ofwed! (aust he sho" on a USGS topo map a tidal[ dwd eD
fts fans rf net aslng GPS)
s. WELL !1 _.. C r
ownwName
See# A�
tj
City ar Town Shot Zip Lode
Arm oode Phone number
S. WELL DETFNLS : r
in.
in.
Material
11. DRILUNG LOG
4}7 wpm Formation Description
r-4
� r
Q 1
1
- 1
1
12. REMARKS_
a TOYAL DEPTH:_
b. DOES WELL MEPLACE EDUSIWG YmEi_L-e YES Cl W I/
c. WATER LEVEL Beiew Top of Casing- — — _ _FT.
{Lase "}. if Above Top of Cas m) -
d. TOP OF CASMG tS FF. Above Lard Surface' -
`Top of rasing to rnnated at►hr Wow land surface may require
a variance in aatordanrz with 15A NCAC 2C .01 fM _
e YI6LO (opm)- W rHHM OF TEST I it tom' 2 .
f_ �CllOwt; Type � F"',C � Atrrattt►t r� D7 - -
t DO kiERE6Y CERTIFY THAT THIS WELL WAS CONSTRUCTE13 IN
ACCORDANCE VWTH M IJCAC 2C, WELL CONSTRUCTION
STANDARDS. AND THATA COPY OF THIS RECORD HAS BEEN
PROVff D i1Q Ti IE 1NELL OWAIER-
3
SEt3tdA E d TIFIVO WELLCONTRACTOR 'DATE
{ke
PRINTED NAME OF PERSON CONSTRUCTING THE WELL

WCONNECTOIS
:e-tg }f•:y�ii•Ir�
w�
0.40197 i 502 0
0.5419� 7,;1 �• * Parcels
+t
I
Line
V4 C o u 17TY
Cir, Limits
40197a t
r
tO
Printed November 04, 2015
See Below for Disclaimer
d
Service Address
R
Address
1
A Service
Roads -Streets
Railroad
t 401 917 11 fl0$
-1-
Border Roans -Streets
r
I : 48 Feat
case be advised that the City of Laurinburg / Scotland County assumes no lie bility for any errors or inaccuracies in the information provided regardless of how data is�
ed or decisions made or action taken by user in reliance upon any information or data furnished here. The user knowingly releases all entities comprising the City of
urinbura / Scotland County G6 system and the Gf5 software vendor that may arise from the mavoino data.

U.S. DEPARTMENT OF THE INTERIOR
U.S. GEOLOGICAL SURVEY
FEET
400
300
Rills]
10U
SEA LEVEL
-100
-200
-300
-400 -
9IP
GR denotes gamma -ray trace
UTHOLOGIC INTEIIPRETATION
Relatively impermeable section that consists -mostly
of clay and silt. These represent confining beds
— Relatively permeable section that consis s of sand or