WI0100172_Regional Office Physical File Scan Up To 9/22/2022

North Carolina
Mail form to:NC DHHS- Division of Public Health
Department of Health and Human Services
Well Contractors Certification Commission
Division of Public Health
1653 Mail Service Center
Raleigh, NC 27699-1653
Well Contractor Certification
Inspection Report
Well Site Location:ro
community, subdivision and Lot #)
��(Town,
Address:T9 j fy_1_ jt�!U TZ'u-dCounty: 13G,, 14 a 004 4A a ,
City/ST/Zip: Date of Site Visit:
InformationSite Supervisor
tInformation
_� /
Name: L
Contractor Company
' J
Name:�/7/��
r� S_ (3C �_
Address: to / ? 5
Address:
T-moo
o oK2!zz-
_p
Phone: 42-3— %�Sl%-'SoOti
, 5-Fol� T a76--Q
Certification # 4-1
Phone:
Well Contractor activities being performed:
Date site activities began: A2 A`i
Expected duration of
GroJ f 1, �
P 6 ��''4`a `h
activities: �(' a (�a C)[ t
'"e
Is Certification Card Present? YES or NO 01.
Picture ID for verification? YES or NO 3
Property
t t
Name:
Address:
Phone:
City/ST/Zip:
Other comments: / 4 1 C F:rvvLi'4-
Complete and sign the appropriatesection
I, attest that on well contractor activities were discovered in progress without the
(Name) (Date)
direct supervision of a North Carolina certified well contractor.
Signature:
Was contractor advised to cease activities until certified contractor is present? YES or NO
I, ,I oil q�-�n e, ,,, eT _ have obtained substantial evidence that well contractor activities were conducted after
(tee)9
January 1, 2000 by(uncertified certified personnel.
Signature:
uc a on
WC-10
Rev. 2/12
F3
i�%

-North Carottna IJepartuiept Q:MnvirP-nmenf,and -XaiuraI Resources -Division of,
IVIS1
WKLL CONTRACTOR CERTIFICATION 0.
fi,WFL�L,PONTRACTQR:
W.ell:Cdntmctdi,(Individual).Narhe
Welf'Co6tractor'CompanyNbrris
Street Address
01yorTown SfAt6 Z10 code
Are( a cede Phonq-JnU'M,b8T
ZWELL INFORMATJON:
WELL CONSTRUCTION P tkm
OtHMASsobiATEb 0ERMIT4(itapolleabW),
1. 'Oit!EiL'.'U-'SE'(Check -'Orfe-Box,). Monitoring [I - MunidlpaVPu01110 0
j0dustriatf,Comm.qrcield AgIricultura-1.0 Recoveryo.,.Injeclidivo,
Irri§!tl6h-b 0 '0 (listu."s,e),
b -bkJLLED
&.YELLLOCATION
(SO6itName; N6mbers.,Community, Subdivision; -LbtNo., �,Pa , 11 zo,.
rcel, code)`
CITY: COUNTY
TO0bdkA0Hid t LAND SETTING: {check appropriate box)
PSI* [3Valley. []Flat .0 R!09 1:!toftv
LATITUDE 31: DMS,'Ok 3X.IXXXXXXXXX
LONGITUDE 75
-&x—xxxxxxx D-x
LatitUdeilohqftude. ,source: MPS, -a'apograpfild"ma
p
(IdcadonW wet! must shown -o-ri. b"'VSGS
this form Anot 4*g GPS)
6, FACILITY d of the d Woll-Is.fo, jeo.)
Facility Name 'Facility ID#X:00,pilcable)
PtrebtAddress
.0ity-or-'Towh-
Contact Name.
'Mailing dress
-
,City,oi-,Town State, Zip Code'
Area cede Phoneatumber
ELL,DETA - ILS:
ai, Tbui-DEPTH
b. DOE WELL ft,EOLAQE tXISTINd,.WELL-? YtSri. NOD
ca WATOMEVEL BelowTbp of C6s1n@:. �FT.
(u6i.0"4&Above ,T- "0 ifig)
d, TOP 1 6F. CASING IS M Above1and'Suifticeli
'-Tdp,bf =Sln term
.-g , in.Med aiforbefowland.surface may reqUir6
a variance in accordancelvvith-1 SAACA02CA1 18'.
e; YIELD (&M).METH
OD OF TEST
f. DISINFECTION: Type--
Ainoun't:
96' MATERZONES.06pthY
Top .. Poft, 6-M
Top• Bottom
Top Bottom
—
TOO BotlomLTop
.Bottom
Top" � Bottom
Thlckn66g/
t,,6Asm: Depth,
Dleirrieter welght iMaterial
To' --�,todom
Ft.
TOP. Bottom
Fi.,
8. bRbUt Depth
Matedaf, Method'
Top—(2 -Sbac '2 o
r Ab�4-c"
I,, PVV
Top .-Zc-D Bottom �S2
Ft."Wc- A- -q
Top Bottom—
F I L.
SCREEN;9. Depth
Dlametef S16tSlie MAteflat
Top
in.
0
Top � Bottom
OP. BOO -
'T RL—
rc- n. in.
-16.tANWOROMEL '-' ' PAM - A
Depth Size Material -
Top UP F
L
TOO Bottom Ff.—
Top
I is DRILLING;LOG
TPP11, Formation Desciiption
4
19, AEMAR
I DC:HEREBY CERTIFY THAT.THIS WELL WAS CONS
1 TED`
RUC_ , - "' 4CC I'- H,
ISA'NcAc 2c WELL CONSTRUCTION STANDARDS.AND.714ATX coPY96
MwFT
RECORD HAS BEN PROVIDED TOJHE34
4LOWNEK,
SIQNATIJRE:aF-',CERTj FIEDWELL C6NTRA DATE
PjRjgEQNAME OF PERSON `CONSTRUCTING THE`WELL.
-Subrt It within 30, days :,df 6drr101dtibihto: Divisidh OfMziterQuality ,.,-- lKw

'F LaILA-i-A-10J"XWV11/11, WELLCQNSTRUCTJ.'0N.jktC0Rh
North. Carolina DeVartmenrofEnVironment- 6 Djo
and'Natural Rdsdurt g,-, ivis � of Water Quality.
w.
WELL CONT 'ACT, R,CERTIFICATION4
1. WELL.CONTRACTO.Rt:
Well Conlractor'(1ndividuil) NafqP
WIKIZOintrac1q,company Name
. . street Addrdsq
City or
ToWn. Slakq Zip Cbde:
Area code Phone number
O
;.:VVEL UNFORMATI i
­1 . R.
OTHER ASSOCIATED: PEkMit*(ift�p' a 1, �plib b e)
SITE;WELL ID W(H'appli6able
1I,WELL USE ,(Cfieck6ne`Bo.*) Mbnitdrirfgo M
phicipal PubIj,c a
InduStriaHCommercial
AgdcultiurafC] Recaveryp.19jec 6ho
IrTiga-tio,po Poor 0 (116t,MS6)
DATE',DRILLED
4-WELL LOCATION'.—
(Strddt,Narne.,NLimboM,PpMMpnity,,,SuW!,Asion,;LotNo.,,,Pafdel;Zf 'Code)
CITY.;
COUNTY
TOPOGRAPHIC f LAND.SETTING: (choqk,jpptoptjjje boxj
0SIope OvAlley 'Pflat- [3RIdigell [10th-er,
LA UD8 36
DIVIS OR 3 XXXXXXXX DD
I j - I
X,.,x
LONOITUDE75 EMS OR 7XAXXXXXXXX,Qb
LatitUdefibrig- itude-:sources, Dspt Oropographicernap;
(focationof-wiii,tnusYb.e.ihown:on.a US S d
PP G A m and6
P , , Vachedita,
.this form1not using: GPS)
S..FACILIT'Y (Name, 6f,th6,bU$irf6s6.Wh6i.tcthe Well Is located.)
Rkillty,Name.
Facility _P#Tf' pplibIca ble ,51redl-Address
"City -or -Town StaW Zip Code:
'00tact Name
Mailing Aiddt6ss
Citror Town,: State. Zip.Code�
Area ,,' node. PkQrkq.nur'nber
O.VIELL DETAILS:
a. TPTAL:PEPTH,
b. DOES ,-WELL:RltOL-AdE.tXISTII,NG,,WELt- . - ROD
� .. I-- � , _ . _. _. _?� YES. Ej
4, WATER .,LEVEL Below Top -oft1 sia ng:, FT
2(Lise "+" ifAbove,Top iofC-a'sIng)
d. TOPcOF:CASING IS
FT,-Abov e1end SUrfaci?.
'Top of casing terminated-atfor beloland suiface::MaY require
a variance -in acccrrdan_ cwY.Ath 16A NCAC 2C.01-18.
6. YIELD (gP1171):
D METHO, ..,OF TEST
f DISINFECTION: Type_
Amodht
Vk�16N AT M ( Vdepith);•
Top_aotibrn
Top_ 8oftcfm_
TO
P_ Bottom
To 13phom
Top- B-61torn-
Top _Bottom
Thickness!
7. CASING. Dejh.� p
Diameter Weight- Material
Top-.B6ttdffi
Top_ Bottom
Fl.
Top ..B6ttbm
Ft
S.. GROUT.' 'Depth
material Method
thod
•R,
To P10 Bottom Soo`
Pt.,
Top
9.:SCREEN. Depth
Qlameter •SiotS , lzg Material
Top
Ft. in.
Tdip-,00tiom-
Ft inc In.
f Top_, BbtI0M-,Ft
in.. in,.
-."10.,SANDIGRAVEL PACK.
depth
Site Maferiai;
Top Bottom
FI.
'Top -Bottom
F1
Top Bottom�
Ft'-
1'I:_DRILIING LOG
Top. Bottom.
F at! nQescdpl;
qffn , o, Ion
J
12.-,REMARI(g-
.A D07HEREDY CERTIFY THAT THIS WELL WAS .c6�sTkUGTED)N ACCORDANCE WITH
1U`NaCM WELL 60NSTRUCTOkSTANDARDS, AND I T THAT A-_CoPY-oF THIS;RE60.Rb5�PR8EEN,PAbVjbtb Tp:ThE-WEILL OWNER:'
...IGNATUR CE
RTIFIED ERTJFIEDX.ELCO
NTRACTOR , 8, , ATE;,
_PN aA D
j:PRINTED ,' WE-017PERSOWCONSTRUCTIN' THE WELL'

Ot
41 NONRESIDENTIAL NMELUCONSTRUCTION."COitp
North .Cai0lini.D6r)artineniofgnviroi)menI
:and Natural Resources- Division of%w Quality
WELL CONTRACTOR CE-RfiVICATI0N4
I,WELL, , g_QNTRAdTOR:
d. TOP OF'CASING IS,.
FT,—A_
bove Land.Sufttb*
4Tbpof casing �rmihaiedatlo�t�i W land
surface may,require
wqfl�,C hi.ractor (Iriddual.) Name a.variarice-In -acc-ordance:'With I 5A WAG 2 , C.61,1181,
Well Contractor Company Name:
-
Stset Address
'City or Town State Zip Cade
L
Area code Phone number
2. WELL IN FORMATION:.
W8LL.60NSTkU,dTibN Ptk'm'rf*
OTHER -ASSOCIATED PERMIT#(if a0064biq)
SITEVELL)DI(V applicable)
&VELL USE (Check One Box) Monitoring El. Muni6ipaI/p_4Wic,,0
jndmtdaI1.bbmmerciaI 01 Agricilitural'o Recdv6ryQ !N66"o-h[]
Irrid4tipri0 Pthar.13 (istur,6),-
DATE -DRILLED
4. WELL LOCATION;
(Strleet.Narne. Numbers,'Community, SiftiVisioni, Ldt NO, Pilicef, Zi
CITY': COUNTY'-.
TOPOGRAPHIC-/ LAND -SETTING, (chec*:apprt.)pda
Ej Slope EiV011dy oFlat EiRldi* bOther,
LATiTODE- 96:
PMS'OR,1X-XXXX,XX)0SX,bb,
LONGITUDE75 "'.DMS OR ZX-.XXX)b(,Xxkx DD
Lafdtjde/i onAde, source- 133 PS 0 r,6pog' i h-
P map,
ofWe1fffiUstbb.;shoiv'jj 6hiiz;02SA a 00ached to
pb_pap,n �
ihis:fqlm using
,Gps
5. FACILITY i(Name of the;,bus as n,, stwhere the:velf 1.9 located.)'
Facility Name Facility jD# (Ifaliiiliimble)
$treaf.Ajdress
City or Town; State Zip Code:
Contact Name.
C4 or Too .8tate, Zip Code
.Area qoO Phone..number.
'A. - WELL OETAIS,
111. TOTAL DEPTH; :%. �_ �. I ­ 1. .. . _* -----------
b.. OdttWELL REPLACE. -.FJC[Stlhb WELLT YES 0 NO 0
e' WATER LEVEL Beldw'T 0.6f Qasj6g__
FTI.
lf,46,,e Top, of,.Casin
e. YIELD
Mt*ot) OF TEST'
fi DISINFEPTION: Type.
.Amount
g. w4bziO.NESjd-epth)t
Top._ Bottom
-Top, Bottom
T_60'_ Roupm—
Top'Bottom -
Top Top
Top,._ aottom
Thickness/
7. 'CASING; 0*4
Diameter Weight Material
Top: f3otlom
Ft..
Top.. B6ttorn
Ft. J
To
p .-P Bplilon
Ft.—
GROUT, Depth;
Material -Method
Top C> .,Bottom LL_>-
Ft., 6-0\,&
Tqp.%� l Bottom ?off
Ft.. Vc q w-
:T it
SCREEN:: Depth
Diameter vottize, Material
*Jqp. BbfioffL_
Ft, in. ifio,
JOO— Bottom
Pis in. In.
:.TopBottomFt
in in.
10i;SANDIGRAVEL PACK:
Depth-
Size. Material
:1;Top �Bottom _
Ft.
Top Worn
Ftw
Top.BottomFt.
Top bottom
l'brirridon Description.
.,a
12i REMARKS: , ,
IDOHEREBY -C'Eik I TJ . FY 7 . MT THIS�WELLWAS.CONSTRUC7tD)t4'AbCbRbAf4cE w"
RECORD NbA62G,"�VtL�,CONSTRUCTION STANt)iRDS .ANPIMATACQP�YC)FTFJiS'
SIGNATUR6`OF CERTIFIED WELL CONTRACTOR : DATE:
F::PERSON�Co
NPTfWCTIN, THRWELL_
641zMl Athih 30 dii�,s Ofto6i Utt n, to: bly Form GW-1 br
P1 o imowof later in formation Processl0g, aP� Dina

p
I..,. WELL CONTRACTOR.
1.qo,r1h doolJO Department of Environment ,
and N , atu ral Resojjrces= -Division of Waltt Qu�jjty.
WELT ,CONTRACTOR CEA-TIF,j I CA, � T19N,#
.
Well: Cdntradtbr'(16dMdtial).Nahe
Welf-Conlractix Company Name
StreetAddress
City or Town State Zip Code
Qr.ea 6o hone,ndmber
.06. P .. "1 1.
2: WELL INFORMATION:
WELLCONSTRUCTI P8'RMITj
OTHEk-AS86biATitbOtRmif# (if fit6ble)
SITE; WELL, lD.#(
3. WELL USE (Checkbne.bo g x) Moni(orjn'- .0- Muni[clip.al(Piublic [j
Indushiad/Commer6laQ3, Agricultural 0 Recoverg3jnJe.ctio'no:
Irii th ir ;(list
gar, n111 0­ g,0. , I use)_
DATE DRILLED
4.-,WEILL LOCATION-:
CITY. COUNTY'
T6066RAPHI'6, I LAND'SETTING! ,(check appropriate boxl.
0sliope.I.Valley ,pFlat. O.Ridjp 00ther
LOTUbE' 36 DW0W3x.nLXxxxxxx
LONPITI)DE75
DMS OR 7x:xxXXkxkx.x DD
LothadpAdngituc'b source:, 030S.- 1O1.Topographic.map?locati6n-ofwe#.muWbethcwo'tndUSES topo r?Ibpa hqa6achedjo,
this -form' if. not:0#0tg GPS),-
1,F4CIL1[TY'(Nampo fthe b6siness'where the well Is located,-)
Facility. Name '-Farilkty,ID#ff ap'pblica 16j
Stre'et-AddrOtt-
City., or Town. State Zip Codei
Conte6fName.
Mailing. -Address
City or Town Sta* .Zip_ -Code
Area ,cod,O-i Phone numb*
&WELLDETAILA.-
a., TOTAL DEPTH:
b, DOES,W8-LL,REl13LACtEXiSt'1[4G WELL! YES�C] NQ;0
M, WATER-I&EL Below Top b , f C9sind'.1­'
(UseI "
Y4760.�Pf sing-)
d: " TO - P OF CASING -IS
-FT. Above Land -Surfacel
-topw casing,tarminated at/orbelow;land surface may tequire
accordanceavariance inwith. 16A.NCAC 2C 011
e. YIELD (,gpm):
METHOD OF TEST
DISINFECTION.
f. DISIN EPTIPN. Type
Amount
g. WAttAlONES (depth):
Top Bottom-
Top_ 8006m
Too_ Bottom
Top- Bottom
Top_ Bottom
-Top. Bottom -
Thickness/
7 CASING: Depth
Diameter W01ilhit Material
TOP- B0ttQm_
Ft:_
Top Bottom
Ft:
Top
F
GROUT- Depth Matbriiii Method
Ft;, c L-v IJ
BottomTop; Z Ft.
Top .Bottom rt.
9- SCREEN.' Debtli
Diameter Slot,Slzo Material
Top-,B I ottom- Ft, in. in.
'Top.Bottorn- FL in.
Top Bottom FL in. in.
-.1.G.-SANDIGRAVEL PACK::
'Depth. Slut Material
TopBottomFt.
Top"BottomFt.
Top, Bottom Ft:.
-.1'1. ORIL LING Lob
Top Bottom Formation Description
t
t.
12. REMARKS. I DO HEREBY CERTIFY THAT THIS WEL
L wAs.'cbRSTR­UCTEb IN ACCORDANCE WiTH
16ANCAdid,'WELL CONSTRUCTION ,STANDARDS;
AND THAT A CDOY THIS-
RECORDOF
H-WPJE� PROVIDED to THE WELL DINNER.DINNER.N
BEE
`MN
..ATURE.OF CERTIFIED WELL:CONTRAdTOR
PKINTED,NAME OFPERSC)
N CONSTRUCTING THE WELL
Submit within 30days of --tothojott h to; Division of*W0DrQ14E1Ryw Informat! Form bW-1
t`b-
I`�,­ , ; on.PrOdEisiging;
t. Ll

North,'CairolinaDepartment of nviton.mentaiidNitural Resources- DiA
Iiibly of Water Quality
WELL C'ONTRACTOR.C.E.kTIF.ICATION#-
j,-WELL ')C0NT.RACT0R:'
Well Contractor (Individual) Name
Well Conlractdr.CompapyNRme
StreetAddress
PitY'-dr ToWn S I (ate Zip Code
Area,code' Phone number
2. WELL wPoRMA-holsi:
WELL dbN8TR'UcTibNPERIVII
OTHER ASSOCIATED PERMIT#(i(ap0IIq6Ie)
SITE WELL ID li(ifapplcab)e)
1.nWELL USE (Chi3ck One Box) Monitoring [i MUniCIpaVPu . blic, [j
Industriaf/commercialo A0dculIu,r.i,3!0,Recwer0:'injection—.
Y .L -3 Irrig'ationo Olherot(ilstuse-
DATE DRILLED
4.WELL LOCATION;
(Slreet,Natrie. Nuffibers, Cotnmunityv$u'b�dtvjjjon
ncI No,.jjrc9IZjp core)
CITY: COUNTY,
TOPOGRAPH101 LAND SETTING: tomckT
ap ropflalabox)
11416130 13-VallOY: ❑ Flat< URidge d0ther
LATITUDE 46. 3
LONGITUDE 76.- .109 OR 7xJ-­
XXXXXXXXX DD'
Laiitudeliongitude';source:, LIGPs, Qro-
P;.
of Well rriust.be ShOlYn-,Gn 4,VSQS OPP Map andoftched10
ifili,iodiiii, nofj!Sing GPS);
6. F-ACI!LIT.Y'(Ngme,oft.hebus.ineg&.Where'ihe:Wdll:is=ldiiAtod.)
Facility Name . Facility 10# (lUppplicab-
re)
Strept Address
qitk.qrTokvn
Slate. Zip Cod6
Contact Name
Mahing,Ad&ess
City or Town` State zo: code
Area .cod6.'Phone; number
.6. WELL DETAILS:
,.,a., T0.-Tt,1,,I,,LME.PTH:-,
bi bots., LL REPLACE EXIST ,L? -YES:b, N60 QN WIEL . I ,
ct 'WATER LEVEL, 1361b1VTop of dash T
Ing:
(Use, t I ov8,Top.of'Castnw,
Id. TOP , CASING IS .­ FT. Above, Land Surface
"
*Topofcasing lerminate Atforbelow land:surace may
require
a Y.aflancein;aCdordance-with 15ANCAC2C.0118.
e- YIELD1613011): . METHOD OF TEST
:j., DISINFECTION.- typet
Amount;
WATER ZONES (06pth)-,
.,,Top
BqtIbrrk_— Top Bott0im
Top TCP�BOUOFTL -
T softom
Top-— ROOM." Top -Bottom
Thickness/
-1. CASING:: Depth Diameter weight Material
Top— $ott0RL­ Ft.
:Top -.Bottom F1
TO'
ROOM— Ff:-
8, GROUT; Depth mat6eial Method
Top D. P6(lom Ft. ( —J
Top Zt) bottom l,,
i-A C- 6; 1 C'.
Top- Bottom
tiorn Ft.
W. $OkIEEN, Depth Diameter Slot Size Material,
P
Top.,
ppd()RL_ Ft.
in. in,.
Top-
. Bottom Ft, in, in.
-Jop—Bo. tlom Ft. in. in
10. sAND1GkAvtL PACK:
Depth Size Material
Top �Bottom —�. Fi;._
Top BdUorfl
Ft,
11-1. DIRiLlIkG LOG
Top Bottom Formation Description
J.,
1VREMAJkft
I DO HEREBY CERTIFY.Tf1KTJH19 WELL WAS CONSTRUCTED IN ACCORDANCE WITH
16A NCAC 2C,,WELL COYSTRUCTIPRS'TWARDSAND viATA 66PYOFTHIs:
"FtE.CORbHM'6';Et?4PROVIDF-DTO-T�HE LL:OWNER;
IEDVELL CONTRACTOR DATE.
PRINTED. NAME OF PERSON
TING
SuOinit'-within ,30 da-ys ofcompletionto0, f n o&fW t r,
quality; information Pe6dess Form GIN'-4b

North Carolina Deparimentof-Environment and Natural Resources- Division of Water OMEN,
WML CONTRACTOR: CERTIFICATION #
1. WELL.CONTRACTORi'
Well Contractor. (!ndividual) Name
Name Well Contractor.0 papy , ._"o, amp
$ireetAddrass
,y or Town:State: Zip, Gpde
Area.codd Phone:.number
.2, WELL INFORMATION:
WELL CO I NSTRUCTiON PERMIT#,
OTHER ASSOCIATED PERMIU(Isp 16):
Oicab
SITIE WELL ID if( ffapplicable)
3..-,VVFLL US.E(CheckOne.Box
Monitoring D Municipal/Public 0,
tndust'r4aVComrnbrdaICI AgribUltqr6lo RecoveryEi, . Injection ci
iriigationo Othero (list use)
DATE=DAILLED
4. WELL LOCATION;:
(Strt!e(NaKe, Nurbb6ri,.C6mmu", SIj
VIA10n, Lot No., Parcel,.Z.1P.Code)
ClTr, COUNTY .
TOPQ.GRAPH.I :1,LAND:SE.rrING*:.(Oeck;apprbpriale bok),
[181006OVilley 090t oRidge. 00ther-
LATITUDE DMS OR 3)(7XikkXXkXX DD,
LONGITUDE 76 XXXXX DD
Latftudehngitude,sourcb: [13PS, Dropographip,map,
(Idcittioh6fwell must -bdshown on,a LIS08�16pomap ;andattachedio,
this io:Ii-401,64ing GPS)
.5.,FACILITY(Name of the business -where the Well is located;)
Facifflif -Name
Facility, 10# (if applicable)
Street Address
.City qrTown state, Zip CojW.
Coniact-Name
Mailing Address
tyD r TO10 State �ZiO:Cod&
y
Area code: Phone number
f.''WELL.'PETAILS:
•a. TOTAL , DEPTH,
bbts4k-L
EXISTING, REPLACE;L-?: YES I!, N&t3
. I AC...,;. - WELL?;
-6-WATER -.L4y.,EL Bilow-rop-of dasIing: F T.
(0sie '4+"JfAbove , Top -of ;. dasi
d. TOP OF is
FT- Above. Land Surface
`Top­ �e . -
I p of casing terminated at/or below land surface mayrequire
, - ,
a variqrIce in:a, ocordance With 16A NCAC� -2C..ol 18.
-'e. YIELD (gpffi):,.,METIAIb0
OF TEST
:,t DISINFECTION: Type`
Amount
MIATERZQNES (depth);;
top Bottom
Top_ Bottom,
Top BouonL
Top Bottom
Too Bottom
Top :Bottom
t CASING: 'Depth
ThIckfiess/
Diameter W , iII46' I ,
t Material
Top Bottom.
Ft.
Top _.Bottom _
Top Bottom
Ft;
B., GROUT:. Depth
Material Method
J&
TOP-- 4_1 Bofiom_3Qe
Ft, iJ 6 Jf— 9 e
:7bp_ Bottom
Ft.
0. `SCREEN: Depth 01)
Diameter Slot Size Material
Top:_ Bottan, -Fi,
in. in.
Top Bottom—
Ft.
TO0L_,R9tIQrTL_.Ft.
4n; in.
`10. SANDIGRAvEL PACK:
Depth
Size Material
Top --------------- ottom
Ft.
Ft;
Bottom'
Ft,
11.'IJklLL-ING.LOG
Top Bottom
Pormationbescription
12l. REMARKS:
ID011H REBY CERTIFY THAT THIS WELLWA5160NSTRU&fib IN ACCORDANCE WITH
E
ISANCAC2Ci`WELLbONSTAUCTtC)NSTA'NDARDS,:AN T14AT xcoP OF,
D_ nr THIS`
RECORD'HASBEENIPRO-
VIDEDT0,1HOWELLOWNER.
SIGNATURE OFCERTIFIEDV.ELLCONTI Ti R DATE'
NAME=
OF P_#KSPN. CQN57RUCTINGTHEWELL
Submit ith1h.. 30:1deIys of =mpleflop t0:pjos!p,bf Water qoajjty Form GWrl:b
a n
DAi, )Inn
In Irn! thin Fr6cew-
gj

North Carolina Departmeritlof Environmenirana Natural Resources- Divisidn;of Water Quality
WELL CONTRACTOR, CERTIFICATION
1'. WELL CONTRACTOR."
Well Contractor. (Individual) Name
W@1I Contractor CoMpa.ny Name,
Street Address`
Ceffy or Town State Zip,Codi
C
Area code. Phon.ffnurnber
1i WELL INFORMATION:
WELL CONSTRUCTION PERM
'OTHER ASSOCIAT.EIJ'P.ERMjT*(j1 applicable)
SITE,W ELL ID (if.applicable) .
3.01EL USE -(Che
ck One Box). Monitoring 0 Munidipil.)Public 0
,Industrial/Commercial :[3 AgHcultiifqj,[]. Recove ation [3 ryo: InILc
Irrigationo Other C) (list use);
DATE DRILLED
4.WELL LOCATION'
(Street Name Numbers, comrriunit), �Su _. �u #vision, Lot No., Parcel, Tip Code)
CITY.", .-,COUNTY
TQPOGFIAPHIC ILAND SETTIMG-,, (6h6ck.approprjaI,1-bok)
oStepe -OV61ley I!TFlat 0 Ridge: o0tho
LATITUDE 36 .6 "IJM8 OR 3k.XXX)M,
XX)( DD
LONGITUDE 76 'D 8`Ok 7x.xxxxxxxxX1DD`
Lallud6llo 03PS " QrqPographicmap
(location
of
shown on: a USES lopo rnap andqffachedto
this form
i
5. 0,AC]Llr.Y (Name.ofthe busirifisS Where 114 Viell'is located.)
Facility .Name ,
Facility 169 (if applicable)
Street Address
City or, Town Slate Zip Code
Cortact;Nam-e.'
'Mailing Address
-pity OeTo" State:' Zip Code,
( . y
Area code: Phonevnu
6. WELL litTAIlLS;
a'. TOTAL DEPTH
b. DOESVELL REPLACE EXIST1146WELL! YtS�ff 'NO
P. WATER LEVELBelo ' wtop of Casing:. FT.-
(Ube,4" if e AbovTop.pf..Cas
1. - , , _,10j)
d. TOP OF CASING IS
,
—1 FT. Above Lande
To ir .Surfar
1.0 casing - terminated- aV6r below 1hrid'surface. may require
&-variance in accordance. -with 1.5A-NCAC,2C'.01 1 a.
6. YIELD
ETHODOFTEST .
J. -DISINFECTION:'Type.
Amount
:,g. WATER ZONES, (depth):
Top_ Bottom—
T6p� Bottom.
;TOP Bottom..
Top_ Bottom__
Top— tI ollom—
Top Bottom —
Thickness/
1- CASING:, Depth
Diameter welghit Material
TOP— Bottom:
Ft.
BOOM:
.1 Ft.
Top— I Bottom
Ft-
•:-8. GROUT:
Material 'M61hod
TOP—_12— Bbiforn:-_-
'7 Z
FL 7�
:.top_,Z- Bottom Ll:�� F
TPP. Bottorn�.
Ft,
9: tdkEtki, Depth,
,Size
at, Size, Material
Slot
Bottom
F 1 1; in. in.
Top_ Bdttbrn—_—,
Ft. in in.
Top_ Bottom
Ft. in: In.
10.UNDIGRAVEL PACK;
Depth Size
Top Bottom Ft.
Too —Bottorn —
'Top _Botlo . 1TV Fi.
11. DRILLI ' NG LOG
Top. Formation Description
t
j"­
REMARks.
tDO:HEREBY,-dtRTiFY THAT THIS WELL WAS CONSTRUCTED'IN A_D' c . E" rtH,
!AAJCAC�M, WELL CONS7RUCTIOWSTAN I PARDS-;AND tHATACOPY dFTHIS
RECORDHpS9EE'
ELL OWNER _
yi%Oyl OEDTOTH _5
r
SIGNATURE OF10ERTIFIEP WELL ,q0NT_ TOR
DATE.
PRINTED NAME 017-PERSON CONSTRUCTING-THEWELL
Ste b,initwithin lddays: ofcompl. 0n­1Q.,DiV.1s1iPn6fWafer Form GWAb-
cjuajjfy__ !hfd Atio-p-
irm ..n Processing:,_

North Carolina Department of Envuonmwt and Natural Resources- Division of Water Quality s 6
WELL CONTRACTOR CERTIFICATION # NCWC 2028 A
1. WELL CONTRACTOR:
_Bobby W. Potts
Well Contractor (Individual) Name
Ferguson's Well and Pumn LLC
Well Contractor Company Name
2731 New Leicester HWV
Street Address
Leicester N.C. 28748
City or Town State Zip Code
8( 28 ) 258-8496
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W 10100172
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection M(
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10/17/2011
4. WELL LOCATION:
1989 White Tree Trail
(Street Name, Numbers, Community, Subdivision, lot No., Parcel, Zip Code)
CITY: Arden COUNTY Buncombe
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope ❑ Valley ❑ Flat []Ridge ❑ Other
LATITUDE 36 a 35 28.2060 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 a 82 , 36.3030 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: (3PS i]ropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City. or Town State Zip Code
Robert &Ada Howell
Contact Name
1989 White Tr e Trail
Mailing Address
Arden N 28704
City or I own—N.C.
State Zip Code
( 828,8 301-2557
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:_30() Ft,
C. WATER LEVEL Below Top of Casing:
(Use "+° if Above Top of Cas
d. TOP OF CASING IS A FT. Above Land Surface -
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15-A NCAC2C.0118.
e. YIELD (gpm): _Q____ METHOD OF TEST Rjq
f. DISINFECTION: Type ChlOrinE Amount i A7
g. WATER ZONES (depth):
Top N/A Bottom
:.Top. Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
:7. CASING:
Depth
Thickness/
Diameter Weight Material
Top NIA
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
:8. GROUT:
Depth
Material Method
Top N/A
Bottom
Ft.
Top
Bottom
Ft.
: Top
Bottom
Ft
9. SCREEN:
Depth
Diameter Slot Size Material
Top N/A
Bottom
Fk in. in.
Top
Bottom
- Ft L- m. —= Ih:___._.— -_.. --_ _:
Top
Bottom
Ft. in. in.
: 10: SAND/GRAVEL PACK:
Depth Size
: Top
Bottom Ft.
Top
Bottom Ft.
Top
Bottom Ft.
11. DRILLING LOG
Top Bottom
0 140
_ 40 / 300
Material
Formation. Description.
DirMay
Rock/Granite
I
en a - nrG •� I
1 J `t i I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
16A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND TKATA COPY OF THIS
RECORD HA?j8EEN PROVIDED TO TF WEL OWNER.
12. REMARKS:
E�IOv 0 9 ZV
Submit within 30 days of completion to: DIA iX G.�J�n btt�ivality _
1617 Mail Service Center, Raleigh, NC 87i6 � '� (919) 907-Mo
Ird6nnation Processing,
WELL
Form GW-1 b
Rev. 2/09

N®NARESIDENTUL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 2028 A
1. WELL CONTRACTOR:
_Bobby W. Potts
Well Contractor (Individual) Name j
_Ferauson's Well and Pump LLC
Well Contractor Company Name
2731 New Leicester Hwy
Street Address
Leicester N.C. 28748
City or Town State Zip Code
8( 28 ) 258-8496
;Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10100172
OTHER ASSOCIATED PERM IT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection N(
Irrigation❑ Other ❑ (list use)
DATE DRILLED-1 0/17/2011
4. WELL LOCATION:
(Street Name, Numbers, Commundy,;Subdl ision .6ot:No_�­Parcel,2ip_Code)
CITY: Arden COUNTY Buncombe
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope []Valley ❑Flat ❑Ridge ❑Other
LATITUDE 36 " 35 28.2000 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 • 82 - 36.3140 DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: V3PS aopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
S. FACILITY (Name of the business where the well is located.).
Facility Name Facility ID# (if applicable)
'street Address
City, or Town State Zip Code
Rohert & Ada Ho` ell
Contact Name
1 PRP White TrPa Trail
Mailing Address
Arden N Q 2870
City or Town State Zip Code
( 829 6 _301-2557
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:_3()0 Ft.
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing) NOV 2011
d. TOP OF CASING IS _ FT. Above Land Surface -
•Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC2C .0118.
e. YIELD (gpm): 0 METHOD OF TEST Rio
f. DISINFECTION: Type C±dQLlne Amount 8 07
g. WATER ZONES (depth):
:Top N/A Bottom Top Bottom
:.Top. Bottom. Top. Bottom.
Top____._:_Bottom Top Bottom
Thickness/
:7. CASING: Depth Diameter Weight Material
Top NIA Bottom Ft.
Top Bottom Ft.
:'Top Bottom Ft
8. GROUT: Depth Material Method
Top N/A Bottom Ft.
Top Bottom Ft.
Top Bottom Ft
9. SCREEN: Depth Diameter Slot Size Material
0
Top N/A Bottom Ft. in. in.
Top' -- Bottom Ft in. in.
Top Bottom Ft. in. 7
10. SAND/GRAVEL PACK:
il ::T
Depth Size Material0
Top Bottom Ft -
Top Bottom Ft. `� )
Top Bottom Ft.
11. DRILLING LOG
Top. Bottom
-Q-----/ 40
40 / 3�0
/
I.
/
/
/
/
12. REMARKS:
Formation Description;
Di la i )
Rock/Granite I T;'
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
REC013p HAS BEEN PROVIDED TO 17 jt_ WELDER. , /
PRINTED NAM OF
THE WELL
information Processing Unit Submit within 30 days of completion to: DWsWwAWater Quality - Infonttation Processing, Form GW-1b
1617 Mail Service Center, Raleigh, NC 27699461, Phone: (919) 907-Wo Rev. 2/09

1 1 ONRESIDENTUL WELL CONSTRUCTION RECORis
ID ¢�
North Carolina Department of Environment and Natural Resources- Division of Water Quality iY ci
�'�' '" ::A• WELL CONTRACTOR CERTIFICATION # NCWC 2028 A
1. WELL CONTRACTOR:
Bob W. Potts
Well Contractor (Individual) Name
Ferguson's Well and Pump LLC
Well Contractor Company Name
2731 New Leicester Hwy.
Street Address
Leicester N.C.28748
City or Town State Zip Code
8( 28 �� 258-8496
Area code Phone number
d. TOP OF CASING IS 0 FT. Above Land Surface*
`Top of casing terminated at/or below land surface may require
a variance in accordance with 1SA NCAC 2C .0118.
e. YIELD (gpm): 0 METHOD OF TEST_ Rip
If. DISINFECTION: Type Chlorin _ Amount A A7
g. WATER ZONES (depth):
:Top N/A Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
2. WELL INFORMATION:
7. CASING:
Depth
Diameter Weight Material
WELL CONSTRUCTION PERMIT#W1O100172
; Top NIA.
Bottom
Ft.
OTHER ASSOCIATED PERMIT#(ifapplicable)
: Top
Bottom
Ft.
SITE WELL ID #(if applicable)
: Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
: 8. GROUT:
Depth
Material Method
Industrial/Commercial ❑ .Agricultural ❑ Recovery ❑ Injection
: Top N/A
Bottom
Ft.
Irrigation❑ Other ❑ (list use)
Top
Bottom
Ft
DATE DRILLED 10/18/201 1
; Top
Bottom
Ft.
4. WELL LOCATION:
1989 White Tree Trail
_-_ ____ (Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
V CITY: Arden COUNTY Buncombe
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope ❑Valley. ❑Flat ❑Ridge ❑Other
LATITUDE 36 0 35 28.2040 ', DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 0 82 ' 36.3120 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: V3PS ❑topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Rohert & Ada How II
Contact Name
_19R-Q Whit . Trea Trail
Mailing Address
Arden N Q 28704
City or Town State Zip Code
( 8281 _301-2557
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:300 Ft.
h.-DOES-WEL-L-REPL-ACE-EXISTING-WELL-?—YES-❑—NO
C. WATER LEVEL Below Top of Casing: N/A I5
(Use •+° if Above Top of Casing)
NOV 0 9:
9. SCREEN: Depth Diameter Slot Size Material
Top N/A Bottom Ft in. in.
7777=--
Top
Top Bottom Ft in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top
Bottom Ft.
Top
Bottom Ft.
Top
Bottom Ft
11. DRILLING LOG
Top , Bofto.m
_01 40
40 300
I
12. REMARKS:
Formation
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.
OF CERTIFIED WE�TCONTRACTOR
UCTING THE
i^form Proc ssina Unit FormGW-1b
Submit within 30 days of completion to: Division quality quality - inforn ation Processing,
1617 Mail Service Center, Raleigh, NC 27699461, Phone: (919) 807-Mo Rev. 2/09

1 !' ONRESIDENTUL WELL CONSTRUCTION RECORD
North Carolina Department of Envuoniment and Natural Resoaroes- Division of Water Quality.
WELL CONTRAC MR CERTIFICATION # NCWC 2028 A
1. WELL CONTRACTOR:
_Bobby W. Potts
Well Contractor (Individual) Name
_Ferauson's Well and PumO LLC
Well Contractor Company Name
2731 New Leicester Hwy.
Street Address
Leicester N.C. 28748
City or Town State Zip Code
8r 28 �) 258-8496
Area code Phone number
2. WELL INFORMATION:
d. TOP OF CASING IS O FT. Above Land Surface -
'Top of casing terminated at/or below land surface may require
a variance in accordance with 157A NCAC2C .01Ia.
e. YIELD (gpm): 0 METHOD OF TEST -Rip
f. DISINFECTION: Type Chlorine . Amount R 07
g. WATER ZONES (depth):
Top N/A Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# W10100172
; Top_ NIA
Bottom
Ft.
OTHER ASSOCIATED PERMIT#(ifapplicable)
; Top
Bottom
Ft
SITE WELL ID #(if applicable)
: Top
Bottom
Ft
3. WELL USE (Check One Box) Monitoring ❑ M unicipa [/Public ❑
: 8. GROUT:
Depth
Material Method
Industrial/Commercial ❑ Agricuftural ❑ Recovery ❑ Injection N(
: Top N/A
Bottom
Ft. -
Irrigation❑ Other ❑ (list use)
Top
Bottom
Ft.
DATE DRILLED 10/18/201 1
Top
Bottom
Ft
4. WELL LOCATION:
1989 White Tree Trail
: 9. SCREEN:
Depth
Diameter Slot Size Material
(Street Name, te Numbers, CommuSubdivision Lot No Parcel, Zip Code)
Top N/A
Bottom
Ft in. in.
_ _ u -= Top
CITY. Arden ` 'COUNTY Buncombe :
Bottom
Ft. in. in.
Top
Bottom
Ft. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
i
Alope ❑Valley ❑Flat ❑Ridge ❑Other
.10.SAND/GRAVEL PACK:
=
LATITUDE 36 °35 28.2060 " DMS OR 3X.XXXXXXXXX DID
Depth
Size Material
LONGITUDE 75 82 36.3180 DMS OR 7X.XXXXXXXXX DD
:Top
:Top
Bottom
Ft.
8
Bottom
Ft j,'_' _? .� 6 _J
Latitude/longitude source: V3PS Cropographic map
; Top
Bottom
Ft r
(location of we// must be shown on a USGS topo map andattached to
:. .
i---,
this form if not using GPS) - I
: 11. DRILLING LOG
S. FACILITY (Name of the business where the well is located.) Top. Bottom Formation Description i J
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Ebert & Ada Ho N _II
Contact Name
_IARQ White Tr P Trail
Mailing Address
Arden N.C.8704
City or Town State Zip Code
( 828 1 _301-2857
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: MD Ft.
b.-DOES-WEt_-L-REPL-ACE-EXiSTINGWELL?- YES-0—N
0 / 40
40 / 300
1
: 12. REMARKS:
Dirt/Clay
Rock/Granite 1
l
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
REC91RD HAS BEEN PROVIDED TO THE MLL OWNER.
SIt;MATU5eOF C RTIFIED
C. WATER LEVEL Below Top of Casing:
(Use °+° if Above Top of Casing) ft rNAM OF PERSON CONSTi
NOV 0 9 (� g
Submit within 30 days of completion to: DivisiacyWater Qu�(I�`iy - Infomuli n Processing,
1617 Mail Service Center, Raleigh, NC 27699461, Phone i
Q/BOG' ®ii
THE WELL
Form GW-1 b
Rev. 2f09

rP 1`f✓
s .. :. N®NRESIDENTUL WELL CONSTRUC ON RECO
�(r
North Carolina t
.� Depariaren of Environment and Natural Resoucoes- Division of Water Quality
��•�._�,., �' WELL CONTRACTOR CERTMCATION # NCWC 2028 A
1- WELL CONTRACTOR:
Bobby W. Potts
Well Contractor (Individual) Name
Ferauson's Well and PUmo LLC
Well Contractor Company Name
_2731 New Leicester Hwy.
Street Address
Leicester N.C. 28748
City or Town State Zip Code
258-8496
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W 10100172
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(Ifapplicable)
3, WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection N(
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10/19/2011
4. WELL LOCATION:
1989 White Tree Trail
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Arden COUNTY BUncombe
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope []Valley. ❑Flat ❑Ridge []Other
LATITUDE 36 0 35 - 28.2050 ^ DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 ^ 82 1 36.3180 DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: W3PS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form ifnot using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Rnhtz &Ada Hn��rPll
Contact Name
19AA White Trap- Trail
Mailing Address
Ards N r R7r�a
City or Town State Zip Code
( 82R A 301-2557
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 30t) Ft_
C. WATER LEVEL Below Top of Casing: N/A
- . (Use'+^ if Above Top of Casing) rITC
d. TOP OF CASING IS 0 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): _Q_ METHOD OF TEST Rip
f. DISINFECTION: Type C:hlnrine Amount A n7
g• WATER ZONES (depth):
Top N/A Bottom Top Bottom
Top Bottom Top Bottom
TOP Bottom Top- Bottom
Thickness/
7, CASING: Depth Diameter Weight Material
Top N/A Bottom
Ft.
: Top Bottom
Ft.
Top Bottom
Ft.
8. GROUT: Depth
Material Method
Top N/A Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top N/A Bottom_...—
Ft�m
Top Bottom
in_e�-
Top Bottom
—
Ft, In In. 1
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bottom Ft
Top Bottom Ft
11. DRILLING LOG
Top Bottom
0 40
40 300
L
12. REMARKS:
F—'
Formation. Description. —
_Dirt/Clav
Rock/Granite 6 0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HIS BEEN PROVIDED TO THf� WELL OWNER.
FI
PERSON
N10V c
Submit v4ntlrin 30 daysof corn ry
1617 Mail Service COntOG Raleigh,NNC 27699461' Ph�on I W �a - _ I �°Oe �,
RSBp Unit
E
Form GW-1 b
Rev. 2/09
0

N®NRESIDENT�lL WELL coNSTRucTION REcoRn 3 g .q
� 9
North Carolina Department of Environment and Neural Resources- Division of Waver Quality
WELL CONTRACTOR CERTIFICATION # NCWC 2028 A
1. WELL CONTRACTOR:
_Bobby W. Potts
Well Contractor (Individual) Name
Ferauson's Well and Pump LLC
Well Contractor Company Name
2731 New Leicester Hwy.
Street Address
Leicester N.C. 28748
City or Town - State Zip Code
8( 28_) 258-8496
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W 10100172
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(ifapplicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection b(
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10/20/201 1
4. WELL LOCATION:
CITY: ArdnnV COUNTY Buncombe.,
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope []Valley. []'Flat ❑Ridge []Other
LATITUDE 36 -35 28,2090 ^ DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 • 82 36.3210 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: V3PS propographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
S. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Rohert A Ada Howpil
Contact Name
I A89 White Trap Trail
Mailing Address
Arden N t'` 28704
City or Town State Zip Code
( 828A 301-2557
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:300 Ft.
d. TOP OF CASING IS 0 FT. Above Land Surface*
`Top of casing terminated atlor below land surface may require
a variance in accordance with 16A NCAC 2C .0118.
e. YIELD (gpm): _0 METHOD OF TEST Reg
f. DISINFECTION: Type_ChJQ In Amount 8 07
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
:.Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
:7. CASING: Depth Diameter Weight Material
Top N/A Bottom Ft.
Top Bottom - Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top N/A Bottom Ft.
Top Bottom Ft
Top Bottom Ft
9. SCREEN: Depth Diameter Slot Size Material
:Top N/A ' Bottom Ft in. in.
Bottom Ft in. in.
Top Bottom Ft. in. in. ---
- -
I
10. SAND/GRAVEL PACK: h
Depth Size MateriO
Top Bottom Ft. is
Top Bottom Ft ; �,
t 1
Top Bottom Ft.
11. DRILLING LOG
Top Bottom. Formation. Description j
.0 40 DirMav
40 / 300
/
12. REMARKS:
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 W BEEN PROVIDED TO THE WELL OWNER_
- - " : SIGNATURE OF CERTIFIE15WEL ONTRACTOR D f
c. WATER LEVEL. Below Top of Casing: N/A F
(Use '+° if Above Top of Casing)
(QI479 A E OF P RSON CONSTRUCTING THE WELL
Nov 2D
Submit within 30 days of completion to: Divisich�f Form GW-1 b
��I/ Quality - Information Processing, Rev. 2/os
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: 'V� Jrti#

1 r ONRESIDENTL4L WELL CONSTRUCTION RECORD
Noah Carolina Department of Environment and Natural Resources. Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 2028 A
1. WELL CONTRACTOR:
Bobbv W: Potts
Well Contractor (Individual) Name
Ferauson's Well and Pump. LLC
Well Contractor Company Name
2731 New Leicester Hwy.
Street Address
Leicester N.C. 28748
City or Town State Zip Code
8( 28 . ) 258-8496
,Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W 10100172
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(ifapplicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agrfcuftural ❑ Recovery ❑ Injection lit(
Irrigation❑ Other ❑ (list use)
DATE.DRILLED 10/21/2011
4. WELL LOCATION:
1989 White Tree Trail °
.(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Arden COUNTY Buncombe
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope ❑Valley. ❑Flat (JRidge []Other
LATITUDE 36 = 35 - 28.1890 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 0 82 , 36.3160 " DMS OR 7x.XXXXXXXXX DD
Latitude/longitude source: V3PS oropographic map
0ocation of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
RnhArt P. Ada Howell
Contact Name
-1989 White Tree Trail
Mailing Address
Arden N 8704
City or Town State Zip Code
(828� _ 301-2557
Area code Phone number
6. WELL DETAILS:
a: TOTAL DEPTH:- 300 Ft.
d. TOP OF CASING IS 0 FT. Above Land Surface*
*Top of casing terminated attor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 0 METHOD OF TEST Rig
f. DISINFECTION: Type Chlorine Amount n7
g. WATER ZONES (depth):
:Top N/A Bottom Top Bottom
Top Bottom Top Bottom
:Top Bottom Top Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
Top NIA Bottom Ft.
;Top Bottom Ft
Top Bottom Ft.
: 8.' GROUT: Depth Material Method
:Top N/A Bottom Ft.
Top Bottom Ft.
:Top Bottom Ft
9. SCREEN: Depth Diameter Slot Size Material
Top N/A Bottom Ft. in. in.
Top _ : Bottom -F
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
Top Bottom
Ft.
Top Bottom
Ft
Top Bottom
Ft F�
(ram
11. DRILLING LOG
Top. Bottom
Formation DescriptioriC, :I tea
0 / 40
DirMay e
40 / 300
Rock/Granite
1
12. REMARKS:
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 H/1S BEEN PROVIDED TO THE WELL OWNER.
SIGNATUR1= OF CERTIFIL15 VAL CONTRACTOR '7-5KT—E
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use °+° if Above Top of Casing) : PRINTED NAM OF PERSON CONSTRUCTING THE WELL
GWA
Submit within 30 days of completion to: Division of Water Quality - infornution processing, Form Rev. 209 b
1617 Mail Service Center, Raleigh, NC27699461, Phone : (919) U74300 109

A.&A
North Carolina Departrnent of Environment and Natural Resources
Dvkion of Water Quafty
Beverly Eaves Perdue Ween H. Sullm
Govemor.' Der
October 12,2011
Rabat and Ada Howell
113 Gavilan Avenue
Coral Gables, Florida
Ref: 1"ufi1tKeOfI8Jec&Mwell P1 11 WI0I00172
Issued to Robert and Ada Howell
Arden, Buncombe County, North Carolina
Dear Mr. and Mrs. Howell:
Des Freeman
Secretary.
1 L=z 'V E 33
NOV 14 20N
In accordance with the appUcation received on September. 28, 2011, 1 am fawarting permit number WI0I00172
for the Construction and operation of a vertical closc&loop geothermal muM&Ijuld
heal p=p injection well system
to be located at 1999 White Trot TniL Arden, Buncombe County. NC 28704. -This permit shall be effective from
the date of issuance until September 30, 2016, and shall be aNed to the conditiDus and lirijitatim deW therein,
including the reqWreomt to install won idgindBegfim tap as WMed In Part 10 and to submit well
construction records as specified. in ftrt VM. 'Be mm to read the eris F Permit to ensure that You we aware of
AM compliance *uirmnents of the pprzp�
You will need tonotifythfs office afleast 48 hours prior to beginning constyuctim and Operation of the injection
Well system. In order to continue uninte:rrmpted legal use of the injwfiari &cUy for the stated purpose,
you moat
submit an application to anew the permit 120 days prior to its expiration In permit is trim erab to
Babe. I not f 10
any pmon without prior notice to and approval I by the Director of the Division of Water Quality.
Please contact me at [phone] or mid=LM2MLftCd=,zox ifyou have mny questism about your pmnit.
Best Regards, ,
1411�,
Mickad Rogers, P.0
(NC & FL)
cc: Landon. DmdwA Asheville Regional ofrace
W10100172?wmit File
Buncombe County Envimnmentsl Health Depogment
Larry Ferguson, Ferguson Well and Pump, 2731 New Leice�lftEWEWFNC 28748
NOV 0 9 201,
Information Processing unit
DWQ/BOG
AQUIFER PROTSMON SECTION
1M Mal SOMM CMW. Raleigh. NOM CarDba 2MAIM
Loa b= 2728 C20W SwWmid, RaImp. NaM UMIM 2704
PhOw- 919-MU21 %FAX 1-, 919-715aM; FAX 2:919-71 SWO 10
An E4U9 OW-MA01MMMUnAam EmMW.
innal Office

Stepp, Jonathan
From: Joe Leonard [e-mail]]
Sent: Monday, March 19, 2012 2:43 PM
To: Stepp, Jonathan
Jonathan,
Per our conversation we grouted (7) 300' wells with NC #9 washed stone then we plugged the top 20' with Pure gold
Bentonite chips.
Joe Leonard
Project Engineer
K-vi'A Inc.
aulmilidsoc crnaris
101 3rd Street
Bristol, TN 37620
Phone [phone] / Fax 5015
jl eonard0ftac-inc. com
CONFIDENTIALITY NOTICE: The information in this e-mail message, and any attachment, is intended for the sole use of the
individual and entity to whom it is addressed. This information may be privileged, confidential, and protected from disclosure. If you
are not the intended recipient you are hereby notified that you have received this communication in error and that any review,
disclosure, dissemination, distribution or copying of it, or its contents, is strictly prohibited. If you think that you have received this e-
mail message in error please e-mail the sender and destroy all copies of this communication and any attachments. Thank you.

�:. Cl)
a•'t1�6 C
CD
f NONRESIDENTIAL ON.Lt1ESIDENTIAL WELL CONSTRUCTION•RECORD tp
' I North Carolina Department of Environment and Natural Resources- Division -of Water Quality ma M
-0 CD j,"D
WELL CONTRACTOR CERTIFICATION # O w..... <0
1. WELL CONTRACTOR: : d. TOP OF CASING IS FT. Above La aufPace' CM
'Top of casing lerminalad at/or below land surf nQ requireWell Contractor (Individual) Name : a variance in accordance with 15A NCAC 2C . 8=—R
n
Well Contractor Company Name : e. YIELD (gprrl): METHOD OF TEST
f. DISINFECTION: Type Amount
Street Address
City or Town State Zip Code
Area Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID 01'applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection p
Irrigation❑ Other 0 (list use)
DATE DRILLED
4. WELL LOCATION:
(Street Name, Numbers, Community, Subdivision, Lot No:,; Parcel, Zip Code)
CITY, COUNTY
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope -❑Valley C]Flat []Ridge ❑Other
LATITUDE 36 " DMS OR $X.XXXXXXXXX. DD
LONGITUDE 75 " DMS OR %X.XXXXXXXXX DD
Latitude/longitude source: BPS []Topographic map
(location o1 well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name. FacilitylD#',(if applicable)
Street Address
City or Town State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
: 9. WATER ZONES (depth):
Top
Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
7. CASING:
Depth
Diameter
Weight Material
:- Top
Bottom
FI.
Top
Bottom-
Ft.
:. Top
Bottom
Ft.
: 8. GROt1T:
Depth
Material Method
Top_Q
Bottom a
Ft.
3Z.. Coo �:f: # c.,, t .t; d t PS
: Top .Z0
Bottom_ 300'
Ft.
Ut. L'j :t Q uf., k<,�, 5 •, f•
Top
Bottom
Ft.
9. SCREEN':
Depth
Dlameter
Slot Size Material
Top
Bottom
Ft.
in.
in.
Top
Bottom
Ft.
in.
in.
Top
Bottom
Ft.
Iin.
in.
10. SAND/GRAVEL PACK:
Depth
Size
Material
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
Top Bottom Formation Description
/
/
:• 12. REMARKS: 1�— t
W
1 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 PROVIDED TO THE WELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑ : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" ii Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
'Submit within 30_days of completion to: Division of Water Quality - Information Processing, Form GW-1b
— - — _ Rev 9/09

,r+ SrATE o
1. WELL CONTRACTOR:
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environinent'and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
Well Contractor (Individual) Name
Well Contractor Company Name
Street Address
City or Town State Zip Code
Area Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
• d. TOP OF CASING IS 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);.
METHOD OF TEST
f: DISINFECTION: Type
Amount
g.. WATER ZONES (depth):
Top Bottom
Top. Bottom
:Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thickness/
7. CASING: Depth
Diameter Weight Material
Top_ _ Bottom _
Ft.
Top Bottom
Ft.
Top Bottom
Ft,
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑ ; 8. GROUT: Depth Material Method
Industrial/Commercial ❑ Agricultural ❑ Recovery Injection ❑ :Topes Bottom 20 Ft. F�LA P L, �v J'o
Irrigation❑ Other❑ (list use) ; Top ZcD Bottom�� Ft. WC tit cr w�5t...�.:
DATE DRILLED : Top Bottom Ft.
4. WELL LOCATION:
(Street Name, Numbers, Community, Subdivision, LotNo., Parcel, Zip Code)
CITY: COUNTY
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE_ 36 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: pGPS [--]Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
9. SCREEN: Depth Diameter
Top Bottom Ft. In.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top
Bottoirr • Ft.
Top
Bottom Ft.
Top
Bottom Ft..
Slot Size Material
in,
in.
In.
Material
11. DRILLING LOG
Top Bottom Formation Description
12. REMARKS:
1 DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
16A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑ : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing:. FT.
(Use "+" if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form Rev. 2/09/09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: [phone]

� .a•STArt'o
NON-RESIDENTIAL ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources= Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR: : d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface may requite
Well Contractor (Individual) Name a variance in accordance with 15A NCAG2C .0118,
Well Contractor Company Name
Street Address
City or Town State Zip Code
U
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(itapplicable)
SITE WELL ID #(If applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial❑ Agricultural p Recovery ❑ Injection.❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED -
4. WELL LOCATION:
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code),
CITY: COUNTY
TOPOGRAPHIC /"LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑.Flat ❑Ridge ❑Other
LATITUDE 36 bms'OR 3X.XXXXXXXXX DD
LONGITUDE 75 '1DMS OR 7X:XXXXXXXXX DD
Latitude/longitude source: ❑OPS 'l][opographic map
(location of well must be shown on a USGS topo map andattachedto
this form if not using GPS)
5. FACILITY (Name of the business where"the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Contact Name
Mailing Address
City or Town Slate Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
e. YIELD (gpm): METHOD OF TEST
f.. DISINFECTION: Type Amount
g: WATER ZONES (depth):
:Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
7. CASING:
Depth
Diameter Weight Material
Top
Bottom
Ft..
Top
Boom
Ft.
To
Bottom .
Ft.
8. GROUT:
Depth
Material Method
:Top C7
Bottom Ly
Ft.
Top L ,
Bottom 3 Ft. WC t&-cr
Top
Bottom
Ft.
.9. SCREEN:
Depth
Diameter Slot Size Material
Top
Bottom
Ft. in. in.
: Top
Bottom
Ft. in. in.
Top
Bottom
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
Top Bottom
12. REMARKS:
t9J e.11 3
Formation Description
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.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
- c. WATER LEVEL Below Top of Casing: FT.
(Use "+^ if Above'Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to:, Division of Water Quality - information Processing, Form GW-1 b
Rev, 2/09
1617 Mail Service Center, Raleigh, NC 27699.161, Phone : [phone]

ill 4`;11'r- � U.-P1 Ai
1. WELL CONTRACTOR:
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -.Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
Well Contractor (Individual) Name
Well Contractor Company Name
Street Address
City or Town State Zip Code
Area code Phone number
2. WELL INFORMATION:
d. TOP OF CASING IS
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):
METHOD OF TEST
f. DISINFECTION: Type
Amount
g. WATER ZONES (depth):
Tap Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thickness/
7. CASING: Depth
Diameter Weight Material
WELL CONSTRUCTION PERMIT# ; Top Bottom Ft.,
OTHER ASSOCIATED PERMIT#(ifapplicable) ; Top Bottom Ft.
SITE WELL ID #(If applicable) :Top Bottom Fl.,
3. WELL USE (Check One Box) Monitoring ❑ Munic'ipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑.(list use)
DATE DRILLED
4. WELL LOCATION:
(Street, Name, Numbers; Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: COUNTY
TOPOGRAPHIC / LAND,SETTING: (chebk appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge. ❑Other
LATITUDE 36 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 "DMS OR 7X.XXXXXXXXX DD
Latitudellongitude source: ❑3PS I]r'opographic map
(location of well mast be shown on a USGS topo map andattached.to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
8. GROUT: Depth Material Method
Top 0 Bottom ZO Ft. �qw e L-v Q1l
Topes Bottom 31�0 Ft. PC— ri -S a S 4a S to Z
: Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top. Bottom FL —in. in.
10. SAND/GRAVEL PACK:
Depth size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
/
/
12. REMARKS:
tt LI
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
: 15ANCAC 2C; WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS,
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
C. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality,- Information Processing, Form GW-1b
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] Rev. 2/09

° STA%Eo-
1. WELL CONTRACTOR:
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Nattiral Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
d. TOP OF CASING IS FT. Above Land Surface'
`Top of casing terminated at/or below land surface may require
Well Contractor (Individual) Name
a variance in accordance with 15A NCAC 2C :0118.
:'a. YIELD (gpm) METHOD OF TEST
Well Contractor Company Name
f. DISINFECTION: Type Amount
Street Address
: g. WATER ZONES (depth):
'
Top Bottom Top Bottom
City or Town State Zip Code
; Top Bottom Top Bottom
Top Bottom Top Bottom
Area code Phone number
' Thickness!
2. WELL INFORMATION:
: 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT#
: Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
; Top Bottom Ft.
SITE WELL ID #(if applicable)
: Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
; 8. GROUT. Depth Material Method
Industrial/Commerciai ❑ Agricultural ❑ Recovery ❑ Injection ❑
:Top D Bottom Ft. "c�. t 6 0 (-� hx=•1.Ab-V *{—
Irrigation❑ Other ❑ (list use)
' Top 'Zr) Bottoms Ft. C. W o 5 �a SEoZ 2
DATE DRILLED
Top Bottom Ft.
4. WELL LOCATION:
(Street Name, Numbers, Community, Subdivision;Lot No., Parcel, Zip Code)
CITY: COUNTY
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
[]Slope ❑Valley ❑Flat ❑Ridge. ❑Other
LATITUDE 36 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 DMS OR 7X:XXXXXXXXX DD
Latitude/longitude source: pGPS Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
or Town State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
c_)
Area code Phone number
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in. in.
Top Bottom Ft, in. in.
Top Bottom Ft. in. in.
; 10..SAND/GRAVEL PACK:
Depth Size
Top.
Bottom Ft.
Top
Bottom, Ft.
Top
Bottom Ft.
Material
11. DRILLING LOG
Top Bottom Formation Description
/ r
12. REMARKS'
6. WELL DETAILS: I'DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS,'AND THAT A COPY.OF THIS
a. TOTAL DEPTH: RECORD HAS BEEN. PROVIOED:TOTHE WELL OWNER.
b: DOES WELL REPLACE EXISTING WELL? YES,❑ NO ❑ SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
C. WATER LEVEL Below Top of•Casing:, FT.
(Use "+" if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form /09
Rev. 2l09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: [phone]

1 `C ONAESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
Well Contractor Company Name
Street Address
City or Town State Zip Code,
Area code Phone number
2. WELL INFORMATION:
d. TOP OF CASING IS
FT. Above Land Surface-
: 'Top of casing terminated atlor below land surface may require
a variance In accordance with 15A NCAC 2C .0118,
: e. YIELD Wpm):
METHOD OF TEST
f. bISINFECTION:'Type
Amount
g., WATER ZONES (depth):
Top Bottom
Top Bottom
:Top Bottom
Top Bottom
;Top. Bottom
Top Bottom
Thickness/
7. CASING: Depth
Diameter Weight Material
WELL CONSTRUCTION PERMIT#/ : Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(Inapplicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED
4. WELL LOCATION:
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: COUNTY
TOPOGRAPHIC / LAND SETTING: (check -appropriate box)
❑ Slope []Valley []Flit ❑ Ridge ❑ Other
LATITUDE 36 _ " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 7.5 " DMS OR 7X,XXXXXXXXX DD
Latitude/longitude source: p3PS ❑Topographic map
(location of well must be shown on a LSGS topo map andattached.to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name FacilityID# (if applicable)
Street Address
City or Town Slate Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES.❑ NO ❑
Top Bottom Ft.
Top Bot(ontFt.
: 8. GROUT: Depth Material
:Top b Bottom Z 0 Ft. i2k, �-_ 60 lct
Top �v_Bottom' d Ft._ tkiC J�— C/
Top Bottom Ft.
9. SCREEN: Depth
Diameter
Top Bottom
Ft. in.
Top Bottom
Ft. in.
Top Bottom
Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top
Bottom Ft.
Top
Bottom Ft.
Top
Bottom . Ft.
Method
Slot Size Material
in.
in.
in.
Material
11. DRILLING LOG
Top Bottom Formation Description
12. REMARKS:
"._.e 0'
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,
SIGNATURE OF'CERTIFIED WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: FT.
(Use "*" if Above Top of Casing) : PRINTED NAME,OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-1b
Rev. 2/09
161.7 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]

NONRESIDENTIAL ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
Well Contractor Company Name
Street Address
City or Town State Zip Code
Area a code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑, (list use)
DATE DRILLED
4. WELL LOCATION:
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: COUNTY
TOPOGRAPHIC / LAND SETTING: (check appropriate'box)
[]Slope ❑Valley OFlat ❑Ridge ❑Other
LATITUDE 36 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 " DMS OR 7X.XXXXXXXXX DD
Latitudeflongitude source: ❑GPS []Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID#(if applicable)
Street Address
City or Town Slate Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:.
: d. TOP OF CASING IS 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):
METHOD OF TEST
f. DISINFECTION: Type
Amount
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thickness/
: 7. CASING: Depth
Diameter Weight Material
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
. Ft.
: 8. GROUT: Depth Material Method
Top h. Bottom Z U FL P—, z
Top_ ZQ Bottom 3k',� Ft. 1J ct 4 `)t 13-21-5 iLe-L
Top Bottom
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top. Bottom
FL in. in.
Top Bottom
FL In. in.
Top Bottom
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
Top Bottom
Ft.
Tap Bottom
Ft.
Top Bottom
Ft.
11. DRILLING LOG
Top Bottom
/
/
12. REMARKS: t s r l l -%
Formation Description
I 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
76A NCAC 2C, WELLCONSTRUc710N STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑ : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: FT. :
(Use "+" if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - _Information Processing, Form Rev. 09 tiO9
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]

x
y ` _
r
CE IN R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
October 12, 2011
Robert and Ada Howell
113 Gavilan Avenue
Coral Gables, Florida
Ref: Issuance of Injection Well Permits WI0100172
Issued to Robert and Ada Howell
Arden, Buncombe County, North Carolina
Dear Mr. and Mrs. Howell:
Dee Freeman
Secretary
L
if 8Lll V
25 2r -1
In accordance with the application received on September 28, 2011, I am forwarding permit number WI0100172
for theconstruction and operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system
to be located at 1989 White Tree Trail, Arden, Buncombe County, NC 28704. This permit shall be effective from
the date of issuance until September 30, 2016, and shall be subject to the conditions and limitations stated therein,
including the requirement to install well identification tags as specified in Part 11.3 and to submit well
construction records as specified in Part VII.2. Be sure to read the entire permit to ensure that you are aware of
all compliance requirements of the permit.
You will need to notify this office at least 48 hours prior to beginning construction and operation of the injection
well system. In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must
submit an application to renew the permit 120 days prior to its expiration date. This permit is not transferable to
any person without prior notice to and approval by the Director of the Division of Water Quality.
Please contact meat [phone] or michael.roaers(@ncdenr.gov if you have any questions about your permit.
Best Regards,
�"'1
Michael Rogers, P.G. (NC & FL)
cc: Landon Dkdkd'son;-Asheville6Regional-Office 3
WI0100172 Permit File
Buncombe County Environmental Health Department
Larry Ferguson, Ferguson Well and Pump, 2731 New Leicester Highway, Leicester, NC 28748
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] FAX 1: 919-715-0588; FAX 2: 919-715-60481 Customer Service: 1-877-623-6748
Internet: wwvu.ncwatemualitv.oro
An Equal Opportunity 1 Affirmative Action Employer
One,
N orffiCarolirla
97fW447 I

w
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Robert and Ada Howell
FOR THE CONSTRUCTION AND OPERATION OF 7 TYPE 5QM INJECTION WELL(S), defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at 1989 White Tree Trail, Arden, Buncombe
County, NC 28704, constructed and operated in accordance with the application received September 28, 2011,
and in conformity with the specifications and supporting data submitted, all of which are filed with the
Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for. Construction and Operation of an injection well and shall be in compliance with Title 15A of
the North. Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until September 30, 2016, and shall
be subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 12th day of October, 2011.
aQ'LU'J*-
Coleen H. Sullins, Director
Division of Water Quality -
By Authority of the Environmental Management Commission.
Permit #W10100172 UIC/5QM Page 1 of 5
ver. 03/2010

Y
PART I - WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must 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). Any 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 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.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II — WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight (48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number 919 715-6166 and the Asheville Regional Office Aquifer Protection Section Staff, telephone
number 828-296-4500.
2. The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation corners) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
3. One well identification tag per grouping or `cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g).
PART III — OPERATION AND USE GENERAL CONDITIONS
1. 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.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). 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 to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit 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.
Permit #W10100172 UIC/5QM Page 2-of 5
ver. 03/2010

.� PART IV — PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. 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 including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
ground water resulting from the operation of this facility.
PART V — OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number 919 715-6166. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
PART VI - INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality 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 permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Division 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 and appropriate samples associated with the
injection. facility activities.
Permit #W10100172 UIC/5QM • Page 3 of 5
veF. 03/2010

PART VII — MONITORING AND REPORTING REQUIREMENTS
I
1. "All required documentation shall be submitted to:
Aquifer Protection Section — UIC Program Aquifer Protection Section
DENR — Division of Water Quality Asheville Regional Office
1636 Mail Service Center and 2090 US Highway 70
Raleigh, NC 27699-1636 Swannanoa, NC 28718
Ph# 919-715-3221 828-296-4500
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Asheville Regional Office within 30 days of completion
of well construction. Copies of the GW-1 form(s) shall also be given to the Permittee and retained on site
to be made available for inspection.
3. A copy of the site map updated with manifold locations required in Part I1.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Asheville Regional Office within 30
days of completion of well construction.
4. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection will be established and an
acceptable sampling reporting schedule shall be followed.
5. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Asheville Regional Office, telephone number 828-296-4500, any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
(C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
6. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
7. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII — PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
Permit #W10100172 UIC/5QM Page 4 of 5
ve r. 03/2010

PART IX — CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a; change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(1).
Notification shall be submitted to the addresses given in Part VII.1 of this permit.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to, the following:
(A) ' All casing and materials may be removed. prior to initiation of abandonment procedures if the
Director finds 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, if the Director determines that failure
to do so could lead to the contamination of an underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the well
through a pipe that extends to the bottom of the well and is raised as the well is filled.
(E) In the case of gravel -packed wells in which the casing and screens have not been removed, the
casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout
injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(1) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.1 of this permit.
Permit #W10100172 UIC/5QM Page 5 of 5
ver. 03/2010

AiD
AUMR
North Carolina Departrrlent of Environment and Natural
Dnation of Water Quality
Beverly Eaves Perdue Coleen H. Sullrm
Governor ' Detector
October 12, 2011
-Robert and Ada Howell
t I3 Gavilan Avenue
CC rd Gables..
Ref: Issuer u o--ft*tMon WtB P"=its �YI4I 1?2`Y
bsued-to-Rabert and-Ada=Howell - - --
Arden, Buncombe County, North Carolina
Dear Mr. and Mrs. Rowell:
0 7 2511
Asheville: Reslonal Office
Acfuifer Protection
Dee Freeman
I. Secretary.
In accordance with the applic atim received on September 29, 2011, I am foawerding permit number WIOI OO 172
for the construction and operation of a vertical dosed -loop goothermd mhed-flaid heat Pump injection well system
to be located at 1999 White- Tree Trail, Arden, Bumoombe County, NC 28704. -This permit shall be effective fl+om
the date of issuance until Sgftmber 30, 2016, and shall be subject to the conditions and liniitatioos stated therein,
including the regoremmt io 11119tall wen motion tap as apedded In Part 10 &ad to submit wen
construction records as specified in Part VIL2. Be me to read the anta+e permit to ensure that you are aware of
all compliance requirement of the permit.
You will need to notify this office at least 48 hours Prior to bgPulling constriction and operation of the injection
well system. In order to continue unmtm*ed legal we of the injection faelity for the stated purpose, you must
submit an application to anew the permit 120 days Prior to its eipiration date. This permit is not umferable to
any person without prior notice to and approval by the Dirwor of the Division of Water Quality.
Please contact meat [phone] or migbavjxo9M1@WA=MDv if you have any questions about your permit.
Best Regards,
Michael Rogers, P.G. (NC & FL)
cc: Landon Davidson, Asheville Regional wee
WIOIOO172 Permit File
Buncombe County Environmental Health Department
Larry Ferguson, Ferguson Well and Pump, 2731 New Leicester Aighway, Leicedw, NC 28748
AQUIFER PROTECTION SECTION
1636 Mai Service C IK. Raleigh. Nom CaMW 2M.4-1 MG
Loraft 2728 Capilel Boutevani, Rako. Nadi CSI&M 27684
Phone: 919-M3221 %FAX 1; 919.715aM. FAX 2: 919-715 M t C sbmersavioe:1:8774238748
IftwotwMinvaWMAWram
M E4a OppMMW IMmake&*m Empklyer
A?waff
�Carolina
i

Nortlt Cantina Department of Environment and Natural Resources- Division of Watcr Quality
WELL CONTRACTOR CERTIFICATION # NCWC2028 A
1. WELL CONTRACTOR:
_Bobby W. Potts
Well Contractor (Individual) Name
_Ferauson's Well and Pump LLC
Well Contractor Company Name
2731 New Leicester HWV
Street Address
Leicester N.C. 28748
City or Town State Zip Code
8( 28 ) 258-8496
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W 10100172
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(ifapplicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery Injection Ill
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10/17/201 1
4. WELL LOCATION:
1989 White Tree Trail
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Arden COUNTY Buncombe
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
LATITUDE 36 ° 35 28.2060 ° DMS OR 3X.XXXXXXxXX DD
LONGITUDE 75 82 , 36.3030 ° DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: W3PS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State ZIp Code
Rnhart A Ada Howell
Contact Name
_1AISA Whit _ Tr _A Trail
Mailing Address
Ard _n N Q 9A704
City or Town State Zip Code
t 828301-2M7
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:3OO EL
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
C. WATER LEVEL Below Top of Casing: N/A FT.
(Use °+• if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface -
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15-A NCAC2C.0118.
e. YIELD (gpm): 0 METHOD OF TEST�Isj
f. DISINFECTION: Type_fJ1IOr1ne .Amount fi n7
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
:.Top. Bottom Top Bottom.
Top Bottom Top Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
Top NIA Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Material Method
Top N A Bottom
Ft.
Top Bottom
Ft
Top Bottom
Ft
9. SCREEN: Depth
Diameter Slot Size Material
Top N/A Bottom
Ft in. in.
Top Bottom
Ft in, in.
Top Bottom
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top
Bottom Ft
Top
Bottom Ft
Top
Bottom_ Ft
Material
: 11. DRILLING LOG
Top Bottom Formation. Description.
0 / 40 DirMav
40 / 3. 00 Rock/Granite
/
12. REMARKS:
• I DO HEREBY CERTIFY THAT THIS WELL WAS CCNSTRLICTED IN ACCORDANCE WITH
16A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND.THATA COPY OF THIS
RECO k PROVIDED TO WE OWNER.
I qgm
��SIGF CERTIFIED WELL CONTRACTOR D E
PRINTED NAMf OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion, to: Division of Water Quality - Information processing, Form GWA b
1617 Mail Service Center, Raleigh; NC276994619 Phone: [phone] Rev_ 2=

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 2028 A
1. WELL CONTRACTOR:
_Bobby W. Potts
Well Contractor (Individual) Name
Ferauson's Well and Pumn LLC
Well Contractor Company Name
_2731 New Leicester Hwy.
Street Address
Leicester N.C. 28748
City or Town State Zip Code
8( 28 ,) 258-8496
;Area code Phone number
d. TOP OF CASING IS 0 FT. Above Land Surface -
*Top of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 0 METHOD OF TEST Rio
: f. DISINFECTION: Type (;hlOrirtA Amount 8 07
g. WATER ZONES (depth):
:Top NJA Bottom Top Bottom
:.Top- Bottom. Top. Bottom.
: Top Bottom Top Bottom
Thickneaa/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight
WELL CONSTRUCTION PERMIT#W10100172 Top N/A Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(ifapplicable
)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 6(
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10/17/2011
4. WELL LOCATION:
1989 White Tree Trail
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Arden COUNTY Buncombe
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
m(siope ❑Valley ❑Flat ❑Ridge []Other
LATITUDE 36 35 28.2000 DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 82 36.3140 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: W3PS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.).
Facility Name Facility ID# (if applicable)
Street Address
City. or Town State Zip Code
-Robert & Ada How _II
: Contact Name
_1989 White Tree Trail
Marling Address
_ Arden N r 8704
City or Town State Zip Code
(828301-2557
Area code Phone number
B. WELL DETAILS:
a. TOTAL DEPTH:_ 300 Ft-
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use °+° if Above Top of Casing)
Top Bottom Ft.
Top Bottom Ft.
: 8. GROUT: Depth Material
Top N/A Bottom Ft.
Top Bottom Ft.
Top Bottom Ft
Material
Method
9. SCREEN: Depth Diameter Slot Size Material
: Top N/A Bottom Ft in. in.
Top Bottom Ft in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size
Top
Bottom Ft
Top
Bottom Ft.
Top
Bottom Ft
11. DRILLING LOG
Top. Bottom
0 / 40
40 / 300
J
l
12. REMARKS:
Material
Formation Description.
Dirt/Clay
Rock/Granite
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
tt4FVP
PROIDED TO WELL OWNER.
IFIE L CONTRACTOR#—D—IAfE---
A
: PRINTED ERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information processing, Form GWA b
1617 Mail Service Center, Raleigh, NC-27699161, Phone: [phone] Rev. 2109

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envi omneeot and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 2028 A
1. WELL CONTRACTOR:
Bobby W. Potts
Well Contractor (Individual) Name
Ferauson's Well and Pump. LLC
Well Contractor Company Name
2731 New Leicester Hwy.
Street Address
Leicester N.C. 28748
City or Town State Zip Code
8( 28 1 258-8496
Area code Phone number
d. TOP OF CASING IS 0 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): 0 METHOD OF TEST_ Rig
f. DISINFECTION: Type Chlorine Amount 8 n7
g. WATER ZONES (depth):
Top N/A 'Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
2. WELL INFORMATION: ; 7. CASING: Depth Diameter
WELL CONSTRUCTION PERMIT# W 10100172 .-Top N/A Bottom Ft.
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(ifapplicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection N(
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10/18/201 1
4. WELL LOCATION:
1989 White Tree Trail
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Arden COUNTY Buncombe
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
C(Siope ❑Valley ❑Flat []Ridge ❑Other
LATITUDE 36 35 28.2040 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 0 82 ' 36.3120 " DMS OR 7X.XXXXXXXXX DD
LatltudeAongitude source: VGPS Oiopographic map
(location of wel/ must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Robert & Ada Howell
Contact Name
19139 Whit . Tree Trail
Mailing Address
_ Arden 28704
City or Town State Zip Code
(828,d 301-2557
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 300 Ft.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0 /
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use °+° if Above Top of Casing)
Thickness/
Weight Material
Top
Bottom
Ft.
Top
Bottom
Ft.
8. GROUT:
Depth
Material Method
Top N/A
Bottom
Ft.
Top
Bottom
Ft
Top
Bottom
Ft.
: 9. SCREEN:
Depth
Diameter Slot Size Material
Top N/A
Bottom
Ft -in. in.
Top
Bottom
Ft in. in.
Top
Bottom
Ft in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft
11. DRILLING LOG
Top. Bottom Formation Description.
0 / 40 Dirt/Clay
40 / 300 Rock/Granite
L
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
st�7iNATOW OF CERTIFIED CONTRACTOR D E
Ws
PRINTED NAM81OF PERSON CbNSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Infonnatiat Processing, Form GWA b
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: [phone] Rev. 2109

N0NRESLDE7WL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 2028 A
1. WELL CONTRACTOR:
_Bobby W. Potts
Well Contractor (Individual) Name
Ferauson's Well and Pump. LLC
Well Contractor Company Name
2731 New. Leicester Hwy.
Street Address
Leicester N.C. 28748
City or Town State Zip Code
8t_ 28 ) 258-8496
Area code Phone number
: d. TOP OF CASING IS 0 FT. Above Land Surface'
*Top of casing terminated aVor below land surface may require
a variance in accordance with 19A NCAC 2C .01 %
e. YIELD (gpm): �_ METHOD OF TEST Rip
f. DISINFECTION: Type Chlorine Amount R n7
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT#W10100172 *. Top N/A Bottom Ft.
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID *(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection N(
Irrigation[] Other ❑ (list use)
DATE DRILLED 10/18/2011
4. WELL LOCATION:
1989 White Tree Trail
(Street Name, Numbers, Community, SubdMaion, lot No., Parcel, Zip Code)
CITY: Arden COUNTY Buncombe
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Alope ❑ Valley ❑ Flat ❑ Ridge ❑Other.
LATITUDE 36 35 28.2060 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 82 ' 36.3180 " DMS OR 7X.XXXXXXXXX DD
LatitudeAongitude source: .W3PS pfopographic map
pocatfon of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City. or Town State Zip Code
Robert P. Ada Howell
Contact Name
1989 White Tree Trail
Mailing Address
Arden N f 8704
City or Town State Zip Code
(828,E 301-2557
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:_300 Ft-
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
c. -WATER LEVEL Below Top of Casing: _N/A FT.
(Use'+' if Above Top of Casing)
Top Bottom
Ft
Top Bottom
Ft
:8. GROUT: Depth
Material Method
Top N/A Bottom
Ft.
: Top Bottom
Ft
Top Bottom
Ft
: 9. SCREEN: Depth
Diameter
Slot Size Material
: Top N/A Bottom
Ft
in. in.
Top Bottom
Ft
in. in.
Top Bottom
Ft.
in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
: Top Bottom
Ft
Top Bottom
Ft
Top Bottom
Ft
: 11. DRILLING LOG
Top Bottom Formation Description.
0 / 40 Dirt/Clay
40 / 300 Rock/Granite
/
L
: 12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RE D HA BEEN PROVIDED TO THE LL OWNER.
: SI A U OF C RTIFIED WA=ONTRACI R- D TE
S
PRINTED NAMI OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - In forliva* n Processing, Form GWA b
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: (919) 807-Mo Rev. 2/09

NONlIWELL CONSTRUCTION RECORD
Nm& Carolina Department of Environment and Natural Resources- Division of water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 2028 A
1. WELL CONTRACTOR:
Bobby W. Potts
Well Contractor (Individual) Name
Ferauson's Well and PUMD LLC
Well Contractor Company Name
2731 New Leicester HWV
Street Address
Leicester N.C.28748
City or Town State Zip Code
Wi ) 258-8496
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W 10100172
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(•Ifapplicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection N(
Irrigation Other ❑ (list use)
DATE DRILLED 10/19/2011
4. WELL LOCATION:
1989 White Tree Trail
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Arden . COUNT,( -Buncombe
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope ❑Valley. []Flat ❑Ridge []Other
LATITUDE 36 0 35 - 28.2050 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 0 82 , 36.3190 " DMS OR 7X-XXXXXXXXX DD
Latitude/longitude source: W3PS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the,well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City, or Town State Zip Code
Robert r, Ada How II
Contact Name
I ARA White Trap Trail
Mailing Address
_ Arden N f 8704
City or Town State Zip Code
(828_301-2557
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 300 Ft.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
c. WATER LEVEL Below Top of casing: N/A FT.
(Use "+° if Above Top of Casing)
d. TOP OF CASING IS _Q 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 (gem): 0 METHOD OF TEST Rid
f. DISINFECTION: Type Chlorine Amount 8 07
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
:7. CASING: Depth Diameter Weight Material
Top N/A Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
:8. GROUT:
Depth
Material Method
: Top N/A
Bottom
Ft.
Top
Bottom
Ft
Top
Bottom
Ft.
9. SCREEN:
Depth
Diameter Slot Size Material
Top N/A
Bottom
Ft in. in.
Top
m Botto
Ft. in. in.
Top
Bottom
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bottom Ft -
Top -Bottom Ft
11. DRILLING LOG .
Top Bottom Formation. Description.
0--/. 40 Dirt/Clay
40 /a00 RockMranite
/
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD S BEEN PROVIDED TO TH WELL OWNER,
SI A U OF ERTIFIE W CONTRACTOR D TE
ebb S
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1 b
1617 Mail Service Center, Raleigh, NC 27699161, Phone: (919) 807-MO Rev. 2/09

NONRESIDENTIAL WELL CONSTRUCTION RECORD
Notch Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 2028 A
1. WELL CONTRACTOR:
_Bobby W. Potts
Well Contractor (Individual) Name
Ferauson's Well and Pump, LLC
Well Contractor Company Name
2731 New Leicester Hwy.
Street Address
Leicester N.C. 28748
City or Town State Zip Code
8(_228) 258-8496
Area code Phone number
d. TOP OF CASING IS 0 FT. Above Land Surface -
*Top of casing terminated at/or below land surface may require
a variance in accordance with 1SA NCAC 2C .0118.
e. YIELD (gpm): 0 METHOD OF TEST Rep
f. DISINFECTION: Type Chlorin - Amount 8 n7
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
Top Bottom Top. Bottom
Top Bottom Top Bottom
2. WELL INFORMATION: : 7. CASING: Depth Diameter
WELL CONSTRUCTION PERMIT#W1O100172 ; Top N/A Bottom Ft.
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection N(
Irrigation[] Other ❑ (list use)
DATE DRILLED 10/20/2011
4. WELL LOCATION:
1989 White Tree Trail
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Arden COUNTY Buncombe
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope ❑Valley. []Flat ❑Ridge []Other
LATITUDE 36 o 35 128.2090 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 a 82 1 36.3210 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: V3PS Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
S. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Rohert_P, Ada Howell
Contact Name
1989 White Tree Trail
Mailing Address
Arden N C 28704
City or Town State Zip Code
(828301-2557
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 300 Ft-
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
c. WATER LEVEL Below Top of Casing:. N/A FT.
(Use °+° if Above Top of Casing)
Thickness/
Weight Material
Top Bottom
Ft
Top Bottom
Ft.
8. GROUT: Depth
Material Method
Top N/A Bottom
Ft.
Top Bottom
Ft
Top Bottom
Ft
: 9. SCREEN: Depth
Diameter Slot Size Material
Top N/A Bottom
Ft
in. in.
Top Bottom
Ft
in. in.
Top Bottom
Ft
in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
Top Bottom
Ft.
Top Bottom
Ft
Top Bottom
Ft
11. DRILLING LOG
Top Bottom.
Formation. Description
0_/ 40
Dirt/Clav
• . 0 / 300
Rock/Granite
1
L
/
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCACf2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
REC70RD
BEEN PROVIDED TO A
W L OWNER. ,
/),D I
:SIGNATLfREOFCERTIFIELIWEL ONTRACTOR DOE
O S
PRINTED NAME OF P RSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information processing, Form GW-1 b
1617 Mail Service Center, Raleigh, NC 27699461, Phone: (919) 807-M0 Rev. 2109

t NONRESIDENTIAL WELL coNSTRucrION RECORD
North Carolina Department of Environment and Natural Resotm:es- Division of Water Quality
1' ""'""" • WELL CONTRACTOR CERTIFICATION # NCWC 2028 A
1. WELL CONTRACTOR:
Bobbv W. Potts
Well Contractor (Individual) Name
Ferauson's Well and Pump. LLC
Well Contractor Company Name
2731 New Leicester Hwy.
Street address
Leicester N.C. 28748
City or Town State Zip Code
8( 28 .) 258-8496
,Area code Phone number
d. TOP OF CASING IS 0 FT. Above Land Surface -
*Top of casing terminated attor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): �_ METHOD OF TEST Rig
f. DISINFECTION: Type Chlarin _ Amount 8 n7
g. WATER ZONES (depth):
Top_ N/A Bottom Top Bottom
: Top Bottom TO Bottom
Top Bottom Top Bottom
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT#W10100172 'Top N/A Bottom Ft
OTHER ASSOCIATED PERMIT#(ifapplicable) : Top Bottom Ft
SITE WELL ID #(if applicable) : Top Bottom Ft
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection fi(
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10/21/2011
4. WELL LOCATION:
1989 White Tree Trail
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Arden COUNTY Buncombe
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
I(Slope ❑ Valley. ❑ Flat ❑ Ridge ❑ Other
LATITUDE 36 • 35 28.1890 DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 • 82 36.3160 DMS OR 7X.XXXXXXXXX DD
Latitude/longltude source: W3PS propographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Robert A Ada Howell
Contact Name
1989 White Tree Trail
Mailing Address
_ Arden N 8704
City or Town State Zip Code
(828301-2557
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 300 Ft-
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO �I
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use •+• if Above Top of Casing)
:8. GROUT:
Depth
Material Method
: Top N/A
Bottom
Ft.
Top
Bottom
Ft
Top
Bottom
Ft
9. SCREEN:
Depth
Diameter Slot Size Material
Top N/A
Bottom
Ft
in. in.
Top
Bottom
Ft
in. in.
Top
Bottom
Ft.
in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
Top
Bottom
Ft.
Top
Bottom
Ft
Top
Bottom
Ft
11. DRILLING LOG
Top. Bottom Formation Description.
0 / 40 Dirt/Clay
40 / 300 Rock/G6nite
1
L
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECO BEEN PROVIDED TO E ELL OWNER.
SIGNATuRr= OF CERTIFI L CONTRACTOR TE
PRINTED NAM OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Dhftlon of Water Quality - InFomtation Processing, Form b
1617 Mail Service Center, Raleigh, NC 27699461, Phone: (919) 807-WO Rev. 2109
09

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCRS
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP MIXED -FLUID GEOTHERMAL INJECTION WELLS
These wells circulate fluids other than potable water as part of a geothermal heating and cooling system
(check one) _x_New Application Renewal* Modification
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: 9/13 , 2011
PERMIT NO. (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence _x_ Business/Organization
Government: State Municipal County Federal
B. PERMIT APPLICANT — For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency:
Robert Spencer Howell & Ada Mesana Howell
Mailing Address: 113 Gavilan Ave.
City: Coral Gables State: FL Zip Code: 33143 County:
Day Tele No.: 305-588-1666 Cell No.: Same
EMAIL Address: adamesanaQvahoo com Fax No •na
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 962465740300000 County: Buncombe
(2) Physical Address (if different than mailing address): 1989 White Tree Trail
City: Arden State: NC Zip Code: 28804
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Ferguson Well and Pump
Well Drilling Contractor Certification No.: _ 2029-a , 2028-a
Company Name: Ferguson Well & Pumn
Contact Person: Larry Ferguson EMAIL Address: fergusonwell(a)excite com
Address: 2731 New Leicester Hwy.
City: Leicester Zip Code: 28748 State: nc County: Buncombe
Office Tele No.: _828-258-8496 Cell No.: Fax No.:828-683-2620 00CEIV
ED/DENR/DWQ
Protection Section
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller) Aquifer er P 18 2011
GPU/UIC SQM Permit Application (Revised 1/24/2011) Page 1

Company Name: HVAC Inc
Contact Person: Joe Leonard EMAIL Address: ilonard hvac-mc.com
Address: 101 3" St po box 788
City: Bristol Zip Code: 37621 State:TN County:
Office Tele No.: 423-989-5000
E. WELL CONSTRUCTION DATA
Cell No.: 423-361.9542 Fax No.:423-989-5015
(1) Number of borings to be constructed*: 7 Depth of each boring(feet): 300
* If existing water supply wells will be used then provide the information in item (4) below.
(2) Chemical additives to be used: R-22
Other
Propylene glycol Ethanol x
(other additives will need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc); Poly ethylene
(4) Well casing. If the well(s) will use casing then provide the tyke (steel, PVC, plastic, etc.), diameter, depth,
and extent of casing appearing above ground:
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite** _x_Other (specify) i�
"By selecting bentonite grout, a variance is hereby requested to I SA 1` AC 2C .0213(d)(1)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from C) to � (feet) � � (,�,, J ��
If well has casing, indicate grout depth: from to (feet)
G. WELL LOCATIONS — Maps must be scaled or otherwise accurately indicate distances and orientations of features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow,
(1) Attach asite-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: Inmost cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be draw: in by hand. Also, a `layer' can be selected showing topographic contours or
elevation data.
GPU/U1C 5QM Permit Application (Revised 1/24/2011)
Page 2

H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer:
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the property deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate :and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Si n o Owner/Applicant
ME
4PrinType Full Name
vvop
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636 RECEIVED / DENR / DWQ
Aquifer Protection SeGtipn
Telephone [phone] SEP 19 2011
GPU/U1C 5QM Permit Application (Revised 1/24/2011)
Page 3

VRtr�RI OiY 00WR1
• � 4I(IIM
v4K 6 K
NOTES:
1. THIS SURVEY MEETS THE FEOUOIEMUITS FOR A CLASS 'A' SURVEY AS
DEFINED IN THE 'STANDARDS OF PRACTICE FOR LAW SURVEYING IN
NORTH CARGIUNA.'
2. SURVEY MAY BE SUBJECT TO RIGHTS -OF -WAY, EASUIDITS.
RESERVATIONS AND RESTRICTIONS. MITTEN AND UNWRITTEN, RECORD AND
UNRECORD40.
5. TOTAL AREA OF PARCEL - 1.52 ACRES
4. ALL AREAS CALCULATED BY COORDINATE COUPUTAYICH METHOD.
5. INS 91RYEY WAS PRFPAIRFD WTNOUT BENEFIT OF ABSTRACT TITLE
AND MATTERS OF TITLE SHOULD BE REFERRED TO AN ATTORNEY -AT -LAW.
6. THE CERTFICAMON SHOWN HEREON 15 NOT A CERTIFICATION OF TITLE,
ZONING OR FREEDOM FROM ENCUMBRANCES.
7. ADOOITONG PROPERTY OWNER INFORMATION TAAEN FROM BUNCOUBE
CO. OS WEB 97L
8. THE PAR IX UES IN ZONE '1C AS SHOWN ON THE FLOOD INSURANCE
RATE MAP .TTOOBBiW DATED 01-0-2010.
9. ALL DISTANCES SHOW! ARE HORIZONTAL GROUND DISTANCES UNLESS
OINERWSE NOTED,
10. DEED REF CAF 4768 PG 105. PB 5B PG 191
11. THERE IS A Y DRAINAGE AN U1IUTIES EASEUETN ON EACH SIDE OF
ALL INTERIOR LOT AND OMSON LINES AND 10 FEET WTHN ALL OUTSIDE
BOLUNDAIIY UNITS. DWT WHERE NOTED OTHERWSC
12. MINIMUM BUIID:NO SETBAQt LINES ME AS FOLLOWS: 2W FRONT (AS
MEASURED FROM ROW LINE). 21 SIDES, 50' REM. AND 20' FROM
PROPERTY U NES ADJACENT TO OIF COURSE SETBACK SHALL BE 5'
ALLONO PROPERTY LINES THAT ABUT THE U.S. FOREST SEWCE LAND.
15. DASHED LINES NOT SURVEYED
14. NO NOS MONUMENT YAWN 2D00'
,AfiR TAUT TIUA�
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SVRKY MAx UMFR MY SUPFRW90H, THAT THE ERROR or CLOSURE IS MOA00
'
$� ASSOCIATES 4�L��T—^ OF
THAT THIS MAR WAS PREPAREDIN ACCORDANCE WIN C.S. 47-30 AS AMENDED.
A .1D t 1, . 1 2 Y A F P A LOT 214 PHASE 2
wlwss MY NAxo ANDsFAL MS_ DAY of 20-.
6
PINS: 9624-65-7403
DB 3424 PG 470
AVERY CREEK TOWNSHIP
M
BUNCOMBE COUNTY, NORTH CAROLINA
SCALE: 1" - 40' 08/30/2011
LICENSURE y C-2806
�SEALYr °
g 2755 r
W. EDWIN HOLMES, P.L.S.
`Z C9,
^0
ED HOLMES AND ASSOCIATES LAND SURVEYORS, PA
1567 PATTON P.O. BOX 17335. NC 28816
01
/// °
PHONE: [phone] FAX: [phone]
828) (828) 25
40' 20' 0' 40, 80' 120' 180 200'

Buncombe County Map
Feet n
0 37.5 75 150 225 300 /�\
r
The Information provided is based on the best available data at the time of currency for all datasets. It is the requestor's responsibility to verify any Information derived from the GIB data
before making any decisions or taking any actions based on the Information. Buncombe County shall not be held liable for any errors in the GIB data. This Includes errors of omission,
commission, errors concerning the content of the data, and relative and positional accuracy of the data.

Buncombe County Map
N
Feet A
0 115 230 460 690 920
The Information provided is based on the best available data at the time of currency for all datasets. It Is the requestors responsibility to verify any Information derived from the GIS data
before making any decisions or taking any actions based on the information. Buncombe County shall not be held liable for any errors in the GIB data. This includes errors of omission,
commission, errors concerning the content of the data, and relative and positional accuracy of the data.

09'/.ZV 2011 WED 16, 18 FAX
0002/0.02
27 September, 2011
Michael Rogers, P.G.
Env! ronmental.Speciatist
N.C,.Division_.of Water:Quaiity; A.P.S.
16aS Mall Service Center
Raleigh, N.C..27699-4636
Dear Mr., Rogers:
I_give-permission for John Judd, ownerdfJudd Builders; Asheville, N:C. to:signanypermits required
which pertain%tothe construction -of the geothermal system planned for our:home.which is.located on
1989 White Tree Trail; Arden, N.C.
Thank you very much far your help,
f^}
/ r
'Ada Mesana H ell
113 Gavilan Ave.
Coral Gables, Fla. 33149
3)0c, 14,

Rogers, Michael
From: [e-mail] on behalf of John Judd Sr [e-mail]]
Sent: Wednesday, September 28, 2011 5:41 PM
To: Rogers, Michael
Subject: Re: Fw: Mesana Geothermal Permit Application
Attachments: howell drill permit.pdf
Michael, here is the signed letter. Thanks for all your help. Call me if I need to do anything else, John Judd Sr.
828-301-2557
On Sat, Sep 24, 2011 at 5:25 PM, Ada Howell <adamesana cyahoo.com> wrote:
----- Forwarded Message ---
From: "Rogers, Michael" <michael.roaers(cDncdenr..qov>
To: "adamesana4lyahoo.com" <adamesana(a-)vahoo.com>
Cc: "fergusonwell(cDexcite.com" <fergusonwell(cDexcite.com>
Sent: Thursday, September 22, 2011 3:52 PM
Subject: Mesana Geothermal Permit Application
Hello -
We have received your geothermal permit application. However, it is incomplete. As the property owner, you need to sign the
application; or if John Judd is signing the application on your behalf, we need a letter from you authorizing Judd to sign the
application on your behalf. You can, if you like, scan in and e-mail the revised signature page, or authorization letter, to mein reply to
this e-mail.
Also, we need the depth of the grout for the wells.
Thank you for your cooperation.
If you have any questions or comments, please advise.
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality- Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line (,919) 715-6166; Fax [phone] (put to my attn on cover letter)
http://portal.ncdenr.ora/web/wq/ns/gMro/pennit-appli cati onsgaeothennApps
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

HCDENR
North Carolina Department of Environment and
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
October 5, 2011
Robert Spencer Howell
Ada Mesana Howell
113 Gavilan Avenue
Coral Gabels, FL 33143
Dear Mr. and Mrs. Howell:
Natural Resources
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. WI0100172
Robert & Ada Howell SFR
Injection Mixed Fluid GSHP
Well System
Buncombe County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on September 28, 2011. Your application package has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Asheville Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit 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] or [e-mail].
Sincerely,
o�A , k�
for Debra J. Watts
Groundwater Protection Unit Supervisor
cc: Asheville Regional Office, Aquifer Protection Section
Larry Ferguson - Ferguson Well & Pump
Joe Leonard - HVAC, Inc
Permit File WI0100172
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] FAX 1: 919-715-0588; FAY 2: 919-715-60481 Customer Service:1-877-623-6748
Internet: www.ncwatemualitv.org
An Equal Opportunity 1 Affirmative Action Employer
NoiihCarolina
Naturally

Buncombe County Tax Lookup - Property Card
Page 1 of 2
A property with WORK IN PROGRESS is currently being reviewed by the Buncombe County tax
department. This review could include a tranfer of ownership, a split parcel, a combined parcel,
and acreage adjustment, etc.. For these properties, you will see the values which were last
approved before the review began. Be aware that these values could change once the review is.
complete. If a parcel is new, you will have access to limited property data until the review is
complete and values have been approved.
COUNTY OF BUNCOMBE, NORTH CAROLINA
Web Property Record Card
Q•.
9624-65-7403-00000
This parcel is currently being reviewed. Values may change.
Owner Information
ADA MESANA HOWELL
113 GAVILAN AVE
CORAL GABLES FL 331�
Locationa989 WHITE TREE TRL
Taxing Districts
Buncombe County
SKYLAND FIRE
Date Printed: 9/22/2011
Parcel Information
Total Property Value: 1,641,800
Status:
Active
kccount:
8242222
)eed Date:
3/17/2010
Seed Book/Page:
4768 / 1465
?lat Book/Page:
0147 / 0194
Legal Reference:
WARRANTY OR SPL/COMP TRANSFE]
Location:
1989 WHITE TREE TRL
lass:
RES BUILDING LOT
Neighborhood:
WALNUT COVE
Subdivision:
THE CLIFFS AT WALNUT COVE
Sub Lot:
214
Ownership History
Transfer
Price
Legal
Deed
Qualified
Vacant
When
Account
Seller Names
Date
Reference
Book/Page
Sold
WARRANTY OR
THE CLIFFS AT
03/17/10
$1,olo,000
SPL/COMP
4768 / 1465
Yes
Yes
8166269
WALNUT COVE
TRANSFER
ILLC
WATERFALL
10/10/03
$850,000
WARRANTY OR
SPL/PARC
3424 / 047o
No: A
Yes
8169857
INVESTMENT
GROUP LLC
Assessment History
Year
Account
Acres
Land
Bldgs
IOther
mpr
Assessed
Dese
Exemptions
Deferred
Taxable'
2011
8242222
1.51
1,641,800
0
0
1,641,8o0
0
0
1,641,800
2o10
8166269
1.51
1,641,800
o
0
1,641,800
0
0
1,641,800
2oo9
8166269
1.51
1,641,800
0
0
1,641,800
0
0
1,641,800
20o8
8166269
1.51
1,641,800
o
0
1,641,800
0
0
1,641,8o0
2007
8166269
1.51
1,641,800
o
0
1,641,800
0
0
1,641,800
20o6
8166269
1.51
1,64i,800
o
o
1,641,800
0
0
1,641,800
2005
8166269
1.51
1,4o8,000
o
0
1,4o8,000
10
0
1,408,000
2004
18166269
1.51
1,4o8,000
0
10
11,408,000
1
10
10
1,408,000
Land Data Total Acres: 1.51 Land Value: Other Value: o
Acres 16 1,800 Improvements
http://www.buncombetax.org/PropertyCard.aspx 9/22/2011

Buncombe County Tax Lookup - Property Card Page 2 of 2
Segment* I Units I Description
i.ri Acres ILOT
Total Building Value: o
http://www.buncombetax.org/PropertyCard.aspx 9/22/2011

Esuncombe Lounty map
N
Feet
0 100 200 400 600 800
The information provided is based on the best available data at the time of currency for all datasets. It is the requestor's responsibility to verify any information derived from the GIS data
before making any decisions or taking any actions based on the information. Buncombe County shall not be held liable for any errors in the GIS data. This includes errors of omission,
commission, errors concerning the content of the data, and relative and positional accuracy of the data.

Rogers, Michael
From: Rogers, Michael
Sent: Thursday, September 22, 2011 2:30 PM
To: '[e-mail]'
Cc: '[e-mail]'
Subject: Mesana Geothermal Permit Application
We have received your geothermal permit application. However, it is incomplete. As the property owner, you need to
sign the application; or if John Judd is signing the application on your behalf, we need a letter from you authorizing Judd
to sign the application on your behalf. You can, if you like, scan in and e-mail the revised signature page or authorization
letter to me in reply to this e-mail.
Also, we need the depth of the grout for the wells.
Thank you for your cooperation.
If you have any questions or comments, please advise.
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality- Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http //portal ncdenr orq/web/wglaps/gwpro/permit-applications#geothermAp[is
E-mail correspondence to and from this address maybe subject to the North Carolina Public Records Law and maybe disclosed to third parties

GRAVEL
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ADA HOWELL
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Pr
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCRC
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP MIXED -FLUID GEOTHERMAL INJECTION WELLS
These wells circulate fluids other than potable water as part of a geothermal heating and cooling system
(check one) _x_New Application Renewal* Modification
int or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: 9/13 2011
PERMIT NO. -,?-a(leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence _x_ Business/Organization
Government: State Municipal County Federal
B. PERMIT APPLICANT — For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency:
Robert Spencer Howell & Ada Mesana Howell
Mailing Address: 113 Gavilan Ave.
City: Coral Gables State: FL Zip Code: 33143 County:
Day Tele No.: 305-588-1666 Cell No.: Same
EMAIL Address: adamesanaevahoo.com Fax No •na
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 962465740300000 County: Buncombe
(2) Physical Address (if different than mailing address): 1989 White Tree Trail
City: Arden State: NC Zip Code: 28804
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Ferguson Well and Pump
Well Drilling Contractor Certification No.: 2029-a . 2028-a
Company Name: Ferguson_ Well & Pumn
Contact Person: Larry Ferguson EMAIL Address: [e-mail]
Address: 2731 New Leicester Hwy.
City: Leicester Zip Code: 28748 State: nc County: Buncombe
Office Tele No.: _828-258-8496 Cell No.: Fax No.:828-683-2620
RECEIVED / DENR / DINp
1'rotertian Section
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller) Aquifer er P 19 2011
GPU/UIC SQM Permit Application (Revised 1/24/2011)
Page 1

r . ,
Company Name; HVAC Inc
Contact Person: Joe Leonard EMAIL Address: ]eonard hva,-mc.com
Address: 101 3' St po box 788
City: Bristol Zip Code: 37621 State:TN
County:
Office Tele No.: 423-989-5000 Cell No.: 423-361-9542
Fax No.:423-989-5015
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: 7 Depth of each boring(feet): 300
* If existing water supply wells will be used then provide the information in item (4) below.
(2) Chemical additives to be used: R-22 Propylene glycol Ethanol x
Other (other additives will need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc): Poly ethylene
(4) Well casing. If the well(s) will use casing then provide the tyke (steel, PVC, plastic, etc.), diameter, depth,
and extent of casing appearing above ground:
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite** _x Other (specify)
"By selecting bentonite grout. a variance is hereby requested to I A NCAC 2C .0213(d)(I )(A). which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from - to ? (feet)
If well has casing, indicate grout depth: from to
(feet)
G. WELL LOCATIONS — Maps must be scaled or otherwise accurately indicate distances and orientations of �����
features located within 1000 feet of the injection well(s). Label all features clearlyand include a north arrow.
(1) Attach a site -specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
,(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
Obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc, can then be drawn in by hand Also, a `layer' can be selected showing topographic contours or
elevation data.
GPU/UIC 5QM Permit Application (Revised 1/24/2011)
Page 2

H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer:
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the property deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate :and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false infonnation. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved. specifications and conditions of
the Permit."
Sin Owner/Applicant
© A4• "SA1410 NIFaVIfSE�/KCoe,
Print or Type Full Name
�l �/QD O )JaD�,r� ) G(�
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636 ECE1VED / DENR / DWQ
Aquifer Protection Section
Telephone [phone] SEP 19 2011
GPU/WC 5QM Permit Application (Revised 1/24/2011)
Page 3

` Uc Fmppi Dim
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NOTES:
I. THIS SURVEY MEETS THE REQUIREMENTS FOR A CLASS 'A' SURVEY AS
BEIM IN 111E 'STANDARDS OF PRACTICE FOR LAND SURVEYING IN
NORTH CAROUNA'
2. SURVEY NAY BE SUB.ECT TO RIGHTS-O'-WAY, EASEMENTS,
RESERVATIONS AND MTRCMONS, WITTEN AND UNWRITTEN. RECORD AND
UNRECO M.
J. TOTAL AREA OF PARCEL . 1.52 ACRES
4. ALL MEAS CALCULATED BY COORDINATE COMPUTATION METHOD.
5. THIS SURVEY WAS PREPARED WITHOUT BENEFIT OF ABSTRACT TITLE
AND MATTERS OF TITLE SHOULD BE REFERRED TO AN ATTORNEY -AT -LAW.
B. TIE CERTIFICA71OR SHOWN HEREON IS NOT A CERTIFICATION OF TITLE,
ZONNO OR FREEDOM FROM ENCUMBRANCES.
7. ADJOINING PROPERTY OWNER INFORMATION TARN FROM BUNCOMBE
CO. OS WEB STE.
a THE PARCEL DES IN ZONE AS SHOWN ON ME FLOW INSURANCE
RAF[ YAP JTOOPoI400A DARK 01-8-2014
S. ALL DISTANCES SOWN ARE HORIZONTAL GROUND DISTANCES UNLESS
OTHERASE NOTED.
1O DEEO REF OB 4768 PG 1465. PS M PC 101
It THERE IS A 5' DRAINAGE ADN UTIUTIES EASEYETN ON EACH SCE OF
ALL NTWOR LOT AND DIVISION LINES AND 10 FEET WTHN ALL OUTSOE
BOUNDARY LINES E2CEPT WHERE NOTED OTNERWSC
12. WNWUY BUILD:NO SETBACK LINES ARE AS FOLLOWS 25' FRONT (AS
MEASURED FROM ROW UNE), 2W SIDES. JD REAR. AND 20' FROM
PROPERTY ONES ADACENT TO OOLF COURSE SETBACK SHALL BE 5'
ALLONO PROPFATY LNES MAT ABUT ENE U.S. FOREST SENCE LAND.
11 DASHED LINES NOT SURVEYED
14. NO NOS MONUMENT WMIN 2OW
1, W. E01MN HOLES CERTIFY MAT M6 MAP WAS DRAM FROM AN ACTUAL
SURVEY MADE UNDER MY SUPERVISOR, MAT ME FAROS OF CLOSURC IS 1:10.000,
MAT THIS MAP WAS PREPARED N ACCORDANCE WTH aS. 47-M AS AMENDER
IMMESS MY HAND AND SEAL TICS _ DAY OF _ 20-.
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PINS: 9624-65-7403
DB 3424 PG 470
AVERY CREEK TOWNSHIP
BUNCOMBE COUNTY, NORTH CAROLINA
SCALE: 1" - 40' 08/30/2011
LICENSURE III C-2806
W. EDWIN HOLMES. P.L.S.
ED HOLMES AND ASSOCIATES LAND SURVEYORS. PA
1567 PATRON AVE.. P.O. BOX 17335' ASHEVILLE, NC 28816
PHONE: [phone] FAX: [phone]
40'
20, 0' 40' 0O 120, 160 200'

Buncombe County Map
Feet n
0 37.5 75 150 225 300 /�\
• r
The information provided is based on the bast available data at the time of currency for all datasets. It is the requestor's responsibility to verify any information derived from the GIS data
before making any decisions or taking any actions based on the Information. Buncombe County shall not be held liable for any errors in the GIS data. This Includes errors of omission,
commission, errors concerning the content of the data, and relative and positional accuracy of the data.

Buncombe County Map
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ie Information provided is based on the best available data at the time of currency for all datasets. It Is the requestor's responsibility to verify any Information derived from the GIS da
fore making any decisions or taking any actions based on the information, Buncombe County shall not be held liable for any errors in the GIS data. This includes errors of omission,
mmission, errors concerning the content of the data, and relative and positional accuracy of the data.

OV28Y2011 WED 16, 18 FAX
.®002/0.02
27.September, 2011
Michael Rogers, P.G.
Enviro nmental.Spe cialist
N.C..Divislon..of Water -Quality, A.P.S.
1636 Mail Service Center
Raleigh, N.C..27699=1636
Dear Mr. Rogers;
1_give permission for John Judd,:owner of Judd Builders, Asheville; N.C. to Sign any permits required
which.pertain•to the construction ofthegeothermal system planned for our home.which is located on
2985 White Tree Trail, Arden, N.C.
Thank you very much for your help,
Ada Mesana H ell
112 Gavilan Ave.
Coral Gables, Fla. 33143
$ k�-, !;LC "AC fig, W�661 OIQPAs wi h �6z aw2w_x1 14'w k L 3)0v 1'44.

Rogers, Michael
From: [e-mail] on behalf of John Judd Sr [e-mail]]
Sent: Wednesday, September28, 2011 5:41 PM
To: Rogers, Michael
Subject: Re: Fw: Mesana Geothermal Permit Application
Attachments: howell drill permit.pdf
Michael, here is the signed letter. Thanks for all your help. Call me if I need to do anything else, John Judd Sr.
828-301-2557
On Sat, Sep 24, 2011 at 5:25 PM, Ada Howell <adamesanaRyahoo.com> wrote:
----- Forwarded Message -----
From: "Rogers, Michael" <michael.rogers(cDncdenr.gov>
To: "adamesana(cDvahoo.com" <adamesana(cDyahoo.com>
Cc: "fergusonwell(cDexcite.com" <fergusonwell(cDexcite.com>
Sent: Thursday, September 22, 2011 3:52 PM
Subject: Mesana Geothermal Permit Application
Hello -
We have received your geothermal permit application. However, it is incomplete. As the property owner, you need to sign the
application; or if John Judd is signing the application on your behalf, we need a letter from you authorizing Judd to sign the
application on your behalf. You can, if you like, scan in and e-mail the revised signature page, or authorization letter, to me in reply to
this e-mail.
Also, we need the depth of the grout for the wells.
Thank you for your cooperation.
If you have any questions or comments, please advise.
Michael Rogers, P.G. (NC & FL)
Environmental; Specialist
NC Div of Water Quality- Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my atm on cover letter)
http://portal.ncdenr.org/web/wq/aps /awnro/pennit-applications#seothennApps
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

CDE
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H, Sullins
Governor Director
October 5, 2011
Robert Spencer Howell
Ada Mesana Howell
113 Gavilan Avenue
Coral Gabels, FL 33143
Dear Mr. and Mrs. Howell:
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. WI0100172
Robert & Ada Howell SFR
Injection Mixed Fluid GSHP
Well System
Buncombe County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on September 28, 2011. Your application package has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Asheville Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit 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] or [e-mail].
Sincerely,
u�A,koV�4
for Debra J. Watts
Groundwater Protection Unit Supervisor
cc: Asheville Regional Office, Aquifer Protection Section
Larry Ferguson - Ferguson Well & Pump
Joe Leonard - HVAC, Inc
Permit File WI0100172
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] FAX 1: 919-715.0588; FAX 2:919-71.5.60481Customer Service: 1-877-623-6748
Internet: www.ncwatemualitv.org
An Equal Opportunity t Affirmative Action Employer
One
No hCarolina
Naturally

Buncombe County Tax Lookup - Property Card
Page 1 of 2
A property with WORK IN PROGRESS is currently being reviewed by the Buncombe County tax
department. This review could include a tranfer of ownership, a split parcel, a combined parcel,
and acreage adjustment, etc.. For these properties, you will see the values which were last
approved before the review began. Be aware that these values could change once the review is
complete. If a parcel is new, you will have access to limited property data until the review is
complete and values have been approved.
*'J ,, COUNTY OF BUNCOMBE, NORTH CAROLINA
Web Property Record Card
9624-65-7403-00000
Date Printed: 9/22/2011
This parcel is currently being reviewed. Values may change.
Owner Information
Parcel Information
Total Property Value: i,641,800
Status:
Active
Dwners: ADA MESANA HOWELLAccount:
8242222
Address:
Deed Date:
3/17/2010
fig GAVILAN AVE
Deed Book/Page:
4768 / 1465
CORAL GABLES FL 33143
Plat Book/Page:
0147 / 0194
Property Locationa989 WHITE TREE TRL
Legal Reference:
WARRANTY OR SPL/COMP TRANSFE]
Taxing Districts
Location:
1989 WHITE TREE TRL
Class:
RES BUILDING LOT
County: Buncombe CountyNeighborhood:
WALNUT COVE
City:
Subdivision:
THE CLIFFS AT WALNUT COVE
Fire: SKYLAND FIRE
Sub Lot:
214
ement:N
Ownership History
Transfer
Price
Legal
Deed
Qualified
Vacant
When
Account
Seller Names,
Date
Reference
Book/Page
Sold
WARRANTY OR
THE CLIFFS AT
03/17/10
$i,oio,000
SPL/COMP
4768 / 1465
Yes
Yes
8166269
WALNUT COVE
TRANSFER
LLC
WATERFALL
10/10/03
$850,000
WARRANTY OR
SPL/PARC
3424 / 047o
No: A
Yes
8169857
INVESTMENT
GROUP LLC
Assessment History
Year
Account
Acres
Land ,
Bldgs
Other
mpr
Assessed
Dese
Exemptions
Deferred
Taxable
2o11
8242222
1.51
1,641,800
o
0
1,641,800
0
o
1,641,800
2010
8166269
1.51
1,641,800
o
0
1,641,800
0
0
i,641,800
2009
8166269
1.51
1,641,800
0
0
1,641,800
0
0
i,641,800
20o8
8166269
1.51
i,641,800
o
0
1,641,800
o
0
11,641,800
2007
8166269
1.51
1,641,800
0
0
1,641,800
0
0
11,641,800
20o6
8166269
1.51
1,641,800
o
0
1,641,800
0
0
1,641,800
2005
8166269
1.51
1,408,00010
0
1,4o8,000
0
0
1,408,000
2004
18166269
1.51
1,4o8,000
0
0
1,4o8,000
10
0
1,408,000
Land Data Total Acres: 1.51 Land Value: Other Value: o
Acres 1,641,800 Improvements
http://www.buncombetax.org/PropertyCard.aspx 9/22/2011

Buncombe Lounty map
N
Feet
0 100 200 400 600 800
The information provided is based on the best available data at the time of currency for all datasets. It is the requestor's responsibility to verify any information derived from the GIS data
before making any decisions or taking any actions based on the information. Buncombe County shall not be held liable for any errors in the GIS data. This includes errors of omission,
commission, errors concerning the content of the data, and relative and positional accuracy of the data.

Rogers, Michael
From:
Rogers, Michael
Sent:
Thursday, September 22, 2011 2:30 PM
To:
'ad m [e-mail]'
Cc:
'[e-mail]'
Subject:
Mesana Geothermal Permit Application
We have received your geothermal permit application. However, it is incomplete. As the property owner, you need to
sign the application; or if John Judd is signing the application on your behalf, we need a letter from you authorizing Judd
to sign the application on your behalf. You can, if you like, scan in and e-mail the revised signature page or authorization
letter to me in reply to this e-mail.
Also, we need the depth of the grout for the wells.
Thank you for your cooperation.
If you have any questions or comments, please advise.
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality- Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
htto://r)ortal.nodenr.oro/web/wa/ar)s/awDro/permit-ar)plications#aeoth ermApps
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