Exhibit1_Notice of intent to drill well.pdf

TENNESSEE DEPARTMENT OF ENVIRONMENT AND CONSERVATION

DIVISION OF WATER SUPPLY-WELL PROGRAM

6th Floor L & C Tower

Nashville, Tennessee 37243-1539

(615) 532-0191 fax (615) 532-0503

NOTICE OF INTENT TO DRILL WELL

Refer to instruction sheet to complete form. Print all information below.

On or about a well will be drilled for the use listed below:

Month Day Year

1. Water well OR Geothermal well (closed loop # of boreholes)

If water well marked, denote Driller Tag Number to be assigned (if known) D ___

2. Anticipated use: Residential Commercial Farm Irrigation Test Industrial (Other) (denote intended use) Will water withdrawn be greater than 10,000 gallons on any one day? Yes No

3. Drilling Contractor (if known) License # __

4. Location of Well (County)

5. Owner of Property

First name Last name

Company Name (if applicable)

Address City

State TN_ Zip

Phone Numbers: Home ( ) Work ( ) Cell phone ( ) (fax) ( ) _________________________

6. Address of well if location is different from above (items # 4 & 5)

City State: TN__ Zip __ _

(If no address can be given, provide driving directions to the site on a separate sheet and send with Notice of Intent)

7. Date submitted Fee Enclosed: Yes No

Fee Amount: $ 75.00 for Notice of Intent for Water Well Fee Amount: $ 75.00 for Notice of Intent for Geothermal Wells: 10 wells or less Fee Amount: $150.00 for Notice of Intent for Geothermal Wells: 11 wells to 50 wells Fee Amount: $500.00 for Notice of Intent for Geothermal Wells: 51 wells or greater Fee Amount $ 75.00 for Notice of Intent for Closed Loop Test Hole for heat conductivity and geology Enclose Check or Money Order made payable to” Treasurer, State of Tennessee” (do not send cash)

8. Person completing form: Well Owner Driller Other (If sent by email then print name of person sending form below) Email addresS: water.well@state.tn.us Signed (if not sent by email)

Send completed form to Division of Water Supply and retain 2 copies of completed form (One copy for owner & one copy for driller)

Distribution: – White - Division of Water Supply Canary – Driller (maintain at drill site) Pink - Homeowner

CN-1240 (Revised 08/06)

RDA 1520

jaychapman Typewritten Text

EXHIBIT 1