20230929_ADI_Received

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NORTH CAROLINA MINING State of North Carolina 1612 Mail Service Center
PERMIT APPLICATION Department of Environmental Quality Raleigh, NC 27699-1612
Division of Energy,Mineral,and Land Resources [phone]
RECEI\\,,
f 104f is recommended that you contact the appropriate Regional Office or the Raleigh Central Office for a PRE-
,; P 2023 APPLICATION MEETING to discuss your intentions and address any questions.
DEML IR Name of Mine
�I' / J
County Qn< �a� River Basin /�oa��ifear> Crop_*
Latitude(decimal degrees to four
places) 3y° LIV ,'T(a Al
Longitude(decimal degrees to four
places) c .1a7 1it �
2. Name of Applicant fy�1,a o-nyu lv-&
Applicant Contact 9/6 Y89 -6,<,z1 Consultant Contact
Applicant Email ►^o-n�� �le 1 ..�O.,,-,,,Consultant EmailjeWrr�,,,
Telephone 9J0-3y7- 3lyq Telephone 9t0-n/ - .$7,/ 7
Cell Phone 9/0 'mr 4./4 Cell Phone gyp J,"-d 15
3 Permanent Address for Receipt of
Official Mail"
4. Mine Office Address /Z 3�2 �,�� Q�•� e{ �j4vLi t�K v.J/P
5. Mine Manager ,(� Aw al rr
Mine Manager Email je, 0,./n0,z01 -3R,
Telephone q/�-3y7�35'yg Cell Phone 9/4 3ygf_asG y
I certify that all details contained in this permit application are true and correct to the best of our knowledge.We
fully understand that any willful misrepresentation of facts will be cause for permit revocation.
Signature""" ..� /f{/� �ec Date a 62 3
Print Name bra
Title
'This will be the name that the mining permit A be issued to and the name that must be indicated on the reclamation bond(security)that
corresponds to this site.
"The Division of Energy,Mineral,and Land Resources must be notified of any changes in the permanent address or telephone number.
"'Signature of company officer required
G.S.74-51 provides that the Department shall grant or deny an application for a permit within 60 days of receipt of a complete
application or,if a public hearing is held,within 30 days following the hearing and the filing of any supplemental information
required by the Department.All questions must be addressed,and all required maps provided before this application can
be considered complete.Attach additional sheets as needed.
Revised September 21,2021 P a g e d

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APPLICATION FOR A MINING PERMIT
G. LAND ENTRY AGREEMENT
We hereby grant to the Department or its appointed representatives the right of entry and travel upon our lands
or operation during regular business hours for the purpose of making necessary field inspections or investigations as
may be reasonably required in the administration of the Mining Act of 1971 pursuant to G.S. 74-56.
We further grant to the Department or its appointed representatives the right to make whatever entries on the
land as may be reasonably necessary and to take whatever actions as may be reasonably necessary in order to carry
out reclamation which the operator has failed to complete in the event a bond forfeiture is ordered pursuant to G.S.
74-59.
LANDOWNER: APPLICANT:
Signature: Signature:*
Print Name: - 1't,. Qcv;dly kJ,/l' Print Name: PJ.'11,41--m �r/ P
(Title, if applicable)
Company Title: CL ey'--
(If applicable)
Address: r` 41, Company:
sav • G Mine Name: Y%4 k,a
Telephone: (9710 )�f7— j 9V q Telephone: (a/!7 )�y 7—161 y
Date Signed: f Date Signed: 3
*Signature must be the same as the individual who signed Page 1 of this application.
One original and five(5)copies of the completed application,six(6)copies of all location maps,mine maps
and reclamation maps,and the appropriate processing fee(see next page for fee schedule)in the form a check
or money order payable to the North Carolina Department of Environment and Natural Resources must be
sent to the Land Quality Section Central Office at the address listed on the front cover of this application
form.
Inquiries regarding the status of the review of this application should be directed to the Mining Program staff at
[phone].
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APPLICATION FOR A MINING PERMIT
AFFIDAVIT OF NOTIFICATION
I, ,an applicant,or an agent,or employee of an applicant,for a
new Mining Permit,or a modification of an existing Mining Permit to add land to the permitted area,from the N.C.
Department of Environment and Natural Resources,being first duly sworn,do hereby attest that the following are
all known owners of record, both public and private, of all tracts of land that are adjoining the mining permit
boundary(including,where an adjoining tract is owned or leased by the applicant or is owned by the lessor of the
mine tract, all owners of record of tracts adjoining these tracts, that are within 1,000 feet of the mining permit
boundary)and that notice of the pending application has been caused to be mailed,by certified or registered mail,
return receipt requested,to said owners of record at their addresses shown below,such notice being given on a form
provided by the Department:
(Adjoining Landowner Name) (Address)
(Attach additional list if necessary)
I do also attest that the following individual is the chief administrative officer of the county or municipality in which
any part of the permitted area is located and that notice of the pending application has been caused to be mailed,by
certified or registered mail,return receipt requested,to said office at the following address:
(Chief Administrative Officer Name) (Address)
[i.e.: City Manager, County Manager, Mayor, etc.]
The above attestation was made by me while under oath to provide proof satisfactory to the Department that a
reasonable effort has been made to notify all known owners of record,both public and private,of all tracts of land
that are adjoining the mining permit boundary (including, where an adjoining tract is owned or leased by the
applicant or is owned by the lessor of the mine tract, all owners of record of tracts adjoining these tracts,that are
within 1,000 feet of the mining permit boundary)and the chief administrative officer of the county or municipality
in which any part of the permitted area is located in compliance with N.C.G.S. 74-50(bl) and 15A NCAC 5B
.0004(d). I understand that it is the responsibility of the applicant to retain the receipts of mailing showing that the
above notices were caused to be mailed and to provide them to the Department upon request.
Signature of Applicant or Agent Date
If person executing Affidavit is an agent or employee of an applicant, provide the following information:
Name of applicant:
Title of person executing Affidavit
I, a Notary Public of the County of ,
State of North Carolina, do hereby certify that
appeared before me this day and under oath acknowledged that the above Affidavit was made by him/her.
Witness my hand and notarial seal,this day of 20
Notary: my Commission expires:
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