WI0400528_Permit (Issuance)_20191028

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTMCATION OF INTENT TQ CON$TRUCT OR OPERATE JNJECTIONWELLS,
These welt ore
the Yale% qfW mace inw be shbmittedwrior to ownsirvetion.
9E_'MH_=Ah tMUSCLOMdAQVID—LUA
As described wells circulate potable wateronly or'a InTxZro of potable water and
porformance.6uhanolog additives as pad of agoothermal beating and cooling system.
09
ft a M a 0— a —D LOOP WELLS
As described in webs circulate a xPrigerant gas as part oft geothermal boaffn&and
cooling system,
Mal Clearly or Dpa-Information, filegiblo,86boftyls, Wifffte JteMrnMA9,I#conzpIeM,
DATE: LO 20_M PERMIT, NOAN 1 0 (j 00 o be completedbyl)")
A: TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO AV CONSTRUCTIM
(1) Aqueous (asper I 52%�A'122�1J: x Number of wells: jz
Numberofwells,_
Rkeot-Expaludbu (as pMrj5ANtA C-MM.
IL STATUS OF WELL OWNER (choose one) .
(1) Single Family Residence 'gubmitthis form two (2) business days prior to coostrovtion,
(2) Buslue '011 1 Submit this form, 30 days i to towtvaction.
(1) Goven �1"IlMunicipa),11 County"op Federal 11 Submit this form 30 days
prior to coostMetion.
C. WELL OWNER —For single family residences list the property owhet(s),, For, OR othem list name of the
business, organization, or government agency and person delegated signature authority
aw Fake'r
113
I)ay Tele Nn,: _
P,MAIL,Addre=
PIFIY$ICAL LOCATION OF WELL SITE.
Fax ,Nb.-
(1) parcel Idotifeationblumber (MI) ofwell
County; _Aiw,
(2) Physical Address (if different than.mailing ad4rosa): 2-Ce-
city, J State.'Me Zip coda:;
UIC/Closed-Loop 00themial Notification (RavlsedVV2011) page I

E. MAPS, PLANS, AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site -specific map showing the locations of the following:
Proposed injection well locations o Septic
site plan. E1
o Se tic systems and associated spray irrigation
a Buildings sites, drain fields, or repair areas
© Property boundaries
e Surface water bodies - 6 Existing or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system
See well construction diagram E-2
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services' Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at httn //poflial ncdenr.org/weeyb/wq/aps/Rw ap . All other additives require approval prior to use.
�b% .r Iry e'to 4 ero k .
G. WELL DRILLER INFORMATION (if lmown)
Well Drilling Contractor's Name: MatthPw Rrnwn Tnav Mu1 l i s Mi l i-nn f ava
NC Well Drilling Contactor Certification No.: 303f_A 99;72—A ISAR—A
Company Name: Yadkin Well :Co. Inc. Contact Person: David Brown 2195—A
City: Hamptonville State: NC zip Codei7020County: Yadkin
DayTeleNo.: 336-468-4440 CellNo.: 116-374-8736
EMAIL Address:. DavidBrown(ayadkinwell.conFaxNo.:
H. HEAT PUMP CONTRACTOR INFORMATION
Address:
City: Ub nv.al
Zip Code:
State: _County:
h)64 s
Office Tole No.:
Cell No.:
FU — ?V - J D 97
Fax No.:
UIC/Closed-Loop Geothermal Notification (Revised 8/512013) Page 2

1. PROTECTION —Provide a brief description ofbow (1) water supply wells; (2) surface wafer bodies;, and (3)
septic systems and associated, spicy litigation sites, dtain fields, or repair areas within 250 feet of the proposed
injection wells will be protected 4wing.codstru0tion ofthe wolfs;
Rd- i weG � t? (e'd
PrX4'r lxaL� w. rtV lc.r
S VARIANCE — pm'suant to 15A NCAC =, M, the Director ofthe AiVisipa of Water Resourcesmay giant
a varanaefrom;applicabte well ennstructiou or operation standards provided that;
(1) use of thewell(s) willnot endanger, hmnanhealth and welfare of the groundwater; and
(2) that construction or operation.in accordancowith the stetidarrls is not technically feasible or the
proposed eoustructionprovides equal or better pratectiorr of the groundwater-;-
Any variance request should accompany suhrruttal of this nolification to expedite evaluation of the request,
The variance request fond can be accessed online at> iteurrtnpncdenr orslaabllaw/ansliswum�permt#
s nations,
K. SIGNATURE$ —'lhe following section is.to be completed as required below or by that persons: authorized
agent. L4A NCAt bit UitV*ea signatures as follows.
(a) for a eorpuration: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner or the, proprietor, respectively;
(e) for a municipality or a state, federal, cur Qther public agency; by either a principal executive
officer or ranking.publicly, elected officia)
(d) for, all others: by the well owner;
(e) for say other person authorized to act on behalf of the applicant: documentation. shall be
submitted with the notification that clearly identifies the person, grants them signature
umhorlty, and is signed and dated by the applicant,
T hereby certify, under penalty of law, that I have personally examined and am famthat, w ith the mfbrmation
submitted in this document and all attachments thereto and that, based on Ny inquiry of those individuals
immediately responsible for obtaining said information, I believe that the i4ormation is true, accurate and
complete. I am aware that there are signi,£lcant penalises, tnehrdtng the possibility offbles and imprba anent:
for submitting false information. I agree to construct, operate, maintain, repaik and if applicable, abandon
the injection well andall relate Xap�pucws in ace rdance with the ISAXE Un+t 0� 2C d2 Rules,"
i
Si tureu roperty Owner/Applicant
tiff p7t YkW
Printar't'ype Futt Name
Signatureo[Authoriied Agent,.itany
Erint or Type X—nName:
UIC/Closed-LOOP Geothermal Not fwoadOn (ILee14e 9150013) Pago 3

ot�-t I
8io r-UQv
262 CiK(-t C- ,
A/C-)
2-L 2 f
more � Ll
fD f qv-�? hey

i�Qrr
soR- _L/
�_ oop / (,
ola in
pp,5sadz T,
.4v
C)o PS
1, 2 Q _,
T'kermuky F
&VOA , PCAATeA
Sur ace, vla
()n¢ < P(Am fte
p;s '�Dr+ 9v4aJ
r-a j oV' y ( I\ s al
(A -Be"
Z c 2 C�1„(a Lk
�
'� e mIu-jo Y,
Rook