WI0100111_GEO THERMAL_20120518

W E--.
North Carolina Department -of Environment and NaturaLResources
Division of Water -Quality
Beverly Eaves Perdue--- Charles Wakild, P. E.
Governor Director
May 18, 2012
Julie Harness
1111 Haven Drive
Saluda, NC 28773
Subject: Notification of Rule Revisions Affecting
Closed -Loop Geothermal Injection Well Permit Holders
Permit Number: WI0100111
Dear Ms. Harness:
Dee Freeman_
Secretary
Our records indicate that you currently hold a permit for a closed -loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards - Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed -loop geothermal injection well(s) have become
"Permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http://portal.nedenr.org/web/wqlaps.
If you have any questions regarding your current permit or the rule revisions, please feel -free to
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636 ORe
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604 NolthCarohna
Phone: 91M07-64641 FAX: 9IM07-6496
Internet: www wwaterauallt ..gm � �{ ' �
An Equal Opportunity S Affirmative Action Employer

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1617'Mail Service Center, Raleigh, NC 27699-161, Phone. t919j 807-6300 Rev. 2M9

Central Files. APS SWP
10/15/10
Permit Number WIOIOO1 f 1 Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilit,
Facility Name
Julie Harness SFR
Location Address
1111 Haven ❑r
Saluda
Owner Name
Julie
Dates/Events
NC 28773
Harness
Status
Project Type
Active
New Project
Version
Permit Classification
1.00
Individual
Permit Contact Affiliation
Anthony Bryant Smith
Driller Well
P❑ Box 204
East Flat Rock
NC 28726
Major/Minor Region
Minor Asheville
County
Henderson
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Julie Hamess
Owner
393 Spring St
Saluda
NC 28773
Scheduled
Qrig Issue App Received Oran Initiated Issuance Public Notice Issue Effective Expiration
10/01110 07/26/10 10/01/10 10/01/10 09/30115
Renulated Activities Reuuested/Received Events
Heat Pump Injection Region commerrts on draft requested 08/31/10
Region comments on draft received 09/01 /10
❑utlail '�.�JL
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AC'
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Goleen H. Sullins
Governor Director
October 1, 2010
Julie Harness
393 Spring St.
Saluda, NC 28773
Dee Freeman
Secretary
Subject: Issuance of Injection Well Permit
Permit No. W10100111
Issued to Julie Harness
Henderson County
Dear Ms. Harness:
In accordance with your application received Italy 26, 2010, 1 am forwarding Permit No. WI0100111 for
the construction and operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well
system located at 1111 Haven Dr., Saluda, Henderson County, NC, 28773. This permit shall be effective
from the date of issuance until September 30, 2015, and shall be subject to the conditions and limitations
stated therein.
Please pay special attention to Part 1.7 of the permit and submit copies of the Well Construction
Completion form (GW-1) after construction. Please submit all data within 30 calendar days of receipt of
this letter to the address below:
Aquifer Protection Section (APS)
Underground Injection Control (MC) Staff
1636 Mail Senice Center
Raleigh, NC 27699-1636
Additionaliy, your UIC system is subject to inspection by the APS and at the tune of the inspection must
display a permanently affixed identification plate in accordance with requirements of 2C .0213(g), Please
insure this is completed in accordance with permit condition Part 1.6 of this permit issued October 1,
2010
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit three months prior to its expiration date, As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Quality. if you have any questions regarding your permit or the Underground Injection
Control Program please call me at [phone].
Sincerely,
�F
�Jo McCray,
Environmental Specialist

cc: Landon Davidson - Asheville Regional Office
Central Office File — W10 100 111
Henderson County Environmental Health Dept.
Freddy Dungy — Southern Comfort of NC, Inc.
Enc: Permit Wloloo111

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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
Julie Harness
FOR THE CONSTRUCTION AND OPERATION OF I TYPE 5QM INJECTION WELL, 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 beat pump system. This system is located at 1 111 Haven Dr., Saluda, Henderson
County, NC 29773, and will be constructed and operated in accordance with the application received July 26,
2010, and in conformity with the specifications and supporting data submitted, all of whicb 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 only, and does not waive any provisions of the Water Use Act or
any other applicable Laws, Rules, or Regulations, Operation and use of an injection well shall be in compliance
with Title 15A North Carolina Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until September 30.2015, and shall
be subject to the specified conditions and limitations set forth in Parts l through IX hereof.
Permit issued this the day of d c7k�e� , 2010.
j.(� Coleen H. Sullins, Director
`�° Division of Water Quality
By Authority of the Environmental Management Commission,

PART I - %AELL CONSTRUCTION GENERAL CONDITIONS
The Pertnittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to ln7ection Wells (15A NCAC 2C .0200). An}, 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 penult, the approved plans and specifications, and other supporting data.
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.
6. Each geothermal injection well system shall bave permanently affixed an identification plate on a nearby
building or other permanently fixed structure indicating the location and presence of underground UIC
wells according to 2C .0213(g).
7. A completed Well Construction Record (Form GW-1) must be submitted for each injection well to:
Aquifer Protection Section - UIC Staff
1636 Mail Service Center
Raleigh. NC 27699-1636
FtiTJ
Aquifer Protection Section- Asheville Regional Office
2090 L,.S. 70 Hn-diwa%
S%vannanod. NC' ?877`'
(S-29) 296-450(1
GW-1s must be submitted within 30 days of completion of well construction. Copies of the GW-1
form(sy shall be retained on -site and available for inspection.
S. Wet] construction records must also be submitted for the existing water supply wells on -site as well as a
site map showing any water supply wells on adjacent properties as specified in NCAC .0211(d)(1 )(D).
PART H - WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight (48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (LTIC) Program Central Office staff_. telephone
number [phone] and the Ash,- ills, Re4-ional Office Aquifer Protection Section Staff, telephone
number (8 ''8 ) 2�-f()-4500.
W 101 Q0111 '-

2. Boreholes shall not connect separate aquifers �vhich have differences in water quality (e.g., shallow
surficial aquifers, saprolite. fractured bedrock, etc.) as specified in 15A NCAC 2C .0213(d){8)(C) and
shall be filled with bentonite grout from the lowermost water bearing zone to land surface as specified in
the pennit application.
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.
N 6V;'V,4&A'M W 040 141',1313a4N-*"-iV1113-L r
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
groundwater resulting from the operation of this facility.
PART V - OPERATIONS AND MAINTENANCE REQUIREMENTS
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 [phone], 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.
wzal D0111 3

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.
Department 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,
.. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART VII — MONITORING AND REPORTING REQUIREMENTS
1. 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.
2, The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Ashevi11c Regional Office. telephone number (8?8) 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;
3. 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.
4. 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
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART IX — CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any ebange 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 that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(1), Well
Construction Standards.
WI0100111 4

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 which 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 Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(1) within 30 days of completion of abandonment.
3, The written documentation required in Part IX (1) and (2) (G} shall be submitted to:
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
WI0100111 5

Permit Number W 0100111
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (50M)
Primary Reviewer
john,mccray
Coastal SW Rule
Permitted Flow
Facili-
Central Files: AP5 5WP
10/01/10
Permit Tracking Slip
Status
Project Type
In review
New Project
Version
Permit Classification
Individual
Permit Contact Affiliation
Anthony Bryant Smith
Driller Well
PO Box 204
East Flat Rock
NC 28726
Facility Name MajorlMlnor Region
Julie Harness SFR Minor Asheville
Location Address County
1111 Haven Dr Henderson
Saluda NC 28773 Facility Contact Affiliation
Wr .'r
Owner Name
Julie
I r- , r-. P
Harness
Owner Type
individual
Owner Affiliation
Julie Harness
Owner
393 Spring St
Saluda NC 28773
Scheduled
►7rig issue App Received Oraft Initiated Issuance pubiit Notice [aqua Effeetiva Expiration
07/26/10
_R_euulated Activities Reoue-.red/Recigived F -ants
Heat Pump injecbort Region comments on draft requested 08/31/10
Region comments en draft received 09/01/10
Outfall M- L!
Wstarbody Name Streeni Index Number Current Class Subbesin

Mccray, John
From:
Davidson, Landon
Sent:
Wednesday, September 01, 2010 1:15 PM
To:
Mccray, John
Cc:
Stepp, Jonathan
Subject:
RE: 50M Geothermal Application
We've reviewed in office.... please move forward with issuance. Thanks
Landon
G . Landon Davitisorl, P.G.
}pct r ... . — ., r.11 Fin
qe
1
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a eb cage: htr:::;:'h2o_enr.stote_nc.us:`aow.htmi
This e-mail contains a public retard which is subject to disclosure to third
port ies and the public pursuant North Carolina's Public Records Low. N.C.
Gen. 5tat. §132-1, etseg. This a -moil moy contain materials prepared
during or iri onticipat+on of a legal proceeding as port of preparation for that
legal proceeding, in which case third party or public access to it is subject to
N.C. Gen. Start. §132-1.9 and may he denied until the conclusion of the legal
proceeding, inciuding the completion of all appeals and post -judgment
proceedings, or, in the case where no legal proceeding has been commenced,
upon the expiration of all applicable statutes of limitations and periods of
repose.
From: Mccray, John
Sent: Tuesday, August 31, 2010 2:04 PM
To: Davidson, Landon
Subject: 5QM Geothermal Application
Mr. Davidson,
Attached is application W10100111 for a 5QM geothermal system for a Single Family Residence in Henderson County.
Please let me know how your office wishes to proceed.
Best Regards,
John McCray

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This map is prepared for the inventory of real property found within this jurisdiction, and is compiled from recorded
deeds, plats, and other public records and data. IJsers of this map are hereby notified that the aforementioned public
primary information sources should be consulted For verification of the information contained on this map. The
County and mapping company assume no legal responsibility for the information contained on this map.
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10/1/2010 10:06 AM

Mccray, John
From: Foster, Rob [[e-mail]
Sent: Tuesday, August 24, 2010 9:45 AM
To: Mccray, John
Subject: Nissan West Injection permit addendum
Attachments: Robert Foster.vcf
Mr. M cCray,
By now, you may have received (in the mail) an addendum to the original injection permit application for the subject site in
Gastonia, NC. The addendum is in response to additional information requested by Maria Schutte during our on -site meeting earlier
this month. Please call me if you have further questlons. Our client is involved in a real estate transaction and would really
appreciate a timely review of the application.
Thank you,
Rob Foster
Robert C Foster, Ill_ PG
Principal Cjeologist and Pititlect Manage
MACTEC Engineering and Consulting, Inc.
2841 Yorkmont Road Ste. 100
Chartoue, Noah Carolina 78"08
Office Phone: [phone]
Nlnbi I e: 7041641-1 14 t
Email rcfosterCDmactec.com , Web www.mactec.com
MACTEC is an industry leaden in providing engineering, envirarimentaI and canstructlori services to public, and private clients,
internationally. The Charlotte, NC office provides you with a doorway to MACtEC's team of 3,000 employees in 80 lucations. Our
local core service lines include Geotechnicai, Environmental, Facilities, Construction Testing and Special Inspections and Non -
Destructive Testing and Inspections. What can MACTEC do for you?
Asheville - Charlotte - Greensboro - Raleigh - Research Triangle Park - Wilmington
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A76;-A,r
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Qoleen H. Sullins
Governor Director
August 5, 2010
Julie Harness
393 Spring St.
Saluda, NC 28773
Subject: Acknowledgement of Application No. WI0100111
Julie Harness SFR
Injection Mixed Fluid GSHP Well System (5QM)
Henderson
Dear Ms. Harness:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality [Division} acknowledges receipt of your permit application and
supporting materials on July 26, 2010. This application package has been assigned the number listed above and will be reviewed by
John McCray.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 - 90 days after receipt of a complete
application.
If you have any questions, please contact John McCray at 919-715-6168, or via a -mail at johmrncemy a7 cdenr.gov, If the reviewer is
unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To review our
new organizational chart, go to httn:llh2o.enr.state.nc.us/docurnents/dwci orkmhart.ndF.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Since y, �f
for Debra J. s
Supervisor
cc: Asheville Regional Office, Aquifer Protection Section
Anthony Bryant Smith (Green River Well & Pump Co., P.O. Box 204, East Flat Rock, NC 28726)
Freddy Dungy (Southern Comfort of NC Inc., 791 South Allen Rd., Suite # 4, Flat Rock, NC 2873I)
Permit Application File W1010011 1
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Raleigh, North Carnpna 27699.1636
Lorahm 2728 Capital Boulevard. Ralegh. North Carolina 275D4
Phone: [phone] I FAX 1: 919.715-0588; FAX 2:919.715-6048 I Customer Service: 1-877-623.67A8
Internet: www,nwraterouaif Y.om
An Equal Qpponuniq % AMrmafive Action Employer
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
August 5, 2010
Julie Harness
393 Spring St_
Saluda, NC 28773
Subject: Acknowledgement of Application No. Wi010011I
Julie Harness SFR
Injection Mixed Fluid GSHP Well System (5QM)
Henderson
Dear Ms. Harness:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on July 26, 2010. This application package has been assigned the number listed above and will be reviewed by
John McCray.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 - 90 days after receipt of a complete
application,
If you have any questions, please contact John McCray at 919-715-6168, or vie e-mail [e-mail]. ncdenr.gov, If the reviewer is
unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To review our
new organizational chart, go to httl-,;llh2o.enr.state.nc.us/documents/dw�l orgehamndf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
5incet y,
1 f
for Debra J. tts
Supervisor
cc: Asheville Regional Office. Aquifer Protection Section
Anthony Bryant Smith (Green River Well & Pump Co., P.O. Box 204, East Flat Rock, NC 28726)
Freddy Dungy (Southem Comfort of NC Inc., 791 South Allen Rd., Suite 0 4, Flat Rock, NC 28731)
Permit Application File WI0100111
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Ralegh, North Gamlina 27699-1636
Locations 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588: FAX 2: 919.71M048 I Customer Service; 1-677-6?M748
Intemet: www-nLtiwaMual .o
An Eaual Oppenranq % Affirmative Rctien Emplayer
One NCarolina
Natural!

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NORTH CAROLINA JUL 36 2m
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 50M WELDS)
`/ New Permit Application OR Renewal (check one)
DATE: 7 /' z 2- . 2010
PERrAn NO. (leave blank if NEW permit application)
A. PROPERTY OWNER(SVAPPLICANT(S)
List each Property Owner listed on property treed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): a W 1 c�Pon Ae 5 5
(1) Mailing Address:
City: S 1 '.� Mate:
HomelOffice Tele No.: N;-$$ '7`i 9
W33EX1W.MF,r;71
�Sk_
Code: �-- County:
(2) Physical Address of Site (if different than above): I I 1 I P.,:?" 6,- .
a
City: Lu der State: LgZip Code: 72 D I County:
Home/Mee Tele No.:
103-F.►Ifrr..r-=
9. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
State:
Website Address of Company, if any:
Zip Code:
County:
Cell No.:
C. STATUS OFLICANT
Private: Federal: Commercial:
State: Municipal: Native American Lands:
GPUt]IC 5QM WeII Permit Appiicatim (Revised 7/2009) Page I

D. WELL DRILLER INFORMATION
c /1
Company Name: GVr4F- e.n 6Q I LIZ-�r_ �Ve (( '
i
Well Trilling Contractor's Name: _ 'A 01- PI < < r a J-
NC Contractor Certification No.:
Contact PersoIIi� F7 EMAIL Address: - i i-e e-nn`,re4-tu,'- l < a. U 5a c7H�Olef
Address: _P. O. 60 _L'Q
City: ll N I W,� Zip Code
Office Tale No.: eaf6 �-^ 13 -12DO
a gy v County:
Coll No,:
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: (' ''� r ^
Contact Person: }. 'L-J )pr p EMAIL address__ C
Address: .7 i--av� , - � +� ,L111i__ �--
� 1 4 - - -
City: �-IA tRQQk� Zip Code: �_ County:
Office T'ele No.; --C Cell No.: (2&, ` r q- j
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. '"TLL CONSTRUCT-rON, D:NTA ISkip to Sectimi rI irthis is a Permit RENEWALF
(1) Proposed date to be constructed: _A, },]-O o Number of borings: IF
Approximate depth of each boring
(2) Chemical additives to be used in closed -loop system (only those chemicals indicated have been approved):
R-22 propylene glycol ethanol other (other additives will
need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc):
(4) Well casing, Is the well(s) cased? (check either (a.) YES or (b.) NO below)
(a) YES if yes, then provide casing information such as tie (steel, PVC, plastic, etc.), diameter.
depth, and extent of casing appearing above ground:
(b) NO
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Hentonite Other (specify)
(b) Grout depth of tubing (reference to land surface): from 5 to 3 `F a (feet)
If well has casing, indicate grout depth: ftm 40 (feet)
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The }manufacturer's brochure may provide supplementary
information.
GPUfUIC 5QM Well Permit Application (Revised 712008) Page 2

RMEluED i t ENR 1 M
AOl PP PQ0T;7rrkrW qe JON
L LOCATION OF W�'r.i fS) JUL 2 s me
Attach two copies of maps showing the following information:
(1) Include a site map (can be drawn) showing: buildings, property lines, surface water bodies, potential sources
of groundwater contamination and the orientation of and distances between the proposed well(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
J. POTABLE WATER WELL(S)
Are there any potable water well(s) on the subject property or adjacent properties? YES NO
If Yes, than indicate location on attached map(s).
X CERTIFICATION
Note: This Permit Application mast be signed by each person appearing on the recorded legal property deed
1.
"1 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 s ifications and conditions of the Permit."
It
_�<-
fgs_@rure a perty Owner/Applicant
u f It _ Hxr r1 e.SS
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUMIC 3QM Well Permit Application (Revised 7/2008) Page 3

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