WI0300185_Regional Office Historical File Pre 2018

Water Resources
ENVIRONMENTAL GILIALITV
October 13, 2016
Elizabeth & Matthew Browder
1515 Dilworth Road
Charlotte
NC 28203
Subject: Permit Rescission
UIC Permit No. WI0300185
Geothermal Heating/Cooling Water Returr Wel
Mecklenburg County
Dear Mrs. and Mrs. Browder:
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
Thrector
Reference is made to your request for rescission of the subject Geothermal Heating/Cooling Water Return
Well Permit located at the above referenced address, Staff from the Mooresville Regional Office has agreed
that a permit is no longer required. Therefore, in accordance with your request, Underground Injection
Control (UIC) Permit WI0300185 is rescinded, effective immediately.
If in the future, you wish to operate a Geothermal Heating/Cooling Water Return Well injection system,
you must first apply for and receive a new permit. Operating a geothermal heat pump injection system
without a valid permit may result in the assessment of civil penalties and/or the use of other enforcement
mechanisms available to the state.
If it would be helpftil to discuss this matter further, please do not hesitate to call Shristi Shrestha
at [phone].
Attachment(s)
cc: Mooresville Regional Office - WQROS
Central Files - Permit No. WI0300185
Mecklenburg County Environmental Health Dept.
Sincerely,
LAJ
Jay Zimmerman* , P.G., Director
Division of Water Resources
State of North Carolina Environmental Quality Water Resources
161 I Mail service Center Raleigh, North Carolina 27699.1611
919 707 9000

Water Resources
ENVIRONMENTAL QUAL. CTY
June 16, 2016
CERTIFIED MAIL # 7015 1520 0000 78:38 4382
RETURN RECEIPT REQUESTED
Steve & Allison Bird
1728 Colony Road.
Salisbury NC 28144
Subject: Notice of Expiration (NOE)
Geotherrnal Water Return/(7pen-Loop Io
it No. WI0300026
Rowan County
Dear Mr. and Mrs. Bird:
PAT MC'CRoRY
t. - NALD R. VAN L)ER VA.ART
n Well
The Underground Injection Control (UI ) Program of the North Carolina Division of Water
Resources (DWR.) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
geothermal injection well system located. on your property at the above referenced address was
issued on January 25, 2012, and will expire o
requirements per 1 5A NCAC 2C .0224(4 the re
calendar days prior to expiration of the permit i
on your property.
If Your Geotherrn
Per permit conditions and
application lust be submitted at least 120
sh to continue operating the injection well
Vater Return Well, is Still Currently BeingUsed for injection:
In truer to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 1 5A, Subchapter 2C, Section .021 1. you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells — Geothermal
Heating/Cooling Water Return Wells). The Corm is also available on-line at our wcbsite
http:;;'portal.ncdenr.orglweb='wq `apsi gw pror'pernut-applicr ti ns.
if1'cur Geothermal Water Return Well is NO LONGER Beim t.lsed for Injection:
ell is no longer being used for in jection, you do not have to renew your perrmit, Check the
box its Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, pl,u.gged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned
according to the regulatory requirements listed under NCAC Title 1 5A, Subchapter 2C, Section
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
PLC:' rri' }�ar€Ra C";uc,1inla Lit

Page 2 or2
If There has been a Change of©wnership of the Property:
If there has been a change of owvnership of the property, an "Injection Well Permit.
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
tJ 1C Program
1636 Mail Service Center
Raleigh, NC 276)9-1636
Failure to submit the applicable forms in a timely rnanner may result in. the asses nwent o
penalties in accordance with North Carolina General Statute 87-94. Thank you in advanc.
your cooperation and timely response. If you have any questions, please contact inc by phone at
[phone] or by email at shristi shre th &ncdenr. owr.
Regards,
J %ro)/' h
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Mooresville- Regional (:)trice WQROS wv/o en losu:
Central Files - Permit No. 'VI0300026 w/o enclosures

Water Resources
ENVIRONMENTAL QUALITY
PAT MCCRORY
DONALD R. VAN DER VAART
June 16, 2016
CERTIFIED MAIL # 7015 1520 0000 7838 4368
RETURN RECEIPT REQUESTED
Matthew & Elizabeth Browder
1515 Dilworth Road
Charlotte NC 28203
Subject:
Notice of Expiration (NOE)
Geothermal Water Return/'Open-Loop Injection Well
Permit No. WI0300185
Mecklenburg County
Dear Mr. and Mrs. Browder
AY ZIMMERMAN
Direcwr
The Underground injection Control (UI.C) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit tier the
geothermal injection well system located on your property at the above referenced address was
issued on December 13, 2011, and will expire on Per permit conditions and
requirements per 15A NCAC 2C .0224(c), the renewal application must be submitted at least 120
calendar days prior to expiration of the permit if you wish to continue operating the injection well
on your property.
If Your Geothermal Water Return Well is Still Currently Being Used for Injection:
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit the enclosed renewal
application (Application for a Permit to Construct or Operate Injection Wells — Geothermal
Heating/Cooling Water Return Wells). The form is also available on-line at our website
http://portal.ncdenr.org/web/wq/a.ps/gwpro/permit-applications.
if Your Geothermal Water Return Well is NO LONGER Being Used for Infection:
If the well is no longer being used for injection, you do not have to renew your permit. Check the
box in Part A of the attached renewal application that you wish to rescind the permit and indicate
the current status of the well (i.e., used as water supply well, irrigation well, inactive, plugged and
abandoned, etc.). If it is no longer being used for any purpose, it must be permanently abandoned,
according to the regulatory requirements listed under NCAC Title 1 5A, Subchapter 2C, Section
.0240. When the well is plugged and abandoned, a well abandonment record (Form GW-30) must
be submitted to our office to certify that the abandonment was properly conducted.
Slale or North Carolina (€.nvtrutmsennl ()oak!), Water Resources
I ()I 1 S,ril sin Cc,2,11,:e a,:i I Et, aGci 6u. Ttio+di Csroliioa 2i99-16I I

Page 2 of 2
If There has been a Change of Ownership of the Property:
If there has been a change of ownership of the property, an "Injection. Well, Permit
Name/Ownership Change" Form must also be submitted in addition to the renewal application.
This form is not enclosed but can be found at the website listed above. Please submit the applicable
forms to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1.636
Failure to submit the applicable forms in a timely manner may result in the assessment of civil
penalties in accordance with North Carolina General Statute 87-94. Thank you in advance for
your cooperation and timely response. If you have any questions, please contact me by phone at
[phone] or by email at shristi.shresth.afilqicdenr.gov.
Regards,
6191.4.,
Shristi Shrestha
Hydrogeologist
Division of Water Resources.
Water Quality Regional Operations Section.
Enclosures
cc: Mooresville- Regional Office — WQROS w/o enclosures
Central Files - Perrnit No. WI0300185 w/o enclosures

North Carolina Department of Environmental Quality -- Division of Water Resources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by rule" and do not require an individual permit when constructed in accordance with
the rules of 15A NCAC 02C .0200. This notice must be submitted prior to construction.
GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS
As described in 15A NCAC 02C .0222 these wells circulate potable water only or a mixture of potable water and
performance -enhancing additives as part of a geothermal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELL
As described in 15A NCAC .0223 these wells circulate a refrigerant gas as part of a geothermal heating and
DATE:
coolisystem.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
, 20 PERMIT NO.: (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(I) ❑ Aqueous (as per 1.5A NCAC 02C .0222) Number of wells:
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER(S) (choose one)
(1) ❑ Single Family Residence Submit this form two (2) business days prior to construction.
(2) ❑ Business/Organization Submit this form 30 days prior to construction.
(3) ❑ Government: State Municipal County Federal*
*Submit this form 30 days prior to construction
C. WELL OWNER(S) — For single family residences, list all persons listed on the property deed. For all others,
list the name of the Business/Agency and person and title with delegated signature authority:
Mailing Address: /5/5 D., 7 !4 1OGd
City: State: 282cs Zip Code: County:
Day Tele No.: CelI No.:
EMAIL Address: Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site:
County:
(2) Physical Address (if different than mailing address):
City: County Zip Code:
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 1

WaterResources
ENVIRONMENTAL QUALITY
August 2, 2016
Mr. and Mrs. Browder
1515 Dilworth Road
Charlotte, NC 28203
PAT MCCRORY
oe err or
DONALD R. VAN DER VAART
Secrel y .
S. JAY ZIMMERMAN
Director
RE: Underground Injection Control (UIC)
W10300185 Browder 5A7 Geothermal UIC
Charlotte, Mecklenburg County
Permit Rescission Request
Dear Mr. and Mrs. Browder:
On June 16, 2016 a Notice of Expiration was mailed from the Central Office of the Division of Water
Resources regarding the expiration of a Geothermal Water Return/Open Loop Injection Well. In a
recent telephone conversation with Mr. Browder, it was indicated that the type of Geothermal well that
was installed at your residence was actually a Geothermal Direct Expansion Closed Loop system. A
permit correction should have been filed due to the change of well type being installed.
As a result, a permit rescission of the geothermal underground injection well heat pump will be
required. A copy of the permit rescission document has been included as part of this correspondence.
Please return the signed permit rescission to the Mooresville Regional office (MRO). The form has been
completed for your convenience. However, the form will need to be signed.
The system that was installed is considered to be permitted by rule (deemed permitted). However, a
completed Notice of Intent to Construction (NOI) is required to be completed by the homeowner. This
form is also included as part of the corrective action needed to be performed to properly record the
Geothermal Well type that was installed at your residence. Upon receipt of the NOI, the MRO will issue
a number that will be used as a record of this well being installed at the above stated address.
Should you have any questions, please feel free to contact me at [phone] ext. 2198 or by email at
[e-mail].
Sincerely,
Edward Watson
Hydrogeologist
Water Quality Regional Operations Section
Division of Water Resources
Enclosures: Permit Rescission Application and Notice of Intent to Construct Application
Cc: Michael Rogers, UIC, Raleigh (email)
State of North Carolina Environmental Quality I Water Resources I Water Quality Regional Operations
Mooresville Regional Office 1610 East Center Avenue, Suite 301 j Mooresville, North Carolina 28115
704 663 1699

iruv. L1. Lvl I 7:JlrlY!
Iru. 7UUL F.
MECKLENBURG COUNTY
1
Land Use & Environmental Services Agency
Groundwater & Wastewater Services
Fax Coversheet
'*NOTICE**
The information contained in this fax may be privileged and/or confidential and is intended only
for the use of the person to who it is addressed, If* reader of this message is not the intended
recipient (or such recipient's employee or agent), you are hereby notified not to read, distribute,
or copy the materials attached hereto without the prior written consent of the sender. If you have
received this fax in error, please notify the sender by telephone call and return the original to us
by mail and you will be reimbiused for the required postage. Thank you.
To: ridkt a_ &' kw- Fax '40- &v 63 la 41-t'U
Phone #:
From: .r2,62A '48( Date: / o f 2a i !
Number of pages transmitted: 2 (including coversheet)
Comments:
-- ; S e(o-A. 9Ia.n 4, cisSpfa% 0 n..c3 uid( arP {`o aa-
uJett 5 . te.n.a-,,� TN( \pu a w
If you do not receive all pages of this fax please call (704).336-5I 03.
❑ Original will not follow
❑ Original will follow via: ❑ U.S. Mail ❑ Hand Delivery ❑
700 North Tiyon Street • Suite 211 • Charlotte, North Carolina 28202-2236
Office It: [phone] • Fax It: [phone]

E. REQUIRED MAPS, PLANS, AND SPECIFICATIONS
(1)
(2)
A site maps must be submitted. It must be scaled or otherwise accurately indicate distances (in feet)
and orientations of features located within 250 feet of the injection well(s). Label all features clearly
and include a north arrow. Attach the site -specific map showing the wells in relation to the locations of
the following:
• Buildings
• Property boundaries
• Surface water bodies, if any
• Water supply wells, if any
• Septic systems and associated spray irrigation sites,
drain fields, or repair areas, if any
• Existing or potential sources of groundwater
contamination, if any
Plans and specifications of the surface and subsurface construction details of the well system.
NOTE: In most cases, an aerial photograph and/or plat map 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 and fields, and other wells, etc. can then be drawn in by hand. Also, a `layer' can be selected showing
topographic contours or elevation data.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. NOTE: Only injectants approved by the NC Division of Public Health, Department of Health
and Human Services can be injected. Approved injectants can be found online at
http://d eq.nc.aov/about/divisions/water-resources/water-resources-perm its/wastewater-branch/around-water-
protection/around-water-approved-iniectants. All other substances must be reviewed by the DHHS prior to use.
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name: _ _ Contact Person:
City: State: Zip Code: County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:
Contact Person:
EMAIL Address:
Address:
City: _ _ Zip Code:
Office Tele No.: Cell No.: Fax No.:
State: County:
Closed -Loop Geothermal Well Notification Rev. 3-1-20I6
Page 2

I. PROTECTION — Provide a brief description of how any (a.) water supply wells, (b.) surface water bodies, or
(c.) septic systems and associated spray irrigation sites, drain fields, or repair areas within 250 feet of the
proposed injection wells will be protected during construction of the wells:
J. VARIANCE — Pursuant to 15A NCAC 02C .0241 the Director of the Division of Water Resources may grant
a variance from applicable well construction or operation standards provided that:
(1) Use of the well(s) will not endanger human health and welfare or the groundwater; and
(2) That construction or operation in accordance with the standards is not technically feasible or the
proposed construction provides equal or better protection of the groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation of the request.
The variance request form can be accessed online at httos://ncdenr.s3.amazonaws.com/s3fs-
publiclWater%20Ouality/Aquifer%20Protecti on/GPU/Geotherm a1 VarianceRequestFormFi Ilab le-
20130805 pdf
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .021. L(e) requires signatures as follows:
(a)
(b)
(c)
(d)
(e)
for a corporation: by a responsible corporate officer;
for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
for all others: by the well owner;
for any 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
authority, and is signed and dated by the applicant.
"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 15A NCAC 02C 0200 Rules."
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 3

L. SUBMITTAL INSTRUCTIONS — Submit one copy of the completed notification package to the each of the
following:
(1)
The Division of Water Resources' Water Quality Regional Operations Section (WQROS) Regional
Office serving the area in which the injection well facility will be located:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Telephone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5043
Telephone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Telephone: [phone]
Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Telephone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Telephone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
-AND-
(2) The County Environmental Health Department in which the injection wells will be located.
Closed -Loop Geothermal Well Notification Rev. 3-1-2016
Page 4

GEOTHERMAL HEATING/COOLING WELL CONSTRUCTION DETAIL
Choose applicable Injection Well design and check the appropriate boxes. Fill in depths below land surface (BLS) and
details of well construction on the blank lines provided. Use additional sheets as needed.
Open -Hole Well Design
❑ Proposed ❑ Existing
❑ Injection; ❑ Supply;
❑ Dual Purpose
Land Surface
Record Depths Below
Land Surface (BLS)
on Lines Provided
Bottom of casing
(Ft. BLS)
Total Depth
(Ft. BLS)
(Ft.)
Screened Well Design
❑ Proposed ❑ Existing
❑ Injection; ❑ Supply;
❑ Dual Purpose
Return or Supply Line
Casing
Grout
WELL DETAILS
Casing Material:
Casing Diameter (in.):
Grout Type:
Grout Depth (BLS):
Top of Bentonite Seal (if present):
Bottom of Bentonite Seal
Screen Material:
Screen Slot Size (in.):
Sand/Gravel Pack
Material Type:
Bedrock
Open Hole
Bentonite Seal
(if present)
Sand/Gravel Pack
Screen
(Ft.)
Record Depths Below
Land Surface (BLS) on
Lines Provided
(Ft. BLS)
(Ft. BLS)
Bottom of casing
(Ft. BLS)
(Total Depth
Ft. BLS)
NC Certified Well Driller Name: Certification No.:

WoterResnurces
o"v/xoNME*vAL Qu^ur,
Mr. and Mrs. Browder
151SDilworth Road
Charlotte, NC 28203
Dear Mr. and Mrs, Browder:
`— PAT MCC&lORY
1 -
DONALD R. VAN DER VAART
8.JAY ZlMMER|N&N
RE: Underground Injection Control (UK]
VV10300185 B,owxder6A7 Geothermal UI[
Charlotte, Mecklenburg County
Permit Rescission Request
On June 16,Z016,allotice ofExpiration was mailed from the Central Office of the Division of Water
Resources regarding the expiration ofaGeothermal Water Return/Open Loop Injection VVeU. In
recent telephone conversation with Mr. Browder, it was indicated that the type of Geothermal well that
was installed at your residence was actually a Geothermal Direct Expansion Closed Loop system. A
permit correction should have been filed at the time of installation due to the change of well type being
As a result, a permit rescission of the geothermal underground injection well heat pump will be
required. A copy of the permit rescission document has been included as part of this correspondence,
Please return the signed permit rescission to the Mooresville Regional Office (K4RO).The form has been
completed for your convenience, However, the form will need to be signed.
The system that was installed is considered to be permitted by rule (deemed permitted). However, a
completed Notice of Intent to Construction (NOI) is required to be completed by the homeowner, This
form isalso included as part of the corrective action needed Mnbeperformed toproperly record the
Geothermal Well type that was installed at your residence. Upon receipt of the NOI, the MRO will issue
a tracking number that will be used as a record of this well being installed at the above stated address.
Should you have any questions, please feel free tncontact meat(784)6G3-1O99ext. 2198nrbvemail at
Edward Watson
Hvdrogno|ngist
Water Quality Regional Operations Section
Division of Water Resources
Enclosures: Permit Rescission Application and Notice mfIntent toConstruct Application
Cc: Michael Rogers, UIC, Raleigh (email)
State ofNorth Carolina |Envt"it"emtalQuality | Water Resources |Water Quality Regional «peru6"ns
Mooresville Regional Office i 610 East Center Avenue, Suite 3011 Mwresville, North, Carolina 28115

North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS)
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
New Application Renewal* Modification X Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Sections A thru E, and NI (signature page) only
DATE: Ai 054 t , 20 [ 1
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application)
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
PERMIT NO. i..o3o618S (leave blank if New Application)
1. Current Use of Well
a. I wish to continue to use the well as ❑ Geothermal Well ❑ Drinking Water Supply Well
❑ Other Water Supply Use- Indicate use (i.e., irrigation, etc.)
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
® Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES RC NO
If yes, indicate New Owner's contact information:
Name(s) F 1-2ci,--eh 12,,-r,t ,ri �✓
Mailing Address: i 5 G S ` 1-2 oc14
City: C_L,1r- I - State:NC -Zip Code: 2 Rza3 County: Ile ,-„ 17u
Day Tele No.: (7i4) 33 B2-9 Email Address.:
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence X Business/Organization
Government: State Municipal County Federal
C. WELL OWNER(S)IPERMIT APPLICANT — For single family residences, list all persons listed on the
propertydeed. For all others, list name of business/agency and name of person and title with delegated authority
to sign:
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Ce11 No.:
EMAIL Address: Fax No.:
. r._ _ ti_,.,__-1 %17..11 Lam.....:♦ A.,..1;nn+:n., Do,, A-15_91114
Page 1

D. WELL OPERATOR (if diffe nt from well owner) — For singl- family residences, list all persons listed on
the property deed. For all others, list n e business/agency an . ame of person and title with delegated authority
to sign:
Mailing Address:
City: tate: Zip • _ ` County:
Day Tele No.:
Email AZldress.:
E. PHYSICAL LOCAT i OF WELL(S) SITE
(1) Parcel Identification N : - (PIN) of we ite: County:
(2) Physical Address (if different than ing address):
City: County Zip Code:
F WELL DRILLER INFO ' TION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certificati No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: tate: County:
Office Tele No.:
Cell No.:
Fax No.:
G. HVAC CONTRACTOR INFO ' TION (if different than driller)
HVAC Contractor's Name:
NC HVAC Contractor License No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County: -
Office Tele No.: Cell No.: Fax No.:
H. WELL USE Will th= ' jection well(s) also be = ed as the supply well(s) for the following?
(1) The injection operate ? YES NO
(2) Personal consumption? YES NO
I. WELL CONSTRUCTION REQ i 1 NTS — As specified in 15A NCAC 02C .0224(d):
(1) The water supply well s .t be construe d in accordance with the water supply well requirements of
15A NCAC 02C .010
(2) If a separate well is used to inject the heat p p effluent, then the injection well shall be constructed
in accordance with the water supply well requirents of 15A NCAC 02C .0107, except that:
ttr_tii n---+ s__t:....+:..._ b.... A 1 ')n7G

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
M. CERTLL+ICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(e) 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 all the person(s) 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."
Signature of Property Owner/Applicant
Print or Type Full Name and Title
Signature of Property Owner/Applicant
Print or Type Full Name and Title
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Submit two copie's of the completed application package to:
Division of Water Resources - UIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
1t7..1l n.._..,.:4 e_. r. n .. A tc 'en14 Pony.. d

North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are `permitted by rule" and do not require an individual permit when constructed in accordance with
the rules of 15A NCAC 02C .0200. This notice must be submitted prior to construction.
GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS
As described in 15A NCAC 02C .0222 these wells circulate potable water only or a mixture of potable water and
performance -enhancing additives as part of a geothermal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS
As described in 15A NCAC 02C .0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: , 20 PERMIT NO.: (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(1) ❑ Aqueous (as per 15A NCAC 02C .0222) Number of wells:
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER(S) (choose one)
(1) ❑ Single Family Residence Submit this form two (2) business days prior to construction.
(2) ❑ Business/Organization Submit this form 30 days prior to construction.
(3) ❑ Government: State Municipal County Federal* •
*Submit this form 30 days prior to construction
C. WELL OWNER(S) — For single family residences, list all persons listed on the property deed. For all others,
list the name of the Business/Agency and person and title with delegated signature authority:
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Cell No.:
EMAIL Address: FaxNo.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site:
County:
(2) Physical Address (if different than mailing address):
• City: County Zip Code:
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 1

Nov 01 11 02: 32p
Lothridge Plumbing 3363572951 p•4
H. OPERATINGDATA
Injection Rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
Average (daily) _18Jgallons per minute (gpm).
Average (daily) _13,00_ gallons per day. (gpd).
Average (daily) 40_.pounds/square inch (psi).
Average (}annary) 4S ° F, Average (July) 68_ ° F.
L. WELL LOCATIONS— Mapsmust be scaled or otherwise accurately indicate distances and orientations of
,features located within 1000 feet oftbe injection weli(s). • Label all features clearly and 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 afgroundwater contamination
(2) Attach a topographic map of the area extending 1/4 wale 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 frog: the applicable county • GJN website. Typically, the property can he searched by
owner more or address. The location of the spells in relation to property boundaries, houses, septic tank.* other
wells, etc can then be drawn in by hand Also, a `layer' ern be cat reoll shooing topographic contours or
elevation da

•
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WELL PERMIT PLOT PLC
pERMiT# mom AIL *moos Pirio in 1,OE•r-02
ADDRESS! 1515 DILWORTH R.D.
Charlotte, NC 2B2O3
WELL SEBACKS:
D.10FEET FROM PROPERTY LINES UNLESS NOTED
>2>t FEET FROM BUILDING FOUNDAT10N I?; SEWER TAP
>50 FEET FROM SURFACE WA11R & RETENTION POND
>1O3 FEEr'FRoM SANITARY SEWEi; LIHE9ISSPTIC SYSTEMS
WELL LOCATION•MUST BE OUTSIDE
.UTILITY RIGHT WAYl1:ASEMENTISWIM BUFFER/
FEMA FIAODPLAINICOMMUN1TY FLOOD HAZARD
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OyvNER/LEGALNENT(P UNTNAME)
STGNATuRE
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DATE
tV.r byuk 5we{LIC� '
AU7HSRIZEDAGE iT(PR NAME)
Plaahute

Caro
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Matthew and Elizabeth Browder
1515 Dilworth Road.
Charlotte, NC 28203
NCDENR
pent of Environment and Nafurai Resource
Division of Water Ctuadtil\
Sans
or
December 13, 201.1.
Re: Issuance of Injection Well Permit
Permit No. WI0300185
Issued to Matthew° and Elizabeth Browder
Mecklenburg County
Dear Mr. and Mrs. Dilworth:
In accordance with your application received November 1., 2011, I am forwarding Permit No. WI03001.85
for the construction and operation of a 5A7 geothermal underground injection control (Ulf) well heat
pump system located at the above referenced address. This permit shall he effective from the date of
issuance until November 30, 2016. and shall be subject to the conditions and limitations stated therein.
Per Permit Condition Part 11.2 please notify Andrew Pitner with the Mooresvilie Regional Office.
(704-663-1699) within 30 clays after the well becomes operational in order for water samples can be
collected from the geothermal system. Also, based upon reported groundwater contamination in
the vicinity, of your home, it is recommended that water from, the well be used for non -potable
purposes only and to check with the Mecklenburg County Environmental Health Department for
any additional permitting or operational requirements.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days 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].
Best Regards,
Michael Rogers, P.G. (NV & FL)
Environmental Specialist
cc: Andrew Pitner, Mooresville Regional Office
Central Office File, W'10'300185
Mecklenburg County Environmental Health Dept,

r
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
Matthew and Elizabeth Browder
FOR THE CONSTRUCTION AND OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A
North Carolina Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat pump
effluent. This injection well is located at 1515 Dilworth Road, Charlotte, Mecklenburg County, North Carolina
28203, and will be constructed and operated in accordance with the application received November 1, 2011, and
conformity with the specifications and supporting data received, 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 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 November 30, 2016, and shall
be subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the ( day of 9-en, 2011
Coleen H. SulIins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0300I 85
UIC/5A7
ver. 04/2011
Page 1 of 5

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
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
;rounds for enforcement action as provided for in N.C.G.S. 87-94.
This pert
this pem
t shall become voidable unless the facility is constructed in accordance with the conditions of
the approved plans and specifications. and other supporting data.
Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface can
the gravel pack or well screen.
0
at
into
Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well
must be sealed with a watertight cap or well seal, as defined in G.S. 87-85(16).
6. Each injection well shall be afforded reasonable protection against damage during construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
A completed "' ' "ell 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
and
Aquifer Protection Section - Mooresville Regional Office
610 E. Center Avenue
Mooresville, NC 28,115
704-663-1699
GW-ls must be submitted within 30 days of completion of well construction. Copies ofthe GW-1.
forms) shall be retained on -site and available for inspection.
PART II - 6EIL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight (4.8) hours prior to constructing each injection well, the Pennittee shall notify the
Aquifer Protection Section-Underg•ound Injection Control (UIC), Central Office staff, telephone number
[phone] and the Mooresville Regional Office Aquifer Protection Section (APS) Staff, telephone
number 704-663-1699.
Within 30 days of injection well completion. Pei nittee; must contact the M mares Mlle Regional Office
APS Staff in order to have samples collected at the source
and injection well.
Pcnn t'N I 300`:;
UIC' A."
vFeo. (:04"2011

3. Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
4. The injection well system must be constructed with sampling ports so that system influent and effluent
may be sampled.
5. The injection well must be constructed to a depth such that it is injecting water into the same aquifer that a
source well, if present, is drawing from.
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.
4. Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
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 which 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.
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 — OPERATION AND MAINTENANCE REQUIREMENTS
I. The injection facility shall be properly maintained and operated at all times.
Permit #WI0300185
UIC/5A7
ver. 04/2011
Page 3 of 5

The Permittee must notify the Division and receive prior written approval fro
planned physical alterations or additions in the permitted facility or activity n
the permit.
PART VI — INSPECTIONS
the Director of any
specifically authorized by
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 niay 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,CKG.S.
Provisions shall be made for collecting any necessary and appropriate samples associated
injection facility actiities.
PART VIl — MONITORING AND REPORTING REQUIREMENTS
Any monitoring (including groundwater, surface water, or soil sampling) deemed n.ecessar 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,
The Pernnittee shall report by telephone, within 4. hours of the occurrence or first knowledge of the
occurrence, to the Mooresville Regional Office., telephone number 704-66 -1699, 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,
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 perfoini satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII - PERMIT RENEW
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
431 C'5.A.7
v er. 04_ 201.1
Page 4.oi.

}
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 that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(1), Well
Construction Standards.
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) A1I 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 -
Permit #WI03001 85
UIC/5A7
ver. 04/2011
Page 5 of 5

Central Files: APS SWP
10/25/11
Permit Number 10300185
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric,g.smith
Coastal SW Rule
Permitted Flow
acliit�r
0
Facility Name
Matthew & Elizabeth Browder SFR
Location Address
1515 Dilworth Rd
Charlotte
Owner Name
Matthew
Dates/Events
NC 28203
D Browder
Status Project Type
Active New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Derry Huneycutt
Driller Well
44283-A NC Hwy 24-27-73
Albemarle NC 25001
Major/Minor Region
Minor Mooresville
County
Mecklenburg
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Matthew D. Browder
1515 Dilworth Rd
Charlotte
NC 28203
Scheduled
Orig Issue App Received Draft Initiated issuance Public Notice Issue Effective Expiration
10/25/11 10/13/1' 1 10/25/11 10/25/11
Regulated Activities
Hea Pump Injectbn
Outfall
Waterbody Name
Stream Index Number
Current Class
Subbasin

NCDENR
Norti Carolina Department of Environment and NaturalResources
Division of Water Quality
Beverly Eaves Perdue Coen H. Suins
Governor Director
10.'2522011
Matthew D. Browder
Elizabeth W. Browder
151.5 Dilworth Road
Charlotte, NC 28203
Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System
Permit No. 'WI0300185
1.515 Dilworth Road, Charlotte, NC 28203
Dear Mr, & Mrs Browder:
Dee Freeman
Secretary
On October 43., 2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
geothermal injection well system for the operation of a ground -source heat pump located at the address. referenced above. An
individual permit is not required for the construction and operation of this -type of geothermai injection well system as long as the
following conditions are met:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North -Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Mecklenburg County Health
Department as they may have additional requirements for this type of system. 'Noncompliance with applicable state., county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Mict 1.Rogerstiuncdenr.gov if you have any questions.
jur Debra Watts
Supervisor
cc: Mooresville Regional Office - APS
APS Central Files - Permit No, W.10.300185
Mecklenburg County: Health Dept,
Air Central of the Carolinas (Wesley Breece)
Derry's Well .Dril ling. Inc, (Derry .HuneyeutO
AQUIFER PROTECTION SECTION
1636 Mai! SerAce RareIgh. North Itharotora 27699-1636
Locator,. 2728 Ctarrtraf Bourthrono Rairtlihrt North saroiina 2750o
Phonth 919.733-322, r FAX 'I. thltOTT54.)58,'2„: FAX 2: 919-715-6546 S'ustornet SeR,NCR. 1-877-S23-67416
Internet: AIM. nowateroualirv.o,,T.:1
ODD:Timm,:
„One,
NorthCarolina
Yititraili/

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
in Accordance With the Provisions of 15A NCAC 02C:.0200
CLOSED —LOOP WATER —ONLY GEOTHERMAL INJECTION- WELLS
These wells circulate potable water only as part ofa geothermal heating and cooling system.
These wells arc "permitted by rule" and do no( require an buividuai permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted priorto construction.
Print or Type Information and Moil to the Addrr ss on the Last Page_
DATE: September 20 , 20 11 _ PERMIT NO. \PICQ 04225 (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence XX : Business/Organization ..
Government: State Municipal County Federal
B. WELL OWNER — Fur individual residences, list each owner on prapetty deed.. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency
Matthew D. Browder & Elizabeth W. Browder
Mailing Address: 1515 Dilworth Road
City: Chariotto ' State: NC Zip Code: 28203, county:Mecklenburg
DayTeleNo.: 704.335.8292 : Cc11No.: 704.361.3139
EMAIL Address: matt@browdergroup . com Fax No.: None
C. LOCATION OF WELL SITE — Where tine injection wells are physically located:
(l) Parcel Identification Number (PIN) dwell site: 123 -105 - 02 County: Mecklenburg
(2) Physical Address (if different than mailing address): Same a s ma i l i ng
City: State: NC Zip Code:
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Derry Hunevcutt
NC Well Drilling Contractor Certification No.: 2663 A
Company Name: Derry's Well Drilling Inc
Contact Person: Derr' Huneycutt EMAIL Address: derrvswelldrilling(awahoo.com
Address: 44283-A Hey 24/27/73 E
City: Albemarle Zip Cade: /0001 State: NC County: Stanley
Office Tele No.: 704-982-3070 CAI No.: 704-985-6135 Fax No.:
RECE VED / DEAR /
AQUIFF:P•PP7Pr..T!nss Ar:cmON
OCT 13 2011

H. CER't'1>H'1CATION (to be signed as
15A NC'AC 02C .0211(b) mquir< all pli :tiota
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 in is all persons listed on the property deed),
bcsi
if an authorized agent is signing tan behalf of tl applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application an their behalf.
"l hereby certify, under penalty of law, that 1 have personally examined and am familiar with the information
submitted in this document and all attacluwants thereto and that, based on my inquiry of those individuals
immrmediately responsible for obtaining said information, 1 believe that the information is true, accurate and
corpictc. 1 am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. 1 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."
Submit the complete application pt ckage to:
Signature of Property Own&Applicant
Matthew D. Browder
Print or Type Full Nn n
Elizabeth W. Browder
Print or Type Full Naso,�
Au
Type Full Name
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]

Oct 13 11 10:09a Lothridge Plumbing
3363572951
p. 1
Using Green
Technology To Build
a
Better World
Dear Tonya,
LothridgeGeo, LLC.
To : _Tonya
Company : _NCDENR
Sent By : Tina Yates
Date : _October 11, 2011
Time :
# of pages including cover : _5 pages
919 715 6048
Cover sheet only :
Following is a Type SQW well application for processing. Thank you for your attention to this mat-
ter,
Regards,
Tina Yat
Office Manager
PO Box 249
Linwood, NC 27299
Phone: [phone]
Fax: [phone]
Email: lothridge a©mindspring.com
RECENED
,OCT 13 2011

Oct 13 11 10:09a Lothridge Plumbing
336357235 1 P 2
Scanr,
Date:_48
NORTH CAROI INA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCFS
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
hi Acmrdance With the Provisions of 15A NCAC 02C 0200
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJEcri N
These wells circulate potable water ordy as part of a geothermal heating, and cooling s3stein
These wet is arc "pcnnitied by ride" and do not require an initvidord permit when !Icy are constructed in
accordance with the rules of I5A NC AC 02C .0200 and this NOUCC is submitted prior to cum-imolai).
'rint or 7).7re Inform:Won and Alm/ to the -4 ddracs on the La q J.
DATE: Septc,mber , 20 11
p.vRivirr (tobcfiflcdinhy MVO)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual Rizidenee _XX _ Busincss/Organization
Ciovcrimienv Static Municipal County Federal
B. WELL OWNER — Fos- 'individualresidences, list wncr property decd. For all others, stale, name of
entity and name of penondelegated authority to sign on behalfof the business or agency
Matt:new D BrowriF-7--Elzoeth W, Browder°
Mal g Addsess. 1515 Dilworch IRad
_ _ ....._
C ity Cbar.1.0ttte _ State: NC Zip Code: 2 a 2 ° 3 county:
. _ •
..
704 .3,35.8292 c it N , 4 . 3 GI. 3 13 9
Day Tele No. - _ — 7 0—
EMAIL Address: Tra t qbrowderqr-ciut -) nor' Fax No.: N3Ile
C. LOCATION OF WELL syrt. - Where the injection wells arc physically ted:
( I ) Parcel Identification Norntxx (PIN) of site 12 3 1. 0
_co__ sleek ;.:xt
timY,
(2)
Physical Addrms (if different than mailing address): arne 716 'n9
City: State: NC Zip Code:
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Narne _ j)prryili ,uneypigL
NC Well Drilling Contractor Certitittion N. 63 A
Company Name: DesDrillnag„,
Contact Person;Ds.cry H.Lincyciitt ,F,MAILAclArsc. s! clqrMNIcilkillingivahoosxml
Address: 44283-A HeN 24/2773 E
City: _Alhepriartc__ Zip Code 28001 _ State: NC County: Stanley
Office 1ete No,: _704-93Q-3670 Ceti No,: _ 704-985-6135 Fax. No:

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•Oct 13 11 10:10a Lothridge Plumbing
3363572951 p.3
E. HEAT PUMP CONTRA(: {'OR INFORMATION (if different than driller)
Company Name: Air Central of the Carolinas
Contact Person: Wesley _ EMAIL Address:nirccntralfcijwindstream,nct
Address: 6216 Clearwater Drive
City: Indian Trail Zip Code: 28079 State: NC Conoly:
Office Tcic No.:.. 704-832-4371 _ Cell No.: _704-309-7510 Fax No.:
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: 6 Depth of each boring (feet): 300'
If existing water supply we1Lv will he used then provide the information in item (4) below,
(2) Type of tubing to be used (steel, PVC, etc): HOPE
(3) Well casing. If the well(s) will use casing them provide the type (steel, PVC, etc.), diameter, death_.
and 'extent oCcasing appearing above ground:
(4) Grout (material surrounding well casing andier piping):
(a) Grout type: Cement Bentonitc** XX Other (specify)
"• 13y Nclectirq hcntunitc gnu. o variinee is hereby reed 1e ! 5A NCAC2C _02 t3(dxlXA), which require+ a can]ni type mutt!.
(b) Grout depth of tubing (reference to land surface): from _300 to ()__ (foot)
Cf nett has casing, indicate grout depth: from to _ (feet)
G. WELL LOCATIONS -. Maps must be scaled or [Abu -wise accurately indicate distances and orientations of
features Iocated within 1000 feet oldie injection well(s). Label all features clearly and include a north arrow,.
(I)
Attach: sits -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
* .E.xisting or potential sources of groundwater contamination
(2) Attach a topographic snap of the area extending 114 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cars, an aerial photograph of the property parcel shorting property lines and structural eorr be
obtained and dnrv:dnuded from the applicable county GIS websita Typically, the proper*, can be searched hV
omrrer name or address. The location of the culls in relation to prupeny boundaries, houses, septic tanks, other
n+mlls, etc: can then be drawer in by hand Also. a 'layer' can he selected showing topographic contours or
elevation data
RECEIVED I D ENR 1 DWQ
AQllIFI R-PPMFr.TICNN SECTION
OCT 13 2011

Oct 13 11 1010a Lothridgo Plumbing
3363572951 p . 4
the Permit,"
11, CERTIFICATION (to be signed as required below or by that pcmon's authorized agent)
i5A NCAC, 02C.„02I l(b) ri,quires that all pennit applications shaB besigncd as follows
for a corporation: by a responsible corporate officer:
2, for a partnership or sole proprietorship: by a general partner or the proprietor. respectivelyt
3, for a municipality or a ...qat c., f&leral., or other public agency: by either a principal cxcanivc
officer or ranking publicly elected
4. :for all others: by the well owner (which means all persons listed on the properyy
If an authorized agent is signing on, behalf of the applicant.. then supply a letter signed by the
applicant that inarn; 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 thcrcto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, 1 believe that the information is true, accurate and
complete, l am aware that thcie 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 appunenances in accordance with the approved specifications and conditions. of
Signature of Property Owner/Applicam
t hew D °r3rowde r
Print or Type FuU Namc
) -
- " '
S g nature. of PrOpcny OwneriApplicani
Elizabeth W. Browder
Print or Type Full Namc
Signature of Authorcred
Print or Type Full
nt„ it any
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center.
Raleigh, NC 27699-1636
Telephone [phone]

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© Copyright 2008 ESR1. AU rig trt re er ed, Printed on Wed Nov 23 2011 11.41.53 AM,