WI0100169_Regional Office Physical File Scan Up To 9/22/2022

Bullman Heating & Cooling Q
:• - . �.y RESIDENTIAL WELL CONSTRUCTION RECORD
g= North Carolina Department of Environment and Natural Resources- Division of Water Quality k t4
WELL CONTRACTOR CERTIFICATION # 3421
1. WELL CONTRACTOR:
David Stratton
Well Contractor (Individual) Name
AWD Services. Inc.
Well Contractor Company Name
258 North Turkey Creek Rd.
Street Address
Leicester NC 28748
City or Town ' State . Zip Code
8( 28 t 683-9223
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W 10100169
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID *(if applicable)
3. WELL USE (Check. Applicable Box): Residential Water Supply ❑
DATE DRILLED 12/6/11
TIME COMPLETED AM ❑ PM
4. WELL LOCATION:
CITY: Sviva COUNTY.)ackson
Tote Road (Balsam Mtn Preserve Lot 253)
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
51Slope ❑ Valley ❑ Flat ❑ Ridge ❑ Other Elev.
LATITUDE 35 ° 23 5B.0000 " DMS OR DD
LONGITUDE 83 ° 51 17.0000 " DMS OR DD
Latitude/longitude source: Rf3PS Dropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Ken Bowdon
Owner Name
Balsam Mtn Preserve Lot 253 Phase 5
Street Address
Svlva NC 28773
City or Town State Zip Code
8�)
Area code Phone number
S. WELL DETAILS: (5) 3 0 0 ' Geo ' S
a. TOTAL DEPTH: (1) 350' Geo -
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
c. WATER LEVEL Below Top of Casing: NIA FT.
(Use 'Y' if Above Top of Casing)
d. TOP OF CASING IS NSA FT. Above Land Surface`
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): NIA METHOD OF TEST NIA
f. DISINFECTION: Type NIA Amount NSA
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
7. CASING:
Depth
Diameter
Weight Material
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
8. GROUT:
Depth
Material
Method
Top 0
Bottom 20'
Ft. Bentonite
Pour
Top 21'
Bottom 350'
Ft. Pea Gravel
Pour
Top 21'
Bottom 300'
Ft, Pea Gravel
Pour
9. SCREEN:
Depth
Diameter Slot Size Material
Top
Bottom
Ft. in.
in.
Top
Bottom
Ft. in.
in.
Top
Bottom
Ft. in.
in.
10. SAND/GRAVEL PACK:
Depth
Size
Material
Top
Bottom
Ft.
: Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
Top Bottom
/
/
/
1
12. REMARKS:
Formation Description
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
Ills A i ?,h 1119/12
SIGNATURE OF CERTIFIEDWELL.CONTRAC.T_OR—DATE_..
David Stratton
PRINTED NAME
Submit Within 30 days of completion to: Division of Water Quality -
1:617 Mail Service Center, Raleigh, NC 27699-161, Phone: [phone]
CONSTRUCTING THE WELL
Processi -J '"
-. � � �!2 Form
Rev.
a
v��

A7A
MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue . Coleen H. Sullins
Governor Director
September 23, 2011
Robert Colton
Balsam Mountain -Florida, LLC
4270 NW 24th Ave., Boca Raton, FL 33431
Ref: Issuance of Injection Well Permits WI0100169
Issued to Balsam Mountain -Florida, LLC
Sylva, Jackson County, North Carolina
Dear Mr. Colton:
u
07 3 0 26 11
Asheville Regional Office
Aryt_tifcr Protection
reeman
In accordance with the application received on September 2, 2011, I am forwarding permit number WI0100169 for
the construction and operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system to
be located at Balsam Mountain Preserve, 40 Back Bone Way (Lot Number 25), Sylva, Jackson County, NC 28779.
This permit shall be effective from the date of issuance until August 31, 2016, and shall be subject to,the conditions
and limitations stated therein, including the requirement to install well identification tags as specified in Part
II.3 and to submit well construction records as specified in Part V11.2. Be sure to read the entire permit to
ensure that you are aware of all compliance requirements of the permit.
You will need to notify this office at least 48 hours prior to beginning construction and operation of the injection
well system. In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must
submit an application to renew the permit 120 days prior to its expiration date. This permit is not transferable to
any person without prior notice to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or michael.rogers(a,ncdenr.cov if you have any questions about your permit.
Best Regards,
f
Michael Rogers, P.G. (NC & )
cc: LEandon Davidson; Ashevil�!egional Office
WI0100169 Permit File
Jackson County Environmental Health Department
Larry Wells, AWD, P.O. Box 125, Leicester, NC 28748
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604 One
Phone: [phone] FAX 1: 919-715-0588; FAX 2: 919-715-60481 Customer Service: 1-877-623-6748 Noo`rw. Cai-ohiia
Internet: www.ncwatemualitv.om
k, a114�
An Equal Opportunity 1 Affirmative Action Employer

W
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
Balsam Mountain -Florida, LLC
FOR THE CONSTRUCTION AND OPERATION OF 4 TYPE 5QM INJECTION WELL(S), 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 heat pump system. This system is located at Balsam Mountain Preserve, 40 Back Bone
Way (Lot Number 205), Sylva, Jackson County, NC 28779, constructed and operated in accordance with the
application received September 2, 2011, and in conformity with the specifications and supporting data
submitted, 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 and shall be in compliance with Title 15A of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until August 31, 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 23rd day of September, 2011.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #W10100169 UIC/5QM Page 1 of 5
ver. 03/2010

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
1. 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
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 permit, the approved plans and specifications, and other supporting data.
3. 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.
PART II — WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight (48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number 919 715-6166 and the Asheville Regional Office Aquifer Protection Section Staff, telephone
number 828-296-4500.
2. The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation corners) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
3. One well identification tag per grouping or `cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g).
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.
Permit #W10100169 UIC/5QM Page 2 of 5
ver. 03/2010

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 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
ground water resulting from the operation of this facility.
PART V — OPERATION AND MAINTENANCE REQUIREMENTS
1. 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 919 715-6166. 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.
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.
2. Division 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.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
Permit #W10100169 UIC/5QM Page 3 of 5
ver. 03/2010

PART VII — MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section — UIC Program Aquifer Protection Section
DENR — Division of Water Quality Asheville Regional Office
1636 Mail Service Center and 2090 US Highway 70
Raleigh, NC 27699-1636 Swannanoa, NC 28778
Ph# 919-715-3221 828-296-4500
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Asheville Regional Office within 30 days of completion
of well construction. Copies of the GW-1 form(s) shall also be given to the Permittee and retained on site
to be made available for inspection.
3. A copy of the site map updated with manifold locations required in Part II.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Asheville Regional Office within 30
days of completion of well construction.
4. 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:
5. The Permittee shall report by telephone, within 48' hours of the occurrence or first knowledge of the
occurrence, to the Asheville Regional Office, telephone number 828-296-4500, 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;
(C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
6. 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.
7. 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
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
Permit #W10100169 UIC/5QM Page 4 of 5
ver. 03/2010

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, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(1).
Notification shall be submitted to the addresses given in Part VII.1 of this permit.
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) 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 that 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,
eachwell 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 copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(1) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.1 of this permit.
Permit #W10100169 UIC/5QM Page 5 of 5
ver. 03/2010

AN �a
KDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
September 12, 2011
Robert Colton
Balsam Mountain - Florida, LLC
4270 N.W. 24Tn Ave
Boca Raton, NC 33431
Dear Mr. Colton:
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. WI0100169
Balsam Mountain
Injection Mixed Fluid GSHP
Well (5QM) System
Jackson County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on September 2, 2011. Your application package has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Asheville Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail].
Sincerely,
for Debra J. Watts
Groundwater Protection Unit Supervisor
cc: Asheville Regional Office, Aquifer Protection Section
Laity Wells — Appalachian Well Drilling
Joey Bullman — Bullman Heating & Air, Inc.
Permit File WI0100169
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Caoital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588: FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Intemet www rimateroualitv.orm
An Equal Opportunity \ Affirmative Action Employer
Noi�b�'_aioluia
,I'm'1

Interactive Site Map
Page 1 of 1
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http://www.balsammountainpreserve.com/interactive-site-map.html 9/13/2011

Rogers, Michael
From: Rogers, Michael
Sent: Friday, September 02, 2011 3:48 PM
To: '[e-mail]'
Subject: RE: Lot 205. Colton/ Balsam Mtn. Preserve
Larry -
I will go ahead and give this permit application to our Administration staff to process. However, in the future it is better if
you mail it to the address on the last page of the application, or fax to 919-715-6048. This ensures that the application
will be received and processed. If you send to my e-mail there is the possibility that it could sit in my inbox for days or
weeks if I am out of the office for training, vacation, sick leave etc.
Thank you for your cooperation.
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality- Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://portal. ncden r.oralwe b/walaps/pwDro/perm it-aDDl ication s#a eoth ermADDs
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
From: LPhillips9898Cd)aol.com jmailto:[e-mail]1
Sent: Thursday, September 01, 2011 5:54 PM
To: Rogers, :Michael
Subject: Lot 205 Colton/ Balsam Mtn. Preserve
Michael, Please find attached file for closed loop goe permit app. Contact me with any questions. Thanks
Larry Phillips [phone]

RECENE0 / iDENR / DWQ
IFFR'PROTFCTInN 4FCTION
Rogers, Michael �SEP 0 2 ZUII
From: [e-mail]
Sent: Thursday, September 01, 2011 5:54 PM
To: Rogers, Michael
Subject: Lot 205 Colton/ Balsam Mtn. Preserve
Attachments: CCF09012011_000OO.jpg; CCF09012011_00001.jpg; CCF09012011_00002.jpg;
CCF09012011_00003.jpg; CCF09012011_00004.jpg; CCF09012011_00005.jpg
Michael, Please find attached file for closed loop goe permit app. Contact me with any questions. Thanks
Larry Phillips [phone]

chit n
r cl This ma Is prepared forinvemo of real property within Jackson Cou ti r p p pa ry p pony My. tfis compiled fromreeortled deeds, putts, and public data ,I:`;;•f;���z;_ r
records. Users of this map are hereby notified thatthe aforemonNonotl public Information sources should be consulted for verlfleaNan.
Jackson County or any County representative assumes no legal responsibility forthe contents of this map. Punted:Sep 01(, 2011

This map is prepared for inventory of real property within Jackson County. It is compiled from recorded deeds, plats, and public data records.
Users of this map are hereby notified that the aforementioned public information sources should be consulted for verification. Jackson County
or any County representative assumes no legal responsibility for the contents of this map. Printed . Se.p 01, 2011

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H. CERTIFICATION (to be signed as required below or by that person's authorized age + CEIVE01 DENR I DWQ
AMIFFR'PR0TFrTl0N SECTION
15A NCAC 02C .'0211(b) requires that all permit applications shall be signed as follows: •SEP 0 2 2011
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 means all persons 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, 1 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. 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."
Signature of Property Owner/Applicant
Print or Type .Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signatul,5yAuthorize gent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
C;PU/U1C' 5Qfvi Pennit Application (Revised 1/2 12011) Pa;-e 3

E.
F.
RECEIVED IDENR/DWO
AQJIFFR-PROTEMION SECTION
NEAT PUMP CONTRACTOR INFORMATION (if different than driller) SEP 0 2 2011
Company Name: BVa,"A/V /IE4T%A/G •4 ig12 lrC-
Contact Person: J0 Y l3WLLmA1L( EMAIL Address:LJu7.l�.btrllm�tN�7ect�iavti •GoM
Address: 17. AFDX
City: 1�s�Ev1iy_ Zip Code: 2AF-14 State: N (:County: TRWA16,9M Bt
Office Tele No.: (�a � v*a5B-. /�a Cell No.: Fax No.: (92e_ 6s a-/oD/
WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: 4 Depth of each boring (feet): 300
x If existing water supply wells will be.used then provide the infonnation in item O below.
(2) Chemical additives to be used: 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): a of - l r.M/C
(4) Well casing: If the well(s) will use casing then provide .the (steel, PVC, plastic; etc.), diameter; depth,
and extent of casing.appearing aboveground: a%/.A
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite** 1 Other (specify)
**By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(1)(A). Which requires. a cement qpe grout.
(b) Grout depth of tubing (reference to land surface): froin to -?-4 (feet)
If well has casing, indicate grout depth: from to (feet)
G. WELL LOCATIONS - Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of theinjection well(s). Label all features clearly and include a north arrow.
(1)
(2)
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 of groundwater contamination
Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the snap narne.
NOTE. In most cases, an aerial photograph of the properhl parcel showing property lines and structures can be
obtained and downloaded from the applicable county, GIS website. Typically, the property can be searclted ht'
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 'laver.' can be selected showing topographic contours or
elevation data.
GPU/UIC 5QM Permit Application (Revised 1/24/2011)
Page 2

Pr
RECEIVED / DENR / DWQ
AQUIFFR'PROTErTION SECTION
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RI;SOUVES 2 ZQ»
APPLICATION FOR A. PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CI.,OSED-LOOP MIXED -FLUID GEO'I'HERMAL IINJECTION WELLS
These wells circulate fluids other than potable water as part of a geothermal heating and cooling system
(check one) ✓idNew Application Renewal* Modification
* For renewals complete Parts A-C and the signature page.
int orType Information and Mail to the Address on the Lost Pine. Illegible Applications Will Be Returned As Incomplete
DATE: 20 1 / 100 1(V
PERMIT NO. �s� S (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence V/ Business/Organization
Government: State Municipal County Federal
B. PERMIT APPLICANT —For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency:
SRL&Am MaumTR6\1-FI.o2iDA 1-LC
R o 9027' G o L�T'aA/
Mailing Address:. �, ?b /V. A/ �Y_'W RYE. r
City: 9040 Rj Z-b/,,! State: E/_ zip Code: 33513/ County: P&M E
Day Tele No.: Cell No.: J — S(p/ —743 V4, Z13
EMAIL Address: 268 6#7S reVPI• 6-OM Fax No.:
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 764?_� -PO- 7S/- 3 County: Ilg6kSDfi/
(2) Physical Address (if different than mailing address): �� .Q�C (3oNE GJfI Y
City:State: NC Zip Code: a?977f
1). WELL DRILLER INFORMATION
Well Drilling Contractor's Name: w ELL $
NC Well Drilling Contractor Certification No.: C�a3
Company Name: 12P1>1-?L & C f -/AN W EZL P2ia-1414
Contact Person: Z_,91eR y EMAIL Address:
Address: iaok 12�
City: 46/CFS7-E12 Zip Code: -297yS State:N-C.County: 19U1V40m96
Office 7'ele Ne.:(82B) Cell No.: Fax No.:
GPI i1UiC ?Q 1 Permit Application (Revised li2a,''2011) Pax 1