WI0100058_GEO THERMAL_20120514

NCDEN R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P. E.
Governor Director
May 14, 2012
Crossnore School, Inc.
Post Office Box 249
Crossnore, NC 28616
Subject: Notification of Rule Revisions Affecting
Closed -Loop Geothermal Injection Well Permit Holders
Permit Number: WI0100058
To Whom it May Concern:
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.ncdenr.org/web/wd/ai)s.
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 Servioe Center, Ralegh, North Carolina 27699-1636 One .
Location: 512 N. Salisbury St, Raleigh, North Carolina 27604 1 ofthCarvlina
Phone: [phone] FAX: [phone]
Internet: www,ncwateroualitv,om
An Equal Opportunity 1 Affirmative Action Employer

Central Files: ARS SVVP
07123/08
Permit Number WIOI00058 Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (50M)
Primary Reviewer
michael.rogers
Permitted Flaw
Status
Project Type
Active
New Project
Version
Permit Classifleation
1.00
Individual
Permit Contact Affiliation
Facility Name Major/Minor Region
Crossnore School Beverly Cottage Minor Asheville
Location Address County
210 Miracle In The Hills Or Avery
Crossnore NC 28616 Facility Contact Affiliation
Wilma BiggerstafF, COO
PO Box 249
Crossnore NC 28616
Owner
Owner Name Owner Type
Crossnore School Inc Non-Govemment
Owner Affiliation
PO Box 249
Crossnore NC 28615
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
07/15/08 07/15/08 07/16/08 07/16/08 06/30/13
R_ egulated Activities Requested/Received Events
Heat Pump Injection Region comments on draft requested 07/15108
Region comments on draft received 07/17/08
Outfali NULL
Waterbody Name Stream Index Number Current Class Subbasin

Central Files: APS SWP
07/22/48
Permit Humber W10100058 Permit Tracking Slip
Program Category
Ground Water
Permit: Type
Injection Mixed Fluid GSHP Well System (50M)
Primary Reviewer
michael.raagers
Permitted Flow
Status Project Type
In review Now Project
Version Permit Classification
Individual
Permit Contact Affiliation
Faciiitv
Facility Name Major/Minor Region
Crossnore School Beverly Cottage Minor Asheville
Location Address County
210 Miracle In The Hills Dr Avery
Crossnore NC . 28616 Facility Contact Affiliation
Wilma Biggerstaff, COO
PO Box 249
Crossnore NC 28616
or-r
Owner Name Owner Type
Crossnore School Inc Nan -Government
Owner Affiliation
PO Box 249
Crossnore INC 28616
Da
scheduled
Orig Issue App Received Draft Initlatad issuance Public Notice issue Effective I-irati n
D71131i1aIIItoIos n�7) (3
Rettuiated Activities RewPA-;tad/Rr caived Event%
Heat Pump Injection Region comments on draft requested 07/1 &08
Region axnments on draft received 07117/08
Clutfail NULL
Waterbody Name Stream Index Number Current Class Subbasin

OF w H rFR
Michael F. Esdiey, Governor
William G. Ross Jr,, Secretary
y l ti Nerth Carolina Depa unant of Environment and Natural Reno=ea
Coleen H. Sullins, Duecter
Diviaivo of Water Quality
July 16, 2008
Dr. Phyllis H. Crain, Executive Director
Crossnore School, Inc.
P.Q. Box 249
Crossnore, NC 28616
Re: Issuance of Injection Well Permit
Permit No. WIOI00058
Issued to Crossnore School, Inc.
Dear Ms. Crain:
In accordance with your application received July 15, 2009, I am forwarding Permit No.
WI0100058 for the operation of a vertical closed -loop geothermal mixed -fluid heat pump
injection well system to be located 210 Miracle in the Hills Drive, Crossnore, Avery County, NC
28616. This permit shall be effective from the date of issuance until June 30, 2013, and shall be
subject to the conditions and limitations stated therein.
Please pay special attention to the bolded language in the permit. In addition, please
submit copies of the Well Construction Completion form (GW-1) and site map after
construction as required in Part I paragraphs 8 and 9. Also, please contact Ms. Julie Vann
at the Asheville Regional Office at [phone] during installation of the well system.
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 Mr. Qu Qi at [phone] or me at
[phone].
Best Regards,
/A_�_4p 49=�
Michael Rogers, EnviroLental Specialist
cc: Landon Davidson - ARQ
Central Office File — WI0100058
David Braswell — Braswell Weli Drilling, Inc.
Avery County Health Dept..
Attachment(s)
one
N4�tq Cara
Avrrtura(lb,
Aquifer Protection Secuan 1636 Mal) Service Center Raleigh, NC 27699.1636 Telephone, [phone]
Internet: hrMJ1v ww.ncwat=uahtyorg 2728 Capital Boulevard Raleigh. NC 276Q4 Fax 1: [phone]
Fax 2: [phone]
An Equal CpporlunilylAfirmafte Action Employer— 50% RMt: "10% Post Consumer Paper Customer Service- [phone]

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
�' �:7�uiitl�i�li:l�iliJ���i:�7l�Fllli�`►1:�'►i�Is77-�7:�ii[i�►is����h'l��i�#I��IiIM-IiCi�►i
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
Crossnore School, Inc.
FOR THE CONSTRUCTION AND OPERATION OF 16 TYPE 5QM INJECTION WELLS,
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 2 10 Miracle in the Hills Drive, Crossnore, Aver), County, North Carolina 28616, and
will be constructed and operated in accordance with the application dated July 15. 2008, 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 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, froin the date of its issuance until June 30.. 2013,
and shall be subject to the specified conditions and limitations set forth in Parts I through X
hereof.
'�
Permit issued this the day of ; Lc� , 2008.
lkcoleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0100058 Page 2

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
i. 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 secured to Treasonably 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 secured with a locldng cap.
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).
8. A completed Well Construction Record (Form GW-I) 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 — Asheville Regional Office
2090 U.S. Hwy 70
Swannanoa, NC 28778
GW-1 s must be submitted within 30 days of completion of well construction. Copies of
the GW-1 form(s) shall be retained on -site and available for inspection.
9. Well 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).
Perayit No. WIO 100058 Page 3

PART la - WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight (48) hours prior to constructing each injection well, the Permittee shall
notify the Aquifer Protection Section -Underground Injection Control (LiIC), Central Office
staff, telephone number (919) 715- 6166 and the Asheville Regional Office, telephone
number [phone].
PART III - OPERATION AND USE GENERAL CONDITIONS
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.
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.
PART IV - PERFORMANCE STANDARDS
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
Pei ittee 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.
1 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.
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
The injection facility shall be properly maintained and operated at all times.
Permit No. WI4100058 Page 4

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 -
Underground Injection Control (UIC), Central Office staff, telephone number (919) 715-
6166 and the Asheville Regional Office, 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.
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. 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.
3. 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 acceptahle sampling reporting schedule shall be followed.
2. The Permittee sball 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, which results in any unusual
operating circumstances;
(S) 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
Permit No. WI0100058 Page 5

the Director, the relevant and correct facts or infonhation -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 VIH - PERMIT RENEWAL
The Permittee shall, at least 90 days prior to the expiration of this permit, request an
extension.
PART IX - CHANGE OF WELL STATUS
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) 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.
Permit No. WI0100058 Page 6

(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 ZC .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 Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27599-1536
PART ILL - OPERATION AND USE SPECIAL CONDITIONS
None.
Pemx tNo. WIa100058 Page 7

5QM permit app at Crossnore school
Subject: 5QM permit app at Crossnore school
From: Julie Vann <Julie.Vann@a ncmail.net>
Date: Thu, 17 Jul 2008 11:17:19 -0400
To: [e-mail]
Hi, Michael,
I am the regional well inspector at ARO. I made a modification to the draft
permit for the above -referenced application on page 4: that is, I would like to be
present at drilling. Otherwise I have no comments.
Thanks
Julie
Julie Vann <Julie.Vannt"uoncmail.net>
NC DENR - Asheville Regional Office
Division of Water Quality - Aquifer Protection Section
Crossnore School NEW SQM.doc Content -Type: applicationlmsword
Content -Encoding: base64
1 of 1 7/17/2008 12.16 PM

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
`wig --I.AN01%- rC
July 15, 2008
Dr. Phyllis H. Crain
Crossnore School, Inc
PO Box 249
Crossnore, NC 28616
Subject: Acknowledgement of Application No. WIOI00058
Crossnore School
Injection Mixed Fluid GSHP Well System (5QM)
Avery
Dear Dr. Gain:
Coleen H. Sullins Director
Division of water Quality
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit
application and supporting materials on July 15, 2008. This application package has been assigned the number listed
above and will be reviewed by Michael Rogers,
The reviewer will perform a detailed review and contact you with a request for additional information if necessary.
To ensure the rnaxinrum 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 Michael Rogers at 919-715-6166, or via e-mail at
[e-mail]. If the reviewer is unavailahle, 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
hno.:llh2o.enr,state,nc.us/documents/dwq oruchart.pdf:
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON TMS
PROJECT.
Sincerely,
for Debra J. Watts
Supervisor
cc; Asheville Regional Office, Aquifer Protection Section
Edd Hill/ HVAC Inc, PO Box 788, Bristol TN, 37621
Permit Application Pile WIOI00058
Aquifer Protection Section 1636 Mail Service Center
Internet wfflLr racsnrpteroualiy-org Location: 2726 Capital Boulevard
An Equal Opportunity/ARlrmatim Action Employer— 50% Rerydledh0% Post Consumer Paper
J01hCarolMIVI;
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

• NORTH CAROLiNA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES WORM
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE �) M WE, _ i S�
---V-l—Nrw Pamit APPHcotion OR Renaw0i (check ene)
DATEL 2,Djp
PERMIT NO. (laars blank if NEW permit application)
RECEIVED ! ❑ENR I DWQ
Aquiex Protadon Section
[ 1 �&��
A. PROPERTY OWNER(SYAPPLICANT(S)
List each Pmperty Owner listed oo property deed (ifowged by a business or go y, sfaie name of
entity end a reprGse�tiva ��(auihority�for signautre}: ■ ! , 4 � nla-1R� �. 4t —
t' t1 sS {jI_ i��r1►�i`F'L• LJr�EGa_
.J z
(1) Maiiing Addroaa•
city: ND e__ sw=A'� zip coca: Z County, � e r
Home/Office Teie No.: " I J j ` 3 d Cell No
EMAIL Address: i r R i W •' r NO p t✓ . ' p o' . a ( ,
jJS f .
(2) Physical Address of Site (if different Own above): �<<
City: b r SteQe: Zip Code' of - ~ County: /vr'C {_,
Home/Office Tele No.:
EMAIL Addn=,
�rr 13. AUTHORIZED AGENT OF OWNER. IF ANY (if the Permit Applicant dons oat own the subject pnoparty,
rh, attach a letter from rh_ o pn4wty owner Agent to insW and operate UIC well)
►Viflf�� r (� Comppy Nntoc: >r_tSl:
d� j Confect Person W f �7t t= �S tg _ �•f�� EMAIL Address:
Address,_ f .
State: !� _lZip Code:
Office Tole No., $ � '7 3 5 - 3 � 1 Call No.
wabwwAd&=ofcompmy,ifarty: W1Uu-i.a-T"o55Nore• - f 6e . p
7
OPUARC 5QM wen Permit Appli anw (Revised 90W) Pap 1

C WELL DRUAJUt 26KH MATIQN
'17:� ► f a t ► 1 'I 'A . 1 1
Wei Urillionooptsaetor'a Names FR tat.S'U-)B
NC Conttadw Csetifresom No: 2,153
Contact NMI-
Addrase: 2 r
City: Zip Cod
Office Tale No.: Z2 jt- 7332a o Z Cep No.:
A HEAT PUW CQI9'FRACTQIi
Company
Conwet Pvsoa-
Amass: f?, a . yov, I
Cky=
OiIIw Tale No.:,d2 q . 9A'9
TKNIRMA• ION Ofdftwent than dd9w)
4 04cIALIL i z C; z.n
L STATUS OF APPLICANT
Pdvaw Federal:
State: _ MumicipaL-
F
a
IWJZCIiON P'ROCEDUM (bridly
Native Amim I=&-.
bow the infection welds) wM bD used]
WELL C'ONS'PRUCTIDN DATA (Skb N Section H if this jj M Famit BlLiALWAL
(1) Proposed dam to be constued: O Numbear of bariags:
Appwhuft depth of cub bwi;g (bk. 2 a ' _
(2) Cbemical addkKm to be used in ckm&lcop (only tme cbmnk als bdicmed bare bun approved):
R 22 �pmpyleme � %ethanol other {orbrr nrcldirivea w�!
need prior approval by NCDENR before me)
(3) Type of tubing m be wed {copper. PVC, etc}:
(4) WelI teeing, h dw walls) cased? (dmck either (a] YES !Orfto 6alaw)
(a) YES if yM area provide c=wS irdasae bm much as Mg (seed, PVC. plensk maw), fir,
dm& and sx= of cuing appowing above ground:
(b) NO V'
(5) Grout(nasdww sraraund M ■wep casing Cm arrdlorpipImgj: m� r
(a) w type: Cement Hartonfoe V Ospot i G Ba D �T
(b) moot depW oftubiog (re[ereaceto herd arrrface]c tofit) 7
If well has taming, indicate grout depth from to {fleet}
C+KMC SW We# Pnrmh Ax tl ads (RwdN4 Vn Pmw Z

RECEOMD 105M I JDM
Agsj4F,( Crnlpr on Sed0n
H. INJECTION -RELATED EQUIPMENT
Attach s diagrim showing the cugkoering layout or proposed modification of the hkiewaft er[uipm+ent and exterior
pipingltubing associated with the injection operafion. The maanuficfturcr`s taochure may provide suppiemenmry
irf�vmoon.
L LOCATION OF WELLS}
Attach two copies of maps showing the following Wbrmation:
(1) ILIclude u site map (ran be drawn) showing buildings, property tines., surface water bodice potential sources
of groundwater contamination and the oriamation of and dWznces 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
geotitermai htw pump wel! systems Label all fares ckarly and include a ndrib arrow-
(2) irit:hada a topographic map of the am w toding one nu'ie f am the propcity bmmdMiee and
indicase the Wlity's location and the map name.
I. CERTIFICATION
Notes- This Piermlt Appliczt1w must be dgaed by jMh perm appmrin6 on the
I rdM tagal propa'tr dead.
" I hereby ou fy, uadw penaaity of law, that I have personally examined and am familiar with the io%rmation
submitted m this docurawt and all atmi;hments thereto and that; based on my inquiry of timm individuals
immediately msponsi-We for obttaiarng said information, I belien that the information is true, arr,zye and complete.
I am aware that there are significam penaltim including the possihility of fines and imprisonment. for submitting
false information. I agree to shuq opeaafr, maintain, 'repair, and if applicable, abandon the injection well and
all related appurtenances in sC00Tdanca Wits► wam,z ,read r-:,'fications Arid cooditiovs of the PcrmiL"
0
Sifnafui� of Prppelrty 0"CrI ppGg�
I da lr--, _ S C, �CIh 0() I G
n4 V :.tId;� P r''-K ry
Print or Type W Name
5igaawte of Pmouty OwneralApplmnt
T' int or Type %H Name
f. N ,
Signmwe of AuthorW_ �Irg nth tF a�' �1 v-
i � le.a55nrn�t r5�-i`t"6J t
Print or Type Doll Name J
Please return two copies of the: completed Application package to:
North Carolina DFNR-DWQ
Agnder Protection Section
UIC Program
1636 Mast Service Center
Raleigh, NC 27699,-1636
Telephone [phone]
GPUMC SQM Wei} Pant AWi atkm [Revised 9l2Dp pow 3

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The Crossnore School - Find Us
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The Crossnore School M Crossnore Academy W Crossnore Weavers W1 Crossnore Gallery Blair Fraiey Sales Store W Miracle Grounds
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Directions
Traveling From Hwy. 221•Marion
Travel North an Hwy, 221-30 mile& -(sea note
below)
Tra►reIIng from Hwy. 105- Boone
Travel out at Boone on Iiwy. 105-approximate
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4`C,
PassiIn na Iee elftatn Hwy- 2212attrafc
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travel a miles (see note below)
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Traveling from Hwy. 181-Morganton
North on Hwy. 181 to Hwy. 221 intersection In
Pineola. turn Left on Hwy. 221. travel 2.3 mlles
(see note below)
NOTE: When entering Crozanore area look for
sign on Hwy. 221 that reads Town of
Crossnore-Home of Crossnore School, Inc.
turn at sign and travel 0.3 miles, turn Right on
Miracle In the Hills Drive.
:: AMPHITHEATRE SEATING CHART
The Crossnore School
100 OAR Drive
PO Box 24D
Crossnore, NC 28916
(829) 7334305 or (800) 5574305
1 nfD@ cross noreschoa1.arg
www.c ros sn o res chop I.org
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Jd•rµv- City � C � --_•. ,
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Spruce RIr
Council on Accreditation
of Services for Families and Children, Inc.
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The Crossnore School
PO Sax 249
http:llwww.crossnoreschool.org/findus.html 7/16/2008

The Crossnore School - Find Us
Page 2 of 2
Crossnore, NC 28616
828-7334305
i n to®crossnoreschool.org
http:llwww.crossnoreschool.org/fiindus.htm] Ili 6/2008