WI0700087_Application_20201112

North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
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 X Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pages 1 and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: October 15 , 20 20 PERMIT NO. _ WI0700087 _(leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit 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).
RECEIVED
❑ Yes, I wish to rescind the permit
Nov o s 2020
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES ® NO NC DEOIDVVR
If yes, indicate New Owner's contact information: Cwtral Oifice
Name(s)
Mailing Address:
City:
Zip Code:
Day Tele No.: Email Address.:
County:
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence Business/Organization X
Government: State Municipal County Federal
C. WELL OWNER(S)/PERMIT APPLICANT — For single family residences, list all persons listed on the
property deed. For all others, list name of business/agency and name of person and title with delegated authority
to sign: Ashton — Lewis Lumber Company, Inc. Michael Lancaster, Vice President of Sawmill Operations
Mailing Address: P.O. Box 25
City: Gatesville State: NC Zip Code: 27938 County: Gates
Day Tele No.: [phone] Cell No.: [phone]
EMAIL Address: [e-mail] Fax No.: [phone]
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page 1

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. CERTIFICATION (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 theperson(s) listed on the propeU 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."
f
4 Nov 0 6 2020
s
NL ji_ ..iDWR
Cor-- ral Office J
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Signature of Property Owner/Applicant
Michael Lancaster, Vice President of Sawmill Operations_
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 copies 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]
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page 4

North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
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 X Renewal* Modification Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Pages 1 and 4 (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: October 15 , 20 20 PERMIT NO. _ WI0700087 _(leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit 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 ® NO
If yes, indicate New Owner's contact information:
Name(s)
Mailing Address:
City:
State
Zip Code:,
Day Tele No.: Email Address.:
RECEIVED
NOV 06 2020
NC DEQ/DWR
Central oMw
County:_ _
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence Business/Organization X
Government: State Municipal County Federal
C. WELL OWNER(S)/PERMIT APPLICANT — For single family residences, list all persons listed on the
property deed. For all others, list name of business/agency and name of person and title with delegated authority
to sign: Ashton — Lewis Lumber Company. Inc. Michael Lancaster, Vice President of Sawmill Operations
Mailing Address: P.O. Box 25
City: Gatesville State: NC Zip Code: 27938 County: Gates
Day Tele No.: [phone] Cell No.: [phone]
EMAIL Address: [e-mail] Fax No.: [phone]
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page 1

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. CERTIFICATION (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 erson s listed on the-pLoVM 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
_Michael Lancaster, Vice President of Sawmill Operations
Print or Type Full Name and Title
RECE®
Signature of Property Owner/Applicant
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Print or Type Full Name and Title
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Signature of Authorized Agent, if any
Print or Type Full Name and Title
Submit two copies 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]
Geothermal Water Return Well Permit Application Rev. 3-1-2016 Page 4