WI0300174_GEO THERMAL_20120518

i..~A7~ •i,~ .. ;~-
---NC----DEMR;·
North Carolina 0epartment of-Eri\1ironment:and Natural Resources
Beverly Eaves Perdue-----
Governor
Brian and Allison 'Price
3101 Doster Road
Monroe, NC 28112
Division of Water-=Quality
Charles-Wakild, P. E.
Director
May 18, 2012
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
PerrnitNumber: WI0300174
Dear Mr. and Mrs. Price:
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 ISA 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 th~ Division of Water Quality. You
may view the revised rules on our website at http ://portal.ncdenr.org/web/wq/ap s.
If you have apy question_s regarding your current permit or the rule revisions, please feel free to
contact our underground injection c·ontrol staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydro geologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St, Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterauality.org
An Equal Opportunity \ Affirmative Action Employer
N~rth Carolina
/vafttrally
Permit Number WI030017 4
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Brian and Allison Price SFR SQM
Location Address
3101 Doster Rd
Monroe
Owner
Owner Name
Brian
Dates/Events
NC 28112
Keith Price
Central Files: APS_ SWP_
06/28/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Perri'lft Contact Affiliation
Brian Keith Price
Owner
3101 Doster Rd
Monroe NC
Major/Minor
Minor
Region
Mooresville
County
Union
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Brian Keith Price
Owner
3101 Doster Rd
Monroe NC
28112
28112
Orig Issue
06/23/11
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
06/23/11
Expiration
05/31/16 06/02/11 06/23/11
Re gulated Activities Re a uested/Received Events -----------------------
Heat Pump Injection Region comments on draft requested
Private residence, single family Region comments on draft received
Outfall h'J L'...
Waterbody Name Stream Index Number Current Class
06/20/11
06/22/11
Subbasin
Permit Nl,lmber WI030017 4
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
john;mccray
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Brian and Allison Price SFR SQM
Location Address
3101 Doster Rd
Monroe
Owner
Owner Name
Brian
Dates/Events
NC 28112
Keith Price
Scheduled
Central Files:. APS_ SWP_
06/23/11
Permit Tracking Slip
Status
In review
Project Type
New Project
.Version Permit Classification
Individual
Permit Contact Affiliation
Brian Keith Price
Owner
31· 01 Doster Rd
Monroe NC
Major/Minor
Minor
Region
Mooresville
County
Union
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Brian Keith Price
Owner
3101 Doster Rd
Monroe NC
28112
28112
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
06/02/11
_R_e __ a_u_la_te_d_A_c_ti_v_it_ie_s _______________ ~R=e__..q-=-u ____ es=-t=e~d~/R~e~c~e-iv~e~d~E~ve=n-t=s __________ _
Heat Pump Injection Region comments on draft requested
Private residence, single family Region comments on draft received
Outfall i'.1ULL
Waterbody Name Stream Index Number Current Class
06/20/11
06/22/11
Subbasin
•~A ~~--~-~-
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Brian and Allison Price
3101-Doster Road
Monroe, NC 281.12
Division of Water Quality
Coleen H. Sull ins
Director
June 23, 2011
Ref: Issuance of Injection Well Permit WI030017 4
Issued to Brian and Allison Price
Monroe, Union County, North Carolina
Dear Mr. and Ms. Price:
Dee Freeman
Secretary
In accordance with the application received on June 2, 20 11., I am forward~g permit number WI03001.74
for the construction and operation of a vertical closed-loop geothermal mixed-fluid heat pump injection
well system. This permit shall be effective from the date of issuance until Ma.y 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 11.3 and to submit well construction records as specified in Part
VII.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 919-715-6168 or [e-mail] if you have any questions about your
permit.
c.:: Andrew Pitner, Mooresville Regional Office
WI0300174 Permit File
Union County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center. Raleigh. North Carolina 27699~1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Pnone: 919-733-3221 \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Cusmmer Service: 1-877-623-6748
Internet www.ncwate rq ualit , .oro
An Equ2i: Opµortunii:-' \ Affirmative Action Ernpioyer
Best Regards, ?£~7
John R. MeCray
Environmental Specialist
NOnehC 1· ort aro 1na
;!Vaturaftu
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
Brian and Allison Price
FOR THE CONSTRUCTION AND OPERATION OF 5 TYPE SQM INJECTION WELL, defined in Title 15A
North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at 3101 Doster Rd, Monroe, Union County,
and will be constructed and operated in accordance with the application received June 2, 2011, and in
conformity with the specjfications 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 May 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 June, 2011.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0300174 UIC/SQM
ver. 03/2010
-Page 1 of 5
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 919-715-6168, and the Mooresville Regional Office Aquifer Protection Section Staff, telephone
number 704-663-1699.
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 comers) 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 #WI0300174 UIC/SQM
ver. 03/2010
Page 2 of_S
' '
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 perm.it 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 919-715-6168. 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 represent3:tive 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 #WI0300174 UIC/SQM
ver. 03/2010
Page 3 of 5
PART VII-MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section -UIC Program
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
Moorseville Regional Office
610 East Center Avenue~ Suite 301
Mooresville, NC 28115
704-663-1699
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 Mooresville 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 Mooresville 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 MooresvilkRegional Office, telephone number 704-663-1699, 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;
( 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 RENEW AL
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 #WI0300174 UIC/SQM
ver. 03/2010
Page 4 of 5
PART IX-CHANGE OF WELL STATUS
1. The Perm.ittee 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)(l).
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
Pennittee shall abandon that injection well in accordance with the procedures specified in 1 SA 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 sopnded 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,
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 Pennittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.I of this permit.
Permit #WI0300174 UIC/SQM
ver. 03/2010
Page 5 of 5
Mccray , John
From:
Sent:
To:
Cc:
Subject:
Attachments:
Hi John,
Pitner, Andrew
Wednesday, June 22, 2011 9:23 AM
Mccray, John
Schutte, Maria
RE: 5QM application
Price 5QM -Union Co GIS.pdf
We're ok with the proposed SQM project. A better map is attached (the adjacent parcel is also Price-owned) and we'd
just suggest that they try to stay at least 50 ft from their water supply well as there appears to be sufficient room to do
so. Let us know if you have any questions.
Andrew
From: Mccray, John
Sent: Monday, June 20, 2011 3:27 PM
To: Pitner, Andrew
Subject: SQM application
Mr. Pitner,
Attached is an application for a mixed-fluid geothermal system for a residence in Union County. Please let me know if
your office has any concerns with the issuance of this permit.
Best Regards,
John McCray
1
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6/20/2011

GoMAPS -Union County NC Public Access http://maps.co.union.nc.us/gornaps/map/Index.cfm
Union County • GIS/1Mapping System · ,:·::~ick ~eaj-ch: .. · . ..·.: ..
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1 of 1
NCDEN�
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
June 16, 2011
Brian Keith Price
Allison Denise Price
3101 Doster Rd.
Monroe, NC 28112
Subject: Acknowledgement of Application No. WI0300174
Brian Keith Price SFR
Injection Mixed Fluid GSHP Well System (5QM)
Union
Dear Mr. Price:
Dee Freeman
5ecrelary
The Aquifer Protection Section of the Division of Water Quality acknowledges receipt of your permit application and supporting
materials on 06/02/201 1. This application package has been assigned the number listed above and will be reviewed by John McCray.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximurn efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 - 90 days after receipt of a complete
application.
If you have any questions, please contact John McCray at 919-715-6168, or via a -mail at john.mccrayCncderingov. If the reviewer is
unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To review our
new organizational chart, go to h�://h2o.enr.state.nc.us/documents/dwq orachart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT
Sincr�-ely, IP ,
for Debra ,1 atts
Supervisor
cc: Mooresville Regional Office, Aquifer Protection Section
Allison (D L Mullis Well Drilling, Inc., P.O. Box 691446, Charlotte, NC 28227)
Joey Dulin (Dulin Mechanical, 1551 Morrison Rd., Harrisburg, NC 28075)
Pemut Applicatior File Vlrl0300174
AQUIFER PROTECTION SECTION
1636 Mail 5eMoe Center. Rai"h, North Catalina 27699.1636
Locanan. 2728 Capital Boulevard, Raleigh, North Carglina 27604
Phone, 91�,-733-32211 FAX 1, 919-71"588: FAX 2: 919-71M0481 Customer Setv ice . 1-877-623 -6746
Irtterne:: www.nmatercualitvn
An Equai Cioponumry I At rma I vekstion Gmpoye-
n2
aa'rchCar�lina
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APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSET) -LOOP MIXED -FLUID GEOTHERMAL INJECTION WELLS
These wells circulate fluids other than potable water as part of a geothermal beating and cooling system
(check one) V/New Application Renewal* Modification
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
Print or Type Ir�rormation and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete,
DATE: 20J
PERNUT NO. (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Goverment: Individual Residence � Business/Organization
H.
C.
D.
Government: State Municipal County Federal
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:
Mailing Address:- 1(] t '-h 0 5JCf—
City: _fi 1^ o � L State: UC Zip Coder I.1 a —County: all
Day Tele No.: �W — (L. to 14 C? Cell No.:
EMAIL Address r# L C l;rua. rr_ GF0 No.: U -
LOCATION OF WELL. SITE — Where the injection wells are physically loc{ eed:
(1) Parcel Identification Number (PIN) of well site: 172 7— M `7 County:
(2) Physical Address (if different than mailing address):
City:
WELL DRILLER INFORMATION
State: NC Zip Code:
GPU/UIC 5QM Permit Application (R.cAsW 1/24/201 I) Page I

Well Drilling Contractor's Name:-~ -::r~ h ("'"\ m. mu \ \ i ~
NC Well Drilling Contractor Certification No.: __ 2~D~0~· ~~~--------------
Company Name;D L r:Qul),·~ lA)e l I Dn11,·rifg. 7N'L
Contact Person: ~\ \ ,' "::£)0 EMAIL Address:~ · c\, \ Mukl )s@bc. l Jsou~ • t1 e
Address: '?Q Bui-... (o 3 14L\l;
City: (Y\ Q, ,-\ D \.-.¼,. Zip Code: ;2 i~~ '1 State: L County: lYl·e..c.KJ-en bu. tj
Office Tele No.(JQ-\.-5Y6:5Co YLJ Cell No.r10j-3(p J-? lo I 9 Fax No.: 1 CH..-5t/5-9''/l/9
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name;::J:::x ,J \ 0 C(\e ch M, \ C ~
Contact Person: --S ne ~::s:::i,. L\ \ ~ EMAJL Address: du.h' Q MrcbM 1 co.SI ®de .. ot.+
Address· 155\ f(\QN\c&oa, tsd. ----
City: r\J._n-{ob~ _ ZipCode:~O'J'2 Stata.~ounty: -:-~OJ"~
OfficeTeleNo,10-kY<::>5-,-a,sz CellNo::10k-3'=1l-ld..<a I ~Fax~N_o~·=-----
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: -~5~--Depth of each boring
(feet): :2 OD
* If existing water supply wells will be used then provide the information in item (4)
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): _p_~~G~------------
(4) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, plastic, etc.), diameter, depth,
and extent of casing appearing above ground: __,No'--=_,_(\.....,,e,=----------------
(5) Grout (material surrounding well casing and/or piping): /
(a) Grout type: Cement__ Bentonite** _✓_ ( Other (specify) ______ _
** By selecting bentonite grout, a vanance is hereby requested to 15A NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from Q to Z. 00 (feet) /µ_
If well has casing, indicate grout depth: from ___ to ____ (feet) f.t /V /V"'/
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
GPU/UIC SQM Permit Application (Revised 1/24/2011) Page2
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
ISA NCAC 02C .021 l(b) 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 the well owner (which means all persons listed on the prope rty deed).
H 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 ip_formation, 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 infonnation. 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." ~ -. /:? Ii-~
Signature of Property Owner/ Applicant
'1?Jri D--0 K,_ itfr e.-
Print or Type Full Name
Signature of Property Owner/ Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ -Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QM Permit Application (Revised 1/24/2011) Page4
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