WI0300190_GEO THERMAL_20120328

/ REsmENTIAL WELL coNSTRucnoN REcoRD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# ::2 o:J fr -2.o3 G:>
1. WELL &RACTO · wi ~ (\ \J ll I S, 1 Kcl 1/1 /) Beik..
. ~ ~(lndMdllal) tiame (.Ue }) DLffiutl ,5 \I alhu\19 Well Contractor Company Name
STREETADDRESS-1-.u-~_...~g,,,a,,1...1...-...-~-,f,-1,,--.,..,.. Cb O f').D-\-k:_. AJ C-di'c3 d\?
City. or~,_ H (\ J/ Zip Code nru,_ '6Cb: '21..0 7 '1 ~ Phonenumber
2. WELL INFORMATION:
SITE WELL ID #(if applicable) ________ ~=----
STATE WELL PERMIT#(ifapplicablel \A ltb:!:(X)\ 9 0
DWQ or OTHER PERMIT #(if applicable.,_ ______ _
WELL USE (Check Applicable Box): ResideRtial 'llate1 SuppJyO ~ q / "1 6'Eo77/E/l'Al,#2-DATE DRILLED .J"-/ -t7-.
·TIME COMPLETED s:5: CD AMO PM)i
3. WELL LOCATION:
c1TY: .................. .a-=-.............. __ couNTY lli<KUA 1ue ,
I \J-e..
(Street Name. Nu
TOPOGRAPHIC/ LAND SETTING:
□Slope □Valley ~ □Ridge □Other _____ _
(check appropriate box)~
c::._ \ \ 1 ' May be in degrees. LATITUDE ~ ~ , minutes, seconds or
LONGITUDE f:__ a 5'0. (p C/ / · in a decimal rormat
Latitude/longitude source: .,0'('jPS □Topographic map
(location of weH must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME --lo..~~~~--1L---1....._.....i11...&..;~~--
~REET ADDRESS l u ...LL~----===--~=""""--f'---'-&..,<;;.~~=
City or Town State , ( ,=81>2,~ ;lcJ~-C(Q._y
Area. code -Phone number
5. WELL DETAILS: /
a. TOTALQEPTH: ~~ A-LL Wl=lLS
b. DOES WELL REPLACE EXISTING WELL? YES D
c. WATERLEVELBela.vTopofCasing: ----FT.
(Use·+• if Above Top of Casing) ----d. TOP OF CASING IS _____ FT. Above Land Surface* .,.op of casing terminated at/or bek7N land surface may require
a variance·in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): .--. METHOD OF TEST 41 Jt.
f. DISINFECTION: Ty_,. -~ Amount C:
g. WATER ZONES (depth):
From To From To
From .---'.,-o From = To ,--. ... 7 From To From To
&. CASING: Thickness/
Depth Diameter Weight Material From ___ To ___ Ft.-----=:;; __ _
From~ 1o r-· Ft. ✓-:__ From ___ To ___ Ft.. __ _
7. GROUT: Depth Material Method
From__Q_ To i.oo Ft. ldAtir[f£~ From ___ To ___ 6"t. ____ _
From ___ To_-__ Ft. ____ _
8. SCREEN: Depth Diameter Slot Size Ma\~. From , ,;Jo ___ Ft. __ in.~ in. ___ _
From ___ To ___ Ft. __ .• ----in. -~c::::»--
From___::::-To ___ Ft._m:. __ in. ____ _
7' ==
9. SAND/GRAVEL PACK:
Depth Size Material
From ~o ___ Ft. . .,--.... .,.......__
From
.,.
To ___ Ft. . .,,---. •. _,,,..__
From To ___ Ft. . ..r---. .-
10. DRILLING LOG
From To ~-, C2 -t?"-V
9' w £llS
11. REMARKS:
Fqrmation OescripPon
c /~y -S:q,,,,d
J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15,\ NCAC 2C, WELL CONSTRUCTION STANDARDS, ANO THAT A COPY OF 11-llS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
J(J b {V r,, ('1 LI~~ ,' 5 3...J J;;t_J-
SIGNA URE OF CERTIFIED WELL CONTRACTORD~ . {
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., 1617 Mall Service Center-Raleigh, NC 27699-1617 Phone No. [phone] ext 568. ,J.
FonnGW:-.1a
Rev. 7/05.
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT ANO NATURAL RESOURCES
NOT[FICATION OF INTENT TO CONSTRUCT OR OPERA TE INJECTION WELLS
In Accordance With the Provisions of 1 SA NCAC 02C .0200
CLOSED-LOOP WATER-ONLY GEOTHERMAL IN,JECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Print or Type Information and Mail to the Address on the Last Page.
DATE: (Y\.ar. , 20~ PERMIT NO.\f\\'1 03 0 0190 (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non-Government: Individual Residence ✓ Business/Organization __
Government: State Municipal __ County __ Federal
B. WELL OWNER -For individual residences, list~ 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:
CarLj 0ra..nK
Mailing Address: / 5 j. lp L lf ,') t.-va...c..,J "7;,y-,,.. , _ . ~-.,. UcU"\bu~
City: {)1c.t·1-I o-H-e., State: OL. ~ip Code: d g,;:, 0 3 County:_ (Y\ e c.F-s
Day Tele No.: Cell No·,:·
EMAIL Address: fax No·
C. LOCATION OF WELL.SITE-Where the injection wells are physically located:
(1) Parcel lden~ific,,ation Number (PIN) of well site: / s-' 0 ' :.::2 :). 3 County: rn e. vk-L.a~ b....{,.n::
(2) Physical Address (if different than mailing address): .5a /1'1 e_
City: State: ~ Zip Code:
D. WELL DRILLER-INFORMATION ' l. .....-; . {:::rn hn yY\l..c.l I Ls
Well Drilling Contractor's Name: /Y) u l I j_;; U,_)_.e.11 Dr··i i ! ~ ,-~c
NC Well Drilling Contractor Certification No.: t:.::9 0 3 .8
Company Name: m 1../. l I j _5 l<.) t_A / -~-,-j_ L l i n~ ;::r;; (.
Contact Person,; {,,A_J /Vlu l I ; ...S ._., Ed!L Add,-ea~·
Address: ~ ;;i OD ~(J_.~.c_J/ f1, L l / .fG ~ .
City: {A"'-cu-Jo-tf-e._1(\~ipCode:,;:l'&~ State:f'Xcounty: (Y)ecJ::-L~~
Office Tele No.: 'JQLf · 9-/5" ~ Cell No.: ________ Fax No,:
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
CompanyNwne: f a-tt--H-.e--r J-{.;4{ "4 { /4,;:.) i' f\4 ;vv:,
GPU/UIC SQW Notification (Revised 3/18/2011) Page 1
RECEIVEDIDENRIDWQ
MARO 6 2012
Aquifer Protection Section
EMAIL Address: Contact Person~ m 't K...R_ &-~~d.J l~ 5
Address: C-l O 3 U.J .. (Y\ C2 I tl 5,-j-' •'II
City: f._o(..Jc f-l t l l Zip Code: c}?J'l3D State:~County:~cer~
Office Tel~ No.: 203 -3 :;() -.J:p(cell No.: _______ Fax No,· go 3-3d9-C>,.;)~
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed•: £ Depth of each boring (feet): c~O
• If existing water supply wells will be used then provide the information in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc): f rQ / 3/ e.Jf i lf U./l.R_ .-5'· D f?.. -· l I f E 3 C,{'0~
(3) Well casing. If the well(s) will use casing then provide the~ (steeJ, PVC, etc.), diameter, .d!mlb,,
and~ of casing appearing above ground: -----~------------
(4) Grout (material surrounding well casing and/or piping): /
(a) Grout type: Cement__ Bentonite•• _V_ O 01ther (specify) _______ _
•• By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(I )(A), which requires a cement type grout
(b) Grout depth of tubing (reference to land surface): from (? to~ (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 the injection weil(s). Label all features clearly and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
• Proposed injection wells • Buildings • Property boundaries
• Surface watet· bodies • Water supply wells
• Septic tanks and associated spray irrigation sites, drain fields, or repair areas
• Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending l /4 mile from the injection well site that indicates the
facility1 s location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property "nes 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 i11 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. .
OPU/UIC SQW Notification (Revised 3/18/2011) Page2
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C 0211 (b) requires that ail permit applications shall be signed as follows:
I. 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 all-crs-onslisttdhe e d
If on authorized agent Is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authortzes their agent to sign this application on their behalf.
1 hereby certify, under penalty of law, that 1 have personally examined and am familiar with the i:formation
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 trite, accurate and
complete, I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit.."
Signature of Property Owner/Applicant
Print or Type Il Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center RECENEDIDENRIM
Raleigh, NC 27699-1636
Telephone [phone]a2l
<�cri- W30 1
MAR 0 6 2012
Aquhr Proledon Se0on
GPINUIC 3QW Notification (Revised 311V2011) Pase 3

VICINITY MAP
1. 54'
IP
zt,
L O T 9
a
LOT 25
I Stephen 8. Mullins, aertlfy that an the I Day of SES PTc� FB 201D,
this map was drawn under my supervision from on actual survey made under
my supervision; that Ws survey was performed to Class A urban Land Survey
Stondards; that the rot}o of preclslon Is 1. 10.000, and there are'I P I I II III
encroachments either way across piWY s except a sho�rW+N GApp
SIGNED
STEPHEN B. MULLINS PLS SEAL
C_C.. . S, L-3059 S.C.R,L.S 10780 _ = SEAL =
SURVEY MAY BE SUBJECT TO AODITONAL = r�Y floc -
EASEMENTS, RIGHTS -OF -WAY. UTIL]TkES,iJ�`r;�
COVENANTS OR RESTRICTIONS, THAT MAY
BE OF RECORD.Is5�%4,`'
LOT 21
DRIVEWAY
ENCROACHING
S�
�I
a 4•MAPLE S'
ro
39.69'
` yo-aHERRY
SST RY
s3DIIJ
p 's RB
AGE
n 3B�aAK
a 1�55 sq.
0.2 acres
LOT 23 RECENED/DENRM
RU RENT ZONING c MAR 4 7+
MAR O L
12
FRONT 20'
SIDE 5•
REAR 35'
Aquifer Protection
MIN OPEN SPACE 6594
Section
LEGEND
P.D.E PUSUC DRAINAGE EASEMENT o MRS NEW REBAR
DP EYJSTRC; IRON PIPE • ERB DaSTING RESAR
DHPL OVERHEAD POWER UWE • ERB-8C ORB AT 6C
•-- CM CONCRETE MONUMENT - �.,� -' FENCE UNE
PPGLE POWER POLE XIPOLE UGHT POLE
p PB TRANSFORMER A MK MANHOLE
CURVE RADIUS LENGTH TANGENT CHORD BEARING DELTA , PHCNE TELEPHONE Box a CAN CABLE Tv BOX
C1 1457.b8 5.79 2,90 5.79 S2818'42"E 013'39" DRAWN Br. sM
PHYSICAL SURVEY AREA COMPUTED BY COORDINATE METHOD
O LOT 22, BLOCK 2, CUMBERLAND PARK 34'
CITY OF CHARLOTTE SCALE 1"= 30'
MECKLENBURG CO., NORTH CAROLINA PREPARES? BY:
STREET ADDRESS. 1516 LYNWAY DRIVE S'TEPHEN B. MULLINS AND ASSCCIATBS. P.A.
TAX PHN-,15101223 REGISTERED LAND SURVEYORS
OWNED BY: ESTHER L. FISHEL
CONVEYED TO;CORY & CARRIE FRANK
RECORDED IN MAP BOOK 4 PAGE 543 601-8 EAGLETON DOWNS DRIVE [phone]
10125 DEED BOOK14-45 PAGE_ PINEVILLE. N.C. 28134 FAX [phone]

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCTOR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C.0200
CLOSED -LOOP WAHR-QZ1Y GEOTHERMAL LN- ECTIM WELDS
These wells circulate potahle water only as part of a geothermal heatinE and cooling system.
These wells are'permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Prier or Type fnjarrnation and Mait to lire Address orr the Last Page.
DATE: (YJ CK,(' . I , 201_�?, PERMIT NO. (to be filled in by D W Q)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence Z Bus inesslOrganization
Government: State Municipal County Federal
8. WELL OWNER — For individual residences, Iist each owner on property deed. For ali others, state name of
entity gd name of person delegated atuthority to sign on behalf of the business or agency:
C 0,(
Mailing Address: 57 I L L€ O waz �—
rr r� u q
City; 641r1T—[ tit F Sate: 4p Code: �3 Caunry,_ � � �J
Day Tele No.. 1$'e� a.
EMAIL Address. Fa No
C. LOCATION OF WELL SITE— Where the injection wells are physically located:
(1 ] Parcel identification Number (PIN) of well site: 11j 10 I � D-3 County'
(2) Physical Address (if different than mailing address)jaiYl e—
_
City: State: NC Zip Code.
D. WELL DRILLER INFORMATION
r i t � ' r .� 1 !P I � l ��� I � �' �s ri �Y1 u. ✓ l f�
Well Drilling Contractor's Name: (y) u I J� L.(;.e
NC Well Drilling Contractor Certification No.: S
Company Name: n43 C
Contact Person; ! i _S Ad
Address: e o 0-
City: r` 1 �f�Zig Code: �0 7 State:( "Xountyi
Office Tele No.;'Cell No.:
RECENEMENNWO
E. HEAT PUMT CONTRACTOR INFORMATION (if different than driller)
Company Name: 'r e/,o a ) 1 A. i J MAR 4 6 2017
Cr U(UIC SQW Notification (Revised 3)1W011 ) Page 1 Aquifer Protection Section

Contact Person; m 't_ K.~-&' ~~d_d /~ _5
Address: CJ. 0 3 LO .. fYla I() ~--}J -~
EMAIL Address:
City: ~o (...Jc H L l J Zip Code: c)-~'13D State:~ County'.~~/(_
OfficeTel~No.: 203 -3 J1-d"p(ce1IN0.: _______ Fax No.· '303-3d9-CGX.r~
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: '6 Depth of each boring (feet): c;:t[)O
• If existing watet supply wells will be used then provide .the information in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc): fol 'f e.J1J lf Jg../U? .-5'· D R -· l I . f E 3 <.~fD~
'(3) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, etc.), diameter,~.
and~ of casing appearing above ground: _________________ _
(4) Grout (material surrounding well casing and/or piping): /
(a) Grout type: Cement__ Bentonite** _V_ O O1ther (specify) _______ _
•• By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(dXl)(A),which requires a cement type grout.
(b) Grout depth of tubing (referenceJto land surface): from (J to iiJ{Y() (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 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:
• Proposed injection wells "' Buildings * Property boundaries
• Surface watet· bodies "' Water supply wells
• Septic· tanks and associated spray irriga~ion sites, drain fields, or repair areas
• Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1 /4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial pho_tograph of the property parcel showtng 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 loct¢on of th·e 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
elevati.on data. .
OPU/UIC SQW Notification (Revised 3/18/2011) Page2
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
1 SA NCAC 42C .4211(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 e all j[ to thC Drg2rEUd
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.
"1 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 P. operty Own erlAppiicant
Print or Type F411 Name
Signature of Property 6wner/ippIicant
Print or Type Full Name
Signature ofAuthorized Agent, if any
Print or Type Full Name
Submit the cornpiete application package to;
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone (919) -793 322i—
qcn- W30 I
RECEW/DENemft
xiuffaP Prot9cfn S.0 !
GPUAJIC sQw Notification (Revised 3i1anoi i) page 3

MINITY MAP
PA-
SI'E7»,�P�
v
LOT
LOT 25
I Stephan S. Mullins, certify that on the I Day of SEPTEMBER 2010,
this mop was drown under my svpts salon from an actual survey made under,
my supervislon: that thle survey was performed to Class A Urban Land Survey
Standards; that the ratio of precleian Is T:10,004, and there are �qp++eillrrrr
nTcroachmenta either way across prop y lines except s she"�tk CA7�a
SIGNED
STEPHEN R. MULUNS PLS S�
N.C.P.L.S. L-3059 S.C.R.L.S 10780 = —
0-540
SURVEY MAY BE SUBJECT TO ADDITONAL "~ yy d;
EASEMENTS, RIGHTS —OF —WAY, UTILITIES, =NJ
COVENANTS OR RESTRICTIONS. THAT MAY
BE OF RECORD,
CURVE RADIUS LENGTH TANGENT CHORD HEARING DELTA
Cl 1457.89 5.79 2.90 5.79 S26'16'42'E 0'13'39"
PHYSICAL SURVEY
LOT 22, BLOCK 2, CUMBERLAND PARK
CITY OF CHARLOTTE
+- ces
uo.Y-Ak 5
CURRENT ZONING MAR 2�
R--S
FRONT 20'
SIDE 51
REAR 35' Aqu*r pM,0,�
►lIN OPEN SPACE 55%
LEGEND
P.O.E. PUBUC DRAINAGE EASEMENT o NAB NEW RMAR
a LIP EXISTING [RON PIPE a iRa EAS)INa REBAR
OHM OVERHEAD POWER UHE a me—BC
ERB Al BC
CM COHCRF'TE LIONUMENT -- . FENCE LINE
PPOLZ PONE! PULE x{LPME UGHT POLE
P9 TRANSFORMER ® MH MANHOLE
: PHONE TELEPHONE BOX , CATV CABLE Tv Box
DRAIN 8Y: SU
AREA COMPUTED BY COORDINATE METTi00
O 3o'
SCALE 1"= 31Y
MECKLENBURG CO., NORTH CAROLINA PREPARED BY:
STREET ADDRESS: 1516 LYNWAY ORIVE STEPHEN B. MULLINS AND ASSOCIATES, P.A.
TAX PIN:15101223 REGISTERED LAND SURVEYORS
OWNED 9Y: ESTHER L FISHEL
CONVEYED TO:CORY & CARRIE FRANK
RECORDED IN MAP BOOK 4 PACE503 601—B EAGLETON DOWNS DRIVE (704)593-11500
10125 DEED BOOK 1445 PACE U4 PINEMILLE. N.G. 28134 FAX [phone]
f
2

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERA TE INJECTION WELLS
In Accordance With the Provisions of 1 SA NCAC 02C .0200
CLOSED-LOOP WATER-ONLY GEQTHE~AL JN,JECTION WELLS
These wells circulate potable water only as ·part of a geothermal heating and cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the ru_lcs of l5A NCAC 02C ,0200 and this Notice is submitted prior to construction.
Print or Type Information and Mail to the Address on !he Last Page.
DATE: (Y\a.r. :2012' PERMIT NO. ________ (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non-Government: IndividuaJ Residence ✓ Business/Organization _._
Government: State Municipal __ County __ Federal
B. WELL OWNER -For individual residences, list each owner on property deed. For aJl others, state name of
entity mid, name of person delegated authority to sign on behalf of the business or agency:
Ca.rLJ 0-MK
Mailing Address: . / 5 j {_p L lt ,') wa:.,c.1 ---z:;:>r , _ . ~ .•· UU\6u.n
City: {)'\c.t-d o-H-e.. State: Of.. "tip Code: ,!;; S,;2 ° 3 County:_ (Y'\ e u::.. 5
Day Tele No.: Cell No,:
EMAIL Address: fax No·
C. LOCATION OF WELL SITE-Where the inj~ction wells are physically located:
(1) Parcel Identification Number (PIN) of well site: { ~-I O l -::~ :). 3 County: (() e ~ l.'2-/\ bu,n::
(2) Physical Address (if different than mailing address): .5-a, /VJ e_
City: State: M,C Zip Code:
D. WELLDRILL.ERINFORMATIO~ , 4 / ,-... .. · U. p)c f::::::r~hn fY\~..1.I ll_s
Well Drilling Contractor's Name: (Y) u·l-1 J.> LU.l,,,c e,.....---(" 1 i ~ r · ·
NC Well Drilling Contractor ~ertification No.: _a O 3 .8 . ,.... ECEIVEDIDENRIDWQ
Company Name: m L{ l t 1 .5 U.} e.---1 1 Dr!. L l I n4 ~ c. R
Contact Person; l,AJ /Ylc.t l I ;_s _ .__,,. ~IL Address· -MARO 6 2012
Address:.~ ;;;;:ioo .5~.u f-{Ll I fG .
City: . {har-/ 0 -tfe/V'.Zip Code: ,;;irs;;,.;;;n State: Q(:.county: /Y)t-' ~ SectlOn
Office Tele No.: rio<..f · 5l-/5"--5?Di Cell No.: ______ Fcg No,:
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Con\pany Name: p t,t,f'l,cH, e-r H--L.4i "4 {' to c, f i' "-4 _;:PY ,
GPU/UJC SQW Notification (Revised 3/18/2011) Page 1
l
Contact Person; m 't K.R_ t--~-d...d ,~ 5
Address: CJ. 0 3 l.V -.. fYt C2 'i n 5.rf./ -~
EMAIL Address:
City: f._oc_Jc_H t l j Zip Code: c).~,3D State:~County'.~er/(_
OfficeTel~No.: 2,03' -3 ,::y-, -dJ?Ccell No.: _______ Fax No.: t303-3d9-0~l.o<t
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: 9-, Depth of each boring (feet):. '"~O
• If existing wate,· supply wells will be used then provide the information in item ( 4) below.
(2) Type of tubing to be used (steel, PVC, etc): Po f 'f e.#1 l/ 1/../l.R .. s · D f?. ~· l I f E 3 L{ D~
(3) Well casing. lfthe well(s) will use casing then provide the~ (steel, PVC, etc.)1 diameter,~.
and~ of casing appearing above ground: _________________ _
(4) Grout (material surrounding well casing and/or piping): /
(a) Grout type: Cement__ Bentonite** _V_-O O1ther (specify) _______ _
•• By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(dX1 )(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to Jand surface): from () to~ (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 the injection well(s). Label alJ features .clearly and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells
"' Surface water.bodies
"' Buildings * Property boundaries
"' Water supply wells
• Septic tanks and associated spray irrigation sites, drain fields, or repair areas
• Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showtng property lines and structures can
be Dbtatned and downloaded from the applicable county GIS website. Typically, the property can be searched
by owner name or address. . Tlie location of the wells in relati.on 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
ele,,ation data. .
GPU/UIC SQW Notification (Revised 3/18/2011) Page2
H. CERTI.FICATION (to be signed as required below or by that person's authorized agent)
I SA NCAC 02C .0211 (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 partnei'Or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a ·principal executive
office1· or ranking publicly elected official;
4. for all others: by ~e well owner (which means aJI 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 theil' behalf.
"I hereby certify, under penalty of law, that 1 have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of th~se 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 ~~erty owner/ Applicant
Cor~ 0--a.r,K
Print or Type
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ .. Aquifer Protection Section
1636 MaiJ Service Center·
Raleigh, NC 27699-1636
GPU/UlC SQW Notification (Revised 3/18/2011)
Telephone (919) i'Ja 3221
<?,o1--lP 30 \
RECEIVED/DENR/DWQ
MARO 6 2ClZ
Aquifer Protection Section
Paee 3
VICINITY MAP
C� {
QP
/ p
SITE
4
LOT
I Stephen B, Mullln6, certlfy that on the I Cay of SEPTEMBER 2010,
this nap was drawn under my superviskvn from an actuol survey made under
my eupervlslan; that this survey was performed to Class A Urban Land Survey
Standards; that the ratio of precision !s 1:10,000, and there are nlgill rlrl+
encroachments either way across pros except s ehoph'S� GgRQ++rrf
�� "killlrrrr Cz
SIGNED
STEPHEN B. MLILUNS PLS Z = Q SEAL
N.C.P.L.S, L-3059 S.C.R.L.S 10780 - - -
C-540 - =f L 3Q59�
SURVEY MAY BE SUSJFCT M ADOITbNAL
EASEMENTS, RIGHTS —OF —WAY, LITIDTIES,
COVENANTS OR RESTRICTIONS, THAT MAY
BE OF RECORD. irfN�I�i I�jV
CURVE RADIUS LENGTH TANGENT CHORD BEARING DELTA
C1 1457.69 5.79 2.90 5.79 S25'16'42"E 0'13'39"
PHYSICAL SURVEY
LOT 22, BLOCK 2, CUMBERLAND PARK
CITY CE CHARLOTTE
CURRENT ZONING
FRO
FRONT zo'
MAR
SIDE 5'
REAR 35'
MIN OPEN SPACE 65%
aquifer Pro
LEGEND
P.U.E. PUBLIC DRAINAGE EASEA NT
• NRB NEW ROAR
a EF EXISTING IRON PIPE
a ERB EXrSTING REBAR
OFIPL OVERHEAD POWER LINE
a ER9—aC ERB AT 9C
CM CONCRETE MONUMENT
� FENCE LINE
}7� PPOLE POWEN POLE
LPOtE LIGHT POLE
D PB TRANSFORMER
■ MH MANHOLE
PHONE TELEPHONE BOX
a CATV CABLE TV BOX
DRAWN Bl`. SW
AREA COMPUTED BY COORDINATE METHOD
D 3D
MECKL.ENBURG CO., (NORTH CARQLIINA SCALE 1•= 3p
PREPARED 9Y:
STREET ADDRESS-. 1516 LYINWAY DRIVE STEPHEN B. MULLINS ANI) ASSOCIATES, P.A.
TAX PIN.,15101223 RECISTE'RED LAND SURVEYORS
OWNED BY;ESTHER L FISHEL
CONVEYED TO:CORY & CARRIE FRANK
RECORDED IN MAP BOOK 4 PAGE503 601-9 EAGLETON DOWNS DRIVE [phone]
26 DEED BOOK 1_ 5 PAGE284 PINEVILLE, N.C. 28134 FAX t7041846-3405
6 1011.1
Secdon

Permit Number
Program Category
Ground Water
Permit Type
WI0300190 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Cory Frank SFR
Location Address
1516 Lynway Dr
Charlotte
Owner
Owner Name
Cory
Dates/Events
NC 28203
Frank
Scheduled
Orig Issue
03/07/12
App Received Draft Initiated Issuance
03/05/12
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
03/Q7/12
Permit Tracking Slip '
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Chad Mullis
Driller Well
9200 Surface Hill Rd
Charlotte NC
Major/Minor
Minor
Region
Mooresville
County
Mecklenburg
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Cory Frank
1516 Lynway Dr
Charlotte
Public Notice Issue
03/07/12
NC
Effective
03/07/12
28227
28203
Expiration
Waterbody Name Stream Index Number Curnmt Class Subbasin
Beverly Eaves Perdue
Governor
Cory Frank
1516 Lynway Drive
Charlotte, NC 28203
AVA
NCDERR
North Carolina D.epartment of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P.E.
Director
March 7, 2012
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
PermitNo. WI03001.90
15 l 6 Lynway Drive, Charlotte, NC 28203
Dear Mr. Frank:
Dee Freeman
Secretary
On March ·5, 2012, the Aquifer Protection Section (APS) received notification of your intent to construct a closed~loop water-only
geothermal injection well system for the operation of a ground-s~mrce heat pump loca{ed . at the address referenced above. An
indiv1dual permit is not required for the construction and operation of this type of-geothermal injection well system as long as the
following conditions are met:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordapce with well construction standards specified in North
Carolina Administrative Code Title _ ISA Section 2C Subchapter .0213, ·and
3. The requir~ notification form 811d associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .021 l(u)(2). Additionally, you should contact the Mecklenburg County Health
Department as they may have additional requirements for this type of ~ystem. Noncompliance with applicable state, county, or
municipal rules and regulatio~s may result in _the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Ro gers @ncdenr.gov if you have any questions.
cc: Mooresville Regional Office -APS
APS Central Files -Permit No. )Wl0300190
Mecklenburg County Health Dept.
Chad Mullis-Mullis Well Drilling, Inc.
Mike Geddings -Panther Heating & Cooling, Inc.
AQUIFER PROTECTION -SECTION .
1636 Mall Seivice Center, Raleigh; North Carolina.27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
lnteroet: www.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer-. .-
8?:l~~fJoorv
for~atts
Supervisor
. One .. -.... North Carolina
./Vn.lu.r17!/g _
FROM 03 02 2012 18:551ST.18:54 P002
r:3
s
t
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES ►�
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 1 SA NCAC 02C A2d0 49
QQ�M210 2 NAILE! MILY Gx02: HE1XAL r.N.rr'_CrDj'Lr MXLL.q
Tlwc Wcll3 eireulate potable water only nt pbrt of ;$ geothermal heaflog anti cooling system.
Thc3C wc113 arc " Per m':Ued lay rule" and do not mlvire or iMIN idtn;l permit when they are con struetcd In
accordance with the rules of t5A NCAC 02C .0200 and thin Notice is submitted prior to construction.
Print yr Type ftijormadon rind Ma8 ro she Addrrxs un the Last Page,
DATt: (Y�,"A'..(` . 1 . 2,01.:2�, PERMIT NO.%aQM 15 0 (to be filled in by DWQ)
A. STATUS OF WSLL OWNER (choose one)
Non -Government: Individual Residence V", ousines'dorganicntion
Government: 5ttttc— Municipal County Fedaral.—
B. WELL OWNFIX - For individual residonces, list gam owner oil property dead. For nil others, state name or
crntity yadnamc of person delegated authority to sign on behalf of ilia busincerd or ugoney:
e ark r--Y� K,
Marling nddress: 1 S j LO L L 11
City: �Ct l'�G`t7' [ Mate; Oe_ip Code: o saw o"3 County:_ m e j-:� LjLr'.. J
Day Tole No.: Cell Ng.,
EMAIL Address. FAQL:
C. LOCATION OF WELL SITE - Where the injcotion wclis Ace physictdly located:
(1) Parcel Tdcntificatior+ Number (PIN) of wall site: C ' 10 [ County: Ili P r•�=t��'+
(2) Phytical Address (if different than mailing uddress): - ja IYl 4 _
City: Stets: SC Zip Cade'
D. WELL DRILLER U001 NYATION ►� `! -n Fs fi i'iY1 �a. l ��
Well Drilling Contrwor's Dame: fn t,t I , �.E� fir"i (i l
NC Woll Drilling Contractor Cert;ficntion No.:
CompanyNamo: M;.t I I _'; O&A
Address: e� a C0 ,Sir- �. f4 t 12
City: 01\ctd- I 0-0_e,(��Ip Code. o2�c'?�7 state: Q�Zot,nty:
Office Tele No.: �7C3��� == Call No.: FDZ.v4,.
E. RVAT ATJMP CONTRACTOR i[NFORMATION (if different than driller)
Canp¢r+yNarrta: P4^4'ke.e- d'C P� e"ot>
OPUlulC SQW 140fiantion (Revisa4 3A&aD11) Page I
RECEIVED 03-02-'12 17:33 FROM- TO- NC DENP P&5 P002/005

FROM 03 02 2012 18:55/ST.18:54 P003
-----··· .,,, ._....
Contact Peraon; m .l K..t.. I-, (.el,/ t~ 5 EMAU, AddcRat
Addrc.s~: &I O .3 W .. ff\ a i fl ~ ·•
City: , ~o ~ rC t l j Zip Code: d-&J'i.30 Stnto:~Councy:~K._
Office Tele No.: .203 ... 3 ;):)-~ollNo.: _______ EaxNo,; go3-3~'1..-C>.;>.~~
F. WELL CONSTRUCnON DATA
(1) 'Nusnber orborinss to be constructed•: __:6_ Dcpth of each boring (feot): t:;lQO
• If cxl.tti,1g wore,· s1,pplJ, wtJlls will h~ ·umJ l'1en p,avida Iha lnformoelon In Item (4) ~low.
(1) Type of tubing tO be U~cd (!t'tccl, PVC. etc): ~Ll./t .2_ .,[' D ~ •· l l f e. s1-1oi
(l) Well CBffing. lt"the wcll(s) will u11c ca:dng then provide the~ {steel, PVC, etc,), diams;rer. AQdl.
and a£mi of ca.,ing appearing 11buvc 1round: ________________ _
----------------------· --· ·---------
(4) Crout (mntcrial :aurroundln& well ca.ciing and/or Pil)ing); /
(a) Gro\ll type; Ccmcnl__ a~nto,,itc•· L Other (specify)-------
•• Dy aolccdna bcntonice grout. a wriancc i:c hn,c,by re1\11caled u, UA NCA.C 2C .02.ll(d)(l)(A), wh1,h tCQ\llrol I l:efflCnl 1.ype grout
(b) Grout depth of Nbing (rcferenoc to land &urfacc): from (? to ~ (foct)
lfwcll has c;asinp., indicate gro\lt dep\h: fro1n ___ to ____ (feet)
G, WELL LOCATIONS -Maps must be scaled or omerwlse a~uratcly indicate distance." nnd oric:nhltinn$ of
tcan,rcs lootatcd within I ooo fei:,t of the Injection wcll(s). Lahr,! gH fr4ur~s plear·LY ynd las;tudo n oorth nn:ow.
(1) Athtoh a site-specific map showing th~ locations ot the following:
• Proposed injcetion wells • Buildings • Property boundaries
• Surfflcc wntc:1· bodies • Water supply wells
• Soplic \ar\ks and associated spray Irrigation sites, dr:iln flclds, ar rep11ir areas
• B.xisting or pote11Lial sources of groundwater c:01Ham !nation
(2) Attar-h n topographic matp of the nrea e,ctending 1/4 mile from the iS1jeccian well site thE1t indicates the
facmiy's location and tho map namo,
NOTE: 111 mo.,, r.111es, nn nerlal 1,hottJg,uph of Iii,: prt,perr., parcel showing properl)I lines tintl struc1ur,1s can
bl! ohl"lnid o.nd ,J11wnloa,l11tl from tire flppllcnblt co11nlj GIS '1Hb$UO. typu:allJ, the propdtty can ba ~•earcht:d
hJI owner nnme or addre.fl, Tl1e locatton of lhtt welf.i• J,, rtlallon to property boundrlfla.r, housca, septic tank.v.
other wellJ-. etc, can then bt drawn In by hnntl, Also. a 'laytr • cn11 .be ~clccte,J .vhowing toJJogrt1pl1ic t:rmtm,r,\' nr
cle,•atto,r data. · .
GPUMC $QW NaUL\CMtlan tRcviied l!tlUZOl ll
RECEIVED 03-02-'12 17:33· FROM-TO-NC DENR P&S P003/005
FROM 03 02 2012 19:56ISI.18:54 P004
N, CERTNICATIDN (to be signed as required bolow or by that person's authariZCd agent)
I SA NCAC 02C .0211(b) requires that all permit applications shall the signed as Follows:
1, for a ceiporation: by a responsible corporate ofticor;
2, for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, fcdcral, or other public agency: by either a principal exccutive
officer or ranking publicly elected official;
4. for all others: by the well owner (whi'ch_rr,eans_t,ll_nemans Iisted_gn_rhe pjaperU dcecl),
If no nuthori:md argent it signing on behalf of the applicant, then supply n letter signed by the
applicant that names and authorizes their Agent to sICA this appllcatlorl on their bob Alf
"l hereby k;z tily, under penalty of Iuw, that I have pers arially examined and am familiar with tlac information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
Immediately responsible for obtaining said information, [ believe that the information is true, accua-aatc And
complete. I am aware that there are signifleant penalties, including the possibility of rioca and Imprisonment,
for submitting false information, i agrGc to construct, operate, maintain, repair. and 1f npp1icob Ic, aboAdon the
injection wall and all re toted appurtenances in Ace* rdance with ri►c approved specificatiow said condit! oaas of
the Portrait"
Signature of P aperry QwnarlAppiicent
Print or Type Ail Name
Signature of Property 0wnWAppIicant
Print or Type Full Name
Signature of Authorend Agent, iFony
Print or Typa FuII Nance
Submit the complete application package to.
DWQ - Aquifer Protection Section
1636 M•ril Service Center
Raleigh, NC 27699-1636
Telephone (90) n_
4,0- U30 1
OPU►UlC 5QW Noll kial01a (Rov100A III A/241 t)
Pace 3
RECEIVED 03-02-' 12 17:33 FROM- TO- NC DENR F&S P004/005

FROM 03 02 2012 19,561ST.19.54 P005
VICINITY MAP
t t
A.
4
SITE
LOT "19
LOT 25
I Stephen 9. Mulling, aerttly thot an they Dey or =xwa 01f),
twe mz woo drawn under my avpar,4oIzm storm GA actual survey mode under
my supervlalan; that this survey Was parlormea to Cio+a A Orhu,r Lund Survey
Sboodonal n=1trwto of aIsion Is1ipd lsg��i+eneroucmatvearay ae= prop y 1Ro a eelncr% CgRfl++•4
r"�w ES51gr'• `v4
v;1"PHE'N o. ++:ULL NS FL,
c—N,C..L 5 L-3059 S,C.R,L,S 14784 `-3a59 e4a -
%were'► WAY ur: Yu"CT 16 AODITONAL u1 ;
COVENANTS OR Reslltlal+aN% THAT Y 'r� •��++rr"U��^pi
COVENANTS
LOT 21
DRIVEWAY
ENCROACY NC
13,37'
fi
�y+a
r`` a 'W'CAK
11,�55 so. ft.
0.2� oc►Oc
N
LOT 23
CURRENT ZONING
a 71N
R-5
FRONT 20'
SIDE 5'
REAR 35'
MIN OPEN SPACE 65X
LEGEND
V.Q.Lr. PUW,IC uuNNAGe L%SEJLNT a NRh
NEW AE@AA
■ fir l:PSTNC WON PIPC r we
100TINa FKW
94P6 0vV4HW Par,FR UNE CAD -DC
00 A7 UC
CY CONUCTE YONVoM '.�-m--wR
gew. pa" POLE x0ax
Ps TRANSPOWrA
Frym mw..
UGNT PeLG
UANIV
CURVL RA61U� LENGi}I 7ANCiN7 CHORD 9EARtNC
DELTA r fewe TWIIQK eau EATV CAM N sax
0 1s51.69 5.79 2-90 5.79 S28'16'e2'E
G'13'39"
PHYSICAL SURVEY
CAeV& er; elm
AACA ONDUIM0 Mr CaaRGMaTF WMW
D 34'
LOT 22, BLOCK 2, CUMBERLAND PART{
CITY OF CHARLOTTE
SCALE I"- 3'
MECKLENBURG CO., NORTH CAROLINA PREPARED BY;
S'MECT ADDRM' 1316 t.YNWAY DRIVE
S7k'PH9JV B, MULUIVS AND AS'SOIZATES, A.A.
TAX PINt16101W
RIsCISTERED LAND SURVEYORS
OWNED 9Y: E5THER L. RSHEL
CONVEYED TC.CORY a: CARRIE FRANK
RECORDCO IN MAP SOCK a PACE=
501-0 FAOLETON DOWNS DRIVE (704)5&1-1900
28_ DEEDBOOK1+iA— PACE-20-4
PINEVILLE,_N,G_25134 FAX [phone]
RECEIVED 03-02—'12 17:33 FROM— TO— NC DENS P&5 P005/005

FROND
03 02 2012 15:541ST,19:54
P001
Post Office Box 3587
Rock Hill, SC 29732
Phone: [phone]
F,, qr%3-329-0286
Fax
Panther
Heating
&
To:
Tonya - NCDENR
From: Cheryl Qeddings
Fax=
919-807-6496
Date: 3012
Phone:
919.807-6301
Pages: 4 to follow
Re:
Notificadon of Intent to Construct or
CO
Operate Injection Wels
Urgent For Review Please Comment Plesso Roply Please Recycle
■Comments: If you need additional Inforwnatlon, please lot me know. 1 will drop
the original and two coplee of #hie in the mail. Thank you.
1-wl
G
RECEIVED 03-02-'12 17:33 EBOM- TO- NC DENR P&5 P001I005