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FROM 7 ANGELA DIJR I EX
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FROM ANGEL; DEJR I EX
PHONE NO. : 336 643 7679 May. 04 2006 07:50W P1
Kill well Drilling, Inc.
9302 Wihhw*y 421
P. C7.Box 548
Colf.x, N.C. 27235
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LocalStart addrPss: Raleigh, NC
End addreos: 2350 Williams Rd,Levrisville NC 27023
Distance: 120 mi (about 2 hours 21 mins)
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DIA2496 Google - Map data ©2OO6 NAVTEam, - Teens of Use
1. Head east from E South St - go 0.1 mi
2. Turn right at S Blount St - g❑ 0.6 mi
3. Continue on Hammond Rd - go 0.4 mi
4. Take the 1-440 ramp to Cary/Durham - go 0.4 mi
5. Merge into 1-40 W/I-440 W - go 5.4 mi
6. Continue on 1-40 W - go 104 mi
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7. Take the I-40-BR E exit 188 to Winston-Salem/YadkinvillelWiikesboro - go 0.8 mi
8. Merge into US-421 N - go 5.5 mi
9. Take exit 244 to Lewisville - go 0.2 mi
10. Turn left at Concord Church Rd - go 0.1 mi
11. Turn right at Williams Rd - go 2.3 mi
These directions are for planning purposes only. You may find that construction projects, traffic, or other

PO Box 651
Kernersville, NC 27285
FAX [phone] PHONE 336
996-3581
AGKBLIRN
la .rc ► u. a-rNarwr L
March 2, 2006
Thomas Slusser
NCDENR, DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Dear Sir:
In order to expedite the construction of -the proposed wells our company has elected to delete the
ethanol dilution freeze protection from the proposed loop construction. We are changing over toe a
mechanical freeze protection for the system protection. Please note the application changes we are
submitting for your approval. Thank you for your help and patience.
Sincerely,
Darren S. Blackburn
General Manager
cn
Cri
W
t

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP
GEOTHERMAL WATER —ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
in Accordance with the provisions ofNCAC Title 15A: 02CA240
Complete application and mail to address on the back page.
This is not the proper form to be used for injection wells in an open -loop geothermal system.
Do not use this form for systems that circulate any substances other than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: ci • 3 f o Z , 24 0 (.0
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES if yes, then continue completing this form.
NO _ ►%If no, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Use A Well() For Injection With A Hear
Pump System, should be completed.
B. SYSTEM FLUID Will any additives be introduced to the system's circulating beat transfer
fluid? 'Phis includes, but is not limited to corrosion inhibitors and/or antifreezes.
YES If yes, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Use A Wells) For Injection With A Heat
Pump System, should be completed.
NO If no, then continue completing this form.
C. PROPERTY OWNER N
Name: Vl . Grp • 1�
Address: 1i40,' AZAd
City: 1- .) ti State: INL+ Zip Code: ) 7c_
County: i y; J -,. 4 Telephone: - (1to 0 Z t b
D. STATUS OF PROPERTY OWNER
Private: Federal: Commercial:
State: Municipal: _ Native American Lands:
113 5I :EI 411 9- 4VW 90
Revised 5/05 GW/UIC-57 CL Page 1 of 4

(Dw&
-c
Michael F. Easley, Governor
WiliiamG. Ross Jr., Secretary
Norllt Carolina Deparunent or Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
March 6, 2006
J. Eric Pike
4155 Winding Oak Trail
Lewisville, NC 27023-8352
REF: NOTIFICATION OF INTENT TO CONSTRUCT TYPE 5QW IN3ECTION WELLS
Dear Mr. Pike:
In accordance with the notification you submitted on March 1, 2006, the Aquifer Protection
Section acknowledges your intent to construct [ 10) closed -loop geothermal water -only
injection wells for the operation of a ground -source heat pump. The system as described in
your notification is deemed permitted by rule (North Carolina Administrative Code Title
15A: 2C.0211(u)(2)) and will not require an injection well permit from the State, but you
should check with your county health department prior to constructing the system because
they may have additional construction or permitting requirements for this type of system.
If you modify your system at any time, including the addition of antifreeze, corrosion
inhibitors, or any other substances to the circulating fluid, you must contact the Aquifer
Protection Section to verify compliance with applicable rules.
Please contact me at 919-715-6166 or [e-mail] if you have any
questions regarding injection wells, associated rules and regulations, or the Underground
Injection Control (UIC) Program.
Best Regards,
<Slow—tAA 4,4X44-QA
Thomas Slusser
Hydrogeological Technician II
UIC Program
cc: CO -WC Files
Sherri Knight, Winston-Salem Regional Office
i]rr
N thCara ina
atierar fy
Aquifer Protection Section 1636 Mail Service Center
Raleigh, NC 27699-1636
Internet: http://h2o.enr.state.nc.us 2728 Capita! Boulevard Raleigh. NC 27604
An Equal opportunity/Affirmative Action Employer- 50% Recycled/10% Post Consumer Paper
Telephone: [phone]
Fax I: [phone]
Fax 2: [phone]
Customer Service: [phone]

March 6, 2006
Thomas Slusser
NCDENR,DWQ
163 6 Mail Service Center
Raleigh, NC 27699-1636
Dear Sir:
PO Box 651
Kernersville, NC 27285
FAX [phone] PHONE 336
996-3581
In order to expedite the constmction of the proposed wells our company has elected to delete the
ethanol dilution freeze protection from the proposed loop constmction. We are changing over to a
mechanical freeze protection for the system protection. Please note the application changes we are
submitting for your approval. Thank you for your help and patience.
Sincerely,
Darren S. Blackburn
General Manager
~
~
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0\
-0 =c
03/06/06 0924 FIX 3369964221
•••• 41 • :
7.
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_ fl1PCA11ONOF INTENT TO CONSTRUCT A CLOSED -LOOP
•
•-•-7•••4t0-.1 *•• GZOTELERPAAL WATER —ONLY DincrioN WELL SYSTEM
• (GROUND COUPLED HEAT PUMP)
Fe .
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BLACKBURN CARTER IO2
NOR_TH CARMANA.
IMPARTMENT OF ENVIRONMENT ANDNATURAL RESOURCES
Type SQW Welk
Aceardwee with the crovisierts aiNCAC Title 15A: 02C.0200
Combat enthrall= told roil to adder= on the hack pap.
.- . . .
- ` - • - Tide b Nide proper lerin le be wed fer lojecties wefts in ea nneurilmtuteothermal system.
germ for eyeemes that eireelste miy subituaccs Ow' iiiimi___Q aler•
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UPWCTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
MT & 1 , 20
irerSTEM CLASSIFICATION Does the mimed System circulate potable Waled' in continuous
* pig Gel trompletebi isolates the fluid from tvie:merit?
YES If yes, then continuo completing this forra.
so, do mot complete die form, Form OW-57 HP, Application For
Permit Tri Construct Anci/Or Use A ',el(s) For hileetion With A Heat
Pm, OYAMei. should be complesed.
girsiva FWU wilt ray Whims be hitroduced to the sritem's circulating heat transfer
▪ d? This inelndea, bat is not ladled to corrosion inlailtors andicr antifreezes.
YES If pm, do not complete this &rm. Form GW-57 HP, Application For
Permit To Crueurticr Andiar Use A Well(s) For Isijection With A Heat
Pimp 4ysieso, should be completed.
NO a/ Mao, then continue completing this form_
PROMTY OWNER
N f.P-Ira c 11 re.
&debuts 0 L c._
Citn Iwo )1=ttl.: II 15._ Manx Zip Code: - ;.)0?„3
14- Telepaxme: —62,tb
grAiUS OF PROPERTY OWNER
Minima: i. Federal: Commercial:
Ilthatioipait Native American Lands
• lipid sips GW/UIC-57 Ct. Page 1 of 4
r.3

03/08/08 09:24 FAX [phone]
• M1
BLACKBURN CARTER
II01
•
•
SLACZSURN CARTER HEATING & AIR CONDITIONING
El
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floc Paz
FICSIUIL]E TRANSMITTAL SHEET
Fxrat
StenBladdxua
nA 3/6/2006
TOT4LI1Q Q VAGffi IeNCI.uIMNC COVEL
2
SENDER'S FAX NUMd=.R
336-996 4,221
1 NDUUS THOMM NUMBER
336-996-3581
i� PLEASE COMMENT k PLEASE REPLY El PLEASE RECYCLE
P.O. lOX E$1 - 1031 INDVITRIAL PARK DRIVEL KERNLIRIVILLE. NC 272115
OFFICE: 336-446-5511 PAX: 3311•946.4221

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP
GEOTHERMAL WATER —ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
This is not the proper form to be used for injection wells in an open -loon geothermal system.
Do not use this form for systems that circulate any substances other than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: _ hoary ►rSr- , 20 aco
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES If yes, then continue completing this form.
NO If no, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Use A Well(s) For Injection With A Heat
Pump System, should be completed.
S. SYSTEM FLUID Will any, additives be introduced to the system's circulating heat transfer
fluid? This includes, but is not limited to corrosion inhibitors and/or antifreezes.
YES If yes, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Use A Well(s) For Injection With A Heat
Pump System, should be complete+
NO If no, then continue completing this form.
C. PROPERTY OWNER
Name:
RECEIVED / DENR j DWQ
AQUIFER PROTECT ON SECTION
MAR 0 1 2006
Address: SO i. Ill :A .,A,d
City: Le„ A,1,j, State: ('� Zip Code: 3 ) 0 .2 3
County: - s L Telephone: 3 544 01 / 0
D, STATUS OF PROPERTY OWNER
Private: if
State:
Revised 5/05
Federal: Commercial:
Municipal: Native American Lands:
GWIUIC-57 CL Page I of 4
TILE COPY

E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility:
Address:
City: State: Zip Code: _ _ County:
Telephone: Contact Person:
Standard Industrial Code(s), SIC, which describes commercial facility:
F. HEAT PUMP CONTRACTOR DATA
Name: pi,. k7uYr, ( r4-et, ► & tCOO , .
Address: .bt7'y (, 51
City: i' yvQ Ir;SV t I l State: , C, Zip Code: °J' 7air5 County: L-s
Telephone: 331-44G - 35FI Contact Person: jinn / hues-)
G. CONSTRUCTION DATA (check one)
EXISTING WELL(S) being proposed for use as a ground -coupled heat pump
well(s). Provide the information in (1) through (3) below to the best of your
knowledge. Attach a copy of Form GW-1 (Well Construction Record) if
available.
PROPOSED WELL(S) to be constructed for use as a ground -coupled heat pump
well(s). Provide the information in (1) through (3) below as PROPOSED
construction specifications. Submit Form1,GW-1 after construction.
(1) Well Drilling Contractor's Name: H CZ I ! 5
NC Contractor Certification number: a 7 0 1
Date to be constructed: M41/64 PAOZ. Number of borings:
Approximate depth of each boring (feet): .3o AI.
/d
(2) Well casing: Is the well(s) cased?
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel Black steel PIastic Other (specify)
Casing depth: From to ft. (reference to land surface)
Casing extends above ground inches
(b) NO �f
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.l.s.):
(a) Grout type: Cement Bentonite v.7 Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
L./around closed loop piping; from 0 to 230 (feet).
around well casing; from to (feet).
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS 1F THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
Revised 5105 GWIUIC-57 CL Page 2 of 4

H. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELL(S) Attach two maps.
( l) Include a site map ( can be drawn) showing: buildings, property lines surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal facilities such as septic tanks
or drain fields located within 200 feet of the ground-coupled heat pump well system. Label all
features clearly and include a north arrow.
(2) location map referencing the site to two nearby permanent reference points (such as roads,
streams and highway intersections).
J. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(I)
(2)
(3)
Hazardous Waste Management program permits under RCRA
NC Division of Water Quality Non-Discharge permits
Sewage Treatment and Disposal Permits
RECEIVED f OENRt· DWQ
AQUIFER PROTECTION SECTION
MARO 1 2006
K. CERTIFICATION
"I hereby certify, under penalty oflaw, 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 ground-source heat pump system and all related appurtenances in
accordance with the approved specifications and conditions of the Permit."
Revised 5/05
(Signature of Well Owner or Authorized Agent)
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizi~g the above agent.
OW /UIC-57 CL Page 3 of 4
L. CONSENT- OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the ground -source heat pump system's well(s)
conforms to the Well Construction Standards (Titie I5A NCAC 2C .0200)
Revised 5/05
•
(Signature Of Property Owner If DifferentTrom Applicant)
Please return two copies or the completed Application package to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW/UIC-57 CL Page 4 of 4