WI0400230_GEO THERMAL_20120523

Beverly Eaves Perdue
Governor
AVA
MCDEMR
North Carolina Departmentof-Envtronment and-Natural Resources--
Division of Water Quality
Chartes Wakild, P. E.
Director
May 23, 2012
James and Marion Deni
161 Pinecrest Court
Boone, NC 28607
Subject: Notification of Rule-Revisions· Affecting---
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0400230
Dear Mr. and Mrs. Deni:
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 the Division of Water Quality. You
may view the revised rules on our website at http ://p ortal.ncdenr.org/web/wq /ap s.
If you have any questions regarding your current permit or the rule revisions, ·please--fee-I-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 Service Center. Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterquality.org
An Equal Opportunity\ Affirmative Action Employer
One
North Carolina
/Vat11rnll11
Permit Number WI0400230
Program Category
Ground Water
Pennit Type
,.
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael. rogers
Coastal SW Rule
Pennitted Flow
Facllit
Facility Name
James and Marion Deni SFR
Location Address
161 Pine Crest Ct
Boone
Owner
Owner Name
James
Dates/Events
NC
R
28607
Deni
Scheduled
Orig Issue
01/26/12
App Received Draft Initiated Issuance
01/18/12
Central Files: APS_ SWP_
01/27/12
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Pennit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
James R. Deni
Owner
161 Pine Crest
Boone NC 28607
Public Notice Issue
01/26/12
Effective
01/26/12
Expiration
12/31/16
Regulated Activities Re quested/Received Events --=----------------------
Heat Pump Injection RO staff report requested
RO staff report received
Outfall NULL
Waterbody Name Stream Index Number Current Class
01/20/12
01/25/12
Subbasin
Permit Number W10400230
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
micnael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
James and Marion Deni SFR
Location Address
161 Pine Crest Ct
Boone NC 26607
Owner
Owner Name
James
atestEvents
Central Files APS SWP
a 1 /25112
Permit Tracking Slip
Status Project Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Major]Minor Region
Minor Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
James R. Den!
Owner
161 Pine Crest
Boone INC 28607
Scheduled
Orig issue App Received Craft Initiated Issuance public Notice 16SL90 Effective Ex iratipn
01/18/12 1/Q(p//z �AINII�
Reaulated Activities Reouested/Received Events
Heat Pump Injection RO staff report requested 01/20/12
RO staff report received 01 /25/12
Waterbody Name Stream Index Number Current Glass Subbasin

JB'A
NCDENR
_ North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
James and Marion Deni
161 Pine Crest Court
Boone, NC 28607
Charles Wakild, P.E.
Director
January 26, 2012
Ref: Issuance of Injection Well Permits WI0400230
Issued to James and Marion Deni
Boone, Watauga County, North Carolina
Dear Mr. and Mrs. Deni:
Dee Freeman
Secretary
In accordance with the application received on January 18, 2012, I am forwarding permit number WI0400230 for the
construction and operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well system to be located
at the above referenced address. This permit shall be effective from the date of issuance until December 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 II. 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) 715-6166 or [e-mail] if you have any questions about your permit.
cc: Sherri Knight, Winston-Salem Regional Office
WI0400230 Permit File
Watauga County Environmental Health Department
Best Regards,
~-Q_ ~::x--
Michael Rogers, P.G. (NC & FL)
David Brown, Yadkin Well Company Inc., 1908 Hamptonville Road, Hamptonville, NC 27020
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 2769~• 1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet www.ncwaterguality.org
An Equal Opportunity \ Affirmative Action Employer
N. 0 ~i..c · 1· 01 u1 · aro 1na /Vaturallg
N.ORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
I~ 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
J airies and Marion Deni
FOR THE CONSTRUCTION AND OPERATION OF 2 (TWO) TYPE SQM INJECTION WELL(S), 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 161 Pine Crest Court, Boone,
Watauga County, NC 28607, and will be constructed and opera~ed in accordance with the application received
January .18, 2012,. 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 cons{dered a part . of this permit.
' '
This permit is for .Construction and Operation of an injection well and shall pe in·compliance with Title ISA 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 December 31, 2016, and shall
be subject to the specified conditions and.limitations set forth in Parts I through IX hereof.
Permit issued this the 26th day of January, 2012.
M\_ Charles Wakild, P.E., Director
'\ Division of Water Quality
By Authority of the Environmental Management Commission~
Permit #W.I0400230 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 pern;iit, 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 919-807-6406 and the Winston-Salem Regional Office Aquifer Protection Section Staff,
telephone number 336-771-5000. ·
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 corners) 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 #WI0400230 UIC/SQM
ver. 03/2010
Page 2 of 5
PARTIV-PERF0Rl"1ANCESTANDARDS
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 permit 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 Pennittee 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 lnj ection Control (UIC)
Program Central Office staff, telephone number 919-715-6166. 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 perm.it, 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 #WI0400230 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
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
336-771-5000
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 Winston-Salem 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 Winston-Salem 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 Winston-Salem Regional Office, telephone number 336-771-5000, 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 rel~vant 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 RENEWAL
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 #WI0400230 UIC/SQM .
ver. 03/2010
Page 4 of 5
PART IX-CHANGE OF WELL STATUS
1. 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, 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.I of this permit.
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) 'fhe 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.
(:q) 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 shail 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 intq or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Petmittee 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.1 of this permit.
Permit #WI0400230 UIC/SQM
ver. 03/2010
Page 5 of 5
Ro g ers, Michael
From: Mitchell, Patrick
Sent:
To:
Wednesday, January 25, 2012 8:55 AM
Rogers, Michael
Cc: Knight, Sherri
Subject: WI0400230 Deni -Staff Report
Michael,
I have reviewed;the parcel on the Watauga County GIS and made an unaccompanied site visit. I found the sketch
attached to the application to be incorrect. The following items are not depicted accurately in the sketch: house shape,
driveway location and shape, parcel shape, and the location of the septic system. The septic is likely located in the back
yard of the home due to the following factors: the front yard is VERY small (too small to contain a septic drainfield) and
very steep, while the back yard is very large and relatively flat.
Based on the proposed location of the two geothermal wells shown in the sketch compared to the septic likely being in
the back yard and the neighboring lot being vacant, I do not foresee any issues with proceeding with permit issuance.
Please let me know if you need anything further.
Patrick
Patrick L. Mitchell, LSS
NC DENR-DWQ
Aquifer Protection Section
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
Phone: [phone]
FAX: {336) 771-4631
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Rogers, Michael
Sent: Friday, January 20, 2012 3:54 PM
To: Knight, Sherri
Cc: Mitchell, Patrick
Subject: WI0400230 Deni
Sherri-
Please find attached a residential SQM geothermal application. Please let me know if you wish to conduct a pre-
permitting inspection or not.
Thanks
NOTE: On January 6 th , the Aquifer Protection Section (APS) is scheduled to move to
the 6th floor of the Archdale Building located at 512 N. Salisbury Street in
1
.J
Raleigh. our mailing address will remain the same (1636 Mail Service Center, ·
Raleigh, NC 27699-1636). If you need to visit APS staff or review files, please
call or email in advance to ensure availability. Please check the APS website
for updates on office numbers and phone numbers as they become available.
Michael Rogers, P .G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
16~6 Mail Service Center
Raleigh, NC 27699-1636
Direct Line 919-807-6406
http://portal.ncdenr.org/web/wq/aps/gwpro/permit-applications#geothermApps
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
2
w���
NDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
James R Deni
Marion Deni
161 Pine Crest
Boone, NC 28607
Dear Mr. Deni:
Division of Water quality
Charles V1lakild, RE.
Director
January 19, 2012
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. W10400230
.lames R Deni SFR
Injection Mixed Fluid GSHP
Well System (SQM)
Watauga County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on 01/18/2012. Your application package has been assigned the number listed
above, and the primary reviewer is Michael Rogers.
Central and Winston-Salem Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. Lf you have any questions, please contact Michael Rogers or
tnichaet.rogcrs@,ncdenr.gov.
cerely,
for Debra W
Groundwater Protection Unit Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
David J Brown (Yadkin Well Co,, Inc., 1908 Harnptonville Rd., Hamptonville, NC 27020)
Winston Petrey (Mountaineer Heating & Cooling, P.O, Box 1905, Boone, NC 28607)
Permit. rile W10400230
AQUIFER PROTECTION SECTION
1636 Mail Service Cen tar, Raleigh, North Carolina 27699.1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604 One
Phone: 91"07-6464 t FAX: [phone] � bCal'D�]Ila
Internet wtwr.ncwaten,ualitv.or �..
Art z Rua, L'ppi;t wmly I Aisrf ow%* Acwol, c+np7 uynr . i

......
vJID<.f 00(}30 __________.
£t :si: 600a-01-n
NORTH CAROLINA
DBPARTMBNT. OP BNVIRONMBNT AND ~ATU.RAL lBSOUR.CBS (NCDBNll)
APPLICATION Jl'OR PERMIT TO CONSTR1JCT AND/OR USE A WELL(S) FOR
INJECTIONWITHAGl!OTBEIOW..'IBATPUMPISYSTEM'°R.i
n'P,E 5QM WELLCS)
~_,/ __ New !'enmt Application Oll. ____ Renewal (check one)
DATE:/• I;/ _. 20.!.!_
PERMIT Np. _______ (leave blank lfN!W per.mlt applloatlon)
A. PI.OPIRTY OWNER(S)/APPLIC.ANt(S)
List IWl PrDJW4tY ~ llsttd 0t1 ~ ~ (jf owned by a. 'b\ltinos., or gowmmem.apncyir state name of
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Homl/0ftiGeToloNo.: {12a .. )(4 • 77 'TI Ce11No.: IJ25-?71-'182~
BMAILAdclress: _____________ ____
(2) l'hysjot! Alidrtu of Stt. (If dllillreat tlun llllove)! C(J. ff'/2..z.J
City: __________ State:-:.... Zip Code: _:5 ____ Co\lllty: ___ _
Home'Offioe Ttl• No.: __.__ ___ ____. ___ ...___~Ci:..::.e1~l Ne..:..o~·•:....· -----------
BM.AIL Addtesa: ___________________ _
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A~: _____________________________ _
City: _____ .........._._ ____ 81ato:_ZlpCode: _____ Coumy: ---------
Of.ace ToJc No.: _________ ..._.... ______ _,.... __ ~_...;iCs.:;,,;:~Jl=N:....:....,o=.: __ _...___......,,.._,..._ ____ _
Webaite Addrt1s of Comi,any. if.any: _____________ _
STATUS 01.I A.PPLICA.Nf
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(i) Psupaaed d*te to #re ' 000tfucW:,
Approximate dopth of each boring (feeQ:
(2) Chudoai addMves to be uted la oloseti loop ystcm (only those dmmleak todieetedh wo been appmvwd):
_IL -22 _Pr0Pylom0 giyoal athauol _ _ et% v i �0 A a � other (Outer tddIdvat< udU
need prior appmat by WMNit before vae)
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(4) W oU casing. It tiro ymil(a) eased? (check ahhet (&>YU a (b,) NO 6aov4
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Ii�ti4f1 h+�•aaaiag, indicate grant 4epih: i�am = � _ _ tv � (i�at)
H. INJECT],9N RELA'1F'ED RQVI PNiZM
Attaoh a diagram showing tits onslassritm layout or proposed modlitoation ut the b3jeWorn egul�mwd and e7t'4ealotr
plpIngltubteg Wi0oiatcd wilh tba Wection Dpemtloa. The rano&otta es brochure may proV do Supplementary
lArination.
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Z3wd bT=ST GOW-01-TI
I. �OCATION OF'WELIAS)
Attach two copies of maps shower the following infarmadon.'
(1) Include a Alt& reap (oert be (VOLWA) show€ * buiU&" property Maas, eusfoa water bodies, patemtWl Sources
of groundwaux oontamirAtlott and the ori=tstaaxi of and disfencan botwou the propoeod well(s) end arty
txivft weU(6) or waste diapoSO fuilidW 10* see etptic Dace or draft taak4 iomted witbiu t WO tbct of the
geotharmal heat pump well system,. T. sbei all fe ulm clearly and
(2) laacludo a topogmphio map of ft arse exiaftft one mile Vom the property botmdwiea end
indicate this fao3lity's location and the map mot,
J. POTABLE WATER WM(S)
Aro there nay potable wawa wal(s) au the 3ub)80 prey ar s4"nt propaz%iar7 ,____YM.9 No
IM4d = Indicate locamdon on attached map(t).
K CERTMCATION
Notei Thk Fermi! ApOaatton must be jfpod by pmg person appi= f, on the rr000rded hpl property dead.
"i hereby e4;ft, under Penalty of law, tlat I have morally onmined and a= itmiliax v4th the infb=tfon
submitmd in tliis documant sad ail anmbnmbr thereto Sad that, beard on my faqutry of thoac Individuals
tmmodlaWy ropO ible for obtaining said le titzutim I b 1loyd that the lntnrzt doxx Is mmv ai"wata. and ompktd.
I am aware that titare ere aigalfimt pealtit , including U possx'bi * of Snes and impriaoomwt far subvattIng
false Infortt kHm I agree to aonstrwet, opatate, mohnaln, rapair, rmd if applicable, ebnndon the itoeotlon well and
all related appurtan=c m in aogordanae Mth =Red
"aiflo�atti`ons and ron=ow of the Permft."
A
Sipatury 00roperty OvMWA,MHcaM
za
Ftint or Tyre pull Name
fttseture of Authorized Agent, If any
PrW or Type Pull Name
Plaeso rotom two copioa of the oaWleta(L Application package to;
Worts Carolina DF2% 1)WQ RECEIVED 1 pENR I DWa
Aquifer Protection SecUen Aquifer Protedon Section
UIC rrogMM JAN 18 kEC'0 ,0I
1636 WA Service Center
Rxielgh, NC 27699•1636
Telepbotke [phone]
11141A•r (AAY lki '-)11
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COMPANY NAME FAx No. PVASE
REPLY
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NUMBER OF PAGES f+LFAS� Q� a�lm
i kCLU ms TWS SHEET RGFFY BY �GMATU
•
-FOR ALL •OVR WATER N6602-
YADKIN WELL CO„ INC.
19" MAMFTOWILLE ROAO
IIAMPTONVILLE, NC 27020
QAvto j. BROWN. VICE PRU.
TOIL 1"RCC COM 24-VMS
i irrm6.imi 48&444o
FAX tM) 490-404B
RES (33461 49#4059
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01-19-' 12 18: 01 FROM-
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