WI0700031_Application_20210217

North Carolina Department of Environmental Quality
Division of Water Resources
PERT NAME/OWNERSHIP CHANGE APPLICATION FORM
I. INSTRUCTIONS
1. Complete this form in its entirety as follows:
(a) Change of Ownership — Provide the information in Parts II and III and submit legal documentation of the
transfer of ownership such as a contract, deed, article of incorporation, etc. The certifications in part IV
must be signed by both the current permit holder, if available, and the new applicant(s).
(b) Name Change Only — Provide the information in Parts II and III. Sign the certification for the new
applicant in part IV.2.
2. Submit the properly completed form to the address on bottom of Page 2.
II. CURRENT PERMIT INFORMATION
I. Permit Number: \N,M 0 -7 O'er O r !
2. Permittee name(s): C+
3. For Business/Governmental Agency- Permit signing official's name and title:
(Person legally responsible for permit)
4. MaiIing Address: N 0 044\mA L u
City: V.t AS•ViS`S4C:`71 tC3
State: Zip: c. 0 ? ,
Telephone number: ( ) Fax number: ( )
EMAIL Address: ,
5. Physical Address of Facility/Well(s) (if different than mailing address)
City:
County: Zip:
III. NEW OWNER / NAME INFORMATION'
request for a permit change is a result of:
_ a. Change in ownership of property/,company
_ b. Name change only
c. Other (please explain):
2.
Permit/Name Change of Ownership Form Rev. 2-18-2020
Page I

New Owner's name(s) as listed on the property deed (Please Print/or Type):
4\\a.. C''`f'c\I N0 T
Gee ti4c. c
3. If Business or Governmental Agency- Permit signing official's name and title:
(Person legally responsible for permit)
4. Mailing Address: 0 C V1 "kOtic. L. V
City: U•, A�v) N fr �� ss State: C_ Zip: e
Day/Cell Phone No. (b (r) 16 1- D ] 0) Fax number: ( )
EMAIL Address: t c\,a tvAA • C �N�!.�a j (� CO C . to ,1 -
IV. CERTIFICATION
1. Current Permittee's Certification (Please print or type):
I, 64TC-? PVC.. 0 , attest that this application for name/ownership change has been reviewed
and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
application are not completed and that if all required supporting information and attachments are not included,
this application package will be returned as incomplete. I understand I will continue to be responsible for
compliance with the current permit until a new permit is issued.
2. New Applic t(s)'s Certification (Please print or type):
I/We, \' C, AVM MD 71\-. i i'15 C4 N (v , attest that this application
for name/ownership 8hange has been reviewed and is accurate and complete to the best of my knowledge. I
understand that if all required • arts of this application are not completed and that if all required supporting
information and attachme s are •t included, this application package will be returned as incomplete. I
further certify that I will o • erase an i aintain the permitted facility in accordance with the permit and related
regulatory requirements.
Signature:
Signature:
SUBMIT THE COMPLETE APPLICATION PACKAGE VIA ONE OF THE FOLLOWING METHODS:
U.S. Postal Service:
Ground Water Resources Section
NC Division Of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
Courier / Special Delivery / In Person:
Ground Water Resources Section
NC Division Of Water Resources
512 North Salisbury Street
Raleigh, NC 27604
Telephone Number: [phone]
Permit/Name Change of Ownership Form Rev. 2-18-2020
Page 2

North Caroliga?Department of Environmental Quality — Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
New Application Renewal* Modification Permit Rescission Request*
*For Permit Rcnewah or R Q , �dpest, complete Sections A thru E;•and M (signature page) only
Pr'nt or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: j 11 , 20 a ] PERMIT NO\ ®7 oX 31(leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application)
I. Current Use of Well
a. I wish to continue to use the well asGeothermal Well ❑ Drinking Water Supply Well
❑ Other Water Supply Use- Indicate use (i.e., irrigation, etc.)
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
❑ Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? YES ❑ NO
If yes, indicate New Owner's contact information:
Name(s) \0, 0 P3 C kN 0
Mailing Address: i 9 C 124tSQ tVL- R
City: ' 'PNW I tot-T01f StateArle Zip Code: s � � County: PyAa} Lr
Day Tele No.: 6t17 ---/ 6 1- ®{ V l Email Address.: k , C Nimt00 71, L
rn
B. STATUS OF APPLIC
Non -Government:
Government:
State
Municipal
Business/Organization
County
Federal
C. WELL OWNE(S)/PERMIT APPLICANT — For single family residences, list all persons listed on the
property deed. !FoI,Nall others, list name of business/agency and ame of person and title with delegated
authority to sign: h P n It WC. C
Mailing Address: 1 Q CM Wi .
City: \11/4+1 i \CW j roir t ' State L Zip Code: ).1 County: e� �
Day Tele No.: fU 1 I f - o r 0 •;;,:: Cell No.:
Geothermal Water Return Well Permit Applicat%$ii Itev. 4-15-2016
Page 1

EMAIL Address: m� "'�- +(.- -Al 7311. Fax No.:
ON trt F9d . Co r
D. WELL OPERATOR (if different from well owner) — For single family residences, list all persons Listed on
the property deed. For all others, list name business/agency and name of person and title with delegated
authority to sign:
Mailing Address:
City: State: Zip Code:
Day Tele No.: Email Address.:
County:
E. PHYSICAL LOCATION OF WELL(S) SITE p -R
(1) Parcel Identification Number (PIN) of well site:�-�-.[* — }i County: 03C,41\1\-k
(2) Physical Address (if different than mailing address): S k
City: County Zip Code:
WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Ce11 No.: Fax No.:
G. HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name:
NC HVAC Contractor License No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
H. WELL USE WilI the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES
(2) Personal consumption? YES
NO
NO
I. WELL CONSTRUCTION REQUIREMENT'S'— As specified in 15A NCAC 02C .0224(d):
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C .0107.
Geothermal Water Return Well Permit Application Rev. 4-15-20I6 Page 2

(2) If a separate well is used to inject the heat pump effluent, then the injection well shall be constructed
in accordance with the water supply well requirements of 15A NCAC 02C .0107, except that:
(a) For screen and gravel -packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
*EXISTING WELLS PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
(c) Casing depth below land surface
(d) Casing height "stickup" above land surface
(e) Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water -bearing zones with 1500
mg/L chloride or greater pax ]5A NCAC 02C .0107(f)(8)
(t) Length of Well screen or open borehole and depth below land surface
(g)
Length of sand or gravel packing around well screen and depth below land surface
K. OPERATING DATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F, Average (July) ° F.
L. SITE MAP — As specified in 15A NCAC 02C .0224(b)(4), attach a site -specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map shall
include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107(a)(2) located within 250
feet of the proposed injection well(s).
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 3

(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
NOTE: In most cases an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
welts, etc. can then be drawn in by hand Also, a `layer' can be selected showing topographic contours or
elevation data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
1 SA NCAC 02C .0211(e) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by all the person(s) 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 their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Signaopet ty Owner/Applicant
(\ c Iwo k
Print or Typir Full Name and Title
Signature off Property r/Applicant
Print or Type Full Name and Title
Signature of Authorized Agent, if any.
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - UIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Geothermal Water Return Well Permit Application Rev. 4-15-2016
Page 4

A. Settlement Statement (HUD-1
OMB Approval No. 2502-0265
B. Type of Loan
IT-. Consumer Finnncini
""' ' >- •i Protercion Bureau.
2015 Forms
1. © FHA 2. © RHS 3. x Conv. Unins,
4. 0 VA 5. 0 Conv. Ins.
6. File Number:
R-16-8100-NP
7. Loan Number:
2600013877
8. Mortgage Insurance Case Number:
C. Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. items marked
"(p.o.c.r were paid outside the closing; they are shown here for informational purposes and are not included in the totals.
D. Name & Address of Borrower:
Anthony C. Canino, Jr. and Wife, Denise B. Canino
101 Channel Run
Washington, NC 27889
E. Name & Address of Seller:
Betty Anne Dicken
Donald R. Dicken Revocable Declaration of
Trust dated October 1, 2001
4628 Mechums River Road
Charlottesville, VA 22901
F. Name & Address of Lender:
First Bank
132 West 2nd Street
Washington, NC 27889
G. Property Location:
101 Channel Run
Washington, NC 27889
H. Settlement Agent:
C. T. Partrick, Jr., P.A.
I. Settlement Date: 12/30/16
Place of Settlement:
204 North Market Street
Washington, NC 27889
J. Summary of Borrower's Transaction
100. Gross Amount Due from Borrower
101. Contract sales price
495,000.00
102. Personal Property
103. Settlement charges to borrower (line 1400)
$9,741.32
104,
105,
Adjustments for items paid by seller in advance
106. City/town taxes to
$ 0.00
107. County taxes to
$ 0.00
108. Assessments to
$ 0.00
109. to
$ 0.00
110.
111. HOA Dues ($1,100.00 for 2016) - Pro -Ration
3.01
112.
113. Flood Insurance Premium 07-12-16 thru 7-12-17
$1,161.00 - Pro -Ration
612.22
120. Gross Amount Due from Borrower
$505,356.55
200. Amounts Paid by or in Behalf of Borrower:
201. Deposits or earnest money
15,000.00
202. Principal amount of new loan(s)
495,000.00
203. Existing loan(s) taken subject to
204.
205.
206.
207.
208. Due Diligence Fee
1,250.00
209.
Adjustments for items unpaid by seller
210. City/town taxes to
$ 0.00
211. County taxes to
$ 0.00
212. Assessments to
$ 0.00
213. to
$ 0.00
214.
215.
216.
217.
218.
219.
K. Summary of Seller's Transaction
400. Gross Amount Due to Seller
401. Contract sales price
$495,000.
402. Personal Property
403.
404.
405.
Adjustments for items paid by seller in advance
406. City/town taxes to
_ $ 0.
407. County taxes to
$ 0.
408. Assessments to
$ 0.
409. to
$ 0.
410.
411. HOA Dues ($1,100.00 for 2016) - Pro -Ration
3.
412.
413. Flood Ins. Premium 07-12-16 thru 7-12-17
$1,161.00 - Pro -Ration
612.
420. Gross Amount Due to Seller
$495,615.
500. Reductions in Amount Due to Seller:
501. Excess deposit (see instructions)
502. Settlement charges to seller (line 1400)
$33,925.
503. Existing loan(s) taken subject to
504. Payoff of first mortgage loan
505. Payoff of second mortgage loan •
506.
507.
'508. Due Diligence Fee
1,250.
509,
Adjustments for items unpaid by seller
510. City/town taxes to
$ 0.
511. County taxes to
$ 0.
512. Assessments to
$ 0.
513. to
$ 0.
514.
515.
516.
517.
518.
519.
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