WI0700189_GEO THERMAL_20100726

Permit Number WI0700189
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal_ SW Rule
Permitted Flow
Facilitv
Facility Name
Robert E. Whitley SFR
Location Address
1307 B NC Hwy 42
Colerain
Owner
Owner Name
Robert
Dates/Events
NC 27924
E Whitley
Orig Issue
07/26/10
App Received Draft Initiated
07/23/10
Re g ulated Activities
Heat Pump Inj ection
Outfall ; •~ I _J
Scheduled
Issuance
Central Files: APS_ SWP_
07/26/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Jeff Stagg
636 Benefit Rd
Chesapeake VA
Major/Minor
Minor
Region
Washington
County
Bertie
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Robert E. Whitley Jr.
1307 B NC Hwy 42
Colerain NC
Public Notice Issue
07/26/10
Effective
07/26/10
23322
27924
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Robert E. Whitley. Jr.
1307 B NC Hwy 42
Colerain, NC 27924
~ ;;-.-;,,,, __ _
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
7/26/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0700189
1307 B. NC Hwy 4:2. Colerain, NC 27924
Dear Mr. Whitley:
Dee Freeman
Secretary
On 7/23/2010, the Aquifer Protection Section (APS) received notification of your intent to ·construct a closed-loop water-onl v
geothermal injection well system for the operation of a ground-source heat pump located at the address referenced above. An
individual 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 accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and 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 Bertie County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Rogers(cv.ncdenr. gov if you have any questions.
Sincerely,
(>t ' ~ e:,.. a.__ --
forDebr~ (\._~ -~UL.
cc: Washington Regional Office -APS
APS Central Files -Permit No. WI0700189
Bertie County Health Dept.
Supervisor
JA Stagg Energy-Jeff Stagg, 636 Benefit Rd. Chesapeake, VA 23322
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Customer Service: 1-877-623-6748
Internet: www.ncwaterauality.org
An Equal Opportunity \ Affirmative Action Employer
NOnel C-r , art 1 aro.1na
/vatural/11
Jul 23 "10 O'a:29p p.1
Ju121 1010:47a p.1
i
NOM CAROLINA
LXPAik't'MlaL%TOF ENV IRONME�fYANi, NA'JURAL lthSOUR : '
NOTIFICATION Or INTENT TO CONS'I UCT A CLO 1F TXXW 0T OTR1PRWVAL
WATER -ONLY MEf."I`lON WPT,I,;iYSTF,M
TYPE Sow WLLL.U:s
In Accordance With the ftwision of NCAC 7`itfc 15A UZC.024d
PrW or the lock page.
DATRR: .. f �- - l Z4LCL- 01 (DO t s 1
l+�ell T}� Ca►r�urn�arn: Darr the prnpasc� system cit'cplatc potable wstr�' o too nciditives) im
Pontinuows pipinphai completely isvlrbz the fluid ft'Dm'the environmacnt (i.v.
cla - gw?
1Cos ' Continue campkdng rin's form.
No _ _ 00 N01 cornplac this J'orm. Complcto ❑dyer UIC applir.21ion forms fbr inscalknz
cilhor a 5117 weI] i`gperrloap wKll 'n'ex -= pouMe wawrin[n the uquiferj ors SQL well (olosoti-
loop wolf c4m9aiP1ng addiriv Such as A -a orbeool, oc ot}icr ant ifrucze or corrosion inhibitors) -
A. IVRO DER x 0Wr4-EA(bD1A" JCANT(S)
Litaa tip Property Owner listed on propmy deed (i r owned by a bu+imcm or Vtwcmnxtd agcrcy, sulc ranee of
dnlily and a MpreSentaLive wA;kuftrity for signature): !� QbC:yA E • ins WA-1
{ I) Mai I ink Addrs-4x: Q �' FPW�
City: CO 1 arc.' slate: 94 zip Code:_ �7 C7 2-4^County: �7-+ Q-
Honw1OFfir.TutcNo.: 252--04--ib
Emai l Addmss: I(o)pg,�+"►� ,.�I CY'"b s.�ta: 1�'� u► . r emu/ �. , -} �j r► t .• Gc3 r"f
(2) Physical Addrw of Well Site l:if dilf`enem than above):
City: — Slate: Zip Cade: County;
Nomejo ice Tde No.: cell Na
B. AU ORIZED AGENT OF OWNER, IF A" (ift7,c Pcrmit Appticane doc,4 no awn du: subjeti proparty,
Bch a Ictner from tic prop My owner awUrikinj; Agsmt to insLuli and Operate UIC well)
Co+r+pmy Namc: - - -
C:onmet PCrsoon: EMAI L r
I"jp Addrem:
city: - -. S=, Z1pCode: County;
Ofrift TC]s No_
WcKihc Addrtrss of Company. iftAy,
Cell No,:
Gifu Ito sow mwnwia vn Ur&C,K rarrm CReviwW W200e) loin I 1

JuI2310 04:20p 9.2
,EUM 1010'47a 0.2
C. WELL MILLER INFORMATION
czavany AL�djL'�-C� ►R'1'dI + ATSC� ` !'�C --- -
wcll DriucrContmetor'sNmc.
NC Ctmtractor Ccrrifcailott No.: �� 3$- �1 _
Cor: act Pcrgor+. �ERF ., ?^� MAl [. Acf s; t L ��_ S•4 4 lw'lG�� t ,C:7r rrl
Address:�-
City: k-f Z.ipCodo. County:
COO Tele No,: _ _ Call Na :
D. HEAT 1'>Li1s+IP CONTRACTOR INFORMATION tirdil"ferew than drilltr)
COMPMy Namc:
rec�•t u '
CentstCt Person -
City, Mir► Zip Code: �_!�L - County.—
Offscc'C'cic Iva.- S -tI$� -38SQ Cell rla.: Sa-3S[�- f 1 tip
E. STATUS OF APPLTCAN I"
Private: X— Federal: Commercial. -
Ste: Municipal. Native AmMor: I.arlds.
F. INJECTION PROCEDURE (brieFiy dcs.�be how the injecti0di well(s) will be used)
QCorH6-oLN L- Ca t—oS. fl L,s> P
G. tiVELL CONSTRUCTION DATA
(1 ] Propaased date is be c siretcted f(NU C� 9 -13 _ . Nwmbcr of borir►gs: --
Appraxsmxft depth of each boring (feet): • Z a o
(2) -Ty pc arlubing tQ be used (copper, PVC, ete): 1 z P -w—
(3) Well cwsing. Is the wcli(s) cased? (check either (a..) Vcs ter (tt.) NQ bc+aw)
(a) Yes i fy4'T. t11Cry pmvtdc Casing information 5clow
Type: s:alvaniaed stscl biadk steel��i�st ather (spxify)
Casing dept11: From _to feet (reference to Iatnd suribec)
CaSittg CKt=ds to &O'Ve ground inches
(b) No
(a) Grout into (material Stwniunding weal casing antitor piping):
(a) G[Uu1 4yj%r. NLUt CCrrtcn LBcntarvito:�VQehar(sp= Y)
(15) Gram pt:acerrreriv. pumvilb Pnassure_, Othcr_,._—
(c) Groul dep1h of tubing (rcfcr=wse to It nd surface)' fnnn .0 _ _... to LtC (feet)
II`wel] his s w4,. indieate Cmut depth: frwn __._ to- Moco
C7pulujc sRw TJRtifladwa of Alen[ Fame (RU46$at A1"Mj PoW 2

J uI 2310'04:29p ' p.3
JO:21 1ta9D:d8a p.3
K WXECTION-REZATED EQiiIPMVVY
Altsch a diagram showing the c4necring layout or proposed Modification of the injMtion equipmcm and =Mrior
Fipingftbing ussociukd with the injection operation, Thu nvnul`acturer'r: brooft re may pmvi* xupplvmcutiuty
infot'mnion.
L LOCAIMN OIP WIRL14y
ikttuch two copies ormapa yhowinb thrc foilowi E irtforrnation:
(I) Include a Site Map (cart be drawn) showing' buildings, propcAy lines, suefaec wmr bodies, potenbal.
$ourres of groun4waterc4m araInation and tine oriantntlon ot'And distrmess between the pmpos;od wetl(s) an4
any existing wel*0 or vrz& dLsPml facilirlcs such w septic tanks w drain ;Fields located within WO text of
the Stoxhcsmal h"sat pump well systurm. Lnb 0 all features clearly and inodh arrow.
(2) The Site Map must; show the- subject property In relation to trw swmundiag area by using at Irw two liked
retr,Mnc4 pthrtts such as roads, steams, andlor highway intersections.
J. CERTIFICATION
Now: This Perstiit Application tat*t ben !XPW by cmrb persop uppmring on the
r �grdod legal property deed.
"I 1wrrhy =Ttify, under pcnalry of law. that I h&ve pcnonally o mined and am familiar with the informallbn
stxbinitted in this document and WT XzwhrzKnt9 thamda and that, based on my inquiry of those individuNs
iIRMC(iiatt Fy JMVW$tbltr far obraininy nW information, I befit re blot the inforrsiasiorn is truer accurate and cumplatc.
I am itw-ere that Ocre arc significant per7ak0including the padsil)ility of lints and iimprisonrnen% for subwhing
Pulse infDnnation. I $gce to construct operate, mmirttairt, repair, alad if appikabit, abandon the injection wall mW
aI, related appu mcnar ccs; in accordAmce with the upprmti.^d %pvcificrauarw and conditionu orit:e pe+snit,"
.9ignanue of I?ropetty Ueu lAppliwr
Mit or'1lypa Full Name and We'
Signature of Propwv OwncrlAppkant
N:m or Type Full Na=-ws title
Sigtatum of Auii7Ur'srod Agcm if any
Print Or Type Full Namc And title
rlcsse return town copies of tltrr cgmpletad Application pwkagr to:
North Cltrolina DEr41R-JDWQ
Aquifer Prr3tediun Scefion-XAC Program
16-16 Mad Sc;rriec Ccoter
Rnlcir,b, NC 27(r"-1&M
Telepbon a (919) 7156935
[;r L)iU1C5QW 14C4 vKiort nfl"=t 1-CM (Kevinxl 812dt) ?"et 3

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Jul21 10 10:47a
P•
E
NORTH CAROLINA
DEPARTMENTOF ENVIRONMENTAND NATURAL ktSOURCES
NOTIFICATi0N OF INTENT TO CONSTRUCT A C1,01 FA-i,00P GFOTR}ERMAL
WATER-ONIX >tNACT70N WC11, WSTEM
TYPE 5 W WELL(S)
In Accordwice With the Provisions of NCAC Title 15A 02C.U20a
Print or rype the required information and mail to uddreas un the hack page,
oATF-� — l _ . 2010
Well Type Conj7rmWioc: Does the proposed system eiroulate potable water only (no add itiues) in
continuous piping that completely isolates the fluid from the environment (I.a.
.� closed-loom?
Ves Continue completing di is form.
No _ Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (Men -loop well iniectipotable water into the aquifer) or a 5QM well (clo%eti-
loop well containing additives such as R-22, ethanol, or other anIifm-ezu or corrosion inhiWtors).
A. PROPERTY OWNERNfAFFLICANT(5)
P-11
List each Property Owner listed on property deed (Wowncd by a bu9;neti%or 6-kYYQmmcnt agency, stat.c namo of
entity and a representative w/authwity for signuturc): 9 010c*4 C. W K I� j r.
(1) Mailing Addy -;-;,- .L30 7 9 _N G tfw l Z-
City: erz- n Sartre: zip cede: 9-7z$ County:- '96- e.
HosnclOFfiu:TcieNo,-. :2s3--3S6��` 1 66 _1_ C.cl}_N_o.:
�"-X Ja-SdLS
EnaiIAddress: { -aGt►Wy $Jfle'
►►'7
(2) Physical Address of Well Site (if different than above).
City: slate: Zip Code: --county:
Horne/Officc Tele No.. Cell No.:
AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant dour not own the ,ubjeCt property,
attach a letW from the property owner authorizing Agent to instull and operate UI C well)
Company Name:
Contact Parson: EMAIL Addrtss�;:
Address: -- —
City: _ �- _ _ — _ smic: Zip Code:
OtTice Telc No.:
Webske Address of Company, if any:
01,Ulu IC So 140ftytiI'm VrIT&at f'urm (IteVjT;Od VZODS)
County:
Cell No.:
RECEIVED, DEN I DWQ
AQUlFFR'PRnTFCTIf1N SFCT1QN page I
JUL 2 8 2019

Jul 21 10 10.47a
p.2
C. WELL DRILLER INFORMATION
Company Namc: o A zl ►•r i e tcrn 5ej
Well Drillcr Conlrwor's NameCta:Rw
'NC: Contractor Certification No.: :Igoa -
Con1w Pervo.-.. F _ r ~ r EMAiL Add
R
Giy_ ck-lp !► 1GY -[ -- Vp Code: °-?aa - - County: ---
r
Office Tele No.: Cell No.:
D. HEAT PUMP CONTRACTOR INFORMATION (if different thus driller)
Company Name: vill lai'tit Ll ut
Contact Demon: f �4 �1 S�f • EMAIL Address: -
Address:... i. _` —
Cily: (ok r M r+ _ "Lip Code: a aY County:
Officc-['cleNo.: CeliNo.: aSar3S&- i S00
C. STATUS OF .APPLICANT
Private- Federal: Commercial:
Sty: Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
99 r
C. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: AU a : 3 Number of borings;
Approximate depth of each boring (feet): • 'Z 0 Q
(2) Type of tubing to be imed (copper, PVC, etc): ! kb Q E
(3) Well casing- is the well(s) cased7 (check either (a.) Yes or (b,) No below)
(a) Yes _ _ if yes, that provide casing information below
Type: alvanized steel black Yuxl�VlaStiC other (specify)
Casing depth: From —_tv feet (reference to land yurlace)
Casing extends to alcove ground inches
tb) No A
(4) Grout Info (material surrounding well easing and/or pi ping):
(a) Gruul lypa; Mat Cement 8enranitC _ 0ifter (specify)
(i)) Grout placement: Pumpin�'X— pressure_. Eicher_.._......
(0 Grout depth of tubing (rcfcrcncc to land surface)' from ---- bo ' h_ (fcct)
I I'well has casing. indicate grout depth: frmn to __ - - -(feet)
cii,uluic 3Qw No,wcaiion of intent Fom, (KCVkcd X)Z( fC) i'°gp 2

DUI 21 10 10:48a p.3
I
1
IL INJECTION -RE, LATED EQUIPMENT
Attach a diagram showing the enginecri% layout or proposed modification of the injection equipment and exterior
pipingftubing associated with the injection operation. The manulacturcr's broehun may prkwidc supplcincuEary
information
I. LOCATION OF WELL(S)
Attach two copies of maps showing the foliowinb information;
(l) Include a Site Map (can be drawn) showing; buildings, property lines, surface w9or bodies., poevntiui
sources of groundwatereontamination and the oriontntion of and dis:furces between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic ranks or drain fields located within 200 feet of
the georhermal heat pump well sy,,4r w. LabeI all ffeatunes clearly and include a north arrow-
(2) The Site Map most show the subject property in relation to the surrounding area by using at ]cast two fixes]
refcrtnce points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: T his Permit Application must be signed by each person appearing on the
recorded legai property deed.
"1 hereby certity, under penalty of law, that I have personally examined anti am familiar with the information
submitted in this document and all a[#sclimcnts thurcto and that, baser! on my inquiry of those individuals
nnmcdiately responsible for obtaining said information, I bclicvethat the information is true, aceuratc and complete.
I am aware that there are significant peoalties. including tlta possibility o2• fines and imprisonment, for submitting
lalss infonnation- i ag= to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved spc6-Hcations and rondittons orthe Permit_"
d1� a j
5ignatttra of Property 0% r/Applicant
-
Print or f�pa EulI N.3tne and title
Siipature of Property Qwrrer/Applicant
Print[ or Type Full Name and title
Signature of Authorivxd Agent, irany
Print or Typc Full Mama and title
Please return two copies of the completed Application pttckagc to:
North Carolina DENR-DWQ
Aquifer Protection Seettion-WC Program
1636 Muil. Service Centcr
it7alcigb, NC 27699-1636 RECaVED I DENR Ir)WQ
Telepbone [phone] AQU1R-R'PI,t)IFr;r1nA sFr-
{ iPtlluiC 5DW Notification orintent l"arrn (ltcvi.sud 812908) � ;i

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Jul'21 1010:47a
PA
NORTH CARD INA
DEPARTMENTOF ENVIRONllAksN`l'AND NATURAL RESOURCES
NOT1117- iCA'nON OF INTENT TO CONSTRUCT A CIA SMi.[1 OP OFOTFiFRMAL
WATER -ONLY INACT7 ON WF,FJ, SYSTEM
TYPE 30W WELL(S)
In Accordance With the Provisions of NCAC "title 15A 02C.020U
P' t l or Type the required i►tjornralran and marl to ad &lr 3 un the hack page.
DATE: � ~I� — at _ -_. 2010
Weil Type Ca►rfirmraiiortc Does the pmpos*d system cimuleft potable water only (no additives) in
continuous piping chat cornpleiciy isolaws the fluid from the environment (i.c.
elowd4pop)?
Year ` Continue completing this form.
No Do Not com*w this form. Complete other UIC application forms for installing
e;IFtCr a 5117 well (open -loop well in*- ing potable water into the aquifer)ore 5QM well Wwed-
loop well conmining additives such as A-22, ethanol, or other antifr=ze or corrosion inhibitors].
A. PROPERTY 0WNERQ9tAFPLICANT(S)
List ear,lt Property Owner listed on property dead (i rowned by a busirn k4 or gorvcrnrncnt agency, state name of
entity and a mpresentalave wAw1horily for signature): g oti cvj 10 Tr
(1) Mailing Address: _1 3 0 7 9 _N G [fw 4 4-_7-
_ ..._
CiEy: cl e-r`'r`. _ Si=-. IN1- Zip Code: �_�`� Co,mty! '9&- i 4—,
HarwJ-OfiiceTcicNo.- V-Sa--331I 66 , CcliNo.: e�5a-3a5 -�SDa
Email Add rt~ss: tT0_6e. ('w+t► 4\C Y ;p e;te: W"'r +•► . r e-ur k :.} E e .1 i t G rn
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code County:
Hom&Offce Tele No.: Cell No.:
a A>!1TEIOR=D AGENT OF OWNER, ]OF ANY (if the Permit Appliount dotr-i not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name
C'onmcr Person: EMAIL Addrebs:
N(p Addm%. _
City: Statc; Zip Codc:
417icc Talc No.: CCU Nix:
Website Address of Company, if any:
RECEIVED UENR I DWQ
6PU101C 50w Mpurcutrun of intent ram, (rtCV6&1 V2008) Atr llP:p'PP0TFrT1nN W,'TION PURR I
JUL 28 2010

Jul21 1010:47a
p.2
C. WELL DRILLER INFORMATION
Company Name: _ Xr►-ei_
Wcll Driller Coniraciofs Name, �0+ �•�-� Cu -jtw
NC Contractor Certification No.:
Contact PGrsorr. F�__ 11 tF _ t ij P kiL,Addms
Address: 3 W f
City: T 75p Code: 3 a County: r — -
Office Tele No.: Cell No.:
D. HEAT PUMP CQHITPACTOR INFORMATION (iidii ere nt than driller)
Company Name: C.C. iljvvof i l ZrIc.
Contact Person: v'-Vl 4['-1.� F,1NAiLAddress:l��}J r�k��i���{tit-t,�► .Lc- V%-
Address: --1 ` f—, 00[ A -. _
City: C614.,cm1% Zip Code: -)ALH County:
Uff%QC1'CleN0.: �'���'3Q$4 CeItNo.: a-35 0- i100
E. STATUS OF APPLICANT
Private: Federal: Commercial:
State; Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
tj o ] V- (I-L-J E L.L__
1
G- WELL coNSTRUCT m DATA
(1) Proposed date to be consrructed. A.V G 13 Number of borings; —7
Approximate depth ofeach boring (feet). 2-ra c>
(2) Type of tubing to be used (copper. PVC, ere): �Ab 9 -- --
(3) Well cay+ng. Is the weiKs) cased? (check tither (a..) Yes ar (b.) No below)
(a) Yes if yc5. then provide casing information below
Type: __gEivanized steel black xteelplastic other (specify)
Casing depth: From feet (reference to sand suribee)
Casing cxt=ds to above gnound inches
(b) No�
(4) Gmut Info (material surrounding well casing findlor piping):
(aj Groul lypl . Nval CCrncnt 9cntonitC _ Dthar{specify)
(b) Grout placerr+ent: pmssurc_. Other .._
(c) Grout depth of tubing (rcfmcnCc to hind surface): from _ 0 -- tact 2— _ (f'ccr)
If well has cming.:ndicate grout depth: farm to _ MOT)
C: ,UjLJiC 3QW WaliflaWOn of lnlcnf Foam (ftwisedArZ t) Pop; 2

Jul2l 1010:48a p.3
K INJECTION -RELATED EQU7PIWENT
Attach a diagram showing the cngtinccring Layout or proposed modification of the injection equipment and exterior
piping/tubing associated tirith the injection operation. The manuracturur'N brochura atay prtswidu luppolumenrdry
information.
I. LOCATION OF WELL4S]
Attach two copies of maps showing the fol Lowing information.
(1 ) Include a Site Map (can be drawn) showing;: buildings. property lines, surface wvau:r bodies, potential
Sources of groundwater contamination and the orientation of and distances between the proposed wells) and
any existing well(s) or waste disposal facilities Such as septic larks or drain fields located within 200 feet of
the geothermal h=t pump well syst4m . Label all '&-atones clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two faxed
re-fccence points such w roads, streams, andfor highway intersections-
J. CERTIFICATION
Note. This Permit Applies don must be signed by each person appearing on Rttc
recorded lept property deed.
"I hereby certify, under penalty of law, that 1 have perSonaltti examined and atn familiar with the information
subtritted in this do-ownent and all amwhments tbemto and that. based on my inquiry of those individuals
irrlmCdiateiy respomiible 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 lines and iimprisonment. Far submitting
false inforination. I agree to sanstruet; operate. maintain, repair, and if applicable, abandon the injection welt and
all related appurtenances in accordance with the approved specifications and eanditions oFthe permit,'"
,?��
Signature of Properly Caw erlApplirattr
i'rint or'Fvpo Full Name and title
Signature of Ftoperty ¢t+vner/ApplicFitt
Prim or Type Full Name and title
5ignmre of Authorizzd Agent, irony
Print or Typc Full Namo and title
Please return two copies of the completed Applicatiort package to:
North Carolina DENR-DW
Aquifer Protmfioti 5eetio MC Program AQYIPAfi P9n DENR IDw
1636 Mull} 9e:rvicc Center N.3F�,"Tj
Ralcio, NC Z709 4636
Telephone [phone]s935 �U� $ ��r�
GPUIUIC 50W Notiricution of intew farm (Rcviwd S1"OX) Pqw 3

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1307B nc hwy 42, colerair , nc - Google Maps
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7/23/2010