WI0700261_GEO THERMAL_20120206

Permit Number .WI0700261
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Fac ilit
Facility Name
David E Bulgher SFR
Location Address
143 Salmon Creek Ln
Merry Hill
Owner
Owner Name
David
Dates/Events
NC 27957
E Bulgher
Scheduled
Orig Issue
02/06/12
App Received Draft Initiated Issuance
01/12/12
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
. Central Files: APS_ SWP_
02/06/12
Permit Tracking Slip
Status
·Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Lisa C. Bulgher
11500 Coastal Hwy
Ocean City MD
Major/Minor
Minor
Region
Washington
County
Bertie
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
David E. Bulgher
Owner
11500 Coastal Hwy
Ocean City
Public Notice Issue
02/06/12
MD
Effective
02/06/12
21842
21842
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
DavidEBulgher
LlsaCBulgher
11500 Coas.talHwy
Unit613
Ocean City,MD 21842
Charles Wakild, P.E.·
Director
02/06/2012
Subject: Acknowledgement oflntent to Construct Type 5QW Iajection Well System
PennitNo. WI0700261
143 SahnonCreekLn.
:Metty Hill, NC 27957
Dear Mr. Bulgher:
Dee Freeman
Secretary
On 01/12/2012, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-only geothermal iryection
well system for the operation of a ground-source heat pump located at the address referenced above. An individual pennit is not required for the
construction and operation of this type of geothennal ~ection well system as long as the following conditions are met:
1. The ~ection well system contains only potable water,
2. The ll!iection 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 funn and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions consti1utes a violation of the North Caro1ina Well Coostruction Act and North Carolina Administrative
Code Title 15A Section 2C Subchapter .021 l{uX2). 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 contactMik:e Rogers at [phone] or [e-mail] if you have any questions.
cc: Washington Regional Office -APS XE s ce1itrat fi' s -Pe To __ -. -0-10....,.)0-2 =1_
Bertie County Health Dept.
$· JxL0cv
for n:f:::wat.ts
Supei?~
Tma Stagg (Pinkston Pump& Well, Inc., P.O. Box 15482, Chesapeake, VA 23322)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location : 512 N. Salisbury St, Raleigh, North Carolina 27604
Phone: [phone] I FAX:. [phone]
Internet: WWW;ncwaterguality.orn
An Equal Opportunity I Affirmative Action Employer
One . · North Carolina ;Va/ur11!!11 ·
Itir)RTH CAROLINA
13HPAIt9"MEN`1' OF ENVIRONmEN•r AND NATURAL RESOURCES (NCDENH)
NOTIFICATION OF INTENT TO CONSTRUCT A!{L=i 2QKI GEOTREfLMAL
WATER-QNI Y INJECTION WELL SYSTEM:
In Accordance with the provisions of NCAC title 15A: 02C.0200, pleato
complete this n❑ti fiCtltit}n and mall to address oil the back page (plem iW ar I= lnfet;tttation),
Well %lfpe Cnn/Irinrtrlrrn: Does the prmpbSer_+ system circulate: potable woutro"IY (no ttdditivesr in
continuous piping that completely isolates the fluid from the environment (Ix.
Cly -)'
Yes .— X_ - Continue completing this form.
No ❑o Not complete this loots. V-omplete other UIC application forms tar instaIlinR
either a 5A7 well (siren -loop well !njolgin potable wooer into the aquifer) or a jQM well (olosed-
loop well containing ridriiti►gk such as R-22, ethanol, or other andfmze or carmsion inhibitors).
A, PROPERTY OWNER(S)I"PLICANT(S)
List gachc Property Owner listed on property deed (if owned by d business or govemment Agency. state name of
entliy and a reprvsen(atiYe wlauthorlty i`ar signatum): V1 0_ - -
(I) Malllnr Address; (I S-OU CIOA '.j< , FIwY (Avfr 6
City: l C� _ GtTY _. State: f L4 Zip Crane: 2.1 F_`l.' _. —county! t►$Aej sr'o
llornce Q fice Tell: No,: YIQ• T2Y'_17P[ CfdLNO-yip- got- eJ.Y
remai I
(2) Physical Address of Well Site (irdifferent than above): SALMON CpeF.K LAN IL
City,MErz.ky. +. lw..— state,N( zipCoda.27-957 — u*. �LQ .
Home/office Tole No.: _ N �A Cell Nn.; N f._&_ .,
H. AUTHORUED AGENT OF OWN?,'% IF ANY (if the P asmlt Applicant o n own the subject property,
attach it IeHer from the: property owner authorizing Agent to install and opurs(e UIC wall)
Company Narnc:--
Contact Person_ —_- - - EM>AIL-. dress,.
Addressr
City: State: Zip Code: County: --
Qfiicc Tele No,: ._� - -- -- Cell No.; - - --
Websltc Address of Company. Irany: __.__.-_
Cif W; J 11C IQ Not Ir mtkln a1'ltilt [it Form (Ruvisad VMS) Par..L 1

C, WELL. DRILLER INF01E IMATION
Company NaTne:-_.- _-Pinkislonp6tMg & Woll,ing,__
Well Driller Contractor's Name: Howard_..E. Gutter_
NC Contractor Certification No.:53$-A
GvAlsct Person_ +j 'i � F�� �__ �_ � f'��e,���l 5 energv,com_ -
Address; FD Hv 14 2-- - - - - -- -
City; ._ChesmiltcL Zip Code: . � , - County:
Dell No.r "7 -5C3!1 7b
1), HEAT PUMP CONTRACTOR INFoRnA,rION (if dirferent than dr011er)
rm
F.
G.
C.oMpuny Nance:__-___ .."
Contact Pumvn: ��1FwAlfts.S
Address:
City:
Office Tele No.:
STATVS OF APPLICANT
Private: X F`ederal
ZipCade, ode: _�..� �. C aunty.-
- — -
CLII No.
camrncrciai: —
State: Municipal: J - Native American Lands:
INJFC'1'ION PROCEDURE (brieOy deso:ribc how the injection weI1(s) will be used)
civothermal. closed Loop System _ —. a NOT A. WATER, WELis"_
WELL CONSTRUCTION DATA
(1) Proposed date to be constructed;
Number of botinS3: ' ,
Approximate depth afeach boring
(2) l'ype of tubing to be: used (coppar, PVC, eio). � •{ i� E_
(3) Well cnssing: is the well(s) eased? (cheek either (a,j Yes gg (b.) No Wow)
(a) Yes - it'ves, then provide tLusing information bdltlw
Type: _galvanized steel �—black steel plastic other (specify)
Casing t'lepthi FMM —to --- -feet (ref rerrce to Land surface)
Casing cxlcn s to above ground incites
(b) No
(4) Grout Info (material surrounding well ottsing unWor piping,):
(a) Gout typr: Neat Cement � Hentnntte \x-- Othrr (Specifv)
(b) Grout placement: Pumptng4-_ pmssuty . tither
(c) Grout depth of tubing (refemice to land surface): from --CL ,. to ?�_ �S� (fat)
If well has casing, indiratt+ grout depth; from _ -- to (#bet)
t+1't11U1Z' 50W NwItia ition of hrlens Vorm (*vl';tat s/2008) hr 2

H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or propoNed modification of the injection equipurent and exterior
pipingltubhig associated with The injection operation: Tile manufarturer-s hrochum may provide .tuppleinentary
information.
LOCATION OF WEL148)
Anach two copics of maps showing the following infor natl in:
(1) Include a Site Ma l (can be drawer) Showing: bulldings, property Ilnes, surrace water bodics. potential
sources of �` b ►rater contamination and the orientation of and distances bet►veeii the prop► sod well(s) and
any existing well(s) or waste diepotral facilities such as septic tanks or drain fields located •► ttthlti 200 Fact of
the goothurmal heat pump well system, Lubec all features clearly and l icy �.�_p{t rev►►.
[2) Thu Site Mop must show the subJcot property In relatlon to the surrounding area by using at least two fixed
reference; points such as roads, strearns, andlor highway intersectionti.
r..
C:t,ariF'ICATION
Note:. This Permit Applicittlon tmu3t bt signed by leach person appearing on the
recorder9 legal property deed.
"I hureby eartify. tinder penalty of law, that I hate personally examined and aryl fi rilluw with the inforrnatior�
submitted in this document and all aft chmvnts theretu and that, b&od on my la4ulry of those lndividuak
Immediately fesponsible for obtaining Said information, I believe that the information is true, accUrate acid complete;.
I am uwaft that thou aft signiflc"t penalties, Including, the possibility of tines and imprisonment, for submitting
(film informaticiri. I agree to Construct, operate, malotaitl. repair, and if applicable, ahandon the injection well and
all related appurtenances in accordance with the approved speotfttatlons and conttitions of the Permit.-
S tt tutV ofprope weer/Applicant
rAvea E essGa�ff
1 -9A C Bra f:Pont or Tope Kill Name and title
Signature of Property OwrwrtApplicant
Print or Type Full Name and title
Signature or A uthorized Agent. if any
Print or Type Full Name and title
Please return two copies of the.cumpleted Application package to:
North Carotltns DENR-DWQ
Aquifer Prattettlon Station-VIC iPrearain
t635 Mail Service Center
Raleigh, NC 276"-1636
Telephone [phone]
CltiUAJIC SQW Now vatioa al'Intctit Ftrrtn (Itcrtsed W200H) PW 3

AAA ; D
f let,
1
�L43 tiN
k 1v
Ee L�j {
5 -
A
p r)
tj,j*ECTURA . s�
WALS:t-W

Rogers, Michael
�d rr�
From:
Sent:
To:
Cc:
Subject:
Attachments:
Mike,
Thanks, this is HZo only ...
Tina. ` . Stagg
'Vice President
Tina Stagg [[e-mail]]
Tuesday, January 10, 2012 12:15 PM
Rogers, Michael
Jeff Stagg
143 Salmon Creek Lane
143 Salmon Creek Lane DEN R Permit Application. pdf
Tinkston. Geothermal
Pinkston Purtt p & Wef.I, Inc.
J A Stagg Energy Enterx7rises, Inc.
P 0 So�l-,Y5482
Chesapea- , VA 23328-5482
757-438-9392 Of 6x,
75 7 -42I -2108 Fay-,
tinaRs tagg ert ercam

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELLN
In Accordance with the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or T�±oe information).
DATE: _ 242.
F
WeH Type Confirmw1on: Does the proposed system circulate potable water only (n❑ additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes —XA Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (aoen-loop well iniecting potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): � VL0 LA fUSU L
(l) Mailing Address: 11S00 60A 7W. YkIY (X( (fI—T
City: OC��v c n- ' State; Ik4 Zip Code: ! `� County:,(,y ��igr�r �
Home�Offtce Tele No.: Y10 - 5'2 Y • 1701 CellNo.: *01— .609 - 091 F
Email ebsite:
(2) P.hysical Address of Well Site (if different than above): -SALMON CREEK LA►V iF—
City: i✓ R icy H 1 L t— State:NC Zip Code: 2 79 5 7 _County: BEIZr ii E co .
Home/Office Tele No.: N
Cell No_: N j r+
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City: State: Zip Code: County-
Off ce-Tele No.: Cell No.:
Website Address of Company, if any:_
GPUMIC 5QW Notification of Intent Form (Revised 812008) Page I

C. WELL DRILLER JNFORMATION
CompanyName: ___ P~1=·nk=st=o=n =P~u=m=p---'&~W~el=l,~I=nc~.-------------------
Well Driller Contractor's Name: ---~H~o~w~ar_d~E~.---'C~u~tt~e~r ________________ _
NC Contractor Certification No.: 3538-A --~~~---------------------
Contact Person~11rJ fi _ ___,,,f.,"---'r---'A-'---"b'---'6"'--_____ -=E=M=-A=l=L---'--A=-=d=d=re=ss=,·r.N@Staggenerg y.com
Address: PO Box 15482
City: Chesapeake Zip Cbde: 23322 County: __________ _
Office No: 757-438-9392 ______ Cell No .: 7 '5 7 . 5 0'-1 7 6 9 5
1 D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: _______________________________ _
Contact Person.,_: ______________ __.c,E=MAc=.=.=IL,,_A'-=d=dr:..:e=ss=: __________ _
Address: _________________________________ _
City: __________ Zip Code: ____ County: _____________ _
Office Tele No.: Cell No.:
E. STATUS OF APPLICANT
Private: _x_
State:
Federal:
Municipal: __
-----------
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Geothermal Closed Loo p S ystem * NOT A WATER WELL*
G. WELL CONSTRUCTION DATA
(I) Proposed date to be constructed: _______ Number of borings: __ a ____ _
Approximate depth of each boring (feet): 2 o ':)
(2) Ty~e.oftubing to be used (copper, PVC , etc): ___ l,_d.Lou..._._P_,f:=': _________ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: ~alvanized steel __ black steel_Jlastic __ other (specify)
Casing depth : From ___ to ___ feet (reference to land surface)
Casing extends to above ground ___ inches
(b) No ~
(4) Grout Info (material surrounding well casing an'd/or piping):
(a) Grout type: Neat Cement__ Bentonite _½,_ Other (specify) ______ _
(b) Grout placement: Pump in~ Pressure__ Other __
.(c) Grout depth of tubing (reference to land surface): from O to 2 . .0 Q (feet)
If well has casing, indicate grout depth : frqm ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 2
H. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification 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)
J.
Attach two copies of maps showing the following information:
(1) Include /si~~-M~ (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources ofgroiffiO\vater 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 geothermal heat pump well system. Label all features 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 fixed
reference points such as roads, streams, and/or highway intersections.
tj,
CERTIFICATION '--\..-',.\( L,,l11...l (jiJ
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"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 wi~piv~ns and conditions of the Permit."
Cbth C ~ ..
Signature of ~~er/ Applicant
£),1V/ll £ IJ(,(Loff~
C
ltSIJ C -fJUlCflete
Print or Type Full Name and title
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies ofthe,completed Application package to:
Norj;h Carolina DENR-DWQ
Aquifer Protection Section-VIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone (919) 715-~935
GPU/VIC 5QW Notification oflntent Fonn (Revised 8/2008) Page 3
tot
Rl
JECTURAL SITE

Jan 1012 04:08p Pinkston Geothsrmat 757-421-2108 0.1
.
Gev IF mn, PINKSTON GR{)TH
p 0 Sox 15482, C6esa
M g757) 438-9392 fh2 [7S
facsimile . -tW
To.- j ] CG��LD+. �' ! l q
L
VA 23328
421-2108
-
CJ a LJ
1
0 Pkmw Recyde
1� 1! S
lustiller
From: �r,1,1 C oaw ill 0
Re- �y3 A�Mo REEr pages:
CC:
Q'Umwd 0 For Review 0 Pkaase C4MMent 0 Pleoae P
7 V L S C► r L
r
L I Cr 09 T-1 d N U L.-
' C] �
Eijx A4 E- Y(r- Fs c, c i p r
-7-/-y� �lo
o
v- C, f TH
-CH
! YOU
a Si
G
L L
Z52 5inq 7695
■ a a. 4 a 6 6 0 a a■■ ■IJ■ .■ a a a.■.■. a•

Jan 1012 04:09p Pinkston Geothermal
757-421-2108 p.2
NORTH CAROLINA
DEPARTMENT ❑F ENV IRONMEN7 AND NATURA L RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LUQP GEODWRMAL
WATER-QNLY INJECTION W ELL SYSTEM:
TYPE S-- W WE, S
In Accordance with the provisions ofNCAC Ti4 e 15A: 02C-0200, please
complete this rfotificarion and mail to address on the hack paiie (please print or � information).
DATE: � 1 � � ZQJ-
i
WeH Type Confirnudion: Does the proposed system circula' potable water on (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
G!O'aril4fo©
Yes _K_ Continue completing ibis form
?4o Do Not complete this form. Complet4other UIC application forms for inst,01ng
either a SA7 well (open -loop well-iniectin potable water into the aquifer) or a 5QM well (closed -
loop well containing additives -such as R-22, etharib1. or otter antifreeze or corrosion inhibitors).
A. PROPERTY O'WNGR(SYAPPLICANT(S) I
List each Property Owner listed on property deed (if owned t;y a business or government agency, state name of
entity and a representative wlauthority for signature)- w 110 Via 6- 0V t 6G uz , _.
(I) Mailing Address: �I5 QU CC),J7;f C
-- ,I
City: C 7- / _ State: &0 Zip (s de: -2 ! a `f 2 _Caunty:eds ale 1f rc�_
HoindOffice TeleNo.: Z//Q - S'2Y- 170f !11, Cell No.: 17l9- (�a - 071
Email Address:pta Ve. �glfba 7gtn� ► 1,
(2) Physical Address of Well -Site (if different than abow 1 p LM OWNCpEFv, '+�
CitOr IZP y I L L_ State: �C Zip C��de: 2 7 5 County: B ER r _t E Co .
Home/Offire Tele No.Cell No.: !' _
B. AUTHORi7T.T1 AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to 10tall and operate UIC well)
Company Name:
Contact Person: EMAIl. Address:
i
Address:
City: State: Zip Code: t County:
i
Office Tele Nv.: _ _ Cell No.:
Wcbsht Addraw of Cumpwry, if any:
GIIUIUIC 5QW Nafigicstion of Intent Form (Revised 8I2006) Page i

Jan 1012 04:09p Pinkstan Geothermal
757421-2108 p.3
501
' D.
WELL DRYLLER INFORMATION
Company Name: Pinkstan Pump $ Well, Inc.
Well Driller Contractor's Name: Howard E. C
NC Contractor Certification No.: 3538-A
Contact Person: 11 ^ CA66
Address: PO Box 15482
City: Chesapeake Zip gbde:
Office No: 737-438-9392 Cell
HEAT FUMP CONTRACTOR INFORMATION (if di
Company Name:
Contact Person:
Address:
3322 County:
-Q 76 R5
than driller)
City: Zip Code: County:
Office Tele No.: CelI No.:
E. STATUS OF APPLICANT
Private: X Federal: Cornwer i
State: Municipal: Native A
F. INJECTION PROCEDURE (briefly describe how the inj
ican Lands:
rn well(s) will be used)
• NOT: A WATER WELL*
.corn
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: N mber of borings:
Approximate depth of each boring (feet): 2
(2) Type of tubing to be used (copper, PVC, etc): lr
(3) Well using. Is the well(s) eased? (check either (a.) Yes r (b.) No below)
(a) Yes if yes, then provide casing informa 'on below
Type: ____galvanized steel black steel plastic other (specify)
Casing depth: From to feet (reference land surface)
Casing extends .to above ground inches
(4) Grout Info (material stn6 coding well casing anl3lor pipin
(a) Grout type: Neat Cement Bentoni e Other (specify)
(b) Grout placement: Pun ping_ Pewsurg Other
.(c) Grout depth of tubing (reference to land su ): from ��� to 2-00 (feet)
If well has casing, indicate grout depth; rrorn to_(feet)
GPUAlIC 50W NIc ifiradon of [flint Farm (Revised W2048) 11 Page 2 •

Jan 10 12 04 09p Pinkston Geothermal
757-421-2108 p 4
H, INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or p
piping/cubing associated with the injection Operation.
information.
1. LOCATION OF WELLS)
i madiFica ion of the injection equipment and exlerior
manufacturer's brochure may provide supplementary
Attach two copies of maps showing the follotiving informatio
(1) Include a Site Ma (can be drawn) showing: bui9 ings, property lines, surface water bodies, potenliai
sources of gro water contamination and the orien I ion of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such septic tanks or drain fields located within 200 feet of
the geothermal heat pump welt system. Label all feat res clearly and include a north arrow
(2) The Site Map must show the subject property in relat'on
to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highw
intersections,
J. CERTIFICATION w' �-t is a
--
Note: This Permit Application most be. signed by each
rson appearing on the
recorded legal property deed. -
"I hereby certify, under penalty of law, that I have perso
Ily examined and am familiar with the information
submitted in this document and all attachments thereto
nd that, based on my inquiry of those individuals
immediately responsible for obtaining said information, 1 beh
ve 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, f agree to construct, operate, maintain, r
air, and if applicable, abandon the injection well and
t all related appurtenances in accordance with the approved s
ificalions and conditions of the Permit."
G
_
5i attire of Protv
e:r/Applicant
+ V1 d Q
G►S�9 � .BG
Print or Type Full
ame and title
5igrtatureafPm
�' Owner/Applicant
t
Print or Type Full
E
ame and tiitle
Signature ofAuth
`'zed Agent, if any
Print or Type Full
` arne and title
Please return two copies of the,complete,
4
jApplication package to:
North Carolina DEIDWQ
Aquifer Protection Section,„ C Program
1636 Maid Service I rater
Raleigh.? NC 2769 1 636
Telephone [phone]
01PU1101C SQW No6f cation of LLtenI Form (Revised V200B) III Pa9c3

Jan 1012 04:09p Pinkston Geothermal
z
3UMOM
A.,
Z - - -
-J
A
2
OF.
.7
Mam
E K L
C 1-7 57
757421-2108
LCP
to-
P.5
ilTECTURAL SITE
SCALgdw-3W