WI0800435_GEO THERMAL_20201029

North Carolina Department of Environmental Quality
Division of Water Resources
PERMIT NAME/OWNERSIDP CHANGE APPLICATION FORM
I. INSTRUCTIONS
1. Complete this form in its entirety as follows:
( a) Change of Ownershi p -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
1. Permit Number: \t/I tJ 80[) '/.3S-
2. Permitteename(s): G,eo'je ...S,ovd (deceo se~
3. For Business/Governmental Agency-Permit si~e official's name and title: ___________ _
(Person legally responsible for permit) •
4. Mailing Address: . ..1)0,11/d Gr,:,y .,{'w,,'"14
City: ""1/fll..-.mo.d I State: ut. Zip: ,ZB 'l'/3
Telephone numJer: <!l!.P.J 795. Bz.cl'b Fax number: L_) ____ _
EMAIL Address: mi-,/, a.../ .,olt\
5. Physical Address ofFac1 ty ell(s) (if different than mailing address)
(.SQ.IMC a,,s o lo c:>llec)
City: ____________ County: _________ Zip: ______ _
III. NEW OWNER/ NAME INFORMATION
1. This request for a permit change is a result of:
/a. Change in ownership of ~perty/company
2.
_ b. Name change only
_ c. Other (please explain):
Permit/Name Change of Ownership Form Rev. 2-18-2020
RE'CENs,
0CLJ6 ZOZ(J
NCOEQ/ow,:r
Centra1 Office
Page 1
New Owner's nanne(s) as listed on the property deed (Please Print/or Type):
DAY; r7 SMIT
3. If Business or Governmental Agency- Permit signing official's name and title:
(Person legally responsible for permit)
4. Mailing Address: Cis riffilk
City: No. Ds? 47 pod ' state: NC Zip:
Day/Cell Phone No. (7/b) 711s. 92 5b Fax number; (—_)
EMAIL Address: _ el� rtp s &if ez 1..2 , CO %
IV. CERTIFICATION
1. Current Permittee's Certification (Please print or type):
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.
ail9 414
AyAor
2. New Applicant(s)'s Certification (Please t or type):
IIWe,aird c�7 , attest that this application
for name/ownership change been reviewed and is accurate and complete to the best of my knowledge. 1
understand that if all requi pa,,r
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
further certify that I will operate and maintain the permitted facility in accordance with the permit and related
regulatory requirements.
Signature:
Signature:
Cy
Date:
Date:
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 Deliver' / in Person:
Ground Water Resources Section
NC Division Of Water Resources
512 North Salisbury Street
Raleigh, NC 27604
Telephone Number: [phone]
Perniit/Name Change of Ownership Form Rev. 2-18-2020
Page 2

North Carolina Department of Environmental Quality
Division of Water Resources
PERMIT NAME/OWNERSHIP CHANGE APPLICATION FORM
L INSTRUCTIONS
Complete this form in its entirety as follows:
(a) Change of Ownership — Provide the information. in Parts II and Ill and submt eyed=�\ 1
� rmentation of the
transfer of ownership such as a contract, deed, article of incorporation, etcWe certificatj�ps in part IV
must be signed by both the current permit holder, if available, and the new applic'
(b) Name Chance Only — Provide the information in Parts II and III. Sign the ceROAM 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: vvIiiBaD 5(.35' coo
2. Permittee narne(s): Ge o f+ c ra yd (dr_t eft -% e Ge�
3. For Business/Governmental Agency- Permit signing official's name and title:
(Person legally responsible for permit) .
4. Mailing Address: j hid Ere Mt1 4
City: NQJ jIeat I State: ,C Zip: Z S 44443
Telephone numb (9ro) 795, edgy?) Fax number: ( )
EMAIL Address: _ ini7. 504 re, I. cowl.
5. Physical Address of Faci ity ell(s) (if different than mailing address)
(.5a►lig_ .s iajcpyiLl
City: County: Zip:
III. NEW OWNER / NAME INFORMATION
I. Thisrequestfor a permit change is a result of:
✓ a_ Change in ownership of pretty/company
b. Name change only c. Other (please explain): De i q j ; 1 p vu p.)e r- �d i $ &.s Cer
Permit/Namc Cbange of Ownership Form Rev. 2-I8-2020 Page 1

New Owner's name(s) as listed on the property deed (Please Print/or Type):
___-D a.vid 6117 ...-cttr:74__
3- If Business or Governmental Agency- Permit signing official's name and title:
(Person legally responsible for permit)•
fn
4 Mailing Address: t �,� i A t ,
City: tip t++"S u CI State. Ake Zip: 29 #4'.3
Day/Celt Phone No. (9/b) 795 . S2 96 Fax number: ( )
EMAIL Address:
IV. CERTIFICATION
1. Current Pennittee's Certification (Please print or type):
I, attest that this application for nameJownership change has been reviewed
and is accurate and complete to the best of my knowledge. I understand that if ail 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 1 will continue to be responsible for
compliance with the current permit until a new permit is issued.
2. New Applicant(s)'s Certification (Please pri t or type):
IIWe, w 4 r aI( 6 r e `7 rr++Th , attest that this application
for name/ownership change h been reviewed and is accurate and complete to the best of my knowledge. 1
understand that if all requir 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
further certify that I will operate and maintain the permitted facility in accordance with the permit and related
regulatory requirements.
le -
Signature: a , ■ Date: ,v) 26f2
Signature: Date: r
}► J p2.
. 1. Zes
, � C
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 Deliver. / In Person:
Ground Water Resources Section
NC Division Of Water Resources
512 North Salisbury Street
Raleigh, NC 27604
Telephone Number: [phone]
Perrnit/Name Change of Ownership Form Rev_ 2-18-2020
Page 2

North Carolina 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 /4enewal* __ Modification __ Permit Rescission Request*
*For Permit Renewals or Rescission Request, complete Sections A thru E , and M {signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: ~,µ~" ~ . 20 :'.7 \ .,.. ~
A.
~~ _ ~O PERMIT NO. w'J:09ol:>lf~(leave blank ifNew Application)
CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New WeU/Permit Application)
1. Current Use of Well /
a. I wish to continue to use the well as&' Geothennal Well O Drinking Water Supply Well D Other Water Supply Use-Indicate use (i.e., irrigation, etc.) ________ _
b. Terminate Use: If the well is no longer being used as a geothennal injection well and you wish to
rescind the pennit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-3O).
D Yes, I wish to rescind the pennit
2. Current Ownership Status . /
Has there been a change of ownership since pennit last issued? [i3'YES O NO
I
If yes, indicate New Owner's contact infonnation: l
Name(s) , U,,..,,~ ~1.:::ji J.
Mailing Address:/ Yeh CW l o.,Jt:,,,
City: tfo.n44.57ia.J State:_..Aic_Zip Code: 2Bl/t/-3 County: /Jea>Jer: I I ·~O .,
Day Tele No.: 'Ill>, 7'15. 'iJ1.. 'fi) Email Address.: djre!~,.,11o.~j"'a«A• com.
B. STATUS OF APPLICANT {choose one)
Non-Government: Individual Residence~ Business/Organization __
Government: State Municipal__ County__ Federal
C. WELL OWNER(S)/PERMIT APPLICANT -For single family residences, list all persons listed on the
property deed. For all othe:'st nrulle ofbusiness/agenc~ and name of person and title with delegated authority
to sign: ...L}0,,11,c;{ <;re,.11 .£.,., ,Tl,.,
Mailing Address: 7ll2 'i!,r o u:,A} ~J,~lu; J. "-..ve
City: Ha'o/"~ko..liL State: ltt_ Zip Code: .28 y·f(.J County : /;ANl,,r
Day Tele No.: -Cell No .: Cf /t). 7 9.!J-_ B..2 9()
EMAIL Address, ,jj rcysM iTA(!Dyuil <<'"' Fax No.: 1"
Geothennal Water Return Well Pennit Application Rev. 4-15-2016 Page I
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 ru!Q name of person and title with delegated authority
t9sign: ..Sa.Me 44«-w~l/12cJAlt1r
Mailing Address: _____________________________ _
City: ____________ State: __ Zip Code:. _______ County:. _____ _
Day Tele No.: --------------~E=m=ai=l =A=d=dr~e=ss=•a...: __________ _
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: 'f,21)2-o'/•21&.S'-oor,IJ County: _ __,~,_~....,N,._,,J,._e=r-
(2) Physical Address (if different than mailing address): _______________ _
.StJUH~ «4 Ata,:t1:iJ A-tf,/;r,;.s
City: ____________ County _________ Zip Code: ____ _
F 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.: ________ Cell No.: Fax No.: _______ _
G. HV AC 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 Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES __ _
YES ___ _
NO ___ _
NO ___ _
I. WELL CONSTRUCTION REQUIREMENTS -As specified in 15A NCAC 02C .0224( d ):
(1) The water supply well shall be constructed in accordance with the water supply well requiremenfs of
15A NCAC 02C .0107.
(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:
Geothermal Water Return Well Pennit Application Rev. 4-15-2016 Page2
NOTE: In most cases an aerial photograph of the property parcel showing property lines and ,structures can be
obtained and downloaded froth 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
wells, etc. can then be drawn in by hand Also, a `layer' can be selected showing topographic contours or elevation
data
114. CERTIFICATION (to be signed as required below or by that person's authorized agent)
I5A NCAC 02C .O2111ee 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. fora 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 persons listed on the pro ert` 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 fox 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."
Signature of Property
Crey
Print or Type Full Name and Title
Sig ir of Proper, wnerplicant
Print dr Type Full Nacre 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 - UXC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application Rev. 4-1 S-2O16 Page 4

North Carolina 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 Ap lication /2enewal* __ Modification __ Permit Rescission Request*
•For Permit Renewals or Rescission Request. comJ>.lete Sections A thru E. and M (signature J>.age) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE ·. ~,""--,20 ..,\ .,.,,-; ~«l . !I!{. 0 PERMIT NO. _a: oQl>b &f~(leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application)
B.
1. Current Use of Well /
a. I wish to continue to use the well as 5]Geothennal Well D Drinking Water Supply Well
D Other Water Supply Use-Indicate use (i.e., irrigation, etc.) ________ _
b. Terminate Use: If the well is no longer being used as a geothennal injection well and you wish to
rescind the pennit, check the box below. If abandoned, attach a copy of the Wi8-oiunent
Record (GW-30).
0 Yes, I wish to rescind the pennit OCT 2 6 2020
2. Current Ownership Status / NC DEQ/DWR
Has there been a change of ownership since pennit last issued? ~YES D ~ntral Office
If yes, indicate New Owner's contact infonnation:
Name(s) , ]).2111; G ~ :;. ~
Mailing Address:/ i ~o::I, ·,a.i> L o.,Je..,,
City: Ho.rttd.$ll4-d State:_.&ic_zip Code: 2BI/IJ3 County: /JetJJe("
I d ·~O • I Day Tele No.: Cfll> ~ 7'15. gz_ 'fi) Email Address.: jr<,l'.::"'i1".~jlff4«A , eoM.
STATUS OF APPLICANT (choose one)
Non-Government: Individual Residence _L Business/Organization __
Government: State Municipal __ County__ Federal
C. WELL OWNER(S)/PERMIT APPLICANT -For single family residences, list all persons listed on the
property deed. For all others~st narqe ofbusiness/agenc~ and name of person and title with delegated authority
to sign: _Ll&v,d r;,,.,11 si,,yl
Mailing Address: '"1{l) "i3,:owA2 &b~l..AJ e:t.Ne
City: /la.ny4 ~ka.d' State: lie._ Zip Code: g e yt(..3 County: f;Alq{,r
DayTeleNo.: -CellNo.: Cf/(). 79-1>-_ B~9()
EMAIL Address: ,/j '3/5"''7-ly,,,rc-Fax No.: ~
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Pagel
D. WELL OPERATOR (if different from well owner) -For single family residences , list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated authority
t9 sign: ..SD-me 44.., wfel/o lt)Al~r
Mailing Address:-------------------------------
City: ____________ State: __ Zip Code: ______ County: _____ _
Day Tele No.: ---------------=E=m=a=il~A=d=d=r=es=s=·=------------
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: 'l-2l)2..S'l·2JCS'• OOfJD County: _.....,~-~...,AJL.:J,,_t"-'r"_
(2) Physical Address (if different than mailing address): ________________ _
..$/XJH~ &.S AW,;lifj ""d'd'.,,,-s:
City: _____________ County _________ Zip Code: ____ _
F 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.: Cell No.: Fax No.:. ________ _
G. HV AC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name: ----------------------------
NC HVAC Contractor License No.: ________________________ _
Company Name: _______________________________ _
Contact Person . .a..: _______________ EMAIL Address:. ___________ _
Address: _________________________________ _
City: __________ Zip Code: ____ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: ----------------
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1)
(2)
The injection operation?
Personal consumption?
YES ___ _ NO ___ _
YES __ _ NO ___ _
I. WELL CONSTRUCTION REQUIREMENTS -As specified in ISA NCAC 02C .0224 (d):
(1)
(2)
The water supply well shall be constructed in accordance with the water supply well requirements of
ISA NCAC 02C .0107 .
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 ISA NCAC 02C .0107 , except that:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page2
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
wells, 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)
d 5A NCAC 02C ,O21 I [elf 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 ail others: by all the persons listed on theproperl3 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, 1 believe that the information is true, accurate and
complete. I ain 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"
Signature of Property t� ��Ap Bean
�i,alr 6rey 7 , h
Print or Type Full Narnk and Tit e
tuf Property
Signa Owner/Applicant
e sniv-4
Print ni Type Full Name and Title
Signature of Authorized Agent, if any
Print or Type Full Narne 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
Telephone [phone]
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 4

BK 4693 PG 2569 - 2587 (19) DOC# 20054197
This Document eRecorded: 09/23/2019 11:35:31 AM
Fee: $64.00 DocType: D1T Tax: $0.00
Pender County, North Carolina
Sharon Lear Willoughby, Register of Deeds
DC:\ cl'% cseajo.,
Akce
This instrument Prepared By:
Cheryl Welch
1940 N FtAVENSWOOD
CHXC'AGO ILLINOIS 60613
After Recording Return To:
GUARANTEED RATE, INC.
4410 N. RAVENSWOOD AVE.
CHICAGO, iLLztTOiS 64640
Loan Number.: 192625394
DEED OF TR1JST
r) r WCO4CE5JM
COLOWAMOISL
(A) "Security Instrument" means this document, which is dated
with all Riders to this document.
(]3j "Burrower" is David Grey Smith, married
Borrower is the trustor under this Security Instrument.
(C) 'Lender "is GUARANTEED RATE, INC.
Lenderis a DELAWARE CORPORATION
and existing under the laws of DELAWARE
Lender's address is .3940 N RAVENSWOO1), CHICAGO,
SEPTEMBER 18, 2019
ILLINdOIS 60513
(C-1) The name of the Mortgage Broker is no mortgage Broker
NOiiTT-1 CI CL1NA - Single Family - Fanriia F. eJFwddie Mac UNIFORM INSTRUMENT - MERS
Form 3034 1101 Page 1 of 14
, together
organized
D0cMa iic Wamar
mwe.dacmagic. Con
Submitted electronically by "Collins and collins Law offices, PLLC"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the fender County Register of needs.

BK46~3 PG 2570 DOC# 20054197
(D) ''frustee"is Collins & Collins Law Offices PLLC
215 Racine Dr. Ste. 101, Wilmington, North Carolina 28403
(E) "MERS" is Mortgage Electronic Regish·ation Systems, Inc. MERS is a separate corporation that is acting
solely as a nominee for Lender and Lender's successors and assigns. MERS is the beneflciftry under this Security
Instrument. MERS is organized and existing under the laws of Delaware, and has an address and telephone number
of P.O. Box 2026, Fllnt, MI 48501-2026, tel. (888) 679-MERS.
(F) ''Note"means the promissory note signed by Borrower and dated SE1.>'l'EMB8R 18, 2019
The Note states that Borrower owes Lender TWO HUNDRED SEVENTY-FIVE THOUSAND AND 00/100
Dollars (U.S. $275, ooo. oo ) plus interest.
Borrower has promised to pay this debt in regular Periodic Payments and to pay the debt in full not later than
OCTOBER 1, 2049
(G) ''Propel'ty" means the properly that is described below under the heading "Transfer of Rights in the Property."
(II) "Loan" means the debt evidenced by the Note, plus interest, any prepayment charges and late charges due under
the Note, and all sums due under this Security Instrument, plus interest.
(I) "Riders" means all Riders to this Security Instrument that are ex:ecuted by Borrower. The following Riders are
to be executed by Borrower [check box as applicable}:
O Adjustable Rate Rider
O Balloon Rider
D 1-4 Family Rider
D Condominium Rider
00 Planned Unit Development Rider
O Biweekly Payment Rider
O Second Home Rider
D Other{s) [specify]
RECEIVED
oc, 2 6 2020
NCOEO/DWR
(J) "Applicable Law" means all controUing applicable federal, state and local stat11te.C~i~~dinances and
administrative rules and orders {that have the effect of law) as well as all applicable final, non-appealable judicial
opinions.
{K) ''Community Assocfatlon Dues, Fees, and Assessments" means all dues, fees, assessments and other charges
that are imposed on Borrower or the Properly by a condominium association, homeowners association or similar
organization.
(L) "Electronic Funds Transfer" means any transfer of funds, other than a transaction originated by check, draft,
or similar paper instrument, which is initiated through an electronic terminal, telephonic instrument, computer, or
magnetic tape so as to order, instruct, or authorize a financial institution to debit o.r credit an account. Such term
includes, but is not limited to, point-of-sale transfers, automated teller machine transactions, transfers initiated by
telephone, wire transfers, and automated clearinghouse transfers.
(M) "Escrow Items" means those items that are described in Scctio11 3.
(N) "Mfscellaneous Proceeds" means any compensation, settlement, award of damages, or proceeds paid by any
third party (other than insurance proceeds paid under the coverages described in Section S) for: (i) damage to, or
destruction of, the Property; (ii) condemnation or other taking of all or any part of the Property; (iii) conveyance in
lieu of condemnation; or (iv) misrepresentations of, or omissions as to, the value and/or condition of the Property.
(0) ''Mortgage Insurance" means h1surance protecting Lender against the nonpayment of, or default on, the Loan.
(P) ''Pel'iodic Payment" means the regularly scheduled amount due for (i) principal and interest under the Note,
plus (ii) any amounts under Section 3 of this Security Instrument.
(Q) "RESPA" means the Real Estate Seltlemenl Procedures Act (12 U.S.C. §2601 et seq.) and its implementing
regulation, Regulation X (12 C.F.R. Part 1024), as they might be amended from lime lo time, or any additional or
successor legislation or regulation that governs the same subject matter. As used i11 this Security Instrument,
NORTH CAROLINA • Single Family • Fannie Mae/Freddie Mac UNIFORM INSTRUMENT -MERS
Form 3034 1/01 Page 2 of 14
DocMaglc~
www.docmaglc.com
BK4693 PG 2571 DOC# 20054197
"RESP A" refers to all requirements and restrictions Chat are imposed in regard to a "federally related mortgage loan"
even if the Loan does not qualify as a "federally related mortgage loan" under RESPA
(R) "Successor in Interest of Borrower" means any party that has taken title to the Property, whether or not that
party has assumed Borrower's obligations under the Nole and/or this Security Instrument.
TRANSFER OF RIGHTS IN THE PROPERTY
The beneficiary of this Security Instrument is MERS (solely as nominee for Lender and Lender's successors and
assigns) and the successors and assigns ofMERS. This Security lnstrnment secures to Lender: (i) the repayment of
the Loan, and all renewals, extensions and modifications of the Note; and (ii) the performance of Borrower's covenants
and agreements under this Security Instrument and the Note. For this purpose, Borrower irrevocably grants and oonveys
lo Tmstee and Trustee's successors and assigns, in lmst, with power of sale, the following described property located in the
COUNTY of Pender
ffypc of Recording Jurisdiction] (NBmc of Rcconting JurlsdictlmiJ
SEE LEGAL DESCRIPTION ATTACHED HERETO AND MADE A PART HEREOF AS EXHIBIT 11 A 11 •
A.P.N.: 4202-59-2165-0000 & 4202-59-3095-0000
which currently has the address of 110 SROWN PELICAN LN
[Street}
HAMPSTEAD
[City]
, North Carolina 28443 ("Property Address"):
[Zip Codel
TO HAVE AND TO HOLD this property unto Trustee and Trustee's successors and assigns, forever, together
with all the improvements now or hereafter erected on the property, and all easements, appurtenances, and fixtures
now or hereafter a part of the prnperty. All replacements and additions shall also be covered by this Security
Instrument. All of the fotegoiug is referred to hi this Security Insh·ument as the "Property." Bonower understands
and agrees that MERS holds only legal title to the interests granted by Borrower in this Security Instrument, but, if
necessary to comply with law or custom, MERS (as nominee for Lender and Lender's successors and assigns) has the
right: to exercise any or all of those interests, including, but not limited to, the right to foreclose and sell the
Property; and to take any action required of Lender including, bu! not limited to, releasing and canceling this Security
Instrument.
BORROWER COVENANTS that Borrower is lawfully seised of the estate hereby conveyed and has the righl
to grant and conve}' the Property and that the Property is unencumbered, except for encumbrances of record.
Borrower warrants and will defend generally the title lo the Property against all claims and demands, subject to any
encumbrances of record.
THIS SECURITY INSTRUMENT combines uniform covenanls for national use and non-uniform covenants with
limited variations by jurisdiction to constitute a uniform security instrument covering real property.
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UNIFORM COVENANTS. Borrower and Lender covenant and agree as follows:
1. Payment of Prlndpnl, Interest, Escrow Items, Prepayment Charges, and Late Charges. Borrower
shall pay when due the principal of, and interest on, the debt evidenced by the Note and any prepayment charges and
late cl1arges due under the Note. Borrower shall also pay funds for Escrow Items pursuant lo Section 3. Payments
due under the Note and this Security Instrument shall be made in U.S. currency. However, if any check or other
instrument received by Lender as payment under the Nole or this Security Instrument is returned to Lender unpaid,
Lender may require that any or all subsequent payments due under the Note and this Security Instrument be made in
one or moreofthe following forms, as selected by Lender: (a) cas11; (b) money order; (c) certified check, bank check,
treasurer's check or cashier1 s check, provided any such check is drawn upon an institution whose deposits are insured
by a federal agency, instrumentality, or entity; or (d) Electronic Funds Transfer.
Payments are deemed received by Lender when received at the location designated in the Note or at such other
location as may be designated by Lender in accordance with the notice provisions in Section 15. Lender may return
any payment or partial payment if the payment or partial payments are insufficient to bring the Loan current. If
Borrower has breached any covenant or agreement in this Security Instrument and Lender has accelerated the
obligations of Borrower hereunder pursuant to Soction 22 then Lender may accept any payment or parlial payment
insufficiellt to bring the Loan current, without waiver of any rights hereunder or prejudice to its rights to refuse such
payment or partial payments in the future, but Lender is not obligated to apply such payments at the time such
payments are accepted. If each Periodic Payment is applied as of its scheduled due date, then Lender need not 11ay
interest on unapplied funds. Lender may hold such unapplied funds until Borrower makes payment to bring the Loan
current. If Borrower does not do so within a reasonable period of time, Lender shall either apply such funds or return
them to Eo1Tower. If not applied earlier, such funds will be applied to the outstanding principal balance under the
Note immediately prior to foreclosure. No offset or claim which Borrower might have now or in the future against
Lender shall relieve Bon·ower from making payments due under the Note and this Security Instrument or performing
the covenants and agreements secured by this Security Instrument.
2. Application of Payments or Proceeds, Except as otherwise described in this Section 2, all payments
accepted and applied by Lender shall be applied in the following order of priority: (a) interest due under the Note;
(b) principal due under the Note; (c) amounts due under Section 3. Such payments shall be applied to each Periodic
Payment in the order in which it became due. Any remaining amounts shall be applied first to late charges, seco11d
to any other amounts dne under this Security Instrument, and then to reduce the principal balance of the Note.
If Lender receives a payment from Borrower for a delinquent Periodic Payment which includes a sufficient
amount to pay any late charge due, the payment may be applied to the delinquent payment and the late charge. If
more than one Periodic Payment is outstanding, Lender may apply any payment received from Borrower to the
repayment of the Periodic Payments if, and to the extent that, each payment can be paid in full. To the extent that
any excess exists after the payment is applied to the full payment of one or more Periodic Payments, such excess may
be applied to any late charges due. Voluntary prepayments shall be applied first to any prepayment charges and then
as described in the Note.
Any application of payments, insurance proceeds, or Miscellaneous Proceeds to principal due under the Note
shall not extend or postpone the due date, or change the amount, of the Periodic Payments.
3. Funds for Escrow Items. Borrower shall pay to Lender on the day Periodic Payments are due under the
Note, until the Note is paid in full, a sum (the "Funds") to provide for payment of amounts due for: (a) taxes and
assessments and other items which can attain priol'ity over this Securjty Iuslrument as a lien or encumbrance on the
Property; (b) leasehold ))ayments or ground rents on the Property, .if any; (c) premiums for any and all insurance
required by Lender under Section 5; and ( d) Mortgage Insurance premiums, if any, or any sums payable by Borrower
to Lender in lieu oflhe payment of Mortgage Insurance premiums in accordance with the provisions of Section 10.
These items are called a Escrow Items." At origination or at any time during the term of the Loan, Lender may require
that Community Association Dues, Fees, and Assessments, if any, be escrowed by Borrower, and such dues, fees and
assessments shall be an Escrow Item. Borrower shall promptly furnish to Lender all notices of amounts to be paid
under this Section. Borrower shall pay Lender the Funds for Escrow Items unless Lender waives Borrower's
obliga!ion to pay the Funds for any or all Escrow Items. Lender may waive Borrower's obligation to pay to Lender
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Funds for any or all Escrow Items at any time. Any such waiver may only be in writing. In the event of such waiver,
Borrower shall pay directly, when and where payable, the amounts due for any Escrow Items for which payment of
Funds has been waived by Lender and, if Lender requires, shall furnish to Lender receipts evidencing such payment
within such time period as Lender may require. Bonower' s obligation to make such payments and to provide receipts
shall for all purposes be deemed to be a covenant and agreement contained in this Security Instrument, as the phrase
"coveuant and agreement" is use<l in Section 9. If Bon-ower is obligated to pay Escrow Items directly, pursuant to
a waiver, and Borrower fails to pay the amount due for an Escrow Item, Lender may exercise its rights under Section
9 and pay such amount and Borrower shall then be obligated under Section 9 to repay to Lender a11y such amonnt.
Lender may revoke the waiver as to any or att Escrow Items at any time by a notice given in accordance with Section
15 and, upon such revocation, Borrower shall pay to Lender all Funds, and in such amounts, that are then required
under this Section 3.
Lender may, at any time, collect and hold Funds in an amount (a) sufficient to permit Lender to apply the Funds
at the time specified under RESPA, and (b) not to exceed the maximum amount a lender can require under RESPA.
Lender shall estimate the amount of Funds due on the basis of current data and reasonable estimates of expenditures
of future Escrow Items or otherwise in accordance with Applicable Law.
The Funds shall be held in an institution whose deposits are insured by a federal agency, instrumentality, or
entity (including Lender, if Lender is an institution whose deposits are so insured) or in any Federal Home Loan
Bank. Lender shall apply the Funds to pay the Escrow Items no later than the time specified under RESP A. Lender
shall not charge Borrower for holding and applying the Funds, annually analyzing the e.'ICrow account, or verifying
the Escrow Items, unless Lender pays Borrower interest on the Funds and Applicable Law permits Lender to make
such a charge. Unless an agreement is made in writing or Applicable Law requires intei·est to be paid on the Funds,
Lender shall not be required to pay Borrower any interest or earnings on the Funds. Borrower and Lender can agree
in writing, however, that interest shall be paid on the Funds. Lender shall give to Borrower, without charge, an
annual accounting of the Funds as required by RESP A.
If there is a surplus of Funds held in escrow, as defined under RESPA, Lender shall account to Borrower for
the exCC-$S funds in a~ordance with RESP A. Ifthere is a shortage of Funds held in escrow, as defined under RESP A,
Lender shall notify Borrower as required by RESP A, and Borrower shall pay to Lender the amount necessary to make
up the shortage in accordance with RESP A, but in no more than 12 monthly payments. If there is a deficiency of
Funds held in escrow, as defined under RESP A, Lender shall notify Borrower as required by RESP A, and Borrower
shall pay to Lender the amount necessary to make up lhe deficiency in accordance with RESP A, but in no more than
12 monthly payments.
Upon payment in full of all sums se<:ured by this Security Instmmenl, Lender shall promptly refund lo Borrower
any Funds held by Lender.
4. Charges; Liens, Borrower shall pay all taxes, assessments, charges, fines, and impositions attributable
to the Properly which can attain priority over this Security Instrument, leasehold payments or ground rents on the
Property, if any, and Commm1ity Association Dues, Fees, and Assessments, if any. To the extent that these items
are Escrow Items, Borrower shall pay them in the manner provided in Section 3.
Borrower shall promptly discharge any lien which has priority over this Secul'ity Instrument unless Borrower:
(a) agrees in writing lo the payment of the obligation secured by the lien in a manner acceptable to Lender, but only
so long as Borrower is performing such agreement; (b) contests the lien in good faith by, or defends against
enforcement of the lien in, legal proceedings which in Lender's opinion operate to prevent the enforcement of the lien
while those proceedings are pending, but only until such proceedings are conclude<l; or (c) secures from the holder
of the lien an agreement satisfactory to Lender subordinating tl1e lien to this Security Instrument. If Lender
determines that any part of the Property is subject to a lien which can attain priority over this Security Instrument,
Lender may give Borrower a notice identifying the lien. Within 10 days of the date on which that notice is given,
Borrower shall satisfy the Jien or take one or more of the actions set forth above in this Seclion 4.
Lender may require Borrower to pay a one-time charge for a real estate tax verification and/or reporting se!'vice
used by Lender in connection with this Loan.
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5. Pl'operty Insurance. Borrower shall keep the improvements now existing or hereafter erected on the
Property insured against loss by fire, hazards included within the term "extended coverage," and any other hazards
including, but not limited to, earthquakes and floods, for which Lender requires insurance. 1l1is insurance shall be
maintained in the amounts (including deductible levels) and for the periods that Lender requires. What Lender
requires pursuant to the preceding sentences can change during the term of the Loan. The insurance canier providing
the insurance shall be chosen by Borrower subject to Lender's right to disapprove Borrower's choice, which right shall
not be exercised unreasonably. Lender may require Borrower to pay, in co1mection with this Loan, either: (a) a one-
time charge for flood zone determinalion, certification and tracking services; or (b) a one-time charge for flood zone
determination and certification services and subsequent charges each time remappings or similar changes occur which
reasonably might affect such determination or certification. Borrower shall also be responsible fo1· the payment of
any fees imposed by the Federal Emergency Management Agency in co11nec1io11 with the review of any flood zone
determination resulting from an objection by Borrower.
If Borrower fails to maintain any of the coverages de.scribed above, Lender may obtain insurance coverage, at
Lender's option and Borrower's expense. Lender is under no obligation to purchase any particular type or amount
of coverage. 1l1erefore, such coverage shall cover Lender, bul might or might not protect Borrower, Borrower's
equity in the Property, or the conlents of the Properly, against any risk, hazard or liability and might provide greater
or lesser coverage than was previously in effect. Borrower acknowledges that the cost of the insurance coverage so
obtained might significantly exceed the cost ofinsurance that Borrower could have obtained. Any amounts disbursed
by Lender under this Section 5 shall become additional debt of Borrower secured by this Security Inslrnment. These
amounts shall bear interest at the Note rate from the dale of disbursement and shall be payable, with such interest,
upon notice from Lender to Borrower requesting payme11t.
A.11 insurance policies required by Lender and renewals of such policies shall be subject to Lender's right to
disapprove such policies, shall include a standard mortgage clause, and shall name Lender as mortgagee ancVor as an
additional loss payee. Lender shall have the right to hold the policies and renewal ce1·tificates. Jf Lender requires,
Borrower shall promptly give to Lender all receipts of paid premiums and renewal notices. If Borrower obtains any
form of insurance coverage, not otherwise required by Lender, for damage to, or destruction of, the Property, such
policy shall include a standard mortgage clause and shall name Lender as mortgagee and/or as an additional loss
payee.
In the event ofloss, Borrower shall give prompt notice lo the insurance carrie1· and Lender. Lender may make
proof of loss if not made promptly by Borrower. Unless Lender and Borrower otherwise agree in writing, any
insurance prnceeds, whether or not the underlying insurnnce was required by Lender, shall be applied to restoration
or repair of the Property, if the restoration or repair is economically feasible and Lender's security is not lessened.
During such repair and restoration period, Lender shall have the right to hold such insurance proceeds until Lender
has had an opportunity to inspect such Property to ensure the work has been completed to Lender's satisfaction,
provided that such inspection shall be undertaken promptly. Lender may disburse proceeds for the repairs and
restoration in a single payment or in a series of progress payments as the work is completed. Unless an agreement
is made in writing or Applicable Law requires interest to be paid on such insurance proceeds, Lender shall not be
required to pay Borrower any interest or earnings on such proceeds. Fees for public adjusters, or other third parties,
retained by Borrnwer shall not be paid out of the insurance proceeds and shall be the sole obligation of Borrower.
If the restoration or repair is not economically feasible or Lender's security would be lessened, the insurance proceeds
shall be applied to the sums secured by this Security Instrument, whether ornot then due, with the excess, if any, paid
to Borrower, Such insurance proceeds shall be applied in the order provided for in Section 2.
If Borrower abandons the Property, Lender may file, negotiate and settle any available insurance claim and
related matters. 1f Borrower does not respond within 30 days to a notice from Lender that the insurance carrier has
offered to settle a claim, then Lender may negotiate and settle the claim. The 30-day period will begin when the
notice is given. In either event, or if Lender acquires the Property under Section 22 or otherwise, Borrower hereby
assigns to Lender (a) Borrower's rights to any insurance proceeds in an amount not to exceed the amounts unpaid
under the Note or this Security Instrument, and (b) any other of Borrower's rights { other than the right lo any refund
of unearned premiums paid by Borrower) under all insurance policies covering the Property, insofar as such rights
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are applicable to the coverage of1he Properly. Lender may use lhe insurance proceeds either to repair or restore the
Property or to pay amounts unpaid under the Note or this Security Instrument, whether or not then due.
6, Occupancy. Borrower shall occupy, establish, and use the Property as Borrower's principal residence
within 60 days after the execution of this Security Instrument and shall cotllinue to occupy the Property as Borrower's
principal residence for at least one year after the date of occupancy, unless Lender otherwise agrees in writing, which
consent shall not be unreasonably withheld, or unless extenuating circumstances exist which are beyond Borrower's
control.
7. Preservation, .Maintemtnce rmd Protection of the Property; Inspections. Borrower shall not destroy,
damage or impair the Property, allow t11e Property to deteriorate or commit waste on the Properly. Whether or not
Borrower is residing in the Property, Borrower shall maintain the Property in order to prevent the Property from
deteriorating or decreasing in value due lo its condition. Unless it is determined pursuant to Section 5 that repair or
restoration is not economica11y feasible, Borrower shall promptly repair the Property if damaged to avoid further
deterioration or damage. If insurance or condemnation proceeds are paid in connection with damage lo, or the taking
of, the Property, Borrower shall be responsible for repairing or restoring the Property only if Lender has released
proceeds for such purposes. Lender may disburse proceeds for the repairs and restornlion in a single payment or in
a series of progress payments as the work is completed. If the insurance or condemnation proceeds are not sufficient
to repair or restore the Property, Borrower is not relieved of Borrower's obligation for the completion of such repair
or restoration.
Lender or its agent may make reasonable entries upon and inspections of the Property. If it has reasonable cause,
Lender may inspect the interior of the improvements on the Property. Lender shall give Borrower notice at the time
of or prior to such an interior inspection specifying such reasonable cause.
8. Borrower's Loan AppUratlon. Borrower shall be in default if, during the Loan application process,
Borrower or any persons or entities acting at the direction ofBorrowe.r or with Borrowe.l" s knowledge or consent gave
materially false, misleading, or inaccurate information or statements to Lender (or failed to provide Lender with
material information) in com1ection with the Loan. Material representations include, but are not limited to,
representations concerning Borrower's occupancy of the Properly as Borrower's principal residence.
9. P1·otection of Lender's Intet·est in the Pro1>et·ty and Rights Under this Security Instrument. If (a}
Borrower fails to perform the covenants and agreements contained in this Security Instrument, (b) there is a legal
proceedit1g that might significantly affect Lender's interest in the Properly ancVor rights under this Security Instrument
(such as a proceeding in bankruptcy, probate, for condemnation or forfeiture, for enforcement ofa lien which may
attain priority over this Security Instrument or to enforce laws or regulations), or (c} Borrower has abandoned the
Property, then Lender may do and pay for whatever is reasonable or appropriate to protect Lender's interest in the
Properly and rights under this Security Instrument, including protecting and/or assessing the value of lhe Properly,
and securing and/or repairing the Property. Lender's actions can include, but are not limited to: {a) paying any sums
secured by a lien which has priority over this Security Instrument; (b) appearing ht court; and(c) paying reasonable
attorneys' fees to protect its interest in the Property and/or rights under this Security Instrument, including its secured
position in a bankruptcy proceeding. Securing the Property includes, but is not limited to, entering tile Property to
make repairs, change Jocks, replace or board up doors and windows, drain waler from pipes, eliminate building or
other code violations or dangerous conditions, and have ulilities turned on or off. Although Lender may take action
under this Section 9, Lender does not have to do so and is not under any duty or obligation to do so. It is agreed that
Lender incurs no liabHity for not taking any or all actions authorized undei this Section 9.
Any amounts disbursed by Lender under this Section 9 shall become additional debt of Borrower secured by this
Security Instrument. These amounts shall bear interest at the Note rate from the date of disbursement and shall be
payable, with such interest, upon notice from Lender to Borrower requesting payment.
If this Security Instrument is on a leasehold, Borrower shall comply with all the provisions of the lease.
Borrower shall not surrender the leasehold estate and interests herein conveyed or terminate or cancel the ground lease.
Borrower shall not, without the express written consent of Lender, alter or amend the ground lease. If Borrower
acquires fee title to the Property, the leasehold and the fee title shall not merge unless Lender agrees to the merger
in writing.
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10. Mortgage Insurance, If Le11der required Mortgage Insurance as a condition of making the Loan,
Borrnwer shall pay the premiums required to maintain the Mortgage Insurance in effect. If, for any reason, the
Mortgage Insurance coverage required by Lender ceases to be available from the mortgage insurer that previously
provided such insurance and Borrower was required to make separately designated payments toward the premiums
for Mortgage Insurance, Borrower shall pay the premiums required to obtain coverage substantially equivalent to the
Mortgage Insurance previously in effect, at a cost substantially equivalent to the cost to Borrower of the Mortgage
Insurance previously in effect, from an alternate mortgage insurer selected by Lender. If substantially equivalent
Morlgage Insurance coverage is not available, Borrower shall continue lo pay to Lender lhe .amount of the separately
designated payments that were due when the insurance coverage ceased to bein effect. Lender will accept, use and
retain these payments as a non-refimdable loss reserve, if permitted under Applicable Law, in lieu of Mortgage
rnsurance. Such loss reserve shall be non-refundable, notwithstanding the fact that the Loan is ultimately paid in full,
and Lender shall not be required to pay Borrower any interest or earnings on such loss reserve, if permitted under
Applicable Law. Lender can no longer require loss reserve payments if Mortgage Insurance coverage (in the amount
and for the period that Lender requires) provided by an insurer selected by Lender again becomes available, is
obtained, and Lender requires separately designated payments toward the premiums for Mortgage Insurance, If
Lender required Mortgage Insurance as a condition of making the Loan and Borrower was required to make separately
designated payments toward the premiums for Mortgage Insurance, Borrower shall pay the premiums required to
maintain Mortgage Insurance in effect, if permitted under Applicable Law, or to provide a non-refundable loss
reserve, until Lender's requirement for Mortgage Insurance ends in accordance with any written agreement between
Borrower and Lender providing for such termination or until termination is required by Applicable Law. Nothing
in this Section 10 affects Borrower's obligation to pay interest at the rate provided in the Note.
Mortgage Insurance reimburses Lender (or any entity that purchases the Note) for certain losses it may incur
if Borrower does not repay the Loan as agreed. Borrower is not a party to the Mortgage Insurance.
Mortgage insurers evaluate their total risk on all such insurance in force from time to time, and may enter into
agreements with other parties that share or modify their risk, or reduce losses. These agreements are on terms and
conditions that are satisfactory to the mortgage insurer and the other party (or parties) to these agreements. TI1ese
agreements may require the mortgage insurer to make payments using any source of funds that the mortgage insurer
may have available (which may include funds obtained from Mortgage Insurance premiums).
As a result of these agreements, Lender, any purchaser of the Note, another insurer, any reinsurer, any other
entity, or any affiliate of any of the foregoing, may receive ( directly or indirectly) amounts that derive from ( or might
be characterized as) a portion of Borrower's payments for Mortgage Insurance, in exchange for sharing or modifying
the mortgage insurer's risk, or reducing losses. If such agreement provides that an affiliate of Lender takes a share
of the insurer's risk in exchange for a share of the premiums paid to the insurer, the arrangement is often termed
"captive reinsurance." Further:
(a) Any such agreements will not affect the amounts that Borrower hos agreed to pay for Mortgage
Insurance, or auy other terms of the Loan. Such agrceme11ts wUI not increase tl,e amount Borrower will owe
for Mortgage Insurance, and they will not entitle Bonower to any refund.
(b) Any such agreements will not affect the rights Borrower hns -if any• with respect to the Mo1·tgage
Insurance under the Homeowners Protection Act of 1998 or any other law. These rights may include the right
to receive certain disclosures, to request and obta[n cancellation of th<l Mortgage Iusurance, to have the
Mo1·tgage Insurance terminated automatically, and/or to receiYe a refund of any Mortgage Insurance premiums
that were unearned at the time of such eauceDation or termination.
11. Assignment of Miscellaneous Proceeds; Forfeiture. All Miscellaneous Proceeds are hereby assigned to
and shall be paid to Lender.
If the Property is damaged, such Miscellaneous Proceeds shall be applied to restoration or repair of the Property,
if the restoration or repair is economically feasible and Lender's security is not lessened. During such repair and
restoration period, Lender shall have the right to hold such Miscellaneous Proceeds until Lender has had an
opportunity to inspect such Property to ensure the work has bee11 completed to Lender' s satisfaction, provided that
such inspection shall be undertaken promptly. Lender may pay for the 1·epairs and restoration in a single disbursement
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or in a series of progress payments as the work is completed. Unless an agreement is made in writing or Applicable
Law requires interest to be paid on such Miscellaneous Proceeds, Lender shall not be required lo pay Borrower any
interest or earnings on such Miscellaneous Proceeds. If the restoration or repair is not economically feasible or
Lender's security would be lessened, the Miscellaneous Proceeds shall be applied to the sums secured by this Security
Instrument, whether or not then due, with the excess, if any, paid to Borrower. Such Miscellaneous Proceeds shall
be applied in the order provided for in Section 2.
In the event of a total taking, destruction, or Joss in value of the Property, the Miscellaneous Proceeds shall be
applied to the sums secured by this Security Instrument, whether or not then due, with the excess, if any, paid to
Borrower.
In the event of a partial taking, destruction, or loss in value of the Property in which the fair market value of
the Property immediate!)• before the partial taking, destruction, or loss in value is equal to or greater than the amount
of the sums secured by this Security Instrument immediately before the partial taking, destruction, or loss in value,
unless Borrower and Lender otherwise agree in writing, the sums secured by this Security Instrument shall be reduced
by the amount of the Miscellaneous Proceeds multiplied by the following fraction: (a) the total amount of the sums
seeured immediately before the partial taking, destruction, or loss in value divided by (b) the fair market value of the
Property immediately before the partial taking, destruction, or loss in value. Any balance shall be paid to Borrower.
In the event of a partial taking, destruction, or loss in value of the Property in which the fair market value of
the Property immediately before the partial taking, destruction, or loss in value is less than the amount of the sums
secured immediately before the partial taking, destruction, or loss in value, unless Borrower and Lender otherwise
agree in writing, the Miscellaneous Proceeds shall be applied to the sums secured by this Security h1stnunent whether
or not the sums are then due.
If the Property is abandoned by Borrower, or ff, after notice by Lender to Borrower that the Opposing Party (as
defined in the next sentence) offers to make an award lo settle a claim for damages, Borrower fails lo respond to
Lender witliin 30 days after the date the notice is given, Lender is authorized to collect and apply the Miscellaneous
Proceeds either to restoration or repair of the Property or to the sums secured by lhis Security Instrument, whether
or not then due. "Opposing Party" means the third party that owes Borrower Miscellaneous Proceeds or the party
against whom Borrower has a right of action in regard to Miscellaneous Proceeds.
Borrower shall be in default if any action or proceeding, whether civil or criminal, is begun that, in Lender's
judgment, could result in forfeiture of the Properly or other material impairment of Lender's interest in the Properly
or rights under this Security Instrument. Borrowtt can cure such R default and, ifRcceleration has occurred, reinstate
as provided in Section 19, by causing rhe action or proceeding to be dismissed with a ruling that, in Lender's
judgment, precludes forfeiture of the Property or othe1· material impairment of Lender's interest in lhe Property or
rights under this Security Instrument. The proceoos of any award or claim for damages I hat are attributable to the
impairment of Lender's intere8t in the Property are hereby assigned and shall be paid to Lender.
All Miscellaneous Proceeds that are not applied to restoration or repair of the Property shall be applied in the
order provided for in Section 2.
12. Borrower Not Released; Forbearance By Lender Not II Waiver, Extension of the time for payment or
modification of amortization of lhe sums secured by this Security Instrument granted by Lender to Borrower or any
Successor in Interest of Borrower shall not operate to 1·elease the liability of Borrower or any Successors in Interest
of Borrower. Lender shall not be required to commence proceedings against any Successor in Interest of Bonower
or to refuse to extend time for payment or otherwise modify amortization of the sums secured by this Security
Instrument by reason of any demand made by the original Borrower or any Successors in Interest of Borrower. Any
forbearance by Lender in exercising any right or remedy including, without limitation, Lender's acceptance of
payments from third persons, entities 01· Successors in Interest of Borrower or in amounts less than the amount then
due, shall not be a waiver of or preclude the exercise of any right or remedy.
13. Joint amlSeveral Liability; Co-signers; Successors and Assigns Bound. Borrowercovenant.sandagrees
that Borrower's obligations and liability shall be joint and several. However, any Borrower who co-signs this Secmity
Instrument but does not execute the Note (a "co-signer"): (a) is co-signing this Security Instrument only to mortgage,
grant and convey the co-signer's interest in the Property under the terms of this Security Instrument; (b) is not
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persm1ally obligated to pay the sums secured by this Security Inslrnment; and (c) agrees thai Lender and any other
Bon·ower can agree to extend, modify, forbear or make any accommodations with regard to the terms of this Security
Instrument or the Note without the co-signer's consent.
Subject to the provisions of Section 18, any Successor in Interest of Borrower who assumes Borrower's
obligations under this Secmity Instrument in writing, and is approved by Lender, shall obtain al1 of Borrower's rights
and benefits under this Security Instrument. Borrower shall not be released from Borrower's obligations and liability
under this Security Instrument unless Lender agrees lo such release in writing. The covenants and agreements of this
Security Instrument shall bind (except as provided in Section 20) and benefit the successors and assigns of Lender.
14. Loan Charges. Lendei· may chal'ge Borrower fees for services performed in connection with Borrower's
default, for the purpose of protecting Lender's interest in the Property and rights under this Security Instrument,
. including, but not limited to, attorneys' fees, property inspection and valuation fees. In regard to any other fees, the
absence of express authority in this Security Instrument to charge a specific fee to Borrower shall not be construed
as a prohibition on the charging of such fee. Lender may not charge fees that are expressly prohibited by this Security
Instrument or by Applicable Law.
If the Loan is subject to a law which sets maximum loan charges, and that law is finally interpreted so that !he
interest or other loan charges collected or to be collected in connection with the Lonn exceed the permitted limits,
then: (a) any such loan charge shall be reduced by the amount necessary to reduce the charge to the permitted limit;
and (b} any sums already collected from Borrower which exceeded permitted limits will be refunded to Borrower.
Lender may choose to make this refund by reducing the principal owed under the Note or by making a direct payment
to Borrower. If a refund reduces principal, the reduction will be treated as a partial prepayment wilhout any
prepayment charge (whether or not a prepayment charge is provided for under the Note). Borrower's acceptance of
any such refund made by direct payment to Borrower will constitute a waiver of any right of action Borrowe1· might
have arising out of such overcharge.
15, Notices. All notices given by Borrower or Lender in connection with this Security Instrument must be
in writing. Any notice to Borrower in connection with this Security Instrument shall be deemed to have been given
to Borrower when mailed by first class mail or when actually delivered to Borrower's notice address if sent by other
means. Notice to any one Borrower shall constitute notice to all Bouowers unless Applicable Law expressly requires
otherwise. The notice address shall be the Property Address unless Borrower has designated a substitute notke
address by notice to Lender. Borrower shall promptly notify Lender of Borrower's change of address. If Lender
specifies a procedure for reporting Borrower's change of address, then Borrower shall only report a change of address
through that specified procedure. There may be only one designated notice address under !his Security Instrument
at any one time. Any notice to Lender shall be given by delivering it or by mailing it by first class mail to Lender's
address stated herein unless Lender has designated another address by notice to Borrower. Any notice in connection
with this Se<:urity Instrument shall not be deemed to have been given to Lender until actually received by Lender.
If any notice required by this Security Instrument is also reqnired under Applicable Law, the Applicable Law
requirement will satisfy the corresponding requirement under this Security Instrument.
16. Governing Law; Seve1·abllity; Rules of Constmction. This Security Instrument shall be governed by
federal law and the law of the jurisdiction in which the Properly is located. All rights and obligations contained in
this Security Instrument are subject to any requirements and limitations of Applicable Law. Applicable Law might
explicitly or implicitly allow the parties to agree by contract or it might be silent, but such silence shall not be
construed as a prol1ibition against agreement by contract. In the event that any provision or clause of this Security
Instrument or the Note conflicts with Applicable Law. such conflict shall not affect other provisions of this Security
Instrument or the Note which can be given effect without the conflicting provision.
As used in this Security Instrument: (a) wol'ds of the rnasculine gender shall mean and include corresponding
neuter words or words of the feminine gender; (b) words in the singular shall mean and include the plural and vice
versa~ and (c) the word "may" gives sole discretion without any obligation to take any action.
17. Borro"·er's Copy. Borrower shall be given one copy of the Note and of this Security Instrument.
18. Transfer of the Property or a Beneficial Interest In Borrower. As used in this Section 18, "Interest in
the Property" means any legal or beneficial interest in the Property, including, but not limited to, those beneficial
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interests t1·ansferred in a bond for deed, contract for deed, installment sales contract or escrow agreement, the intent
of which is lhe transfer of title by Borrower at a future date to a purchaser.
If all or any part of tile Property or any Interest in the Property is sold or transferred (or if Borrower is not a
natural person and a beneficial interest in Borrower is sold or transferred) without Lender's prior written consent,
Lender may require immediate payment in full of all sums secured by this Security Instrument. However, this option
shall not be exercised by Lender if such exercise is prohibited by Applicable Law.
If Lender exercises this option, Lender shall give Borrower notice of acceleration. The notice shall provide a
period of not less than 30 days from the date the notice is given in accordance with Section 15 within which Borrower
must pay all sums secured by this Security Instl'Ument. If Borrower fails to pay these sums prior fo the expiration of
this period, Lender may invoke any remedies permitled by this Security Instrument without further notice or demand
on Borrower.
19. Borrower's Right to Reinstate After Accelemtion. If Borrower meets certain conditions, Borrower shall
have the right to have enforcement of this Security Instrument discontinued at any time prior to the earliest of: (a)
five days before sale of the Property pursuant to any power of sale contained in this Security Instrument; (b) such
other period as Applicable Law might specify for the termination of Borrower's right to reinstate; or (c) entry ofa
judgment enforcing this Security Instrument. Those conditions are that Borrower: (a) pays Lender all sums which
then would be due under this Security Instrument and the Note as if no acceleration had occurred; (b) cures any default
of any other covenants or agreements; ( c) pays all expenses incunc<i in enforcing this Security Instrument, including,
but not limited to, reasonable attorneys' fees, property inspection and valuation fees, and other fees incurred for the
purpose of protecting Lender's interest in the Property and rights under this Security Instrument; and {d) takes such
action as Lender may reasonably require to assure that Lender's interest in the Property and righls under this Security
hlstrumenl, and Borrower's obligation to pay the sums secured by this Security Instrument, shall continue unchanged.
Lender may require that Borrower pay such reinstatement sums and expenses in one or more of the following forms,
as selected by Lender: (a) cash; (b) money order; (c) certified check, bank check, treasurer's check or cashier's check,
provided any such check is drawn upon an institution whose deposits are insured by a fedei-al agency, instrumentality
or entity; or (d) Electronic Funds Transfer. Upon reinstatement by Borrower, this Security Instrument and obligations
secured hereby shall remain fully effective as if no acceleralion had occurred. However, this right to reinstate shall
not apply in the case of acceleration under Section I 8.
20. Sale of Note; Change of Loan Servicer; Notice of Grie,•ance. The Note or a partial interest in the Note
(together with tliis Security Instnunent) can be sold one or more times witl1out prior notice to Borrower, A sale might
result in a change in the entity (Imown as the "Loan Servicer") that collects Periodic Payments due under the Note
and this Security Instrument and performs other mortgage loan servicing obligations under the Note, this Security
Instrutnent, and Applicable Law. TI1ere also might be one or more changes of the Loan Servicer unrelated to a sale
of the Note. If there is a change of the Loan Servicer, Borrower will be given written notice of the change which will
state the name and address of the new Loan Servicer, the address to which payments should be made and any other
information RESP A requires in connection with a notice of transfer of servicing. If the Note is sold and thereafter
the Loan is servked by a Loan Servicer other than the purchaser of the Note, the mortgage loan servicing obligations
to Borrower will remain with the Loan Servicer or be lransferred lo a successor Loan Servicel' and arenot assumed
by the Note purchaser unless otherwise provided by the Note purchaser.
Neither Borrower nor Lender may commence, join, or be joined to any judicial action (as either an individual
litigant or the member of a class) that arises from the other party! s actions pursuant to this Security Instrument or that
alleges that the other party has breached any provision of, or any duty owed by reason of, this Security Instrnment,
until such Borrower or Lender has notified the other party (with such notice given in compliance with the requirements
of Section 15) of such alleged breach and afforded the other party hereto a reasonable period after lhe giving of such
notice to take corrective action. If Applicable Law provides a time period which must elapse before certain action
can be taken, that time period will be deemed to be reasonable for purposes of this paragraph. The notice of
acceleration and opportunity to cure given to Bonower pursuant to Section 22 and the notice of acceleration given
to Borrower pursuant to Section 18 shall be deemed to satisfy the notice and opportunity to take corrective action
provisions of this Section 20.
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21. Hazardous Substances. A'> used in this Section 21: (a) "Hazardous Substances" are those substances
defined as toxic or hazardous substances, pollutants, or wastes by Environmental Law and the following substances:
gasoline, kerosene, other flammable or toxic petroleum products, toxic pesticides and herbicides, volatile solvents,
materials containing asbestos or formaldehyde, and radioactive materials; (b) "Environmental Law11 means federal
laws and laws of the jurisdiction where the Prnperty is localed that relate to health, safety or environmental protection~
(c) "Environmental Cleanup" includes any response action, remedial action, or removal action, as defined in
Environmental Law; and (d) an "Environmental Condition" means a condition that -can cause, contribute to, or
otherwise trigger an Environmental Cleanup.
Borrower shall not cause or permit the presence, use, disposal, storage, or I el ease of any Hazardous Substances,
or threaten to release any Hazardous Substances, on or in the Property. Borrower shall not do, nor allow anyone else
to do, anything affecting the Property (a) that is in violation of any Environmental Law, (b) which creates an
Environmental Condition, or (c) which, due to the presence, use, or release of a Hazardous Substance, creates a
condition that adversely affects the value of the Property. The preceding two sentences shall not apply to the
presence, use, or storage on the Property of small quantities of Hazardous Substances that are generally recognized
to be appropriate to normal residential uses and to maintenance of the Properly (including, but not limited to,
hazardous substances in consumer products).
Borrower shall promptly give Lender written notice of (a) any investigation, claim, demand, lawsuit or other
action by any governmental or regulatory agency or private party invol viug the Property and any Hazardous Substance
or Environmental Law of which Borrower has actual knowledge, (b) any Environmenml Condition, including but not
limited to, any spil1ing, leaking, discharge, release or threat of release of any Hazardous Substance, and (c) any
condition caused by the presence, use or release of a Hazardous Substance which adversely affects the value of the
Property. If Borrower learns, or is notified by any governmental or regulatory authority, or any private party, that
any removal or other remediation of any Hazardous Substance affecting the Property is necessary, Borrower shall
promptly take all necessary remedial actions in accordance with Environmental Law. Nothing herein shall create any
obligation on Lender for an Environmental Cleanup.
NON-UNIFORM COVENANTS. Borrower and Lender further covenant and agree as follows:
22. Acceleration; Remedies. Lender shRII give notice to Borrowet· 1>rlor to Rcceteration fo1lowing
Borrower's breach of any cov,mant or agi·eemeut in this Secudty Iustrnment (but not prior to acceleration 1111der
Section 18 unless Applicable Law provides otherwise), The notice shall specify: (a) the default; (b) the action
required to cure the default; (c) a date, not less than 30 dRys from the date the notice is given to Borrower, by
which the default must be cured; 1md (d) that failure to cure the default on or before the date specified in tlle
notice may result in acceleration of the sums secured by this Security Instniment and sale of the Property, The
notice shall further Inform Borrower of the right to reinstate 11fter 11cceleration and the l'ight to assert ha tJ1e
foreclosm·c p1·oceedl11g the non-existence of a default or any other defense of Borrower to acceleration and sale.
If the default Is not cured on 01· bcfo1·e the date :specified in tl1e notice, Lender at its option may require
immediate payment in full of all sums secured by this Security Instrument without further demand and may
invoke the power of sale and any other remedies permitted by Applicable Law. Lender shall be entitled to
collect all expenses incuned ht pursuing the remedies provided in this Section 22, Including, but not limited to,
rcallonable 11ttorneys' fees and costs of title evidence.
If Lender invokes the powe1· of sale, and if it is determined ha a hcarJug held In accordance ,Yith Appllcable .
LalV that Trustee can proceed to sale, Trustee shall take such action l'Cgarding notice of sale and sh1dl give sueb
notices to Borrower and to othe1· persons as Applicable Law may require, After the time requlre<l by Applicable
Law and after pnbllcadon of the notice of sale, Trustee, without demand on Bon·ower, slrnll sell the Property
at public auction to the highest bidder 11t the time and pl11cc and under the terms dfsignated In the notice of sale
in one or more parcels and in any order Trustee determines. Lender 01· its designee may purchase the Property
at any sale.
Trustee sl,all deliver to tile purchaser Trustee's deed conveying tlte Property without any covenant or
warranty, expressed or implied, The recitals in tile Trustee's deed shall be prima facie evidence of the trnth
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of the statements made therein. Trustee shall apply the proceeds of the sale In the following order; (a) to all
expenses of the sale, including, but not limited to, Trustee's fees of 5 . 000 % of the gross sale price;
(b) to all eurts secured by this Security Instrument; and (e) any excess to the person or persons legally entitled
to It. The interest rate set forth in the Note shall apply whether before or after any judgment on the
indebtedness evidenced by the Note.
23. Release. Upon payment of all sums secured by this Security hnstrument, Lender or Trustee shalt cancel
this Security Instrument. If Trustee is requested to release this Security Instrument, all notes evidencing debt secured
by this Security Instrument shall be surrendered to Trustee. Borrower shall pay any recordation costs. Lender may
Charge Borrower a fee for releasing this Security Instrument, but only if the fee is paid to a third party for services
rendered and the charging of the fee is permitted under Applicable Law.
24. Substitute Trustee. Lender may fVom time to time remove Trustee and appoint a successor trustee to any
Trustee appointed hereunder by an instrument recorded in the county in which this Security instrument is recorded.
Without conveyance of the Property, the successor trustee shall succeed to all the title, power and duties conferred
upon Trustee herein and by Applicable Law.
25. Attorneys' Fees. Attorneys' fees must be reasonable.
BY SIGNING UNDER SEAL BELOW, Borrower accepts and agrees to the terms and covenants contained in
this Security Instrument and in any Rider executed by Borrower and recorded with it,
David Gre
Witness
(Seal)
-Rnrrower
L,2 /
� \. (seal)
Cynthia Cassell Smith -Borrower
Witnes&
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BK 4693 PG 2582 ❑OC# 20054197
NORTH CAROLINA
[Space Below This tine For Acknowledgment]
Fender County.
kolot-a-
G. (kINS
foam ofnolariring official and his official line)
du hereby certify thin
David Grey_ Smith AND Cynthia Cassell Smith
Mere give Me name of the indisidual whose acknowledgment is txing taken)
personally appeared before me this day and acknowledged the due execution of the foregoing instrument
(or attached document
(deaeripifon ofdoaiment)
Witness my hand and (where an official seal is required by law) official seal this the
day Of SEPTEMt3ER 2 019 (month/year),
emo nurn:ronnevr,U
se OWNS
'� ' `4
0 0 t
\%/HANG
rll �HmH0fi
(Official Seal)
(Official Signature of Notary)
1atli
964—,Notary Public
(Notary's printed or typed name)
My commission expires:
Loan Originator! Adam Slack, NMLSR ID 203603
Loan Originator Organization: Guaranteed Rate, Inc, NMLSR ID 2611
2.0
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BK4693 PG 2583 DOC# 20054197
Loan Number: 192625394
Date: SEPTEMBER 18, 2019
Property Address: 710 BROWN PELICAN LN
HAMPSTEAD, NORTH CAROLINA 28443
EXHIBIT "A"
LEGAL DESCRIPTION
A.P.N. # 4202-59-2165-0000 & 4202-59-3095-0000
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BK4693 PG 2584 DOC# 2005419Z
,•
Exhibit "A"
Tract One:
Being all of Lot 38R, as shown on map entitled "Recombination Plat for
Olde Point Section 6" recorded in Map Book 58, Page 97, Pender
County Registry.
Subject to the Decf arati~ri of Restrictions recorded in Book 722 at Page
100 of the Pender County Registry; Subject, AJso, to the Articles of
Association of Section 6, Homeowners Association as recorded in Book
722 at Page 101 of said Registry.
Tract Two:.
Being all of Lots 52 and 53 Revised as shown on the map entitled
"Resurvey, Combination, and R~divisfon of a Portion of Sidbury Acres"
recorded in M~p Book 24 at Page 3~ of the Pender County Registry,
reference to which is hereby made for a more particular description.
BK4693 PG 2585 DOC# 20054197
Loan Number: 192625394
710 BROWN PELICAN LN
APN: 4202-59-2165-0000 &
4202-59-3095-0000
PLANNED UNIT DEVELOPMENT RIDER
THIS PLANNED UNIT DEVELOPMENT RIDER is made this 18th day of
SEPTEMBER, 2019 , and is incorporated into and shall be deemed to amend and
supplement the Mortgage, Deed of Trust, or Security Deed (lhe "Security Instrument") of the same date,
given by the undersigned (lhe "Borrower") to secure Borrower's Note to GUARANTEED RATE,
INC., A DELAWARE CORPORATION
(the "Lender") of the same date and covering the Property described in the Security Instrument and localed at:
710 BROWN PELICAN LN, HAMPSTEADj NORTH CAROLINA 28443
LPropaly Addr~s
The Property includes, but is not limited to, a parcel of land improved with a dwelling, together with other
such parcels and certain common areas and facilities, as described in
COVENANTS, CONDITIONS AND RESTRICTIONS OF RECORD
(the "Declaration"). l11e Property is a part of a planned unit development known as
Olde Point
IN a me of Planned Unit De,•elopmcntl
(the "PUD"). The Property also includes Borrower's interest in the homeowners association or equivalent
entity owning or managing the common areas and facilities of the PUD (the "Owners Association 1') and the
uses, benefits and proceeds of Borrower's interest.
PUD COVENANTS. In addition to the covenants and agreements made in the Security Instrument,
Borrower and Lender further covenant and agree as follows:
A. PU D Obllgatlons. Borrower shall perform all of Borrower's obligations under the PUD' s
Constituent Documents. The "Constituent Documents" are the (i) Declaration; (ii) articles of incorporation,
trust instrument or any equivalent document which creates the Owners Association; and (iii) any by-laws or
other rules or regulations of the Owners Association. Borrower shall promptly pay, when rlue, all dues and
assessments imposed pursuant to the Constituent Documents.
B. Property Insurance. So long as the Owners Association maintains, with a generally accepted
insurance carrier, a "master" or "blanket" policy insuring the Property which is satisfactory to Lender and
MULTISTATE PUO RIDER-Slngle Family
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BK4693 PG 2586 DOC# 20054197
which provides insurance coverage in the amounts (including deductible levels), for the periods, and against
loss by fire, hazards included within the terin "extended coverage," and any other hazards, including, but
not limited to, earthquakes and floods, for which Lender requires insurance, then: (i) Lender waives the
provision in Section 3 for the Periodic Payment to Lender of the yearly premium installments for property
insurance on lhe Property; and (ii) Borrower's obligation under Section 5 to maintain property insurance
coverage on the Property is deemed satisfied to the extent that the required coverage is provided by the
Owners Association policy.
What Lender requires as a condition of this waiver can change during the term of the loan .
Bol'rower shall give Lender prompt notice of any lapse in required property insurance coverage provided
by the master or blanket policy.
In the event of a distnbution of property insurance proceeds in lieu of restoration or repair following
a Joss to the Property, or to common areas and facilities of the PUD, any proceeds payable to Borrower are
hereby assigned and shall be paid to Lender. Lender shall apply the proceeds to the sums secured by the
Security Instrument, whether or not then due, with the excess, if any, paid to Borrower.
C. Publlc Uablllty Insurance. Borrower shall take such actions as may be reasonable to insure
that the Owners Association maintains a public liability immrance policy acceptable in form, amount, and
extent of coverage to Lender.
D. Condemnation. 1lie proceeds of any award or claim for damages, direct or consequential,
payable to Borrower in connection with any condemnation or other taking of all or any part of the Property
or the common areas and facilities of the PUD, or for any conveyance in lieu of condemnation, are hereby
assigned and shall be paid to Lender. Such proceeds shall be applied by Lender to the sums secured by the
Security Instrument as provided in Section 11.
E. Lender's Prior Consent. Borrower shall not, except after notice to Lender and with Lender's
prior wrilten consent, either partition or subdivide the Property or consent to : (i} the abandonment or
termination ofthePUD, except for abandonment or termination required by law in the case of substantial
destruction by fire or other casualty or in the case of a taking by condemnation or eminent domain; (ii) any
amendment to any provision of the "Constituent Documents" if the provision is for the express benefit of
Lender; (iii) termination of professional management and assumption of self-management of the Owners
Association; or (iv) any action which would have the effect of rendering the public liability insurance
coverage maintained by the Owners Association unacceptable to Lender.
F. Remedies. If Borrower does not pay PUD dues and assessments when due, then Lender may pay
them. Any amounts disbursed by Lender under this paragraph F shall become additional debt of Borrower
secured by the Security Instrument. Unless Borrower and Lender agree to other terms of payment, these
amounts shall bear interest from the date of disbursement at the Note rate and shall be payable, with interest,
upon notice from Lender to Borrower requesting payment.
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6K 4693 PG 2587 DOC# 20054197
BY SIGNING BELOW, Borrower accepts and agrees to the terms and covenants contained in this PUD
Rider.
e
seen
David Gr [Seal}
in th �Uorniwcr Oat . a Cassell Smith -mower
MULTISTATE PUD R112E13 - Single Family
Fannie Mae/Fsedd Mac UNIFORM INSTRUMENT
Fonn 3160 1101 Page 3 of 3
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ROY COOPER
MICHAELS. REGAN
Seaetary
S. DANIEL SMITH NORTH CAROLINA
Environmental Quality Director
October 29, 2020
David & Cynthia Smith
710 Brown Pelican Ln.
Hampstead, NC 28443
RE: Acknowledgement of Application No. WI0800435
Geothermal Heating/Cooling Water Return Well
Pender County
Dear Mr. & Mrs. Smith:
The Water Quality Regional Operations Section (WQROS) acknowledges receipt
of your permit application and supporting documentation received on October 29, 2020.
Your application package has been assigned the number listed above, and the primary
reviewer is Shristi Shrestha
Central and Wilmington 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 Water Quality Regional
Operations Section (WQROS) 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 ofa complete application. If you have any questions, please
contact Shristi Shrestha at 919-707-3662 or email at [e-mail].
cc: Wilmington Regional Office, WQROS
Permit File WI0800435
Sincerely,
For Rick Bolich, Chief
Ground Water Resources Section,
NCDEQ Division of Water Resources
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street I 1636 Mail Service Center I Raleigh, North Carolina 27699-1636
919.707.9000
Permit Number W10800435
Program Category
Ground Water
Permit Type
Injection Heating/Cooling Water Return Well
Primary Reviewer
michael.rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
Estate of George Spayd SFR
Location Address
710 Brown Pelican Ln
Hampstead
Owner
Owner Name
Estate of George Spayd
Dates/Events
NC
Orig Issue App Received
10/7/2015
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
28443
Draft Initiated
Scheduled
Issuance
Central Files: APS SWP
11/19/2015
Permit Tracking Slip
Status
In review
Version
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Wilmington
County
Pender
Facility Contact Affiliation
Public Notice
Owner Type
Non-Government
Owner Affiliation
Jennifer Lemieux
115 Branch Rd
Spruce Pine
Issue
Requested /Received Events
RO staff report requested
RO staff report received
Additional information requested
Additional information received
Streamlndex Number Current Class
Effective
NC 28777
Expiration
10/14/15
11/12/15
11/19/15
11/19/15
Subbasin
Artia
NCDENR
North Carolina Department of Environmental Quality
Pat McCrory
Governor
November 20, 2015
Estate of George Spayd
c/o Jennifer Lemieux
115 Branch Road
Spruce Pine, NC 28777
Re: Issuance of Injection Well Permit
Permit No. WI0800435
Geothermal Heating/Cooling Water Return Well
Pender County
Dear Ms. Lemieux:
Donald R. van der Vaart
Secretary
In accordance with your permit application received October 7, 2015, and additional information
received November 19, 2015, I am forwarding Permit No. WI0800435 for the construction and
operation of geothermal heating/cooling water return well(s) located at 710 Brown Pelican Lane,
Hampstead, Fender County, NC 28443_ This permit shall be effective from date of issuance until
October 30, 2020, and shall be subject to the conditions and limitations stated therein.
Please Note:
• Per Permit Condition Part II.7, a copy of the Well Construction Form(s) (GW-1),
which is completed and signed by the well contractor, must be submitted to this
office and the Wilmington Regional Office within 30 days of completion of the
well(s). Copies of the GW-1 shall be retained on -site and available for inspection.
• Per Permit Condition Part 111.2, within 30 days of injection well completion and
operation, Permittee must contact the Wilmington Regional Office APS Staff (910-
796-721 5) to have influent and effluent samples collected.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days prior to its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Resources_ If you have any questions regarding your permit or the Underground
Injection Control Program please call me at [phone].
1636 Mail Service Cente;, Raleigh, North Carolina 27699-1636
Phone. 919-H67-64641 Internet httpilwww.ncvater.org
An Equal Oppodunily V Affirmative Action Empfayar —Made in part by recycled paver

Estate of George Spayd
Best Regards, ,era, P.~C:::
Underground Injection Control Manager (UIC) -Hydrogeologist
Division of Water Resources, NCDENR
Water Quality Regional Operations Section
cc: Jim Gregson and Morella Sanchez-King, Wilmington Regional Office
Central Office File, WI0800435
Pender County Environmental Health Department
Page 2 of2
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH, NORTH CAROLINA
PERMIT FOR THE USE OF A WELL FOR INJECTION
In ·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
Estate of George Spayd
FOR THE CONSTRUCTION OF 1 GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S),
defined in Title 15A North Carolina Administrative Code 02C .0224(a), which wiU be used for the injection of
heat pump effluent. The injection well(s) located at 710 Brown Pelican Lane, Hampstead. Pender County, NC
28443 will be constructed and operated in accordance with the application received October 7, 2015, and
conformity with the specifications and supporting data received November 19, 2015, all of which are filed with
the Department of Environmental Quality and are considered a part of this permit.
This permit is for construction of an injection well shall be in compliance with Title 15A North Carolina
Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well
construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until October 30, 2020, and shall be
subject to the specified conditions and limitations set forth in this permit.
Permit issued this the 20th day of November 2015.
S. Jay Zimmerman, P.G.
Director, Division of Water Resources
By Authority of the Environmental Management Commission.
Pennit #Wl0800435 UIC/5A7
ver. l l/15/2015
Pagel of5
PART I -PERMIT GENERAL CONDITIONS
1. The Permittee shall 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). 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 is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data [15A NCAC 02C .021 l(a)].
3. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data [15A NCAC 02C .0211 (I)].
4. This permit is not transferable without prior notice and approval. 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, including any supporting materials as may be appropriate, at least 30 days prior to the date of
the change [15A NCAC 02C .021 l(q)].
5. 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 [15A NCAC 02C .0203].
PART II -WELL CONSTRUCTION GENERAL CONDITIONS
1. The well supplying water for the geothermal heating and cooling system shall be constructed in accordance
with the requirements of rule 15A NCAC 02C .0107 except as required in Item #2 below.
2. Any injection well shall be constructed in accordance with the requirements of rule 15A NCAC 02C .0107
except that the entire length of the casing shall be grouted in such a way that there is no interconnection of
aquifers or zones having differences in water quality that would result in degradation of any aquifer or zone.
For screened wells, grout shall be emplaced from the top of the gravel pack to the land surface. For open-
end wells, the casing shall be grouted from the bottom of the casing to the land surface [15A NCAC 02C
.0224(d)(2),(3)].
3. Bentonite grout shall not be used to seal any water-bearing zone with a chloride concentration equal to or
greater than 1,500 milligrams per liter. In areas where elevated chloride levels are known to exist or are
probable, such as coastal areas, chloride levels shall be verified in the field to determine existing conditions.
[15A NCAC .0225(g)(8)].
4 . The injection well system shall be constructed such that a sampling tap or other collection equipment
approved by the Director provides a functional source of water when the system is operational. Such
equipment shall provide the means to collect a water sample immediately after emerging from the water
supply well and immediately prior to injection into the return well [15A NCAC 02C .0224(d)(4)].
5. Each well shall be secured to reasonably insure against unauthorized access and use and shall be sealed
with a watertight cap or well seal as defined in G.S. 87-85(16).
6. Each well shall have permanently affixed an identification plate [15A NCAC 02C .0107(j)(2)].
Permit #Wl0800435 UIC/5A7
ver. 11/15/2015
Page 2 of5
7. A completed Well Construction Record (Form GW-1) shall be submitted as described in Part VI.5 of this
permit.
PART III-WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing each injection well, the Permittee shall notify the
Underground Injection Control (UIC) Central Office staff, telephone number 919-807-6496 and the
Wilmington Regional Office Staff, telephone number 910-796-7215. [15A NCAC 02C .021 l(k)].
2. Within 30 days of injection well completion/operation, the Permittee shall contact the Wilmington Regional
Office Staff in order to have samples collected at the source well and injection well. [15A NCAC 02C
.02ll(k)]
PART IV -OPERATION AND USE CONDITIONS
1. The Permittee shall comply with the conditions of this permit and properly operate and maintain the
injection facility in compliance with the conditions of this permit and the rules of 15A NCAC 02C .0200,
even if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02C .021 l(i)J.
2. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface water
or groundwater resulting from the operation of this facility. 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 that may be required,
such as the repair, modification, or abandonment of the injection facility [15A NCAC02C .0206].
PART V -INSPECTIONS [15A NCAC 02C .021 l(k)]
1. Any duly authorized officer, employee, or representative of the Division ofWater Resources (DWR) niay,
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 pennit, may
inspect or copy any records that must be maintained under the terms and conditions of this permit, and may
obtain samples of groundwater, surface water, or injection fluids.
2. DWR 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 samples of the injection facility's activities.
PART VI -MONITORING AND REPORTING REQUIREMENTS
1. Records of well construction, repair, or abandonment shall be submitted within 30 days of completion of
such activities. Copies of such records shall be retained on-site and available for inspection [ISA NCAC
02C .0224(±)(2), (4)].
2. Monitoring of any well may be required to ensure protection of the groundwater resources of the State· and
compliance with the groundwater quality standards specified in 15A NCAC 02L [15A NCAC 02C
.0224(f)(l)].
Pem1it #WJ0800435 UlC/5A7
ver.11/15/2015
Page 3 of5
3. The Permittee shall report any monitoring or other information that indicates noncompliance with a specific
permit condition, that a contaminant may cause a violation of applicable groundwater quality standards, or
that a malfunction of the injection system may cause the injected fluids to migrate outside the approved
injection zone or area. As specified in rule 15A NCAC 02C .0211 (r), noncompliance notification shall be
as follows:
(A) Oral notification shall be given within 24 hours of the occurrence, or first knowledge of the
occurrence, to the Wilmington Regional Office, telephone number 910-796-7215.
(B) Written notification shall be made within five days of the occurrence and submitted to the addresses
in Item #5 below.
(C) The written notification shall contain a description of the noncompliance and its cause; the period of
noncompliance, including dates and times; if the noncompliance has not been corrected, the
anticipated time it is expected to continue; and any steps taken or planned to reduce, eliminate, and
prevent reoccurrence of the noncompliance.
4. The Permittee shall record the number and location of the wells with the register of deeds in the county in
which the facility is located. [ISA NCAC 02C .0224(f)(3)].
5. All forms, reports, or monitoring results required by this permit shall be submitted to:
UIC Program Staff
Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Water Quality Regional Operations Section
DWR Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
PART VII -PERMIT RENEWAL [15A NCAC 02C .0224( c )]
As required by rule an application for permit renewal shall be made at least 120 days prior to the expiration
date of the permit. This permit condition does not apply if the Permittee chooses to discontinue operation
of the well for injection of effluent from the geothermal heating and cooling system associated with this
permit.
Permit #Wl0800435 UIC/5A7
ver. l l/15/2 015
Page 4 of 5
PART VIII-CHANGE OF WELL STATUS [15ANCAC 02C .0240]
1. Procedures for temporarily or permanently abandoning a well are the same as those specified in rule 15A
NCAC 02C .0113. While some of those criteria are given below, the Permittee bears the responsibility of
complyirig with all applicable regulatory requirements.
2. If a well will no longer be used for any purpose, then it should be permanently abandoned according to rule
15A NCAC 02C .0113(b) in order to prevent the well from deteriorating and acting as a source or conduit
of contamination, which is prohibited by General Statute 87-88(c).
3. If a well _is taken completely out of service temporarily, the Permittee shall install a water-tight cap or well
seal that cannot be removed without the use of hand or power tools.
4. When injection operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall permanently abandon that injection well in accordance with the procedures specified in 15A
NCAC 02C .0l 13(b), which include, but are not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The 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 in accordance with rule 15A
NCAC 02C .011 l(b)(l)(A),(B), and (C).
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In those cases when a subsurface cavity has been created as a result of the injection
operations, each well shall be abandoned in such a manner that will prevent the movement
of fluids into or between underground sources of drinking water.
(F) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0224(f)( 4) within 30 days of completion of abandonment.
5. The written documentation required in Part VIII (4)(F) shall be submitted to the addresses specified in
Part VI.5 above.
Pennit #Wl0800435 UIC/5A7
ver. l 1/15 /2015
Page 5 of 5
Division of Water Resources
Water Quality Regional Operations Section
REGIONAL STAFF REPORT
Date: 11/6/2015 Permittee(s): The Estate of George S pay d
Permit No.: WI0800435
To: Michael Ro gers County: New Hanover
Project Name: Geothermal O pen-Loo p Injection Well
Regional Login No: Geoff Ke gley
L GENERAL INFORMATION
I. This application is (check all that apply): 0 SFR Waste Irrigation System IX] UIC Well(s)
IX] New O Renewal
D Minor Modification D Major Modification
;~ECEIVED/DENR/DWR
NOV 1 2 2015
Water Quality Reg~onat
Operations Section
I .,~' J ·\//, e,
0 Surface Irrigation D Reuse D Recycle O High Rate Infiltration D Evaporation/Infiltration Lagoon
D Land Application of Residuals
D Distribution of Residuals
0 Attachment B included
□ Surface Disposal
0 503 regulated O 503 exempt
D Closed-loop Groundwater Remediation IX] Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? IX] Yes or D No.
a. Date of site visit: 11/6/2015
b. Person contacted and contact information: Jennifer Lemieux 828-776-2953
c. Site visit conducted by: Geoff Ke gle y
d. Inspection Report Attached: D Yes or IX] No.
2. Is the following information entered into the BIMS record for this application correct?
IX] Yes or D No. If no, please complete the following or indicate that it is correct on the current application.
For SFR Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: __ Method Used (GPS, Google™, etc.); __
e. Regulated Activities/ Type of Wastes (e.g., subdivision, food processing, municipal wastewater): __
For UIC Injection Sites:
(If multi ple sites either indicate which sites the information a pp lies to, co py and paste a new section into the
document for each site . or attach additional pa ges for each site )
a. Location(s): 710 Brown Pelican Lane, Hampstead, NC 28443
b. Driving Directions:
c. USGS Quadrangle Map name and number: __
d. Latitude: Longitude: Method Used (GPS, Google™, etc.); GPS
APS-GPU Regional Staff Report (Sept 09) Page I of 4 Pages
Division of Water Resources
Water Quality Regional Operations Section
REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description of Well(s) and Facilities -New, Renewal, and Modification
1. Type of injection system:
l2J Heating/cooling water return flow (SA 7)
D Closed-loop heat pump system (5QM/5QW)
D In situ remediation (51)
D Closed-loop groundwater remediation effluent injection (SL/"Non-Discharge")
D Other (Specify: )
2. Does system use same well for water source and injection? D Yes IZJ No
3. Are there any potential pollution sources that may affect injection? D Yes IZJ No
What is/are the pollution source(s)? Septic tank 50 ft away from source well . What is the distance of the
injection well(s) from the pollution source(s)? 50 ft.
4. Whatis the minimum distance of proposed injection wells from the property boundary? -40..ft
5. Quality of drainage at site: l2J Good D Adequate D Poor
6. Flooding potential of site: [8JLow D Moderate D High
7. For groundwater remediation systems; is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: __
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? l2J Yes or D No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Injection Well Permit Renewal and Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
D Yes D No. If yes, explain:
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes D No. If yes. explain:
3. For renewal or modification of 2:roundwater remediation permits {of any ty pe). will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? D Yes D No. If yes, explain:
APS-GPU Regional Staff Report (Sept 09) Page 2 of 4 Pages
Division of Water Resources
Water Quality Regional Operations Section
REGIONAL STAFF REPORT
4. Drilling Contractor: Name:
Address:
NC Certification number:
Complete and attach NEW Injection Facility Inspection Report, if applicable
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the Application:
This review was conducted for a new permit for an open loop underground injection
geothermal well heat pump system for the subject residence. On November 6, 2015,
staff visited the home to inspect the proposed well system location. Proposed injection
well site appears appropriate.
2. Attach new Injection Facility Inspection Form, if applicable
3. Do you foresee any problems with issuance/renewal of this permit? D Yes ~ No. If yes, please explain
briefly. __ .
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
APS-GPU Regional Staff Report (Sept 09) Page 3 of 4 Pages
Division of Water Resources
Water Quality Regional Operations Section
REGIONAL STAFF REPORT
7. Recommendation: D Hold, pending receipt and review of additional information by regional office; D Hold,
pending review of draft permit by regional office; 0 Issue upon receipt of needed additional information; 18]
Issue; D Deny. If deny, please state reasons: __
8. Signature of report Preparer(s): ,~ Yf?e5, ½-,; / # >
Signature of APS regional supervisor: ~
Date: U / 'l /:>Of '5°' //
VL ADDITIONAL INFORMATION AND SITE MAP (Sketch of site showing house and waste irrigation
s ystem, spra y or drip /ield1 location ofwell(s), and/or other relevant information-SHOW NORTH ARROW)
APS-GPU Regional Staff Report (Sept 09) Page 4 of 4 Pages
C`ri1 OIA " . , l'i+Liao �I
01 + i4�[h' 0::+.�lii
L J-ry i \
a. "R, ' �'
I.
r " a3 el r ••• • ! �7%#A i
-44-1 ‘.4*: 4 z . :,; .c-''. vii .
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r ,.
is_44114igi4 • If%4A7/11 tikt _ ', \
LEGEND:
0 Proposed Injection Well Location
•
Existing Well Location
Base map adapted from Fender County GIS website.
H,m ,,,C Geothermal
ARkl•Geathermalcpm MO270291'9
TITLE: Proposed Existing Geothermal and FIGURE:
Proposed Injection Well Locations
'JOB: SCALE: DATE: DRAWN BY:
Spayd 1 ° = 100' 9/25/15 EFC

Ro g ers, Michael
From: Rogers, Michael
Sent:
To:
Cc:
Friday, November 20, 2015 9:53 AM
'[e-mail]'; [e-mail]
King, Morella s; Kegley, Geoff
Subject:
Attachments:
FW: WI0800435 Estate of George Spayd Geothermal
20151120091627555.pdf
Please find attached the geothermal well permit for the above project.
-----Original Message-----
From: Michael Rogers [mailto:[e-mail]]
Sent: Friday, November 20, 2015 9:16 AM
To: Rogers, Michael <[e-mail]>
Subject:
This E-mail was sent from "RNPAC7DDO" (Aficio 2075).
Scan Date: 11.20.2015 09:16:27 (-0500)
Queries to: [e-mail]
1
`Rogers, Michael
From: Kegley, Geoff
Sent: Friday, November 20, 2015 8:40 AM
To: Jim Corvette; Rogers, Michael; [e-mail]
Cc: King, Morella s
Subject: RE: Wi0500435 Geothermal
Attachments: PB060002.JPG
It was 4 inch PVC casing. I could not find a well tag. Picture of well head attached.
-Geoff
Geoff Kegley
Hydrogeologist
Division of Water Resources
Department of Environmental Quality
[phone] Office
[phone] Fax
Geoff. Keg iey(aMcdenr. gov
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
IC�-"clothing Compares.--.,_
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may he disclosed to third parties.
From: Jim Cornette [ma ilto:[e-mail]
Sent: Thursday, November 19, 2015 3:28 PM
To: Rogers, Michael <[e-mail]>; lemieuxj!@yahoo.com
Cc: King, Morella s <[e-mail]>; Kegley, Geoff <[e-mail]>
Subject: RE: WI0800435 Geothermal
I do mean 4". It appeared to be galvanized steel, but I did not look closely_
Thanks.
Jim
James L. Cornette, PG, CWD
Applied Resource Management, PC

ARM -Well Drilling
ARM -Geothermal
P.O. Box 882
257 Transfer Station Road
Hampstead, NC 28443
910.270.2919 (Office)
910.512.4890 (Cell)
910.270.2988 (Fax)
From: Rogers, Michael [mailto:michael.roqers @ncdenr.g ov]
Sent: Thursday, November 19, 2015 1:49 PM
To: Jim Cornette; lemieuxj l taly ahoo.com
Cc: King, Morella s; Kegley, Geoff
Subject: RE: WI0800435 Geothermal
What's the material-PVC, etc., and I think you mean 4 inch correct?
From: Jim Cornette [mailto:jim arm @bellsouth.net]
Sent: Thursday, November 19, 2015 1:34 PM
To: Rogers, Michael <michael.ro gers @ncdenr.gov>; lemieux jl @y ahoo.com
Cc: King, Morella s <morella.sanchez-king@ ncdenr.gov>; Kegley, Geoff <[e-mail]>
Subject: RE: WI0800435 Geothermal
Michael,
No GW-1 is available. The well is old. It is a 4' well. Water quality indicates that the well is between 100' and 180' deep.
Jim
James L. Cornette, PG, CWD
Applied Resource Management, PC
ARM -Well Drilling
ARM -Geothermal
P.O. Box 882
257 Transfer Station Road
Hampstead, NC 28443
910.270.2919 (Office)
910.512.4890 (Cell)
910.270.2988 (Fax)
From: Rogers, Michael [mailto:michael.rogers @ncdenr.aov]
Sent: Thursday, November 19, 2015 12:33 PM
To: '[e-mail]'; lemieuxi1@v ahoo.com
Cc: King, Morella s; Kegley, Geoff
Subject: WI0800435 Geothermal
Jim-Do you have the GW-1 for the existing well for this site? If so, please email back as attachment. If no GW-1, please
provide well construction info including grout types/depths. Hit reply all when responding.
Thanks.
Michael Rogers, P.G. {NC & FL}
Underground Injection Control {UIC) Manager -Hydrogeologist
2
NCDEQ-DWR
"water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms
NOTE: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
3
Rogers, Michael
From:
Sent:
To:
Cc:
Jim Cornette <[e-mail]>
Thursday, November 19, 2015 3:28 PM
Rogers, Michael; [e-mail]
King, Morella s; Kegley, Geoff
Subject: RE: WI0800435 Geothermal
I do mean 4".
Thanks,
fVl-, ft
It appeared to be gal~~ ,steel, but I did not look closely .
Jim
James L. Cornette, PG, CWD
Applied Resource Management, PC
ARM -Well Drilling
ARM -Geothermal
P.O. Box 882
257 Transfer Station Road
Hampstead, NC 28443
910.270.2919 (Office)
910.512.4890 (Cell)
910.270.2988 (Fax)
From: Rogers, Michael [mailto:[e-mail]]
Sent: Thursday, November 19, 2015 1:49 PM
To: Jim Cornette; [e-mail]
Cc: King, Morella s; Kegley, Geoff
Subject: RE: WI0800435 Geothermal
What's the material-PVC, etc., and I think you mean 4 inch correct?
From: Jim Cornette [mailto:[e-mail]]
Sent: Thursday, November 19, 2015 1:34 PM
To: Rogers, Michael <[e-mail]>; [e-mail]
Cc: King, Morella s <[e-mail]>; Kegley, Geoff <[e-mail]>
Subject: RE: WI0800435 Geothermal
Michael,
No GW-1 is available. The well is old. It is a 4' well. Water quality indicates that the well is between 100' and 180' deep .
Jim
James L. Cornette, PG, CWD
Applied Resource Management, PC
ARM -Well Drilling
ARM -Geothermal
P.O. Box 882
257 Transfer Station Road
Hampstead, NC 28443
1
910.270.2919 (Office)
910.512.4890 (Cell)
910.270.2988 (Fax)
From: Rogers, Michael [mailto:michael.roqers @ncdenr.gov]
Sent: Thursday, November 19, 2015 12:33 PM
To: '[e-mail]'; [e-mail]
Cc: King, Morella s; Kegley, Geoff
Subject: WI0800435 Geothermal
Jim-Do you have the GW-1 for the existing well for this site? If so, please email back as attachment. If no GW-1, please
provide well construction info including grout types/depths. Hit reply all when responding.
Thanks.
Michael Rogers, P.G. (NC & FL)
Underground Injection Control (UIC) Manager -Hydrogeologist
NCDEQ-DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms
NOTE: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
2
Rogers, Michael
From: King, Morella s
Sent:
To:
Wednesday, October 28, 2015 2:30 PM
Rogers, Michael
Cc: Gregson, Jim
Subject: RE: WI0800435 Staff Report Request
Ok, I printed it and will attached it to the application I have here. Geoff will prepare the staff report.
Thanks!
Morella
Morella Sanchez King
NCDENR Division of Water Resources -Water Quality Regional Operations Section
Wilmington Regional Office: 127 Cardinal Drive Extension; Wilmington, NC 28405
[e-mail]; (P)910 796 7218 -(F) 910 350 2004
From: Rogers, Michael
Sent: Wednesday, October 28, 2015 2:28 PM
To: King, Morella s <[e-mail]>
Cc: Gregson, Jim <[e-mail]>
Subject: WI0800435 Staff Report Request
Here is the SRR I sent 10/5/15.
Michael Rogers, P.G. (NC & FL)
Hyd rogeo lo gist
NCDEQ-DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http:ljportal.ncdenr.org/web/wg/aps/gwpro/reporting-forms
NOTE: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
1
Ro gers, Michael
From: Rogers, Michael
Sent:
To:
Thursday, October 15, 2015 4 :26 PM
King , Morella s; Gregson, Jim
Subject:
Attachments:
FW: WI0800435 Spayd Geothermal
20151015154934941.pdf
Here is the staff report request for Spayd. Thanks.
-----Original Message-----
From: Michael Rogers [mailto:[e-mail]]
Sent: Thursday, October 15, 2015 3:50 PM
To: Rogers, Michael <[e-mail]>
Subject:
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
Scan Date: 10.15.2015 15 :49:34 (-0400)
Queries to: robin [e-mail]
[Windows User]
Morella
Not sure who reviews the UIC Open Loop Geothermal Systems. Can you go ahead and have someone start to review
this package? We've gotten several calls about it since, as I understand, it's involved in a real estate sale.
Please send your comments to Mike Rogers. We'll also send a hard copy in case this is hard to read . Thanks!
Debra Watts
Supervisor, Animal Feeding Operations and Groundwater Protection Branch Division of Water Resources North Carolina
Department of Environmental Quality
919 807 6338 office
[e-mail]
512 N. Salisbury Street
1636 Mail Service Center
Raleigh , NC 27699-1636
Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be disclosed
to third parties.
From : Karon [e-mail] [mailto :[e-mail])
Sent : Wednesday, October 14, 20 15 4 :43 PM
To : Watts, Debra <debra.watts @ncdenr.gov>; Palmer, Gwendolyn M <[e-mail]>
Subjec t: Me ssage from KMBT _ 423
1
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
Date: October 15, 2015
To: Morella Sanchez-King/Jim Gregson
From: Michael Rogers, WQROS -Animal Feeding Operations and Groundwater Protection Branch
A.
B.
C.
D.
Telephone: [phone] Fax: [phone] E-Mail: [e-mail]
Permit Number: WI0800435
Applicant: Estate of George Spayd
Facilitv Name:
Application:
Permit Type: Geothermal Heating/Cooling Water Return Well
Project Type: NEW Project
E. Comments/Other Information:
D I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above-referenced application for your
review, comment, and/or action. Within 30 calendar days, please return a com pleted W Q ROS Staff
Report.
When you receive this request fonn, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WOROS Reviewer: ___________________ Date: _____ _
COMMENTS:
NOTES:
FORM: WQROS-ARR ver. 092614 Pagel of 1
Rogers, Michael
From: Watts, Debra
Sent: Wednesday, October 14, 2015451 PM
To: King, Morella s, Kegley, Geoff
Cc: Rogers; Michael, Watts, Debra
Subject: FW: Message from KMBT_423
Attachments: SKMBT_42315101415410_pdf
Morella
Not sure who reviews the tJKC Open Loop Geothermal Systems. Can you go ahead and have someone start to review
this package? We've gotten several calls about it since, as I understand, it's involved in a real estate sale.
Please send your comments to Mike Rogers. We'll also send a hard copy in case this is hard to read. Thanks!
Debra Watts
Supervisor, Animal Feeding Operations and Groundwater Protection Branch
Division of Water Resources
North Carolina Department of Environmental Quality
919 807 6338 office
debra.wattsncden r. gov
512 N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699-1636
NC
Nothing Compares...-.
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: [e-mail] [mailto:[e-mail])
Sent: Wednesday, October 14, 2015 4:43 PM
To: Watts, Debra <[e-mail]>; Palmer, Gwendolyn M <[e-mail]>
Subject: Message from XMBT_423
1

Pat McCrory
Governor
~A --
North Carolina Department of Environmental Quality
October 15, 2015
Estate of George Spayd
c/o Jennifer Lemieux
1 15 Branch Road
Spruce Pine, NC 28777
RE: Acknowledgement of Application No. WI0800435
Geothermal Heating/Cool ing Water Return Well
Pender County
Dear M s . Lemieux:
Donald R. van der Vaart
Secretary
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on October 7, 2 015. Your application
package has been assigned the number listed above, and the primary reviewer is Michael Rogers.
Central and Wilmington Regional_ Office staff will perform a detailed review of the
pro vided application, and may contact you with a request for additional information. To ensure
maximum efficiency in processing permit applications, the Water Quality Regional Operations
Section (WQROS) requests your assistance in providing a timely and complete response to any
additional infonnation requests.
Please note that processing standard review permit applications may take as long as 60 to
90 days after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail].
cc: Wilmington R e gional Office, WQROS
Permit File W I0800435
Sincerely,
. ~~~ L,.,r Debra J . Watts, Supervisor ·
(/" Animal Feeding Operations & Groundwater
Protection Branch
Division of Water Resources
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Phone: [phone] I Internet: http://www.ncwa ter.org
An Equal Opportunity\ Affirmative Action Employer -fvlade in pa,i by ,ecycled paper
George William Spayd -1926 -2015 Page 1 of 1
J
George William Spayd
March 23, 1926 -April 22, 2015
George William Spayd, 89, of Hampstead and formerly of Currie passed peacefully from
his earthly life on Wednesday, April 22, 2015 at his home.
-"He was born March 23, 1926 in Philadelphia, PA, the son of the late George Wiley and
Elizabeth Rowley Spayd. He was preceded in death by his wife, Joanne Auchy Spayd.
George is survived by his daughters, Dr. Sara Spayd of Garner NC, Jennifer Spayd
LeMieux (Fred) of Spruce Pine NC and Martha Spayd Bursey (Bruce) of Sandford NC;
grandchildren, Jessica LeMieux Weil (Page) of Boulder CO, Capt. Will LeMieux of
Southern Pines NC, Hannah Bursey and Lilly Bursey both of Sanford, NC.
George graduated from Lansdale High School in Lansdale, PA and attended NC State
University where he studied horticulture. During WW II, George proudly served in the
US Army. He and his wife, Joanne settled in Currie NC where for many years George did
what he loved most, owning and operating Spayd Fruit Farm. George was a member of
American Legion Post 167 in Hampstead.
George possessed a keen intellect, sharp wit and engaging personality. Amongst the
legacies George leaves are the importance of God, Family and Country.
A graveside service will be at 3:00 p.m. on Saturday, May 9, 2015 in Riley's Creek
Memorial Cemetery in Rocky Point with Chaplain Parthena Skipper officiating.
Following the service there will be a reception and time of sharing memories at the Spayd
home in Hampstead.
The family would like for you to consider a memorial gift to Lower Cape Fear Hospice
Foundation, 1414 Physicians Dr., Wilmington, NC 28401 or to American Legion Post
167, PO Box 337, Hampstead, NC 28443.
Shared memories and condolences may be sent to the family by selecting "Memory Wall"
above.
Quinn-McGowen Funeral Home of Burgaw.
http://www.quinnmcgowen.com/new _ view.php?id=5352239 10/15/2015
09/29/2015 19:01 8667843089 THE FEMIAS PAGE 01/06
l;rOR.l'H qAROLJN."A DEPARTMENT OF ~ONMB'NT.AND NA'.fURAL ~9Ul\~
AP-PLICATION FOR A.PERMIT TO CONSTRUCT OR :-01'.ERA,U INJECTION WELLS
.ln ~dance With the:P.rovisl.083 o~ ls.A NCAC p2c ,Qg,24
GEOTHERMAL HEATING/COOLIN G·WATER RETURN WELLS.
These wells injett g:rowld:waiet d1rec'tly ;intQ .tne sub$urface as part of a .geoth.e:tmaf hl:!alina and cooling system
(check ooe) ~ew Applfoation _ ___,Renewal* ---Modificatioo
P.rlnt or Tjff fr,fm.maliiln. ·and:Milil to. the Aifi!ress:on tl,.s.Iast Page.. Illegible Applications .Wtll Be I'.e~d M l~te:
DATE: ~ept~25 , 2015_ t:!Vt Ut:, 'U\ ...
PERMU'NO~ vJ ('O'if tXJ L{ \ <'c1eaveblanldf:NevrAppti~on) r I\
A. STATUS OF APPLICANT(~ one)
Non.-Oovemment.
Go\lft!W.ent:
Individual .Residence .JL_ Business/Organization ._
State Munfoipal ~ County_ Federal
B. . WELL OW,Ngafe~ltMIT.APPLICANT-For individual ~:sidelice:i, foit owner(s) on property d~d. :for-all
othw:'$, list name .of entity g name of person delegated anthorily to sign on beba1f of the business or agimcy:
Tb e.l!stah!i ofGeorge Spayd
c/o Jennifer Lemieux
Mailing.Address: : . ..e...11,,_,,S=.B=ran=-ch~Rd=----------------------~-~
City: Spruce. Pine Sta:te: . .E_ Zip Code:-287...........anc-_~Cowicy: M,itelutll
~ T~l'C1 No.: .,...828~•7...,7..._6 .. =29=5=3 ____ ........ ___ -=Ce""ll._.N=o..,.,: _______ ~~--~--
EMAlL Address: lemi euxu@vahoo .cotn Fax No.:
C, \\'ELL . O;n:KA.TOR (~ difl'~t. from ~I ,Offll-),.... fQI' mdivi~id r.esi~~ •. list ownet(~) .~ property )
de,ed. For all others,. list nam.c :of ~ty. and name of person deleg,e:ted authority to· sign ~-behalf ._of the.
bus.iness •1>ragency: ____ ~---------------------
Mailing,/i.ddress: ---------~-----~--------,,,--'----.--~-
City: __________ State:_. _Zip Code:, ______ ~,·---~--
Pay nte N"o.: Ceil No.:
·EMAILA~: F No.:
D. i..OcATlON OF WELL SITE-Where the. inJection we.lls enfpb.ysfoa11y loeated:
(1) Parcel Xdentif~'Number (PlN) of well $e: 4202-S9-21 l0-000 Couiey: =Pender---~-J'f. ~12-
(2) Physioal Address (if ~than mailing address): 71 o·B rgwn Pelican Lane
-----~-----------~-1i~sr
_ State:,~ Zip.(:c;ide: -=28:::....:4=43::..-____ _ City: Hainpstead
µPt,J/l1IC 5A7'Penmt ~ (R~ 5/~/2.01~)
09/29/2015 19:01 8667843089 THE FEMIAS PAGE 02/06
E. WELL DRIU..E~ INFOJUlATION -. ' '
Weil D~itlins.Contmctor's,N~t: J~am.es ... ·==L= . ....,,eomette""""'=· =-· -~--------------
NC W~ Drilling_·contmctOl'Certification No:: =24=24 __ ,h _______________ _
Cotupany Nrune:Aooliecf R.es oun:e Manag ement .
ContsctP~on: Jim Cornette EMAU,Add_te~s:•Jiili. ann@beTisout,h.um -
AddreM: 257 Transfer Station .Rd
City: Hpmp!!t.ead Zip Code: 28443 . Staie: Jm._ County; ...,jP--'=P:ee='-------
Offlt:iC T-eie No.: 2l0¥70·29.i9 Cell.No.: 9U) .. 5124890 FnNo.: 91.0-270-2988
·F. .BVAC-CO~CT-0.R. lNFQRMATION (if .different than driller')
HVAC Cootr-acior's Name; .,.G=eo=· ui;=e .... S..._001.....,.qr=d-------------------~--
:NCHV.A,(; Con,,ractpr Lia;ise No.: __ 31..,_68 __ 9 _______________ _
CumpanyN~:Applied Reooun;e N!W!!eemmt. PC .
CowactPerson: George ~d EMAIL Address:George ann@b~
Ad~ss: 257 T;ransfer Station Rd
City: Hampstead . Zip Code.: ~ S~: ~County; .._Pen ..... der=· __ _
Office Tele No.: '910-270-221 9 Cell No.: 91-0-2:ti-7.641 Fax No.:910::270:-2983
G. WELL USE Will the injection:~U(~)-~ be ~ as t;be SlllWlY wems) for~ follow~?
(I) ·Thed~ection operation? 'YES___ NO _,=,.:X.____
(:?). Pet11onal ooru;umption? YES ___ NO _. X_· . __
H. WELL CONSTRU.CllON llEQUIBEMENTS-A$ -sp.ecif:fed m 15A NCAC 0'2C .0224@t
(l)
('2)'
The ·water sUpply -well ~l tic ~d· in~ wi1h the water sttppLY. well requirements c;rf
JSA NCAC02C .0107.
{3)
If' a s.ep~ well is l,ised ·t() i)ajeq._tbe_heat pump :~uem,. th61:1 .the. 'il)jection well $ball ~ consttucte.d
.in accord8noe with the wat«' supply well l'equiremeJJ:tii of 15,8:, NCAC 02C .OJ QZ. except that:
(~) For screen and gra.vel--pacl«ld we&; the emire I• of casing shall be grouted -n-om..the top
i;,f the :aravel _pack to land sur.f~;
(b) For oP®--end we~ 'li:'litbnUt:sct~ thl, casing sbsll'be grouted, from. the battom:oftl_le ca.sh:ig
to lai,,d stltface, ·
A satnpling:tap ot other approv~ collection equipment shall piovide a functional source ofwatei-
durin,g system Operation .for the collection of watei-samples iw.tnsdiately after water em.erges-:from the
supply well ·and immediately prior to injection. ·
Gl>U/UlC ,11.1 -~ .Applir.stion ~ Sl:23/2014)-.Pagc2
09/29/2015 19:01 8667843089 THE FEMIAS PAGE 03/06
I. W£LL CONSTB.OCllON SPECIFICATIONS.
(1) Spc,!Cify -tb.~ nutnbet' ~ fype ·ofweUs to .~ use.d fqi: th~ g~thei::.tM! beatingl'oo.Qlitig•system.:
l ~XlSTING WELLS 1 :PROPOSED-WELLS
•For extsti,,g wells, pleas.e attach a "COPY '1,[the Well:C<J1'1StrUJ:tion Re.cord"(Form GW-,J) ifavallable.
(2) A~ a·sGbematic ~ of each water supply and 11\ioction well serving the geothenn.al
heatipg/tj>oling system, A rringl&. ~iagram c!jri: be used {o.r wells having 1he 5mll.C ~ion
specificati0Il5 M toos-as the dlagram clearly idtl'lti:fies or distingui$hes e:aeh weli from one ~-
Each diagram shall dem.onstrate eompliaooc with th~ ~ll.construetion-:~~:,; $.P£Pified -in Part
H abt:>ve .and:sball:include, at.anrinilnum, the followq well-constructio:o spec~i-
(a:) Depth of each. boring_ below land surf~
(b) Well ·casing wd screen type, th:iclmess, and diameter
(c) Caiiing dq,th below land,sudaoe
(d) Casmg:hmght "~tjckv,p~• abo~ l~d $1.ll!f~
( e:) Grwt material(s)'SUJTOun4ins c~ing-~ d~~ below land~
Note: bBnt.a_nittr gruuta ql'e prli/1ibifed for set.zftr,g water·b~g ~nes with, 1500
mg/L chl'ori<le dr g'reatf!fpet-L5d, NCAC 02C .0107((}(6)
(f) Length of well scr.een. or open borehole ancl depth below lsnd sw:face
(g) Length of sand or ~-paokiag ai:-ouod well s~een and depth bdow land smf~
J. OJ'EBA.TING DA;TA
(l) lnjeetion-Ram : Average (daily) lO:J.5 gallons per~ (gpm),.
(2) Injectipn Volumei
(J) Injectioti Pressut~:
{ 4) Injection Tempeta.ttlre:
Av~~~ (daily) 720:--1,080 gallons per 9&Y (gpd),
Aver~ (da,t'ly) ~~~ fuch (psi) ..
A-verago(lanuaiy)-2!_° FtAveres.e·(Juty.) _a° F.
l<. SITE "1AP-&~tid ip 15A NCAC 02C. .W24(b)(4}. att~ 8c:~ifie map that is .so~ ot otherwise
accnrilte1¥,mdicates distmices end M\'ITT.tanons of the~ed f~tures fr-om ,the :injection well(&). lb, :ute map
shall include. the following: ·
(.l) A'iJ watcr~upply welts,~ watflF bodies; an4 septic systems iD.c.luding ~eld. waste
application~ m,dr~pair :area.~d ~ 250 feet -of the in~ctioa well(s)_..
(2) AJ,;yother·potential.SQU:rcesefc.Q~onlisted :iril5f\.NCAC02C,0107(a_){2)l~d -withm'25Q
feet ,ot.the-propo~ mjectiw:we.11.(s). ·
(3-) Property boundar.ies located within 250 feet of the P8(~1 on which the pi:0p0jed injection -well( i),are
to br. locate.d . .
(4) An·arrow orienting the site to one-of th$ cardinsJ dir~o:a., (nqrth. south. west Ol' east)
NOTE: Tit · 1libSt -Cll$6$ an .psria/ pliDio~h.:.r,f t/U! pr.open, parm s1unving propm.,.11,,u-1JP1d stmtltlres ,can,·b~
obtainetl an4 · lt11wµOfflkd fit!~ ~e opplica.lik c,,a,d,J. QIS; websiif!. 'l)pictttlJ,, the property .c~ lie . Sllll'cl,.ed,by
owne,r IUDrle, ()I' otldmts. The loca'tJtm of"t'he welll•i,i.r11(snvn ~ property boumlarlu, .hfH4~ 1$i!p'lic-u,nk,~ other
w.e&,. di;. em,. t/wi. be drawn in b,, ~ .Abo, .a 'lqer.» ,:an_ b~ sefeeid sht:»Ving tiJp!Jgr,,p'lu.c co~ ,,-
elfnlfJBon_ data. ·
GPU/UIC '-A7 ~-Appliaaticm ~-'/23~&14)
09/29/2015 19:01 8667843089 TI£ FEMIAS PAGE 04/06
L. CER.TIFICA TION (to be signed as required below or by that person's authorized egent}
l.SA NCAC OlC JIDj(e) requires that all permit applications shall ba sign~ as follows:
1. tbr a corpol'8!icm: by aresponsible corporatO officer;
2. for a pmtnetship or sole proprietorship: by a geoeral partner or the proprietor, TeSpectively;
3. fot a muoioipality or a state, fed.end, or other public agenoy: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by 1he well owner (person(s) listed on the property deed).
If an au.ftlorked agent is sigain& on bt!talf of the applicant, the• supply a letter siped by tbe
applicant that names and aud.1.llrizes their agent to sign this applkalioil ()Jl their behalf.
"I hereby certify~ tmder penalty of law, that I have personally examined and ~ familiar with the illfonaation
submitted in this dooument and all attachments thereto and· that, based on my inquuy of~ individuals
hnmediarely lllSpODSible for obt.aininB said imurmation, 1 believe that tho information lB ~ aecurate and
complete. I am ~ that then: are signific:aot penairiM, mcludios the J)081ibility of ~es end imprisonment,
for submitting nuse infunnation. I agree to construct, operate. mahttain. repair~ and if appliceble, abandon the
utjection well and all related ~ces in !lCcordam::e with the approved specifi.011.tiom and conditions of
the Pmnit.'" ·
~~§.-ci~~ ~ 1,i~ Owner/Appheani
::T1 r"\Y') L ~ ~t ~ • I e rn , <i ~
Print or Type Full Namo • '
Signature of Pr<)perly Owner/Applicant
Prim (J( Type Full Name
Siplture of AutooriZfJd A.sent. if any
Print or Typo Full Name
Submit two oopies of the completed application package to;
Undergn>und lnjection Control Program
NC Division of Water Relon:rees
1636 Mail Service Cenw-
Raleigh, NC 27699-1636
Telephone [phone]
OPUJUIC 5A7 Permit~ ~.ised S/23/2014)
e19/29/2015 19: 01 1366794089
THE FEMIAS PAGE B5/66
GEO i BARIVIAL HEATING/COOLING WELL CONSTRUCTIQN DETAIL
Choose app/kbteIij8dion Fro design and ebeck the 'apprqpriaie boxes. Fill i depths dm/ &talk of well COMM4C110h
the blank likes prowded Ust additionatsireets as needed
Oneniofr Well
Prccilogd i Drifting
jectifin; SuPPIY:
Dual Pinpose
keturc or Sum* Line
Ca ain8
Grout
Casing Material:
'Casing Diameter 04
twain g Thiele (in.):
Grout Type;
(Mt, benakitei
Screen Material;
Screen Slot Size (in.,)$
Sold/Gravel Pack
Material.
Bedrock
Open Hole,
/OD
NC Certified Wed Dter Name
•Seret*A1 ell Desi n
ProPc4 Existift
britaion;U Supply.
0 Duel PuToge
T
BeruonIte Seal
elfPresen0
Sand/Gravol Pack
Meet
•
ceo
Record-Dothe. Bow
LandSurffic4 Lkw
Fray.ieltd
17.0
.gzo
It)
CertifiCalitql
(Ft)

LEGEND:
• Proposed Injection Well Location
9 Existing Well Location
Base map adapted from Fender County GIS website.
x
A
MGeotherm
al
ARM-Geathcrmaiwm 910.270.2919
TITLE:
JOB:
Proposed Existing Geothermal and
Proposed Injection Well Locations
SCALE: DATE: DRAWN BY:
Spayd 1" = 100' 9125115 EFC
FIGURE:
1

A ppendix A
A DMsiOn of Applied Resource Management P_c_
09/ 30/2015 16: 29 6667943069 THE FENIIAS
..�-•'1•.,a"�.: ;e?^_. ={�-; ._-''_.'ems': S`."• •1,•- "- .^'�L:. ?.10,:,..;-t -
PAGE S1/02
A •
PEN❑£R COUNTY HEALTH DEPARTMENT
P.D. Box 1209. Burgaw. NC,28425
Telephone [phone]
SEPTIC TANK IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
Article 11 N.C. General Statutes Chapter 130A
and
Pender County Rules and Regulations
Wie,0v,s- pl—
Owner/Agent _ Ga C�; cvs= & •�b19.[ritr . _Sf + �1 Date 2/2/2,7 Per+nit SO /107
Address Go .Sr�r"1 r; vinfifl7.Rer„r7 ACdC
?,ou Lkerrl LAN T f -
Location of Site
Subdivision 0 LOE PC/p.17- Lot # Section/Block G
House Iv Mabile Horne [ .] (#Bedrrn) Business [ ] (#Employees/Member5/Seats)
SEPTIC TANK Sin i 000 Gat- NITRIFICATION FIELD & 0 Sq. Ft.
NUMBER OF LINES 2- X LEMGTH �3 R. DEPTH / -2-2-In- BED SYSTEM SIZE
LOCATION OF SYSTEM: ee layout sketch or aiteolied plot Aran. No CHANGE fN.SEPTIC TANK
SYSlI OR ITS LOCATION WITELCNIT PRIQ[? APPf� 7L FHQ PENT. COUt HE4LTIi irPT
THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR INTENDED USE CHANGES. G.S. 130A-335(1)
0
T
E
MINIMUM HORIZONTAL SEPARATION OF SEPTIC SYSTEM TO NEAREST:
Wes$-ft., Property Lino: 10 ft., Foundation: 5 ft., Ditch or
Subsurface Tile: 25 ft. (10 ft if upslope).
SPECIAL INSTRUCTIONS OR REOUIREMENTS:
��`}} c. -Si icy r�r,..l 1IChY
f3- Ja-137
.3—/0447 err 4
Cie. 2 1.tirok E A+.
LAYOUT SKETCH
_sets'4'54tero ' T
s/ /s cam)
� I�"o`-`7T
o >: trite P'`
E,e4-r1 9 frzte
This permit does nOt constitute a warranty or guaramee and satisfactory performance Is nOt assured by the
Ponder County Health Department.
IMPROVEMENTS PERMIT BY.
CERTIFICATE OF COMPLETION BY:
Installed by:
PCHD/EH-3 Rev, 11-89
PERMIT VA+ ID 5 EARS
--�� DATE f

~ -2., Qf ft!-µ,,.,~
-II-501107
Cf/J~ I J-t'I-'~
8667843089
en~ ~ s.7 /4 C , s,,/2,/4 1 CpP
THE FEMIAS CM-~ PAGE 02/02
G:,e.O~~ e--;, 00~1'1NE: sl'~yb
~~"..,..:..;-\~ 9'.J\ \ 0(
RECEIV_ED
MAH 1 11994
ENVIRONM£NTAL HEALTH
FENDER COUNTY HEALTH DEPARTMENT
P.O. Box 1209, Burgaw, NC 28425
Telephone 919l259-1233
SEPTIC TANK IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
Article 11 N.C. General Statutes Chapter 130A
and
Fender County Rules and Regulations
c -O:•--tPr-i •t n4ANC 1 23? we4 -MM-IS
Owner/Agent �%�'" Date ' / /42, Permit # 500113C`
Address AltiK dd l4/►^p " f i' (, 43
Location of Site
Subdivision -OW ET: ( irdr Lot # `TT Section/Block 4
House [yi Mobile Home [ ] (#Bedrm) I Business [ ] (#Employees/Memberslseats)
SEPTIC TANK SIZE l O Gal_ NITRIFICATION FIELD _8 Sq-Ft.
NUMBER OF LINES 3 LENTH 95— Ft. DEPTH t 21 In. BED SYSTEM SIZE
LOCATION OF SYSTEM: See layout sketch or attached plot plan. NO CHANGE IN SEPTIC TANK
SYSTEM OR ITS LOCATION WFIHOUTPRIORAPPF.iOVALF8 )M PEA COUNTY HEALTH DEPT,
N
0
T
E
THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OF INTENDED USE CHANGES. G.S. 130A-3350)
MINIMUM HORIZONTAL SEPARATION OF SEPTIC SYSTEM TO NEAREST:
Well: 100 ft., Properly Line: 10 ft., Foundation: 5 ft., Ditch or
SubsurfaceTile: 25 ft. (10 ft if upslope).
SPECIAL INSTRUCTIONS OR REQUIREMENTS:
Li►] rAUSRA LLfW —1144 JCt
.95
-LAYOUTS1 TCH
Iu
t
This permit does not constitute a warranty or guarantee and satisfactory'performance is not assured by the
Pander County Health Department.
IMPROVEMENTS PERMIT BY:
CERTIFICATE OF COMPLETION BY:
Installed by:
PCHD/EH-3 Rev. 11-89
.r..' _LNG
PERMIT VAl IO 5 YEARS
DATE /- 0 c
IC 0

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LOCATION MAP
NOT TO SCALE
LOT 45
FENDER COUNTY HEALTH DEPT.
ENVIRONMENTAL HEALTH SECTON
P. 0 . BOX 1209
BURGAW, NC 28425
PERMIT 6-60 z-if _
PAGE 2-- OF a_
(W-r4 -72
SIGNATURE DATE
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PLOT PLAN
for
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LOT _ 41
SECTION REV. SUBDIVISION c L. fie Poi tiT
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SCALE 1 " - 5 °.
TOWNSHIP P�ijp co. N.C.
DATE 3' I -3 -95
JACK G. STOCKS
N.C. Registration No. L..856
COPYCAT

TYPE'
PAGE L OF
ciii
MUER COUNITHALimPARruNT 114Ap#OoS CO 13 5
P.O. BOX 1209, RIJRGA W, NC 28425 RECORD # S373
PHONE: [phone]
IMPROVEMENT PERMIT / CONSTRUCTION AUTHORIZATION
���� t # OPERATION PERMIT
OWNER / AGENTS,1 DATE at 7 2OFERMET# 6 1 i38! D
L 16 K4-v‘- , fi.. r ,t_ �7
ADDRESS c g oLfe,+T i .L y-p6 1.)C.r� � PHONE o� 7 Q --52A
SITE LOCATLON`f f-Lu ti �� �7 C -A-*t' �, �( r—C 1i 3° V f P4 .ec . 4o
CLILL2n o 1A, c °r r &LG._6.1.0"v .r.--P c
t -f (2,1Ci [ 6I o Y) (LA-
SUBDIVISION 1 _ . j r ► LOT# 3-5 SECTION / BLOCK 42
HOUSE VI -MOBILE HOME r ] € # Barra. j,4-f' BUSINESS j j i# EMPLOYEESIMSNBERS/SEATS}_
WA 1'Ltt SUPPLY: PUBLIC [ 1 WELL [ A--TOTHER DESIGNATED WETLANDS: YES I 3 NO ['r
BASEMENT/LOWER LE PLUMBING YES ( ] NO f �SYS'I slur MINIMUM REVIEW FREQUENCY
DAILY DESIGN FLOW gQ_gpd DOMESTIC WASTEWATER [{.3' INDUSTRIAL WASTEWATER - [ j
LTAR 10. p gpd/ft2 TANK SIZE 1 600 Gallons NITRIFICATION FIELD 60 0 Square Feet
NUMBER OF LINES 3 LENGTH 6 7 Feet DEPTH / Inches
{Gt.4.
B rAP SYSTEM SIZE ger, ��
********IF GARBAGE DISPOSAL UNIT IS TO BE USED AN EFFLUENT FILTER SHALL BE INSTALLED*
**********************Ink *•#************4*$***********************************42*********************ski******
SEE LAYOUT OR ATTACHED PLOT PLAN
NO CHANGE IN SEPTIC SYSTEM OR ITS LOCATION WITHOUT PRIOR APPROVAL
FROM THE PENDER COUNTY HEALTH DEPARTMENT_
THLS PERMIT IS SUBJECT TO REVOCATION iF TEE SITE PLAN, PLAT OR INTENDED USE OF THIS SITE CHANGE&
G.S. 130A-335 (f)
***********v**********************************a************************************************************
MINIMUM HORIZONTAL SEPA ION OF S C SYSTEM {Sec Section .1950 a-c} J f p
5 YEAR IMPROVEMENT PERMIT : ISSUE DATE 74zD i A
IMPROVEMENT PERMIT, NO EXPIRATION DATE: ISSUE DATE
COMMONS / ADDITIONAL INFORMATION:

At(
77-7
N 9
ED
gge-)10j 1
C77-.
(-4-1t)
RENDER COUNTY HEMS DEPT _
ENVIRONMENTAL HEALTH SECTION
P. 0. BOX 1E00
MCAT NC 2842
PERMIT # I rJ 1 D _
So
3

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PEVDER COUNTY HEALTH DEPARTMENT
P.C. Box 1209, Burgaw, NC 28425
Telephone [phone]
SEPTIC TANK IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
Article 11 N.C. General Statutes Chapter 130A
and
Pender County Rules and Regulations
Owner/Agent Date J .. 1- Permit#
Address e 0 'r I file v4.•
Location of . Site i-tcf'ci, 1 nI IM .44`1.9'ti Je _ t{ AgL Sr 7-Q "/C "j i fe.
C f+
Subdivision
}-�r ���tL�� r'.•;� .�-• r! err:¢. Lot# � sect ian/$lack
House [N. Mobile Home [ ] (# Bedrm) Li Business El (# Employees/Members/Seats )
SEPTIC TANK SIZE j (1D 1) Gal. 60 NITRIFICATION FIELD q(' () Sq . Ft.
NUMBER OF LINES ir2" LENGTH . Ft. DEPTH / ,dIn. BED SYSTEM SIZE
LOCATION OF SYSTEM: See layout sketch or attached plot plan. NO CHANGE IN SEPTIC
TANK SYSTEM OR ITS LOCATION WITHOUT PRIQ? APPROVAL FROM PENDER COUNTY HEALTH DEPT.
N
0
T
E
MINIMUM HORIZONTAL SEPARATION OF SEPTIC SYSTEM TO NEAREST:
:
Well: 100 ft., Property Line: 10 ft., Foundation: 5 ft., Ditch or
Subsurface Tile: 25 ft. (10 ft if upslope).
SPECIAL INSTRUCTIONS CR REQUIREMENTS:
LAYOUT SKEIVE
Si
100
r
* * * * * * * •-� -�*r
This permit does not constitute a warranty or guarantee and satisfactory performance
is not assured by the Pender County Health Department.
14PRD PERMIT BY: C, . 4: r -+-€:,K r.1-[ - PERMIT VALID 36 MUMS
DATE:
D 101
CERTIFICATE OF COMPLETION BY:
Installed by: Gr ---
PCHD/EH--3 Rev. 7/88
4�,

1 Q
,lI-y
V,
IMPROVEMENTS PERMIT A.PP1.ICATION
Pe xter County Health Department
Environmental Health Section, P.O. Box 1209, Burgaw, NC 28425 435193
919/259-1233 Diate Received 1 7 1 1 r j
1 as)
owner/Agent Lee '4' 1 ve r More YS 5) L1(p
Addre -^ k C.
CA-11--Q-Ct_ "V( a n4.� [� Cv , 1
Directions to property: S 1L 15- ' — iCt' -i."
=oiiCr� ,�� —C'�� Tic
subdivision 5 i ck6 CeCA-ag Lot NO. 41V 4/7 81ock/ act
Lot Size 1 0-CD [ _ O House Mobile Flame Busir ) /
Dwelling - no. of bedrooms 7 ; business/other
Water supply - Individual PA Public [ ]
ContractorAddressf] _ J
Remarks LCl 7J ' LAC �1 �`t �� ( ! ] � C' /2 14 / l k�.2 ex.t ff 1)7 41)(1.
- no. emplayees,members,seats
Loan: Fm' [ ] FHA [ ] VA [ ]
Fees Paid: Evaluation ((1 (pv Permit _ perceived by: 45.
NOTE: Issuanoe of an Impr[rits Permit by this office des not necessarily Haan
that the structure or use of the septic tit System meets county zoning and
land use regulations. Contact the Ponder County Zoning Officer or Planning
Department if you have questions concerning zoning -
Signature of Applicant: �C J {� �-+_ Date
PC1-D EH/103 Rev. July Ei8
* Site Layout *
aitt-
)
i
1 ,- ri r ..

i
FENDER COUNTY HEALTH DEPT-
ENVIRONMENTAL HEALTH SECT ION
P. 0. BOX 1209
BURGAff, FS 28425
PERMIT # ) //657 -
2
SIGNATURE DATE'

WT/r.Nn,+w.x..�.
Pender County Health Department
Environmental Health Division
803 Walker Street, P.D. Box 1209
Burgaw, NC z8425
Phone: [phone] Fax: [phone]
www.p elide rco a ntync. gtQV
Wastewater System Operation Permit
Parcel Pin: 4202-59-2300-0000 Permit Number: 14-158H
Property ,Address: 709 Brown Pelican
Owner: Sean Mcentee
Address: 709 Brown Pelican
Hampstead, NC
System Installer: Ssdbuty
Facility Type: Single Family Dwelling
System Operator: N/A
REWIRED INSPECTIONS
ORC Inspection every: ]VGA
PCHD Inspection every. N/A
System Classification: Llhar Trench -25%) Chamber
System Type: MR
In accordance with NCGS t3oA u and 15A NCAC /8A Section .19ov, This Operation Permit is issued to:
Senn Moenlee
For the operation of a 360 GPO wastewater treatment and disposal system.
Cuttditians
t. This permit shall he effective only with respell to the nature and volume of the waste specified. Water softener backwash is not allowed in the System,
2. This permit is transferable; however, any conditions unposed on this permit shall also transfer to the subsequent owner.
3. The system shall perform and be properly maintained and operated at ail times in accordance with Rile .1961.
4. The owner, or other contractually rrsrpuusible party if applicable, is responsible for compliance with 15A NCAC i8A section .tgoa.
5. En the event of failure oFtl,e system to perform satisfactorily (as determined by the PCHD), the owner, or other responsible part if applicable, shall take
such corrective actions as required by the Department within the specified period of time,
6, No traffic, vehicles of excavations shall be allowed on the system or the repair area.
7. Appropriate permits shall be obtained from the PCHD prior to any repair; to the system or additions of Dow.
& The owner (and ORC, 'sF applicable) shall notify the PCHD of any malfunction or necessary repairs.
9. The owner is responsible Fvr keeping the plumbing system of the facility in good repair and eliminating leaks, drips, or excess flows as they are found.
to. A useable repair area as design■laced by the PCHD shall be maintained and ttserved Far the addition to or replacement of the initial drainfield.
1r, Refer ro 'he 'as -built' inspection record on file at PCHD for System lusteIlarion specifications.
ta. Ferrite For Types If and VI systems expire in S years. Owner must contact PCHD 6 months prior to expiration For permit renewal.
33. The system shall be maintained and operated at all times in accordance with the Schedule of Operation and Maintenance shorn on pg x of this permit.
34. Unless specifically allowed for nil the Construction Authorization, systems are nor designed for garbage disposal use
15, See page s for any additional conditions.
This permit may be suspended or revoked for non-compliance with any permit condition,
ISSUED: 4-14-4
Registered Environmental Health Specialist
EXPIRES: N/A

Page 2
SCH EDU E OF OPERATION AND MAINTENANCE
FOR ALL SYSTEMS:
• Every 12 months: Septic tank shall be inspected for influent/effluent line blockage, tank/riser leakage, and solids
accumulation. Blockages or leaks shall be repaired. Septic tanks shall be pumped out when solids (scum & sludge)
reach 1/3 of the liquid volume. Effiuent filters shall be inspected and cleaned or replaced as necessary.
• Every 6 months: Drainfields shall be inspected for seepage or saturation, settled ground surface, broken pipes,
maintenance of vegetation, protection from traffic, and diversion of surface water.
• Every 6 months: Ground surface around tanks and drainfield shall be checked for areas of depression or ponding.
• For grassed sites: Grass shall be cut regularly and when it exceeds 8 inches in height. Lightweight mowers shall be
used for cutting grass.
• For wooded sites: Saplings, briars, brush and grass shall be eliminated by hand cutting and/or herbicides as often as
necessa1y. Dead trees shall be removed by cutting at or near ground level. Stumps should not be removed.
FOR SYSTEMS WITH PUMPS:
• Every 6 months: Pump tank shall be inspected for leaks and solids accumulation. Leaks shall be repaired and solids
removed as necessary. Do not allow solids to reach the height of the pump intake. Pump, controls, floats and alarm
shall be checked for p1·oper operation. All components of the pump/control system shall be kept in compliance with
the current design standards.
• Every 6 months: A pump delivery rate shall be determined. Pipes and fittings shall be checked for leaks.
• Every 6 months: Drainlines shall be flushed of solids accumulation with the valves opened. Pressure head
adjustment shall be made to obtain the designed delivery rate. Pressure head measurements shall be recorded.
• Every 6 months: Water meters, pump meters and counters shall be read and recorded .
FOR TYPE IV, V, AND VI SYSTEMS;
• The pennitee, as well as any subsequent o,vners or other contractually responsible parties, shall keep an operato1·
(ORC) under contract who is certified for subsurface wastewater treatment and disposal systems. The permitee or
owner shall notify any future or subsequent system owners of the requirements contained in this permit, including
the requirement for a management entity contract. Notification of any changes to the owner's contract with the
system ORC or a change of ORC shall be submitted in writing to the PCHD at least 30 days in advance of the
change.
• Monitoring and inspection frequency shall be as specified in Rule .196i and any state approvals.
• All monitoring data and maintenance records shall be kept on file by the ORC and a copy submitted to the owner
and the PCHD. Reporting frequency shall be as specified in Rule .196t as well as any state approvals.
ADDITIONAL CONDITIONS:
DO NOT DRIVE OVER ANY PART OF SEPTIC SYSTEM.
WA
Applicant:
System Installer:.
STs MANU,��
STI3 -
CA 141-'15Jk
PIN: 9 ' " 6a` -206
TEWATER SYSTEM INS TA LATION RECORD
PLupaty° Description Ne pf. V' 7O1 (34PtAAA Pett.ke 1
Sysltm Type.
GAL
DATE
PT ILIA\L2.
PT -
DATE
PSI Pal
LEAK TEST LEAK TES
PRETEST 1► PRETES n
RISERS: INLET_ OUTLET.__ INLET ISER
EFFLIJFd T FILTER OUT :'f RISER
BRAND _ PL _ GPI
MODEL
PIPE SEALS OK
CONTROL PANEL "PUMP
BRAND 7' B R.A N D
MODEL �•' MODEL
FLOATS ALARM OK
PULL ROPE
SUPPLY I
SFZE:
_O O COVER
_PESSURE TEST
PDR INI IAL:
Et DING:
-SULT:
Initial Meter Rending}: ETM Events
FLOAT Sk3'PPORT
FLOADJUSTED
E LOSU RFJCON D U I T
UCT SEAL/GROUT
TIME
TIME
MINUTE=
Date
a_UBSTITUTED SYSTEM TYPE INSTALLED
GPM
By this signature, the installer certifies that the
decision to substitute the accepted system for the s+stein type I),rnniiteci ►gas made by the Owner.
DATE Ei15 t7I!:s VET TO ❑0
-NM( K-e Al4,3 i 4- 2 Gi. L(,j /
)IAGRAM
FJNA L INSPECTION COMPLETED

low
FIVE YEAR LIMITED WARRANTY
NORTH CAROLINA
STANDARD WARRANTY
EZCCow, L,P. ("EakV. ) hereby extends the following FIVE (5) YEAR Lihnited Warranty to the original purchaser of a new E ' datinhcid sysienr
installed by as authorized tusteIler. Tire BZfar• dnsinheld system is warranted to be free From defects in meter;ai and wortar•,anship under
normal use, subjecl to the lamas and conditions Ircreia.
WARRANTY ELIGTR[LTCY:
The system owner is eligible for this Licirred Warranty provided all of idle terms mati conditions of this Limited Warranty have bear mat. Thietemta
of this Limited Warranty shall extend to the original purehaaerRswaeoweer and to eneh subsrq:let owner cf the horde during the term of this Limited
Warranty, This Limited Warranty covers only the perortnanee of tie FZ1rur draiafield system as rnanufaclured and installed in accordance with the
inennfataurer's design spccrf nations and applirabla stale rules and regulations.
OWNER'S Ofll.ICATIONS AND MAINTENANCE
I. The system owner [Hunt retain evidence that septic tank solids (diges cd sludge) have been properly removed ante every thirty-six (35)
month.
2. The system owner mast not landscape over the L°2/ku•dmiunalct system with treks tar shrubbery lnlr erect any structures er place heavy itoris
over the dntinf old,
3. The system owner must retain this Limited Warranty signet by an authorized €T,1xr drainleld swam installer and 6 properly issued
Operation Permit.
WHAT IS WARRAN(N.DAND FOR HOW LONG:
The EZ,fee prefahricnr i druinfieid system is warranted for FIVE (5) YEARS from the dale installation of the system Is completed, to be free from
defects in material or workmanship. Rttring tote windily period, IEZHaw, L.P, shall, et its option, repair or replace any defective system oompooents at
no charge for labor or materials. REPAIR OR REPLACEMENT OF THE DEPECTIV&.PRGIJUM' IS TILE EXCLUSIVE RIIMEDY LI DER THIS
LIMITED WARRANTY. Any replacement or repair part, are warmnled for the rensamdnr of the warranty period or ninety (90) days, whichever is
longer. Under this Lirnilcd Warranty, B2iiow. LP will provide Daly for rep Limn en1 and 111.5tallatiosi of defective E7.j3ar'draisificld system parts Owner
s[turr be responsible fur any 0111a7 w.sls, tni:1udtng but net [united to re-soddtag and any permits required for installation.
WHAT W NOT COVERED BY TIIIS LiMJTED WARRANTY:
i . The septic husk, fillers, eft] do it distribution b1x(es) or other system cW aperients.
2. Innprepor designs or installation, including but not limited to repairs/replacements necessitated doe to hnproper or inscan ate soils analysis, the
use Of incorroct applicaliea rates or tnadequale sizing criteria.
3. Landscaping or re -sodding costs.
4. Repair work perforated without EZtlow aulllerizatiorn.
5. assuage Caused by nnnutloriud or improper attachment, alterations or inodiItcutiona, including l.*it not limited to Um tax of centoxtiles or
pion le pipe.
6. Dtnnnge carved by flood, earthquake es other natural disaaier,
7. Damage or Nil lure rhea to improper maintenance or rack of me wr mantrenanec.
1. Perinea do a to etre:naive water usage, improper grease diupoaal or other oxcctsrva on lnrpltt rW use.
9. Failure caused by plating stntcturex or plan! :material over the dtoiaficld et• by stresses or vehicular traffic greater than that prescribed in the
installation or operation instructions.
CONDITIONS OE LIM/TEO WARRANTY:
I. The design and installation of the =flee= drainfreld system is performed necnrding to the ru;cs and regulations of the North Carolina Dew -
meel of Environment and Natural Resources and the CQ 0111issionl for Health Services_
2. The EZ/lar•drain held system is subject to use penrtilled by appltabie slate or local rules rind regulations for en -silt wastcw l Clr systems„
3- Installation of the drain hald system is performed only by an artthanzed EZttaw installer.
NOTICE.OF WANRAr!CY CLAIM:
lb obtain warranty service tender this 1.aaailed Wirrranly, the system owner Ir11IFt notify EZJtow, L.P. within ninety (90) clays after discovery of any defect
nod oblein on authorization mother for investigation, repair, or replacement servico. Notice should be sent to: l!ZtIow, L.P., Cr Business Park Road,
Old Saybrook, CI 0d475, Toll Free Plume: 1.800-0/.1.89-7759. EZflow wine non pay for any o:e>nr. rnpaiis, i7r rcptns: monis for which prior nuIliorixation
has not Iran obtained.
DISCLAIMER ❑FANir LIMI AI'IUN ON WARRANTIES:
OTHER THAN THE EXCLUSIVE WARRANTY SPECIRCALLY SET FORTH HERIIIN, NO OTHER EXPRESS OR IMPLIED WARRANTIES
11AV1 BEEN MADE OR W'TL 13i3 MADE BY OR ON BEHALF OF SZFLOW, LP. SYdrLOW HEREBY D15CT.AIMS AND EXCLUDES ANY
IMPLIED WARRATfrlltS OP MERCHANTABILITY OR 1rITN3SS FOR A PARTICULAR PURPOSE. THE WARRANT'tWsS AND REMEDIES
CONTAINED HEREIN ARii EXt7.UMV1 AND DO NOT INCLUDE INCIDENTAL, CONSEQUENTIAL OK SPECIAL ❑AMvMAGTiS, LOSS OF
USE, 1NCONVENR3FICE, OR LOSS ORDAMAOE TO PERSONAL PROPERTY, WHETHER DIRECT OR INDIRECT, WHETIRgi ARIS[NG TN
CONTRACTOR IN TORT.
'PHIS LIMITED WARRANTY GIVES YOU SPECIFIC LEGAL RIGHTS, FEDERAL OR STATE LAW MAY GIVE YOU CERTAIN O'FI34R
RIGHTS THAT ARE NOT CONTAINED HEREIN.
Print PurduserRicnneowner Narnt
Signature
INSTALLER CRRTIPICA1'1ON
741ea9 Wna4s Aoklyors , JC vv.
ip"f
"1 certify that the EZ $w rkeittfietd system hat been tasts:led properly and is nceorrtarwe with the blEltralordeslatlsrtion proeedtrres, applicable
North[ Carolina warrowator lows and regulations and all health departaneel permits."
L1sta11ar Boma ask Name
Hy;�t
f. t
Till _ _ C,� J
This warranty la provided in triplicate. One copy shall go le EZtlow, L.1', tune Io the local health departlnerll, and 0110 to the system owner.
CA Mt--- /519
1
}

A t.I,I I.I,III.1 b
North Cuafln, FuMTh
rvaly,ySkia, Evandny. EnryNxiy.
PENDER COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL IiBALTH DIVISION
803 Walker Street, P.O. Box 1209
BurgEtw, NC 28425
Phone [phone] FAX [phone]
.www.pendercountinc.gov
WASTEWATER SYSTEM CONSTRUCTION AUTHORIZATION
Parcel PIN: 4202-59-2300-0000 Permit #: 14-15811
Application Date: 3-26-2014
Applicant:
Address:
Phone:
Sean Mcentce
709 Brown Pelican Lane
Hampstead, NC
910520-095S
Associated IP #: N/A
Owner: Same
Address:
Phone:
Property Address: 709 Brown Pelican Lane
Property Description: OldePPoint Lot 40
Permit Type: Rmislentinl Repair
INITIAL SYSTEM
Design Flow: 361gpd System Type:
No. of Bedrooms: 3 System Class:
Septic Tank: 1000gn1(nlin) Nitrification:
Pump Tank: NIA Nita Trench Depth:
noriz Trench Separation:
Lot Size (Acres):
Facility Type: Single Family Dwelling
Water Supply: Private Welt
REPAIR SYSTEM
System Type: Other Trench (-25%)
System Class: mg
Nitrification: 3+ x gww
Max Trench Depth: 24"
Horiz Trench Separation: 9 feet
Conditions/Comments:
- NOT I71351GNFU FOR GARBAGE DISPOSAL.
-INSTALL DRAIN LINES ON CONTOUR.
-IF GRA.ViTY FLOW CANNOT BE MAINTAINED A PUMP TANK WILL BE REQUIRED.
-STAY 15' AWAY FROM FISH POND.
-THE DRAINFIELD MUST BE SEEDED FLUOR TO SYSTEM APPROVAL.
REFER TO Tits ATTACHED SITE PLAN SHOWING THE SYSTEM AND FACILITY LOCATIONS AND OTHER SYSTEM SPaCLItICA'I'IONS,
TI11S AUTIWI ['IATION SHALL BECOME INVALID AND MA Y BE REVOKED IT THE INFORM A'OON SUBMITTED ON THE APPLICATION
OR SITE PLANE INCORRECT, FALIS1r1ED, OR CHANGES OR 1F THE slits IS ALTERED OR IP THE SYSTEM INSTALLATION'S IS NOT
COMPLETED BEFORE THE EXPIRATION DATE. T1H4 SYSTEM SHALL IDS INSTALLED IN ACCORDANCE WITTk
1VRRT0 CAI 1ttUSA_ADMINISTRA'ITVF, CODE TIT' OE ISA ,1U0e6
.APN.lCM0&$YSTEM APPROVAL.%
-PE DXRCOUNTYHEALTII DEMRTh1FNTpoi Jags,
ISSUED: 3-28-14
Registered Environmental health Specialist
EXYIRES:3-28-19 ��

Map
Scale: 1:40
PenIZr
PENDER COUNTY HEALTH DEPT.
ENVIRONMENTAL HEALTH SECTION
803 S. WALKER ST,
Hi3RGAW, NC 28425
PERMIT# f- f r t5j 1
PAGE OF
SIONATUE J j _ DATE ? ,fig-1 t
hltp:I/gis,pendercauntync.govinewgisisitelP¢ intTemplales/No(0aaspx[3/2820I4 2:30:44 I'M]

.Tvpical Setbacks Required By State Rules Unless Othenvise Specified In Writing:
1. Any private water supply sources, including any well or spring 100 feet
2. Any public water supply source 100 feet
3. Streams classified as WS-1 100 feet
4. Any other stream, canal, marsh, or other surface water 50 feet
5. Any Class I or Class II reservoir 100 feet from no1111al pool
6. Any permanent storm water retention pond
7. Any other lake or pond
8. Any building foundation or building footing
9. Any property line
10. Top of slope of embankments or cuts of 2 feet or more
11. Any water line
12. Drainage systems:
A) Interceptor drains, foundation drains, and storm water diversions
I) upslope from system
II) sideslope from system
III) downslope from system
B) groundwater lowering ditches and devices
13. Any swimming pool
14. Any other nitrification field (except repair area)
15. Drip line ( outennost edge of a structure)
elevation
50 feet from flood pool
elevation
50 feet from normal pool
elevation
5 feet
10 feet
15 feet
10 feet
10 feet
15 feet
25 feet
25 feet
15 feet
20 feet
5 feet
Any changes to the proposed plans must be approved by the PCHD
*
Please do not allow any traffic, construction, excavation, utilities, material storage, or any other disturbance to take
place on the designated septic areas. These activities may void your permit.
*
The Owner is respollsible for marking any property lines, corners, proposed house site, outbuildings, decks and
driveways. The Contractor is responsible for ensuring that the well or septic system is installed in the proper
location and that all setbacks and conditions on the permit are met.
*
The system must be installed/repaired by a Registered Septic System Contractor
*
For systems with a pump, the Registered Septic Contractor is responsible for insuring the proper installation of the
electrical components. An electrical permit must be obtained and a person with a valid North Carolina SP-PH
Electrical license must provide electrical service to the pump controller and alarm.
*
It is the responsibility of the Registered Septic Contractor to call the PCHD to schedule the installation inspections.
*
The Registered Septic Contractor is responsible for backfilling the system components so that no areas are subject to
the retention or ponding of surface water.
*
After the installation is completed, some settling of the backfill material may take place. The system Owner is
responsible for eliminating settled or sunken area, stabilization, and final landscaping of the ground surface.
*
When the Construction Authorization is issued for a Conventional or Accepted System, the Owner may choose to
substitllte any Accepted System for the permitted system, provided there are no changes necessary in the specific
line locations, depths, or distribution system. When a substitution is made, verification that the Owner made the
system choice will be required prior to issuance of the Operation Penn it
*
It is the responsibility of the Owner to ensure proper maintenance.
-.. _ .. _, __ .-------·-·-····-···-----------·~ • .. ,_ . . .. · . . --------.---·-·· ___ .. ___ _
' ,,,. SYSTEM TYPE _,u:-~_
f AGE_• _t_ OF ~
PENDERCOUNTYHEALTHDEPARTMENT MAP# '2 H / 0{)8Ci)J Lf Z
P.O. BOX 1209~ BURGAW, NC 28415 o,:, c,
PHONE: [phone] RECORD# ':2 o .:;>o 0
IMPROVEMENT PERMIT/ CONSTRUCTION AUTHORIZATION
OPERATION PERMIT
--=)
PERMIT# 5 i l (t2S 1 oWNERt AGENT r-•·\t~ .. t PL,wd.c s C:./o Chiu? 21 oArn l f 7-5/:19
ADDRESS P.o .6ox-. 2>1 n -f{~sfel<A D~ . PHONE 27Q?:,3/'1-
SITELOCATION ~fl J» &~v.,. CJ,-Ah f.c{ ~VA ..4#f CX)U4 sb;.,,c:a:..J~
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~Vn {2.f-D'(:\ ~Y" P~(C<-n J ,cJ: ,·~'txdor-~t_/t.
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SUBDIVISIQN D / ck_ Pe-J LOT# 4 d-. SECTION /BLOCK &:i
HOUSE [ v'JMOBILE HOME [ ] {#Bdrm. } -5 BUSINESS I ] {# EMPLOYEES/MEMBERS/SEATS} _____ _
WATER SUPPLY: PUBLIC [ ] WELL [ v]"OTHER =------DESIGNATED WEIL.ANDS: YES [ J NOH-
BASEMENT/LOWER LEYJA. PLUMBING YES [ l NO [ vJ SYSTEM MINIMUM REVIEW FREQUENCY ____ _
DAlLYDESIGNFLOW ~h() gpd DOMESTICWAS1EWA1ER n INDUSTRIAL WASTEWATER [ J
LTAR () .CJ gpd/ft~ TANK SIZE q OD Gallons NITRIFICATIONFIELD Yoo SquareFeet
NUMBER OF LINES :,_.. LENGTH & 7 Feet DEPTH cit/ Inches
BED SYSTEM SIZE -x----
*''"''***** -=----' "•; ·. . -~lD-P~•~~******** • ;.p • ~ • .,~ -~~~~~
************************************************************************,**********************************
SEE LAYOUT OR ATTACHED PLOT PLAN
NO CHANGE IN SEPTIC SYSTEM OR ITS LOCATION WflliOUT PRIOR APPROVAL
FROM THE PENDER COUNTY HEALffl DEPARTMENT.
TillS PERMIT IS SUBJECT TO REVOCATION IF THE SITE PLAN, PLAT OR INTENDED USE OF THIS SITE CHANGES.
G.S. 130A-335 (fJ
**************************'**********************'********************,j(l!l*"'***********************************
MINIM1JM HORIZO=~ SEPTIC SYSTEM {Sec Section ... 1950 a-c}
s YEAR IMPROVEMENT PEruvnT: ~ _.,,, lft::.') 1ssUE 0A1E .:J-b s/?c; "" : ~ .,
IMPROVEMENT PERMIT, NO EXPIRATION DATE: ____________ ISSD"E DATE ____ _
CONDIDONS / ADDITIONAL INFOID,1ATION: ______________________ _
-()_V\ .LJ.1. Lu.LJ ~r--&JJ . bt..-=· •__,:c:.l--"A......,,~li=...,hJi.4.=· =7, .c::::...a:;__
1
........ o ........ LJ..____,~!,:::::r'\,,=-=--'=t<"-P,, l __ _ ' uu \) f u ~&»n·c...~k.-
CONSTRUCTION AUIHORIZATION: ~~
VALID FOR 5YEARS FROM THE DATE OF ISSU:ANCE o~iENTl'ERMf.
/11 I} /1 J/
ISSUE DA1E r2-/:J..5/?.9 •
~ ...........