WI0500220_DEEMED FILES_20201006

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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 WELLN
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
C K ONE OF THE FOLLOWING:
New Application Renewal* 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: 20 PERMIT NO. 20 (leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application)
1. Current Use of Well
a. I wish to continue to use the well ask Geothermal Well Drinking Water Supply Well
❑ Other Water Supply Use- Indicate use (i.e., irrigation, etc.
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
❑ Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? YES ❑ NO
If yes, indicate New Owner's contact information:
1 an. r I
Name(s) --
Mailing Address
City:
Day Tele No.: _
L91i
6N>� CCCL b
"FcElft
OCT 06 2020
C nh Q� Wig
e
J�.� T o-ZIA-? � —County: 0 Imo/ IA
State: Zip Code: ty:
194_ 0 3�U Email Address.: ACO.t-•�>, CkA44!� qAct, 1-60",
B. STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence X 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, list name of business/agency and name of person and title with delegated authority
to sign:
Mailing Address:
City: �-i s.�-a,*, State: NC- Zip Code: 7 County: Sl*_W�e-
Day Tele No.: $� a' Cell No.: 9-G -7 c;- GO &-1 �5-d
EMAIL Address: *510l^' �l` G ee}��� ►v►h� Z cax No.:
-&—T
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 1

D. WELL OPERATOR (if different from well owner) — For single family residences, list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated authority
to sign:
Mailing Address:
.City: State: Zip Code: County:
Day Tele No.: Email Address.:
E. PHYSICAL LOCATION OF WELL(S) SITE
(1) Parcel Identification Number (PIN) of well site: ��� oZz3 f�0County: OT
(2) Physical Address (if different than mailing address):
Fa
W
City:
WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name:
Contact Person:
Address:
City:
Office Tele No.:
County
Zip Code:
Cell No.:
EMAIL Address:
State:
HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name:
NC HVAC Contractor License No.:
County:
Fax No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State:
Office Tele No.: Cell No.:
County:
Zip Code:
Fax No..
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES NO
(2) Personal consumption? YES 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 requirements 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 Permit Application Rev. 4-15-2016 Page 2

(a) For screen and gravel -packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
(b) For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
(3) A sampling tap or other approved collection equipment shall provide a functional source of water
during system operation for the collection of water samples immediately after water emerges from the
supply well and immediately prior to injection.
J. WELL CONSTRUCTION SPECIFICATIONS
(1) Specify the number and type of wells to be used for the geothermal heating/cooling system:
*EXISTING WELLS PROPOSED WELLS
*For existing wells, please attach a copy of the Well Construction Record (Form GW-1) if available.
(2) Attach a schematic diagram of each water supply and injection well serving the geothermal
heating/cooling system. A single diagram can be used for wells having the same construction
specifications as long as the diagram clearly identifies or distinguishes each well from one another.
Each diagram shall demonstrate compliance with the well construction requirements specified in Part
H above and shall include, at a minimum, the following well construction specifications:
K. OPERATING DATA
(1)
(2)
(3)
(4)
Depth of each boring below land surface
Well casing and screen type, thickness, and diameter
Casing depth below land surface
Casing height "stickup" above land surface
Grout material(s) surrounding casing and depth below land surface
Note: bentonite grouts are prohibited for sealing water -bearing zones with 1500
mg/L chloride or greater per 15A NCAC 02C. 0107(1)(81
Length of well screen or open borehole and depth below land surface
Length of sand or gravel packing around well screen and depth below land surface
Injection Rate:
Injection Volume:
Injection Pressure:
Injection Temperature:
Average (daily) gallons per minute (gpm).
Average (daily)
gallons per day (gpd).
Average (daily)
pounds/square inch (psi).
Average (January)
° F, Average (July) _
° F.
L. SITE MAP — As specified in 15A NCAC 02C .0224(b)(4), attach a site -specific map that is scaled or otherwise
accurately indicates distances and orientations of the specified features from the injection well(s). The site map shall
include the following:
(1) All water supply wells, surface water bodies, and septic systems including drainfield, waste
application area, and repair area located within 250 feet of the injection well(s).
(2) Any other potential sources of contamination listed in 15A NCAC 02C .0107(a)(2) located within 250
feet of the proposed injection well(s).
(3) Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
(4) An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 3

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)
15A NCAC 02C .0211CeJ requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer
or ranking publicly elected official;
4. for all others: by all the person(s) listed on the property deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
Permit."
Signature of Property Owner/Applicant
6 L�
Print or Type Full Name and Title
Signature of roperty wner/Applican
Print or Type Full Name and Title 14
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - UIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 4

North Carolina Department of Environmental Quality
Division of Water Resources
PERMIT NAME/OWNERSHIP CHANGE APPLICATION FORM
I. INSTRUCTIONS
1. Complete this form in its entirety as follows:
(a) Change of Ownership — Provide the information in Parts II and III and submit legal documentation of the
transfer of ownership such as a contract, deed, article of incorporation, etc. The certifications in part IV
must be signed by both the current permit holder, if available, and the new applicant(s).
(b) Name Change Only — Provide the information in Parts II and III. Sign the certification for the new
applicant in part IV.2.
2. Submit the properly completed form to the address on bottom of Page 2.
II. CURRENT PERMIT INFORMATION
1. Permit Number:_ W1 o 5-6 00: -
2. Pennittee name(s):
3. For Business/Governmental Agency- Permit signing official's name and title:
(Person legally responsible for permit) r
4. Mailing Address 1_, )ccc n 11nSV
City: � � i 1� � _ State: JX Zip: --r7 -%
Telephone number: (� 1 °� )'7`l Fax number: (_)
EMAIL Address:',Y!
5. Physical Address of Facility/Wel () (if differe than ma' mg ad ss)
4`. �Ti
City: t 4! County: _ VCAM?= F Zip: ';7-
III. NEW OWNER / NAME INFORMATION
1. This request for a permit change is a result of:
—X a. Change in ownership of property/company
_ b. Name change only
_ c. Other (please explain):
2.
Permit/Name Change of Ownership Form Rev. 2-18-2020
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New O er's nam s) as listed on the property deed (Please Print/or Type):
3. If Business or Governmental Agency- Permit signing official's name and title:
(Person legally responsible for
4. Mailing Address: I l '
City: �a� _ State: C, Zip:
Day/Cell Phone No. �`) a�" V dI "�i7" Fax number: (�)
EMAIL Address: � C)0, t,
IV. CERTIFICATION
1. Current Permittee's Certification (Please print or type):
I, . attest that this application for name/ownership change has been reviewed
and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
application are not completed and that if all required supporting information and attachments are not included,
this application package will be returned as incomplete. I understand I will continue to be responsible for
compliance with the current permit until a new permit is issued.
2. New Applicant(s)'s Certification (Please print or type):
I/We, 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
further certify that I will operate and maintain the permitted facility in accordance with the permit and related
regulatory requirements.
Signature: Da' c:
Signature:
Date:
SUBMIT THE COMPLETE APPLICATION PACKAGE VIA ONE OF THE FOLLOWING METHODS:
U.S. Postal Service: Courier / Special Delivery / In Person:
Ground Water Resources Section Ground Water Resources Section
NC Division Of Water Resources NC Division Of Water Resources
1636 Mail Service Center 512 North Salisbury Street
Raleigh, NC 27699-1636 Raleigh, NC 27604 RECEIVED
Telephone Number: [phone] OCT 06 2020
NC DEQ/DWR
Central Office
Permit/Name Change of Ownership Form Rev. 2-18-2020 Page 2

II����f�Villl�l�lf,ll IIII
RECENED
20171106000219060 DEED
Bk:RB6387 Pg:36
11/06/2017 08:23:36 AM 112
OCT 06 2020
NC DEQ/DWR
FILED Mark Chilton
Register of Deeds, Orange Co,NC
Central Office
Recording Fee: �26.00
NC Real Estate X: $700.00 00
NORTH CAROLINA GENERAL WARRANTY DEED
Excise TaxA I 00Oo
Parcel Identifier No.�61Q� - Z 3 ' «�0 Verified by County on the day of , 20,___
By:
Mail/Box to: Margaret S. Davis, Alexander, Miller. Schupp
& Davis,_L.L.P., 1526 East Franklin Street. Ste. 202, Chapel Hill,
This instrument was prepared by: Alexander,
Miller,
& Davis. L.L.P.. 1526 East Franklin Street, Ste. 202, Chapel Hill.
Brief description for the Index: LoA ti 5
NUN
fS'chupp
`YlGfa
Sp� row
THIS DEED made this 3rd day of . _ November , 2017 , by and between
GRANTOR
S COTTD. DYRENG
and
CHELSEA B. DYRENG,
a married couple
202 S. Main St,
Manti, UT 84642
GRANTEE
CRISTIANAA. COSTA
and
NOAH B. CHASE, QS�et\an� i f\ cemmo"^
1811 Valley Creek Drive
Hillsborough, NC 27278
Enter in appropriate block for each Grantor and Grantee: name,, mailing address, and, if appropriate, character of entity, e.g.
corporation or partnership.
The designation Grantor and Grantee as used herein shall include said parties, their heirs, successors, and assigns, and shall include singular,
plural, masculine, feminine or neuter as required by context.
WITNES SETH, that the Grantor, for a valuable consideration paid by the Grantee, the receipt of which is hereby acknowledged, has and by
these presents does grant, bargain, sell and convey unto the Grantee in fee simple, all that certain lot, parcel of land or condominium unit
situated in the City of Hillsboroggh Township, Orange County,
North Carolina and more particularly described as follows:
BEING ALL OF LOT45, NEW HOPE SPRINGS, SECTION TWO, PHASE D,AS SHOWN ON THAT PLATAND SURVEY
PREPARED BY ENT LAND SURVEYS, INC., DATED DECEMBER 11, 1998, AND NOW ON FILE IN THE OFFICE OF THE
REGISTER OF DEEDS OF ORANGE COUNTY IN PLAT BOOK 83 AT PAGE 104 , TO WHICH REFERENCE IS HEREBY
MADE FORA MORE PARTICULAR DESCRIPTION OF SAME.
The property hereinabove described was acquired by Grantor by ins went recorded in Book page
All or a portion of the property herein conveyed X includes or woes not include the primary residence of a Grantor.
A map showing the above described property is recorded in Plat Book page
Page 1 of 2
Submitted electronically by Alexander. Miller & Schupp. LLP in compliance with North Carolina statutes f!overninq recordable documents and the
terms of the Submitter agreement with the Orange CounIX Register of Deeds.

Q ����IWDI�IuN�pIIMiYIIYlIII
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto belonging to the Grant" In fee
simple.
And the Grantor covenants with the Grantee, that Grantor is seized of the premises in fee simple, has the right to convey the some in fee
simple, that title is marketable and free and clear of all encumbrances, and that Grantor will warrant and defend the title against the lawful
claims of all persons whomsoever, other than the following exceptions:
IN WrMESS WHEREOF, the Grantor has duly executed'the foregoing as of the d4 and yeg first above written.
(Entity Name)
Prinrl We Name & 71tic:
By (S MU
PrinVtjype Name & 714� - _ - PrIwA) pe Name!
Priat/lype Name & Title._ PrinVPype
.Stmeof CountyorGityof ► �;: i'
1, the undersigned Notary Public of the County or City of and 0(nfe_gfo s'q dl certify thAll
SCOTrD. DYRENG and wife; CHELSEA B, DYRENi _personally rsonallystppear+ed beforek , tli dayand'iDd�fa le edth
execution of the foregoing lastrurmw for the purposes therein expressed. Witness my hand and ,IJo p) a`tamp or seal rsj%.dny i
. 20 17
Op
My Commission Expires: d
(Affix Sea])
Notary's
01
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State of - County or City of `- s
I, the undersigned Notary Public of the County or City of and State aforesaid, certify that
personally appeared before me this day and acmowledged thedue
execution of the foregoing Instrument for the purposes therein expressed: Witness my hand and Notarial stomp or seal this day of
20_.
My Commission Expires:
(Affix Seal)
__.Notary Public
Notary's Printed or Typed Name
State of - County or City of
L the undersigned Notary Public of the County or City of and State aforesaid, certify that
personally came before me this day and acknowledged that
-he is the of , a North Carolina or
eorporatioollimited liability company/general partnership/limited partnership (strike through the
Inapplicable), and that by authority duly given and as the act of such entity, —he signed the foregoing instrument in its name on its
behalf as its act and deed. Witness my hand and Notarial stamp or seal, this day of 20_.
My Commission Expires:
(Affix Seal)
NC Bar Assoctettoa Form No. 3 A 1976, Revisad O 1977, 20t1Z, ?.a13
PrIaW by Apmwent with the NC Bar Aarocradon — 1931
Notary's Primed or Typed Name
Public
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71tis standard farm tun beta approved %.' O�Q
CarWW Bar Auodadoo -NC Bar Farm Na 3
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TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtanances thereto belonging to the Grantee in fee
simple.
And the Grantorcovenants with the Grantee. that Grantor is seized of the premises in fee simple, has the right to convey the same In fee
simple, that tide is marketable and free and clear of all encumbrances, and that Grantor will warrant and defend the tide against the lawful
claims of all persons whomsoever, other than the following exceptions:
IN WITNESS WHEREOF, the Grantor has duly executed the famVing as of the der and yeg first above written.
(Entity Name)
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State of - County or City of
L the undersigned Notary Public of the County or City of and State aforesaid. certify that
pe =nallyappearedbefommethts daymOnclmowledgedthedue
exemnion of the foregoing Inawment for the purposes therein expressed: Witness my heard and Notarial stamp or seal this day of
. 20^.
PriaVlYpie Name & lisle'
$r. (SEALI
Printfrype Name & Titles_ - PrWrype Name,
By,
Frintll)pe Name & Tills.`
Printfrype
Smeof O-Xf-007-t) CountyorGityof -Z. ........ ..
I. the twdersigned Notary Public of the C or City of and liifc tjfo way
SCOTTD.DYREN(3eeadwrife CHEL5EA13.D _ `'"
_ Q personallyappeatedbesfoj& thlfefuyand ' le
execution o foregoing Instrument for the purposes therein expressed. Witness myhand and.Nq nl stamp or seal is�f
20-9
©cmo6em . . T. .
My Commission Expires• _ G
(Affix Seal)
My Commssion Expires:
(AMx Seal)
Notary's
----- Notary public
Notary's Printed or Typed Name
State of - County or City of
L the undersigned Notary Public of the County or City of and State afomaid, certify that
personally came before me this day and aalntowtedged that
—be is the of , a North Carolina or
cogmr atioa/ltmited-liability company/general partnenhipllimited part umbip (strike through the
Inapplicable), and that by authority duly given and as the act of such entity, _jm signed the foregoing Instrument in its name on its
behalf as its act and deed. Witness my hand and Notarial stamp or seat, this day of 20_.
My Commission Expires:
(Affix Semi)
NC Bee Assockdw Poem No. 3 A 1976, Revised 01977, 2tiaQ, 2013
MOW by Agxman adth the NC Bar Assadui® — 1981
Notary Public
Notary's Printed orTypext Name M �®
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Ibis standod fora, tuu been a
i MOW aar Asso"an - NC Bar F=m No. a GO�Qefe

le* C
17 52 Property Tax Bill Detail
Y
b Ats
COSTA, CRISTIANA A
Property Tax
Real Property
CHASE, NOAH B
Description:
45 SEC 2 PH D NEW HOPE
Bill Status:
UNPAID
SPRINGS P83/104
Bill Flag:
Bill #:
0000308738-2020-2020-0000-00
Location:
1811 VALLEY CREEK DR
Old Bill
HILLSBOROUGH NC 27278
Old Account #:
Mailing Address:
1811 VALLEY CREEK DR
Due Date:
9/1/2020
HILLSBOROUGH NC 27278
Interest Begins:
1/6/2021
Parcel #:
9862231960
Lender:
930
Real
Deferred
Use
Personal
Exempt & Exclusion
Total Assessed Value
Value Rate Tax Districts
$357,000 .86790RANGE
$0
$357,000 ORANGE
$0
$0 RANGE
$357,000
0681(-ROVE FIRE
lescription Amount
ax $3,098.40
(range County Solid $142.00
Jaste Programs Fee
$243.12 1
Interest: $0.00
Total Billed: $3,483.52
Last Payment Date
Discounted Correct Due if paid by 8/12/2020: $3,483.52
Discount Period: 07/01/2020 - 08/31/2020
RECEIVED
OCT 0 0 2020
NC DEQ/DWR
Central Office
0000348352620202020000000003087380