WI0800248_Application_20211201

North Carolina Department or Environmental Quality
Division of Water Resources
PERMIT NAME/OWNERSHIP CHANGE APPLICATION FORM
I. INSIRUCTIDNS.
I , Complete this form in its. entirety as fol lows:
{a} Chance of Ownership — Provide Ilre information in Paws 11 and III and subm it legal documurtaiion of the
Iransfcr of ownership such as a contract, deed, article of incorporation, etc. The cmrtiiic-nliorra in part IV
must be signed by both the current permit holder, ilravailotile, and the mew applicqnr(s).
(h) Narne Change LIMN — Provide the information in Farts 11 aard 111. Sign the certiIii a#ion for the new
app]irarL in part IV.2.
2. SubmiL the properly ooaripleccd form to the address on bottom of Page 2_
L CURRENT ram IT INFORMATION
I_ Permit NUM hers l lei 450e6ajq-li
2_ Acrmirtcc nsme(s): c.0+u r-L E.I LA H ,+!'
3_ For BusinessiCrovernin nt l Agency- Permit signing official's name and ldLle: lJ )A
(Eason i gal ly responsible for perm ill)
4. Ihlailinfi Addies-s! a't_. ok‹i ie iv e.
City: rr,IP 571r5PArti SLai e: 13 6 Zip 5
Telephone number, 1 (f a) ± 4 O Tto Fax number: ( ) x A.
EMAI Ls Addre ; F� e� (csc nr 4,ti r C. .
AA
EitgsgdAdclrm of Facility/WOW {if different than rnai I irk address)
bar
City:
Cam„ Zip:
111, NEW OWNF 1 NAME INFORMATION
I . Ibis request Fora permit change is a resullt F
a. Cbanze in ownership ofprape tyicompeny
b_ Name change only
o. Other (please explain):
I rmi11N rrK'Ch n&of iloci-ahij+Fc i Rev_ 2-IF1-20r20
Page ]

2. New Owner's narnWs as Listed on She property dead (PIeaie Frith. or Typo:
tT CL
> x� u
3. lc Businees or Governmental .agency- permit signing 0.f1.cial's name and title: r`)
(Person legal Ik responsible for permit)
i. Mailing Address:
{'it}.. State._ Zip:
GDyfCel I Phone No. ( ) Fax num bed ( }
EMAIL Address:
I V. j T I FIc.4TIoN
I. Cumin[ Fermium's Certification (Please prioi or type):
], , _ eAiest that this appl i4iii imrr for name ev i ership chimp has been reviewed
acid i$ accurate and c mplete 10 the best or my knowledge. L understand that if all required parts of this
opplieation are not c,alnpleted and that i f al I requited supporting information and attachments are not included,
this application peke will be returned as i ncom p[ele, [ understand I will ctz'ntinue o be responsible for
compliance with the current permit until a new permit is issued,
2. New Applirant(sYs Certification (Please print or t;rpe);
111We, 1 ± : . c'E U , attest firer this spplicerion for
narmr rnunership change h,.; borer rev dewed and is accurate iirid complete to the begs of my knowledge_ i
understand Chia i r all required parts of this applits]lion are not c inpleieri and that if all required suppori ling
information Rasa attachments are nut included, this awl ration p ukage will be returned as ifterin ode. 1 Further
certif+' Thai t will operate andmaintain the permitted facility in acrordance with the permit and related resliiata7
rc uirrm
Signature:
107-i
]
SU IL3MFT THE COM METE APPLICATION PACKAGE VIA ONE OF THE FOLLOW INC METHODS=
U.S. Posh]Se(vIti
Gr utmd Water Resources Section
NC Division Of Water Resouroe.s
1636 Mail Service CenteT
Raleigh, NC 27699-1636
5pccial Delivery / 1ri.Persoj
(?round Water Resource Section
NC Division Of Water- Rcsvuro
512 North Salisbury Sircet
Raleigh. NC 27604
Telephone Number; C919)707-9OcXJ
PcrrniVNinm Chas a UrIV rstrIpFrail I Fit•. 2-L
Page z

North Carol in a Department of Environmental Quality — Division of V4'atcr Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL ES}
In Accordance 'Whh the Provisions of ] SA NCAC ' _0224
GEOTHERMAL HEATING/COOLING WATER RETURNi WELL S
These welks) injcc1 groundwater dinwi Iy inRo. the subsurface as part of a geothermal anti cooling spsiein
CHECK Q JE OF THE FOLLOWING:
New Application Renewal* Modification Permit Rescission Req nas:I*
*Pm. Permit Renewals or Rescission Request', complete 6.ctrons A trio E. and M l u iii ore page] only
Pry or ;rye Arrictirmariotr and .kira ro the Address on the Last Page. lfegrtfe Appfncor* m Ff'i d & Ri.'rirrnerf.-tv incomplete
DATE: Nov 17 , 20_21 _ PERMIT NO.. ([cave blank i f New Application)
A- CURRENT V4' F:I.I. USE & owr'ERSHI P STATUS (Leave Blank if New Well/Fermi 1 Application)
1, Current Use of Well
a- I wish to continue to tree the well as Geothermal Well 0 Drinking 'Water Supply W'c I I
Other Watcr Supply Use. [ndicate use (i_e_, irrigation, etc,)
�_ Terminate. Use; lithe well is no ]irti - being used as a geothermal injection well and you wish to
rewind the perm il, ..ht uk the bo:s below, if abandoned, attach a copy of the Well Abandonment
Record (GW-3c)_
❑ Yes, ] wish rti rC'ic i nd she pain it
2. Current Ownership SORBS
Has there been a change of ownership since permit last issued'? OYES 0 NO
If yes, indicate New Owner' contact information:.
N nc(s) Sots & Sheila 5.1.thultz
Mailing Address- ] 1.I Golf Terrace Drive
e
City; _. Hampstead Slate: NC_Zip Code: 2 143 County, _ USA
Dad' 'l ele No,; 602-11 a-5976 Em i I .Address.: shot Iaschtrhm$3(a�e mail,ccur
R. STATUS OF APPLICANT (choose one)
Non-Cravetimient: Individual Residence [3usinessiOrgan izetion
Government: State Municipal County Federal
C. OV4'NER(s).+PERMIT APPLICANT - For single family rnsidenccs_ list all persons I irked on the
property deed. For al I t}ncCrs. list name of business/agency and name of person, gml. title wilts delegated authority
ko sign: Seat Schultz Shci la Sch pltz
Mai]ir►g Address; 11Terrace Drive
City: Hernpst State: _NC_ Zip Code:284.a3 County; Fender
Day Tele Na2-d I -597 Cell No_1502-4 I 1976
RMAII_ Addy s- shei]aschu]i2S3q aileora Fax No,;L`+N1A
otib-weal 11 Eger Reim Well Pernjii Alva- teorm R*K, 4.15-2O 16 Page 1

D. WELL OPERATOR (if different from well owner) — For single family FC5idiCIIDC5, list all persons listed an
the property deed. Fora!! others, I i ss natne I5usinessioigencylA name of peen and title with delegated authority
to sign; f
Mailing Address:
City: Stale: Zip Code: County:
Day 'Tele No.: Email Address_:
E. PHYSICAL LocATiori OF WELL(S) SITE
(l) Parcel Identification Humber (P[N) of well site: 3 ,(n' Sltolg' County! Pt= r-) e.
) Physical Address (if different than mailing 8ddre5}_ FJ+c
Oily; County Zip Cade:
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drifting Contractor Certification No.:
Company Name; _
Contact Person: EMAIL Addressl
Address:
City_ Zip Code: _ Stale: C corny
Office Tele No-: Cell N _: Fax No.:
G. HVAC CONTRACTOR INFORMATION {if di Weren't than driller)
HVAC Contractors Name;
NC I-EVAC Contractor license No.:
Company Name
Contact fin; EMAIL Address:
Address;
t ity: Zip Code: _ Slate: _County;
Office Tele No.: Cell Na_: Fax No.;
H. WILL USE Will the injection wc110)) also be used a the supply we] Ids) for lihe following?
(I)
(2)
The injedion operation?
Personal consumpiion?
YES.
YES
NO
NO
1. WELL CONSTRUCTION REQUIREMENTS -. A pe i find In 15 }i NCAC 1 ' .c 22.1 f d j:
(I) The water supply well shall be cimsirucied in ac:curdance with the water supply well requirements of'
I SA NCAC U2C _0107.
(2) ] f a vMe]] is used io inject the heat pump elifluont, limn thy injection vMell shall be constructed
in aceor dnnce'r'rith the water supply well requi r@uient5 of I SA NCAC 02C .O 107, except that:
Geolfrerrilol Waier Reiter'. Well Penult Affilimtion RE'L'. A.] Aflo
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NOTE-. hi' rnosd ODES orr1 Mehra! pilaregruph of the prrgJefat Parcel sf4owfrrg pr#pefiy lines are "I'4:r"re.¢
pbtoini d and dowrtioarieri from Me Applicable mow" G'IS website, TyPireNy', r e pravpertY oak be' se4 rched h ,
owner home or a difre'.'. The location of fIc was iror Maim to propentf hehi dories. ArtsliSeN, srprlt tawks, other
weftsi etc. can rkra9 be rir+rwIa in by bind Ake; 'layer' carp be seferreai laPEIP aphir mower of efevatrrnr
data
M, C. FRT1FICATIUIN (to be signed as required below or by that persons authorized agent)
15A NBC 02C .0211(e) requires that all. permit applications shall be signed as fr�Llrrs� s:
S. for a corporation: by a responsible corporate of cCr
2_ for a partncrship or sole praprictcrship: by a genera] partner pr the proprietor, rc p ti Iy;
3. for a municipality or a state, federal, or either public agency- by either a principal executive Vicar
or ranking public ly elected oftic ial,
4. for All others: by all the per aiti(s) 1 ism on the propertiy dew,
If art aau1ho ri d agent is signing on behalf of the applicant, then supply a letter surfed by the
applieurrt that names And authorizes their agent to sign this applicaiiurl en their I}ckalr.
hereby certi ty, under penalty of law, ghat I have personally examined and am tam i I iar with the information
suhrnined in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately rc pa nsihIe for obtaining said information, 1 believe that the in tormatLoii is true. accurate and
complete. I am aware [hat there are significant penalties, including the pc 5si bilily of fines and imprinnmer
for submitting false informiitiun, I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances In accordance with the approved specitication5 and conditions of the
Permit.--
SClid*--
signature of Prope ever er'Appl leant
_Sheila M Schultz, Owner
Print or Type Full Name gad. Title
Signa[ufe of Property Owner'1 ppl icant
Scott A Schulte, Owner
Print or Type Full Name and Title
Signature of Authorized Agent, i f any
Print or Type Full Name and Title
Submit t++rn eopies of the completed application package to:
Division of Water Resources - U Ic
Water Quality Regional Operations Section (ROS)
1636 1 aiI Senice Center
Raleigh, NC 27699-1636
T€l€phone [phone]
CreDtherrnaL Renn.n well Permii Aro1 iLn it n I. .. 4-15..,2ll 16 Page