WI0700458_Application_20220509 (2)

RECEIVED
MAY 0 9 2022
North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTIO6OWN
In Accordance With the Provisions of 15A NCAC 02C .02'
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 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. WI0700458 (leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New WelUPermit Application)
1. Current Use of Well
a. I wish to continue to use the well as ® 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 k NO
If yes, indicate New Owner's contact information:
Name(s)
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
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 o ers, list name of business/agency and name of person and title with delegated authority
to sign: l-01it... +- AlS2
Mailing /Ad11dress: 43?- M r I I �,o
W 2S
City: 1k*Trb 10 State: NC- Zip Code: a-1 $ i County: IkPdia. -Or+
Day Tele No.: aS.)--1 q575 -1
EMAIL Address: (f ,t t4410 1 dk4.70: CO »P' Fax No.:
Ce11 No.:
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: ) Pr
City: State: Zip Code: County:
Day Tele No.: Email Address.:
E. PHYSICAL LOCATION OF WELL(S) SITE P I a— oX n°q 0/0 p n
(1) Parcel Identification Number (PIN) of well site: & P 56 7g-6'063 County: pC�C°�c -1L0"
(2) Physical Address (if different than mailing address):
City: County Zip Code:
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name: .fir & 6LLt`CKYI U6
NC Well Drilling Contractor Certification No.: f .Z I w3 —�
Company Name: 51 t c 6t mks W Q.(l aft 1110
Contact Person: a 6 11 -4 C s.Lt 5 EMAIL Address:
Address: C 3 629 Lk I S, i h )..VI E
City: k;p j.J-, ij4,rin Zip Code: 47 gg. 1 State: PC. County:
Office Tele No,: Cell No.:
Fax No.:
G. HVAC 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)
(2)
The water supply well shall be constructed in accordance with
15A NCAC 02C .0107.
If a separate well is used to inject the heat pump effluent, then
in accordance with the water supply well requirements of
the water supply well requirements of
the injection well shall be constructed
15A NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application Rev. 4-15-2016
Page 2

(3)
(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.
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:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
(c) Casing depth below land surface
(d) Casing height "stickup" above land surface
(e) • 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)(8)
(f) Length of well screen or open borehole and depth below land surface
(g)
Length of sand or gravel packing around well screen and depth below land surface
K. OPERATING DATA
(1) Injection Rate: Average (daily) gallons per minute (gpm).
(2) Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: 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 .0211(e) 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."
gnat* of Property
operty Owner/Applicant
Qio 14t5fYI. Pr7 +4/ nv11 r
Print or Type Full Name and Title
Neer
Signature of Property Owner/Applicant
1JiS FiPt Y ,R P p-rCLOD'
Print or Type Full Name 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 - 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
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
In Accordance With the Provisions of 1SA NCAC 02C .0224
GEOTttERMAL 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 }Renewal* Modification Permit Rescission Request*
*For -Permit Renewals or.Rescission Rat,, complete Sections A thni E. and M (signature page) orgy
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: 20 PERMIT NO. (leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Biankif New Well/Permit Application)
I, Current Use of Well
a. I wish to continue to use the well as 01. Geothermal Well 0 Drinking Water Supply Well
0 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 youwish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abartfewitto
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? 0 YES NO
If yes, indicate New Owner's contact information:
Name(s) _
Mailing Address: --
City:
Day Tele No.:
MAY 0 9 2022
NC DEQ/DWR
Central Office
State: Zip Code: County:
Email Address.:
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 otters, list name of business/agency and name of person and title with delegated authority
to sign: 1-- �? i'Devvi.se A J.
Mailing Ad dress: 41-3id
City: _ Wf'6311MbirD M State: Zip Code: c}) S County: P- .t'ot.4- t"+
Day Tele No.: ? 5 N Cell No.: g-S-.01
EMAIL Address: arA61#640 4 di-m COI Fax No.:
Geothermal Water Return Well Permit 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 and name of person and title with delegated authority
to sign: _
Mailing Address:
City:
Day Tele No.:
kpi
State: Zip Code:
Email Address.:
County:
E. PHYSICAL LOCATION OF WELL(S) SITE P �-- l 0a 004r? R
(I) Parcel Identification Number (PIN) of well site: (r►' 5178" 7 1'063 County: Ee - e+
(2) Physical Address (if different than mailing address):
City:
County Zip Code:
F WELL DRILLER INFORMATION
• Well Drilling Contractor's Name: (lei 6 0-erWc,
NC Well Drilling Contractor Certification No.: .Z i p 'ft
Company Name: 5 6 Lke () Q, I l N i I1 t y�j
Contact Person: Tali (ii. i t EMAIL Address:
Address: c134,9 u A, Nag 161 E.
City: l P t la-, to 4fril t l Zip Code: }) / State: County: ier ri.
Office Tele No.: _ Cell No.: Fax No.:
G. HVAC 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) The injection operation?
(2) Personal consumption?
YES NO
YES NO
L WELL CONSTRUCTION REQUIREMENTS — As specified in 15A NCAC 02C .0224( d
(1)
(2)
The water supply well shall be constructed in accordance with the water supply well requirements of
15A 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 15A NCAC 02C .0107, except that:
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 2

J.
(3)
(a)
(b)
For screen and gravel -packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
A sampling tap or other approved collection equipment chill 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.
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:
(a) Depth of each boring below land surface
(b)
(c) Casing depth below land surface
(d) Casing height "stickup" above land surface
(e)
(1)
(g)
K. OPERATING DATA
Well casing and screen type, thickness, and diameter
Grout materials) 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 NC4C 02C .0107091) .
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
(1) -i---Injection Rate:- ----
(2)
(3)
.(4)
Injection Volume:
Injection Pressure:
Injection Temperature:
Aver -age (daily) _ gafio nute4gpm).
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 :02245 b Oh 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(02) 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 `layers 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 .0211(e) 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.personfs) 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, retsair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of the
Permit."
Owner/Applicant
-PfYYL. P -
Print or Type Full Name and Title
Signature of Property Owner/Applicant
i)E +J1SE F'HP-T Prp
Print or Type Full Name and Title
Signature of Authorized Agent, if any
Print or Type Full Name acid 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
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL(S)
In Accordance With the Provisions of 15A NCAC 02C .0224
GEOTHERNIAL HEATING/COOLING WATER RETURN WELLS)
These wells) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK, ONE OF THE FOLLOWING:
New Application )(Renewal* Modification Permit Rescission Request*
*For Permit Renew orResc�ionR complete
� Sections Admit E. and M tsignatuze fie) 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. (leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Weil/Permit Application)
1. Current Use of Well
a. I wish to continue to use the well as IN Geothermal Well 0 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).
0 Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? 0 YES k NO
If yes, indicate New Owner's contact information:
Name(s)
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
B. STATUS OF APPLICANT (choose one)
Non -Government Individual Residence X. Business/Organization
Government: State Municipal County Federal
C. WELL OWNER(S)IPERMIT APPLICANT — For single family residences, list all persons listed on the
property deed. For all others, list name of business/agency and name ofperson and title with delegated authority
to sign: ke.0 tit - beMSE M Qy'f
Mailing Address: 4 11 I Exod
City: Wd�P 4htd6trb iN State: NC- Zip Code: a"? 8 81 County: 12,e6LASOff
Day Tele No.: .??5)- q5-)-1 Cell No.: 1345- -1-1
EMAIL Address: + diLoo: cookFax No.:
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: l
City: State: Zip Code: County:
Day Tele No.: _ Email Address.:
E. PHYSICAL LOCATION OF WELL(S) SITE P 1 u— t ~ C
(1) Parcel Identification Number (PIN) of well site: 6,P ` 08- 7/ `10 3 County: be --Po -
(2) Physical Address (if different than mailing address):
City: County Zip Code:
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name: 1-61 60..11E+5
NC Well. Drilling Contractor Certification No.: Q 1 an - Ft
Company Name: 5c Gu.rc, l u s iD Q.E1 dig 11119
Contact Person: 4,1 61 i , fc-AS EMAIL Address:
Address: Q 1109 1, St 1 Out Ito Li
City: biPfc 1.)-1 Pj kiln t ; Zip Code: ? gf State: % County: 6SLc: ''
Office Tele No.:
Cell No.: Fax No.:
G. HVAC 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) 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

(3)
(a)
(b)
For screen and gravel -packed wells, the entire length of casing shall be grouted from the top
of the gravel pack to land surface;
For open-end wells without screen, the casing shall be grouted from the bottom of the casing
to land surface.
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.
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 41all include, at a minimum, the following well construction specifications:
(a) Depth of each boring below land surface
(b) Well casing and screen type, thickness, and diameter
(c) Casing depth below land surface
(d) Casing height "stickup" above land surface
(e) 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(tfl8) :
(f) Length of well screen or open borehole and depth below land surface
(g) Length of sand or gravel packing around well screen and depth below land surface
K. OPERATING DATA
- - - (1) -_- -- --Injection Rate: - -
(2)
(3)
(4)
Injection Volume:
Injection Pressure:
Injection Temperature:
Average.(daily) moons -per- n ute-(gpm).
Average (daily)
Average (daily)
Average (January)
gallons per day (gpd)-
pounds/square inch (psi).
° F, Average (July) ° F.
L. SITE MAP — As specified in 15A NCAC 02C .0224( b )14), 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:
(I) 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(02 ) located within 250
feet of the proposed injection well(s).
(3) Property boundaries looted 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 photlt 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 .0211(0 requires that all permit applications chap 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 theperson(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 en 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."
gnatutof Property Owner/Applicant
Print or Type Full Name and Title
Afsi toy,
Signature of Property Owner/Applicant
OE .J SE Prop, CLOt"'
Print or Type Full Name 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 - 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 Page4