WI0100157_Regional Office Physical File Scan Up To 9/22/2022

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b
HCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Kenneth and Kathleen. Gootee
306Ma«nolia Drive
Metaire, La 70005
Division of Water Quality
Coleen H, Sullins
Director
June 21, 2011
Ref: Issuance of Injection Well Permit WIOIOO157
Issued to Kenneth and Kathleen Gootee
Cashiers, Jackson County, North Carolina
Dear Mr. and Ms. Gootee:
Dee Freeman
Secretary
,;�-ON 24 200
Asheville Regional Office
Aquifer Protection
In accordance with the application received on May 09, 2011, I am forwarding permit number WIO100157 for the
construction and operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system. This
permit shall be effective from the date of issuance until May 31, 2016, and shall be subject to the conditions and
limitations stated therein. Specific attention should be paid to the requirements to include a minimum depth of
20' for the injection well bentonite cap specified in Part I.3, the requirement to maintain a minimum distance
of 25 feet from any injection well and the residence as specified in Part I.4, to protect the well during
construction of the site as specified in Parts I.6 and IIA, and to submit well construction records as specified
in Part VII.2. Be sure to read the entire permit to ensure that you are aware of all compliance requirements of the
permit.
You will need to notify this office at least 48 hours prior to beginning construction and operation of the
injection well system. In order to continue uninterrupted legal use of the injection facility for the stated purpose,
you must submit an application to renew the permit 120 days prior to its expiration date. This permit is not
transferable to any person without prior notice to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or [e-mail] if you have any questions about your permit.
cc: cindcit Da ici'sQn Asl villa 12e�xionaLCfil-K—
WI0100157 Permit File
Jackson County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] FAX 1: 919-715-0588; FAX 2: 919- 1i 5-60481 Customer Service: 1-877-623-6748
internet: www.ncw.ateroualitv.org
Best Regards,
John 1V1cCrav
One
NolthCal-o111-1a
An Equal Opporlunry `, Anirmativa Action Employer

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION 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
Kenneth and Kathleen Gootee
FOR THE CONSTRUCTION AND OPERATION OF 4 TYPE 5QM INJECTION WELL(S), defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at 23 Wild his Trail, Cashiers, Jackson
County, and will be constructed and operated in accordance with the application received May 9, 2011, and in
conformity with the specifications and supporting data submitted, all of which are filed with the Department of
Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation of an injection well and shall be in compliance with Title 15A of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until May 31, 2016, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 21 st day of June, 2011.
J
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #W10100157 UIC/5QM Page 1 of 5
ver. 03/2010

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must 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). Any 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 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.
3. Bentonite grout must extend to a minimum of twenty (20) feet in depth and will penetrate five (5) feet
into consolidated bedrock.
4. Injection wells shall be placed at a minimum of twenty-five (25) feet from the residence.
5. Each injection well shall not hydraulically connect separate aquifers.
6. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
7. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II — WELL CONSTRUCTION SPECIAL CONDITIONS
1. The well head shall be protected throughout the drilling and construction process. In the event that
temporary casing is left in the borehole for a portion of the drilling and construction process, it shall be
covered with a secure, water tight cap. Temporary casing shall terminate no less than 12 inches above
grade.
2. At least forty-eight (48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number [phone], and the Asheville Regional Office Aquifer Protection Section Staff, telephone
number [phone].
3. The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation corners) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
4. One well identification tag per grouping or `cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g).
PART III — OPERATION AND USE GENERAL CONDITIONS
1. 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.
Permit #W10100157 UIC/5QM Page 2 of 5
ver. 03/2010

,�
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). 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 to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. 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.
PART IV — PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. 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 including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
ground water resulting from the operation of this facility.
PART V - OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number (919) 71 5-6168. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
PART VI - INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, 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 permit, 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.
Permit #W10100157 - UIC/5QM Page 3 of 5
ver. 03/2010

2. Division 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 and appropriate samples associated with the
injection facility activities.
PART VII — MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section — UIC Program Aquifer Protection Section
DENR — Division of Water Quality Asheville Regional Office
1636 Mail Service Center and 2090 U.S. 70 Highway
Raleigh, NC 27699-1636 Swannanoa, NC 28778
Ph# 919-715-3221 Ph# 828-296-45UU
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Asheville Regional Office within 30 days of completion
of well construction. Copies of the GW-1 form(s) shall also be given to the Permittee and retained on site
to be made available for inspection.
3. A copy of the site map updated with manifold locations required in Part II.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Asheville Regional Office within 30
days of completion of well construction.
4. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection will be established and an
acceptable sampling reporting schedule shall be followed.
5. The Permittee shall report by telephone, within .48 hours of the occurrence or first knowledge of the
occurrence, to the Asheville Regional Office, telephone number [phone], any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure- due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
(C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
6. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
7. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
Permit #W10100157 UIC/5QM Page 4 of 5
ver. 03/2010

PART VIII — PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
PART IX — CHANGE OF WELL STATUS
The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(1).
Notification shall be submitted to the addresses given in Part VII.l of this permit.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if the
Director finds 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, if the Director determines that failure
to do so could lead to the contamination of an underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the well
through a pipe that extends to the bottom of the well and is raised as the well is filled.
(E) In the case of gravel -packed wells in which the casing and screens have not been removed, the
casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout
injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(1) within 30 days of completion of abandonment. .Copies shall be
submitted to the addresses given in Part VII.1 of this permit.
Permit #W10100157 UIC/5QM Page 5 of 5
ver. 03/2010

4.
��F WATFRQ State of North Carolina
�O G Department of Environment and Natural Resources
Uacowr Division of Water Quality
Aquifer Protection Section
Regional Staff Report
To: Aquifer Protection Section Central Office
Attn: John McCray
From: Jonathan Stepp
Choose an item. Regional Office
I. GENERAL SITE VISIT INFORMATION
1. Was a site visit conducted? ❑ Yes or ® No
a. Date of site visit:
b. Site visit conducted by:
c. Inspection report attached? ❑ Yes or ❑ No
d. Person contacted: and their contact information: (_)
e. Driving directions:
Application No.: WI0100157
Regional Login No.:
- ext.
II. PROPOSED FACILITIES FOR NEW AND MODIFICATION APPLICATIONS
1. Facility Classification: (Please attach completed rating sheet to be attached to issued permit)
2. Are the new treatment facilities adequate for the type of waste and disposal system? ❑ Yes or ❑ No
If no, explain:
3. Are site conditions (soils, depth to water table, etc) consistent with the submitted reports? ❑ Yes ❑ No ❑ N/A
IF no, please explain:
4. Do the plans and site map represent the actual site (property lines, wells, etc.)? ❑ Yes ❑ No ❑ N/A
If no, please explain:
5. Is the proposed residuals management plan adequate? ❑ Yes ❑ No ❑ N/A
If no, please explain:
6. Are the proposed application rates (e.g., hydraulic, nutrient) acceptable? ❑ Yes ❑ No ❑ N/A
If no, please explain:
7. Are there any setback conflicts for proposed treatment, storage and disposal sites? ❑ Yes or ❑ No
If yes, attach a map showing conflict areas.
8. Is the proposed or existing groundwater monitoring program adequate? ❑ Yes ❑ No ❑ N/A
If no, explain and recommend any changes to the groundwater monitoring program:
9. For residuals, will seasonal or other restrictions be required? ❑ Yes ❑ No ❑ N/A
If yes, attach list of sites with restrictions (Certification B)
FORM: APSRSR 04-10 Pagel of 3

III. EXISTING FACILITIES FOR MODIFICATION AND RENEWAL APPLICATIONS
1. Are there appropriately certified Operators in Charge (ORCs) for the facility? ❑ Yes ❑ No ❑ .N/A
ORC: Certificate #: Backup ORC: Certificate #:
2. Are the design, maintenance and operation of the treatment facilities adequate for the type of waste and disposal
system? ❑ Yes or ❑ No
I.f no, please explain:
3. Are the site conditions (e.g., soils, topography, depth to water table, etc) maintained appropriately and adequately
assimilating the waste? ❑ Yes or ❑ No
If no, please explain:
4. Has the site changed in any way that may affect the permit (e.g., drainage added, new wells inside the compliance
boundary, new development, etc.)? ❑ Yes or ❑ No
If yes, please explain:
5. Is the residuals management plan adequate? ❑ Yes or ❑ No
If no, please explain:
6. Are the existing application rates (e.g., hydraulic, nutrient) still acceptable? ❑ Yes or ❑ No
If no, please explain:
7. Is the existing groundwater monitoring program adequate`? ❑ Yes ❑ No ❑ N/A
If no, explain and recommend any changes to the groundwater monitoring program:
8. Are there any setback conflicts for existing treatment, storage and disposal sites? El Yes or ❑ No
If yes, attach a map showing conflict areas.
9. Is the description of the facilities as written in the existing permit correct`? ❑ Yes or ❑ No
If no, please explain:
10. Were monitoring wells properly constructed and located? ❑ Yes ❑ No ❑ N/A
If no, please explain:
11. Are the monitoring well coordinates correct in BIMS? ❑ Yes ❑ No ❑ N/A
if no, please complete the following (ex and table if necessary):
Monitoring Well
Latitude
Longitude
0 II
0 , II
0 It
0 ,It
0 It
0 ,ff
0
0 , //
0 , „
0 ,
1.2. Has a review of all self -monitoring data been conducted (e.g., NDMR, NDAR, GW)? ❑ Yes or ❑ No
Please summarize any findings resulting from this review:
13. Are there any permit changes needed in order to address ongoing BIMS violations? ❑ Yes or ❑ No
If yes; please explain:
14. Check all that apply:
❑ No compliance issues ❑ Current enforcement action(s) ❑ Currently under JOC
❑ Notice(s) of violation ❑ Currently under SOC ❑ Currently under moratorium
Please explain and attach any documents that may help clarify answer/comments (i.e., NOV, NOD, etc.)
15. Have all compliance dates/conditions in the existing permit been satisfied? ❑ Yes ❑ No ❑ N/A
If no, please explain:
16. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit?
❑ Yes ❑ No ❑ N/A
If yes, please explain:
FORM: APSRSR 04-10 Page 2 of 3

4,-
IV. REGIONAL OFFICE RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes or ® No
If yes, please explain:
2. List any items that you would like APS Central Office to obtain through an additional information request:
Item Reason
3. List specific permit conditions recommended to be removed from the permit when issued:
Condition Reason
4. List specific special conditions or compliance schedules recommended to be included in the permit when issued:
Condition
Reason
Bentonite grout cap shall
Bentonite grout indicated in permit to extend 5 feet into consolidated rock with
extend a minimum of 20
no minimum grout depth stated
feet below ground surface
Well or well system shall
Well construction plan is to fill borehole with pea gravel for most of the length
be no less than 25 feet from
and cap the borehole with bentonite; the permit application indicates that at least
any building perimeter
one of the wells will be less than 25 feet from a building perimeter
5. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office
❑ Hold, pending review of draft permit by regional office
❑ Issue upon receipt of needed additional information
® Issue
❑ Deny (Please st to reasons: )
6. Signature of report preparer:
Signature of APS regionaP upervisor:
Date: v
V. ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: APSRSR 04-10 Page 3 of 3

Beverly Eaves Perdue
Governor
Kenneth Gootee
Kathleen Gootee
306 Magnolia Drive
Metaire- LA 70005
i.
KDENR
North Carolina Department of Environment and Natural
Division of Water Quality
Coleen H. Sullins
Director
May 19, 2011
Subject: Acknowledgement of Application No. WI0100157
Kenneth & Kathleen Gootee SFR
Injection Mixed Fluid GSHP Well System - SFR
Jackson
rce Neville Regional Office
W Lol_llfer r" 1; rem �i q
Secretary
Dear Mr. & Mrs. Gootee:
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on May 9, 2011. This application package has been assigned the number listed above and will be reviewed by
John McCray.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be -aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 - 90 days after receipt of a complete
application.
If you have any questions, please contact John McCray at 919-715-6168, or via e-mail at [e-mail]. If the reviewer is
unavailable, you may leave a message, and they will respond promptly.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
OUJt^',
for Debra J. Watts
Supervisor
cc: Asheville Regional Office, Aquifer Protection Section
Tarheel Water Treatment, Inc (Michael McClure)
Andrews Auld Heating & Cooling (Bruce Auld)
Permit Application File WI0100157
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] l FAY 1: 919-715-0588: FAX 2: 919-715-60481 Customer Service:1-877-623-6748
Internet: www.nmateroualitv.org
An Ecual Gpponunity'� Ammative Action Emplover
One
No thCaloiina

e .
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS r
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP MIXXFD-FLUED GEOTHERMAL INJECTION WELLS
o
These wells circulate fluids other than potable water as part of a geothermal heating and cooling system rrb
/' Renewal* Modification
(check one) ✓ l�iew Application
For renewals complete Parts A-C and the signature page.
or Type Information and Mail to the Address an the Last Page. Illegible Applications Will Be Retwned As Incomplete.
DATE: y-o?.D , 20�
PERMIT NO. NM'1) 1. t-) (� (t3 __ (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non -Government: individual Residence ✓ Business/Organization
Government: State Municipal County Federal
PERMIT APPLICANT — For individual residences, list each owner on property deed. For all others,
state name of entity and name of person delegated authority to sign on behalf of the business or agency:
C, UCG'TC G I )_11, tl_:� VN ev W
�(�CT�C j�ATH +✓� /�
Mailing Address: 3 c(-2
City: M iaz `r A � 1Z State: 1...A Zip Code: �5 County:
Day Tele No.: 5 04 32�5Z r G Cell No
EMAIL Address: en C?O# fl Fax o.:
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(]) Parcel Identification Number (PIN) of well site: 751 3 -3Q 85 -5 County: 50r�
(2) Physical Address (if different than mailing address):
iQ-)L)
City: q 5111`S State: NC Zip Code:�7
D, WELL DRILLER INFORMATION
Well Drilling Contractor's Name: L�IdF fit- f� ram'
NC Well Drilling Contractor Certification No.:
Company Name:_ �n \ -r� r'�' I l A f
Contact Person l,,Yttl�Cy�1 ���C- ��P EMAIL Address
Address' 3 L! -1 `4 C7f-0 C %CS2
r-7 ilk Ni11 Zip Code: A .�D t -7 qstate: &txounty: :1
City: 4
Office Tele No.:, J92- 3%9- 07410 Cell No.:
Page ]
GPUMC 5QM Perni t Application (Revised 112412011)

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: LZg,,F- W 5 A v LrP j-- Kl.N (-t L 4C L K &`
m
n
J
1'1
\
'11U
Contact Person f-� It -J LJ V L �2 EMAIL Address• 6 ^J
Address: '-2-2, 4--p
0 z
1� ry: ,{M
City: '1` tip- p1 FL 1� l A J Zip Code: c=�� State Coun
-
G
Office Tele No.: fh7 Z Cell No: �� ' 3 �/ ' Z ) Fax 90 , 34� 1- ( fZ
Q
F. WELL CONSTRUCTION DATA
a
borings to be constructed*: Depth of each boring (feet): (R n
(1) Number of —
* If existing water supply wells will be used then provide the information in item (4) below.
(2) Chemical additives to be used: R-22 Propylene glycol Ethanol Ll
i
Other (other additives will need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc):-
(4) Well casing. If the well(s) will use casing then provide the type (steel, PVC, plastic, etc.), diameter, doh,
%A
and extent of casing appearing above ground:
0
c�
(5) Grout (material surrounding well casing and/or piping): 1A
`� p ca.�e� Cu�aShe �
(a) Grout type: Cement Bentonite** Other (specify) 4 � � o ^� ° • t-)
•* By selecting bentonite grout, a variance is hereby requested to I SA NCAC 2C .0213(d)(t )(A), which requires a cement type
gmm
(b) Grout depth of tubing (reference to land surface): from .LJ— to 230 (feet)
If well has casing, indicate grout depth: from to (feet)
G. WELL LOCATIONS — Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1) Attach a site -specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1 /4 mile from the injection well site that indicates the
facility's location and the map name.
NOT& 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 webske. Typically, the property can be searched by
owner nano or address. The location of the wells in relation to property boundaries, houses, sepdc tanks, other
wells, eta can then be drawn in by hand Also, a `layer' can be selected showing topographic contours or
elevation data.
CpUMIC SQM Permit ApplicaWon (Revised 1/242011)
Page 2

05/0402811 -07:44 1328-349-4662
AN DREWS AUL.A
m C)E9amICAYMN (to be d9wd as rapimd WOW or by tb§t MUM'S Mtborized't)
PAGE 04/04
15A NCAC 02C .02110) MOM that xh pertnit ap*afiaas shall be dpW as follows:
1. for A QmPmadon% by a mpp%Wbk corpod t officer,
2- for a "MKS* or $do ptvptie ovAip: by a gwwat parwr or lire pr+a dew, m8potively;
3. fm a mmkip * or a state, federal, or oar public agency: by either a principal executive
Viers cc rates pt&&Iy elected official;
4. for all o3 mv, by the well OwAec (which a #S� $11 oi�ssotrs lamed an tea nroaerty deedl.
It an a� m as wbw of tt3e � "My a letter by tkee
appr
mattw amm aw 6160rhm tb&agmt to sip thb applimaaa as titer babalf
" 1 hereby ,trader pwift of law, ti* t bane personally wed and am familiar with tfta ivafOrmudw
submiMd is VIb & m mt and aU atW mtcttm ttterata and tiler, based On ray LuQWry of those Mvidttals
sty responsible far obralntng said itafotm&dM X believe drat the ix►fora ,Qn is true, aflcutate sad
mow, l am awam tl>at twe ate sig mew pmaldes, inctdding fire law" Of and ant,
for subtttittlog fatse iettOnoaatioat. 1 agree to cr m% apmoo, maw, rep*, and 11 eppplkdWe, 6midan she
Wje� well and all reldtted qMtmw9S is ?=Otdom with dte app vvmd ad cvntt16M of
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Roles, NC 2709-1636
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This map Is prepared for Inventory of real property vAfhln Jackson county. it M compdad from recorded deeds, plats, and public data
- records. Users of this map are hersby noUW that the aforemenUonod pubec IMorenatkm sources should be consulted for verlHuUan.
` Jackson County or any County representative aesnnws no legal responsibility for the Contents of Ode map• .. Printed :Apr 28, 2011
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This map is prepared for inventory of real property within Jackson County. It is compiled from recorded deeds, plats, and public data 0; a
S records. Users of this map are hereby notified that the aforementioned public information sources should be consulted for verification. ,,
Jackson County or any County representative assumes no legal responsibility for the contents of this map. Pri nted: J U n 21, 2011