Avery UIC Deemed Permitted 2015

CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURkIL RESOURCF-
NOTMCATION OF MTENT TO COMTRUCT oiR.OpERATlE INJECTION WELLS
2'hese wdlls are'pormYtted by rule"and do not require an individual permit when constructed in accordance tvlth
the rules oMAIVCAC 02C.02004' X his notico inwt be submitted�rtor to construction
OEOTH LRNY Q AQ-U—BORS-C L,OSED LOOP WEUS
.As described iu 15A NCAC 02C.0222 fb ese wens circulate potable water only or a mixture ofpotable water and
performance-enhancing additives as part of a geothermal heating and cooling system,
OR 1
GEOTJHERZVlAIG D C�'EA'ANSLOT+F CLOSED LOOP WELLS
As desorlbed to 15A NCAC 02C.0223 f1we wells circulate a refrigeraut gas as part of a geothermal Beating and
cooling system,
NORTH CAROLWA DBPARTMBNT OF ENVIRONMENT AND NATU[tAL RBSOURCI3S
PfInt Clearly or 23peDiformadom Vlegible,Sttbintttals 3�i11Be TleturnedAsXrscorr:pXete.
DATE: 20 PFRItdITNO.k'j'Zo1 3 S�
®0 (to be completed by DWQ)
A. TYPE, Op'GEOTHEMWAL CLOSED-LOOP WELL TO BE COkSxRUCT+D
�o a'
(1) Aqueous(as per 15ANCAC 02C.0222): �t Number of wells:
(2) Direct Bxpausion.(as per 15ANCAC 02C.0223) Number of wells:
B. STATUS OF VMLL ONMR.(choose one)
(1) Single Family RwidenceIx Submit this form two(2)business days prior to construction.
(2) Business/organization Submit this form 30 days prior to constraction,
(3) Goveinment: State Municipal Counter. Federal Submit this form 3 0 days
prior to constt•uciion. �.
C'. WELL ONMR--•Vor single farnily residences list the proparty ownex(s). For all others,list name of the
1'busmlesg,organization,or gaveznmeat agency and person delegated signature authority:
Mating Address:
City: State: Zip code."��County:
DayTeloNq.• Ca
Cl k llNo..•
RMA17,Address: � � � � Q .
�1�__ Fax No' " '" •
D. PHYSICAL LOCATION OF WELL SITU
(1) Parcel Idehtiftc�attion.Number(PIN)of well site:
Cotihty:
(2) Physical Address if[�di€i'erantthanmailingaddress): '� ) ,� ,
City: � ,, __- _ Stater NC Zip r,O1n
Code: . �`y
RECEIVED
DWQ/UIC/G7osetlLoop Geot)lermalNotifiratlon(Revised4/30/20I2) D&Ion of Water Resources Page I
MAR, 2 7 2015
Water Quality Regional Operations
Asheville Regional Office

E, MAPS,IPLAM,AND SPEcVjCA.TYONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located-
within 250 feet of the injection well(s), Label ail features clearly and include a north arrow, Attach a
site-specific map showiag the locations of the following:
At! veS-ide►� (( ( Lo A lh
G Proposed injection well locations '
o Buildings -red S•/
Pxoper-tyboundazies
G Surface,water bodies �--
Water supply wells
Septic systems and associated spray irrigation sites,drain fields,or repair arose
b B)d3 ft of potential.sources of groundwater contamination
(2) Pkus and specifications of the surface and subsurface construction details of the well system.
F. TV +S AND COINICENTRA.MNS'OF+ ADDZTIS -- List any additives that win be used and their
concentrations. Only additives that the Department of Health and Mman Services'Division.of Public Health
determines do not adversely affect human health shall be used, A list of approved additives can be found
online at httv!6ortal.ncdenr oxsJwa (wq/fps/awuro, All other Additives require approval prior to use.
E'hu f V't�n('1'efi � la �•N.o
G. WE,LL DRMLER INFORMATION(if known)
Well DxMin Contractor's Name: (7ody Mullis) (Matthaw Bx6wn) (Milton Cave)
NC Well Drilling Contractor CartificationNo.: 2572-A 3036-A 3548-
CompanyNaine: Yadkin Well Company,Inc,_ Contact Person: David Brown(2195-A)_
City: HMfonville _ State: NC Zip Coda:27020 County: Yadkin
Day ToleNo•: 336A68-444.0 Coll NO.: 336-374-8736
EMAMAddress: [e-mail] Fax No.: 336- 68-40 8 '
IT. �EAT1'TJiY➢JP CQNI'RACTORINFORMATION
CompanyNamo: vqv
ContactPeison +c,41 a 8yeI'ke 4 BMAILAddress
Address: t$7 o Lrjx,_,y woysQ. _--
City: �'�2e_f WQ o Zip Code: State:,County: �-E�A.
Office Tole NO,; 14(j g r o n Cell No, FaX No,•
�._�•..._
DWQ/OIC/Ctosed-Loop Qeoff,1 w6tifiaatiori(i 61sed 4A n012) page 2
}
3
4 i

7y '
J
x. PROTECTION -Provide abriofdescription of how(1)water supply wells;(2)surfacewaterbodies;and(3).
septio systems and associated spray irrigation sites,drain fields,or repair areas within 250 feet ofthsproposed
We-otion wells will be protected during construction of the wells:: L
4 n D L 4 j rrt2 A �l 7-r a,- /2 e eel/
S. VARIANCE--•Pursuant to 1SA NCAC 02C.0241 the Director of the Division of Water Quality may grant a
variance fxotza applicable well construction or operation standards provided that:
(1) use of the well(B)will not en.daugerbumanhealth and welfare or the groundwater;and
(2) that contraction or operation in accordance with the standards is not technically feasible or the
proposed construction provides equal orb otter protection of the groundwater.
Any vat'ianoe request should accompany submittal of this notification to expedite evaluation of the request.
The varlane®zroquest form canbe accessed online at http•//portal.ncdenr ore/web/w /cis/Qwnro/peo
�nlications
X SIGNATURES—The following section h to be completed as required below or by that person's authorized
agent. 15ANCAC 02C.0211(e)xequirea signatures ae follows;
(a) for a corporation: by a responsible corporate officer,
(b) for a partnership or sole proprietorship: by a general partner or the propAstor,respectively;
(o) for a municipality or a state,federal,or other public agency: by either a principal executive
officer or ranking publicly elected official;
(d) for all others: by the well ownsr;
(a) for any other person authorized to act on behalf of the applicant: doeiunentation shall be
submitted with the notification That clearly identifies the person, grants them signatare
authority,and is signed and dated by the applicant.
"I hereby certify,under penalty of law, that 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 ieorrmation is trtie, accurate and
coinplete. Iam aware that there are significantpenalties,including the possibility offines and imprlsonment;
for submitting false inforIla
tion. I agree to copn ct, operate, maintain, repair, and if applicable, abandon
the h1 ection weld and all ted ap ena t cordance with the I5A NC4C 02C 0200.Rules."
Signature i'P wtter/Appltcattt .
Print or Type FullNamo
Signature ofA.uthor[zed Agent,if any
?rlttt or Type M Name
DWQjMC/Closed Loop Goo-theimol Notification(Rovised 4130/2012) Pages

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01/11/2016 15:11
COVER PAGE ---
TO :
FROM : DEWEY WRIGHT
FAX : [phone]
TEL : [phone]
COMMENT :
RECEIVED
Omsion of Water Resoureft
JAN t I MS
Water OualRy Regional Operations
Asheville Regional Office

_ h
01/11/2016 15:11 82826461251 DEWEY WRIGHT PAGE 01
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by rule"and do not require an individual permit when constructed in accordance with
the rules of L—AL N ,-I C 02C•t 200. T his notice must be submitted prior to construction
GEOT ERM L A U EOUS CLQSEEI,-LOOP WELLS
As described in ),-),A NCAC QIC.0222 these wells circulate potable water only or a mixture of potable water and
performance-enhancing additives as part of a geothermal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS
As described in 15A NCA . 02C.0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Prini Clearly or Type Information, ,illegible Submittals Will Be Returned As Incomplete:
DATE: Pt-t- 41 , 20 15 PERMIT NO. 01©.0_9jr_(to be completed by D W R)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED �[
(1) Aqueous(as per 1 SA CAC 02C ,0222): Number of wells:
(2) Direct Expansion(as per I SA NCAC p2_ . 223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family ResidencelK Submit this form two(2)business days prior to construction.
(2) Business/Organization Submit this form 30 days prior to construe '
(3) Government: State Municipal_a County]a Federal Submit this form 30 days
prior to construction.
C. WELL OWNER— For single family residences list the property owner(s). For all others, list name of the
business,organization,or government agency and person delegated signature authority:
Mailing Address: slK k100Q RZ
City: Cw= State:041 Zip Code: op �+T�unty: C �"FL-k
Day Tele No.: 4 �` Cell No.: l 3�3
EMAIL Address: t5 W It M� F+aX No.: 70 "' 7T5�'
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site:
County; 69_T_j_1_t1 WkepQP
(2) Physical Address(if different than mailing address): �� !
City: 1171Q, LIC State: NC Zip Code: �►
UIC/Closed-Loop Geothermal Notification(Revised 8/5/2013) page I

01/11/2016 15:11 82826461251 DEWEY WRIGHT PAGE 02
E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately
within 250 feet of the injection well(s). La indicate distances and orientations of features el 1 res e1 rl an i clu e a no arrow. Attach a
site-speciFc map showing the locations of the following: located
• Proposed injection well locations
• Buildings Septic systems and associated spray irrigation
• Property boundaries sites,drain fields,or repair areas
• Surface water bodies
• Water supply wells • coma $contamination
Potential sources of groundwater
contamination
(2) Plans.and specifications of the surface and subsurface construction details of the wells stem.
Y
F. TYPES AND CONCENTRATIONS y RATIONS OF ADDITIVES _ List any additives that will be used and their
Only additives that the Department of Health and Human Services Division of Public
determines do not adversely affect human health shall be used, A list of approved additives can is
online at tt :# orta1. Health
!Ld nr or web/wo/aa./ �r to- All other additives require approval prior to use:be found
G. 'WELD,DRILLER INFORMATION(!f known
Well Drilling Contractor's Name: W ) ID N7Rt
��t~ �� olett P to
NC Well Drilling Contractor Certification No..
Company Name:- 11
City: Js®pfJ t, i� t Contac erson: 1Rr)
State: Ah Ct, zip Code; 20 i
Day Tele No.; .. � ounty: L1J •�
Cell No.:lrltrlAll,
Address: 4,1
I ax No.:Mid-
H HEAT P'JMP CONTRACTOR INFORMATION
RMATION
c7
Company Name: CkW4L
Contact,person: At
Address: w.o, E ILA dres
City: -•
Offic zip Code: Q " State: J
�� • �ou G►9
e Tele , a — nty:
Cell No.:&*-'� ,"
ax N
UK7/Ca0sed,Loop Geothermal Notification(Revised 815/2013)
Page 2

01/11/2016 15:11 82826461251 DEWEY WRIGHT PAGE 03
. h
P1t0T W'f'&0N,
'd,•s•bnief
septic systems and associated ' On of t+ow 1
injection ells will be Protected duringm ation sites,drtdnfie a Supply wells;(2)sarface water bodies;and(3)
� construction of the wells: repair areas within 250 feet of the
proposed
P RE C.4MM401
C. 506
J v
A`UANCE-.ptt,Setat,t to l}
a variance from applicable. d` �C�241 the Director pP cable wail construction or o of the Division of Water Resources
(l) use of the welf(s)will not endangerPernttQh standards Provided may grant
human health p ed that:
(2) that construction or operation in accordance with the a welfare or the
Proposed CO�truction provides Bronndwater;and
Any variance requestshould acco equal or better t standards is trot technically feasible or the
The"-wiarrce►•equest form can be ml y ° pro ection Of the groundw�,
f the notification tv li i n accessed online at .DPW ite evaluation Of the request.
I. cde
a o/ a it-
K. SIGNATURES -The f
agent, 5 N AC 02C following
section is to be co,npleted as re
1 e requiressignatutes,as.fa Quired below or by that
l)a►vs; person•s autho,ized
(e) for a corpQrBtion_ by a res
(b) for a partnership or sole pansible corporate otftcer;
(c) for a munici 1• ProPrietnrship: by ageneral
offjcer Or Or a sue' or Partner or the prOPriator,respectively;
(d) for all tanking publicly elected OfAci$lother public c3': by either a princi al ex�a) f o0i by the w$ll.,>ivnar, P ecutiv@
submitted witu.
h
�o�1 to act 00 behalf of the
authority, the notificationddtethat clearly identifies tahPepitCant: docurnentation shalt be
ty,and is signed and dated by the applicant oR, grants them signature
"I hereby cert6, under
submitted in this doc Par►alry of law, that I h
umegt aid eve Perron
examined and am
� teotiateli�resp ,F;l,/c o. a!!attic fa►niliar with the i
f ubtc7iru'tt said
tl,er t v�ormat/Pn
COMP101''e. I Q!!i Qly bvJ wawriopt.
O and tlfAl, luxaBd'.oN t
far stab die that there are si of believe thtrt the l �o equpr3' of throe i+�'idtn2ls
mittl g false ir{for tlon I $ cant Penalties, including the rntaTrah is true, Qccurate and
the in we!!told a!1 related a agree to construct p passibillty oflj�s
Ppurtena"Ces in accordance
with
th tgln, re wrd intpriga►tmeht,
4 rdaitre with the! N h- ��i Plicable, abandon
• Zk•� Rules.
eoaf?�ycrt9 0wftaA�V, --
Printer I FOR Name
guature 6fA
Print or Iypc Fud Name
d'C;, 4'rsrtt�ettnafiliotification(Revised 8/3/20;3)
Page 3

A/11/2016 15:11 82826461251 DEWEY WRIGHT PAGE 04
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D, '4
RECEIVED
11 ffton of Water Resource!
Water Quality Regional Operations
NORTH CAROLMIA DEPARTMENT OF ENVIRONMENT AND NA.'URA %'!e Re renal Office
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These'-wells are '�permlifed by rrrle"and do not require an indlyidual peritif!lvhen constructed in accordance with
the rules of Thb notice must k4 sail milled in-for to con truciton
GEOTHERMAL AQUEOUS CLOSED-LOOP WFLL8
As described in (LNG.AG Q .0212 these wells circulate potable water only or a mixture ofpotablo water and
perfo manc&etihancing additives as part of a geothermal heating r?nd cooling system,
OR
GEOTHERMAL DMECT EXPANV 10N CLOSED-LOOP WnLLS
As described h1 15A NC !02G.022.-these wells circulate a refrigefeirt gas as part of a geothermal heating and
cooling system.
Print Clearly or 2')rpe Arfa•�nation. Illegtble Sttbmltfals Wfll BeYYti'elurne�l As lircomplete.
DATE: 2 ' , 20� I'E1ti1VIIT 1VO.w.I'� �0�2 (to be eornpleted by DVIrR)
A. TYPE OF GEOTIM,RMAL CLOSED-LOOP WELL TO BE CONSTRUCTED 3-320'
!' POO.
(1) Aqueous(as per 15A NCAC 02C•0222): E4 Number ofwells:
i (2) Direct Expansion(as per.15A NCAC WC.0223) _ Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) ' Single Family Residence. Submit this form two(2)business days Irrior to construction,
(2) Business/Organization Submit this form 3D days prior to construction,
i (3) Government: State IvlunicipaI_a County ja Federal D_Submit this'form,30 days
prior to constructiou.
C. wuLL 0WNEkt—For single family residahz es list the property owner(s). For all others, list name of the
business,organization,or government agency and person delegated signature authority;
r
Mailing Address:
City: ejJ41467TE state", Zip Code�awlo County:_ V,
Day Tole No,: Cell Nb,;
EMAIL Address: Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site; 19 PC o o G 17 d"Z)e 0 00 00 -
County. AV"y
(2) Physical Address(if ciiff'erent than mailing Address);; �f NV��1 � �-
Z cs^,ltl�•pL1S� �b4�2't' ���cty/l.UL�, N�' ?�8_ C�-�,�
City; L/►MILL State.-NC Zip Code: 2,$44(o
tilC/Closed Loop Geolhemral Notificadou(Revised 815/2013) C'agc t

L MAPS,PLAINS;AND' SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection,well(s). Label all features clearlynd a -n ude a north arrow. Attach a
site-specific tnap showing the locations of the following:
a Proposed injection well locations o Septic systems- and associated spray irrigation
C Duildings SCG S�_(�r sites,drain fields,or repair areas
G Property boundaries �'�
G $urfacewatorbodies ( o Existing or pote>7tial sources of groundwater
Water supply Nvells contau►iitation
(2) flans and specifications of the surface and subsurface eonstru.ction details of the well system.
Ste �vacv�r.S k-2
F. TYPES AND CONCENTRATIONS OF ADMIVES - List any additives that will be used and their
concentrations. Only additives,that the Department of health and Human Services'Division of PublicHealth
deteriniues do not adversely'affect human health shall be used. A list of approved additives can be found
online atlit42:/Iportal.nedenr.org/web/wq/ems/pwi)ro. All other additives require approval prior to use.
� -{-e r 2a a l •
G. W&ELL DRILLER INFORKATION(if Imown)
Well Drilling Conti-actor's Name: M a g t.+ a 131,40r Soc(v MU t f't S lgj'j�s n
NC Well Drilling Contractor Certification No.: 3036.4 2 S 7 2 A w 3 1-0$.A
Company Nam e; --`a J:K t n ( t .�h C Contact Person: b ao l d Q vat h 2 i q S�J�
City:: M'd on V-,(_is_ State: ej& Zip Code;_IL0?a Cotmty:_
Day Tele No.; ��n Cell No...33C— ,3 ?se- Y 7 6
EMAIL Address: _tau;A Q ro w w A t/12d tc i r w 0.1 t., Fax No.;
voW%
1I. HEAT PUMP CONTRACTOR WORNIATION
Coiripany Name:_ r� „ ���,y� ( loot
Contact Person.- SA..,:.. F-MAEL Address
Address; jeo r3oh 7/so ^
City; Qgio&g- Zip Code: State:Pt;_.County: .(�.�d
Office Tele No.; g2 2 CV- m L za Cell No.: Fax No.:
UIOCloscd-Loop oeotltenrral Notification(Revised 8/5/2013) Page'2

X. PROTECTION—provide a brief description of how(1)water supply wells;(2)surface water bodies;and(3)
septic systems and associated spray Irrigation sites,drain fields,or repair areas.witbin 250 feet of Me proposed
injection wells will be protected during construction of the wells:
kloodea areaa scir•�,uo �a,r,.lrar
W 1 TnIN S$o r-R's latt %lP' Aeecte k
.�. 'VAIRIANC,—Pursuant to 15A NQAQ 02C.0241 the Director of the Division of Water Resources may grant
a variance from applicable well construction or operation standards provided mat:
(1) use of the wells)will not endanger human bealth and welfare or the groundwater;and
(2) that construction or operation in accordance with the standards is not technically feasible or the
proposed construction provides equal orbetterprotection of the grmindwafer:
Any variance request should accompany submittal of this'notification to expedite evaluation of the request.
The vhriance request form can be accessed online at http://poital.ncdenr oLg�web%wglaps/gw^prc/pernvt=
a�plipations
K.. SIGNATURES—'The following,section is to be eorripleted as required below or by that person'.authorized
agent. 15ANCAC 02C.U211(e)requiros signatures m follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partber or the proprietor,respectively;
(e) for a municipality or a slate,federal,or other public agency; by either a principal elceculive
officer or ranking publicly elected official;
(d) for all others: by the well owner;
(e) far any other person authorized to act on behalf of the applicant: documentation shall be
submitted with the notification that clearly identifies the person, .grants thein signature
authority,-and is smiled and dated by the applicant.
`1 hereby certify, under penalty of law,that 1 have personally examined and ant fan iillar with the information
sa mitted in this document and all attachments thereto and that, based on my inquiry of those individuals
Immediately responsible for-obtaining said irformadon, 1 bellave that the information is true, accurate and
colnplele. 1 am aware that there are e significant penalties, including the possibility of frnes.and iniprisorzment,
for submitting false iq ormoi on. ,l agree to construct, operate, maka,u.1, repair, ana,if applicable, .abandon
the injection.well and all related apparrtenances in accordance with the.1 SA 1VCAC,02C 0200 Rules."
�',�•1 � �.-;;ram_
J SignAture of Property OwnerlApplicmit
t7oNa�r CRoSL4i�� �
Print er Type Full Norte
Signature of Authorized Agent,if arty
Print or Type Tull Name
UIUC.lond-Loop Geothermal Notil5eation(Revised 015/2013) Page 3

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RE
t�slon
AUG279200
Water Ouafi
Asheville Regional Office
08/29/2016 10:28
COVER FADE
TO :
FROM : DEWEY WRIGHT
FAX : [phone]
TEL : [phone]
COMMENT
i

08/29/2016 10;28 82826461251 DEWEY WRIGHT PAGE 01 .
DEWEY WRIGHT WELL Sr PUMP CO.,INC.
"" [phone]/Toll free 1-877-250-3727
105-421 BYPASS-P.O.Box 308
BOONE,N.C.28607
FAX[phone]
a N.C.Water&Air Resources Reg.#266
:91g� N-C.Water Well Contractors License
DRILLED W . . C(INTRA(T 15-
Date: _
'For good and valuable mutual corgsiderations as hereinafter set forth,the undersigned Contractor,and each of the
undersigned Owner(whether one or more)agree as follows:
This contract is made and will be performed subject to all well laws and regulations and specilically to"N.C.Well
Construction Regulations and Stan ards:'hereinafre cal d�the Regulations.
Co tractor will atte pt to drill ell(s) - on r��{y kscFFtbed below:
h I ,I(rV 1 1
on or near Road ft O -
will start each hole inches in iameter and finish not less than inches in diame r:to discontinue drilling at Owner's
discretion:will furnish and drive 6 1/4 inch.pipe permitted by the Regulations.
Contractor guarantees workmanship and materials but DOES NOT GUARANTEE QUANTITY OR QUALITY OF WATER
AT ANY SPECIFIED DEPTH.
The Drilling Contractor does not assume responsibility for clean-up of residue from the ground drilling or for damage to
property.including but not limited to the private road or driveway serving said property,during ingress or egress.
Owner will pay Contractor for each hole:(a)in accordance with the schedule below:(b)for labor and materials furnished by
Contractor to cap or valve artesian wells.to plug pr seal abandoned holes or non-potable,mineralized or polluted wells;and(c)
for any other special requirements pursuant to..the
�Regulations.
Each of the undersigned warrants that
are the legal owners and are seized in fee of the herein described property where the well is to be drilled and have the right to
encumber same. This contract is the entire agreement. No agent of Contractor is authorized to vary this contract. No additions,
deletions or alterations shall become a part.of this contract unless endorsed and signed by an OFFICER of Contractor by any
Owner.
I. Cost per foot for drilling: $ I.S e oo per foot *NQTE*Pumping system NOT included in
GALV casing: $ per foot price per foot.
PVC casing $ per foot &U� (�
Q p Grout fee $ I A� �
PAYMENT SCHEDULE:Payment for all sums due Contractor will be made:
( ) Cash on completion.
(`.+® Within thirty(30)days from date of completion.
( ) Other provisions:
IN THE EVENT THiS ACCOUNT IS PLACED IN THE HANDS OF AN ATTORNEY FOR COLLECTION OR SUiT
INSTITUTED TO COLLECT. THE SAME OF ANY PORTION THEREOF.I AND/OR WE AGREE AND PROMISE(S)TO
PAY ATTORNEY'S FEES OF 15%OF THE BALANCE THEN DUE AND OWING. Regular billing date is the first of each
month with the balance due and payable net the 10th. If your account is paid by the loth of the month following billing,only the
net amount of the statement will be payable,otherwise.A LATE CHARGE OR FiNANCE CHARGE IN THE AMOUNT OF
1 1/2%PER MONTH CALCULATED ON THE i ST DAY OF EACH MONTH ON THE BALANCE AS OF THE I ST OF THE
PREVIOUS MONTH(LESS PAYMENTS AND CREDITS TO SAiD BALANCE)WILL BE CHARGED UNTIL PAYMENT
1N FULL 1S MADE. 1 1/2%PER MONTH IS AN ANNUAL PERCENTAGE RATE OF I81/o.
DEWEY WRIGHT WELL&PUMP CO..INC.
OWNER: Mad� 1F�4 nA10 CONTR OR:
OWNER: mto_ktk)Q+ F A-A) By (44
fficer)
ADDRESS:�� `•a'4;A�`� CQ / Yt�� �^
PHONE:
BY y PHONE:
(Agent)

r ` 18/29/2016 10:28 82826461251 'DEWEY WRIGHT PAGE 02
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--0830�20`1`5 09:38
COVED FADE
TO :
FROM : DEWEY WRIGHT
FAX : [phone]
TEL : [phone]
COMMENT :

08/30/2016 09:38 82826461251 DEWEY WRIGHT PAGE 01
DEWV WNeNT WELL & PUMP CO., INC.
[phone] Toil free [phone]
105 By Pass (P.O. Box 308)
Boona, North Carolinas 28607
FAX COVER SHEET
Fax: [phone]
TO: e, l oQ�de
FROM:
DATE.-
PAGES: including fix cover sheet
�a r

08/30/2016 09:38 82826461251 DEWEY WRIGHT PAGE 02
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