Burke UIC Deemed Permitted 2015

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LothridgeGeo, -LLC.
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Company NG Z�Pr of $('
Sent By
Date :
Using Green
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Technology To Build
a #of pages including cover :
Better World
Cover sheet only
5 3 $ RECEIVED
OvWon of Waxer ResourCft
MAY - 1 2015
Water Ouaiity Regional Operations
Asheville Regional Office
I
Phone, 336-357-2202
PO Sox 249 Fax: [phone]
Linwood, NC 27299 Email: [e-mail]

Lothridgegeo 3363572951 p.2
NORTH CARof NA DEPART&EN'f`OF ENVUZONMENT AND NATURAL USOURCES
N()TITICATION OF.L TENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are 'permitted by rule"and do not reepdre an individual pernilt when constructer)in necoi dnnca with
the rules.of 15.A NCAC 02C,:0200*%. T71S raatice»rust be submitted prior to construction.
GEOTftERMAL AQUEOUS CLOSED-LOOP WELL
As described in 15A.NCAC 02C.0222 these,wells circulate potable water only or a mixture ofpotable water and
performance-�enliancing additives as part of a geothermal heating.and cooling system.
OR
GEOTMRMAL DIRECT EXPANSION CLOSED-LOOk WELTAS
As described ifl 15A.NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geothermal.heating and
cooling system.
Pr'n�:t GFearly of Type"1'itfdhnation. Illegible Sub"f ials WHI Be Returxerl tis Iitcotnlifete
DA.T'E: 01 2.0 1 PEPOUT N0. W20 I M F (to be completed by DVS%Q}
A. TYPE OF GEDTPTERMAL CLOSED-"LOOP WELL TO BE CONSTRUCTED
{1) gueotis .as per 15A IvCAC 02C.0222): Number a#welts: .
(2) Direct Exparision.(as pet•15A NCAC 02C.0223) Number of wells:
D. STA.TUS OF WELL ONVNER(ch000ss one)
-.Y.,.....SingtQX_ 11.1,yresidence=5ubmitthis form two(2)business days priorto construction.
1 (f,;,) : Bti`sinesslOrganizatioa Submit this form 30 days prior to construction.
(3j""' 6044unent: State Municipal� Courtty Federal Submit this fona 30 days
R prior to constriction.
C, VVEL,L OWN'M_.P�r single family residences.list the.property owner(s). Ioi all others, list Warne of the
business,organization,or.gover-Ainetit agency and person delegated signature authority:
ltittuling-Address:
1 f=�X t2 VV IZ
City:C State: �J�" zip Code:117,q C�aunty: --
Day Cell No.. t�� I _=ifs 57 _
EMAIL Address: G�'�Gtr l f� /�'r �• C�ita1 Fax No.-
D. PRYSICAL LOCATION Or WELL SITE' �,�p iucG
(1) Panel 1d.0 fication:Number(PIN)of well site;
3T7(� Lj <173 {�' �
coon �� C�� DJ
t,o ze
(2) Physical Address(if different than mailing address):
State:NC Zip Cdde:
t
DWQI[JI((Closed-T oop Gcotliermal i0tir"icadon lfievised 4/W2.(112) .
....•:� ��,:�k>,�:a�a^::-Taxss-s-..�;.�:..:;.crsc*.+,^.scxt-�:.-:...,._.:.".^:.`::.-c:::'•ti�.r-w—..-::t�:-r;=.,.,.�:rr;•=f"��%'rs�,::;�:-v:,�,.,::-,:::::;^•. , _�., .. .. .. -.

Lothridgegeo 3363572951 p.3
);.. MAPB,PLANS,AND`SPECIFICATIONS
;) Maps insist be scaled or otherwise.accurately indicate distances and orientations of features located
within 2W feet"of#he injectionwell(s). LaW all features clearly and"include-a.north arrow. Attacl,a
site,--specific map showing the locations of-the following:
• Proposed injection well locations • Septic .systems and associated spray irrigation
Buildings sites,drain fields, or repair-areas
• Pxaperty"bound.aries
a 'Suiface:water bodiies • Existing _or potential. sources of groundwater
• Water supply wells contamination.
(2) Plans and specifications of the surface and:subsurface construction.details of the well system.
V. TYPES MlD C©NCEN-RATIOi`7S OF Al3DITI•VES ---I;ist any additives that wall be used and their
concentrations. Only additives-that the DeparhumtofRea;th and Iduman Services'-Division.of Public Health
determines do not adversely affect.human health-shall be used. -A list of approved additives can be found
onlane at:h#tvllvortal ncder►r:orweb/wgfaps/ v> . All other additives teyttiie approval prior to use.
.G. WELL DRILLER WORNIATION(if known)
Well DrillingContractor's Name: C3A� �1v's 7 r c e,
NC lideil"Drillirig Contractoj Cerdfickdort"No..:
WG
twl- Uf21 N�7 ��G
Company Name:. �JSi tCr� ' Contact Person:'
City: :. State: 2ip.Code:a�73 County:
Dsy•Tele No; �` - `lc - i{5�$. Call N.a.:
EMAIL Address` Jv5"rrc���'2�`t�krcci,u�@ FaxNo,:
H, y►TPUMP CONTRACTOR TKFOR1YIc�i.TIQ..N
CoinpanyNamei Foothills Heating and A'ir
Coitwppers-oir John Griffin EMAIL Address:heatman3 a2bellsouth.net
:Address: PO Box.2594
City,. Hic4car zap Code: 28603 State;NG County: Catawba
Cfflc�"TeteNo.; 828:3241212 CONNo:;" 828 312 3775 FaiNo.: 828 328 $860
L)WWCIClosed-7.ocp'"Geothdririal D[otifiostion.(Rsvised 4 j34120I2j`.: . Pa�c 2
' :::YlriJ�Y� '1'T�4C".�.V.C:KM.�'aRY,..�'.,T.7E1tiT:-NTC(.�:H.\�^�71.+�]a'.�:Y:Mn� .1._�:.f"s'a'::•:y.{l:[•C«...a...ra��r,.,r...�::.a :C..y_;r ..r..a ..
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Lothridgegeo 3363572951 p.4
I. PROTECTION—.Prov3de 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 within 250 feet of the proposed
injection wells 1.3IiLl.be protected during construction of the wells: -
�7. VARIANCE—pursuant to 1 SA NCAC 02C.0241 the-Director-.of°the Division of Water Quality may grant a
variance from applicable well construction or operation standards provided that:
(1) use of the vrell(s)will.not endanger human health and welfare or the groundwater;and
(?� that construction or operation.in accordance with the standards is not technically feasible or the
proposed construction provides equal orbetter protection of the srotmdwater.
Any variance request-shouid acconipany submittal of this notification to expedite evaluation of the request.
thi)varianceTequest form can be ac'cessed.online at biro•/!Aortal.ncdenr.orgLweb/w•a/ans/awpro/nermit-
apolicalions
K, SIGNA.T.URES-=Thr.:following section is to be completed as required below of.by that persori'.s authorized
agent. ISA NCAG 02C.0211(e)requires signatures as follows:
(a) £Br a corporation: by a responsible coiparate officer',
(b) for a partnership or sole:.-proprietorship: by a general partner or the proprietor,respectively;
(c) for a municipality or a state,federal, or other,public agency: .by either a principal executive
officer or ranking publicly elected official;
(c). .. for-all-oihers: by the weii'owfter,. _..
(e) for any other person authprized to act on behalf of the applicant: documentation shall be
submitted with The notification that cleady identifies the person, grants them signature
authority,.snd is signed and dated by the applicant.
``l lteieTi}�certify, r4rt4er penalty of law, that I have personally exnmined and am familiar with the 1 fonnatiar.
submitted in this document and all attachments rheretn and that, based on my inquiry of those indi-v:duals-
immediately responsibk for obiabOng said information, f Wleue that the infonnat#on Is true; accurate aizd
complete. I am aware that there are sign fcantpenalties, iraIuding the possibility of-fines and imprisonment,
fop subiriifiing false information. I,agree to construct, operate,,mainrahr repair, and if aopllcabla, abandon
tlzs injection-well and ail related appurtenances in ciccoedance with the 15A NC4C 02C 0200 Rules.401 "
ignnt Property dtvndr/Applicant
PAW,-or Type Full Namt.
.Signature of Authoricad Agent,if any
;Print ar Type Full N me '
DWQIUIC(CJa$ed-Loop CeW=malNotification(Revised 4130012) P"6G 3 :
.,:�_ _ _.v •.vy. -! vl.:: F'- 1i3,'•'k'-",�,o.lt^_.'C'..^+K.fJ�:: Yrrftr.:.�.��s'1 r:'Y�,:K •'.L .:%SZ??:>'rc'�i �,y':
..:_.4...r:�•,•F d�„i.i.:^7�::ccs.•.,.:"-s_:F�t�i:7�'h,._-�'�FZ�-:d. ..

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Burke County,NC Print Map
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Burke County, NC
DISCIalmer.The InYorn-140n cortained on this page is taKon from aerial mapping,tax mapping,and public records and is NOT to be construed or
used as a survey or'loqaldescr*ftn'-Only allcansed professional land surveyor can legally determine precise locations,olovations,lengtrt and
direction of a line,and areas,
Parcels
PIN;2764687266 Lot:2413 Sale Amount.,140000
Record Number,58844 Deed Book:1923 Sale Date:912912010
owner Name 1:GERVASIC)G RGORY J&LORI J Dead Page:328 cityNam.:Connally springs
owner Address:I FOX RUN RD Deed Date:9129/2010
Owner City;CHESTER SPRINGS Acres;2
Owner State;PA Assessed Value;135808
ownarZtpi 19425 Land Value:135808
Map No!87
Page:4
0 Block.3
(D
Attributes at point:N:748240.E:1266767
:2 Fire Districts School Districts Voting Districts
s Fire:LOVELAUY Elementary:E-RUTHERFORD COLLEGE Precinct: 11
0 MlddW M-HERITAGE Name: bard) I
KIgh: H-DRAUGHN MC House: W
NG Senate:46
Townshipa Watersheds
CARD Stream Name:L2ko Rhodhiss
PCA Class: VVS-IV C
hflPJ1W—,Yr1bn:j-n-1 Md—on&Assnele �M—.a.qdas!!—CM
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urke County NC Property Card bttp://www.meb-,is.net/nc/burke/propeitycard.php`tpid=58844
UMNF.R.SHLY V1iii0 A002 15 IS403 301 PROPERTY DBCRI PTIO N MAP NUM7BER CARD ID
I,L16078 LRT J D A rvIS2ON6
LT2!B yOF CONNALLY 8P RECORDNUMBERi. 58844 1 FOX RUN AD LU LAWT FIRE ROUTE 87 4 3240
CAE615tR 6PAINC9 PA 19425 LISTER;86040213
DEE0:1973 328 09292010 1l0000-99 REv1xx:DI062006
TOPO STREET LZ EONINU 1. 0 RES HD
PA PDBNATE 4
SEPTIC NOTEG,PB28 179THRU196
ZLECIRIC :LAND XTU
LJNDU HRATB'PRNT'DP37• JRAT2-UNITS=LND-VALUE
TFSTM
18OLA1 Px o.70AC 2l0000 a00 O.e0
3 34DLA BAL 0.87AC 6000OOI 0.87 4350
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4193PPLOOD PLI 0.13ACI 16001 1 1 1 16001 0.241 208 O
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LA1ID VALVE: 135006
HR IZR RATE, N T^ PB-
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OTHER VALUE:
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FNDA T FTYP I
9P-L0OM1P:2-BY-CLASS
ppLLPN FLOORS HEATMIR ''LT•17GI,
9KTCH 5F•Sitti� AREA RATE•ORAF�HHAT EANl.' T=AD3RAT• AREA= R F=STR-VALUE
STRUCTURE VALUA, 0
AL
LpNp 1JSB00 210000 66 9053RLV/AC
0THERPBAT 0
OTAOCZ= 0
.TONAL 174l 00 Y40000 4GY
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WOMICATION OF INTMO TO CW$ZOTOXOR OuRATE Mj.ECTM w.FLiLq
These wh1b are '�pqrmilMd by. -rOtelll a-"d,d,'- d* d I'pertnIhNihetacons.ru 4 -cvd i a�c--or'd 'th
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GEOTHERMAL,:A_OUEO?U9CLOSED-LOOP WELLS'.
Aad,-b.sciibQdiu 15ANC`AC,02C ;02,22-these�-w..eM circulate pO%bl6 water.o4 , amiktumof potable water and.,.-,,Y'or a
Xogiga ts
performance-olffian dd*ti asp%t Ofa&bthermd heatingana coolingsy�tprp.
M V
Old
WYLLS
,GE(OT=14 RMUMMECIR CT DAM
described. n-1-.'MNCAGO2'G".0223 those wells circulate a tk geothermal fie�ct igefan 4s.'as��affof a.keother
cooling system.,
XOkTI-1',:C,,AROLNA,DEPARTAMN ENVII fT AND.NATUI AT:RESOURCES
-Wo.Oirty or:6pe Will B" AqNtved
D AT,E t 2,
(fObGcomP11*dby_ DWQ)
'-TYPE M GE -THEZIAL C ILTOBE-CWTUCTIM:
(1) AVPQ-49(as'per MANCAC,020:-.022'222)�, V/ Number of 3 .
p . ­ .0223. -. - ..: __ -
MiOct'B, dffsidA.-(a9 erl5A'NCA'G.G2C- N ------
STATUS OF WRMOWNER(chooso one)
singtq Fain qy Residence.__V's"Ibmuthis form two(2) 'days prrgr to consfxuctloA,
(2) Business/Otganizati6n, _8iibin1t.thfiffpM.3
(3): State, Municipal, County.. . txlmit phis form 3"0 days
prior t6 rdWom
WMt OW" For single family residences--list:the;property owf tor(s).. For.all others;.lis t:name of the-,
business,organization,or goLvetnment:agency and.persqg delegated s' -, tore authority;
Mailing Address:
ceflNo.:
_N
,D.. PHYSICAL LOCATION 0F, ,'VMLL,SIT:
P,,
Q,yyr/
(2) Physical Address.-,(if diffexent-thanmiaia address;A
City: Scat . TVAP_�EIVED
Ovision of Water ResourcM
DWQMIC/Closed-Loqp'QothelNoicato ( Ased-4/301014 30 2015mR
water Quality Retfienal Operations
Asheville Regional office

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R MAPS,PLANS,AND.API+CIFICATION
(]) Maps must be scaled ohwaccurateyino aaa distances and ozientations of:features located.
Within 250_feet of the injection well(s):. Label all feaiiires cleanly and include a-n°xth a3t.o Aftach a
site-specific map showing the locations ofthe follovuiug:
Proposed infection well;locatons t
6 :Buildings
a Propertyboundaries
o R-daceW-ater`.bodies
Water sup_plywelis
Septio sYstems:and associatecl,spTay irrigation sites,dra n.fzelds;or repair areas
o Existing o :potential sources,ofgrouridwater contamination(2) Plans and:speciRcat ons of the suz.face,and subsurfaco constractio:details of the well systeiri,
TYPES AND CDNCENTRATrONS OF ADDITIVES List any additives that will tie used and tlie=
concentrations.. Only additives that the Department of Health and Huinan.Services'Dzvzson of Public,lIealth.
determines,do'not adversely affect human health::sha11 be.used: A 1istof appoved.;additives can be found
online at httg:Llportal.ncdenr org/web/wa/a sp / ro. All other addifNes:require approvaX prior to use
ME, LL DRUMER INFORKA:ON(ifknown).
WelfDiiling Coritracto�;'s,Name: (Jody'Nlzill s.) (lVlatthew Brown) (Milton Cave).
_
N `W 6Il.Drill ng Conikacfox'Cent i e5tion No:: 2572-A 3036=A 3548=A
Co%iipanyNai e: Yadkin Well Company"f nG. Contact person David Brown,(2105-A)
City:: flamntonyille . State. ;NC Lip Code:27d20 County: IYadkin
Day`Te!q-No.:: 336=468-4440 Cell't�To.:' 336-�874A736
} Fax No..-. 336-468-4048`
ElVI' ,A.cldress: chief,di7lee nsn;cozn
II. REAT.P . C�Dl�i`g'> C`t'�I�' t ff'ORMA 'IOI�t
Com an Nam
IJI 1 tS
Y �e
CantactPersou: EtV1AlI:Address^ __
:Address:.
Cz -
tY ZYp Code,; State: County:
Ofxce�e� 'o -i
Coll
ax o`,
DWQIE}ZQIClased l cop'Geofhaimal toiif cation( evised4/3;O12Q12j. age ,
4L:tn�-0i•`an.7Q�1;xTh�ae..�\r�n1uN}yy.<..:�1.9

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FPOTE( TQl S'zovicle a brief description of how,,(X)wafez supplywells,,(2)surface water bodies,:and(3}:
septic systems and':assoclated sp ay1mgation sites,dwa fields,ox zepa areas with n.25.0 feet of the proposed`
zuiection wells:�villbe-protectecl:cluiug construction oftletivellss:
ilt-._.- 1� !o IA� ✓'�Pf. l"✓`�it'J+ .�r`YS Ga� CV YIl�,
ekcg
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V _ lal Pursuant to'1SANCAG 02G 0241 the Director.of the I)Otis ono Water Quality.may grant
Variance fromi appl3cab e well consiiuction,.or operation standards prow cled ihat:
(1) usa ofthe wells)willrxot e4dangox huinau:health and welfare or.tl ogroundwater;and.
(2} drat constrticfiort or operation in_aecordmo c�rith ti e standards as not technically feasible or eh
..
proposed construction pxovides equal.or.betterprofiection oftfie groundwater:
Any variance request should aceoiaparty submittal ofth s notification to.expedite=evaluat?on of:the request.
Theaizanee a equest form can beaccessed onlne:athttu:Ilnortal:ncdenr or /y�ab/ivq/tips%gw�ro(penaut=
applications
8-_The`following se�tion t's..to be completed as,.req, dl below or by-that person's aufihorrMd
agent UA,NCAC 162C.0211(e)requires signatures as f~ollows>
(a: fora corporation:. 'by a responsible coirporata officer;
b}. for a partnership or sole propiietorship: `by a general pgoui or the proprietor,zespect yely:
(c) for a;municipality or a,state,.federal, oi.other public.agency; .ty either a pain ci— executive
o:ffioer or ranlcirig publiclyelectod offzcial;
R for all of hors:. by the well mvvner,•:
'0 for any othevi)erson autl orized.:;to act; on behalf ofthe applicant documentation sha11 be
submitted' With. the notification that clearly identifies the person, -grants them signature
authority,and is signed and dated;by the-applicant
I hereby eertify,un lerpenalty of Zaiv,.that�liave1aersonally'examined and anti familiarvith the irtfot7rta or.
NbmWed in this document'and all:attachments thereto.and that,,based.on iary rnqiirry of°those inclWcluals
iinmetliately responsz7�le for obtazriing said'i�ormation..X believe that the rnforriratron is'trese, accurate and
eo1nplete Iam awnre tliat.there:are signifteantpenalttes; nchtding thepossi/iilary, offines araii: mprisortmerit.
for submittingfalse information: I agree to conskitct, -operate,, maintain, repair, and f appliei bde, abanclorti
the it jection well an d'allreZat cippurtenances in accordance with the IV NC d2C:02Qf1
gnatui a ofI'roperty Osvn.e/Applcant
]g rit or Type]li l Name
Signature:ofA.uthorizodAgent,16riy
l
Pant or Type:I Ii N4*
T3WQ/CJI�%Cl'oseiLoopC,eotliem�alNotiftcafian(ReviszdM301�012} �age�3 '
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NORTH CAROLINA.DEPAR3'MEN:T OF ENV AND NATIJ1tAL:RESOITRCFS
NOTIFICATION OF INTENT�TO CONSTRUCT O:R OPERATF,INJECMN WELLS:
These wells are 'pernritted:by rule."and do not mquire an in&rvjdualpermit when:consftweted in accor4mce-with
the rules of-I5 CAC 02C.020#k-.This notice must bembmitted rtor to.construcdon.
GEOTHERMA.L.AOUEOUS:CLOSF,D-LOOP R�.ELLS
As described in 15A`NCAC OIC.0222:tliese:-wells ciiredlate.poti6le-water only or.a:tmixtitre of.poiable water and.
performance-enhancing additives asTart.of.a geothermalbeating:and cooling'system.
OR
GEOTHERMAL DIRECT-E)'ANSION CLOSED-LOOP'W.,ELLS
As:desmbed in.>l5A:NCACO2C.0223 thesewells.eirculate arefrigerant gas.-as part-ofa•geofliermal heating and
cooling system.
.Print Clearly or Type Infonnat(om :iffegible:$46miaa -Wi-li Be ReturnedAs Incomplelle
DATE: 8 20-Aa PERMIT NO-.WTOI 0A_T ( (tabe.completed:byDWQ)
' A. TYPE'OF.GEOTECE1tMALCLOSED-LOOP WE TO BE -ONSTRITCTED
(1) Aqueous(as per:l5A:NCAC,,02C.0222). Number:ofwells: wJt.Q,T2o1
(2) Direct Expansion(as-per,15ANCAC 02C.62 3) Number-ofwells: Z eY,6
B. STATUS OF WELL OWNER(choose one)
(1). Single Family Residence i!S.alimit:#liis ior�n fwo.t2):basiness`days prior°to constraction:.
(2) Business/Organization . St&nJt this form-30 dgY..,pirioeu conis.,truetion:
(3) Government: State Municipal. County Federal:_ . Submit.this:ibrm.30:days
prior to construction.-
WELL OWNER=For single.family residences list the property owner(s).- For all others, list name of the.
businessiptganization,.or.govemmenta/geppy.and person-delegated'sig oblre:sutlority:
Mailing:Address: �' . . W►:.� ; ; •li:. Tt 1:��.
City; _ ►�r`t11 State: -)J—C-: zip ccid,:�ounty:.
DayTele.No.
BMA L Address. Mks l*ft� D3�dCi;4Ak�`:a'rOMFazhlo.::.
D. 'PHYSICALLOCATiON.OF WELL SITE
p
(1) Parcel ldenti fication Number(PIN)of well
(2) Physical Address'(if different than mailing address):
City:. State:NC Zip.Code:
DWQIWC/Closed-Loop.Geothemial Notification(Revised.00/2012), Page 1

E. MAPS,PLANS;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 clearly•and include amorth arrow. Aftach a
site-specific map,showing the locations ofthe following:
• ' P
roposed:injection well locations eptic:systems and associated spray irrigation sites,.
drain fields,or rep,*areas.
uildings
P.
roperty boundaries Misting. or potential sources of grpuridwater
:contamination: S'
urface water bodies
• W
ater supply wells
(2) Plans and specifications of the surface and subsurface cousttuctton dctails:of tliowell,s3 iff
F: TYPES AND CONCENTRATIONS OF ADDI ra-S - List.any additives that:will .be.used acid their
concentrations. Only additives that the Department of Health-and Human Services'Division of Public Health
determines do not adversely affect:human-health shall be used. A list of approved additives tcan be.found:
online at http;JJporrtaLncdenr:oruJweb/wa/ans/awuro: All other additives require approval prior to use:
CQ0 76 EA��N(3s\cs\ 8020 "ems
G. WELL DRILLER INFORMATION(if known).
Well Drilling Contractor's Name: Robert Larry Wells .
NC Well Drilling Contractor Certification No:: . 26.03
Company Name: A'WD;services Inc. Contact Person: Larry Wells
City: Leicester. State: _NC. Zip Code:28749 County: Buncombe
DayTeleNo.: 828-683-9223. Ce11 No.;828-215-9334
EMAIL Address: Wells750549@b'ellsouth.net . Fax Flo.: .828:683-9203.
H. HEAT PUN P CONTRACTOR INFORMATION
Company Name: Bullman.Heating and°Air
Contact Person.,.Josh Guthrie EMAIL Address:.joshg@hu!hnanheating.com
Address:10 Red Roof.Lane
City: Asheville Zip Code: 28804 State: NC County: .Ounconibe
Office Tele No.: [phone] Cell No... [phone] Fax No::f828)..658-1001
DWQ/MC/Closed-Loop Gwtha=I.Noti6cadon'(Revised Q30/2012) Pagel,

'1?rovide;a brief description;of how:(]):water siipply%yellsy(2)>surface:water bodies;and 3
Septic'systems anti associated sprayim.Sation sites,drairi'fields,or repair areas;widi 250 feet ofthe:piopased
injection wells will be protected.-during:consttuctioit•:of the:wells;.
ree_e:S Soc�s► .
. ..........
J. V,ARIANCE:']?'M'antto 1.5A N.CAC 02C.:024i the Director of the:DiA iozi ofWAterQuality in grant a.
vaz tance'from appttcable t ell:construction or:operation standards provided-that:
well's• will not.bndan erhuman he a ltli:arid.welfare or•tJie: oundtvater"and
,' • ::..... , , (,) that constiiictiori orope6tion;:Yn-aceordance-.ivitli:the°standards.is nofiaecYuieally feasibl�orttie
' proposed::construation provides equal or:laetter:priotection oftlie.ggromdWater.
Anyvariancese msub italthis noticaion.toeaedite n
ti p i
beaesec.oieM rThev n o w Mv oJ rnit
K::: :SJE.GNATURES '[Tie:followiing aection.is.to b completed as,required below or by that person's autizoriaed.
agent:: t Al. ACQ2C,Q217.(ej.requires sigiiatures.as.follows:
[a}' fora:corporation: .by axe5pgnsible corporate officer;
. :fora:partnership arsale proprietorship: by.a general:partner or the prciprielor,:respectively=
(c) for a municipality or a state;federal;'or other public:agency: .by either a.pFincipal.executive
off c r er rankui�e
.f. 'i lIother by bl cial,
::: .. • :.; ...;:::'...: f. .::' . . s... i ell:owner, off
_....... . (e)
for any.otiier:person.':authorized to act on behatf.of the:appiieant: documentation:shall.be:' -
:..
sub' d with iiotif cati n th at clean identi
o ,arid.isaigned;and dated by the applicant..
es the".person;:grants..tlieiit :signature
;:..-..
erih":cer7i. ,_.rrHclet�: eria[ .,,o lax;tliatlrai}e: ersa»aft `examined and am`giniliat'is,Ttlralie.irr atrrrat�a�r,'..
;srt[drifted_in.. is,&ktirnent`arid.al/attar{rmerits tli�reto aril tbaf; based.:on �tr_ iri airy,of.tliase indiiizdrrals
Y q . .
rtruirediiifel r pnsrb[e;_©r'obfairrri. said J OtTrrativn,.I belieiJe lftQt t1ta,°!Pr 0r7r1QllOri':IS.tl trG acctil afe,clttd Y-- f e.
: Gottrpleta I;anr aware tlrattiere are•sigrr fccrtit:per. e possiliilitY ofries:and:imprisdrxtrrer ,:. :...
or srr&ttrrtttrt txlae ' d .•-
:irzfo�rrratton. I agreei ld eonslruct, ope►are:.rtroirrtain,.repair, aril if app.jocdb[e;,afid►rdon
'-: tfie i jeetion is=eIl zrtrd all iae[ated appr r7erra: be 6izlan qe is+ith the 1.5A-NCAC 02C-0200 R6k&." :
pplicant: .
attire.: .,.:rape 'Qiner/A
' nt or�Type Futi`Narise'..
. . Signafuce;of:Autiturizcd"Agent;`i€�atiy;
Psint r.7'jr`pe Fiili lYIIme
Fl! QIUIGC..tostd= Geotfi IAoP. Cnnajhotilicatrciii'(ttcvised9/3Ut?Oi2).;. aa&

name j project
date
tasks ' Z
V'
—. s

L. SUum TTAL- NSTRUCTIONS—:Submit one Dopy of tlie:complete l:riot ficatiori package.ty the each of tTie
following:
(1) The Divis ori:of Water Quality Regional Office serving the area... which the:injection`"11 facility:
will;be 16cated:
�....,;y,•-�a �,s, r r .0 �-r,� .�^ c.�'`'�. -,i l�h t.. a'��.w���t.� � '",�r'T tr •._mot y
a ry_,• -.;kt 2 R
\ 1
Asheville.Reg onal`Office Washington:Regional Offce.
2090 U:S..Highway:70 943 Washington Square Mall
Swannanoa,NC 28778 Wasliingion,NC'27889
Telephone:[phone]. Telephone:[phone]
Fax:[phone] Fax:_(252)9'-5-3716
Fayetteville Regional Office Wilmington Regional Office
225 Green StreeC-Smite 114 127 Cardinal-Drive Extension
Fayetteville,NG 28301-5043 Wilmingtan;.NC-28405.
Telephone:[phone]' Telephone:(9.1.0),796-7215
Fax:[phone] Fax.(91.9)350=2004
Mooresville Regional Office Winston-SalemAegional Office
6.10 East Center Avenue,Soito.301' 585%1 town Street
Mooresville,NC.2:8115 Winston-Salem,NC 2710T-2241.
Telephone:[phone] Phone;(336)771:4.000'
Fax:[phone] Fax:.[phone]
Raleigh;Regional.Office
1628 Mail Service Center
Raleigh;NC 27699-1628
Telephone:[phone]
Fax:.[phone]
(2) -County-Health Department in which the injection well-facility will-be located.. A.list:of eoimty'health
departments can be found online at h=:I/www ncalhd.or county_htm:
:DWQ/UIC/Qosed-Loop Gwttiein►al.Nptifiaatiou.(Revised 4/30/201'2) fage 4

1DNUIMI Ilesown�
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL 1ESOURCES
NOTIFICATION OF INTENT TO CONSTRUCTOR OPERATE INJE CTION LR 017
These wells are 'permitted by,rule"and do notrequire an individual permit when construch din accordance with
the rules of ISA NCAC 02C.0200* This notice must be submitted 'or to co Region
Asheville Region ofAoe
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in 15A NCAC 02C .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 NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print nearly or Type Information. ,Illegible Submittals Will Be Returned As Incomplde.
DATE: 20 PERMIT NO. �10 01-X (to be completed by DWG
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C.0222): ✓ Number of wells: 2 wells @ 350'each
(2) Direct Expansion(as per 15A NCAC 02C.0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence X Submit this form two(2)business days prior to construction.
(2) Business/Organization Submit this form 30 days prior to construction.
(3) Government: State Municipal County Federal _Submft 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: 3 3 5 ��et M c3,�,S �V•�
City: C O.n1"Zon State: �kQ Zip Code: 9l16 County: 1r\ ooc1,
Day Tele No.: Cell No.: 8al; --76`3- a'18'�
EMAIL Address: Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site: 84-16 r 01 — \S9 0
County: \Ags4 ooCl.
(2) Physical Address(if different than mailing address):
C�s-'�.cN �V'-1 �J ec cro.� 1ec3► o cc� �a� �
City: State:NC Zip Code: cag-} k
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 1

� Lf�>l�rlll�l� j
E. MAPS,PLANS,r�.be
SPECIFICATIONS
Maps mu scaled or otherwise accurately indicate distances and orientations of features located
ti within 25Q feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
'* �vite`5pbcific map showing the locations of the following:
• • p
reposed injection well locations eptic systems and associated spray irrigation sites,
• drain fields,or rep*areas
uildings
p
roperty boundaries xisting or potential sources of groundwater
• contamination g
urface water bodies
• W
ater supply wells .
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDIIMS — List any additives that will be used and'their
concentrations.- Only additives that the Department of Health and Human 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 http://portal.ncdenr_org/web/wq/ays/awa)re. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Robert Larry Wells
NC Well Drilling Contractor Certification No.: 2603
Company Name: AWD Services Inc. Contact Person: Larry Wells
City: Leicester State: NC Zip Code:28748 County: Buncombe
Day Tele No.: 828-683-9223 Cell No.: 828-215-9334
EMAIL Address: [e-mail] Fax No.: 828-683-9203
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Bullman Heating and Air
Contact Person: Josh Guthrie EMAIL Address:joshg(a,buUmanheatina.com
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804 State: NC County: Buncombe
Office Tele No.: [phone] Cell No.:[phone] Fax No.:(828Z658-1001
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

name project
elate
G
tasks
i
46
JJJ o .
r e l ov
V'eo �oce5 �o lsJe��

r• >
I. 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 within 250 feet of the proposed
injection wells will be protected during construction of the wells:
NzJe At-Lei v Qe.
J. VARIANCE—Pursuant to 15A NCAC 02C.0241 the Director of the Division of Water Quality may grant a
variance from applicable well construction or operation standards provided that:
(1) use of the well(s)will not endanger human health 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 or better protection of the groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation,of the request
The variance request form can be accessed online at httoWportal.nedenr.o web/wq/aps/cwnro/permit-
applications
Y— SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C.0211(e)requires signatures as follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner or the proprietor,respectively;
(c) 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 owner;
(e) for any other person authorized to act on behalf of the applicant: documentation shall be
submitted with the notification that clearly identifies the person, grants them signature
authority,and is signed and dated by the applicant.
"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 ISA NCAC 02C 0200 Rules."
SignaturWPro Owner/Applicant
Daly M,-A ao 'a
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQMIC/Closed-Loop Geothermal Notification(Revised V30/2012) Page 3

L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Quality Regional Office serving the area in which the injection well facility
will be located:
kl 4! tj
y :
No
�T'.i
>.ik a ., 4} 4� ufh iz.1r ' t.. n p+,-" �• ,{ tt i 3Tk
�L E
a N x
� 4f,:+t�� �:
SZ SS fk� U'
r
..),:
INV
Asheville Regional Office Washington Regional Office
2090 U.S.Highway 70 943 Washington Square Mall
Swannanoa,NC 28778 Washington,NC 27889
Telephone:[phone] Telephone: [phone]
Fax:[phone] Fax:[phone]
Fayetteville Regional Office Wilmington Regional Office
225 Green Street,Suite 714 127 Cardinal Drive Extension
Fayetteville,NC 28301-5043 Wilmington,NC 28405
Telephone: [phone] Telephone: [phone]
Fax:[phone] Fax: [phone]
Mooresville Regional Office Winston-Salem Regional Office
610 East Center Avenue,Suite 301 585'Waughtown Street
Mooresville,NC 28115 Winston-Salem,NC 27107-2241
Telephone: [phone] Phone: [phone]
Fax:[phone] Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh,NC 27699-1628
Telephone: [phone]
Fax:[phone]
(2) County Health Department in which the injection well facility will be located. A list of county health
departments can be found online at http://www.ncalhd.orgLcounty.htn.
n.
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

Pilo IIIAS
6 l �3a
NORTH:CA1t>LINA DEPARTMENT OP ENYIRO�+�l",Rk `+A�3 NA.. ..:�.07.Al~S��fRi ES
:;= (�TFI€A� LOFAI1 �2Q CPER 1W-1 MI
:These titrelis are.' rmttted rote it� l+►idual
�.. t,y,r_ Caw
the rules of I.5A NCAC 02C.0,2 ;Thrs rroHcermust be auubsrirueii p�3or#d c©��a c .
As described .=.15AxIGAC 07 dwre e
perfoimance�enhancmg addrt�yes as pat#afa;gthe�znal$eadu�g.aadcoo(u} !tam,G:
UR
As descttbed in:15A.NOAG U'L 0223"these wells circ late a , ^"geraiYtgas.as par'�af�:geotheinal tiea#iitg and
eoolingsystem,
.:, .- .Pri�tl,ClQatlyorT,�q�lnjIo�r.��ll �jl��ulrm�ttups-�Bgl�etWrHed ,��rcorir� <;';:.-:
bATE� 9 I ` n p - DJQ)R WJ
f x'
A. TYPE OF GEOTHERMAL CIASFD=LOOP WEiL.TO$E rfiJN 'RUCD:.. : :. ;
. e
(2) direct•Expansiow(�s per--1 SA NCAC-02C".02.23)
"
B: STATUS OF-W.ELL OWNER(choose one)
(1) Stngle Famtly�Residence'. Sutunt thlivpr�n tvo tinsyas pro #o construtlga
(2) Btt5tltessl'Orizatton Sphittit phis fa�cax0 days pttr to canstracon.
.i
..:C�avernmen-State. . . pat ottrt#yT. x y Atmict C' Federal Snb�i lfri 30.da s
C... WEI�LVII M i~b :s gle=ain l3r resident;. ,list t}e P l7e r�s) For t] of the
F business,ortzatton,o :govemment agency anti p�tsort delegated ssgiiature°atitfrorit�r: .
w�z;, "� � : $ ,rc.f ,o 're y�►� ,� -the
.ems
_. . . JlliQ R` ►1,�;. ySye-A..
Mailing Address:: � $�Y" W �g-► 'a;D�s.>t [(
City: 42M w
Day NON j� a Cell to
A .f
S
ENiAiI,aAldress n 1 _,jr atcl3o t>
3 4F
<.
-
............ ... .... ....tr....r..':..isa-.:J:...,v.- ..M..xr.-...._sev:ss.w.:»-,:x...._ _
A. IlLi1LL Sx v'P=u
tl).... -"i' 1't fibfid&1
County:' pLtz k'eQ.
- (2) PhyAcd Andess�tf difererd,4 mailing
address}:. .
State:�C r Code. _
'DWQn lc.tclo Loop Gebthennai Notification(RevLsed'4*M,012). � " page l
.

::
a, . _.........
___.
J t
l
P14N$r A SPECMCATIONS.
alas_meggjbe scaled or.otherwlse accurately•indicate:distances and:orientations of features-located
v.4tiiiii?:.5.feet ol:the injectioh we11(01 LAW U-features elea--I and Include.a xwrth..ari-ow: A•tsach a
site-specific map shovuing the:locations bf the.following, .
• Pr • sed`itlj Woji well:locations. Septic systems and aasoc`iated spr4Y irrigation
• Buildings sites,drain fields,or repair areas
Property boundaries .
• Surface water bodies. Existing or potential. sources of groundwater
• �►Pl3`
Water wells corium imoon
.
.(2) Plans and Specifications of the surface and subsurface construction deWis of the well:eystem:.
F. TYPES AND-CONt NTRATION3 OF A)OITM$M Last any add ti*,-#tat will be used.:and their•
concentigtioiis, Qniy;adcLhves.that the Depacar,e of Heal#1 .and Human Sernees'lvjs3or3 tsf Fu$lic:health
determines do trot*edyerseiy affect.Human health shall be Atsed.. :A list of approved additives can.be'fWO—
online:at t 111 ortai°ncdenr org&weblwgta s/ w ro. All.other additives requit a approval prior to use:
.r wit A .
G. W19LL DRII T�E&MORMATION(if known)
Well Drilling Co'ntractoes Name: Robert.Larry Wells
NC Well Drilft Contractor Certification NW-* 2603
Coto Name:' A:WD'$"vices Inc. ContactPerson: Larry Weis.
City-,. Leice0q. State: NC Zip Cade;28748 County::`Buncombe;..
t
Day'Pele No.: 828-b833 9223 .... Cell:No.:828-215-9334
EMAIL Address: [e-mail] Fax No.: 828-683-9203
K BEAT PUr"CONTIa�cACTOR WFORMATION
Company.Name: . . ,ta J +Q a
17
Contact Per idress: <`. `� OU
Address:
City.0 ` .. 'A Zap Code: . $fate: „County.
Once Tele lVo:i r'1 `- tti . Cell No 710 j. �1. ��,. Fax No.: '
DWQ1U1C/C16sed-L.oV Geoi}ier"No"cadom(ReAsed 413012021 Pap.2

,y
.• .l/lam) �� � Q�'t�'L .. _. - .

! t
,PFovtde a beef descnptton of hpw(1);waterrsupplxFwells,..(2)st�rfa a wa# r Os;and(3)
septic systems and.associated is irrigation,sites,drain.fields,or repair areas;within 20 feet othe.Proposed
injection'wells:will be protected:during construction of the wells:
Silt Fence will be used to contra(solids and run.off from drilling
. A •
variance from livable we b �ire -standards
t1RIANCE Fursuanto l SAtZ4"1 the Direetolvif tite Diinsiot;of later Quality may grant.a
app s xtc>a pr, pexationistandards provided that:
{}l) case oithe wdt1� witfi not enzlanger ftiman health and welfare or the groundwater,and
(Z) that ctitastrlii z . orppergtion in accordwce with the standards is not:technically feasible or.the
:..
pro pi sed,.ctsi st�iicttoi is oA es.equal or:better protection of the groundwater.
Any variance req4!*..Al W-151.accoinpany.submittal ofthis notification to expedite evaluation of the request
The variance request fora ,can'be accessed online at hilp:llpariabledennor u+eb.wgiapsiguf pro/}arm it-
a lic:a of s
I�. SIGNATIII�ES,TW followin&Qe'Iection is to'be completed as-required beln v=fir by tua,, tson's authorized
agent Ii5A NCAG 02C,.0211(e)'rrequires signatures as follows:
(a) for a c�osporatxori: 6y a responsible corporate officer; x
(b) for a partnersltip:or sole proprietorship: by a general partner of the*opnetor,respectively,
(c) fora municipality or a state; federal,.or.other;public.agency. by either a priitcipai°executive
afi'cer ortanktr�tgpublichy'elected®ffzcial;
for all oche y rs: b the:well owner;
(e) far an}r'other person:�tliorized tot on.behalf�afe apptisntr= ocfi»entatron.shall be
submttied 'th notification that clearly ideiitifies� the°pe�on;4=g=ts them signature
.authority;and�is.ftned and dated'by.the'appl'icant ''
I hereh r ee ify;°%2ndel petza t�af'aw, that I.have personalty ez'alsurreif d t afar'with'the Irrfoxmation
submited mhsdrcureraattachmens hreo m hose n s� y
n
lmmedutt+ely}•esponsih?e for vlia?at ung said 41nf6►ma4ion, I believe lhat'the>t d r33��is true, apcutate and
complete:.1 am aware that there=are sigriificai:t penrtlties, inch di b slbiltZY o rig'$ mprisoninetit,
for submitlzng ftzlse trrjormtation":l agree to construcA.operate, matntalrr, repalr, tw?.IrYzippi cWe, akvdi n
the injection well and'allrelated appurtenances in accordance with the 15A NCAC OC,!Q24E1
t �I
Signature o operty'DwnerlAppltcaat
`r x.
byre ry o .
IFeI!'Name
, .. .�. :.. see.
3ignatnretof Authorized Agent,if any'
w6cor Type Fdll Name
DWQ/UICICIosed-Lboli thermall ificetioa:(.Revised413.i3J 0i2). 'aF4e.3--

RE NED
ioMiioaitilMMrh.owcM
NNA: S0.ARTIViENT QF ENVIRONMENT AND NATURAL.&ESOUEtCF.S
F E B - 6 2017 F INTEA€T TOCONSTRUCT UIt{3PERA,TE1tiT3ECTIUN:WELLS '
d iSy rule"Gird do not requfr a an rndlvrdual permrt,whan eoticlPvcl2dYn actoTdance•wrth. '
SA NCAC•02C'0200t.Thidno7icamitst besub►nifted.0hirlb-construction,
Water sheviH Fleg d ffloo � OTHERIVIAL-A 1UEOUS CI;(__WWLOOP WELLS ;Asheville Regional t'?lfloe -
AC 02C 0222 thetovelis circulate potable water only or a t tixtike of potable,"tern-d
rice-enhapang acidipves as-p_"art cif a:,geothermal heatir<g and cooling sy_steni.
►'THERMAIi DIRECT EXFANSIO, ON GI OSED-LOUD WELLS
JCAC 02C.0223 these wells circulate a refrigeant gas as part of a geatfserrrial,heating":and"
coo[ing'systeM
`ely or Type Itrfotmaiton Illegl5le NabmhWs=MY Be Rettuned As Ixcotnplete", i
20 PERMIT NO
(to 6e completed by DWQ)
ruERMsr CLOSED-LOOP:WELL O.BECONSTRUCTED
i(as per.I5,-MAC 02C,0222) _" Number:of wells ,
xpansion(as per 1 SA NCAC 62C:0223) Numbei of wells:
SELL OWNER.(choose one} "
=amily-Residence Submit tbtsTorm•twgdZ business days prior to eoastruetiot�
3siOrganizativn" Submit this form30 days:;prior_to"constr_uctton
inept;:State Nlutirctpat :County._. _;Federabr °Submit tf�ts form 304Ays
prior to construction
R Fot;smgle"faintly residences list the propetEy.owner(s} -For all.others,;lcst name'of the`
tzatzon,or government agency person delegated sigriatiue authority:
_ _ o �► `�.y� e� , �� f1 �;o f�re� � -to �- y���PPs �_p
Fit n�:� 1gt,+"yi'f R Gy oit' Rca.c<61�. .TY�s'f 'o� fr„t Fed 2`8 2003
ss: �,2':S`f lt"' IN
C am+ _ State L Zip Code:2g6f County-_ 'T,0 Ct �o y'Ytf/
Cell No.
•t/6�1 a t �?ha� �� •Cam, Fax No.
• -
W.CATION OF WELL.SI`l'E
•1 ldent�fication Nurttber(P1N)c f wail site: 7 _
7ty 13 uv
;ical Address Of'different than ir►ait,ing address}
State•NC Z:1pCode:
Geoditraisl Nadfication 41302012)
Page. 7

OEM. 3S -�
. ®wiacsieA>ir�INll*enicM!>)
E: MAPSJI AMN ,AND.SPECIFICATIONS
(I) Map must be scaled':or otherwise"accurately indlca;e distances.and orientations of features ocot
within 250 feet ofthe injection wet!(s). libel ail features clearly and include a•-north arrow. Attae>j a.
C
site-spec fici)ap showing the locations of.the folio, 3 e,q� pte a- �.•*?4h�aory i
-
Ptopased injection well locations Septic, systems and •tissociated spray itrigation.
•. Buildings sites:drain fields,or iep*aTeas'
• Property boundaries
w Surface water bodies Existing or potential sources of groundwater
• Watersopoly wells contamination
(2) Plans,and specifications.of the surface and subsurface construtt•►andetails bf the well system'.
F: TYPE&AND'CONCENTRATIONS OF ADDITIVES—iList any additives that vAll be,used:and their
;canoentrations.. Only addi Ives that the Department.of'Health and Huirian!Seiyices',D vtston of Pubitc';Health
detwnines do not adversely'affect human health shalt be used. A list of apprOved additives can be::found,
online a htt :&prtal hcdenr.oiWweb/wq gw_oro. Ml other additives;require appmval prior_to'use.
i .
G, WELL DRILLER II ORMA`TION`(If known-)-
Well Drilling Contraetbes Name:
T1G Weil Qriling ContMtor Certsfication No.:
Company Name: ' M Contact Person: A ��
Sa N Zip; a -S :otYCty: 1
Day Tele No_�tq
r6�aa CeILNo.:'�b � �
EMA[L Fax No.:
;Address-�i�8�'�C� 1,1�2��R����' --
_
IL HEAT PUMP CONTPACTOR INFORMATION
Company.Name: - t� , �
Contact....
... .. _. '' �.,•.�.
on: ILA _
-
'�„� := Zip Code: State .County:
QfficeTeleNo.: Cell No.: 4�;-'} t — ",� Fa�ldo
DwQ/UtGC1o=&LoW Owthermal Natificatiai(Revised 4 M.012) Paka 2
1

welts, 2 surface water bodies,and(3).,
I, pgpTEC'TION Provide a biw"desan'tcon of how(1)water supply ( }
Soo
systems and associated spray imgati6ti sites;Arain fields,or.tepair areas within 25Q feet of the proposed
fnjectan wells will.be protected during eonstiuctionoftbe wells
- -
Silt F nce will be s d o oritrol o ids and
drill m run off from : -
w
yARiANCE Pursuant to,15A NC-AC 02C 0241`TMthe Director of.the]3iyision of Water Quality may grant a`
variance from applicable well consi uction-or operation standards:provided that:
(1-) use of the wells)will not endanger humai►health and welfare or the groundwater aiid
(2). that construction or operation in accordat►ce:vvith o ion ofi re the gratt.
ndw tuna er.ic
lly feasible'or the
proposed cortstruchon provides eyua3 or better p t
rsC
Anj+variance request should accompany submittal of this/ orticdenr: aeh-Hvrion afrequest
Tle variance request,forrn can`be accessed:onitne:at....1�n_._---
tins
Tate following; ection is to bs-completed as-required_below.or by that peison's'authorized
Ii SIGPiATURES.= res as follows:
agent. :15A NCAC OZC.0211(e)requires signatures
a Efor a�coiporatton* by a.respons ble corporate-officer, ro etor :res ect'ively;
O rietorshi b a. eneral partner or the p pn P
(b) -for=a partnership or sole;prof.,_ p' y g
c for a municipality or a state;federal, or other public agency :by either a prlricipai exem iae
_ O
officec or ranking publicly elected official,
(d) for ali others by the well owner,
other: on aiithonzexl'to act on behalf of-the applicant ;docurnentatton shall be
(e) for any, Imo. . identifies the ;person; gram them, signatur
e
submitted with;the:notification. that clearly,
`atithority,and issigned A,nd.d_ated by'ttie,applxcarit:
examined and am fairifltar with the t format:on
raw,71tat 1,hgmpersonaI ' u o those imlivtduats'
1 hereby certify; pew . t►r?'
submitted vs Ihas docwi?ent and all attachments thereto and that based °a,,orma on true, accurate ant!
►nmediirtely responsible for 0 'hWh g'said trtfor►rtcition I lieve t teethe s b lity of fines and imprtsonmeir+t,-
are that there are.signOcant penal[tes, trictuating[ pQ icable, abandon
complete 1 om aw. rare tnaintairr repair,"and f ap#
for submitting=false informWon 1 agree to construct, ope
the injection well-,and all related appurtenances in accordaNee rvith'ttie I SA NCAC 02C Q20Q Rules
Owner/Applicant -
- 9ignat6re o ropes°tY
Prhik or Type F all Nanee
-Authore an
Sigaature of _nt,if Y
Pr 'tor Type Full Name
- vised 4/30012).
�DWQIUICICIosW_Loop GeOhermal N iicahon'(Re.

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-NORTH CROLINA'DEPAR3`IVIENT OE;ENIRONIvIEI�ITAlbNATUItA ;RESOUit ;:
NOTg`ICATI{JN OFINTENT TO CONSTRUC OAL-'OPERATE CTION V�ELI:S. .
These wells:ara pe!+�ltted-bY rule"ar�d do:nol require ztn rndfvirluar!permYt:wh�ri eores ed �` �»
:
ahe rules of I SA 1VCRC'02C 020Q�.:This notica must" a m fled rior to c evlMe p
GEOTHTRMAUAdUEOUS:CLO`SED-LOOPWELI:S : -.`': -_
As described in 15A;NCAC`02C'.0222 th sevirells circulate potable v�i, r:only or .a. ...a of potalile water and:
performance enhancing additives as part-ofa Geothermal lieatfiitg and.cooltng systeM
GEOTHE9—MAL:DMECT'EXP-ANSION GtiUSED=IAOP WEu
As'descnbed'in 15A NCAC 02C U223 these wells circalate a tefrigerent gas as p..ilrt of a:geothemial.Heating and
" .
cooling system:
Print:Cleatly o rit:Be Returned:ffs Ifice. .lets.:
DATE: T. (t6be;comple�edbyi3lN� '
A:. ... ..
..:TYPE.OF CEOTHEYtMA�L:CLOSET?=LO:OP''RL TO=BE CON;;TRUG 'ED.. `.
. .:.
A ueous as . .... ..: : :.;
(1.). q . ( _; er-15ANCAC:020:0222) Nurtther ofrwells a -
(2) Direot:Expairsion(a9;per1SANCAC..OZG;;Q223) :' '. :.' :Number ofyve7lss .'..:. . .
B.'. STATUS OF WELL:O."— M(ehoose':. )
(1.) Single Farreily l?tiesiclence_Sub ilt,thy:�Pa�itY'•two'(2);dusiness'iiays.prior to constirucr on .
{2): Busiiiess/Or gan.. ion" Submit this forur 0 flays pnoc to construet�oit
Oovernment:':;State '.Munici .: Caun F@deral Submit€his foi cu:3O,:da S
. ,.. .':. pro
C. �VELI OWNER 4:For singly family residdnces list the rroperty owners) For all others, last mine nl.the
business, genization,:or goyemenent ageney and person delegated signature authority:° '
hl
L.
' .. sr .
... . : '•.�.TG. ,"rt ,.�::G`:. -.:.. T FYI�;�: ..`;.
es
.. IV�arhng Addr
City: a 5 yl�:/��C State; Zip Code, �� County v/�G
Day Tele No; No x�Z fs 71d
EMAIL Addtess rr� L. .
- - -
D PHYSICALLO ATION,:OF WEU.SITE:' -, "
(l.): :..'P.arce7 Identifcation'Number P1N :of:vel]<srte
�..., ) ..
'
ical:Addiess(if differe nt'tlian nnaYli cldress) c
.. .......:
NC .Zi bode::.
DWQOC/C1ose�, pp-Cmthemgl Notification(Revised 413020.. :;:..:...:' :Page I

MAPS,PLANS,AIN D SPECIFICATIONS .
. ,MApsslt st a scaled or otherwise accurately indicate distances and orientations of features located
's n 250 f et of the injection well(s). Label all features clearly and include a north arrow. Attach a
+tea ' map showing the locations of the following:
Loa
• Proposed injection well locations • Septic systems and associated spray irrigation
•. Buildings, sites,drain fields, or repair areas
• Property boundaries
• Surface water bodies • Existing or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human 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 ht�ti/A ncdzn ortal, r y;a.ps/ w ro. All other additives require approval prior to use.
20%Environal
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Larry Wells/David Stratton
NC Well Drilling Contractor Certification No.: 2603-A/3421-A
Company Name: A WD Services Inc. Contact Person: Larry Wells
City: Leicester State: NC Zip Code:28748 County: Buncombe
Day Tele No.: 828-683-9223 Cell No.: 828-215-9334
EMAIL Address: [e-mail] Fax No.: 828-683-9203
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:Bullman Heating&Air
Contact Person: Josh Guthrie EMAIL Address:[e-mail]
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804 State: NC County: Buncombe
Office Tele No.:(828)-658-2468 Cell No.: (828)-712-7488 Fax No.:(828)-658-1001
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

name Project
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I

I. PROTECTION—Rrovtde a:bncf desotiptioit of how(1).water.supply w Is, ( surface water b..odtes,and(3)
septic systems and:aSsoctated:spray urtgation stte5,drain fields,or repair eas tlitn��O;f(' of the proposed
iMection.wells will be protected dunng constructtori of the wells :
i... .
5iltFence`:wiIl be used,tocoritrolcolids and'ruttoff:froiudrillin`-.::. - ' . - -
r.
:
:
:
3 . . VARIANCE Futstiant to 1 SA NCAC 02C.0241.1he Director of the Dives ori: f Water Quality shay grant a.' .
variance from applicable>welt constructton.or operation.standards pTOW, dahat -
1 useof:the wells will note► " i( ) ( � danger human health and.welfare or th groundwater;:and. .
is
(2) that cosistruchon:or.operatic'n in:accordance: flte::s#artdards is n t techttscally feasible or the
pro posed:constructtan pmvsdes:equai or_better:protectton of the gro ntlwater :
Any uarsance request should., npt unt1e:. gtestn
Thevanance.requeStfcrm can be accessed onisne at enro. Wve fw:ttra}IS&€'vptwpermit-
appl.icaticyus:
IZ. SIGNATURES The:followsng section is.to be completed as required below or..by that person's authorized
enf i SA:NCAC 02C 021-1 a u�res si
. .: O:req gtttras.as fol l Qws
•
(a) for a corporation::by a.responsible corporate officer,..;`.
( ) for a`partnership.or_sole propnetorship by.a general partner o the proprietor,respectively;
(c) for a inuntcipality or a.Aate, federal, or oche"r puiilic agency: werther a pnncipai exectittve.: :.
officer or:rank ublicl electec[;official;
.p. . Y
.(d) for all others:.:,by the.well;ownei,
(e) far any other person authoiized toact on behalf of the a.ppl cant documentation shall..
subtriitted ith the notYfication..that clean . deitttfies'the erson, grants them si
: - Y _ gnature .
aut4brlty 'an.1 is tiloo and dated by t)a:applicant
`7hereby certify, under petaaltj�of lrxw; that l have,personally examined and *f liar h the rnformanon '
submitted in flits document and all Hereto and that:based on inquiry.ef those tmlividuals
tmrnediately°responsible for obtcurung sate!it formatron, 1 heltev� that 3lie rmattvn is true, accurate ayrd
qq
ete comp plere QYe st cant enalhes, tnclzcdirlg thepossib$lity affines andrmprisonment,
: 1 am aware 3hat th and
for.sitbmitti�g f tTse rrfdrmahon I:agree.Yo construct, operate, mutntarri;_°rc of applzcable, abandon..
the inectiori well and a11.eel ated.appurtenan CO;o accordance with the 15A NC C.00 D200 Rzrle :"
guMure Ope.ppert,Owiier/Appl cant
r
or Type Full Na
Frit me
I
' Signature of Aothorized•'.Ageht,tf arty .
" n-or-:Type':Ru11 Name
DWQ7UICICIosed-Loop Goothermal Notification(Revised 4130t2012) Page 3
_

I:. M. MITTAL:INSTRUCTIONS Submit one copy of tYie.completed nt ti oatiot�package to the.each:of the
following:
The.Division of;VllateO uality Regional Office serving the.area in which the injectton,well facility
' wili,be:.tocated:.';• _ __
i r
a A—
.. .. _
_
Yr
�" n f
2S �.! y uT 't 5•..
S'
: 1
v
i
•r�
'.Asheville Regional_Offae '' : ash3ngtoi�RegonaT_Office': .'
943''Wasliiilgton Square Mall.
Swannanoa,.NC 2878 Washmgtfln,NC 27889
Tele:hone= 82._:296-45t1� ' " Te1:epYionec:{25 )946-6481-
p. t
Fax:(828)29;9-7043;: Fax:(252):975 331:5
FayetteviIIe:Regioul;0ffice:.. ' Wilmington'RegionalOf$ce:'
225•Green,Street,Suite 714 :: 127'Cardiial Dnve Extension':`:.
Fayetteville;NC 28301 SU43. ... ' : . '' Wffi ti toxi,NO 28405
Telephone [phone]Q: PTelephone-(9-16)796 72 5.
Fax:{910)350 2Q04
Mooresville.-Region l Office:. .`'; insfon-i alem Regional O ee
610°],ast.Ceriter Avenue,:Suite 301: 585 Waughtown Street
Mooresville;I�IG 28115:. ' .: ;' Winston Saferr NC 27107 2.41-
Telephone.'(704);663 1699 .. :... Phone (336 000'
Fax:(704).663=6040 Fax: 771631
Italeigli Regional 0
1628:Mail;Service.canter
Teie hone�::. 1.9:7g7=4200 '
'
. . P
FaX;;{91:9)' 71,h71.8.
(2) County Fiealth;Department in.which-the iljectia'n W-e.A facility vtnll be located.. A list of county hearth
.departments cari:iae`.found online ai httnIlwww ncalhdior COWL Yh
A'
D.VuQ/�lIC/Closed-L$op Geothecmat;tptificat'ion(Revised 4130T10I2);.::.;"`: Page

North:Carolina, ?epa>htment.of=Environme>4ta1liy Dvision: f Vtr:: es�uu ±es . .
NURCAnONTON .TIEPNj;:CONDUCTi�PY T EO
Thermal conductivity test wells are used to determine the amount of heat.that:the:sub urface.may
transmil n a given depth interval for the purpose of designing geothermal_hea ngund:codling
Pursuant to Z5A NCAC 02C:fl23fl,.thermal conductirv�ty test.wells shrrtl be subject to.the regular©ry
. ..
.requirements applicable to geothermal''aqueous or°direct expansaan closed-coop wQlls:designed to
single,anvil -residences:
These wells are�`permitted by°rule"and do not require on:individual permit zv m eons&wt-'d in :.
accordance with th-e rz lev of15A NCAC 02C.0200
This.no&e mast be submMadat least two:(2).brrsliiesc rlays.nrinrtv_cortstxuctior�
Print L'leurly Ole Type Information. ideglble.Subm&als..ilW:Bc ReturnedAs Incomplete
18
DATE: 2/23 .20 PERMIT NO. L Q� 0 0 91 Z{tt be completed.by-l?WR)
A. TYPE-OF THERMAL CONDUCrI'VITY TEST WELL:TD BE.CONSTRUCTED. . .
3. @500' .:..
(1) Aqueous.(as per•15A NCAC 02C.0222): Num.ber,.0.fwellsr
(2) Direct Expansion(as_per 15A NCAC 02C.02231, Numlier:af.weDs:
B. STATUS OF WELL OWNER(choose one)
(1) S.ingle-family.Residence -
(2) Ausin6ss70rganization X
(3) Government: ;State Municipal County Federal.'-
C.. WELL:-OWNER(S) single family residences;list alt.persons listed ontheproperty..deed.-For all;otiiers;;.
list name:'of Business/Governmental Agency and mime of person ayscl title wrtli delegated aut�rity W sigi:
North Carolina School of Science-and Mathematics
KevinBaAer-Director of Westem Campus Planning .
Mailing.-Address. 1001 Burkemont Avenue,260.Moore Hall: 77
..
City: Morganton $ .NC Zip Code;
20655 Cotitifyi Bake
Day Tele No.: 8287448-3540 Cell No.:
: Kevin.Baxter ncssm.eduEMAIL Address: Fax No::
I31V Sim s' =i�r
daprc2$
. W PHYSICAL LOCATION OF WELL SITE..:. FEB.
(I) Parcel identification Number(PII�ofwell site: 2702 09:8718
water Qu.►ih%� -'o i'npErations
County: Burke Ashevrr ; -narti;F��
(2) Physical Address(if different than mailing address): 517 W.Fleming Drive
.City Morganton County Burke Zip Code;: 28655
Thermal Conductivity Test Notification Rev.3-1-2016 page 1

_
E. MAPS. :PL-ANS.AND.SPECIFICATIONS
(1) Maps-must be scaled or otherwise accurately indicate distances.and orientations:of_::features.:located:.':. .
within 250>feet of the-injection wells : LabeI alF.features clean .and indlude a:north arrow .mWE
site=specifie:map showing the location's of following:
•' .Proposed injection well locations •' .;Septic systems• and.:.associwed;-•spray`irrigation:;
• Buildings sites,:drain fields,-.. repa i areas ,
• Property boundaries
• Surface.wader bodies • Existing .or potential: sources :of.graundwater::..:
• Water supply wells contamination
(2) Plans and specifications of the surface.and subsurface•construction.details;afthe Well:system.
F. TYPES AND-,CONCENTRATIONS OF ADDRIVES 7 List- any additives.that will.be:used and:their:,
concentrations.. Only additives that fife Depaiiine of Health and Hunan Seances'Division of:Pulilic;Health-
determmes do not:adversely affect:human-Health shall be used. A list of approved additives can be-found
online at http f na aovlabout/divisionslsvater resources7water-duality regj�tmat-opg} d groundwa r
bo
protection. All offer additives requuu apptoval prior to use..
N/A
WELL'DRU M.INFORMATIf1N(if known)
W. eli Drilling€ontmctoe..s Name: Robert Lahy.Wells/David C Stratton
NC:'Well.Drillinga>ontractor:Cerffiication No.: 2603-A%3421=A :
Company Name. .AWD Services Inc. CantactPerson : Larry.
City, Leicester. State:. NC. Z. Code_28748. Coun Buncombe
tY. :.;.. tj!�
3aay.Tele.No.:. . .828 683-9223 Ce1d No.: 828-215-9334,
EMAIL Address:. [e-mail] FaxNo,; 828=683 920.3
It AEAT PUMP°CONTRACT'OR:INFORMA3'IUN' -
Company-lame: NIA.
Contact.Person: EMAIL Address:..
Address:
City: .Zip Code: State• County:
Office Tele No.: Cell Nm:
Thermal Conductivity Test Notiiicwoti Rev.3-1-2016 Page 2:.

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L.. 'SUBMITTAL INSTRUCTIONS.-Submit one.copy of thb-:gompleted not'iieation package tc0 the each offt
following.
(1) The.'Division of Water Resources Regional Office serving.the:area.in wbi&_tlie'i�j�ctianvet!..,faca ity
will be tocatetl:
Washington-Regional'
Asheville Regmnat OBice %3 Rfiashtngtt a` gnare-Iviall
2090 U.S.Highway 70 Washingtori,..NC 27889`
Swamimioa,NC 28779 Telephone::(252)W9 Wl
Telephone:.[phone] Fax:(252)975=3716
Fa3v:(828):299-7043
' �ilmington�I#e�laanl:Offi�e.,',:
Fayetfeyilk Reeml Office. 127'.Cardinal'Drive.>✓xtensia is
225 Gteen.Stteet;Suite 714' WIlmingUmNC 2 1f5 ..
Fayettevt!!e,NC 28301-5043 Telhone (91'0}796-7215.:
:Telephone;.{910)�33.-3300 Tax:�910)<350=20t?4. .
Fax:'(9I0)48.6-0707
" - Winston :.lem +�na40f ..
00r..esyilteRegionol affi+ce 450.W Bates Nliili.,. eite 3
b1.0'Fast Center Avenue,Suite 301 Winston-Salem, C 271:a5:
Mooresville;NC 28115 - Phtirn (33Gj TAG=9 `': .
Telephone:[phone] 4x:
Fax:(704):663-6040
Raleigh Regiougl Office
1628'Mail Service Center
ltaleigh;NC 27699-1628
Telephone:'(919)7914100
Fax:[phone]T18.
AND
(2) County Environmental I ea1t31 Department in.which the injection well Iac i(y wiU`be:located,'.:
Thermal.Conductivity Test Notification.Rev.3-1 2016 Paged:

MORGANTON SITE
Institutional Buildings
(To Remain)
a Institutional Building
(To be Demolished)
Wet Weather
Drainage
Swale
Agricultural Buildings Scale,
(To Remain)
Distance between bores is greater than 100 feet, All structures are 50-100 feet away from bores.
Well Plan LEGEND
GEOTHERMAL TEST WELL LOCATION DIAGRAM
Depth: 500 Feet
Materials:Thermally Enhanced Bentonite Grout, NoM Cmolhu School of V1d Y 0
1-1/4"single U-tube,SDR 11;PE4710 ram«( 517 W.Hemk'g DdVB
Test Fluid: Water Test Well Locs�fiiOn ��y�j��fQ MMankpl%Bloke COU*. NOM Ca MUM
i

Moore, Andrew W
From: R.Tyler Smith, P.E. <[e-mail]>
Sent: Friday, March 02, 2018 4:00 PM
To: Moore, Andrew W
Cc: Yahoo
Subject: RE: [External] Test Wells Notification
Attachments: NCDEQ Boring forms.pdf
E e nal email.Do o cl'c links or ope a ac rrne is ''ess verified e d all s spiel email as an att ch ent to
Andrew,
I have chased down the info on the waste water system for the school. They are on a private network of sanitary sewer
lines across the campus that ties in the City of Morganton sanitary sewer main at the south main at the southeastern
corner of the campus. The City main runs in a north-south direction along the eastern edge of campus.
I have gotten a CAD file for the layout of the private sanitary lines from the school facility director. The map include with
the attached permit has been updated to show these lines with relation to the proposed test wells. All of the wells are
scaled to be 25 feet from the sanitary line.
Please let me know if you have any additional comments. Thank you for your help with this permit.
Have a great weekend,
R.TYLER SMITH, P.E.
ECS SOUTHEAST, LLP T 828.665.2307 D 828.785.4185 ( C 828.450.9315
www.ecslimited.com
Confidential/proprietary message/attachments. Delete message/attachments if not intended recipient.
From: Yahoo [mailto:[e-mail]]
Sent: Wednesday, February 28, 2018 6:54 AM
To: R. Tyler Smith, P.E.
Subject: Fw: [External]Test Wells Notification
Good Morning Tyler,
I received the following message from Andrew Moore with NCDENR.
He has the NOI on hold until he receives the information concerning
the location of the waste disposal system. Please remit this information
at your earliest convenience. If you have any questions please feel
free to contact him for clarity.
Thank you,
Shannon Ward
i

Ir r l
e44� � l �. t,• s=
Institutional • •
• k
` I y ' •L-� It
'f ��5t ali:Vic. S'.+r�,ice. i is 3"' I 1 I i L,f Y, °+, c.. V• 5 ,`] f
Institutional Buildings
(To be Demolished)
x- A1
j
Ad
l
�'ham!
-t
Wet Weather V
Swalb
i
Goode Earth ' • •©201.8 Gryle 400 t
p N
Well Plan LEGEND
GEOTHERMAL • ' •
Type: -. ( `
Depth:500jeet
S \ . . .. Mathematics
,Materials:Thermally Enhanced Bentonite Grout
Pritoiits&f -• Fleming

E
REMOTEFILL GOODWINAVENUE
......... ........
STORAGE
• ; BUILDING
\
TANK do NOTES
STOCKPILE
(I5x16k3.5'J - -
00 50 G LEGEND
• •' ' . ODO GALLON � OIL 6 GREASE�ACK ,
--GASOLINE - - - - -
-- UST VENT LINE
-- UST PRODUCT PIPING -'
\ ® DISPENSER
i
PUMP HOUSE
r HILLSIDE
�O'Q I /
t i % TERRAINE.i.C.
J ! V ENVIRONMENTAL SERX11CM
- Figure 1
?:=~ raNK er Site Map
5000 GALLON '
I DIESEL
NC School for the Deaf
517 Fleming Drive
\`
�. \ J Morganton,North Carolina
i
STOCKPILE
\ �\
DWF1 BV:MMG CHK BY: MTZ
STORAGESHED \♦`\\
SCALE:1'=10' APR By;,iLY
DATE:06-18-97 FILE: CH970528.01D
I •

N(RTA -T,M � T'OF N NAT M)t ,RESOURCES
NOTIM-AT16S of nNUNTITO cONsTx T:o UlPEtATE WOcrYoN WELLS
These velTs are"perinatted b},rule'and`ily not`regiai�a an'ir�tlri�U ' pitrrsit+vh�n�rinsdruct-d in aczotdcWce`with;
aid,mules Thrs mice iatust be sialirrtr##ud p►�yr f�"co�uk ttctaon.
GlE4TIIERM�L AlJUEO..[TS.CLUSEI}LOOP�irELLS:
As.dasrritied iii l5A NGAG.U2C'.0222`these;�vells ctrculatepotable water"duly'or'a'rriixture:of gotabfc.watcr and
performance=enhanemg.additives<as parrt"cif ageotheiffiM zedting:and cooling system:
OR
;G1✓O l[tIYtAL DIREC T.EXPANSION CLOSED-LOOP`WELLS
�1s described_in 15A"NGAC"(l?C 0?2�these wells,cttculate a rzfrigerant;as",as part of.a geotheirnal'teat�ng ancl'
cooling-system: "
F iii Clearly':ar 7tp�iiifoiirsatccct�; Ilfegrble Su6t� tt��apls.W ll,�e Returner As ditcvmplet ;"
-DATE: I 20 PERMIT NO U�5 0 1 6 0 2E? {to be-c6ibpleted by DWR
TYPE O!±GEOTHERM iL CL' SEQ;LOOIP WEL ,.TO"B]E'CUNSTIt0CTEO
-
1`' A coos as et'1-5A NCA'C 02C-:0?22)i N irntier"af well;s.;. -�
( ) Direct Exp,46sion as per 1zA NCAC 02C. 0223� Number of:wells
B. ST. ATUS':OF W EL L UWNER`(cboose;one):
(l) Single Family RgWence. : Su mrt this fo�rni two(2}busuiess days friar to;construction.
{2) BnsinesslOrgam ar on. Submit this vrm 3U'days prior to construetion..
(3) Government State Municipals County. 'Federal, Submit..t>ais for n.30 days
- - , prior.tn cnhstryetion.
C;. �i�EtiL OW 1EIt-Far single fairuly residences list the property owner(s). Tor all:otbers�_list.:name of:tiie:
husiness;vrgnuization,or goveiziment agency and-:person.''delegated signature au on w
1
t . .
Mai ingAdciress:
Gl. e�
Cr Statea�+�=, Zip;Cty:: e...�
od Coun_
Dayr i cle 1+To.
EMAIL Address:
& ALL"ocaTr6 OFW-TiL M
1j ; Eaicel"Identitica#ian"Nuiriber " ..IN of vve}1 sitz:� 7
Countye:
2. PliysicalA,ddress if different than ipaflin address �" `
C °State:�tC Zi Code; -
UIC�Glosed:Loop<Gcoth�rmalN.gtifi�.aton�Iteviseil.$f�/2Q13), �'��I

E
f
:� -IvIA1��,PLa»S;A: 1D SPEC]EFI'.C�AT]CtflNS.
(3 '= Maps must;be sealed or atherwise.aceiva#eIy indicate ii3stanees and grzentations af;features located,
within 25(l?feet of:t�ie infection wells}, Label all:feature clearly anc include a north Sao
site-speoi c inap;showing the locations,of; following:
+ =Proposed injectionwell locatbris • Septic systems aril associated ;spray trigatlon
Buildings si#cs`,draw_f elds,or xcpair,areas
Property boundaries.
Suifa6c'waterb6.die-s +. Existing Or.,, patent4t sources oil gi'oundw'ater
w Wa ter supplywclts contasiinafion
(2): l fans and Oec&Flcdfioii&ohhe'surface size#sot surface:co strrzetYon det- is o€ilze well system_,
tv
]F TYPES CONCF.NTRA' TTtANS b ADD? b VES —List,any:.additives bat,-W41 be used:and tl3eir
concentrations (hily.additives that>ilie Departi5zee of Health.ari i Huiiian Services'Bivxsioii{vf Public Healela
- ,
deternitres do not.adversely:affect}iiiiriai health shall';13e used A list of apprayed.additives ran.b found
onli ncdezir.org/weblwclalislwti All;otbex aldltives requite-approval pnor,:to use,
G. -WELL DRILLER INFORMA`P14Ia!;(ifknowti)':. r
Well-Drilling:Gon#ractoesN " �iClel
.. 1�iC'VVeII Drilling Cantrac#or Certif�a an 1Vo:: � �='' �^:
Company Name. U- �t t Contact Person .;
C State . ' c• zip Cod cx%Coun City: 1.� �.a p:,. ._. _ -. tY�
y ' r �..' Cell No �^ "c` --Da Tele.Nos: _
EMAIL Address Wild
.:�I.b4 dolb.�� _: Fax I+To:
IL ft_AT'PUMP CONTRACTOR IPIIi<C1Ri11ATl C3N>
Company Name,
Contact Pers. EMAFL,,Acldress'. L'+spy
,Address:
Ci State
te d�' ip Code � � County.
(7ffice Tel_e No. µx - Cell.No l� fax
U sed-I:aop Geotl%ermul N tification.(Retiuwd 815/Zb'!3); Pale 2.

I PROTECT[IOI�I Piovtde ,bnef ilescrtpt on of how(1)water supply.wells,(2)surface water:bad
septic systems and associated spray irriatibn sites;drain fields;.or repair areaswtthin'2S0"feet-
of the,propcsetl:
rnj tjoz�welts�vlll•(e protected during construction of the. cells
VARIAN'CK— drsu4nt ta:t5A MACIrOW 0241 the DireCtarOf the 17 vtston of�tFater Resources may grant:
a variance`fronn applicable well Construct on or.ogera on'standttri s provided that:
(1 use of the tivell(s)will;not endanger humatthealtlz;and.welfare or the groundwater;octet
constxttetion or aperarion,`in accordance wrtlt ibe-standards is riot technically fzastble_or the
,.,."
proposed construction pr yides,equal'or better proteefi of the groundwater.
Any variance request sbauld accompany subtnittaT of this nattfication`to_.expedite,evaluation of the request..
The,;vatlance'requesr,�'orm,ean ba,acce5sed"�online:at http_�%portal:ricdenr:oraltiveblwcl%apslewprolpermit-.
a" lcati ns _
1I : S Ethe flwt mdardwh s authorsz IA . i ps '
:agent; 15A NCAC-OTC 0?l](e)requires:signatures as:follows:;:
(a) fora cotporatton by a responsilale cotporatc officer!
(b) foia parttierslitp ai4 sole prop netiirshtp -6y a gteral partner arthe proprYefcir,erespeetivelX;
-(c) fox.;a municipality or a s{a'te,federal.-or'other:pubi c:agency: "ley either a.princjpal executive;;
officer or ranking'pubttcly.,,elected ofcat;;
(d far„all"others "by the well owner;;
(e) for.;any other person authoriied-to act'-bnn',bdWf of the appl"team: doduhi6ntation shall toe':
°subiriitfed with, the: notification "thdf clearly;`identifies the, pecsoti; :grants'. theiii, signature;
authority,and is's grted-and.datc:; the applicat}t
1 hereby certtfv tinder,pena(ty of law, that l°ha epg�sonQ(1}= arrainetl and ztn familiar tuath;,the mfotmcttaon
suli»iitted in'this docurvient and alb;attacl rrients thereto and'that,:based do my iii u ry.vf.'those.zn"clavidu lr
immediately responsible`for obtaining-said infi07Wt )!;- I beli6e'thdi-the itjfarmatidn is true, accurate and
cby4lela I ant-atiu�rre that there are stgn(cant ertalties; rncltiding the possibilct�=offnes gad tmpi�isorr»Rent;
for szrbmitdng false' n ormatton I agree-to construct, operate_?naittthin, repair and appCceabte,:abandon
the injection 1ye11;and all related appurtenances in.'accordance with the 15A 7VC i G"f) C'Fl2flfl°Rtales,''
Signature of:Fr petyfhrnerlAppficant
Raitt nr.Tyge��11 Natne
C Signatnce Aut of horized`Agenti if any.
print or Typc�'ull.Name
UICICIased Y uop:C3enthennal notification(Revised 8'5/2C}13) Pa�c'3

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July 14.2019. Burke County,, NC
A 75 15U � ,tarp
Owner_ EGKEL,JAMES A PIN:- 2734788679
44 MARSHALL DR PIN EXT' '000
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REID: .61302 1:994
Property Value: ;$141;500 ;¢ a
EGG HARBOR TOWNSHIP, NJ 08234 1� Y - 1 inch=83 feet
Acreage: 2.1
Property 2667 WATERSIDE'BLVD NW Deed Book; 00231.8 asctarmer rheWormet►namlaGred an MIS pap Is taken fmmneRat:rmwng
Address VALDESE 28690 tax—ppIng.wWpq lio records.and.ls NOT tv be wnstnrod'ar,used es.a ow 0y
Dead Page; 00881
PROPERTY DESG. or 7eya►,desrnp6on` Cxrfye trcensetd protessronat lanot sun!ayw can tegalty
Deed Date: 10131/2017 dsianr me precise locatbns,elevations,length enatikeoNan oRallr�a attar rsae,