Cherokee UIC Deemed Permitted 2012

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NORTH`CARQL�I±IA DEPARTiViENT+UF ENVi$ON SIJRCES
NOTIFICATION OF INTEI�TT TO CONSTRi1CT*,' OPERATE INJECTION WELLS
T/reseYWplls,a�e 'pen�ritfed 'rule"anddo rtot;l:6lfrrn�A>?:ndtvrdualperlrrt w{TQl C077S11TIClCd 1I7`QCCO1'�[lI7CG'lUTJh;
the rules:of 13i11VCAC Q�C Q�00. ?7�is=riotrce mt si be siibnritted prior to`corrstructionI
'GEOTHERMAL AQUEOUS CLOSED=LOOP WELLS
As,described�in,15A NCAG=02C.0222 tliese.wells:ciiculate;potable waver only or,a;mixture ofpotablevater and
perfarmauee ei�liancing additives as part=of a geoihetuiai;::heating and cooliiig:system.
DR,
GEOTHERMAL DIRECT EXPAND ION CLOSED=LOOP,''WELLS
,As described in.I5A•NCAC:02C 0223'thes Hs cucplate a iefngerant-gas as part of a geijthennal heatingaud_
;cooUngsysteui;
Print Clegrly or Tjpe lnforalron:;Illegrbieubmillalsll Be Refueled As lncompll
DATE. 144 All' . 20 ti... PERMIT N,O.. T O 10 0 Z TO to lie m leted b DWR):
A. TXPE OF;GEOTHERMAL;CLOSED-LOOP WELL TO BE CONSTRUCTED
(1).. Aqueous(as per 15A NCAC 02C_0222) : Number of wells :
{2) Ul
Direct Expansion(as per I5A NCAC 02C 0223).,_ Number of,wells
B . STATUS OF WELL OWNER(c�oase orie)
(1) Single Family Residence Snbmit this form two(2)i vs�ness.days Pryor to;constrnef o 1.
(Z}= Business/Qrgaruzation Suhmft this form 30 laysptii®r to construction.
(3} Govenunefit State lVlunic al Cann p ty Federal Suhinit this form 30 days
prior to co$strciction:
C . WELL OWNER=For`sna$le fatruly:residences';hst the>-property ownei(s) For dR others,Itst name:of the
business,.organization,or govem ment agency and person=delegates sig6ature;autI onty;
--nwnn
Mailing Address ,S Nl'D R tx10� y —
Cifiy: LalR501f\ State; , ode.,—
Aidss,: Fax No
PHYSICAL>LOCATIONOF WELL'SITE
(1) Parcel IdentificatonNutnber(PIN)ofwellsitet�5a0-��5'� yo1�0�0
"
Cfltiiity cry t�oKa
2 Ph ical A :.
( ) ys ,ddress;(if different than tnailuigaddress) '. . .
City: State NC: Zip Code;„
UICIClosed Logp Grothemwl Notificahon'(Re�nsed&5/2UI3) pn ;1
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E MAPS,PLANSAND SPECIFICATIONS.
0.) Maps must;be scaled or otherwise,accurately Indicate distances and orientations of'features located,
within 250 feet of the mje--coon well(s)..Z»bel all`features=clearly°:and include a north arrow, Attach_6.
site=specific map slowuigthe,locations of`the following:
• Proposed=injectioawell locations. Septic systems aad.:'assocated 'spray irrigation:
�- Buildings sites,drain:�fields,or repair areas
• Property boundaries
•, Surfawvater,bodies Bxlsftn p g
_.g �or : ottnrial sources of roundwater
Water�supply wells` contamination
(2) Plans iiii ciflcations of the sufface and subsurfAca constiuction_detaib.of the well system.
T. TYPES AND CONCENTRATIONS OF ADI3ITI S Ltst any additives that twill be used and,their
concentrations Only:additives that the:Department of Health and.Hulnan;Services'Dlviston ofPubfic:Health
determines do not;adversely affect human health shall be' used,: A list of approved',additives can be found`,
online athttn://nortaltncdenr.ornlweb%dva/atis%awdro All,other,4Wciuve5require•approvalpnar10use
G.: WELL.-DRILLER:INFORMATION(if known)
We11 Drilling,Contractor'.s:Name M'FS r -
NC'Well Drilling Witractoi cokfificatloii
Company'Name 1�� Oh f ,l� nQ 'r+r±c. CoutactPerson .,� !gD'A&yI
�?+ S
=-
CityRtc1S5'�OWY1 State �s,: ZIp;Codeo1County
Day Tele No 102 �Qta3 Cell No SSa 8 �5l 533p
EMAIL Address f.l.�soln i,�ell d dGete a.r gal, FAXNO
H; HEAT IPUMP CONTItAC i'OR INTORMATION
Coriipany Name `1 t� 5 l ,�n�'��nAT.
Contact personal j .:NE�.i,JM�4h\. EMAIL Address..:.
Addres il .Ske �. . .
Clty�,��t�� IZ. ( N ZIp Code State; Gountyngw:n
r
OfEce Tele No 54l� Ce11No. Fax No
Qb$`b Aoo $
tAClClused:l i op GebthdrdW'.Norification(Revised 8 512013)' Page 2

I PRO'I"ECTI®N Provide'a bnef:descnption of how;(!),water-supply weUs,(2):sudke water.`badies Mad(3)
septic systems and'associated spr y uiigation sites,drain fields',or repair areas-within 25.0 feet_of;die proposed
injection wells wilt be protected during construction o f the weds::
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J VARIANCE, Pursuant to;,15A--NCAC 02C 0241 the-Director of the Division:of Wafer Resources may grant.
a"variance from applicable<well construction or�gper 'ion standards,provided that:
(, use cif.-the w-qU(s)will'pot endanger human health-and.wel'fare or_the,groundwater,and
c tncodne wndsis not technicaly feasibleor theope s2 thata onor
proposed constructton`provides,equal<orbetter protectton.of the groundkvater.
Any variancerequest should aeoo npany subrulf l`ofthis notification to�exped►te evaluation of:tfie.request.
1'he:variance request>form can be:accessec. onluieat.httli//partat ncdeni_org/web/wq/al) pro/germit-
:applications
K. `SIGNATURES=The following section is to be::complefed as required below or_by that person's autfiorized.
agent 1.5A NCAC 02C 02 t l fc).requiies signatures as`fol[oQvs:
(aj for a corporation.*`by a responsil3e corporate officer,
(bj for a partnership or sole proprietorship by a generafparhier or#the proprietor,respectively.;.
(c) far a muiiicipalitya or state,federal, or°other public agency by either_a principal eXecutive
officer or'ranldii_ "blicly elected official,
(d). for all others by�the well owner,.
(e) for any other person authorized lto act on behalf of,the applicant documen#ution shall"be
submitted:with=the notification}that clearlyidentifies the person, ,grants ;them signature='
authority,and i5 signed:and dated"by the applicant
"I`hereby,certify,under penalty of la►+J, drat I have personally ezamaned:and am familiar��tfr the information
submitted in this dacumettt and all attachments thereto'and that based on mY=rnqurry of those utdeduals
trttmediafely respaiistble for obtazntng said tit *dti�n; I belreiJe that the rnfQrmation s true;; accurate and'
complete: la ofaware that:there are:significant penalties,,including`the possrbrTtty of fines and imprisonment,_
for sztbmifting false a formuhon I agree,'to conslnwct`operate=ritaintdin, repair, and if. appl1 ble,. 'ban 9
the in well and all related appurtenances rri accordance x�ith the.13A NCC 02G`0200 Iltles "
Signature"of Pr arty Owner/AppI[cant
Prinf }peFuliName-
Sigaafare of Aa`t oiizea'Agent,if*y
-Print ar T pe Fu11-Narue
UIC%Closed Loop`Geothe�ial2�Totification(Revised>3/5i2013) Page 3'

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On-sitelNastewater Cherokee +County Health V.epalrtmen P ,t#2013
228:Hilton Straet Murphy„Not#ft Carolina 289�{828);835-3853 Ass fisted PDWW Permit NA,,
EXISTING SYSTEM PERMIT/REAPPROVAL
Appficantlt merm Jas 9 Sharo Chapman: PIN# 44590055742800,. Zone.WF°•Acreage 7 65:
Rroperty Descnption:Cedar Ualley Lots 6=9(5 norwood Valley R4
Type of Faclhty:'Resldew7tlal,3 bedrooms Design Flow 369 gpd;
Ty
Ls.•dfst nce..to water supply acceptable? YES.
Is where a visible system malfuri'dU6 r9 'NO
as the septic sysiem,5ized as
needed? YES
Is;the bwlding location satisfactory with setback requirementsT WA
Was original-septic permit`I' ' ted? NO.,
Does th0eptic system appear to be on the property'? YES.
AP.PR®VED FOR;.RECONNECTION YES:
Permtt ConclM nss
If system fails:affer reconnecfion,,a repair permit":must be_obtarned_and th--system ceparred or:reptaced..
Diagram'(Notto Scale):
Out Bank. y�
r .
wey
proposed r1 .
3BR'House: '
WELL Pa, "
a
IOQ' Magnolia
timated Tank.
fiNj
Fill'=
1'.
r Estimated Dramfieid:; -
ve
L
v
{
EXISTING SYSTEM DISCLAIMER This permit,Fepresertts our best attempt at interpreting site and septic system cortd'itwns:>Oihce-a;saptic system is
baekfiiled i#can be very drfficuit to detenntne,�ts exact location There is"also the chance the`ssptic system was modhfied or damaged efte_r it was:
installed.,This permit,is not guararhteed`to:be accurate Also there is no guarantee;that the saptic system wilt fundion;propertya
This perrrhitiauthorizafion ts:sutrject to"evocatiog if the rnformatton submitted in the applicatio'h is found to have been 5t>cocrect fat§ified or changed;:the
siteas altered orintended:usechanges;-andj0-subject to;the provisions of thea:aws and.,R.ules for Sewage System"Cottecbon;Treatment and Disposal "
of the Pirigb Carols a Adminlstmtive Code:
issue Dafe;.10I23/2013 TrevorPeterson;;REHS 2143 Authorized:.State Agent