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NORTH CAROLINA.DEPARTMENT OF ENVIRONMENT AND-NATURAL.RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCTOR OPERATE INJECTION WELLS,
These wells are"pern gted by.wile"and dowot requbw an individual:pernritWien'consthicted in accordance Will
the r ulas of I SA NCAC 02C.0200: TJiis:nolice must be.strbnritted prior to conslnrction
GEOTHERMAL AOUEOUS CLOSED-LOOP WELLS .
As described in 15A NCAC 02C,0222 these wellscirculate.potable water only or'a mixture of potable water'and
"performance=enhancing additives as part ofa,geothd 'heating and cooling:system.
OR
GEOTHERMAL DIRECTEXPANSION CLOSED-LOOP'-WELLS
As.described in 15A NCAC 02C.0223 these wells circulate a.rgfterant,gas as.part of_a'geotl ermal heating and
cooling system.,
Print Clearlp or.Type Information. Rlegible.Submittals Will Be Returned As Incomplete.
A,
s y
DATE: toy. 20 PERNIIT NO.W 1 3 z-z- - .(to Be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(l) Aqueous(as per 15A"NCAC 02C.0222): Number of wells:. = -
(2): Direct Expansion(as per,I5A NCAC 02C..0223) _ Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single FamityResidence Submit this,fortmtwo(2)budness:days prior to construction.
(2) Business/Oigani ation Sghrgit this forth 30 days Prior to construction.
(3) Government State Mutucipal County-L_J-- Federal . Submit this form 30.days
prior to"cd strnCtion..
C. WELL OWNER—For""single:ftinuly residences list the property owner(s). 'For all others, list name of the
business,organization,of.' ' _ertuneihtagd cy 4dperson delegated signature.autl ority:
MailingAddressJ 1�i4`�ES t�lta jltij� 'j5D"
City: ALL L
l Stater Zip:Code 3U;6 County rt
Day Tde No.: Cell No::
EMAIL Address: " Fax
No.-
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel identi ficatiion Number(PIN)of we11.site:
-County:
(2) Physical Address(if different than_ marling`°address) oZ 00 .9 WAAO"
City: .f-�A d�"Y:10_ State> CC Zip Code: !An-4.
UIGClosed-Loop'Geothermal Notification(Revised815/2013) Pare I

E. -MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately-indicate distances and orientations of'features located
Mthin.250 feet of the injection well(s). Isabel all features clearly and.include a north arro«t: Attach.a
site-specific map showing the locations of the following:
• Proposed infection 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 Piiblic Health
determines do not adversely affect-human health shall be used. A list of approved additives can be found
online at httn'1/Mortal ncde�u.or� veb7vra%ans/aw�ro. All other additives require approval prior to use.
(Al=s&
G. NVELL'DRILLER NNFORIVUTIQN(if known)
Well Drilling Contractor's Name-.;(. SOY►
NC Well Drilling Contractor Certification_No.: ' L-L. C..XQ 1414
Company Name: "160A W eLL dz l l{n� ?w: Contact Person: %w«+w+u� SQL?
City'&Ass ot:n State., Zip Code4VQ3 County: iikhk@D__
Day Tele No.:IaT '1377- UGto3 Cell No.
EMAIL Address:) �;I{nn.t�gA'&kn &.J", •.C01 ax No.: 37= 04103
11. HEAT PUMP CONTRACTOR INFORMATION
r.\nnAj t].� 1
Company Name: E 1@C t� -
Contact PersonUOI&AG 1 EMAIL Address-. -
Address: 11 �A)d Rt, `
City: y�'I ls- Zip Code ,2�- 964 - State. -+ LCounty:
Office Tel NTo.: gar 3 q-1 i 3(A Cel1 No. Fax No.:
UIC/Closed-Loop Geothermal Notification(ReN iced 31V2013) Page 2

I. PROTECTION—RwVide:a brief description of how(1)grater 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 zvill,be protected during construction of the wells:
5 SAD
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I VARIANCE—Pursuant to.15A NCAC 02C,0241 the Director of the Division of Water Resources may grant
a variance from applicable well construction-or operation standards provided that:
(1) use of the wells)Will not endanger human health and ii elfarvor 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 htip•/Iportal ncdenr oi--/weblivglapslauFnro/vermit-
aMl ications
K. SIGNATURES The following°section is fo,be'completed:as required below or by that person's authorized
agent. I5A NCAC 02C.0211 fc)requires:signatures as follows:
(a) fora corporation: by a responsible"corporate officer;
(b) for a partnership or sole proprietorship; by a general partner:or the proprietor,respectively:
i (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 -%ith'the 'notification that clearly identifies the person, grants them signature
authority,_and is signed and dated by the applicant.
"1 hea'ehir certifiT,under penalh:of lain thatl hare personally examined and am fbin liar idth the information
submitted in this document and all attachinents tliereto and that, based on my hquhy of those individuals
immediately responsible for.obtaining said information, I believe that the it formation is true accurate and
complete. 1 am aware that there are sigrrifrcant perrahies, 7rrCl1ldirlgahe pOSsllltlrtji of frnes and imprisonment
for submitting false irrforiimation. I agree.to constrrrc% operate, maintain,'repair,:crud.:f applicable, abandon
the injection well and all related appurtenances in accordance with the IS4 A ICAC 02C 0200 Rifles."
signiti re'ofPropertyOwner/Applicant
kw.
Print or-1 -pe FuIl Name
Signature of M44062ihd Agent,if any
Print or Ts pe Full Name
LUC/Closed-Loop(seodrermal'Nodfieation(Revised SIV2613) Page 3

L, SITBMgT TAL iNS31t><JCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Resources Regional Office serving the area inwhich the injection well facility
will be located:
t /1NSYflH-SALEM
Jl Y ry C t f
r4SMEVILLE ` <�IVASHINGTON
LL
�4 ORES
FYETTEUILLE
Ashevilte,Regional Office Washington Regional Office
2090 U.S.Higheyay 70 943•Washington Square Mall
Srvannanoa,NC 28778 Washington._NC'27889
Telephone:[phone] Telephone:[phone]
Fax:[phone] Fax:(252)975=3716
Fayetteville Regional'0.f ce Wilmington Regional Office
225 Green Street,.Suite 71.4. 127"Cardinal'Drive Extension
Fayetteville,.NC 283.0iv-5043 Wilmington;NC 28405
Telephone:[phone] Telephone.[phone]
Fax`[phone] ,Fax:[phone]
Maaeescille`Regional.Office -Winston.Saten ;Regiobal.Office
610 East-Center Avenue.,Suite 301 585-WaughtoWn'Street
Mooresville,NC 28115 Winston Salen,NC 27107 2241
Telephone::[phone] Phone:(336)771=5000
Fax:(7(14).603=6040 Fax:[phone]f
Raleigh' egioiralOffice.
M28 Mait'Service Center
Raleigh;NC-27699-1628
Telephone:'(919)'791,-4200
Fax:[phone],718
(2) County Health Department in v��hich the'injection well facility�311 be located. A list of county health.
departments canlie fauad`online at htID://vnww.h'ca'Ihd.orm/c6v tv.htm.
UICClosed-Loop Geothennal Notification(Revised 8/5)201.3) Page 4

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