Haywood UIC Deemed Permitted 2015

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE IN•J"LCTION WELLS
Thew WELLS are peYmilted by rule-and do noL raquira pio jndNjdzjol pQYrn11 Whan constructed in ac=-danee With
t/te rules of 15A NCAC 02C.0200t. This notice mu t e submitte LioY to con trucrior�.
GE0THERNfA7•AMEOUS CLOSED-LOOP WELLS
As descnbed in 15A NCAC 02C.0222 thesc'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
GEOT DIRECT E"ANSION CLOSED-LOOP'WELLS
As described in 15A NCAC 02C.OZ23 thtse wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Prfnt Clearly or Type Inf6rmatfon. Iffegible Submittals Wil!Be Retzartzed As I�repynpfeta
DATE: May 13 20 15 PElt-MIT NOW TO W P3 6` (to be completed by DWQ)
A. TYPE OF GEOTIEMRMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C.0222); X Number of wells: ? @ 300'
(2) Direct•EXpansion(as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL 0VV1%M1lt(choose one)
(1) SiYigle Family residence X .gubmit this form two(2)bvsthess days prior to construction.
(2) Business/Organization_Submit this form 30 days prior to construction.
(3) Government: State Municipal_.._. County Federal SubYnit this forme 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:
Patrick & Kathie Johnson
Mailing Address: 2301 Stonebddge Way_
city: Fla ler Beach_ ___ State: FL zip Code:32136County: Flagler.
Day Tele No.: D36 299-4979 Cell No.. 386 316-1434
EMA1LAddress: KathiejohngonrnQgma•I.com Pax Nv.:
I?. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site:_8606-97-0678_
County: Haywood _
(2) Physical Address(ifdifferent than mailing address): 230 Hopper Cove
City: --Waynesville state:NC ZipCode: 28786
nwQ/U1ClCIosc�Loop Gegthermal Nod fication(Revised 413V2012) Page I
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E. MAPS,PLANS,AND SPECIFXCATIONS
(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 glearly and include a north arrow. Attach 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
Property boundaries
• Surface water bodies a 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 AND CONCENTRATXONS 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.tpJ/pQgL.11c<ienr,or-/web/wa/aps/Z,—Ap-o. All other additives require approval prior to use.
20% Environai
G. WELL MMLER)(NFORMATION(if known)
Well Drilling Contractor's Name: Robert Larry Wells
NC Well Drilling Contractor Certification No.:
Company Name: AWD Services Inc. Y Contact Person: Larry Wells_ .
City: Leicester State: W. Z CP ode;28748 'County- 13uncombe `
Day Te1e No.: $-683-9223 _ _ ____•_ Cell No.: 828-215-9334
EMAIL,Address: Wells750549@Wlsouth_net ._._ ._ Fax No.: $28-683-9203
$. HEAT PUNXP CONT)E:ACTOR INFORMATION
CompanyNatne: Bullman Heating & Air
Contact Person: Josh Gutherie . EMAIL ddre s: osh(dbullmanheatirl .com
Address: 10 Red Roof Lane
city: Asheville Zip Code: 28804 State:NC County: BunCOGnbe
Office Tele No.: $28-65$-2488 Cell No.: _.... _ Lax No.: $2$-658-1001
DWQ/UIQ/Closed-Loop Qeothencnal Notification(Revised 4130/2012)
Page 2
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-Disclaim er:Ttm maps m Ihis sba are mol mrMs,They are
Haywood Jaunty ��`red frrn lheinvledfrorlory recur eperL eds,p ats in o
j�dsdlctnn avid are ocrnpiledlran recorded tloeds,plelsand otT�er m
I inch=50 feet - µblie records and dale.Users of This.silearehejeby ratified that -
the SrCF=enlcned pubiicArirmry itformetion sDVices amlid be
May 18-, 2015 comulbed fat vwlksbon d anyinforrmlim omleiri d m these
ifs•Haywmd caurty and the wabsiba plaviler asmne no legal
responsibilr2y Jar be informadm conlairsd on the se maps

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1- PRO TFCTION—Provido a brief description 01 ;1 1;v:V.aV,-pply.vells;(3)surface water bodies;and(3)
septic systems and associated spray irrigation s tes •irsin kids. nr repair areas within 250 fctt of the proposed
injection wells wl]]bc<protcctea(luring consn-ucdo-r o me vvkti i
Silt Fence will be used to contain run_off'f(om_� )j��
D. VA 2TANC)E--Purcu�nt T+, !Sq uC.�C E)?,C',Cl : Dire(:;r•r the Divisinn of Water Qutality 1-nay giant a
variance from dp))fieable Weil construction or stamisrds provided that:
(1) use of the wells)will not endanger i•.:aiar: heaitli and welfare or the groundwater;and
(Z) thai consu•uction or operatlo,l in the;standards is not rcchnieally feasible or the
proposed construction provides cquai httter n;ot(ection ofthe groundwater.
Any variance requasr should xccornpany submitta: ii'this notifiraiion to expedite evaluation of the request.
The variance request form can be accessed online Ai itn.rli�5�ra1,_i� tausfawurolpertnit-
anpl icatiofill
- SIGNATU;XS—The f'ollmling section is to 11.)+9 :vmrplered ae, required below or by that person+s authotizod
agent. 15A NCAC 02C .0211(e)requires 5ignafiiFi2s as follows:
(a) 'fora corporation: by a responsible:corporate.officer;
(b) for a partnership or sole propriWMt --hil); by a general partner or the proprietor,respectively;
(c) for a muriieipa?ity or a state,fudii r•xll,or OTbal�public agency: by either a prirxeipat-executive
ofTictr or ranking publicly official.
(d) for all odium: by the tvell owner
(e) t"or any othtr parson authorized it' act on behalf of thr; applicant: docurnentabort shall be
submitted with the notircatior• -hat Clearl}• identifies thr•persbrt. grants them signature
'authority',and is sighed and d&Ld ';%",:he applicsnt.
"1 hereby F,!�rrifj', reader pdnaill-of law, that C,'torv:';.>errgriUlll.exc?rnihed and ain faini1jar tvirh the Information
*Pbmived in this docr�rnelzt and crll Qttachmetu.+ !h87Y10 rnhd that, based on rrry Inquiry of those Individuals
immediately responsible fa,pbtaitring said rr ti,n.urrio t, : ;,eiteve that the sn}or)r,alinst is true, acawafe and
r"r)rnplete. !am Clv a-V J;2at rhar-&arc sig„if u rr;.r taltr;.+. :1);-lulling the possfUliA.offines arrd.imprk--wn'ent,
-for szeb ittink [tlse inf0emation. r agree tv con tract, upr,,,u•, maintain, repair• and if applicable,.abandon
the fnfectiwr tivall WWI all,CIOle-a'4ppm0'renance,, r.r:t>r,.rztlte tVith the I qA N ' OlC 0�001tules."
Sign 're of Property Owe er/AppliCant _
Print or-('ype Fui ?game
_ .._.. ...........
.
Signature(if ALITh6rixed Aget)&if arty
Yrtnt or l'.5'()P gull Vame —
DWQ)0lCJCIg9ed-L0op Oeorl,.ermai N-otuicgion(RCviscd 4t3or').(i:
Page 9
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prepared from Use lnweracry of reai properly fouid wildn Uri;
/� „ )irisdirlbn and are compiled rran recorded deeds,plats
Haywood
ar#other-
. C ou I 1 pWb records and data.Users of Ihis,sit-are hereby notified Oral C!D
P 1 Inch=50 feet Oreafoementionedµrbllcpr-hziyhfomsationsoutoesftUdbe N
oarm&ad for ve-fiaiion d any info rma lion contained on these
L May 1 8, 201 5 - maps,Haywood oou-dy and The websila provider assraneno legal
P responsibility for the Irformalion contaned an Ihesemaps.

AWD SERVICES, INC.
Appalachian Well Drilling & Water Filtration
P.O. Box 125
Leicester, NC 28748
Phone: [phone]
Fax: [phone]
Owner, Larry Wells
To: Andrew Moore
Fax: [phone]
From: AWD Services Inc. (Appalachian Well Drilling)
Date: 5121115
Pages: (including cover sheet) 2
Re: Requested Map Correction (Distance from dwelling)
Patrick & Kathie Johnson
230 Hopper Cove
3 $
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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
3s
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 I SA NCAC 02C.0200� This notice must be submitt d rior"to 'ohstruction."`
RECEIVE
F­ :GEOTHERMAL IJEOUS"CLOSED-LOOP WELL ptvision of waterReso ces'
As described,in 15A NCAC.020.0222 these"wells"circulate potable water only or a mix re of potab le-water'and
performance-enhancing additives as part of a geothermal heating and cooli g system. U 2 205
OR
Water Quality nec at perations
GEOTHERMAL DIRECT EXPANSION CLOS D-LOOP LLS Asheville ftegionai "lice
As described.in 15A NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geothermal Beating and -
cooling system.
DATE: . ,_20�y PERMTT.NO.WIG 1-0 0370 (to be completed by 17WQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED "
(1) Aqueous(as.pef 15A NCAC 02C.0222): !/ Number of wells:
(2) Direct Expansion(as per 15A NCAC 02C.0223), Number of wells:
B. STATUS OF WELL OWNER(choose one)
(l) " Single Family Residence_j,!!�%ubmit this form two(2)business days prior to construction.,
(2) Business/Organization Submit this.forin 30 days:prior to construction:
(3) Government: State Municipal County Federal Submit this form 30 days.
prior to construction..'
C.: WELL OWNER- For single farnily'residences list the property owner(s). " For all others, list name of the .
business,organization,or government agency and,persori delegated signature authority:
Mailing'Address: gS IrJ to 'j< R6-��
City: "i✓1 tl�le State: Ad C' Zip Code:AVMCounty: �34.,0
Day Tele No.: X a 7 3 q`�95�- Cell No.: y 1
EMAIL Address: CJy1 rt'o�� el',�,'�t�t^..cn
f' Fax No.:
D. PHYSICAL LOCATION OF WELL SITE 2
(1.) Parcel Identification Number(PIN)of well site:
County:. ��1t fond
(2) ,Physical Address(if different-,an mailing address):
City: State:NC Zip Code:
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(§). Label all features.clearly and include a north arrow. Attach a
site-spec showing the locations of the following:
DWQlUIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Pagel

• Proposed injection well locations Septic systems and associated spray irrigation sites,. "
• .Buildings .. 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 weII 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,.htt :// ortal.neden•.ors/web/w /a s/sworo. All other.additives require approval prior,to use.
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractors Name: �-l�S�1 Vl1 jou.
NC Well Drilling Contractor Certification No.: I = '
Company Name: -Contact Person:
n�,�, 2 �.
City: 1 Stater Zip Coded/ �lLounty:
Day Tele No.: Cell_No.: `
EMAIL Address r W Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION.
Company Name:Bullman Heating&.Air .
Contact Person: Josh Guthrie EMAIL Address:joshg@.bul.linanh&atinsz,.com
Address: 10 Red Roof Lane
City: Asheville Zip Code: -28804_State::,NC County: Buncomne
Office.Tele No.:(828)-65$2468 Cell No.::_(828)-712-7488 Fax No.:(828)=658-1001
DWQ/UIC/Closed-Loop Geotherinal Notification(Revised 4130/2012) Page 2

L. 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:
" nn
t G
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. he
that;
l):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.vanance'request:form can be' accessed online at.littp://portal.nedenr.oreAveh/wqtaps/gwprolpermit-
annlications
K. 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: 8y 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:o cial;
(d) . for all others: by the well owner-
(6) 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.
7.
I hereby.certify, underpenalty 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 foe obtaining said information, I believe that the information is,true,accurate
complete.. I am aware that there.are signicant penalties,.including the possibility of fines and imprisonment;
for subriritting false rni'rnation. I gree donstruct operate, maintain,repair,.and if applicable;abandon the
injection well and 1'l"related ap rtenan-es in acco ante with the,1 SA NCAC 02C 0200 Rules:
f
g.atur of Property Owne App cant
pint or Type Full ame
Signature of Authorized Agent,if any
Print or Type F611 Name .
DWQ/UIC/Closed-Loop Ge'othermg.Notification(Revised 4/30/2012) Page 3

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NORTI3 CAROL'NA'D1 pARTMENT OF ii:' P,0!QMF't,!'1 A1,1D NATURAL RESOURCES
1VC►•I WICATION OF INTENT TO CONSTRI W 1'�011 OPEP—AXE Il\NXEC"I'ION WELLS
Z' -Ve we11s are"Permitted by'UIC"anddn nnr regutr'L• • indMd:tal perntij when ce)nsfructed in CtCeordartce with
the reties rf•15A NCAC 02C'.0200 .
C•lN;O`l.'1CC1+.r21ViAY.;&Qu—gOtis CLOSkq&QOP WELL
As described in I SA WCAC 02C,' .0222 these wells circt last,potable water only or a mixturt of potable water and
performance-enhancuhg additives as parr geothermal heating and cooling system.
GEQTREPJV1kL DIRECT XPA::SIQN t,1,08 2:Loop 7CFT
Av-dcscribod in 1 SA TTCAC 0273 these wells eir, rta5 as parf of e,Kegthermal heating and
Cooling-lVsrern.
Print Clearly o, 7ppe 4forrnadom Megible Subinektnls bill Be Roar ced As rncglnpkir,
DATE: June 23, 20,.. . 15 PER-Myl,No. coMpleYed by DWQ}
a ©0377
A. TYPE OF GEOTIIE'R A L CLOSED-LOOP WiELL To BE+CONSTRUCTEb
(1) Aqueous(as pen l5A NCAC 02C_0222): X Number of wells- 3 Q 300'
(2) Direct Lxpa;nsion(as per 15A NCA.C;02C .0223) Number ofweUs:
R STATUS OF WELL OWNER(choose one)
(1) Single Family Residence X Slabimit tWs form two(2) business days prior to eonstructjox.
(2) BusivessfOrganizatior. _Subw t this form 30 days prior to construction.
(3) Government; State Municipal.. County __ Federal Sabneit this Iorin 30 days
prior to congmedaii.
C:- 'WELL OWNER-- For single family residences list The property owner(s). 'For all others, list name of the
bukness,organization,or government agency and Person delegated siguaf ire authority.
Mailing Address: 127113 L] Drive N
City: 1?_aMesville State: _NC Gip Cade -V runty: USA
':ax l eie No.. 85
RMATL Address:
D. PHYSICAL LOCXrION OF WELL SITE
(1) Paroel Xdcntificatiau Nu
m
ber TIN)of Well site: $Lal�•8��278_.
(2) Physical Address('if different shuts rttailing, iddress
State:NC Zip Code:
:. &A.PS,PLANS,AND SPECIFICATIONS
0WQ/UI'.QC'losed-Loop Geothermal Notificatirin(Re\dsed 4/30i2012; '
Page f
ZB 39dd SNI S30IAN3S G1d cozGcegeze 66:OT iGiTGI ►/IIIR1

(I.) Maps musr be scaled or otherwise accurai e.ty mdiCare distances and orientations of fieatures located
within 250 feet of the injection well(s). Label all fexturea clearly and include a ag&atrom. Attach a
site-specific map showing the locations of the following:
Proposed injection"It locations Septic systems and associattd spray irrigation
c Buildings sites,drain fields,or repair areas
® Propertybo-andaries
Surface watarbodies i;-Xibring or potcnUal sources of groundwater
a Water supply wells• contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system,
F, TYPES AND CONCENTRATIONS Off+ kDDITTVES Li&t any additives that will be used and their
concentrations. Only additives that the Departmew of Health and Human Services' Division of Public Health,
deterntiues do not adversely erect human heaitb shall be used. A list of approved additives can'be found
online athtkn'1p4 g,tledenr.or /webJwn/atfsl tyorc. All other additives require approval pjprw ,
20% Environal
G. WELL DI d LER 1[11T)1<O•RMA'1',IO ,(if known: .
Well 07illing Contraot0T'S JNwne: •. Robert Larry Wells
NC Well Drilling Contractor Certification No.: 2603
CompanyName: AWT)Services irAc.. _ enfuct Pcrspn: .Lart�W�lls
City: Leimtsr ."P,rr NC i;odo2874.&nty:—aUn-9QMbe.
bay Tele l�o_: 828-683-9223 828-215-9334__
EMAIL Addzt*s; [e-mail] Fax No.,
828-683-9203
FWAT PUMP CONTRACTOR INFORMATION'
C'ontactperson;.._� i,S3titluie, --- MA11 �gG,ress: oslr Mheatin com ....-•--
-'V1 s: ]0 Red Roo,:
City- Asheville .Gip Code: 28804,St8a ;wnty 13ttncrnn❑e _
Offiice TeIe No.:(828)-658-2468.--Cell No x No,•_ (828-658-1001— —-
D'WQAjTC/Coscd-Loop Geogwemal Notification(Revised 4M/2012;
Page?,
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X PXOTBCTIQN—Provide x brief description of ha.,, (l) waEer supply wells; (2)sufface Warer'bodies;and(3)
septic systems alld associated spray aTigation sites:drain fields,or repair areas within 250 feet of the proposed
injection Wells will be protected during construction of the ivells:
Silt Fencing will be used to control solids and run off,
J. V.,41t ANC)r—pursuant to 15A NCAC 02C.02 P he Director of the Division of Water Quality may graph a
variance from applicable well construction or operation standards provided that:
(1) uae of the Woll(s)will not endanger human health and Nvelfare or rile groundwater;and
(2) that constmetion or operation in accordance with the standards is not technically feasible or the
proposed construction provides equal w better protection of the groundwater,
Any xvmjance request should acoonxpauy aubmittai cA this noti47eaLioa to expedite o'valoation of tlrc request_
The variance regeest form can be accessed online a i ii.trn:/;portal.ncdearxlrgl xreblwg/aps/ prolyermi
applications
K. SIGNATURES Tile following section is to be;;ompleted as required below or by that persons authorized
agent. 15A NCAC 02C.0211(e)requires sigturturca as fallow,:
(a) far a eorporz:don: by a responsible corporate officer;
(b) for a partnership or sole proprietorship; by a general partner ar&I.proprietor,respectively;
(e) for a municipality or a state, federal, or other public agency_ by either a prineW executive
oflCer or Tanldng publicly elected official;
(d) for all others: by the well owner,
(e) for any other person authorized .o act on behalf of the applicant: docamcsttation 4411 be
submitted with the notification that clearly identifies the person, grants them signature
authority,and 7s signed and dated by the applicant,
"1 herehy.cerfify, under penalty of'law, &hat 1 have Personally examined a4d•am famWar w#h the j4(orrw on
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immadiate2y responsible for abtaizuireg$aaa' infartazalion, 1 believe teal tract iriformalion is fte, aceurare and
complete. 1 am aware that there are significant penalties, including the possibility of fines and irnpri onmeiat,
for stei5mi#ttng false information. X agree to c0nst;WT, operate, Maintain, repair, and if appYicabl� abandota
the W-ection Welland all related appurtenance in aeenrdanee with the 15.A MC.4C 02C 0200'Rades.
stars of ropem owner/Applicant
Craia,M Martin __ _
Tit or Type p'gll Nama
SignaeureofAwh,:,,•:2e�Agent. :c„s�•..._._ _
Prior or
DWQ/UIC/Closcd-Loop Geothumal Notification(Rzvised 4/3 012 0 1 2' i'ege 3
170 3Jdd SNI S3SIAN3S QMd COZGC898ZB GC:0T 51;0Z/90/L0