Henderson UIC Deemed Permitted 2012

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND.NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS 1�
These wells are 'permitted by rule"and do not require an individual permit when constructed in accordanceawith
the rules of ISA NCAC 02C.0200*. This notice trust besubmitted prior to construction:
GEOTHERMAL AOUJEOUS CLOSED-LOOP WELLS
As described in I5A 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.
IQ
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: � 0 ,'20_]_?, PERMIT NO. (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C.0222); Number of wells: /
(2) Direct Expansion(as.per 15A NCAC 02C .0223) Number of wells:
R STATUS OF WELL OWNER(choose one)
(1) Single Family Residence:;Submit this form two(2)business days prior to construction.
(2) Business/Organization Submit.tbis form 30 days prior to construction.
(3) Government: State. Municipal_ County Federal Submit this form 30 days
prior to construction.
C. WELL.OWNER—For single family residences list the property owner(s). For all others, list name of the
business,organization,or government agency and person delegated signature authority:
w
Mailing Address: d
City: ,,, P State: Zip Code��j)lCounty:
Day Tele No.: 4 7Li- 2 7 Cell No.: ,02Z
EMAIL Address: tLx biel t��'i FaxNo.:2 70�J
D. PHYSICAL LOCATION OF WELL SITE
..(1) Parcel Identification Number(PIN)of well site:
County:
(2) Physical Address(if different.than mailing address): SOt .
City: State:NC Zip.Code:
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) 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 a north arrow. Attach a
site-specific map shoving the locations of the following:
o Proposed injection well locations o Septic systems and associated spray irrigation
© Buildings sites,drain fields,or.repair areas
® Property boundaries
O 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 httpJ/portal.Ldenr.org/web/wq/aps`/Z- �vpro.nc All other additives requir approval prior to use.
��, rd MOW
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
D. BEAT PUMP CONTRACTOR INFORMATION
Company Name:
Contact Person: .Sow . MAIL Address: r��
Address: /
City: 6 o i,f l e Zip Code:Z (0 .'State: County:
Office Tele No.: �� ' $�� 2 Cell No.: ELF-62Z- f i}' Fax No.: 2 -2700
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/3012012) Page 2

4
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:
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 endariger 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 http•/!portal nedenr ors/web/wq/aps/�proXenn
aotilications
K SIGNATURES—The following section_is to be completed as required below or by that person's authorized
agent. ;15A.NCAC 02C.021 l(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;
(a) for any other person authorized to act on behalf of the applicant: documentation shall be
submitted wi& the notification that clearly identifies the-person, grants them signature
authority,:and is signed and dated by the applicant.
`7 hereby certify, under penalty of late, that have personally;exam ined 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 sign'i ena ti including the possibility of fines and imprisonment,
far submitting false information. a to construct, _ perate, maintain, repair; and if applicable, abandon
the.injection well and all.related a e ces in a ordance.with the 15A NCAC 02C 0200 Rules.
Mg tore of Property Owne pplicant
Print'orTyp Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQMC/closed-Loop Geothermal Notification;(Revised 4/30/2012) Page 3

jr ,
L. SUBI%MTAL 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:
SAL
impIGH i'. �,_ i` ,t '•
J
■y�q�
?: .r 1. `\ �1, � t _ .f � ■j���"e•Z'-7„A� 1 {y_�y_]�i. j ;, ' ; '
Rf 6l� Y'f�ii- F±1 l"' ''+4 ! .�i(.@ ``!•�AV�' '�-V�O�• .
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.liegional-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 In://www.ncalhd.oriz/couniy.htm.
couniy.htm.
DWWC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR,OPERATE INJECTION WELLS
These wells are,"permitted by rule"and do not require an individual permit.when constructed in accordance with=-
the rules of 15A NCAC 02C.0200*. This notice must be submitted prior to construction.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in 15A NCAC 02C'.0222 these wells circulate potable water only or a mixture of potable wate"r.;and
performance-enhancing additives as part of a geothermal heating and cooling system.
`,j
OR
? _ CM r,
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 Clearly or Type Itrformadon. Illegible Submittals Will Be Returned As Incomplete.
- DATE: /� �1 - - -20 PERMIT NO:- - - (to be-completed by D WQ) -
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC,02C .0222): L� Number of wells:
(2) Direct Expansion(as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence_✓Submit this,form two(2)business days prior to construction. N
(2) Business/Organization Submit this form 30 days prior to construction.
(3) Government: State Municipal County Federal Submit this form 30 days M
prior to construction.
C. WELL OWNER- For single family residences list the property owner(s). For all others, list name of the a< N
business,organization,or government agency and person delegated signature authority: l� °
�''�, e57 1 Mx. i
)
Mailing Address: �3 I'� g� jV _j/1 A V ,44z
City:G_)/'1 7 J ',^).J Z• State: Zip.Code3p _County: A!;Ji�J��/ n
Day Tele No.: (C�`� ��LS' �' _�' l3 Cell No.: (CisC,L/ l 7 3 I
EMAIL Address: f-PI oc pyc;, , [ems, Fax No.: �C1�L/� I (-,,
�--� D. PHYSICAL LOCATION OF WELL SITE
y' �Cr �- ��i-r--
-fr (l) Parcel Identification Number(PIN)of well site: �-r—� 0 f?
County: Y
(2) Physical Address(if different than mailing address): t t- rL, r�r A10L i A 4✓/1� yT
C,V ry
City: i{i C Q A' 14 State:NC Zip Code: Ztq 7C/ rig
DWQMC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page I

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 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 • 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 htIL://portal.nedenr.orJ%veb/Nvq/al)s//�_tivpro. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION.(if known)
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name: Contact Person:
City: State: Zip Code: County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
DWQMC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

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 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 • 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 atUiro. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION(if known)
M f
Well Drilling Contractor's Name: �'l
NC Well Drilling Contractor Certification No.: 10
Company Name: cLeu Lit, Gee a Contact Person:
­,---
City:&+ 4"_fl C. State: i L Zip Code:; County:
Day Tele No.: 0$— 7AP`" Cell No.: ?9y-a L 6S'2�
EMAIL Address-yiwcle W by , j&I&))_j rob Fax No.:
H. HEAT PUMP CONTRACTOR INFORMA1ION
Company Name:
Contact Person: EMAIL Address.,
Address
zwl-
City: Aembate Zip Code: 7 State: &-County: &Lv
Office Tele No.:�°{�(=�7�-`� (7 Cell No.: ���) �(�� Fax No.:
MQ/U1C/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

N
X

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:
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 fort i.can be accessed online at littp://portaLncdenr.orJweb/4vq/aps/-wpro/permit-
aopiications
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: 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 offtnes 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 15A NCAC 02C 0200 Rules."
Signature,of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent,if any,
Print or Type Full Name
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) 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:
WINSTON-SALEM _
RALEIGH
ASHEVILLE -- WASHINGTON
ORESVILL
FAYETTEVILLE
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://��w��.ncslhd.ore/countv.htm.
DWQMC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

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:
.WINSTON-SALEM.
RALEIGH
ASHEVILLE
WASHINGTON
-. OILL
RES`
FAYETTEVILLE
- -- --- ------- ----- --- -- -
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-l 628
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 httl�.i w�>w.ncalhd_c�ra!ruui,t�.hu".
DWQNIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

09/18/2013 09:57 8286656576 MIKES HEATING AND PAGE 12/16
O 1 0O2fo 1
NORTH CAXOLINA,DEPARTMENT OF,ENNgRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These w211s are 'perRided by rule"and do not regrmr an igWnrldual permit rvften constructedln accerdsnc With the fides of IsA NCAC 02C.02W s noti a mint fled tD cti
GEOTHERMALL ll OUS CLOSED-L0OP W_ELLS
As described in 15A NCA t-ULC.0222 tbme Wells circulate pomble water only or a mixture ofpotablc water end
performaAce-enhancing additives as part ofa gcotbG=Sl heatsug and cooling system.
OR
GEO E AL IRE T EX AN ON OS -L P WELLS
AB described in 15A NCAC 02C A223 thcss wells circulate a refrigerant gas as pare of a geothermal heating sued
cooling system
Arin!Clearly or Type information. Illegible Submillals W111 Re Returned As Me mpl¢,fe,
DATE: 9 /4 2013 . PERMIT N0.0tr0 02.G j (to be completed byDWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueons(as per 15A NCAC 02C.0222): X Number of wells: 2
(2) Direct Expansion(as per 15A NCAC 02C.0223) Number of wells;
a. STATUS OF WELL OWNER(chooseone)
(1) SiAgle FatbulyResidence_K Submit this form two(2)business days prior to construction.
(2) l3usinesV/0rganj7,Ation Submit this form 30 days prior to construction.
(3) C3ov0rnmeat: State— M1M-ieipal_ Caanty— Federal`Submit this form 30days
prior to construction.
C. WELL 0 W ME R-.Far siaglc fhmily residences list the property ovwcr(S)_ For all others, list name of the
business,organiZation,or government agency and person delegated signaWre authority:
t 14
-l-r
Mailing
�7Address:�
City, &C State; Zip Codc: otm
Day Tel No.: '7D q- &'q ~ Cell No.:
151VL1.1J Address:
D, PHYSICAL LOCATION OF WELL SITE
(1) Fatcel Identification Number(pIN)ofwcllsite.
County:_qtajn C W1 f `
(2) P*ical Address(if different than mailing address): R7*3 ht-s 1A •LJdt�J�I1Q
City. 2f uy(�,. State:NC Zip Code: �7�
DWO!MUClosed.Loup Gealhamsl NOdfiralion(Rmiacd 4/30/20 M
Page t

09/18/2013 09:57 8286656576 MIKES HEATING AND PAGE 13/1�,___
E. MAPS.PLANS,AND SPEC IFICATIONS
(1) Maps must be scaled or otherwise accurately indicata distatrccs and orientaticma of features located
within 250 feet of the injection well(s). Label 9U Le=$e earl and' cl a arrow. Attach a
sitc..specific map showing the locations of the Following:
• Proposed injection wed)locations • Septic systems and associated spray irrigation
• Buildings sites,draiu£colds,or repair arm
• Property boundaries
• Surface water bodies Existing or potential sources of groundwater
■ Water supply wells contamination
(2) Plans and specifications of the surface and ttubndsce construction dohs 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 5mviocs'Division of Public Health
dotcrmines do not adversely affect human health shall be used. A list of approved additives can be found
online at 41t11//pvital.ncdenr_or {�eb/wo/aos/�waro_ All other additives require approval prior to use:
Ethanol - 20%
G. WELL DRILLER INFORMATION(iflmown)
well D.614A9 contmctoes Name- Robert La Wells
NC Well Driftg contractor certitieatiea No.: 2603
CocxpatryName: CotttactPcrson: Larry Wells
city: Leicester state, UQ 7ip cod2874ebouaty:Buncombe
Day Tale No_-L828) 683-9M __ ceu No.: $ 2'l - 3
EMAIL Address.v-eQs750549@b Is ut . et--U No.: 82$ 683-9203
H HEAT PUMP CONTRACTOR INFORMATION
Company Name: M i k '
contaetPerm-Ronald Hatbcock EMAILAddressronald0.mikesheatint�andcooling_c4rn
Address., 329 Dogwood Rd.
City,t, Candler Zip code: 287287155 State: County.
btTice Tcic No.: 82� 8) 665:4 43 Cen No.: Eu o.{828) 665-6576
1}wq/tl7C/C1osM-Loop Gmthamal NaUfkbdon(Revised 4/3DM12) Inge 2

09/18/2013 09:57 8286656576 MIKES HEATING AND PAGE 14/16
1. PROTECTION—Provide a brief description of how(1)water m supply wells;(2)surface water bodies;and(3)
septic Pystes and.associated spray tmgatien sites,dtaim fields,or repair areas within 250 feet of the proposed
injection wells will be protected during constrnution of the wolfs:
Silt Fencin
J. VAR I A N C k_Pursuant to 15A NCAC 02C.b241 the Director of the Division of Water Quality may grant a
variance:ffi=applicable wOE construction or operation standards provided that:
(1) use of the Wells)will not eftdangar hummtl health and welfare or the groundwataq and
(2) that construction or operation in accordance with the standards is not technically feeble or the
Proposed w0stsnction provides equal or better protection of the groundwater.
Any variance request should occompany submittal of this notificatiom to expedite evaluation of the irquer.,t,
The variance request;form can be accessed or Uftc:at h :l/ lmodenr. web/w /a /
applications t-
K. S I G N AT U R ES—The following section is to be completed as required below or by that person's authorized
agent 1 SA NCAC 02C.023 1(c)requires signatures as follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a partnership or sole pmptictorship: by a gedetal'partner or the proprietor,respeetive�y.
(c) far a municipWAY or s state,Federal,or other public agency by either a principal exec rdye
officer or ran;dng publicly elected official;
(d) for all others: by the well owner;
(0) for any other person authorized to act on behalf of the applicant documentation shall be
submitted with the notification that clearly identifies the person, g(mts them signature
authority,Md is signed and dated by the applicant,
"f haralry certify,lmd-PCWAY of taw, that T have Pemonaky
submitted in this d0cment and all attachments�to and that, ba e my Mury of hosejl I in1a15
immediately responsible foe obta/Wing safii inftmation, 16elfeW that 8Je Informatlen is tune accutate ad
complete. /am aware that Wre are s*ir1cant penalliM fncludi efie bl1J of llnes and imprisotre a fOr snabmitting false informalko. l agree to cQnstlucl, operate maintain lr,a it spplicab/e,abandon
the ihjectfnq we/!and all related s t7epances in accordance with the 15A NCAC UZC 0200 AW&I"
Signature of Property Ow rlAppllcant T
�rToeFull]dame
Signature of Authorized Agent,i aany
Print or Type Full Name
DWQ/MrJCJ0$e&Lrwp C.cathermnl Notifimdon Uk&h cdA/301,t012)
Page 3

09/18/2013 09:57 8286656576 MIKES HEATING AND PAGE 15/1�-,.-,
L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the 0wh of the
following:
(1) The Division of Water Quality Regional 0f5ee Serving the area irk which the injection well fael7ity
will be located:
Asheville Regional Office Washington Regional Office
2090 U.S.Highway 70 943.Washington Syuarc Mall
Swannanoa,NC 28 77$ Washington,NC 27889
Telephmc;[phone] Telephone:(252)W5-GAB]
Pax_(828)299-7043 Fmv(252)975-3716
Fayetteville Regional Office Wilmington Regional office
225 Green Street,Suite 714, 127 Cardiml Drive Extension)
Faycttuville,NC 28301-5043 Wilmington,NC 28405
Telephono;[phone] Tcicphme;(910)796-721 5
Fax:(970)48b-0707 Fox.[phone]
Mooresville Regional Office Winston-Salem Regional Office
610 East Center Avenue,Suite 301 585 WaugNown Stied
Mooreswlle,NC 29115 Winston-Salelx�NC 27107-224)
Telephone;[phone] Phone:[phone]
Fax.[phone] Fax:[phone]
Raleigh Regional Office
1623 Mail Service Center t
Raleigh,NC 27699-1628
Telephone:[phone]
Fax:[phone]
(2) County Hcatth Department i0 which the injection rove])facility will be located. A list of county health
de:paitt=m can be found online at Ittt..;iAvww.ncatbd4uV4 eunq htm.
DWWOCImed-.Loop 0c0thw=1 P 0tL6rmdcm(Revised 4/3 0/2 0 1 21 Pnge 4

09/18/2013 09:57 8286656576 MIKES HEATING AND PAGE 16/16
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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by rule"and do not require an individual permit when constructed in accordance with
the rules of 15A NCAC WC.02004` This notice must be submitted prior to constr-uction=---
ID
GEOTHERMAL AQUEOUS CLOSED-LOOP WELS � �EWE
L
As described in 15A NCAC 02C.0222 these wells circulate potable water only or a mixture of potablg, �er.ap4 2 3
performance-enhancing additives as part of a geothermal heating and cooling system. UU
l
OR Ashevi'le Region A 01-fiice
ilifer P_r_oi_e '<tirn
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELD"As described in 15A NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete
DATE: �1CTOg�2 201:?5 PERMIT NO. W 10 A O D 7-°P 4 (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C.0222): Number of wells: 2- 340 r`31.
(2) - Direct Expansion(as per 15A NCAC 02C.0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence V=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 Submit this form 30 days
prior to construction.
C. WELL.OWNER- For single family residences-list the property owner(s). For all others, list name of the
business,organization,or government agency and person delegated signature authority:
�Dtl-ty Antd (�Llsopl (�'1`01�d. `"(�P�Qt�t�S .
Mailing Address: 202 8 P`('�2R.is L P-ki r
City.ttffRt. .C`R�SOl•i�V.ILL, State: NC, Zip Code:2�i County: lA�ls�Qs�
Day Tele No.: S2g SSl 8002- Cell No.:
EMAIL Address: c1-R'MMWS 'MSNt.C_1`1 Fax No.:
D. PHYSICAL LOCATION OF WELL SITE Q
(1) Parcel.Identification Number(PIN)of well site: 15 2�22 3CZ
co
(2) Physical Address(if different than mailing address):
City: L' State:NC Zip Code: 2g2Q
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page I

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 a north arrow. Attach a
site-specific map showing the locations of the following:
• Proposed injection well locations • Septic systems and dssociated spray irrigation
• Buildings sites,drain fields,or repair areas
• Property boundaries .
• Surface water bodies 0Existing 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 htM://portal.ncdenr.ora/web/wq/aps/gwpro. All other additives require approval prior to use.
4 t5tii' p i &.kbftr= InCDr7LCt*r= 6,6Y666
L.oc� VOL utika IaPPRv,[ _'L0 GP�l10n1S I!n I4 GPd- owa> .�F Acvrl F22_�
E 114( MOL 25% C9ty rJ'lP��tosJ,
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Robert Lang 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 Teele 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: gLUbflys Payi W. PlI2
ContactPers on:gUm1' SCAL-RP tV ,S EMAIL Address:gam&RWES(P-8&LLSod��,�1i=7
Address: R©. .22)0tc
City: E=f D WPc4 Zip Code: 2-S--2.9 State: KC County: I.RE RLL `
Office Tele No.: Sn 2'425 Cell No.: Fax No.:
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

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: .
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 littp://12ortal.ncdenr.org/web/wg/aps/gwpro/permit-
W12lications
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: 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 relate app enances ' ccordance with the 15A NCAC 02C 0200 Rules."
Signatur Property..0 er/Applicant
do.NN 6 r)RK Es
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 3

i 1
' Area bycoordmate computation �'""� ���KK� r;
VICInify Map
Tf d/
s.
. � � ,M-'= '��CC 0.21'abave ground Ali j111 tNa
S aS^ - I I 1 Javthan Cmek
Jonathan Creek Drive / 1,, Oes/epmentCe,in'.
Paved,Private �/ / i i �' ss�/Bb A0Sda4005
Ile •5•
• / (,11,//� j/`,� //W / ,/ rr/ 526 412e,( ecm
590 0C4'above ground
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50'ROW ^gl'\rl 7qG.P�1 , 529.0 39 We LL T V
as per Plat 51de 4005 _ '1 II11 l`�� `�`1 111 `11`� •\ 1'�12. �CAl1C-'DeL�l 152a �-D GA I D(�� �. F
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r1 ` ,FBI\ 1�\ \�`E `�` `• `3\� __ _.___ Bemgall of Lot 14of
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i�I I` 1 4 •.� F`1 \�, "` '-' -'----- recorded at Plat 5hde 4005
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11
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Budchng Setbacb as per Plat 51rde 40L15: -.` GOa�1, �I\Y, �� \�.\\``, -_- -------""---' Site plan for
Front=SO'from the Pro Gad - `•+ `1 11
Sde im 10' PertY �9z� 111�1 ��� `\we L` John Barnes
Rear.l5' i'11 ` y �soz s -si0
a
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---- I•ElP Alison Barnes
111
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Curve Rados Length Chard 4-. chard Bean , ' g Bq°46'59'W 196.IT Total
j1 I'E/P 1tl -Owners-
[C/_ 142.41' RI GO' 21.54, N001.521161w 4 1 D.B. II99,P 584
Co 141.41_ 74.5T 73.72' N'IB°2B'28"E •round l3` Ia 9•
I g b Revised:Apnl 9,20 IS.,added proposed tapo and elevations.
Jonathan Cn;ek
Cauna Bsanng Distance �, _ Onelopmemt Co.!x. 9� Revsed:April 12,2013;modified proposed dove and proposed elevations.
Cl _ N05°l9'0/'W4A75 I� Pin:9529-22-J028
N Legend, Mills River Township THenderson County,NO
PCM=Enstng Concrete Monument
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Notes: PT E/9 Existng Iron Stake
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2.The locations of underground vtditias are based on ab-3ret rid st—ture, Tie Line PT m Unmarked Pant
and...ord drawings prawded fa the surveyor.Loci bons o/underground 9/$°56Y1TP 24,92' ROW Right Of way ASSOCIATED LAND SURVEYORS
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20 0 20 40 60 3.5urvcyor has made no—ligation or independent search for easements of record, a T/Ped m TGephone Pedestal P.O.BOX 578-HORSE SHOE,NO 28742
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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by rule"and do not require an individual permit when constructed in accordance with
the rules of 1 SA NCAC 02C.0200". This notice must be submitted prior to construction.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in 15A NCAC 62C .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 Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: S � 2014 PERMIT NO.VVJ:01,0 01 k 1 _(to be completed by D WQ)
T
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) - Aqueous(as per 15A NCAC 02C .0222): _DIL_ Number of wells: o�
(2) Direct Expansion(as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence N 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__Submit this form 30 days
prior to construction.
C. WELL OWNER— For single family residences list the property owner(s). For all others, list name of the
business,organization,
Norr,government agency and person delegated signature authority:
QJ
Mailing Address: jg5 �1�` ?eY �rL�21Ci�
City: I-". -�ao " \V'u State: NG Zip Code:B[i( County: 1�\PJ SOr,
Day Tele No.: ���_(s2S(stl Cell No.: C0X06 '-30_)R _ 9?9
EMAIL Address: '(Y) (70,)fft ri+s at Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site: 4 5 1 11 04. RECEIVED
County: -1e�d `�on Division of water Resources
(2) Physical Address(if different than mailing address):
APO 3 0 2014
City: State: NC Zip Cod :
Water Quality Regional Operatlons
Asheville Regional Office
DWQ/U I C/Closed-Loop Geothemial Notification(Revised 4/30/2012) Page I

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 a north arrow. Attach a
site-specific map showing the locations of the following:
• P
roposed 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 S
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 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 http://portal.ncdehhni-.or;hveb/wq/aps/2wpro. 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: 9c LU-y,_, \Var-,r_, -+-1-,; p�
Contact Person: �) `G �oaers EMAIL Address:flC,�eeYs .� �ena.;�2ciJ+1nc.Conn
Address: 10 - � L4 I
City: 4`�S1�,"1tt_ Zip Code: J�— State: N C,County:
Office Tele No.: Cell No.: ,�..�i.3, 3 � Fax No.: «I'
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

a i
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: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 littg:Hportal.ncdenr.or./web/�vg/aps/gwpro/permit-
applications
K SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .021 l(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 inqui7y 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 I5A NCAC 02C 0200 Rules."
Signature o roper ner/Applicant
Print or Type Full Ndme
Signature of Authorized Agent,if any
Print or Type Full Name
DWI)MIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 3

t _
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:
1RUIIV8~rofi.SA-LEM.._.
N
'WASHI;NGTON
RESVILL
�...M ! 1.
F�YET�TE1/ILLE f
ji7.
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:/hvww.ncalhd.orIZ/countv.litm.
DWQ/U1C/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

.�see
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Vic. S.-;,f,e. �+"•���-'=5E
")-, , }}
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1117d 0"c -S-A�/y
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by rule"and!do not require an individual permit when constructed in accordance with
the rides of ISA jYCAC 02C.0200 This notice must be submitted prior to construction.
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 Clearly or Type Information. Illegible Submittals;fill Be Returned As Incomplete.
DATE: PERMIT NO. � OZ (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BECONSTRUCTED
(I) Aqueous(as per 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)
(1) Single Family Residence VSubmit 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 Submit this form 30 days
prior to construction.
C. WELL OWNER— For single family residences list the property owner(s): For all others, list name of the
business,organization,or government agency and person delegated signature authority:
Mailing Address
City: He4f5o IJ State: Zip Code:�$493 County: : e-+"&rso n
Day'fele No.: 62��g�o Cell No.: AA--M-3404
EMAIL Address: 1- �� -�S� fi`"� '.Cc�s'+� Fax No.: -OR — IRO
D. PHYSICAL LOCATION OF WELL SITE
.
(1) Parcel Identification Number(PIN)of well site:
County:
(2) Physical Address(if different than mailing address):
city: State:NC Zip Code:
MQ/U1C/Closed-Loop Geothermal Notification(Revised 4/3012012) Page I

d
E. NIAPS,PLANS,AND SPECIFICATIONS
(1) Maps tntist 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 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 • 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 F::..,: _ ;; All other additives require approval prior to use.
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company NN1amepC_64E L.U� I.Q.I.P,f'_-Q Contact Person: _Se_g� jell 4k�a
City:fl �1f 4Q i V1� State: AL Zip Code:,&_�3 County: N-aW ,_
Day Tele No.: �Q2s 72 - -hJ`2 Cell No.:
EMAIL Address: ual!� R -9o�2 , C0,01 Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company.Name: &gDt�11?�nf)
Contact Person: p (ky— Ic,f � EMAIL Address: _—
Address:1! --L�-
City: Zip Code:2 State: County:
Office Tele No.: ''2 ��s\ �—Cell No.: —Fax No.: _

• v
i
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/JS- c oc

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 wit}in250 feet of the proposed
injectionw.�ells will be protected during construction of the wells:
ct
c/�l� zk 4 U.,7f9:�
J <
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 htti,,!-Irorml,n0ei1r. elf"\\
ap1iiratian�
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: 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'ldiv, that 1 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, 1 believe.(hat the information is true, accurate and
complete. 1 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 15A NCAC 02C 0200 Rules."
J
` -Signature of P erty Owner/Applicant
Lck-
Print or Type Fol Name '
Signature of Authorized Agent,it any
Print or Type Full Name
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4130/2012) 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:
WINSTON-SALEM
RALEIGH
ASHEVILLE WASHINGTON
ORESVILL
FAYETTEVILLE
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 hn�aah��i w.ncalhd.cuglcount�.htm.
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are"permitted by rule"and do not require an individual permit when constructed in accord(ince with
the rides of.15A NCAC 02C.0200.._This notice must be submitted prior to construction.
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
r
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 Clearly or Type Information. Illegible Submittals If-'ill Be Returned As Incomplete.
�
DATE: 2P (, PERMIT NO. to be completed by DWQ)
- . �- / 7 , � l
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C:0222): Number of wells: /
(2) Direct Expansion(as per 15A NCAC 02C .0223) Number of wells:
RECEIVED
B. STATUS OF WELL OWNER(choose one) wvwon of wawr Resounw
(1) Single Family Residence 1-1_Submit this form two(2)business days prii ir to construction.
(2) Business/Organization Submit this form 30 days prior to eonstructi n. : . , MAY 15 2014
(3) Government: State Municipal County Federal Submit this form 30 days
prior to construction.
W or Quality Regfona►Operattort=
C. WELL OWNER— For single family residences list the property owner(s). F e Offtee
business,organization,or government agency and person delegated signature authority:
CIS., La
Mailing Address Pei J?--,
City: State: C Zip Coder-i�3 County:
Day'fele No.: "6Q����to.�f Cell No.:AJ�K—qQ,--3 40H
EMAIL Address: L .�� S i5 �.0 Fax No.: �R_ [AQ
-- D. PHYSICAL LOCATION OF WELL SITE �D a\ �"�
(1) :Parcel Identification Number(PIN)of well site: �
County: Nr1
(2) Physical Address(if different than mailing address): <<S Gw=
City: He-1 6s-so N U i( n" State: NC Zip Code:
MQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 1

E. MAPS,PLAYS,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 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 • Existing or potential sources of groundwater
• eater supply wells contamination
(2) Plaits and specifications of the surface and subsurface construction details of the well system:
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;:;:.­: _ .a.� ... ,;; , ^ .�. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION (if known)
- h f,i1-,ram a��s
Well Drilling Contractor's Name:
NC.Well Drilling Contractor Certification No.:
Company Naine{.I iOL,, Contact Person'.
j 1�
City: / ;/I pp State: Zip Coder vj County:
Day Tele No.: U Cell No.: ,
EMAIL Address: 6MCI i;W CON Fax No.:
H. HEAT PUMP CON:TACTOR INFORi TION 1
Company Name:
Contact Person: 11 EMAIL Address:
Address:X
City: Zip Coder State: County: fJ
Office Tele No.: ,Cell No.: _Fax No.: _

I
^ P
�01 J � /
� � l
ti ..
�a
a
7Qa
IZ19

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:
� r l
ag
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 weli(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 htih.`rpott�l.ncd�r�r.��r T,'�1c_h���llap�����.t�rct �ertl�it=
i>>1 irttiom
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: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner or the proprietor,respectively;
(c) fora 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 lacy, that 1 have personally examined and am familiar w th the information
submitted in this document and all attachments thereto and that, based on my nrguiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. 1 am aware that there are significant penalties, including the possibility of frnes�and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection ivell and all related appurtenances in.accordance ivith the 15A NCAC 02C 0200 Rules."
a
Signature of P erty Owner/Applicant)
La-
Print or Type Fol Name
Signature of Authorized Agent,if any"
Print or Type Full Name
I
MQ/U1C/Closcd-Loop Geothermal Notification(Revised 4/30/2012) 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:
WINSTOWSALEM
..RALEIGH-
ASHEVILLE WASHINGTON-
ORESVI.LL
FAYETT_EVILLE..
Asheville Regional Office Washington Regional Office
I. 2090 U.S.Highway 70 943.Washington Square Mall
:Swannanoa,NC 28778 Washington,NC 27889
Telephone:[phone] Telephone:[phone]
Fax:[phone] Fax:(252):975-37.1.6
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 z Winston-Salem,NC 27107-2241
Telephone:[phone] Phone:[phone]
Fax:'[phone] Pax:[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 hiip:/hvw%v.ncaihd org/countv.htoi.
DWQ/UIC/Closed-Loop Geothennal Notification(Revised 4/30/201.2). Page 4

�-Mid-
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by rule"and do not require an individual permit when constructed in accordance with
the rules of I SA NCAC 02C.0200 . This notice must be submitted prior to construction.
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 Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: q' 3 PERMIT NO.{q-.�Q 10d ZA 0 (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 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)
(1) Single Family Residence ubmit 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 Submit this form 30 days
prior to construction.
C. WELL OWNER— For single family residences list the property owner(s). For all others, list name of the
business,organization,or government agency and person delegated signature authority:
Mailing�Address•
n �}
City: Y ► 4 0 bj m to State: A Zip Code:Psd County: H e d• o �
Day Tele No.: Cell No.: 27- 3Q 2 ' 7�
EMAIL Address: Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site: 2 / 2 y )ND k013IP6
County:
(2) Physical Address(if different than mailing address):
City: State:NC Zip Code: 95W
DWQ/UICICIosed-Loop Geothermal Notification(Revised 4/30/2012) Page 1

r
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 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 • 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;n�f :_;,,�rtai.�i�.k,lr.�» ++,tih'+�..tj a� ����1?} All other additives require approval prior to use.
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: ads
p
NC Well Drilling Contractor Certification No.: Ti
i
Company Nacne: Jjv' vut�e \, Contact Person: A-W
Vol
City: State: ! _Zip Codeo>�3 County:
Day Tole No.: _J` -�n, �2� l� Cell No.:
EMAIL Address: Fax No.:
H. HEAT PUMP CONTRA TOR INFORMATION
1
Company Name: ! �
Contact Person: ! EMAIL Address e C C c7
Address:
City: Zip Code: State: County: �
Office-Tole No.. �� `)) 0`f._ Cell No. 7 0> —100 Fax Ng,
MQ/U1C/Closed-Loop Geothermal Notification(Revised 4/3012012) Page 2

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:
)I
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 littp://portal.nedenr.org/ eb/Nvq/aps/�wproll ermit_
applications
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: 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 offnes 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 15A NCAC 02C 0200 Rules."
Sig cure of Property Owner/ pplicant
c��az- VXS� 1 I-9
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 3

N

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:
=:WINSTON-S&LEM_
RALEIGH -.
ASHEVILLE WASHINGTON
QRESV.ILL
FAYETTEVILLE .` =
. O
V.
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 hM://www.ncaihd.org/couniy.htm.
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

�Y��vr-d rlz/ fir
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are `permitted by rule"and do not require an individual permit when constructed in accordance with
the rules of 15A NCAC 02C.0200*. This notice must be submitted prior to construction.
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 Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: �- 20 PERMIT NO. W l©\Q` 2-cA Z (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 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)
(1) Single Family Residence 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 Submit this form 30 days
prior to construction.
�C WELL OWNER_ For single family residences list the property owner(s). For all others, list name of the
;or'—businessg m azation,or government agency and person delegated signature authority:
))kit,tv J&� 1(gy
Mailing Address: 0, 1 .S�2 4h j_�—City: e"y4 State: n C . Zip Code:)!°j
County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
D. ) PHYSICAL LOCATION OF WELL SITE
(1) 'Parcel Identification Number(PIN)of well site: l
County: l.lJIVIZ
(2) Physical Address(if different than mailing address):
wtk h am,. U._ G p
City: Y�U�^> o. State:NC Zip Code: 0 (�
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) 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 a north arrow. Attach a
site-specific map showing the locations of the following:
• • P
roposed 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 S
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 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 http://i)ortal.ncdenr.org/web/wq/aps/g"ro. All other additives require approval prior to use.
/tw � 11
G. WELL DRILLER INFORMATION (if known)Well Drilling Contractor's Name: — �%A
NC Well Drilling Contractor Certification No.:
Company Name: C �.{,Lt*,�J f k Cgontact Person: _ nk
City: State: Zip Code;L0,kounty: ✓ / / '� ,
Day Tele No.: �� oq& Cell No.:
EMAIL Address: Fax No.:
H. HEAT PUMP CONTRACTOR INFORMAT ON
Company Name: A��
Contact Person: ( EMAIL Address: C Go`�
Address: ,City: — Zip Code: WS"2 State: A_County:
Office Tele No.: Cell No.: �(�7— 1(7g�7 Fax No.:
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

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:
d- i .N"'' V Wi
K `
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 http://portal.ncdenr.org/web/wq/aps/gwpro/permit-
applications
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: 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 certijy, 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 i accordance with the 15A NCAC 02C 0200 Rules.AZ
"
pignature of Yroperty O /Applicant
C !/-/,4/Z VICY -S,4N'�,—
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQIMC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 3

�Do H �,� c���
� .S� '
3►' � 1� �
��
c��v
���a���
��
/�
N

1 y
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:
O
T IL E
G
O�
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.org/county.htin.
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

_ �eCr,��.it ✓�, /mac y '
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NC/TnTCATYON TO CONCTPUCT TnFLP- IA CONDUCT)E V1T`SZ'TEST W,ELYLS
Thermal conductivity test wells are used to determine the amount of heat that the subsurface may
transmit in a given depth interval for the purpose o.f designing geothermal heating and coolzn&systems.
Pursuant to 15A NCAC 02C.0230, thernsal conductivity test wells shall be subject to the regulatory _
requirements applicable to geothermal aqueous or direct expansion closed-loop-wells designed to serve
singlefamily residences.
These wells are "permitted by rule"and do not require ah individual permit when constructed in
accor4ax7ce with the rules of 15A NCAC 02C_0200.
This notice must be submWed at least two (2) busi�aess days prior to constracdo z.
Psi t Ckarly or Type Ihforntadwn IIIegible Submittals Will Be Returned As Incompleta
DATE; May 5 zo 14 PERMTT NO.wEc 1 o o. . , (to be completed by DWQ)
A. TYPE QV-THERMAL CONDUCZ.MTY TEST VV ELL TO BE COPISTRUCTED
(1) Aqueous(as-per ISA NCAC 02C_0222): X Number of wells- �
(2)- Darea Expansion(as per 15A NCAC 02C .0223) Number of wells:
B. STATUS.OF WXLL OWNER(choose one)
(1) Single Family Residence_
(2) Business/Organization X
(3) Government: State.. ___ Municipal County Federal
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:
Mona Lisa Foods Warehouse Expansion
Owner- Barry Callebaut USA, LLC
Mailing Address: 51 oad
city: Hendersonville_ State: NC zip Code:28792--ounty: Henderson
DAy Tolc•No.: •(�2�8)6$5-2443 Cell No.,
EMAIL Address: 'Fax No.'
�. PHYSICAL LOCATION OF WELL SITE
0) . Pokel Identification Numbcr(PIN)of well site:
County Henderson
(2) Physical Address(if different than mailing address): 51 St. Pauls Road M w�
City: Hep-dersonville state:Nc Zap Code: 28792
DWQMIC/Thermal Conductivity Trst Noiifuation(Revised 6/612012) Page 1
TO SJdd SNI S30IAH,3S QMti EOZGC898ZB LT:9T VIOZ/90/50

E. MAPS,PLANS,.AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicette distanoos and orientations of features located
within 250 feet of the injection well(s). Label a1J_features clearly 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 * Existing or potential sources of groundwater
+ .Water Supply wells contamination
(2) Plans and specifications of the surface and subsurface conmuction derails of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITTVES -- List any additives that will be used and their
concentrations. Only additives that the Department of Health and Hurnan 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:,'(porta All other additives require approval prior to use.
None-Water Only
Q WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name'. Larry Wells
NC Well Drilling Contractor Certification No.: _ 2603A
Company Name: AWD Services Inc Contact Person: Larry Wells
City. Leicester State: NC zip Code:28748County_ Buncombe
17ay Tele No:: _(828) 683-9223 Cell No.: [phone]
EMAIL Address:[e-mail] Fax No.:_ ZaA6 -92W3
IL 1EKAT PUMP CONfiRACTOR)NFORMATrON
CompanyNawo: Cooper Construction Company Inc. ,.
Contact Person: Berry Halbert EMAIL Address: bhnlbQ rn nPaWQ0, rprn
Address: Pb Box 806
City: Hendersonville Zip Code: 28793 State: County: Henderson
Office Tele No.: . [phone] Cel[No.: [phone] Fax No.: [phone]
D'WQ/UIC/Thennal Conductivity Test Notification(Revised 6/612012) Page 2
Z0 39dd SNI S30I/AH3S QMti 6OZ66898Z8 LT:ST bTOZ/90/90

11. IPROTEC7MN r provide a brief description of horn(1)water supply wells;(2) surface water bodies; and(3)
septic systems and associated spray irrigation sites, drain fields,or repair areas within 25Q feet of the proposed
injection Wc11s wAll be protoctcd during construction of the wells:
Silt Fence
Required Set Backs
J. VA aANCE—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 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 hgp_//gortaLncdciv,o�.�.-/webhvolaps/rwprolpermit-
aapolications
K. SIGNATURES—The following section is to lie 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 responsiblc corporatc 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 ocher 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
author-sty,and is signed and dated by the applicant.
".F hereby certify, under penalty of law, that I have personally exam xned and am familiar with the information
submitted in this document and all attachments ther'eta and that based on my inquiry of those individuals
immediately responsible for obtaining.said information, I helieve that the infos�riation as 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
Me mjeetion well and all related appurtenances in accordance ivith the I SA NCAC 02C 0200 Rules."
Signature of Property Owner/Applicant
Barry Callebaut USA LI.0
print or Type Full Name
Signature ofAuthorized Agent,if any
Barry Holbert Cooper Construction Company, Inc.
Print or Type Poll Name
DWQ/UTC/Thertnal Conductivity Tesi Notification(Revised 6/612012) pgge S
60 39Gd SNI SMIANM GMV 60Z6£89eZ8 LT:9T bT0Z/50/50

_ 51�12°ly
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
N0TYk`itCAT110N TO CONSTRUCT THERMAL CONDUCTY'VI(TY'LEST VM)f <aS
Thermal conductivity test wells are used to deter-rnine the an2.0ur2t of heat that the subsurface may
transmit in a gt ven depth inter'vaZ for the puePOse of designing geothermal heart g and cooling systarns.
Pursuant to 15-d IVCAC 02C.0230, theryi:al conduetivlty test wells shall be subject to the regulatory
requirements ctzPlieable to geothermal aqueous or diner expansion closed-loop wells designed to serve
single fcm�ily resideyt�es.
These wells are 'permitted by rule"and do not require an irrdividral permit when consrp Wted in
accordance with the rules of 15A NCAC 02C.0200.
ors notice dust be sul Witted at kzWt two 0 business days OtW to ag jF rucrlon.
P i►tt Clearly or Type Itcformation. Illegible SubmitWs Will Be Returned As Incomplete.
DATE:_May 5 , 20 4 PERMIT NO.
(to be completed by DWQ)
A. TYBE OF-THERMAL CONDUCTIAWY TE$T WELD,,TO BE CONSTRUCTED
(1) Aqueous(as•per 15A NCAC 02C.0222): x Number•ofwells•
(?), :Direatxpsnsiott(as per 15A NCAC 02C .0223) Number of wells:
$. STATUS.-9.1`WELL OW] )R(choose one)
(1). Single'Farniiy Residence_
(2,) . Business/Organization X
(3) ' Government: State Municipal County _ Federal
C. FELL O`OVN)ZR'-•For single family residences list the property owner(s). For all others, list name of the
-business,OFganizadoh,or government agency and person delegated signature authority:
Mona1isa Foods Warehouse Expansion
Owner: -Sagy Calle.baut USA LLC
Mailing Address: { Pa 40 R _
City:' Hb-hdersonville state: NC zip Code:2S792County, Henderson
Day Tel6No.: _W$ a85 Z Cell No.
i3Ivl,A IL Address: Fax No.
D. PEECYSICA)L,LOCATION Op WELL SITE
0) 'Parcel,Iderltifloation Number(PIN)of well site: 0601-34-6388; -6635
County H 9r _
(?). Fhysical,Address(if different than mailing address): 51 St. Paufs Road
City' n onvilie, State:NC
zip Code: 2$792
DVVQNICIrlteraral Coryductivity Test NOTM'GatiOn ftvjmd 6/612012)
Page I
TO 39Vd ONI S30IAN3S GMV 6OZ66898Z8. 95:9T bTOZ/80/50

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 wvell(s). Label all features e1 d'ncI 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 o Existing or potential sources of grouridwvater
• Water supply wells contamination
(2) plans and specifications of the surface and subsurface construction details of the well system.
IF. TYPES A" CONCENTRATIONS OF ADDI[TTVES — List any additives that will be used and their
conomtrations. 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 Iist of approved additives can be found
online at I1ttnJ/n43 trtl_iZcdenr.or /vr�b/wraps/wut�o_ All other additives require approval prior to'use.
None-Wafter Only
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: . Larry Wells
NC Well Drilling Contractor Certification No.: 2603Ay
Company Name: AWa Services Inc Contact Person: Larry Wells
City: Leicester State: NC Zip Cade:28748County: Buncombe
Day.'Tele No.' 82$ 683-9223 Cell No.: 82$ 215-9334
EMAIL Address:WellS750549 bellsouth.net Fax
H. HEAT PUMP CONTRACTOR INFORNI.ATION
Company Name: Cooper Cansti ucfiian CompanyJ2R�•�^
Contact Person: Barry Holbert - EMAIL Address: b11 ( .cclonerr;nnpm
Address: PO Box 806
City: Hendersonville Zip Code: 28793 State:—County- Henderson
OffiiceTeleNo.: _�$28)692-7238 CellNo.: 828)243-5313 Lax No.: 82.a)6W71a7$
D'WQ/UICrfhennal Conductivity Test Notification(Revised 6/6/2012) Page 2
Z0 39VC1 SNI S30IAH3S QMti COZ66898ZB 99:91: b1;0Z/80/90

05/08/2014 15:56 8286839203 AWD SERVICES INC PAGE 03
. • • ., •:►:: • fit,
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L pRUTTMON—Provide a brief description of how Cl)water supply Yvells; (2) surface water bodies; and(3)
septic systems and associated spray irrigation sites, drain fields,or repair areas within 250 feet of the proposed
icijeouon wells will bo protcottd during construction Of the wells:
Silt Fence
Required Set Backs
'V'A.112il NCE—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 regtlest
The variance request form can be accessed online at h4gg Lportl�l.nedennorahveb/wermit-
apu{ications
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: 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 datcd 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 believd 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 relcrted appurtenances in accordance with the 15A NCAC 02C 0200 Rules.
fr�10wft�,/Ar.e�ftnt �CZBara1keh-q11" l.'QA
gnature o
MLull me
Sig a ure of Authorized Agent,if any
Barry Holbert Cooper Construction Company, Inc.
Print or Type Full Name
DWQARCrthermai Conductivity Test Notification(Revised 6115/2012) pie 3
b0 SJdd DNI SSEI11iM QMd EOZGC898ZB 99:9T bZOZ/80/90

,05/13/2014 12:09 8286839203 AWD SERVICES INC PAGE 01
100
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CARO+,IN" DEPARTMENT OF ENVIR014 ENT AND NATURAL IRE-SOURCES
N.OTI[1f'YCNTItON OF INTENT TO CONSTRUCT OR OPERATE I( IJECTION SELLS
These}yells are `permitted by rude"and do not require an individualpennitiNhen constructed in acc0r Clarice ivith
the rules of 15,,1 NCAC 02C.0200*. This notice ntust'besubnzifted prior to construction.
GEOTHERMAL AOTMOMCLOSED-LOOP WELLS
As described in 15A NCAC 02C.0222 these wells circulate potable water only or a mixture ofpotable water and
performance-enhancing additives as part of a geothermal heating and cooling system.
OR
GEOTHEMTAL DMECT EXTA4SION 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.
NORTH CAROLINA DEPARTMENT OF ENVIRONiblENT AND:NA.TURAL RESOURCES'
Print Clearly or Type Iitforrrafion. Illegible Submittals Will Be Returned As Incomplete.
OATS: %— [Y , 20 PEI RART NO. 01 3 0 to be completed-by DWt)
A. TYPE OF GEOTHERMAL,CLOSED-LOOP WELL TO BE,CONSTRUCTED
(1) Aqueous,(asper 15ANCAC 02C.0222): ✓ Number of wells;
(2) Direct Expansion(as per 15A NCAC 02C.0223) Number of wells:
B. STATUS OF WELL OINNER(choose one)
(1) Single Family Residence_Submit this form two(2)-business days prior to construction.-
(2) Business/Organization_X Submit this form 30 days prior to construction.
(3) Govenirrient:, State Municipal County Federal Submit this form 30 days
prior.to.construction.
C. WELL.OWNER.—For single fainily 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: _ j S-4,
City: geAJ ej.--j ys lle- State: /VC Zip Code: County: eA
DayTeleNo.: 9.2,9- KRX- .?_V�3 Cell No.:
BMAIL Address: Fax No.:
D. PHYSICAL LOCATION.OF +LLBITE
(1) Parcel Identification Number.(PIN)of well site: 001 -3 4�3 ST"
County: 'LJ2,vd�it
(2). Physical Address (if different than mailing address): _ l 3, , f'�ca/►
City: State:-NC ZiO Code:
DWQMIC/Closed-Loop Geothermal Notification(Revise(1480/2012) Page

MAPS,PLATdS,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 featues clearly and include a north arrow. Attach a
site-specific map showing the locations of the following:
Proposed injection well locations
Buildings 4
Property boundaries —'
Surface water bodies
o ' Water supply wells
Septic systems and associatc&spray irrigation sites,drain fields,or repair areas
Existing of potential sources of groundwater contamination
(2) Plans and specifications of the surface and subsurface construction details of tho well system.
TXPES AND CONCENTRATIONS OT ADDITIVES -- List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Set vices'Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at littp://pc)rtal.nedenr org/web/wq/a� wuro. All other additives require approval prior to use.
G. WE+11 DRILLER INEORIVUTION(if known)
Well Drilling Contractor's Name: Mullis)ullis) (1Vlatthew Brown) (Milton Cave)
NC Well Drilling Contractor Certification No.: 2572-A 3036-A 3548-A
Company Name: Yadkin Well Company,Inc. Contact Parson: David Brown(2195-A)_
City: $amptonville State: NC Zip Code 27020 County: Yadkin
Day TeleNo.: 336468-4440 Cell No.: 336-374-8736
EMA"IL.Address: chief [e-mail] Fax No.: 336-468-4048
�I. RE PUMP CONTRACTOR INFORMATION
Company Name: C:QL,1,e u .i► �I yt s t ► n a .L�► e
Contact Person: l ,V y y Alln eJ- ENTAIL Address J, ®1 C ppync>y car,
Address: Pa 9ON 904
City: pn fir,fon V J lie- Zip Code: 2?7q 3 State:)/L County: e"`J i l-o rt
Office Tele No.: `09' �612 72,3 S Cell No.: -Z Fax No.: 9285, 651b- R q
DWQIUIC/Closed-Loop Geothermal Notification(Revised 4/30/20.12) Page 2
I

IC. P lRO`I"E+CTION—Provide a brief description of how(1)water.supply Swells; (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:.
,SC.-cam!i►'�t��•�—y�}__T-s 'f"•� C 4'y.�.'"P'L?l!n �y,C) C ,c. .�a�R P
i
I V1igZJ ANCE—Pursuant to 15A NCAC 02C.0241'thb Director of the Division of Water Quality may grant a
variance from applicable well construction or operation standards providedthat:
(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 betterprotection of the groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation of the request.
The variance request.forin can be accessed online at htt�://poital ncdenr org/web:wg/aps%Qwn o/Z)eiiliit-
applications
X SIGNATURES —The following section is to be completed as required below or by thatperson's authorized
agent, 15[1 NCAC 02C.0211(e)requires signatures as follows
(a) -ior a corporation:- by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner or the proprietor,,respectively;
(0) 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:
"T hereby certify, under'penalty-oflativ, that havepersondlly exam Tied and altx familiar with the infornralion
submitted in this document and all attaclimenfs thereto and that, based on.rrZy inquiry of those individitals
immediately responsible for obtaining said information, Tbelieve that the information is true, accurate and
coinplete:. I am aware that there are significantpenalties; includ►ng the possibility offrries and imprisonment,
for submitting false information. I agree to construct,, operate, maintain, repair, and if applicable, abandon
the h?eetion ivell and all related appurtenances in:accordance ivitli the 15A NCfIC 02C 0200 Rules."
v _
Signature of Prop Olvner/Appliza&
Print or Type Tull Name
Signature of Authorized Agent,if any
Print or Type Full Name
MQ/UIC/Closed Loop Geothermal Notification(Revised 413012012) Fage3
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