Jackson UIC Deemed Permitted 2012

NORTH CAROL(N11 DEPARTMENT-OFENVI:RONM8NT AND NATURAL RESOURCES
NOTIFICATTON OF`INTENT TO CQNSTRUCT OR OPERATE INJECTION WELLS .
These wells°ure"permitted y.r ule":and do not require,an' di ideal Perin t hen:constr?rcted.in.accorcfance with
the rules 6f.I5A NCA.0 02C.020V, This notice inu.st be submitted prior to construction.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in-1 SA NCAC 02C.0222.Ahese'wells circulate::potable water only or a.mixture of potable water and
perfonT ance enhar cing additives:as.part ot;a.geothermal-heati: and coolipa system.
OR:
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS
As described in.15A NCAC"02C.0223.these wells circulate a-refrigecant'gas as part-of a"geothermal heating and
coaling system.
ffi
Print Clearly or Type Information. Illegible Submittals Wi11-Be Returned As.Incomplete.
DATE: November 7,2012_ PERMIT NQ. �l dU o`�n(to be,completed by DWQ)
A. TYPE OF.GEOTHERMAL CLOSED-LOOP WELL TO.BE CONSTRUCTED
(l) Aqueous(as per 15A NCAC'0?C:0222) .k:. Nuinber,ofwells.'3
(2) Direct Expansion(a$.per 15A:NCAC 02C .0223j Numlier;of wells.
B. STATUS OF WELL OWNER,(choose one)
(1) Single Family;Residence�Xx .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 6.wner(s) For all others,, list name of the
business,organization,.or:government agency and person delegated.signature authority:
Stephen/Gale Barnett
Mailing Address: 2845 Ramsgate N.W.-
City: Atlanta State: G.A. Zip Code:.30305' County.: Fulton
Day Tele No.: _(404)309-3699 .: Cell No
EMAIL;Address: galeth.a msn:com Fax Nip:;:
D. PHYSICAL LOCATION:OF WELL SITr
(1) Parcel Identification Number.(P1N)'ofwell site: 7672-704514
County:Jackson
(2) Physical Address(tf different than p ailing address):Balsam Mountain Preserve, lot# 162 ShooFly
Way
City: S lvy a State.: NC Zip Code: 28779
MQUIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 1

t,
E. MAPS,PLANS,AND'SPECIFICATIO.NS'
(1: Maps must be scaled or otherwise accurately indicate distances,and orientations of:features located
withln.250 feet of the.injection wells) Label alllfeatu7es clearly and include a.north arrow. Attach a
to specific map showing the locations ofthe'following
Proposed injection well locations: • Septic systems and .associated spray: irrigation
"Buildings sites,drain'fields,or repair areas
Pro e � boundaries
_ p rtY ,
• : Surface water'bodies Eatsttng: 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
F. TYPES-AND CONCENTRATIONS .OF ADDITIVES,- 1 isr-any ;additives that will be used and their
concentrations... Only additives thAt.tl e Department of Health and Human Services'Division of Public Health
determines.do'notAdversely affect huinan:healtli.sliall be used A list of approved.;additives can be found: :
on me at utla:fflx�rtal.1 cclenr.e in'��eb/ c�r�i s/Rw0o All other additives require approval prior to:use:
none:
G WELL DRILLER INFORMATION. (if.known):
Well Drilling Contractor's Name: Larry Wells
NC Well Drilling Contractor Certification No.: 2603
Company Name: Appalachian Well Drilling_ Contact`Per'son: Larry'Wells
City: Leicester State: NC_ Zip Code:28748_ County:
Buncombe
Day Tele No:: [phone] Cell No :i .f828)215-9334.. .
EMAIL-Address: Fax No..
If. HEAT`PUMP CONTRACTOR INFORMATION''`
Company.Name:Bullman Heating.and Air.
Contact Person:_loev Bullman�. hMAI(,Address:
Address::P.O.Box
City: Asheville Zip Code: 2881.4 State:- N.C. County:'Buncombe.
Office Tele No.:(828)�58-2468 Cell No Fax No.:
DWQ/UIC/Closed=Loop Geothemial Notification(Revised 4/30/2012) Page 2

11t0?I2012 14:00- 4043500093 CA14ON 01498 P. 004f004
• I I
X, PROTEC ON-Provi.04 brief description of haw(1)wager supply-Wells;.(2)smfjce water b dies;and(3)
Septic systems and associated spray irrigation sites,drain fields,or repair areas within j20 feet o the proposed
injection wells will be:protected during construction of tile,wells_
Water sir 1 well ltas riai bei}n d 'led.T4Ta surface•water bo'ies.S tic S to o '`n' No
s ra irri olio -sizes : ,
J: '�SRIrS�IM Pursuant to l$A.NCAC 42 :0241 the'Ltrector ofths DtVtaian of Wader Quality nay 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;ar d
(2) that construction or operation in accordance with the s=dards is not technically feeble or'the
proposed construction provides equal or Better protection a f 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 l�tt�;li pRt ; l_ c' .a „eblw �a slew 1 rmit-
applications I
i
K, SIdNA 'iT::�-the following-section:is to:be OtM)leted-as requl ed below or j that perso 's:autlzorized
agent. SA CAC G2C,U21 t(e)tegwres signatures as'follows; i
(&) for a corporation bya.:zespans�ble ccirpvratd Officer;
(ly) fora partnership or sole proprietorship: by a general partner or the proprietor,T- pactively;
(c) for a:mudicipality or a state;_federal, or other public agency; by�ithor a prin4pal executive
officer or ranking publicly elcoted officiai;
(4) for all.others; by the well owner; i
(e} for any other.person;authorized to act:on.behalf of the applicant: docuxnen sign shall be
submitted with the notification that;clearly idaotijas the person; grants t m`sigtlattlxe
authority,and is signed,ripd.dated qy the ap Vicaiix. . .
117 hereby`certify, under:penalty of fury, that I have pen Bally exai rimed aitd nun familiar with t e in flomation
submitted in this document and all attachments thereto and that, based.on my irtgWiy of to individuals
lmmedlarely responsible for obtaining said inform,2 on, I belteve• art the:informaRbrt is true, accurate and
complete; I ant aware:ihat there are significant,penalties,including the p6ssiRI10i of fines and imprisonment,
for n(baliiting false inforMZgAgn, I agree to construct, operate, maintain,.repair, an'd if applieableI abandon
the injection well and all related appurtenances in actor c42A the 15r1 4C 0.200 R es
ign tt�rzo r ortyC! an
-1?rtnt or Type'Full Ngme i
$stature 0 ki 4 did Agent,if any
F rtnt.ar I'ypg>I�itll tvasne �
JAW:Q�UIC/Cf05 d-LOG} Geothermal N01ffeation(R:eMsed 4/3G!2012) i i 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 individualpermit when constructed in accordance with
the rules of I5A NCAC 02C.0200 This notice must be submitted prior to construction.
o�
GEOTHERMAL AOUEOUS CLOSED-LOOP WELLS > (D
As described in 15A NCAC 02C.0222 these wells circulate potable water only or a mixture of potable wate_and`__,
performance-enhancing additives as part of a geothermal heating and cooling system, i�
OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS 0
As described in 15A NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geothermal heatiQand
- cooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: _ , 20 )� PERMIT NO. (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
0) 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 L-Iubmit 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:
LLCM L, Zayid
Mailing Address: 7
l p �63 County-
City: State: � Zip Code• rr�� !!
Day Tele No.: Cell No.. 0'-d� 3
EMAIL Address: Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
3
(1.) Parcel Identification `Number(PIN)of well site:
County:( Physical
/�
2 Ph sical Address(if different than mailing address): J Q`p 151,1556-p4 .�) y
City: State:NC Zip Code: ow
_...:._1 wi_.:c__.:__in A Pnm 1

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:
�L/I?t'ii/rP�o
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 lmp://portal.nedenr.ora/webl wq/a S/-W ro/ ennit-
gpplickliolls
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 related appurtenances in accordance with the I5A 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

NORTH CAROLINA
DEPARTMENT OF ENVIRONMBNT ANDNATURAL,"SOURCES
NOTYTICATYON OF,]ENTJCNT TO CONSTRUCT A CLOSED-LOOP GrOTHCIi+� v0�i
WATER-ONLY IN3TCTION WELL SYSTl;,M
�• m ca
TYPIC SOW WE,LLt•S1 0 2.
a © o,
In Accordance With Ilse Provisions ofNCAC'l'itle 15A 02C,0200 CD
a
Prfrrt or l�+pe tfre regrtir'erl irrfol urrrliorr nrrrl rrrnil to nclrJresr on lire back page.
c�
DATE.:
M-11 TYP Conf1 mallon: Does the propose(l systerrr circulate potable water orrlx(110 additives)in
continuous piping that completely isolates tide %laid from the envirotlment(i.e.
c{o�ed-leer})?
Yes. Continue completing 1his form.
No Do Not complete this form. Complele other UIC application forms for iltstalling
either a 5A7 well Lopen-loop well in•e i r potable water into the aquifer)or a 5QiNA well(close(1-
loop well containing additives such as R 22,ethanol,or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNCR(S)IAPPLICANT(S)
List each Property Owner listed on property(deed(if owned by a business a•government aged ,state i me'of
Vilify and a representative wlauthority for signature):
Da✓L ;ZJWA R 2 44 5 L. L &T1fvA)
(1) . Mailing
//Address- /V,:30 S1404NNAN
City: State:5 Zip Code:_j l4 y�/V*y. 121
� � Count dyv(•
Houle/Office Tele No.: Cell No• 9$0 7474
Small Address: i41v� j"�JGmprL Zolll�lebsite• ��/�
(2) Physical Address of Well Site(if different 111811 above): 3 C'j
City:Wit'�� Slate: "t-=G Zip Code: 2%"i t`i
Rollie/Office Tele No.
Cell No.:
R. AUTHOIILZED AGENT OIL OWNTIR,IF ANY(if lire Permit Applicant does not own the subject property,
attach a letter fi-on)tide property owner authorizing Agent to install and operate UIC%volt)
Company Name:
Contact Person: EMAIL Address::
Address:
City: State: Zip Code: Courl
ty:
Office.Tele No.:
Cefl iVo;:
Website Address of Company,if any;
GPU101C 5QW Notifrr,Uinn of i"terrr Fnnn(Rexvsed 812008)
m.+ Annie en++nu riniv-7n 1 I 4a7 AMI

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 litip://portal.ncdenr.ory web/wqlaps/g«pro. All other additives require approval prior to use.
I Al
,e.s
G. WELL DRILLER INFORMATION(if own) �����
Well Drilling Contractor's Name: ff
NC Well Drilling Co tractor Certification No`�.::���[� /
Company Name: S�vl►11,~r b.� �'�'"b7 Contact Person: -y-' ` Moog�.
City: h6l State:4C==_ Zip Code,2M3 County:
Day Tole No.: -)74 e 6M Cell No.: — wi 7P —EMAIL Address: iyicig Wg!q 7bM00),CW V Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:
Contact Person: Q4,tuzg, EMAIL Address: ` e \ ' .Cowj
Address- d
City: CW Zip Code:g 7- State: Ac County:
Office Tole No.: Cell No,;
MQ/U1C/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

s �
� a
1-01
0 7, 3
�'` 3 )UO

INJECTION-RELATED EQUIPMENT
Attach a diagram showhtg the engltteering layout or proposed modification of the Necdon equipment and exi
piping/tabing associated with the h9ection operation, The mantt
infortnation. facttirer's broclture may provide suppleine:
L LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(I) Include a Site Map (can be drawn) showing: buildings, properly lines, surface water bodies
sources of groundwater contamination and file orientation of and distances between tite proposed well(s)
any existing well(s)or waste disposal facilities such as septic tanks or drain fields located within 200 fef
the geothermal heat pump well system. Label ON features clearly and include a north grrow.
(2) The Site Map must show the subject properly in relation to the surrounding alva by using at least two fi
reference points such as roads,streams,and/or highway intersections.
J. CERTWCICATION
Note: -, Tills-Permit Applfcatlou=inust-1 esigned by a
recorded legal proporfy deed, person appearing on the - -- - —
"I h-"V • tify, under penalty of law that t have
sui' r personally examined-and aln familiar with the informati
irate document and all attachments #ie"eto and that, based on lay inquiry of those individu;
` bible for obtaining said inforinatiou, I believe that the information is true, accurate and comple
' e are significant penalties, including the possibility of fines and imprisonment, far subtni8i;
' 'X agrce to construct,operate, aintain, repair, and if applicable,abandon ilia i
: ices iri accordance with the p v fcations and conditions of the perrntjection Iveli ai
Signature of Property owner/Applicant
n�(�
PCint or'1�►pe Full ame and tine
a ofI'rope3 neNApplicant
NAJ
Prin or Typc Full Name and title
Signatw�e ofAutttorizcd Agent, fany
Print or Type Fu11 Name attd title
Please return Uvo copies of the colnpteted Application package to:
NOrtl1 Carolina DENR-DWQQ
Aquifer Protection Seetiou.U)!C Progrars
1636 Mail Service Center
Raleigh,NC 27699-1636
Te"Vhvue(919) 733-3221
GI'UA)[C SQXV Natifccation oHnleat Form(goviscd 8/2QU8)
C-d nr_ni 1 On7)1 XnJ Anne+ nniinu dr,47'7n 1 1 97 nc

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:
WINST©N-SALEK `
RALEIGH t
ASHEr/ILLE; WASxHINGTON
VILL
t
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:(919)'571-4718
(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.ncaihd.orWcoLiiit-Nt.htm.
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES I
NOTIFICATION OF INTENT TO"CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by rule"and do not require an Individual permit whelr constructed in accordance with
the rules of 15A NCAC 02C.0200 . This notice must be subinittedarior to construct[ it
OOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in 15A NCAC 02C-.0222 these weils.circulate potable water only or a mixture of potable water and
performance-enhancing additives as part ofageothermal 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.
E
Print Clearlyor Type InformAtion. Illegible Submittals Will Be Returned As Incomplete.
DATE: .3- / —/ 20 PERMIT NO. fl 2 S _(to be completed by DWQ)
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 ntit this form two(2)business days prior to construction.
(2) Business/Organization Submi#this form 30 days prior to construction. i
(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, Iist name o the
business,organization,or goveriment agency and person delegated signature authority:
J�
Mailing Address: GT lei
City: Ytrr4649 State: TX. Zi Code: Cottn
Day Tele No.:. Cell No.:
EMAIL Address: lZew d -.1-@r"o i n e@ V i.corn Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) -Parcel Identification Number(PIN)of well site: 767Z - 86 --7 o6 3
County: JACXsOva
(2) Physical Address(if different than mailing address): l S J Ac t�ttt�fL �nl -----
City: _,S-xv }- State:NC Zip Code: -28779
DNQN[C/Closed-Loop Geotherntal Notification(Revised 4/30/2012) Page 1
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014 16:00 8437925910 ENT PAGE 02
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NORTH CAROLINA DEPARTMENT OP ENVIRONMENT AND NATURA1,RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OP RATE INJECTION WELLS
These wells rne.'permllled by ride"and do►rat require car ludivldual permit when oo);M-noted In actor elanoe with
the#-tries of I5A NC,tC 02C.0200 . his uatice nuts( sttbtullted prlo p co�, etrtc l�l�ltL
U&,MERMAL AOUSOuA CLOUD- &3WILS
As described in 1 SA NCAC 02C.0222 those wells circulate potable water only or a mixture ofpolable.water and
peritotmonce-enhancing additives as part obi geothermal heatbtg and cooling system.
OR
GEOTHELDIRECT EXPANSION CLOSED•LOOP WELLS
As described in I!A NCA C 02C.0223 these wells circulate a refrigerant ges as put of it geothermal heating and
cooling system.
Prltrf Cleolily nor 7yl)e!i fotntatlost XlleglbteStlBntlrtats lylll,BaRelrtntedAs�fitcatttplele.
DATE: 3 1 L ` I `7 , 20 PERMIT NO, WS 01 0 Q-0 la (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSAD-LOOP WELL TO DE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C.0222); Number of wells:
(2) Direol Expansion(as per 15A NCAC 02C.0223} ___ Number of wells: .
STATUS O1R WELL OWNER(choose one) RECE:VrR
Division of Vdaces
(1) Single Family Residence_ ubmit this form tsvo(2)busluess days rior to constructi
(2) HusinosslOrganiaation„_Sttbmlt this forin 30 days prior to coast etlon. q
(3) (IoVeCttttl@nl: State Municipal County Federn Sp0W Yto eon4ihlsdflIII ysC, WELL OWNER For single family residences list the property "ner(s), i:orV&?j3-1 11 nj1EA3 �1e r,s
bttailltss,orgauizatlon;or govenlittent agency L11A person delegated sigtunture a ,
MaUbtg Address: I 01 Ld tp,�,
City: State: se- Zip Code;!�lyq County:
pny'FoleNo.• 8N3-'1°IS'- xx el- Cell No.: BKts 8so g9 l
EMAIL Addtess: L C h�,1q a Fax Na:
D. PHYSIC.A.L LOCATION OIL WELL S1TR
(I) 'Pateel ldet;tltloation Number(PIN)of Well site: -766 1— 95 ' 41Rd
County: Jnc�t on
(2) Physical Address(if dift'hrernt than malting address); - --
City; .� Y� State- xipCode: B�h� —
DWQNIC/Ctnscd•i oopOW110nualNotlfic 010A(ILevi"d 413012012)

CIJ/11/-LCJ1ffi 1p:YJYJ 043/7L0710 MN 1 rmur—- 1'JJ
�. 1V1Ak9;-YLAIY$ AND'SPEGIFIC/t;'�'IONS .,. , - .
{I) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 2$0.(het of tlte injection well(s). Libel all features-eleArl, AMMM01y. AttAeh a
site•speolflo map showing the 10oa110119.Of_tha fotto%ving:.
• Proposed-injection well kocations_ • Septic—syalains 60d assoaieicd spray In•lgetlon
• Buildings shos,.drain,fields,or repair areas
• Properly boundaries
• Surface water bodies • Existing or poteutlai sources of ground}vater
• Water supply wells contenilnation
(2) Plans and specilications of(lie sitr&ce and subsuititce'consietiction details of the%veil system.
P. TYPES AND CONCENTRATIONS OF.AODIMUS„-,LW any additives,that will.be used and their
Concentrations. tJ1A additives that the Departinent of IkMth acid Human'Services'Alolsion of pgbllo Health
detenniites do'riot adversely atf'act human health shall be used. ` A jlist of approved'additives can be found
online at Inti�: i�t>, ;1�;)lra?��tr.nt�,;«ch ti�ct:;�i)•71<<�• All other additives require approval prior to use.
G. WELL DRILLER INFORMATION(if known)
Well Drlllitt Contractor's Name: .;,.
g '- ..
NC Well Drilling Contractor Cerd citron No.: '
-
Zlp CodoQg2y3Countyr
Tete No. � ' '� 2 -LASS - Call-No.:-
' - - --- - - -_- - -�-
BM1A1LAddress: 4. 6.W1kkefi 20") , C�`�'I Fax'No.:_
I
If, HEAT PUMP CONT TO XNXtU MA'T ICON
` r
Company Nance: --
ContaetPerson• r� MAI4
Address• IAO .�, -
Clly: _ Ztp Coda:..�� ? Srate:.�LCounty: t
..
()Rice Tole No.: Call No.:,­
o.:�( �'7---J�� NO 1__
.an.nn nn•in .. n . .ter . ... • . ..�n.�-. n. Oil
i.

uJ/ta/LViY AU.UU OYJ/74U7.LV GIVI rHCfC UY
j• PROTMCTION-•Provide a brief descriptlon ofhow(1)water
supply wells;(2)surface water bodies;and(3)
septib systems and associated spray irrigation silos,drain fields;or repair-areas withh)250 feet of the proposed
ittieetion%vejls will he protected during eonstruolloll of the wells:
j
J. VARIANCE—Pursuant to 15A NCAC 02C.02,41 the Director of the Divisiol)of Water Quality may grant it
variance om_ap_plloable well cotisUvetiot2 or operatiQn.stttr)dar�is provided-thgt: ___
(1) use of ilia 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 feasibler or the
proposed construction provides equal or better protection of ilia groundwater.
Any veriatnee requestsltnit accompany submittal of this notiticstion to expedito evatudtfan of cite request. '
Tile i0lidaitoe rt~quot form ean*e'accessed online.At in'tar,//mrli�l_ilcililit:,car;�ti��c�tZ/irci/a!1>=s!
cljihj[cJlli�ns . : ,, -
SIGNATURES—The following section Is to be completed as required below or by that person's authorized 1
agent, 15A NOAC 02C.0211(e)requires Signatures as follows:
(a) ibr a corporation; by it responsible corporate ofiiaer;
(b) ibr a partnership or sole proprietorohip: by a general partner or the proprletor,respectively;
(c) for a municipality or a state, federal,or other public agency: by either to principal executive
officer or ranking publicly elected offlelal;
(d) for•all others: by the well owner;
(e) The atty other person authorized to act on behalf of the npplteanti "doeume tatlon shall be
submitted with the, notifccalion that clearly Identifies the person,.:grants them signature
authority,and is signed and dated by ilia applicant.
"X Ilereby certify, u►rder perralry�of laly, lhai I have personally examined and am farnillar walk the infol-mallon
submillod/it Ihls doctiment.and all a►lachmenis !hereto and that, based on my inquiry of those Ihdlvlduals '
limmalkely miponslble for oblafning said lr foimallon, I believe that Ilia-hotimillon it trite, accurate and
camplate. iam aware that ther0 aia Agn#lcant.penaltles, ihchtding the possibliq offlnes and bnprisamrent,
for submlfllilgfalse hlformallm. I to consirrtel, operate, mafirtath, repair, and tf applleable, abandon
the•injeetlon well a►td all related app r7e1 once lrr ac trance i ith the 15A NCAC 02C 0200 Rules."
MOW of-Fral» 't)wnerf pplloaufw.
_ / _. • 1(•rfnl•or�TypaFrr)I Nnn,o +
alknnture of Aufharized Aaant,if any
Print or,Type Mill.Name !
DWQlU1C16oscd=Lod)tleotheniml Notiflcaiton(Rcvlscd 413012012) Pnge 3
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SUBMITTAL,INSTItUCTIONS—Submit 0110 COPY Of the Completed notification package to the each of the
fbilowing:
(1) Tire Division of Watel,Quality Itegl0j,61 Office xW118; 1he area In which the Injection well he
will b)a located.- ql(ty
RALEIGH
ON
SOON
Asheville Regloual OMOO
Wnshluglon Regional Office,
2090 U.S.Highway 70 943 Washington Square Mall
SWO11111100a,NC 28778 Washington,NC 27889
Tdlophwis:[phone] Telephono:[phone]
Pax:[phone] Fax:[phone]
ftyetteville Reg(onn I-Offlce Wilmington ROR(Olml office
225 Greeli Stteet,8 ifte 714 127 Cardinal Drive Bx1enslon
Fayett6ville,NC 28301.5043 Wilmlngtoll,NC 28405
Toloplione![phone] Telephone:[phone]
Fax.-[phone] Fax.[phone]
Mooresville Regional Office Winston-Salem Rogionol Office
610 HatCenter Avehua,Suite 301 585 Waughtown.Street
Mooresville,NC 28115 Winston-Salem,NC 27107-2241
Telephone:[phone] Phone:[phone]
Fax:[phone] Fax.[phone]
Rolelgh.ftlonal Omee
1628 Wil'Sovl6e Center
Raleigh,NC 27699.1628
Telephone:[phone]
Fox:[phone]
(2) County Health DOI)arlinwit In which the Injection well fhollity will be located. A list of county health
(lbpgrlinents can be found online,a()Lyp-,1Jw
DWQ/U1CVC1bsed-Loop Geothemifil Nodfleation(1(ovised 4/3012012) PK&e 4

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 accordance with
I the riles of'1 Sri NCAC 02C.0200 . This notice must be subrniired p-jor 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 ii"ill Be Returned As Incomplete.
---DATE:--- ) j W� to be completed b
( P Y ON®01-� com DWQ)
4 -/� � / � 20 PER IT_NO._ _ �
i
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TOO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C .0222): y 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_ L--S-,bmit this form t`vo(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 0 days
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:
RECEIVED
U i L� �`1 `� wston of water�esoun
Mailing Address: i t2 t G 2014
City: ��L- �j�Z-L� State: Zip Code: 3 1ottnt}': —
Day'fele No.: Cell No.: _{�aatltyRe�lenatCp¢ratlona
EMAIL Address: DLiKl4w Fax No.:
Asheville Regional Office
O. PHYSICAL LOCATION OF WELL SITE
(1} Parse!Identification Number(PIN)of well site: 7 f
County: 'r-- S C)^J
(2) Physical Address(if different than mailing address): 167 Y
City: r�v L tft .4 State:NC Zip Coder
DWQ/Li1CIClosed-Loop Geothermal Notification(Revised 4/30i2012) Page f

.. . . . . . . . . . . . . .
. . MAPS,.PLANS,AND SPECIFICATIONS:,-.
(l) Maps iiuist be.scaled or otherwise.accurately:indicate distances and orientations of-features located
Nviihin 250 feet of the injection well(s).-Zabel all features clearh�and include a north arrow. Attach a
site-specific;map shominq the locations of the following:.
Proposed infection-well locations o Septic systems :and associated spray irrigation
Buildings sites,drain:-fields,or repair areas
Property boundaries
Surface water bodies Existing .or potential. sources -of. groundwater
o Water supply wells coniainination
-(2) Plans and-speeifications of the surface acid subsurface construction detaiis of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any.additives that will be used and their
- = concentrations.O.my-additives:that.the-Department ofIdeaith-and-Human-Services?Division-o"ubkHealth
determines do.not adversely affect human health shall be used. .A. list of approved additives can be found
online at :;r,. , ;;:.;:.,t :, : :• ,_ y 'T- + r:.,. All other additives require approval priorto.use.-
L
O;. NVELL DRILLER INFORMATION,(if known)
Well Drilling Coiitractor-s Name: $ 1 /wDn;S
NC.Well Drilling Contractor Certification No..:'
Compa9ny Natiie: `� }�( e�i I IV1 C C�oGritacl Person: J '^-/� �
Cit}:/T ;� State: Zip Code/��� ouiity: :
Day Tele No.:
2 (e -BPS Cell No::.
EMAIL Address-Till 10—e IS ' � I� Wyax h!o-:
H. HEAT PUMP CONTRACTOR. IIN FORIMATION
Company Nai.ne: bzm .
Contact l?erson: EMAIL;Address: s�V?
--
.��
City: r Zip.Code:. StaterCounty;
. .
office, Tele.No:.. 'Cell No,: /(��= ���.�Fax No.:

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II. 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:
ry
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 tltis notif cation to expedite evaluation of the cegtiest"The variance request form can be accessed online at. ;i; :: ,. ..
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, federaf, or other public agency: by either a principal executive
officer or ranking publicly elected official;
(tl) 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 herebycertif},, under penahy of�law, that I have personally examined crud am fziniliar with the inforn7ation
submitted in this docr1117erat and all attachments thereto and that, based on m3% inquiry of those individuals
immediately responsible for obtaining said information, I believe that the inlor-mation is true, accurate,and
complete. I an:mvare that there re si nif:cuw penalties, 7clxding the possibility of;fines and impri_somnent,
for submitting false information. I agr e to cons wct p •ate, maintain, repair, and if applicable, abandon
the injection well and all related )pur•t n nc s it rc •1 ► e lvith the 15A A'CAC 02C 0200 Rules."
Signatur of re er y Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQ!U1C/Closed-Loop Geothermal Notification(Revised 4!30!2012) page

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:
:t IZALEIGH
ASHEVILLE WASHINGTON
77,
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 hq://www.ncalhd.org,/counly.htm.
DWQXW/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

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