Jackson UIC Deemed Permitted 2015

Z-0 397 �a
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 NC.4C 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 NE®
performance-enhancing additives as part of a geothermal heating and cooling s fain. Dihs[on My Resources
OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WEL AUG 3 1 2016
As described in 15A NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geo heating and
cooling system. Water oualdy R glonal Operations
Asheville ec0nal 2 fic- e
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Inc
.DATE: � � , 201 PERMIT NO.VJS�7I0© (to be completed byDWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per ISANCAC 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) j
(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.
rWELL OWNER For single family residences list the property owner(s). For all others,list name of the
`businre�ss;tsfganiiation,or government agency and person
l delegated signature authority:
�itatt�l d dGCNe 1� 1VOOUVA YJ
Mailing Address: A61 All W.
City: Llqa f 6 tI e State: f4e- Zip Code:gp,County: Aj 6V,.vbu/'�
Day Tele No. 20Y- X97'7114,R Cell No. -ON-a3G- 27- 8 Z
EMAIL Address: &&bAm y CLI Qt(,M 4;1.(-o Fax No.: ?N,a 6"1- &77 {
D. ` .
PHYSICAL LOCATION OF WELL SITE. /
(1) Parcel Identification Number(PIN)of well site 7692 -,00..- 35 7 -3
County: )AG1GSo 1y
(2) Physical Address(if different than mailing address): _i9 9 464e&We w A f
City: S YL ✓R State:NC Zip Code: off$7 T
DWQMIC/Closed-Loop Geothermal Notification(Revised VW2012) 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 reps$areas
uildings
P
roperty boundaries Asting 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.
i
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://aortal.ncdenr.org/web/wq/aps/ewnro. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION(if known)I
Well Drilling Contractor's Name: ��S`1 'e V11 JN b
NC Well Drilling Contractor Certification No.: a 137—A
Comp an Name:o f 11 V2 W t 612 to y Contact Person:
City &t s .'ei g2 State: Zip Code•1LO County: AG{,—'S6"
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION 1
Company Name: `-�� 1i�-wh_ �J
Contact Person: s 1 /n EMAIL Address:Chl r aLtL 5 AI s+a—J�G/
Addr. b $ '
City: J0JAAd 44 Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
DWQNIC/Closed-Loop Geothennal Notification(Revised 4/30/2012) Page 2

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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
ou
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 http://portal.ncdenr.oWweb/wqlaps/wpro/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: t
4
(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 ranldng 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.
V 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 r lated appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
Si re of Property Oivner/Applieant _
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/3017012) 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:
W.,INSTON-SALEM
RALEIG H
A$HEVILLE
= _ ,:; 1111ASHINGTON
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) Comty Health Department in which the injection well facility will be located. A list of county health
departments can be found online at http://wwNv.ncalhd.or county htm.
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

Q�315 (7So gam,
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 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:. �'� ' D—1�, 20 f PERMIT NO. W-,r—010 0 3S2 (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: ©b
(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
business,organization,or government agency
and person delegated signature authority:
Mailing Address: f.�©� mad!
City:.0urTaw N State: Zip Code: 11o13County:
Day Tele No.. old -3Zt9AC13 Cell No.: 00 1 - -L
EMAIL Address: 5i 1 8c�cco%�rcir�c.��voo��ta�tr �. x No.:
D. PHYSICAL LOCATION OF WELL SITE (D
ro on
(1) -Parcel Identification Number(PIN)of well site: f � i �n
ty: �"J460,j o Caun ' r\- 9 M
o °C7
(2) Physical Address(if different than mailing address): o 2
� 0
' o
w
City: State: NC Zip Code:
DWQARC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 1

McKenzie Dillingham
From: Sharon DeBacco <[e-mail]>
Sent: Wednesday,April 08, 2015 8:50 AM
To: McKenzie Dillingham
McKenzie,
Paul and I authorize you to sign our geothermal application as our agent.
Thank you
Sharon DeBacco
Sent from my iPhone
This email message and any attachments are intended for the exclusive use of the addressee(s)and may contain
confidential or privileged information. If you are not the intended recipient, please notify Ironwood Pharmaceuticals
immediately-by either replying to this message or calling(617) 621-7722-and destroy all copies of this message and
any attachments.
Thank you for your cooperation.
i

V
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 hitp:_; z�r!.�I.n ,I I? ,cll ti�i�"t :21 <.�� :;-u. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name:
NC Well Drilling Coptractor,Certification
Comps lit tue: l.(,U.(�l. 1 Contact Person:
City: State:i Zip Code3 County:
Day Tele No.: _ Cell No.: `� (6--
EMAIL Address: V/V!(.I11 I,Co W Fax No.:
H. HEAT PUMP CONTRACTOR INFO TION
Company Name:
_ 1__�Lrvn P-qq
Contact Person: all I EMAIL Address:
Address
City. Zip Code: 1 State: County:
Office Tele No.: Cell No.: M I WFax Ng,•
MQUC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

�J
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:
A I., w4m A7
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:/.iportal.ncdenr.orah�ebermit-
a )lications
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 signiflcant 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 re ed appur ces in accordance with the 1 5A NCAC 02C 0200 Rules."
�gnature of Property Owner/Applicant
Print o pe Full Name
Si re of Authorized Agent,if any
Print or Type Full Name
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 3

�1 s
\ r
r

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
Y RALEIGH
ASHEVILLE WAS HINGTON',,"
:.O,RESVILL _
�FAYETTENI'LLE
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 h!Ltp://www.ncalhd.org/couniy.htm.
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

4jr i
t
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 ari individual permit when constructed in accordance with
I
the rules of 15A NC.4C 02C.0200; This notice-must be submitted_prior to construction.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in 15A NCAG02C.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.
is
OR
E` GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP:WELLS i
As described in I M NCAC 02C.0223;these wells circulate_a refrigerant gas:as part of a geothermal heating and
1
cooling system..
Print Clearly or"Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: 20 _r PERMIT NO.WQ 10(3.5 G Q _-_ (to be completed by DWR)
4
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
i
(1) Aqueous(as per 15A NCAC 02C.0222): Number of.wells: 3
' 2 Direct Expansion as per 15A NCAC 02C.0223) Number of wells:
i
B. :STATUS OF WELL OWNER(choose one)
(I)• Single)amity 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 ja- Federal Submit Phis form 30 days
prior-to construction.
5
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: .
JARRkrf dJ/1 U 3
Mailing Address: Z2 AaIRt+-90 wt4 ( RAI*( :W ZI
City: _�P N rR a' State: ,L. Zip.,",nq County: U4 PAW ..
I
Day Tele No.: 40q —QC9 ytr'{I Cell No.: -_
EIVIAIL'Address:. Fax No.: _
E
D. PHYSICAL LOCATION.OF WELL SITE
,
(1) Parcel"Identification Number(P IN);of well site;
county:
(2) . Physical Address{if different than mailmg,addressLj
)_
City:, State;1.�isio resources 1
UIC/Closc&Loop Geothermal:Notification.(ReviscOS/5/2013), APR 4 2015 Pag i l
-} Water Quality Regional Operations
' ' Ashevflle Regional office `:

E. MAPS;PLANS,AND SPECIFICATIONS.
(1) Maps must be scaled or otherwise.accurately indicate distances and orientations of features located
within 25.0 feet of the injection well(s). Label all features clearly and include a"north arrow. Attach a
site-specif c.map.showing the locations of the following:
• Proposed'injeciion well locations • Septic systems :and associated spray irrigation
a Buildings sites,drain fields,or repair areas
• Property boundaries
a 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 thatthe Department of Health.and;Human Services'Division of Public Health
Aetermines do'not adversely affect human health shall be used. A:list of approved.additives can_be::found
online-at.http://portal.ncdenr.or web/wq/aps/Mro. All other additives require,approval prior to.use.
N4
G WELL-DRILLER INFORMATION(if known),
Well Drilling Contradtor'.s:Name: CRVEI S k-OD- -J
NC Well.Drilling Contractor Certification"No:: 20" A-
CotnpanyName L pots-&W- UiLkContact Person: CAWS 4-VD&04
City: , �C1*N. U� State:$J' _ Zip. ode:ZL77 f County: I'�1+4 G;. •
Day:Tele No.: 8z:. 30- c r' ( Cell.No.: Q
EMAIL.Address:. CJK&dd (�?7 ID4n,Aikk Gdy. Fax•No::
H. HEAT PUMP CONTRACTOR INFORMATION
Company-Name: IAaneewr-ALJo AlRil�n e COali,Jl) ]'.
Contact Person:�Rt?,w_L- �4t;,.t� _EMAIL Address:
Address:_1 9 i' - Lk 1 Ga. .D✓-.
City:. Ad1t•U�J Zip Cod e3Y.. State:KL.County:. "� i4'{'
"Office Tele No;; Bzh:3,19': q1,4 Z Ce11.w Fax No.:
UIC/Closed,Loop Geothermal Notification.(Revised 8152,013) Page

A 4
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 field's,or repair areas within.250."feet of-the proposed
injection wells will be protected-during construction,of the wells:
J. VARIANCE—Pursuant to 15A NCA002C.:0241,the Director of the Division of Water Resources may grant
,4 a variance from applicable,well construction-or operation standards provided that:
(1) use of the well(s)will-not endanger human health and.welfire.or the;groundwater-,acid
(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 notificatioh'to expedite evaluation ofihe'..request..
-The variance request,form can be accessed online at htta://portal:ncdenr.or veb/wqlaps/gwpro/permit-
gpplications.
K. SIGNATURES—The following section is.to ba completed as required below or by that person's.authorized
agent. 1.5A NCAC'02C.0211 iel 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 orranking,publicly elected.official;
(d) foralf 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.their signaturd
authority,and is signed and dated:by the applicant.
"1 hereby certify;under-penalty of law,Aat,1 have personally examined and am familiar with the.inforliidtion
subinitted in this,document and,all attachments thereto and'that, based on my.nquiry of-those individuals
immediately responsible for obtaining said information, I believe:that the information is true,.accurate and
complete. I am'aivar"e_that there are significant penalties incliiding.the possibility",'of fines and imprisonment,
-
for submitting false inforinatio I agree to-construct;" " rate;maintain;repdir„.and if applicable, abandon
the injection well and all rel d.appurtenan"ces in . ord nce'wiih,the 15A NCAC 02C 0200 Rules:."
lgnature: Pr e: er/ plicant
RRf
Print or TypeIV,Name;
$ignsture of Authorized:Agent,if,any
Prini orType Fufl Name
UIC/Clo4wkqop.Geotliermal N,otifcation,ftvised 8/5t=3) Page:3

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This map is prepared for inventory of real property within Jackson County.It is compiled from recorded deeds,plats,and public data records.
Users of this map are hereby notified that the aforementioned public information sources should be consulted for verification.Jackson County or
any County representative assumes no legal responsibility for the contents of this map. RrI IItGU.A�?i' 1 4 r 201

RECEIVED :`;:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATU RESOt water Resource
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJI L1+S
CTION '
These wells are permitted by rule"and do not require an individual permit when construc ed in acco�e�ifh 015
the rules of 1 SA NCAC 02C.0200. This notice must be subrnitted rior to con traction.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELL RE ; ,�� ,M Office
As described in 15A NCAC 02C.0222 these wells circulate potable water only or a mix r ; ,
performance-enhancing additives as part of a geothermal heating and coon system.
OR JUN 1 5 2 15
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP LLS
As described in 15A NCAC 02C.0223 these wells circulate a refrigerant gas as part of a eot Wffi%1 l�i(i eaqqQnal Operations
cooling system. Asheville egiona Office
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: , 20 PERMIT NO.WT 010 01 Z (to be completed by DWR)
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 l_ County]a Federal,I �n 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:
N L:.. CCOb'r��
Mailing Address: 3 OC, M A Cat-?OL.I A —DR
City: !' P-rA 1 f2/t� State: Zip Code:?bap S'County:
Day Tele No.: SOY-—�e Ce g — 761 G Cell No.:
EMAIL Address: KIPA P ! oo4A e . ".1, Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
9
(1) Parcel Identification Number(PIN)of well site: 34 z 3
County: I TA GKS0-,J N
t U a gI
(2) Physical Address(if different than mailing address): LT- E� I4AILQq U I £LO LJ
City: CA514 1EX-S State:NC Zip Code, fg�T�
UIC/Closed-Loop Geothemial Notification(Revised 8/5/2013) Page I

MAPS,PLANS, SPECIFICATIONS
5 .• (1:) r 1.Maps must1be 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
a
site-specifi map showing the locations of the following:
•. Proposed nijection well locations • Septic systems and associated spray irrigation
- Buildings sites,drain fields, or repair areas
• Property boundaries
t Surface water bodies Existing or potential sources of groundwater
• Water supply wells contanunation
(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
deternunes do not adversely affect human health shall be used. A list of approved additives can be found
online at littp:Hpoi-tal.ncdettr.org/web/wq/aps/gwpro. All other additives require approval prior to use.
AjI4
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: eN R l 5 H ra DD 1r'I
NC Well Drilling Contractor Certification No.: ZOO{q 4
Company Name: 14606P —B"- WdQ Un6(;Na_ &L Contact Person: CH/LiS 4E7pD9)^J
City: r�'2�9��LI State: 4)C_ Zip Code:=y County: M4:fa
Day Tele No.: 82$ - 3(.q-4 S_0t ( Cell No.:
EMAIL Address: Fax No.:
H. HEAT PUMP CONTRACTOR INFORMArr'TION
Company Name: e' �oUay
Contact Person: _3t 2L4Y Aud d EMAIL Address:
Address: (Dt� Ll�o ✓- ,S";4-c 1
City: +1 Zip Code, 873q State:1UC County: ►'�tA-f- A
Office Tele No.: Cell No.: Fax No.:
UIC/Closed-Loop Geothermal Notification(Revised 815/2013) Page 2

'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 constriction of the wells: j
J i�`t" rC�'ltGtc �UsiR2y if 1T—
J. VARIANCE—Pursuant to 15A NCAC 02C .024 I the Director of the Division of Water Resources may grant
a variance from applicable well constniction or operation standards provided that:
(1) use.of the well(s)will not endanger Inman health and welfare or the groundwater;and
(2) that construction or operation in accordance with the standards is not technically feasible or the j
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 hup:Hpoi-tal.ncdenr.or web/wq/aps/gwpro/permit-
applications
i
K. SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C.0211(0 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 exmnbred and ani familiar with the information
submitted in this document and all attachments thereto and that, based on my im jury of those individuals
ininiediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I ant aware that there are significant penalties, including the possibility of fines and intprisonnieni,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the it jection well and alllr aced appurtenanceqq in accordance ivith the I SA AtCAC 02C 0200 Riles."
/'
Signature of (iper ivner/Applicant
l•
Print or Type Full Nanie
Signature of Authorized Agent,if any
Print or Type Full Nanie
WC/Closed-Loop Gcothenual Notification.(Revised 815/2013) Page 3

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Jackson County,NC Detailed Tax Parcels Report Monday,June 15, 2015
Owner 1: GOOTEE, KENNETH E
Owner 2: GOOTEE, KATHLEEN
Physical Address: LT E84 HARDY VIEW LN
Property Description: LT E84 MOUNTAINTOP
Account Number: 103549
PIN: 7562-34-2236
Mailing Addressl: 306 MAGNOLIA DR
Mailing Address2:
City State: METAIRIE LA
Zip Code: 70005
Deed Reference: 2047/608
Deed Date; 2014-09-05 00;00:00
Sales Price: $330,000.00
Assessed Acreage: 0.64
Map Sheet: 7562.03
Plat Reference: 12/932
Fire District: CASHIERS 5 MILE
Appraisal Neighborhood: MOUNTAINTOP
Neighborhood Code: 15067
Township: HAMBURG
Township Code: 15
Total Building Value: $0.00
Land Value: $690,000.00
Total Value: $690,000.00

i
i
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION,OF INTENT TO.CONSTRUCT OR OPERATE INJECTION WELLS f
These.wells are 'permitted by rule"and:do not require an individualpermit when constructed in accordance with
the rules of 15;1 NC 1 02C.0200. This notice must be submitted prior to construction. i
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.
i
OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP-WELLS
As. described in 15A•NCAC:02C.0223 these wells circulate a refrigerant gas as part ofa geothermal heating and ((
cooling system. I
Print Clearly or Type Information.Illegible Submittals Will Be Returned-As.lncomplete.
DATE;-A>QIQII �$ 20 PERMIT NO. 003 S L (to be completed by DW.R) 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:
t, I
B. STATUS OF WELL OWNER(choose one)
(1) Single Family.Residence Submit this form two(2)business days prior to construction.
(2) Business/Organization Submitthis form 30 days prior to construction:
(3) Government: State Municipal County ll Federal f 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:.
MailIin1g Address; 9547 PA2K. A14A)O Q.
City: 3LUf 0.54 Statei:,0 14 Zip.Code.:_qWLCounty:
Day Tele No... Cell No.:
EMAIL Address: Fax No.:
'D. PHYSICAL LOCATION OF WELL SITE(1) Parcel Identification Number.(P.IN)of well.site: 158````T�. 71 Y4 /
County-
(2);
o i
r Lull—
A)
i ,(2): Physical..Address,(if different than mailing address):
A)044 440i pj
City. L.A5t11 L23. State:NC. Zip Code; /
RECEIVED
pivision of water Resources
UIC/Closed-Loop Geothermal Notification(Revised 8L5/2013) Page I
1
JUL 2 9 2015
Water Ouariity Reglonal Operations
Asheville Re ional Office

- j
i
I
i
E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps,must be scaled-or:otherwise accurately indicate distances and orientations of features located
within 256 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 j.
Property boundaries
• Surface water bodies • Existing: or potential oe dwterso
• Water'supply wells contamination
;. (2) Plans and specifications of the surface and subsurface construction details of the well system. }
r
F. TYPES AND CONCENTRATIONS ;OF ADDITIVES — last any additives.that will be used and their
concentrations: Only additives that.the Department of,Health.and.Human'Services'bivision of Public Health
determines do not adversely'.affect human health shall be used A list of approved additives can be found
online at.httl2://Vortat.ncdenr.ore/we,b/wq/aps/Mr6. All other additives cequtre approval prior to use.
- t
{
G. W ELL DRILLER INFORMATION(if]mown)
Well Drilling Contractor's Name:
NC Well-Drilling Contractor Certification No.: 2O4(4 .
Company Name: •141ODOY —16-7205. Contact Person: c 141t Wer—Do Z
City: 1; k44,P-) State: ALC= Zip Code: County:- 1d.t
DayTeleNo:: AW 349 -qrq I Cell:No.:
1
EMAIL Address: Che dd 20 41 `raw:(islti►- Fax No.:
i
H. HEAT PUMP CONTRACTOR INFORMATION _ I
Company Name:__Y/Tnt 4j VA1 ,04 f C, u Lu.G,
Contact Person: 'la Pr'fFM,011 .:EMAIL Address::
i
Address:2 Lu v j 3` .
City:- sawc* Zip.Code:'ZgG7B. State: County. !�
Office Tele No.: Z.'3Zf3 Cell No; Fax:No.:
i
UIC/Closed-hoop-Geothermal Notification(Revised_8/5(1013), Page-2
{
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;draim fields,offt air areas within 250 feet of the proposed f
injection we will be protected during construction,of the wells:
i s
F
J. VARIANCE,-Pursuant to 15A N'CAC 02.0..0241.the':Director of the Division of Water Resources may grant
a variance from applicable well-construction or operation standards provided that:
(1) use of the,well(s)will not endanger hurnan'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 ofthis notification'to expedite evaluation of the request.
The variance request form can.be accessed online_ athttn://Qortal.ncdenr:or /web/wq/aps/gwproipermit-
a0plications
i
K. SIGNATURES The following section is to be.completed-as required below or by that person's autliori2ed
agent. 15A NCAC 02C M l l(e)requires signatures:as follows:
(a) for a corporation: by a-responsible corporate officer;
(b) fora partnership.-.or soleproprietorship: 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: documentarion 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 amOhiliar with the information
submitted in this document and.all attachments thereto and that; based on my inquiry of those individualsj
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. Pam 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 j
the injection well and all re ed appurtenances ifi ccordirnce xdth the 15A,NCAC 02CO200 Rules::"
f
S natu o.Prope ty O - er/Applicent
Xar,�,
Print or Type Full, me.
Signature of Authorized Agent,if any
f
Print or Type Full Name
f
UIotloscd-Loop Geothermal Notification.(Revised'.8/5/20.13) Page 3

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This map is prepared for inventory of neat property within Jackson County.it is compiled from recorded deeds,plats,and public data records.
Users of this map are hereby notified that the aforementioned public information sources should be consulted for verification.Jackson County or
any County representative assumes no legal responsibility for the contents of this map. P t I I1l*ed.Apr 28, G41 5
i

NORTH CAROUNA LJEFARTM- �-"TOF F,\;ViRONM NTA?,--D-N A TURA I,RVSOURC-F-11-1
INCqUICATION OVINTEYVI 0 CONSTRE.Cr OR 0P1FW4j"F-' 1NJEC'T1().N WELLS
7714+`a waa rArc 'pijrrnwt:d47.v U2C*'AWj. Ju: r.tdrvt�Judtparm -Alyy 4'4,-,v1ruc(VY art accordance wt(h
AQUEOUS CLOSM-LWP UA
Asdftcrib in t5AXCAC-02C421 I.he!;r veils int-cu!Ue P4Mblc water only or a Mimra of potable water and
WbmAnof,enhancing addinve"at part n; a gerAhermal boating and 000fiag pystern.
C - D-1-,0.QF WEL
DIREC.'r EXPAINSIMN CLUE
;:00litig 4YSEM-
Prim,Clearly oo YyM 1000rhudi0lb if M 8eR&wrnad,4s btcamp4oe.
DATE: A5 40-1).20AC—) comple OWQ)
ted try
A.
TV'FE OF QF-()THERKAL CLOSED-1-00F WELL TO BE icows-rRucTEID
1) Aqueour,(asper 15ANCAr,'ol2c 0,2221 %11� Number of wells:
(2) Direct Upamion(as per 151) W"AC 0 IC t!22F)
IL STATIUS OF WELL Old ER-(choost one}
h1-5 forin two(Z)basimz5;days prior tQ construction,
(2) BusineWOrgzmiMion Subrail this form 30 days prior to construction,
(3) Govemment: States_„_ Municipal County Federal—­Submit this farm 30 days
prior to consuvction.
C- WIFXL OWNEP,,- !'or singlC family residences iisl the property owner(s). For all others, list rame of tho
business,orguuzhd(),Vti Or govunmcnt agency end person delegated signature authority:
Mailing Address, 1 11 -WA)l
City: State, -r
Day Tele No.: v X ZiP Code:--r" County:___
Cell No.: -71
FMAltAdd=s- Fa-% N
PHYSICAL LOCATION OF W K U- ls'YfE
P=el Idenril'ication Nurnbtr of well site:
Couftl;y:
City.
-
IC Zip Code:
DW�JUfC/Ctos Loop Goothernial
Paw I
TO 39Vcl ONI S30IAN3S GMV EBZ6E898Z8 6 t2:8 0 ksp y Z'#f/,-

E 1pS,>f'��R•S,A-ND SPXCYFlCA'X'#{)N
i t t Maps must he scaled or olherwls� aetumlely india%tt diwtances and arieMtions of feaunma Epp
within 250 feet of the 4ection t,relt(s). i,,ah l l eSturG - I t�$n 4ct� s r.ow, Atr h a
site-spociflc reap showing thr, iocatitm5 jai the following:
Proposed injec don w6l! locations m Septic syeterrs and associated spray irrigation
• Ruildings sites,drain Rinds.or re?air areas
properly boundarle3
• Surface water bodies Existing or potential sources of groundualar
a Water sWl)•wells CgtrtarttitTation
�2) flans acid specifrcat:ions o�the surface and subsurface Construction derails of the well system,
F. T YI-ES AND COINCENTRA,'il:'IONS OF ADDITIVES — List any additives char will be used and their
COn ent�ations. Only additives tlrar tht Department of Haalth and Human Serv;ces' Division of Public ljealzh
determines do not adversely affect human health shall be used. A list of approved additives can be fauna
online Qt htt Jr real_icdeltr.or /we +w�i /Lw uro, All ocher additives require approval prior to use.
(X\
G. WFLL UMLLER INFORMATION i if known:
Well Drilling Contractor's Name: Robert L.arr;
NC Well Drilling Corltritmor Certif mior,1\o.: 1�03
Company Noe: AWD Services tnc..,--�_ Contact Person: Larry Wells—
City: Leicesrer Mate; .NC' .Zip Code:28748 , County: gun am
Day Tale No.; 82 '3-2V5 C.etl No, 828-3 t 5-4334_
ENLULAddress; Wei ls750549@bel!south.net_ Pax q.:— 8-ti8 - 203 --
H. HEAT PUM CONTRACTOR INFORMATION
Company
_d'm
City; AS)Nt Ji -e - :Lip Code:-Q.!8 q__ S[ate:NC County:
Office Tele No,
. awQlt;lClCloaed_t.octp Cieadrrtznmrai'.�rOti�eeuivn{t2Fv;,�,].�.3ano:?,
R •
S ZO 3JJd ONI SMIM3S QMd C0ZGC898Z8 Cb:80 9Z8Z/CZ/60

09/23/2015, 08:43 8286839203 AWD—SERVICES INC PAGE 03
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fi'!tU'1`I?E:"E oiN'•1-`FtTv)dQ d tx cCdc:•-(,prr,,,t.,t i,,,,, (I?'rater supply wells.(Zi sur{arc vva.Mr bctdt'C':and(3)
�r`Ptir'SYSI Inb 31`14)•as5QCJWd 4PN- Y'trrilrr►(r0!l s!ir,-'!rain tlClds,nr mpair txrta5 within 250 Fmt of the proposod
+tliWian walls a,i11 IV.I toot-ii dull wt runanrx 1101-1.of the welly;
Poe
3. VAk111NCE •Pumsu unt to 1 SAv NV('A(-;)?(' ,q2a! trlc DireetOrOf the Division Of Water QuaNrp may grant a
veriartee(tarn applicable well cafl±itruc„�,,,,1'nl,cr:+u(,n strtrldarcis provided that:
(1) v'sr 01 It1G Wcll(s)will 1*1 -Ild;illym,hta:wll health and welfare or the groundwater,and
(2) thaC c.ptxstrui lic>t+or Fullest+li(rlt ',I accnidunce will~the standards is not rtChnjcajly feasible or the
Proposed r'OnstzttMOI}si cquai tr ktfer proTecrioll of'the groundwater
Att}varianec request should accotrl}xrr,; wul)mittat ttj,tlti,notilioation tit expedite evaluation of lhtt requcsl,
The valiww c raciu $t fbr mn be trCQe�eCd(3F1IIT7( al il[t�:�/RQCtnl.ncden!,,(ir Y�vcbiw. fgwpr�'�Cirmit-
K. $i(`NXEUjAFS- I,hc 1•allowisg�cGI1011 is tU he Ln(npleted as required below or oy that pcmn's authorized
119011t, tSA'NCAC 02C.4ZI 1(0)requires signalurc',its foilow5:
(a) far a Corporation_ lhy responsiba:corporate officer;
(b) Corr partnership or:alc propri,.(ursi7ip: I3y a general parEher or the proprietor,respectively;
n
(0) for a ,unicipalif). ;u•tr Mute, iedcrai, or other public agency: by eithcr a principal eYecutivt
officer ur ranking lruhlg!1v elected official;
(d) for all sinters. by d,a%vell ownur.
(a) for tu!y ,uhetr perwu;, :wthorizul ,u act on behalf or the applicant; socttmrttertiora steal! be
Submitted with t1,t• 1101ificatiun Illar clearly identifies fhe per';on. 4mnb them signature
authority,and is Sigre(i rued dawO fry the applimil.
hereby•ceruj}t, under Imi7xi4 na i n;, rirn(I ntrvs peril 7a0v Ksan*jned and am illmfiiar with the tra
Iormarian stJrmltlxd in this llur,•Ftnrepi! lrYrrf(?i1 tulrrr hrrTentc /lrr:r4(r� rrnt(that,al, r,» r,{v biquiry o0bore ;rrc�tyldrds lT7tt►tctltlilply,rNS/�t7ttsihl�- Ivr vl?Aar+ring Sold fir/r�r'r41rlr7Tt• I Z ee&&ve shut the 1gfbrn a ion is true, 4CCUrare and
Complete. lam aware that thMe arts iit;rrrifc•(otf penairles, including Ore,nossibdir offines and imprisortmeru,
rOr 5ttht)litt{11K/CjlJf/inlLrryllIIIVTT. r1.�rC•i fU ivrrT.\TruPt, ryhgruty' rrturttrarn. ru Tr,
the ikd.dun well 02 00 gi es. ubcvrdon
�+�t•tTii reld(e'!l lij+r�7Nhrruul�,•:;Jt,..';r.>rdUr:cc+t�rrh rllc i5!t ,�v�:�t['Q)C QZI��7tlES.•.
�t.
a.
IgnAhtn ui t'rrrprrt.+iwr,ertgpplkant
• i'c act n+ '1 y�tr.Muir Nlmp �'�"'•
Signxture of Authprsred Agent,if anv —'
•'•---�..._,.-.,.. .. Print or F'
ype F FIT "'Ara
t1WQtiJtf![Iwad-L,oan l tonc�rmal ti(,tificati�rt((ict 11.,a,;.t;'Jo 0lzl
Page
b0 39dd SNI SMIM3S CMd E0Z6E898Z8 Eb:80 91:9Z/EZ/60

RECEIVED
(vision of Water Resourcatl.
NORTH CAROLINA DEPARTMENT OF EM71RONMENT AND NA : AL RES ,E�
NOTIFICATION OF INTENT TO CONSTRUCTOR(1PERAA triouckd
ECTION'WELL`S:
These wells are `permitted by-rule"and`do not�reguire-an individual pezntit when co hi accor dance witi,
G 020t1. This notice mustbesubmitted rfor tnttt�lla Replonal O eratlons
s evi!!c RpOonal
Oi"ice
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As'described in 15A NCAC 02C.0222 tbese wells circulate potable water-only or a mixture;of potable water and
performance-enhancing additives-8 part of a geothermal'beating and,cooiing.system,
OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS
As-described in 15A NCAC 01C.0223 ibese wells circulate a refrigerant;gas as'pagbf a geotlrerinal heating an,,
cooling'system:
Print Clearly'or Type-Infornraaorr .Illegible Sub)nittals Will Be RemrnedAs Jncampwe.
DATE 20/S PERMIT NO. 031 3(to be completed byDWR)
A-. TYPE'OF GEOTHERMAL CLOSED-LOOP WELL TO.BE CONSTRUCTED
(Ij Aqueous(as,per']5A NCAC�02C.0222): Number-of wells:
(2), Direct Expansion(as per?; A NCAC 02C.:;.O__223) Number.of wells:
B: STATUS OF WELL OWNER(choose one)
(1) Single Family Residence Submit this form,two(2)businessdays prior to coil' metiom
(2)' Busmness/Organization Submit this form 30 clays prior to construction.
{3) Government: State Municipal r Countyn Federal.H Submit this form 30 days
prior to construction.
C. WELL OWNER—Foi single.family residences list die property,owner(s). For.all others; list name of:the
business,organization,<or government agency and person delegated signature authority:
Mailing Address: 1 L og!h Dew
City; C...id.t Lee" N E.t State: N L Zip Code: OCounty: C.1Cto+ _
Day Tele No.:
EMAIL Address:. Fax No.:
D. PH'4'SICAL LOCATION,UF WELL SITE
(1) Parcel ldentfi'cation Number(P1N)bfwell site:
County: AclCSo4
(2) Physical Address(if differenfthan_mailing.address):
City: State:NC Zip Code:
UIG/Closed=Loop_GeotliermalNotification(Revised;8/5/2013) Page 1

V
i
MAPS,PLANS,,ANU SPECIFICATIONS
(1.). Maps must-Be scaled or otherwise accurately indicate distances-and,orientations of features.located
withun ZSO�feet,of the injection wells) Label all features clearly and include a north arrow. Attach:a.
site-specific snap showing the locations of the following:
x . 'ProposedInjection well locations a Septic systems and associated spray irrigation
.Buildings sites,drain fields,or repair areas.
a Property boupda'es
Surface�water bodies w Existing or potential sources. of groundwater
Water supply wells contamination
(2) Plans and.specifications oftlte'surface-a'nd'-subsurface construcfion details of the well system.
P. 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 PubEe-Healih
determines do not adversely affect human health shall be used. A list-of approved additives can be.-found
online at http://i)ortal.nedenr.org/web w la s/gwMo. All other additives require approval prior to use.
A)hk
G. WELL IDRILLER'INFORMATION(iflmowri)_
Well Drilling Contractor's Name: epoe'
NC Wen'bril.ing Contractor Certification No.,:
Cornpany.Name. wm+ Rt+S. Contact kerson: - �8-1ft% Oircot?4
City-;. BJ1L.L,t+J _ State.- Ak-- Zip Code:ZWlq County. Ni44AA.
Day Tele No:: � 'I� t+q' $ ( � Cell No.:-
EMAIL,Address: ✓ora a` ;�,Gsn+ Fax No.:Jdl�,a=
k AEATTUMP CONTRACTOR INFORMATION
CorrlpanyName: g8 4 G- IM-M-4 W),_
Contact Person .. M'cM4yi 4. EMAIL.Address:.
Address: 4 .. 9a :.
City: ri##') Zip Code: V t Stale: County: 'IA
Office Tele'No.: '24 -97.0 Cell No.: Fax No::
UIC/Closed-Loop Geothermal Notification(Revised,8/5/2013) Paget'

—.R`ep. 11. 20t5 9_780 No. 1-876 P:_ 1 y
PR. C fON--PiYivide a brief dO$QtiPoon_af how-(l)wati*•au wells:. 2 sof oe,vat!et badies�md.. 3
septi 'syste8 and asso�isted spray itrieti6ai sites,diaud fields;vt repais_areas wtBhin aso:f+�t of thc; sroYiased
itricdfivn weils'witl,k�e.pcotectcd dwriai�"sons;ruction•Qf dte.cvetls;
81
j. rew
Jr. -VAtiIANCE=P►vaujntto.t3ANCI dlc.024.i the krO*cfAbe'Diviuivn.ofWaeerResoi>m5_. ay.gicant
i'a isslee.4iom applie bte well constructt4n:or aperadon atgrfdatds ps�svided t. ,
(ij ascof the well(&)will nO i0i to tgca 3iutria®bealth and welfare or the grov ivvatei; ii'
Q): that coaetruction oT operation in accordance with the•staridards is not techoWi lly feasible:ar she
•ptvposed-ctinstcucto�}��d�s equalgr.bett�'pmteccion:ef t4►e:grourid�a�t� .
AtYy v�ri2slce rcquCSCshoald accvwpogy ss6 l of.iliss aoaficaaaaa to ercpedito evaluation of_the ae"ast
Th'e variance requestfOM eim be a Wed'ustli aLhtin l v rtal ncdetir orate RgI nmigenj
apG lcations '
�. SIGNATURES-Tie f®ilou! section is to be�.ccmplel authorized
ag¢ft. IIA NC-Ad 62C-.0211 fcl rquiees,s g aatures as fpltows:,
(a) £vi io&pbratron. by reVonsible-corparateoffieer;
(b)- for a':paCttre;sli2p oa s41e propnetocship:,by a peaeral past=yr dui propric kcr;respectively;
(G) fos&munrespallty or a state,federal,or outer public.agency: by citb�z'a principalCupvc
ofGccr or ranking jx6Uctjr cl"ected official;.
(d) frx ali<-athees: byihe vicll mwnee,; -
(e) for an ostler persaa•auttiari do act on 6eI a f of the�pplicat,t -docwneratiah.shall be%
sub=itsoii with thy,nasific'MOO that cle'Orly'tdentifies the petsvn; n� them,stg ague:
'atithoxiry,and is sinned®nd dated by;the.appiacaat:: .
' hsr�by certify, up,arpeiealty of law,the i Rave psrsoteally exxama ped.a»d am fct►nilzaa►�with lke d ormatton
scebm tted in.this document and .ew -aiad thub' bored on my inquiry of those it&Viduak
amntecffatcly responsible for oblabibig Said injarrnai on; !be&eve that the infohnad A is_ti3t accrerate„and
corraplete. 1 am,aware that there are s�grrJtcaritppenal`eres;imcluderig Chi possibrlity offtreea and imprisonment,
for:ubmittitg false?information. 1Wge lo,constru'cl,,opergte, and;Ff appikable,-abandon
the'inleCtion well wtd+711 related paerleira�ces in.pecardumee till;tkeYSA.'ifC.iC.A2G 02[JR_Ru1�•`°
"fitmr of Feapesty Owac
Prim;or TvwIrmu Namne
ggcweuro ofAut4arised Age$t,Wray
Pitt'orlype NII Name
viers;io�a-�XrDp.GC�thetrnlll NO�tfcafioil�ROV196ti$I5/ZOI.�� �'8$6,�
?sd L L/R-tz7;o-A7R 095:,LO:5106'dsS:

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CA
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HUFFMAN GEO yy f.
, �..
This map Is prepared for inventory of real property within Jackson County.It is compiled from recorded deeds,plats,and public data records.
Users of this map are hereby notified that the aforementioned public information sources should be consulted for verification.Jackson Comity o
any County representative assumes no legal responsibtitty for the contents ofthis map. Printed-Oct 02, 2� 5

is uu
NORTH CAROLNA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO.CONSTRUCT OR OPERATE INJECTION WELLS
These wells,are `perirtitted by.rule"and do not require an ndividualPer:initwhen constructed in accordance with
the rules of'15,1 NCtfC 02C.0200. This notice must be subinitteel prior-to constnuction.
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 ClearZv or Type Information. Illegible Submittals Will Be Returned As Incomplete.
_ o
DATE: ,'20 /�i PERVIITNO.WTO�V`�� � (to be completed by.DWR)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE.CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C .0222): ® Number of wells: G�
(2) Direct Expansion(as per 15A NCAG 02C .0223' Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single.Fainily,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
business,organization,or government agency and person delegated signature authority:
su011wado teuol6ad Ai ano jamm
Mailing Address: d 1 Lik VE0A .E
City: ,.A!nQ State: Zip Code, 12-County:
Day Tele No.: Cell No.:
swinosey aetem le uo�sU�
'EMAIL Address: Fax No.: t" -i
D. PHYSICAL LOCATION OF WELL SITE `` a
(1) 'Parcel Identification Number(PIN)of well site:
County: UA_C;KSor
(2) Physical Address(if different than mailing address): 5 D -B(A RL LkijC
`City: State:NC Zip'C.ode: S�f' ;
lilGClosed-Loop Geothermal Notification(Revised 815/2013) Page 1

E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be sealed 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 http://poi-ta.l..iicdenr.org/web/wg/aps/awpro. All other additives require approval prior to use.
L4,
G. WELL.DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Rls An-)a­�—i
NC Well Drilling Contractor Certification No.: 2014YA
Company Name: fkDD60 Tl?,�S- Contact Person: /Ld:S 14-DO&IJ
City: KL;ta State: .NC Zip.C.ode:Z9' YCounty: AIA-C.ors
Day Tele No. 82-A• 30- 9,5 q f Cell No.:
F< F EMAII'Address: C.�d A.) u �-�✓oaA+i s� C-0m Fax No. 6Z$- a Z4"�7 t
k
1rI. HEAT PUMP tOON�TRACTO R INFORMATION /� l
Compquy Name-. i Tl-fnA-A)
14E4'6 64 QC-
Contact-Person: IoAlnutit 1TAUJ EMAIL Address:
Address:_2D,-('2C# ASS 19 2;3
City: . SC"aU 6CA Zip Code: 248 State: County: &0a7
Office Tele No.: �/� •�82, ?Zrd'�'Cell No.: Fax No;:
UIC/Closed-Loop Geothermal Notification(Revised 8/5/2013) Page 2

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s�e..7sr.r,a..'Ixsve!i eTr�.� c:Ati-
dic of Wzi;el 114�aW zrzcti
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i.(` 3 ,:the tt '1i1'+t�s:i itrt'Cx}anc Ytrrtenr;k<ahh xrxi euclta �ir>tih .4;:< al
s'� r4axf.ttt.<._a c y Gn.rc�n uS ....r�tYaC n th-EShaa.>!ari`-'i r ti txe lanes iv_,.{�x«s .K
iwz s•,,i rtnu2Kn }>.., •� a%,arctcr;si z.ti u 7xii .ln rn,vatc�
.. �3t�'�'Jd1L7a'1Cc€CTdi;rS[Y..uu.d�te Fr. .�:dsi ?l;{;)si,tCnv ss::a:•.5sn�'it7l'7[f71�+>"xyC�it C"�a�',alFi au: iLe>s'y,'~_4i - -
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},. sit`eA i.1:Y2 - fltc eyl y *c:s 4t.eh{_ss P k x ti,ei i r as is Y{s r t .: nt hz,zl�ii orri rlx._x,i
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ctrt ;i a} ist 'ta, x x p ycrct, t3tY by ziremra s4.C'tYt i urarq.r.tr c
_a,,,xa i�:��ccz}a.c C b.Sa
r5i e%1 rir.ras��t;s r>•i?;{ic l�•r>tr:ze;ci s>s'fi.:s i";
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Stilt:'i i•(,i w ib :i'tc {Xi;�K3L•L?n.iEsY•' y:fa':rs} k}'•QY:.2€:i Ofe 'i+ccci;i: ^."dPdS i!;•C:r vs yaixuC ,
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l

tckson County,NC Detailed Tax Parcels Report Monday, April.25"Yo I
f �
� :r5hi1)•H744
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a.t .. ..:. a.0 ..
--,--rn-n-.. tmmn.t+m.-wery ,.......rt•.»•...-..-......_.. ....m-n,-......
...
NARNING:THIS IS NOT A S RVEY!*T iF�i s- � Rtl I
,ap is prepared for inventory of real property' ), r Q= E
ithin Jackson County. It is compiled from
!corded deeds, plats, and public data ;;r, ,°z '� i IT
!cords. Users of this map are hereby notified!
!at the aforementioned public information' �-
>urces should be consulted for verification.
ickson County or any County representative
>sumes no legal responsibility for the
intents of this map.
vner 1:� WILLIAMS, DAVID TRUSTEE
vner 2:
lysical Address: 547 BURL LN
operty Description: LT E120 REV MOUNTAINTOP
:count Number: 17.4214
N: 7562-32-6894
ailing Addressl: 16201 TALA VERA DE AVILA
ailing Address2:
ty State: TAMPA FL
p Code: 33612
>ed Reference: 2048/167
red Date: 2014-09-11 00:06:00
des Price: $0.00
:sessed Acreage: 1.01
3p Sheet: 7562.03
at Reference: 20/566
•e District: CASHIERS 5 MI
>praisal Neighborhood: MOUNTAINTOP
:ighborhood Code: 15052
twnship: HAMBURG
iwnship Code: 15
ltal Building Value: $0.00
nd Value: $450,000.00
,tal Value: $450,000.00

9 ,
d�✓�V�� �1 1 7 jr'f•►7� V«UW� � /'�+hJV� e
7562-23.-675.9
• j ""^,..,,.,; sate
i
6
ti h
7562-32-5943 _
f :'r
;•t 7562- _894 ;f
-'FA �...t� ♦ 's
1 75f�2-32-66'�2
<..yi
el
` ., . 7562-32-075 , .
7562-32-4771 `
W -E.
April 25, 2016 1:500
0 0.004 0.008 0.016 mi
fa6be8a77b2644ccbe58b479Od344491 -- Leader Line o 0.005 0.01 0.02 km
'r9176ee69f17c4fe2be8277739884920e Lot Line
Overiide 1 — Subdivision ROW
Parcellines - Tax Parcels

Moore, Andrew W
From: heddenbroswelldrill <[e-mail]>
Sent: Friday,April 29, 2016 10:31 AM
To: Moore,Andrew W
Subject: Fw: Fwd: signed form as requested
Hedden Brothers Well Drilling, Inc
73 Holly Hills Vista RD
Franklin, NC 28734
Phone: [phone]
Fax: [phone]
www.hedd-enbrosweildrill.com
On Friday, April 29, 2016 9:26 AM, Tim Sadlon <tim@sad Iona ndassociates.com>wrote:
See owners authorization below.
Thank You,
Tim Sadlon
Sadlon and Associates, Inc.
79 Chapel Hill Drive
Franklin , NC 28734
Ph. 828-421-1115
Website : Sad lonandAssociates.com
OF School of Building Construction 1987
Begin forwarded message:
From: David Williams <dwilliams(aD_wagfl.com>
Date: April 29, 2016 at 9:10:27 AM EDT
To: Tim Sadlon <timCcDsad Iona ndassociates.com>
Subject: Re: signed form as requested
am ok for Sadlon and Associates to drill on our land in Cashiers. Thank you
Sent from my iPhone
On Apr 29, 2016, at 8:59 AM, Tim Sadlon <tim(cDsadlonandassociates-.corn> wrote:
David, see email below. Looks like the State needs your authorization to go forward with the drilling of
the wells for the Geo thermal system. If you would just email me your ok that would be good.
Thank You,
Tim Sadlon
1

Sadlon and Associates, Inc.
79 Chapel Hill Drive
Franklin , NC 28734
Ph. 828-421-1115
Website : SadlonandAssociates.com
UF School of Building Construction 1987
Begin forwarded message:
From: heddenbroswelld rill <heddenbroswelldrill(cD-frontier.com>
Date: April 29, 2016 at 8:45:55 AM EDT
To: Sadlon and Associates <tim sadionandassociates.com>
Subject: Re: signed form as requested
Reply-To: heddenbroswelld rill <heddenbroswelldrilla-frontier.com>
April 29, 2016
Tim--Andrew @ NCDENR in Asheville called me this morning. He needs a short email
from the owner stating you have authorization to sign the geo application form. I am so
sorry to trouble you. His email address is and rew.w.moore(a-)-ncdenr.gov
Thank you
April
Hedden Brothers Well Drilling, Inc
73 Holly Hills Vista RD
Franklin, NC 28734
Phone: [phone]
Fax: [phone]
www.heddenbrosweildrill.com
On Tuesday, April 26, 2016 6:29 AM, Sadlon and Associates <tirn aDsad Iona ndassociates.corn>wrote:
Your message is ready to be sent with the following file or link
attachments:
CCF04262016_00001Jpg
CCF04262016_00002.jpg
CCF04262016_00000 Jpg
Note: To protect against computer viruses, e-mail programs may prevent
sending or receiving certain types of file attachments. Check your e-mail
security settings to determine how attachments are handled.
2

s. -•s
RECEIVED
ONlston at.watw Resaulwol
JUl 2 3 toi
NORTH CAROLINA DEPARTKI iNIT OF,ENV1RONIMEN T AND fitA I I kZA1,RESOl.1RZIP i
NOTMCATION OF IlNTF-Nr' TO CONSTRUCT OR'OPF,"TE JEC�dlC� e�F4F A�is3i�]ff ce ns
7hFiye.ivcXls.yre " er:nittcd d P 3 a .a b} rsslc criacl o.riol r¢ ulty ah intlivrdupt .6ir�ni7when conslrucied.in°ciccardance with
the rldas of ISA NCAC o2C.o2o0*. This notice must be'submided prior tQ con traction:
GEOTfWR&SAL AOUEOTIS CLOSED`1r00P WELLS
As described in 15A NCAC 02C 0222 These wells circulate potable water only:or a mixture of
potable water and "
perferrinance-enhancing additives as part of geothermal heating and cooling system.
OR
GE()T 3ER,YIAI.,VIRECT EXPANSION CLOiS 17 LOOP�t T-f T,.S
AS described.in I5A NCAC 02C 0223 ,hese.wells circulate s-ref'rigerr nC gas as ptu C of.a geotfiermal Iteatingand
cooling system,.'
.Print Cmdtjy or xype fnfarmdoon. Illegible:S'u4bMittals glll Be ItoitarnedAs 7rscnnaplete.
-' s�ATE. 0121120 16 PE -MlET N0.1 /�O l���Ila—(to be completed by DwQ)
A. TI.'PE OF GEOTHeRAIAL CL0 SED-LOOP;NVI✓'LL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C:.0222): ' X 5 @l}l�'
Number of wells:
(2) Direct Expansion(as per 15A NOAC 02C.0223) Number of wells:
B: 'TATUS OF WFI,lG.OWNER(choose one)
(l) ,Single Faintly Residence X Snbmft this form two(2)business days pr onto constructian,
(2) BusinesVQ rganizatton Subinit this ►rm 30'days.Pr tic to constraetton.
(3) Government State (vlu•nicipal 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:
Mfilhrig Address: (o-07-- W A KE P c LST 'led
City. _ fo g a-0 7 6 State: tU ... 2 i p.Cade ZG cou c�j�t
nty. . f t"r~
.
Day Tele No:: Ce]1`NO..__�1��
EMAIL Address:` C i"da Pr�sr� a�,. .rl �' ax No.:
D. PRY$ICAL LOCATION OF VNIELL SrrE +
(I) 1'arcei IdeiitifiealionNumber(PIN)of well site:— 4-G�
(2) Physical Address(if different than mailing,addiess):.':1- . lydki. g e r'j
City �Iv o� State:;I�Ci Code {2 8
1)WQ/UIC:dascc Loop Geotb=m',ti Notification(Rwisud 4110M]2)
Page l

C'sWe3 ;tit 1r
i
L+. .MAPS,PLANS,A ND SPECIFICATIONS
(l) Maps.Ymust be scaled or otherwise.accurately indicate distances and orientations of features located
within 250 feet of the injection'wen(s). Label all features clearly_and.irxclude a north arrow. Attach a
site-Specific.map showing the locations ofthe following:
6 Proposed injection well locations * Septic systems and associated spray irrigation
• Buildings sites,drain fietds,or repair areas
* Property boundaries
a Surface water bodies * Existing or potential sources of groundwater
6 Water,supply wells. - contamination-
(2) Plans andspecifications of the surface and subsurface construction details;of the well system.
F. TYPES AND CONCENTRATIONS Or' ADDITIVE.— 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 hn :!�/parlor.nctienr.or 'web/wRlaps/0!yp_%. All other additives requite approval prior to use.
17% Ethanol
G. WELL DRMLE)R INFORMATION(if known)
Arell.Drilling Contractor's Name; Robert Larry Wells-1 David C Stratton
INC Well Drilling Contractor Certification.No.: 2603 3421 - -�
Company Dame: AWD Services Inc. � YContact Person, Larry Wells
City: Leicester State: NC Zip Code:28748 -County: Buncombe
Dq Tele No., 82&683=9223 Cell NO.;828-215-9334
EMAIL Address: Weils750549@zbellsouthmet, Fax No..: 828- 83=9203
U, HEAT PUMP CONTRACTOR INFOR-jIfATIoN
Company Name: Mountain Air Mechanical
Cotltact Person: Rick Cooper EMAiL!address: rick,a�rmountainaimiechanical.
Address: 27.L001) Road — COCn
—
City: Arden Zip Coder 28704 State: NQ,,.ounty:
Office Tele No.: 82$-654-1001 Cell No.* fiat lib.
DWQ/U1C,,Ctoscd-L00p Geothermal NOLMM360n(Revised 4130!ZO12) '

r ,.y
I. F4TECTX+CDhT-Provide a,brief description of how(1) water supply wells;(2)surface water bodies;and•(S).
septic systems and associated spray irrigation sites,drain fields,or repair areas within 250 feet of.the proposed'
injection wells wilt be protectedAuring construction of the wells:
Si1t.Ferice will be-used to control solids and run off fi•orn drilling:
J. VARTAINCl Pursuant to 15A NCAC 02C.024]'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 Weil(s)wi 11 nofi endanger human health and weifare 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 ofthe gt-oundwater,
Any variance-requestshould accompany submittal of this notification to expedite evaluation of the request.
The variance request form can be accessed duliuie at h U?tiZU2jjl.ucdenr.or tvc11, 4�}al?sr l ic��permit-
z�iteaii >iiti —
SIGNATi7Rl✓S—The following section is.to be completed as required below or by that person's authorized
agent. i 5A NCAC 02C.0211(e)requires signatures as follows'-
(a) fora corporation. ley a responsible corporate_officer;
(b), fora partnership or sole proprietorship: by a general partner or the proprietor,respectively;
(e) 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 bi half of the 4pplicant: documentation shall be
submitted with, the 'notificaiion that clearly identifies the .person, grants them signature
a0iority,and is signed and elated by the applicant.
111 Hereby cei�tcjy, 7nder;penalty:bf W,.that 112aue personally examined and wn familiar yyith:the information
submitted in this,dgawiient,and,all attachments'thereto And t1ra1, based on itty inquiry of those individuals ,
lrr rrsed%ately:r•esponsible far o&atning,said inforrrtaraon, believe that'the information is true,.accacrcrte rind
complete. Tarn aware that there are signf9cant penralties, including;the passibility offines and inaprtsonnreftt,-
for szabnzitting false inforrnatiora: I agree to_6.rzstr u.C1, Operate; maintain, repair, anal if cappilcable, abandon
the iVeatiora'well and all related appurtenances in accordance with the 1 SA NCAC 02C 0200 Rules."
Signntu a •PrOO.rtyUtvner/Aipliciint
/co73_iCV c7
Print or Type Full Naino
- Signature ofAttthorized Agent,if any
Print or Type Fnll.Name
MQ/U1C/Closed-Loop Oeothem al Notificatitm(Revised 4/30120121 page 3

tea.
4 � -
asp +• �. �ca
z

RECEIVED
_ Mfton of Water Resource@
5E P 2 9 2016
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT,AND NAT Wig ai raflc '
NOTInCATION OF INTENT TO CONSTRUCT OR OMRA.TE F; qff c
These wells are -permuted by rule"and do nol ragxire an Individual permit whan co�zstructed IPA 6tc,111;17Ce with
the rrsles of 15A NCAC 02C.0200- nj' notice must be submitted prior to construction.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in 15A NCAC.02C.0222 thesa wells circulate potable water only or a mixture of potable water and
performance-enhancing additives as part of a geothermal heating and cooling system.
OR
GEOT)g)Ei21Vir�L D=CT EXPANSION CLOSER-LOOP WELL$
As described in 15A NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
,Pr'inr Ck4rly or Type fnfvrmatibn. Illegible Submitltrls Will Be 1Return2d As Incomplete.
DATE: September 29 , 20 t$ ', I%k.MIT NO.VJTO\ 0 6`f S-7 (to be,completed by DWQ)
A. TYPE OF GEOT nn L CLOSIED-LOOPVEEItTO-BE CONSTRUCTED 2@260�
3@275
(1) Aqueous(as per15A NCAC 020.0222). x Number of wells: �Q320
(2) Direct Expansion(as per 15A NCAC 02C.0223) _ Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence X ,$ubwn t this4urm•two(2)business days prior to construction.
(2) Business/Organization Submit thii0orm'30 days prior to construction.
(3) Government: Stag 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:
Carl D Ring
Mailing Address: 2555 Norton Road _--
City Cashiers State: NC Zip Code28712County. Jackson
Day Tele No.: 828-743-3281 Cell No.:
EMAIL Address: Fax No,;
D. PRYSICAL LOCATION OF WELL SITE
7552-94-7780
•(1) Parcel Identifioation Number(PIN)of well site:
County:. Jackson
(2) Physical Address(if differentthan•mailing address): 538 Wlshaway Road
city. Cashiers State:NC Zip Code: 28712
DWQ/U1C/C1oI�Loop Qeothermal'Notification(Revised 4/30/2012) Pap 1

E. MAPS,PLANS AND IPECMCATIONS
(i) MVS'west be scaled or otherwise accurately indicate distances and.orientations.of features located
widia250-ketof the injection well(s). Label all&W=s cleUly and.iU_ch1d-_e&north arrow. Attach.a.
site�-specfflc map showing the locations of the following:
roposed injection well locations eptic systems and associated spray irrigation sites,
drain fields,or.rep*areas
ididings
• P
roperty boundaries xisting or potential so=u s of &omdwater
contamination S
urf-ace wader bodies
W
oer wpply wells
(2) Plans and specifications of the surface and subsurface constniction details of the well systern.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
coacentritions. Only additives that the Department of Health and Human Services'Divisioix of Pnblio Health
determines do not adversely aMet butoan health shall be used A list of approved additiveA can be.found
online at hVp-,//po#P All other-additives=quirc approval prior.tD use.
20%Q Lthgnol and 80%Water
G. WELL DRILLER DiFORMATION(if known)
Weld DrUng Contractor's Name: Robert Larry Wells
NC'Well Drilling Contractor Certification No.: 2603
Company Nance: AWD Services Inc. — Contact Fmon-. Larry Wells
City! Leicester State: NC, Zip Code:28748 County: RUcombe
Day-TeleNo.: 828-683.!-9223 Cell No.: 828-215-9334
EMAMAddress: WeHs750549@beUsout1LneL— FaxNo.: 828-683-9203--
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Bullmpxx gagga and Air
Contact Perm-, J6Sh,QAg)de EMAIL Address,jo-shg@luIIm e�axota
Address; to Red Roof Lane
City. Ashovjlle�Zip Code: 28804— State: NC.---.-Couoty. Buncombe
Office Tele No.: [phone] Cell No.:(828)'712-7488 Fax Xo.:(828)08-l0Q1

� ti A

I. PROTECTION—Provide a brief description of bow(1)water supply wells;(2)suiface water bodies;and(3)
septic systems and associated spray irrigation sites,dra%fields,or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
kMvjde Silt Fencing at LQr ter retention pond if necessary
J. VARIANCE—Pursuant to 15A NCAC 02C.0241 the Director of the Division of Water Quality may gmnt a
variance from applicable well construction or operation stew $ provided that:
(1) use-of the well(s)will not endanger hw naa 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 thin notification to expedite evaluation of the request.
The variance request foirm can be accessed online at http://�orral.nedenr, r�*/web/w /c�aps/gw8;o/,ge��iiit-
Mplications
1- SIGNATURES—The following section is to be completed as required below or by that person's-autborized
agent. 15A NCAC 02C.0211(e)3regi*es signatures as follows:
(a) for a corporation- by a responsible corporate officer;
(b) for a partnership or sole proprietm aliip: by a general partner or the proprietor,respectively;
(c) for a municipality or a state,federal,or other public agency: by either a principal exgcutive
officer or ranking publicly elected official;
(d) for all others: by'the well ownw,,
-(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.
"(hereby certify, under penalty of law, that.t have personally examined and'am familiar with the information
submitted in this document and all attachments thereto and tha4 based on my inquiry of those indtvkWals
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 submittingfalse information. I agree to construc4 operate, maintain, repair, and rf applicable, abandon
the injection well and all related appurtenances in accordance with the 1 SA Y 4C 02C 0200 pules.
all +?S'
$ overty Owner/Appucsnt
r r
Print or
Signature of Authorized Agent,if aay
— Pria or Type Fall Name

L. SUBMUTA.L INSTRUMONS—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 inecAm well;facility
will be located:
;:.;i':h. .,�>A�mil'�>yi;.r,Idfl'�;J�.r''' "•�i i«a.'.::�.P-`7ity^',.••l�.
•i4> `�itS'i!*.'1"i; •::1,-�°.a.'�'F—�� Fi��::i7lvl ::r1�514;i:.i�'tr•¢Y: ,,,,�i' n
5Y �,�.3 �,�,' '„j�R'..i: '«y j b�•. fed•.( •'�:.. .i:F'^'1'••, _ y� ;.l
d � �;.. ^'.S:��i,.. ;o,+'t',:�m�:..i :.(r;• ,..,r,,t ,e Irk 4. �. ,5..� •.s:}
�S''•:'.'„.'i•fir•. C.!':: '�>l ',"-,�""'
"1•
Vf
AsbevMe Regional Office Washirtgtan Regional OMce
2090 U.S.Highway 70 943 Washingtm Square Mall
Swannanoa,NC 28778 Washington,NC 27889
Telephone:[phone] `telephone:(252)'946-6481
Fax:[phone] Fax:(252)975-•3716
Fayeftevllle'Regiooal Office Wilmington Regional .Office
225 Cmen Street;Suite 714 127 Cardinal Drive Extension
Fayetteville,NC 28301-'5043 Wilmington,NC 9-8405
Telephone:[phone] Telephone:[phone]
Fax,[phone] Fax:[phone]
Mooresville Reg 01W Office' Winston-Salem Regional Office
610 East Center Avenue,Suite 301 585 Waughtown Sheet
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--1629
Telephone:.[phone]
'Fax:[phone]
(2) Cowty Health Department in which the injection we11 facility Will be located, A list of county health
departWeuts can be found onlim at hqp://www.nealhcLi>reJcounty.hO•

9/29/2016 Corporations Division
North Carolina
Elaine F Marshall DEPARTMENTOF THE
Secretary SECRETARY oFr STATE
PO Box 29622 Raleigh,NC 27626-0622 (919)8072000 Account Login Register
Click,Here To:
View Document Filings File an Annual Report Amend a Previous Annual Report
Print a Pre-Populated Annual Report form
Corporate Names
Legal: Blue Star Ranch, LLC
Limited Liability Company Information
Sosid: 1405002
Status: Current-Active
Annual Report Status: Current
Citizenship: Domestic
Date Formed: 10/6/2014
Fiscal Month: December
State of Incorporation:
Registered Agent: National Corporate Research, Ltd.
Corporate Addresses
Mailing: 212 South Tryon Street Ste 1000
Charlotte, NC 28281-0001
Principal Office: 212 South Tryon Street Ste 1000
Charlotte, NC 28281-0001
Reg Office: 212 South Tryon Street Ste 1000
Charlotte, NC 28281-0001
Reg Mailing: 212 South Tryon Street Ste 1000
Charlotte, NC 28281-0001
Company Officials
All LLCs are managed by their managers pursuant to N.C.G.S. 57D-3-20.
https://www.sosnc.gov/Search/profcorp/l0637204 1/2

9/29/2016 Corporations Division
Manager: Carl Ring
806 Sweetbriar
Memphis TN 38120
Secretary: Patricia Ring
806 Sweetbriar
Memphis TN 38120
hftps://www.sosnc.gov/SearcWprofcorp/10637204 212

LRESOURCES
D
ouro"
17
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATU NOTIFICATION OF'INTENT TO CONSTRUCT OR OPERATE I ratlans
These wells are 'permitted by rule"and do not require an individual permit when C"' . ff
the rules of 1SA NCACO2C.0200t This notice must be submitted for t �
GEOTFiF_RMAL 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: May 15 , 20 17. PERMIT NO,•/1d` 00 y rS (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP:WELLTO-BE CONSTRUCTED 2@330'
(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 x Submit this fiorin•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 aH others, list name of the
business,organization,or government agency and-person delegated signature authority:
Gerard M. Schuppert, Jr. and Cynthia L. Schuppert
Mailing Address: 5210 Highland Falls Lane
City: Katy Stater TX ' Zip Co&_77A50County:
Day Tele No.: 2 1-828-5594 Cell No.:_713-530-6781 or 281-352-9311
EMAILAddress: cschuppert0att.net Fax No.:
[e-mail]
D. PHYSICAL LOCATION OF WELL,SITE
(1) Parcel Identification Number(PIN)of well site: 7672-32-7089
County: Jackson
(2) Physical Address(if different than-mailing address):
908 Boar Ridge Road
City: Sylva State:NC Zip Code: 287.79
DWQ/UIC/C1ose�Loop Geothermal l�totification{Revised 4/30/2012j Page 1

J
E. kkps,"PLANS,AND SPECIFICATIONS
Maps must The 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
—site-specific map showing the locations of the following:
0 Proposed injection well locations • Septic systems and associated spray irrigation
0 Buildings sites,drain fields, or repair areas
0 Property boundaries
0 Surface water bodies • Existing or potential sources of groundwater
9 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!)Ltp.-`!porta1.ncdem-.o web/,A"ipL/gw
—pro. All other additives require approval prior to use.
20%Environal 80% Water
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Larry Wells/David Stratton
NC Well Drilling Contractor Certification No.: 2603-A/3421-A
Company Name: AWD Services Inc. Contact Person: L4=Wells
City: Leicester — State: NC Zip Code:28748 County: Buncombe
Day Tele No.: 828-683-9223 Cell No.:.828-215-9334
EMAIL Address: —wells750549abellsouth.net Fax No.: 828-683-9203
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:Bullman Heating&Air
Contact Person: Josh Guthrie EMAIL Address: '[e-mail]
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804 State: NC County: Buncombe
Office Tele No.:(828)-658-2468 Cell No.: (828)-712-7488 Fax No.:(8 28)-658-1001
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

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....wB �, \,t\ A,\ \``\ \ ``� ''\\ '\�` `� auaw •♦\,�` ` -a -lj:)f�WNr°rE"-,__•._.-___ ___'_ �� i j �' f 1 { 'i , l\, \ry \` 5 1\ ry / , , /'/ L�-�
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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:
Silt Fence will.be used to control solids and runoff from drilling.
All required set backs will be met.
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 htip:l/poi-tal.ncdenr.org/web!1%y/a/ %Tw o/permit-
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 offines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all relaed appurtenances in accordance with the I5A NCAC 02C 0200 Rules."
mil/
giaftleqprop-rly bwnbrilkPolkait,
• GertarcQ �� � �a1.�:13P�.. �P: i c _al
Print ype F Name `
496ature Outhorized Agent,if any
.Print or.Type M Name
MQMIC/Closed-Loop Geothermal Notification kmmaau w.,V14V,Z.) Page 3

North Carolina Department of Environmental Quality—Division of Water 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: C1 1 20 PERMIT NO.:!JV,TO to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED(select one)
(1) 6Aqueous(as per 15A NCAC 02C.0222) Number of wells: 2—
(2) ❑Direct Expansion(as per 15A NCAC 02C.0223) Number of wells:
B. STATUS OF WELL OWNER(S)(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 fdfm 30 days prior to construction
C. WELL OWNER(S)—For single family residences,list all persons listed on th propertjV6,
list the name of the Business/Agency and person and title with delegated signa e authority:
ns
Mailing Address: �_ CAE h, 1 j Water Quality RegionalOpemft
s evu w
City: L► �/f f 9 DC.-k State: R Zip Code:7 DUICouQnty: .
Day Tele No.: SL(M,M 1 I S Cell No.:
EMAIL Address: lei, cosj )Y,ri nC bu.. I Uer-. Fax No.: 7 4�
D. PHYSICAL LOCATION OF WELL SITE —7
(1) Parcel Identification Number(PIN)of well s 1
ite: / jr,8
County: J A Gk-s-,--%n
(2) ®Phy1sical Address(if different than mailing address): 1C/ S/ / P /� ✓ �1�'1G)
Closed-Loop Geothermal Well Notification Rev.3-1-2016 Page 1

E. REQUIRED MAPS,PLANS,AND SPECIFICATIONS
(1) A site maps must be submitted. It must be scaled or otherwise accurately indicate distances(in feet)
and orientations of features located within 250 feet of the injection well(s). Label all features clearly
and include a north arrow. Attach the site-specific map showing the wells in relation to the locations of
the following:
• BuiIdings • Septic systems and associated spray irrigation sites,
• Property boundaries drain fields,or repair areas,if any
• Surface water bodies,if any • Existing or potential sources of groundwater
• Water supply wells,if any contamination,if any
(2) Plans and specifications of the surface and subsurface construction details of the well system.
NOTE. In most cases, an aerial photograph and/or plat map of the property parcel showing property lines and
structures can be obtained and downloaded from the applicable county GIS website. Typically, the property can
be searched by owner name or address. The location of the wells in relation to property boundaries,houses,septic
tanks and fields, and other wells, etc. can then be drawn in by hand Also, a `layer'can be selected showing
topographic contours or elevation data.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. NOTE: Only injectants approved by the NC Division of Public Health,Department of Health
and Human Services can be injected. Approved injectants can be found online at
http://deq-nc.Eov/about/divisions/water-resources/water-resources-permits/wastewater-branch%round-water
i)rotection/oround-water-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
G. WELL DRILLER INFORMATION#:Well-DriIlingg.ontractor's Name: -�I AN PC q'�—
NC Well Drilling Contractor Certification No.:
,L*.-.;.-:Company Name:_I os- W Q 1 Contact Person: _� p (ln ftlq r.�
City: State: �J C Zip Code? County: pr Gl<-f 0 -�
Day Tele No.. �, - S-�`O Cell No.: ,SC-' 23 z-c)
EMAIL Address: G— TP en p hr OS �D C4YY', ) - ,-1 Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:
Contact Person: 6,p n e EMAIL Address:
Address:
City: _ a; '� Zip Code: ?S State: i QCounty: C.I<
Office Tele No.: 4 ` T 7 / Cell No.: 3c/1 -O g IS- Fax No.: 5-9 6 " -7 I
Closed=Loop Geothermal Well Notification Rev.3-1-2016 Pale 2

I. PROTECTION—Provide a brief description of how any(a.)water supply wells, (b.) surface water bodies, or
(c.) 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 CL�6A P11 rn-I j2 /AA dole
v
J. VARIANCE—Pursuant to 15A NCAC 02C-0241 the Director of the Division of Water Resources may grant
a variance from applicable well construction or operation standards provided that:
(1) Use of the 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 ll tps://ncdenr.s3.amazonaws.com/s3fs-
public/Water%200uality/Aquifer%2OProtection/GPU/GeothermalVarianceRequestFormFillable-
20130805.pdf
IK 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 ao ee 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 0wner/Applicant
CUr-his �rc�d b�cr-u
Print or Type Fdfi Name
A �t
Signature of Authorized Agent,if any
rint or Type Full Name
Closed-Loop Geothermal Well Notification Rev.3-1-2016 Page 3

JACKSON CO�INTY HEALTH DEPARTMENT '
,iCE NUMBER DATE PIN
E0RATIONG PERMIT
U 6 E~ - - OW t
PATTERSON JAMES 0 WADE HAMPTON COMPANY
PO BOX 385 PO BOX 386
CASHIERS NC 28717 CASHIERS NC
ELEPHONE: _ _
PECIFICATIONS: `3 ` --' - 2
i
OC TION/DIRECTIONS:
DE HAMPTON
E : REVB' ` IGN O W ATUF NER OR AUTHORIZED AGENT:
00 5684
The above signature indicates that 1 have read,understood and concur with all rovisiFinformationoutlined on the back
-
on_ TYPE. SYS. �
SZ. TANK h&0 / SZ. CHA1M�B IYA— IS DPER. REO
REMARKS:
L r
.I
3` X 7r
S
OWNER/INSTALLER RESPONSIBLE FOR COMPLIANCE W�H ALL APPLICABLE STATE RULES
DATE. ISSUED ENV HEALTH SPEC '
DATE. APPROVED ENV HEALTH SPEC [ . f
JCHD.2500(6/136)

JACKSON COhNTY HEALTH DEPARTMENT
-,.OE NUMBER DATE PIN
eQUE• EE . . O 3
105
PATTERSON JAMES O, WADE HAMPTON COMPANY
PO BOX 386 PO BOX 366
CASHIERS NC 2 717 CASHIERS NC
£LEPHONE:
PECIFICATIONS: :704' "—`-
-C TIONlD1RECTIONS: /
:�-; " R IGNAfUA -0Y 6WWE'lk-0R'4UTH0RlZED AGENT:
OL71 5684
The above signature indicates that 1 have read,understood and wncur with all 4rovisioniand informafion as outlined on the badc.
We-lI
t�ra-P
#DEDRMS _ TYPE. SYS. G VvQdr AY�0.S
SZ. TANK lh,90 SZ. CHAMR q IT DPER.-REQ
REMARKS: �rvs�I/ r_d�s t o I7S ti 3br U
- `ice` SI•� -
52- r -�m a — _
N S e �f � 1
12
Closes-
• Ste,
S G�
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+0 [eses+
-Fou�c( a-h o ru ---
avilcin REas owmiso a
SEP 6 2011
Water Oualfty Regtonat Opens
�... Ashevilseviiie Regional Office
OWNER/INSTALLER RESPONSIBLE FOR COMPLIANCE WI�fH ALL APPLICABLE STATE RULES
DATE. ISSUED ENV HEALTH SPEC
DATE.APPROVED ENV HEALTH SPEC f S
;CI1D-250(6W) -

SCArr C-D
North Carolina Department of Environmental Quality—Division of Water 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.: a Q SZD (to be completed by DWR)
A. TYPE OF GEOTHERMAL,CLOSED-LOOP WELL TO BE CONSTRUCTED (select one)
(1) A Aqueous(as per ISA NCAC 02C.0222) Number of wells: _�q
(2) El Direct Expansion(as per 15A NCAC 02C.0223) Number of wells: �F �'= �.
... ..cf tidaY�r Resourca9
B. STATUS OF WELL OWNER(S)(choose one) JAN 2 Q 2019 ,t_
(1) Single Family Residence Submit this form two(2)business da s prior to construction. =-
(2) Business/Organization Submit this form 30 days prior to con strilkfaQual!tV Regional Operations
Ashctrip'_�n `ne,^f 0icCe
(3) ❑ Government: State Municipal County Fed -
*Submit this form 30 days prior to construction
C. WEEL OWNER(S)-For single family residences, list all persons listed on the property deed. For all others,
Est the name of the-Business/Agency and person and title with delegated signature authority: >
, (Pge
d -Er-q n K
Mailing Address: .3
City: S'V V--A- State:IVG Zip Code?-9'7T County:J-;, -C`<S,�)!V
Day Tele No.: Cell No.: g zg 3w 9 2-9
EMAIL Address: Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN) of well site: 7�� � ✓� ®�
County: $C 4_&D, /j
(2) Physical Address (if different than mailing address):
City: Co-Linty Zip Code:
Closed-Loop Geotliermal Well Notification Rev.3-1-2016 Page I

E. REQUIRED MAPS,PLANS,AND SPECIFICATIONS
(1) A site maps must be submitted. It must be scaled or otherwise accurately indicate distances (in feet)
and orientations of features located within 250 feet of the injection well(s). Label all features clearly
and include a north arrow. Attach the site-specific map showing the wells in relation to the locations of
the following:
• Buildings Septic systems and associated spray irrigation sites,
• Property boundaries drain fields, or repair areas,if any
• Surface water bodies,if any • Existing or potential sources of groundwater
• Water supply wells,if any contamination,if any
(2) Plans and specifications of the surface and subsurface construction details of the well system.
-NOTE. In most cases, an aerial photoaaraph-and/orplat map of-the-property parcel showing property lines-and
structures can be obtained and downloaded from the applicable county GIS website. Typically, the property can
be searched by owner name or address. The location of the wells in relation to property boundaries,houses,septic
tanks and fields, and other wells, etc. can then be drawn in by hand Also, a `layer' can be selected showing
topographic contours or elevation data
F. TYPES AND CONCENTRATIONS OF ADDITIVES - List any additives that will be used and their
concentrations. NOTE: Only injectants approved by the NC Division of Public Health,Department of Health
and 'Human Services can be injected. Approved injectants can be found online at
http•//deq nc gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/�-yround-water-
protection/around-water-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
.waft-eg- 0", — .-) a
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: XJ Tl
NC Well Drilling Contractor Certification No.:
Company Name: f+r G f nne ���5 ���+,� . Contact Person: -r7 4v%
City: lfi State: Zip CodeZ z? County:J:Q1Gt3 0xo-
Day Tele No.: 2,k S h_ S S1C Cell No.: /3 2 0
EMAIL Address: Fax
FaxNo.:
rl
H. HEAT PUMP CONTRACTOR INFORiVIATION
Company Name: f,�
Contact Person: l�C'L,ac, 9 .1T l EMAIL Address: �-
Address: �1 I 1�J 21 �� low e/
City: S'kt 1 V-A Zip Code: IA 7S State: N;C County: ��&k5 3
Office Tele No.: 8 - y�7 I. Cell No.: C1 - g s Fax No.:
'tlosed-Loop Geothermal Well Notification Rev.3-1-2016 Pa__e 2

511 5120 1 8 ENV Health Permit
- a
Jackson County Department of Public Health
538 Scotts Creek Road,Suite 100 ��� PermitSylva, NC 28779
Phone: [phone] FAX: [phone]
i
Reference Number: Permit Number" 2018-11086-9-6562
PIN: 7539-45-8443 Application Hate: 4/4/2018
Owner: DAHLQUIST, SUZANNE I City: SYLVA NC
Address: 143 ELK RD Zip Code: 28779, I
Lot Number: SR 1316
Service Type: IP/CA/ OP/Well Permit Bedrooms. 3
Directions To Site: East Fork Rd. to Early Deitz Rd to Elk Rd.
b
- - - - _- - ---- _ - ---
Oo Ey
f Water Resouroe9
le �, 2 4 2019
Regianai pperafions .
a Pnn^^?'Q`f?ce
li
L
L
L�
3:
11
Fee: $620.00 Receip
1
c
EHS• 5 /�S9 Issue Date:
n
E@-1S: Approval Date:
N
I
Signature: Date:
ILI
11
N
• h
http:llcioudapp.roktech.net/JacksonPermitslEnvHealthPermit/Wel3PermitDrawing.aspx?EnvHeafthPermit--9985
1

. r /
I. PROTECTION—Provide a brief description of how any(a)water supply wells,(b.)surface water bodies,or
(e.) septic systems and associated spray, irrigation sites, drain fields, or repair areas within 250.feet of the
proposed infection wells will be protected during construction of-the wells:
ur OQ V
�in 1hY acK'. t:2Y� �'Jc7C11rC
J. VARIANCE—Pursuant to I5A NCAC 02C.0241 the Director of the Division of Water Resources may grant
a variance from applicable well construction or operation standards provided that:
(1) Use of the 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 ofthe groundwater.- -
Any variance request should accompany submittal of this notification to expedite evaluation of the request
The variance request form can be accessed online athttns:ffncdenr s3-amazonaws.com/s3fs-
oubiic/Water'/o20OualitvLAouifer°/o20ProtecdonfGPU/GeothermalVarianceReauestFormFillable-
20130S05-13
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 municipality or a state,federal,or'other public agency- by either a principal executive
officer or ranldng 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
authwity,'and is signed and dated by the applicant
`7 hereby certify, up-der penalty of law; that I have personally examined mud an:familiar ivith-the information
submitted in this document and all attachments thereto and that, based on my inquisy of those indtvzd ads
immediately responsible for obtaining said information, I believe that the information is true. accurate and
completes I am aware that there are significant penalzies, including the possibility offines and imprisonment
far submiltino false information. I agr to constntct�p�ate,mai�xiain,repair, and if appl cable;ab=don the
injection well and all related r�a�ices ace�r/danek wit e _4 NCAC 0?C 0200 Rules."
- / , ,�
Siganto of Property Owner/Applicant
j Prl6torTypeF - e
I-
i.nature of Authorized rent,'if any
Print or Type Full Name
Closed-Loop Geotheanal Well Notification Rev.3-1-2016 Page 3

Moore, Andrew W
From: Moore, Andrew W
Sent: Monday,January 28, 2019 10:42 AM
To: AAA GREENE BROS/WNC ([e-mail])
Subject: Request for Additional Information, Dahlquist/Frank Geothermal Well System, 145 Elk
Road,Jackson County
Attachments: Example.pdf
On January 24,2019,the Division of Water Resources (DWR), received the Notification of Intent To Construct Or
Operate Injection Wells (NOI)for the subject system.After a review of the form, DWR had determined the application is
incomplete and cannot be processed until the following information is received:
1. Section E.(1) Please provide a map that accurately depicts the distances between the proposed geothermal well
location and building perimeters and the septic system.The map provided is not scaled and does not provide
these distances. [15A NCAC 02C.0222(d)(4)]
2. Section W.(2) Please provide plans and specifications of the surface and subsurface construction details of the
well system to include grout type, anticipated depth, and casing diameter. I have attached an accepted-example
for your reference. [15A NCAC 02C .0222(d)(6)]
The NOI is deemed incomplete and you do not have authorization to construct the well until the requested information
is received.
Feel free to contact me if you have any questions.
Andrew W. Moore, P.G.
Environmental Specialist—Asheville Regional Office
Water Quality Regional Operations Section
NCDEQ—Division of Water Resources
828 296 4684 office
email: [e-mail]
2090 U.S. Hwy. 70
Swannanoa, N.C. 28778
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
1

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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 ride"and do not require an individual permit when constructed in accordance with
the r•irles of 15A NCAC 02C.0200". This notice must be submitted nrior 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. V
Print Clearly or Type btformatiot. Illegible Submittals 1011 Be Returned As Incomplete.
DATE: _g 20 I PERMIT NO.'VV-TO`O®5'S IR (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C.0222): V 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
business,organization,or government agency and person delegated signature authority-
1-64 Usn(S UL-F' ,S4cs�k G�i her
r
Maiiing Address: ;t 3 5 I� tcwet�— f k
City: L-o hi i,we o L State: Zip Code:321;SOCounty: 5e t.•.�a
Day Tele No-.: Cell No.: DivisionWyVani,R ,.ources
EMAIL Address: Fax No.:
:. AUG 3 C: 2019
D. PHY'SICAL LOCATION OF WELL SITE "'•ry
1 _ (Yater Ouailbi R^riDr2!Operations
(1) Parcel Identification Number(PIN)of well site:
County:- --�"
(2) Physical Address(if different than mailing address): _3 T i c - 12.�
City: <4 l v A- State: NC Zip Code:
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:
P
roposed injection well locations eptic systems and associated spray irrigation sites,
drain fields,or repaid'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 ncdenr ora/webhvq/aps/izwpro. 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.: Lt3 "4
Company Name:d elg W�-`t° J Contact Person:
City;} Ivaki 4 C, State:11L Zip Code:9—A 3County:--
Day Tele No.: Cell No.: 76 ` &S
EMAIL Address: Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:Bullman Heating&Air
Contact Person: Josh Guthrie EMAIL Address:ioshagabullmanheating.com
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804_State: NC County: Buncomne
Office Tele No.:(828)-658-2468 Cell No.:_(828)-712-7488' Fax No.:(828)-658-1001
QWQ/U1C/Closed-Loop Geothermal.Notification(Revised 4/30/2012) Page 2

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7682-24-4530
7672-90-6375
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7682-24-5113
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Information depicted hereon is for reference purposes only and is compiled from the best available sources.The County of Jacleon assumes no responsibilltyfor errors arising from use or miss

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:
a
J. VARIANCE—Pursuant to 1 5A 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 wells)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 littD•Npo►tal nedenr ortr/web/wa/aps/L pro/nermit-
TRlications
I- SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent. 1 5A 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 herebv cer75,, under penalty of law, that I have personally examined and cnrt familiar with the information
submitted in this doczanent and all attachments thereto and that; based on my inquiry of those individuals
immediately responsible for obtaining said informations, 1 believe that 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 ip?forntation. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all.related appurtenances in accordance with the 1 A RrC4C 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(Rcvised 4/30/2012) Page 3

ntbmtired to rhis document and all atrachtnenra thereto and that, based on my inquiry of 1110se lydlvidttats
lmttlediaWy raspmrstble for abtaintrte satd ireormation, I believe that the,irrformalian is true, accurate and
coniplale. I an:anore rhat there am rtgni/icant penalties, lncluch'ng the passibility ol'fines and bHpt'19o)1me11f,for
submunng false informalM819ftature
&PrvPErktQw
ate, maintain, repair, and if applicable, abandon 06
i1wfion well and all relatvlrh rho I SA NCAC 02C 02D11 Roles."
aerlApplteant
Print or Typo Fall Nams
Signmuro ofAuthorlred Agent,Ifeny
Print or Typo Full Nam
I, SUBNITTALLNSTRUCTIONS—Submit one copy afthe completed nolifioation peckngc to the each ot'tho
following:
(1) Tice Division of Water Quality Regional Olfioe mrving the areg in whim the inf ettion well facility'will
he located;
iyW- ire` ', 4av _� '•f ;',� i ,h::i: 'i
Asheville Reillorad Office
2090 U.S.Highway 70
Swaenanoa,NC 28778
Telephone:[phone]o
Faa:[phone]
FayettcvMo Regional Office
225 Green Street,Suite 714
Fayotteville,NC 29301-5043
Tatalthone:[phone]
FaX:[phone]
Mooresville iReglimel Ofllee
610 Beat Center Avenue,Suite 301
Mooresville,NC 28113
Telephone:[phone]
Fox:[phone]
g00/ypO� aadg ouTOTgoN TRvto-4rai 0056 SED GOD XV.n 6Z 19 oast 6TOZ/8Z/S0

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are"permitted by nde"and do not require an individual pennit when constnicted in accordance with the
ndes of MA NCAC 02C.0200°. This notice must be submitted prior to constniclion
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in 1$ANCAC 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
cooling system.
Print Clearly or Tjpe lnfarmation. Illegible Submittals iViABe Returned.4s Incomplete-
DATE: d ��
20 Iq PERINHT NO. Y ( 0 (to be completed by
DINIQ
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous (as per 15A NCAC 02C .0222): V Number of wells:
(2) Direct Expansion(as per 15ANCAC 02C.0223) Number of wells: V
010 0; i r;iVVaier Resources
B. STATUS OF WELL OWNER(choose one) f
AUG ' 0 2019 '>: :
(1) Single Family Residence Submit this form two(2)business days prior to constructio E;
(2) Business/Organization—Submit this form 30 days prior to construction. Water Oualfir Pgr,?Onal ODerations
(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:
0 IcA C_Ll tc_� \i+C:Y-1
City: State:
C Zip Code:Lbuc...t,
Day Tele No.: L&L 'b G-D �,b 2_�L
Cell
No.:
FXLAJL Address: Fax
D. PHYSI(.'Al.LOCATION OF WELL SITE
Parcel IdentificationNumbr(PIN)of well
site:
County: C,Lz?C,
Physical Address(if different than mailing address):
� C-4--
Citv. \J ck-
State: Zip Code -2
E. NIAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accuratek- indicate distances and orientations of features located
within 250 feet of the injection well(s). La6el all features cleariv and include a north arrow. Attach a site-
specific map showing the locations of the following:
•Proposed injection well locations
•Buildings
•Propenv boundaries
•Surface water bodies
•Water supply wells
Septic systems and associated spray irrigation sites.drain fields.or repair areas
•Existing or potential sources of groundwater 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
comentraiion�s 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
All other additives require approval prior to use.

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7671-06-85 81 ��
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7672-20-4939
7671-16-2249
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7671-06-5266
7672-90-637 5
7 672-90-6375
7671-06-2081
7671-05-7810
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August 30, 2019 1:2,257
0 95 190 380
0 0.03 0.06 0.1:
Information depicted hereon is for reference purposes only and is compiled from the best available sources.The County of Jadsan assumes no responsibilityfor errors arising from use or mis

G. WELL DRILLER LFORNL►TION(iflmown)
Well Drilling Contractor's Name:
NC NVell Drilling Contractor Certification No.: t 3 7 44-
Compam•N=eL"I }J�6-AP).W.. 'ttI UXU- _�,yyC�ontact Person:
City: � r J- pi n r�, State�'i Zip Cod12 �'1•C? unn•o :_ J r17A i ()J9
Da}Tele No.:
tC� f Cell No.:
E\LaIL Address:
H. HEAT PUMP CONTR-ACTOR INFORINLATIO\
Company Nance: Millman Heating&
Contact Person_ Josh Guthrie EMAIL Address:
josflQ'a-bulim�nhe�tin g.cont
Address:10 Red Roof Lane
City: Asheville Zip Code: 28804_State:NC _,County:
nco ne
Office Tele No.:(828)-658-2468 Cell No.:-(828)-712-7488___ Fax No.:(828}-658-1001
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 Gelds. or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
s, VO "", /1)4-c t
bod 1/k/Oc
.I. VARIANCE—Pursuant to 15ANCAC 02C.0241 the Director ofthe Division of\Pater 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 httn ort rl.ne aenr.:+r^+sets+su_roL, V.2nit-:rr cfi stiuns

I� SIGNATURES—'Ilse following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C.0211(c)requires signatures as lbllows:
(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 with the notification that clearly identifies the person,grants them signature authority.
and is signed and dated by the applicant.
'•I hereby certify; tinder penalty of law; that I have personally eramined and am familiar with the information
submitted in this doctiment and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information. 1 believe that the irfonnation is true. accurate and
complete. 1 am aware that there are significant penalties,including the possibiliq>of fines and imprisonment,for
submitting false information. 1 agree o constrict. perate, maintain. repair. and if applicable, abandon the
injection well and all related appurtena es in accorj ,ce with the 1&1 A7CAC 02C 0 0ORules."
L,orrt-p-.owner/Applicau
S I+Et2t S i ate D�kv ST"LkJ
Print or Type Full Name
Signature of Authorized Agent,irany
Print or Type Full Name
L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each ofthe
following:
(1) 71re Division of Water Quality Regional C>llicc serving the area in which the injection well facility will
be located:
�IU.}NSTt�'N `sAL:EJi i
^' RALEIGH
WASH NGTON
p} LL j
FAYETTEViL1.E
p�
Ashe{ide Regional Office
2090 U.S.Highway 70
Sw•anmanoa,NC 28779