Madison UIC Deemed Permitted 2012

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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES t� -
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS. C
These wells are "permitted by rude"and do not require an individual permit when constructed in accordancLwith,
the rules of 15A NCAC 02C.0200". This notice must be submitted prior to construction. J �s ;
GEOTHERMAL AOUEOUS CLOSED-LOOP WELLS
As described in 15A NCAC 02C.0222 these wells circulate potable water only or a mixture of potable water'and_J ✓i
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� — , 20 PERMIT NOAAAi 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:
I 1
(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:
r
City: State:PC Zip Code AR�3 County: .
Day Tele No.: Cell No.:
EMAIL Address: :j d 0i),"t An C4 'C©�'� Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) =Parcel Identification Number(PIN)ofwell site: 1
County: MU\t
(2) Physical Address(if different than mailing address).
City: State: NC Zip Code:
DWQ/UIClClosed-Loop Geothernial,Notifucation(Revised 4/30/2012) Page I

E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site-specific map showing the locations of the following:
• Proposed injection well locations • Septic systems and associated spray irrigation
• Buildings sites,drain-fields,or.repair areas
• Property boundaries
• Surface water bodies • Existing or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services' Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at hit ,�,rt i; ��;t s r.��.r_'u ei; �.�.a� : :��.)ro. All other additives require approval priorto use.
lieJ2k
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name: Contact Person: Mud
r �
City: /�._ State: � Zip Code: County:Day Tele No.: �^ �0�2`7�� Cell No.: � " 7�G '6-
EMAIL Address:—yffic,1K um A��e �Ii'J Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATI N
Company Name: C-
Contact Person: - 1 Lt EMAIL Address: e L r co
Address: O
City: �.. i�.^^Zipp Code: wPV1 State:nL County:
Office Tele No.: Cell No.: M' 70 — JO EL Fax NQ : f n-696-G 3 (
MQ/U1C/Closed-Loop Geothernial Notification(Revised 4/3012012) Page 2

I. PROTECTION—Provide a brief description of how(1)whier 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 protect during constructiotrof the webs: J)
J. VARIANCE—Pursuant to 15A NCAC 02C.0241 the Director of the Division of Water Quality may grant a
variance from applicable well construction or operation standards provided that:
(1) use of the well(s)will not endanger human health and welfare or the groundwater;and
(2) that construction or operation in accordance with the standards is not technically feasible or the
proposed construction provides equal or better protection of the groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation of the request.
The variance request form can be accessed online at http://portal.nccienr,org/ eb/Nvq/apsiQwpro/permit-
applications
K SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C.0211(e)requires signatures as follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner or the proprietor,respectively;
(c) for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
(d) for all others: by the well owner;
(e) for any other person authorized to act on behalf of the applicant: documentation shall be
submitted with the notification that clearly identifies the person, grants them signature
authority,and is signed and dated by the applicant.
"I hereby 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 dare that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all related appurtenances in actor ce with e 1 SA NCAC 02C 0200 Rules."
k
Signature of Property Owner/Applican
gcvi
Print or Type Full Name`
Signature of Authorized Agent,if any
Print or Type Full Name
PWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 3

s>

L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Quality Regional Office serving the area in which the injection well facility
will be located:
WINSTON-SALEM: -
-RALEIGH
ASHEVILLE _ WASHINGTON
O.RSSVILL
FAYETTEVILLE _
Asheville Regional Office Washington Regional Office
2090 U.S.Highway 70 943 Washington Square Mall
Swannanoa,NC 28778 Washington,NC 27889
Telephone:[phone] Telephone:[phone]
Fax:[phone] Fax:[phone]
Fayetteville Regional Office Wilmington Regional Office
225;Green Street,Suite 714 127 Cardinal Drive Extension
Fayetteville,NC 28301-5043 Wilmington,NC 28405
Telephone:[phone] Telephone:[phone]
Fax:[phone] Fax:[phone]
Mooresville Regional Office Winston-Salem Regional Office
610 East Center Avenue, Suite 301 585 Waughtown Street
Mooresville,NC 28115 Winston-Salem,NC 27107-2241
Telephone:[phone] . Phone:[phone]
Fax:[phone] Fax:[phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh,NC 27699-1628
Telephone:[phone]
Fax:[phone]
(2) County Health Department in which the injection well facility will be located. A list of county health
departments can be found online at http://www.ncalhd.org/county.htm.
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT:AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitter)by rule"and db not require an;individual permit when construcied in accordance with
ahe rules of I SA-NCAC 62G.020t). Tliis notice must be.submitted prior to constructions
GEOTHERMAL.AOUEO:US CLOSED-LOOP WELLS
As described.in 15A NCAC 02C.0222 thesemells circulate potable water:only or a mixture of potable water and
perform Tice-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'Typ"e Information. Illegible Subiiuttals.F.11 Be Returned As:Incomplete.
DATE: JulY, 7 2014 PERMIT NOAVS09NOOV0 (to be completed by DWR),
A. TYPE OF GEOTHERMAL CLOSEQ-LOOP WELL T.O.BE CONSTRUCTED
(1) Aqueous(as.per 15A NCAC 02C.6222): a Number of wells 2
(2) Direct Expansion(as-per 15A NCAC 02C.0223) Number of welts:
B. STATUS OF WELL OWNER.(choow one)
(1) Single Family Residence -I..Submit this form two(2)businessdays prior to construction.
(2) Business/Organization Submit this form 30 days prior ta.construction.
(3') Government: State Municipal ll Qbuntya Federal Submirthis'form 30 days
prior to construction.
C. WELL 4)WNER.—For single fa mily'.residences list the property owner(s): For all others,.list name of the
business,organization,or govemment ageric}r and.person-delegated signature authority:
Timothy A. Hale
Leslie Hale
Mailing.Address: '227 Plantation Rd.
City:. Houston States TX. Zip Code:77024. County:
Day Tele.No.: (71:3)722 7292 Cell No.:[phone]
EMAIL Address: [e-mail] Fax
D. PHYSICAL-LOCATION-OF WELL SITE
(1) Parcel Identification Number'(PIN)-ofwit!site:8789.424384
County:: Madison
(2) Physical Address(if different than mailing'address):
70-Red Fox Trail
Marshall
City:. State:NC Zrp Cade:: 28753
ag
IJIClC[osed=L'oop GeotHercnal tlotification(Revised B/512013) Pe t

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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 injectionwell(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
d Buildings, sites,drain fields,or repair"areas
® Property:boundaries
• Surface water bodies ® Existing or pote.h(W. sources of groundwater
o 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
concentfations. 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 b-q://portal nedenr org/web/wn/apalMro: All.othq additives,requ"ire approval prior to use.
Ethanol - 20%
G. WELL DRILLER MORMATION--(if known)
Well:Drilling Contractor'sNarne': Robert Larry Wells
NC Well Drilling Contractor.Certification No.: .26,03
Company Name: AVVD Services Contact Person: Larry Wells
City. Leicester 'State: NC Zip Code:28748 County:Buncombe.
Day Tele No.: {828}683-9223 Cell No::[phone]
EMAIL Address: we11s750549@bellsouth'.net F�No.:(828)683=9203
.K HEAT PUMP CONTRACTOR INFORMATION
Company Name:Mike's Heating & Cooling
Ronald Hathcock
Contact Person. EMAIL Address: °[e-mail]
Address: 329 Dogwood Rd.
City.: Candler Zip Code: 28715 State: NG County: Buncombe
Office Tele.No,c (828)665=4343 Cell No.: Fax No.: (828)6-05-6576
U1C/Closed-Loop:Geothermal Notit'ication{Revised S/5/200) Page 2

I. PROTECTION Provide a hriet description,of ho.cry('l)tivatcr supply Wells:(2;).surf11#:water bodies:_and(+'i
septic systems-and associated spray irrigation sites;drain fields;or repair areas within 250 teei 'the' roposed i
injection welis gill be protected during.constructiomof the wells:
Silt Fencing
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J VARIANCE—Pursuantto 13 1 02C..02 l l the Director of the.Division of Water Resources may grant
a variance from applican1 well construction or operation standards prnv idediha
(1) use of.*svell(sjAvill not'ndanger human;heal.th:and welfare or the groundwater:and
'(?). that construction.or operation in accordance with the standards is:not.technically feasible or the
proposed constructionpro:v ides.equal or 6etter'prcitectidn o I f the-groundwater,
Any variance request shquld accompany subinmaI of this not iticatiori lu expedite evaluation of the request,
The variance requesrforn!can be acecssed cinline at hit p:'aortal.ncdenr.orP_iWdb,,'wu+apsre+.'pro.hermit
appticafinns
K. SI'GNATbtRES--The follnvvii*i section is io be compicied as requiter belch-or by that pt'rson's authorized,
tagcnt-15A NCAC UIC.1921 1(0 requites.signatures as Poll)ws:
(ai feu a carporation: by n responsible corporate officer:'
(b) for a pattnership.or soli;proprietorship: h� a general partner Ur thrproprietor.rt�pecitii cl}
(c) fora mufti'ipality or a state. federal,or,other public agency: -by either.a principal d%ecitti�e .
officer or ranking.publidy elected.ofcial'. i
(d) for A,others: b_`the.itielf owner; j
(e) "for any other person authorized to act on behalf of the applicant:. documentation shall be
subrnittcd with the: notification that clearly 'identifies the person,. grant-, them, signature
authority.and is signed and dated by.the applicant•.
"I hereby ceri6, wider penalty eiflaw, ihaf 1 have personally exanibied aha'am fain liar-with the informgfi,;n
--ubnllgl d hi.-this'dacriniew cirtli'till ariachnients�therero and illai,' ''based(in my 71iy-riri;r rf those inYividwils
inMie tiaterlf r,rpew.vilfk.for nhtuinhkt -said irifnrawflan• l fi 1k've'.thut the igtbrination is true rtcew—ale and
complete. I un)'cnfiure rhai ilicr�ctr sl niJicunt_pent ltres.:iitgNdmg'tfze possibillt t•nj..•Jirw c-and tmpri ontnerti,
fr r stibniitiing_lalst tnfvrmauan. l ugrte to construct r)peruie »trtiiiiuin repair uird ffaliplicub(r..ahuiidart
rlii rr�c c tion trel!uttd uil`r 1�rtL:i unpurt +rrurrrs,iit ut• rdance with Me 114.k't !C il_;`t1'nll Rules.
Si.nature of Prapert}OwneriApplicant, T��
Print orT}'pc Full-Name
Jignature of.authorized Agent,ifany
Print tsr Type F+�ll\atne
t9c'l'klsrd=l.Sup Ciritricrta:d`t;ttticatiin tk�u�:•d K�^_iif�l !'3e�
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L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Resources Regional Office serving the area in which die injection well facility
will be located:
t., f
a� 7
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TO
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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:(910)`350-2004
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 fist of county health
departments can be found online,at http://�vwNv.ncalhd.orZfcounty.htni.
U1C/Closed-Loop Geothemial Notification(Revised,815/2413) Page 4

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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are permfued by rule"and do not require an individual permit when eonsoveted in a=ardanee with
the rules of ISA NGC 02C.0200t This notice nncst be srtbmitted gdar to eatrstrrtctiorc
GEOTI �L AQUEOUS CLOSED-LOOP WELLS
As described in 15A NCAC 02C.0222 these wells circulate potable water only or a mixture of potable water and
perforinaace-enhancing additives as part of a geothermal heating and cooling system.
OR
GEQYi'8ERMAL DIRECT EXPANSION C}ASEWLOOP WELLS
As described in 15A NCAC 02C 0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Prbtt Clearly or Type Informadlon. Illegible Submlttt fs HIM Be Rdurned As Incomplete.
DATE: 20 + PERMIT NO.w-1-0 r 0 0 1 (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED rr "
(I) Aqueous(as per 15A NCAC 02C.0222): Number of wells: 1D
(2) Direct-Expansion(as per 15A NCAC 02C.0 ) Number of wells-
IL STATUS OF WELL OWNER(choose one)
(1) Single Family Residence,X 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 eomtruction.
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:
( tut t_ caaS�t.Tt�G. t� I�'+t�E PAL
Mailing Address: tutor &y l�F 9LIM 5"0
City: W SttaReS Stan: J;I—. Zip Code County:
Day Tale No.:,,ef�: Cell No.:_ A-5, 11 Z
EMAIL Address Fax No.•
a
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site: &76"i 66
1 �ivf on w�i� lcas Physi !'Address Of different than mailing address): &t'ie /CI AS —we
JUL 2 � City: State:NQ Zip Code:
Water OuaRgy1w-4-C bo `�'rewliertoal Tlotifigiion(ltevisat 4I302012) p�1
v;Re y�nionai b(f),e t

E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 2S0 feet of the injection well(s). Label all features clearly and include a north arrow. Atinch a
site-specific map showing the locations of the following:
• Proposed injection well locations • Septic systems and dssociated spray irrigation
• Buildings sites,drain fields,or repair areas
• Property boundaries
• Surface water bodies • 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 ADDTPIVES — 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://porW.ncdenr ore/web/wa/agglawpro. All other additives require approval prior to use.
G) 2%
—f
G. WELL DRILLER INFORMATION Qfknown)
Well Drilling Contractor's Name: Robert Larry Wells
NC Well Drilling Contractor Certification No.: 2603
Company Name: AWD Services Inc. Contact Person: Lang Wells
City: Leicester State: NC Zip Code:28748 County: Buncombe
Day Tele No.: V&683-9223 Cell No.:828-215-9334
EMAIL Address: Wells7S0549®bellsouth.net Fax No.: 8287683-9203
E. HEAT PUMP CONTRACTOR INFORMATION /
Company Name:
Contact Person: -V' c_L.a Z EMAIL-Address-
Address:
City: u:L.a Zip Code: D..V")10 State: County: 12
Office Tale No.: Q.R 1WQ �J 651- Cell No.: a.$ -7 — 12.1 Fax No.: RIV `L$
DWQ/UICICiased-Loop Goothcmal Notirmfim(Revised 4130/2012) page 2

L PROTECTION—Provide a brief description of how(1)water supply wells;(2)surface water bodies;and(3)
septic systems and associated spray irrigation sitm drain fields,or repair area within 250 feet of the proposed
injection wells will be protected during construction of the wells:
J. VARIANCE—Pursuant to 15A NCAC 02C.0241 the Director of the Division of Water Quality may grant a
variance from applicable well construction or operation standards provided that-
(1) use of the well(s)will not endanger human health and welfare or the groundwater,and
(2) that construction or operation in accordance with the standards is not technically feasible or the
proposed construction provides equal or better protection of the groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation of the request
The variance request form can be accessed online at httoJ/portal.nedenr ore/web/wo/ans/gwnro/2gMit
applications
K SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent 15A NCAC 02C.021 l(e)requires signatures as follows:
(a) for a corporation: by a responsible corporate officer,
(b) for a partnership or sole proprietorship: by a general partner or the proprietor,respectively;
(c) for a municipality or a state,federal,or other public agency: by either a principal executive
officer or ranking publicly elected official; °
(d) for all others: by the well owner;
(e) for any other person authorized to act on behalf of the applicant: documentation shall be
submitted with the notification'that clearly identifies the•person, grants them signature
authority,and is signed and dated by the applicant
V hereby certify wuder penalty of Lam 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 irrformatlon I believe that the information is true, accurate and
complete. I am aware that there are significant penaltles,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 relat enan-es in accord,99c with the 15A NCAC 02C 0200 Rules,"
aature of Property caper/Applicant
Print or Type Full Name
a
Silpatu re of Authorized Apep y
Print or Type Full Name
DWQMIC/Closedd oop Geothermal Notification(Revised 4/3o/Z012) 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:
RA 1r4H
pgi�lA ,t ;' ��•. �WA' HIIG 'Ol1t
1-
Asheville Regional Mee Washington Regional OfSice
2090 U.S.Highway 70 943 Washington Square Mall
Swannanoa,NC 28778 Washington,NC 27889
Telephone:[phone] Telephone:[phone]
Fax:[phone] Fax:[phone]
FayettevWe Regional Office Washington Regional Office
225 Green Street,Sutte 714 127 Cardinal Drive Extension
Fayetteville,NC 29301-5043 Wilmington,NC 29405
Telephone:[phone] Telephone:[phone]
Fax:[phone] Fax:[phone]
Mooresvffle Regional Office Winston-Salem Regional Ofnee
610 East Center Avenue,Suite 301 585 Waughtown Street
Mooresville,NC 28115 Winston-Salem,NC 27107-2241
Telephone:[phone] Phone:[phone]
Fax:(7")663-6040 Fax:[phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh,NC 27699-1628
Telephone:[phone]
Fax:[phone]
(2) County Haft Department in which the injection well facility will be located. A list of county health
departments can be found online at hgR:/Iwww.ncathd.orpJcounty.htm.
DWQ/UIC/Clossd-Loop Geothamd Notifeeatian(Revised4130n012) Page 4

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