Madison UIC Deemed Permitted 2015

�. RECEiVED
Division of Water Resource!
i
JUL 2 8 2015
NORTH.CAROL-INA DEPARTMENT OF ENVIRONMENT AND:NA onal Operations
NOTIFICATION OF INTENT TO CONSTRUCT-OR OPERAT I, .
These wells arc'permitted by rule"and do not require ran individual permit when construeted.In accordance with
the rules of t Sd WdW 020.0200t nis notice.must be submitted prior lg Qommwkn.
QVOTHERMAL AQUEOUS CLOSED-LOOS WELLS
As described in 15A NCAC 02C.0222 these wells circulate potable waiter only or a mixture of potable water and
performance-enhancing additives as pelt ofa 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 ofa geothermal heating'and
cooling system.
Print pearly or Type lnforwatlex Illegible}Submittals Will Be Returned As Incomple&
20� PERMIT NO.WI:0 00 3 7% (to be completed by DWQ)
A. TYPE OF GLOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED s
(1) Aqueous:(as per ISA NCAC 02C.0222): L�f Number of wells: r�
(2) DirectlExpansion(as per 15A NCAC 02C'.0223) Number of wells:
B. STATUS Olr WELL OWNER(choose one)
(1) Single Family Residence ubnfit this form two(2)Business days prior to construction.
(2) Business/Organization Submit this form$0 days prier to construction.
(3) Oovernmart: State. Municipal County. Federal Subioit this form 30 days
prior'to construction.
WELL OWNER For single family residences list the property owner(s). For all others,list name of the
`busirie iiig6ni tion,or government agency and person delegated signattm authority:
Ck t ayA WL Clad
r--
Mailing A s: .� � , LI j O � d
City: S GI/ State: AZ�-_ Zip Code: County: A�hreim e-
Day Tele No.: _ Za R:oI , C� OV3 Cell No.:
EMAIL Address: -clq rk19cvel�d�llf��0�') Fax No.:
D PHYSICAL LOCATION OF WELL SITE
(1) Parcal Identification Number(PIN)of well site: /%
County: ! Ifdh l�f
(2) Physical .Address(if different than mailing address):_ &w G19/key T rri o c-A
0
City. rt II State,NC_ Zip Code: ;Q9 S
=Q1111001oied-Loop Geothermal Notificetion(Revised 41309012) Page 1

E, MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be 9.6ded' or otherwise. iccuratelY indicate-distances and orientations of Attach
features-located
within 250 feet-of the injection well(a). Label W-feamM clearly a-
and include nmffi w.arro '" - '
ft6h g
Bite-specific mop showing the locations-of tho following:
ioposW injection well locations optic systems and associated spray irrigation sites,
drain fields,orrep*'am
,oildings
P
Toperty boundaries xisting or potential sources of groundwater
• contoninqiion S
mWe water bodies
W
iter'supply Wong
(2) Plans and ap6cifications of the surface and subsurface construction daidils df'the well system.
F. TYPES AND CONCENTRATIONS.OF ADDITIVES - List any additives that will be used and thiir
concentratidni. Only.additives that the Department of Health and Hmnan Services'Vivislon.of Public Health
determines do-not'adversely affect hurnag health shall'be used. A list ot'ap" pr'"oved additives can be found
online at :hQrWncdmLorj&e require
_�A M ogdmmro. All other additives. approval prior to
G. WELL DRILLER INFORMATION(if known)
Weill Drilling Contractor's Name: 2&7iWy Certification No.:
Company ame, Contact Person:7 e
City` - state: Zip Code&�5 Countr. M j
DayWeNo.: Cell No.:�
2�1 C'
EMAIL Address: - 1 4149 J_@ 4011 60-07 Fox No.:
EL HEAT PUMP CONTRy. AC INFORMATION
00'ractor
CUP,
A Q'
CompanNarnm. ,
Contact Person: cv E-MAILAddress:
Addr N*JJIC
City:ZIV4
4-d"g,Uag A Zip Code: State:&L—sountr. _8qVW'&-L&
Office Tole No.: Cell No,:. �07Lt Fax
DWQWICUosed-pop.Geotheapid Notification(ReWded 4/30=12) Pap

n ! r
Y
• w' R •� .. � yjy� R' '1
!
t.; ,�'f 'C � a t`4 �� �`` ,�i- �Yt '!1� ,�� 1,5•'R ti
40.
x
< R Awl
3. 1
b
r '

Iy
�N
� J a
i
7

I. PROTECTION—Piovide 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
injectiOA walla will be protected during construction of the ails:
J. VARIANCE-Pursuant to 15A NCAC 02C.0241 the Director of the Division of Water Qaality.mny grant a
variance from applicable well-construction or operation standards provided that:
(1) use.of the well(g)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.
'fire variance request form can be accessed online at 1i0oitiil ncdenr yrQ�reb/wy(/apernfit
gpolieations .
X SIGNATURES—The following section_is to be completed as required.below or by ihat.pt rson's authorized.
agent l SA NCAC 02C:0211(e;)requites signatur=its follows:
(a) fora 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 oticial;
(d) for u1 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 .identities the person, giants thein Signature
authority,and is signed and dated by-the applicant
"I hereby cerl{fy, under penalty.of law, that I have personally examined and am familiar with the Information
Pbmilled in this document and all attachments thereto and that, based on my inquiry:of those individuals
immediately responsible.for obtaining said Wormation,I believe that the information is true, accurate and
complete. I.am aware that there are signiftant penalties,lncluding the possibility offtnes.and imprisonment
for submitting false►gformadon. I agree to construct operate;mat taln, repair, and(fapplicable, abandon
the Injection well and oll relate )'!;�a ',e e I SA NCAC 02C 0200 Ruks"
r �,
ii�
Sign r Property OwaerlAp//pl��lclant
P t or Type Full Ntm�
Signature of Authorized Agent,if any
Print or Type Full Name
MQUC(Closed-Loop Geothermal Notification(devised 4/39=12) Page 3

L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Quality Regional Office serving the area in which the injection well facility
will be located:
WINSTON'=SALEM - y
RA -OGH W
- ASHEVILLE - WASHI,NGTON
ES, 'ILL
-AYETTEVILLE
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 hiip://www.ncalhd.oriz/counW.htm.
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

NORTH CAROT TNA DEPA.RTMENI*OF Et1VIRONMMENI'ANII NATURAL ItI.SOUROPS
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION NVELLS
Those wills are •permilled ht•rule'and do not requir;r an individual permit when crnslructed in accordance wiih.
the rules of lS.9 ,ti'C.f C U2C.D200". .77tis nntiCe ngrst he serhmitic�»ior to ronstr�uvton.
GE,01'IITRi�]AL AQUEOUS CLOSED-LOOP WELLS -
As described in 15A \CAC:02C: .0222 these wells circulate potable'%i,atcr only or a mixture of Potable water and.
performance-enhancing additives as part of a geolhemial heating and cooling systertt.
OR
GE0'1'11ElZMAL D1REC'r EXPANSION CLOSED-LObP NVE111,S
As described in 15A`'CAC 02C.0223 dice;i.clls circulate.a refrgerant gas aspart of a geothermal heating and.
caolith�r•a}•stem.
Print
Ovardr or TtiPeJnjormntion. Illegible Submittals Will Bc Returned.GIs IrrrnmPletc.
Dt1TF, 20 PEitbll'l NO. 1-� � `Q)
_ T (tii b`c compic�cd by D11
A. ypi,,: OF.(xc),i,ni- zm,%i,CLOSED-LOOP.'wEL/L TO BE COtiSTRLTCTED
(1)` Aqueous(as pci- 15A NCAC 02C .0222): �V_ Number of w ells:
(2) Direct Expansion(as per 15NNCAC 02C .0223) Number of wells:
B. STATES OFAVELL OWNER.(choose oihc)
(1) sing
lc I nnily.Residcncc_ nbmit tltis'iorm hqo (l)business dais prior to construction.
(2) Business/Organization Subriut this form 30 days prior to construction.
Q) Govcnunent: Slate Municipal County Federal Submit this form.30 daps
prior to construction,
C,' WELL 0NN'.NER For single ftunily residences fis; the.property owrcr(s). For all others: list name of the
business,organization;or goverment a,;,cncy and person delegated signature authority:
LhCyaal
C I~__Pi 'Tra. DO--T"frt a1 7�a�
Mailire Address:
333—LcS__�S.f1S�
C ity: fldA-LLJai.lY)l^Ll�3cr` Stntc:. Zip Cadc:_ C >I count}: fle_yi`F3R
Day`I'cle No.: Cell No.:
E%MAtl,Address: - �. afCxn Ft, �'�CG� _. Fax NO." -- - - --.
ll "['11.1�1CAI LOCATION OF WEL L SHE %' c s`c1 jCD
o!f101�Uo! as allln� tit on Number(PIt).of IQsifc: _ a ��
1- 3.23-Qy 1_1--
+ fiuol; t�d0 p:uol6aa�k��R�?i�M a CD�. Ertl
' a
Physical Addt=ss'(ifdiffercnt•than t;hi �, adcircs�j: �� _ R_�!___vL6 z0__IZa�__ _aM
to o c inr _ ��� � cd
( City: . L I C f'._k�t_I ° y_ Szn°r\( : .Zip.ctttie:
pwnosey ;o uolsut i i? —
CIBA13 38
- y . .

- r
E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site-specific map showing the locations of the following:
• Proposed injection well locations • Septic systems and associated spray irrigation
• Buildings sites,drain fields,or repair areas
• Property boundaries
• Surface water bodies • Existing or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations.--Only-additives that the Department-of Health-and Human-Services'-Division-of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at ixti�;_}�c? t.71_i"i�nr.c)r`_��Li,'}).�jaj) ,tit}�rc�. All other additives require approval prior to use.
AL
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: YC�� �'�
NC Well Drilling Co tractor Certification No.: / 7_
Compare Natne: Contact Person:
City: State: I)(: Zip Coda__Z�3 County:
Day Tele No.: Cell No.: J2
EMAIL Address: Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
JW,Company Name:
C f
t
Contact Person: EMAIL Address:
Address:
City: Zip Code M State:A.(,County:
Offfcelele No.: Cell No.: /��� _ Fpx Ng,:
DWQIUICiClosed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

Jit
1 4
if
r r �
y
. 8

� �o�► � � Cat �,'/1 L���� l� 'N `
s
f � ,
1V
I
I

1. PROTECTION_Provide a brief dcscriptioa of hots(i)water supply wells; (2)surface.rater bodies; and (3)
septic systems and associated spray irrigation sites, drain fields,or repair areas within 2504feet of the-proposed
-injecdon wells wil! be protected dcring construction of the avcils:
J. 1'ARIANCI•;—Pursuant to I5A.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) cist of the a cll(s)will nut.endanger llunnast.health:and welfare or.the Voundwater;.and
(2) that construction or operation in accordance with thestandards.is not technically feasible or the _
— _Pr opo�corislruV,;in i pi:o�•: esi s equal or licu­re r protection of the eround%vaier.
And•• variance request should accompany submittal of this notification to e pedite evalualion.of the request,
.I'he variance request fora can be acccssed.oniinC at,l:, t�riportal.ncde_r.r.o�g��vcliltvnls:psle�ti•pro�criti:t_
at)"lications _
K. SICNATI,RES —The following.section is to be cc)npieted as required tv low.or ha,'that perscitt's authorized
went.. I� , NCAC 01 .021 1(c)recsuires signatures as follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a parinerslii.p or sole proprietorship: by a general partner or the proprietor.respeciweiv;
.(c) foe n municipality or a state, federal, or tither public agency: by ciihcr s p inc pal execii;iN c
officer or-ranlcrnt pul)licly elected (iflicial:
(d) for all others: by the well ovaier;
(e) for any oilier person authorized to act on behalf of the applicant; documentation shall be
submitted with the notification that dearly identifies the person: giants theii) signature
autttoiity;and is signed acid dateti by il,c applicant.
11 hereby cerirly, unaler J.)cn rlty of low,.that 1 have ir,sonallr.examinetl and am familinr IVA the hifin-motion
-submitted in this (loctarrent aril crll.attuchnien& thereto and ihtit, .based oil my'inquily of those. indiviclttals
ininierliatelr responsible fi)r obtaining said=ilybOU'lliort: 1 hriirye Iilot.tfre injorniariotr is true, accitrRft' and. . .
ccrml)lete. 10177 aware Iliat nt p• rallies, inchreling the possibilitt,ofl7ncs and impricotrntetrt.
for slihtilitting filar. infinwinliott_ 1 a,�f c• 10 c.` 1511)icl, operow, r aiwanr, relmir, and rf a1114icahle. flbattdon the injeetion it•cll and all'related crjtp r•lellc cis in(tool-dance)rich the 15A :tiICj1C•02C 0200 Rides.
Signature of Property Ou ner`Anplicant
_ Print or T%_PC Full NUme
Signature of'Aulhnrized Agcnt, if`unv
Print or Type full Name

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 WAS;HINGTON'
O,RESVILL
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/coun!y.htm.
DWQMIC/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 'perinitled 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 tqjTons1ruction­,,-
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS L`:r­­
As described in 15A NCAC 02C.0222 these wells circulate potable water only or a mix of potable Rd1b
DEN=D
performance-enhancing additives as part of a geothermal heating and coolie system.Division"of'Water Rksources;
1?c
OR
' s�sources
2 1 [015
OCT
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP LLS
As described in 15A NCAC 02C.0223 these wells circulate a refrigerant gas as part'bf.a eothormal heating and
0
cooling system. VVRter QUeRy Regfonp Opera
tions
ons
Print Clearly or Type Information. Illegible Submittals Will Be Return4 S"'Incomplete.
DATE: 2-1- 20 PERMIT NO.W�I Ot 31 (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: o v
(2) Direct Expansion(as per 15A NCAC 02C.0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence "ub t 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.
WELL OWNER; For single family residences list the property owner(s). For all others, list name of the
"+usiness-,0fgaffiiia­iion,or government agency and person delegated signature authority:
MailingAddress: 30-j- C,i c,*y-1C�-">C­- A- -SaLA-c—c-c- A r-f- 1`
City: A4"Kclidl-e— State: NC- Zip Code:2-?Soc/ County: bg-
Day Tele No.: )%r-- Cell No.: (51 S &LI 3- Z-S 671
EMAIL Address:S,tXu-+e-<- -7 C,1 !S Fax No.:
PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site: 2-,5
County: t-A r-j.-&-, -c c>v.
(2) Physical Address(if different than mailing address): '1 3 Ge..ct le_
City: M 0 V-S State:NC Zip Code: 2S'757
DWQUC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 1

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:
• 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 ..........orti�_'��th.fly z�>>, ,�hr;,. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: ao.5� pl,tjlm,,6
NC Well Drilling C ntractor Certification No.:
Company Name: Contact Person: JL (9
City: t ` State: )ILZip Code 3 County: -G di"
l�0 5 l�"
Day Tole No.: 7 Cell No.:
EMAIL Address:-SM4,1 K W" i ('00 Fax No.:
H. HEAT PUMP CONTRA TOR INFORMATION
Company Name:
Contact Person: EMAIL Address: t C,�
r �
Address• . 1J'L
City: YJ Zip Code: 1 State: ottnty:
Office Tole No.: Cell No.: IL 46 FFgx N9,;
DWQfUIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

l�
IDA
7*5
Ca
5b �
............... .......................... ....................... .....................f]
S�Sae�

vs-
id I '#
d a
V{
Qp
" � ♦ �' �' ,, {"'�.�"' ' � ,, + .'��r gyp;
44
4
IN �.
.
r
r
r

I. PROTECTION—Provide a brief description of how(1)water supply wells; (2)surface water bodies; and(3)
septic systems and associated spray irrigation sites,drain fields, or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
A t 1
� j S
ti
J. VARIANCE—Pursuant to ISA NCAC 02C.0241 the Director of the.Division of Water Quality may grant a
variance from applicable well construction or operation standards provided that:
(1) use of the well(s)will not endanger human health and welfare or the groundwater;and
(2) that construction or operation in accordance-with the standards is not technically feasible or the
proposed construction provides equal or better protection of the groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation of the request.
The variance request form can be accessed online at htti)://portal.ncdenr.drg/web/wg/aps/ewpro/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 ivith 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 related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 3

L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Quality Regional Office serving the area in which the injection well facility
will be located:
,w
WINSTON "SALEM"
v.,
MLE1GH
5`
L
- ASHEVILLEy _ _ WASHINGTON
'ORESV<<LL k F
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.
DWQMC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

LATURAL
CEIVED
of Water Resources
C 1 .0 2015
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT ANESOURCESNOTIFICATION OF INTENT TO CONSTRUCT OR.OPE � nst a ion luThese wells are "permlrred by rule"arsd do nob require an individual permit p
the rules of 15A NCAC 02C.0200'x 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
Qooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete
DATE: December 7 20 15 PER -kp::Po f to W I I (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO,BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C A222): X Number of wells:l @ 350' 3 @ 270'
(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 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:
John Julian Hawthorne
Mailing Address: 115 E Washington Avenue _
ci�y: . Lake Bluff state: zip code: . 600+1unty: _ Lake County
Day Tete No.: .847-772-6260 � `"` Cell No.. 847-204-1308
EMAIL Address: [e-mail] Fax No.: 828-682-3428
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site:---_8789-31-2517
_
County:_ -BUAC ED
(2) , Physical Address(if different than mailing address): _3793 French Broad Parkway
City: Marshall ___.. State:NC Zip Code: 28753.
DWQ/UIC/C1ose�Loop Geothermal Notification(Revised 4/30/2012) Page I

i
j)1
31 E. MAPS,PLANS,AND 'SPECIFICATIONS
,.- . .._ (1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250'feei of the injection well(s). Label all features clearly and include a north arfow. 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://Qortal.ncdenr.org/web/Lq/aps/<gwpro. All other additives require approval prior to use.
20% Environal
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Robert Larry Wells_..
NC Well Drilling Contractor Certification No.: __2603
Company Name: AWD Services Inc. ....... _ ___ _ Contact Person: Larry Wells
City: Leicester State: NC 'Lip Code: 28748 County: Buncombe
Day Tele No.: 828-683-9223 Cell No.:828-215-9334
EMAIL Address: Wells750549@be llsouth.net____. _. Fax No.: 828-683-9203
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Bullman Heating and Air ,
Contact Person: Josh Guthrie _ EMAIL Address• joshg(cb-bullmanheating com
Address: 10 Red Roof Lane
City: .Asheville zip code: 28804 State: NC county: Buncombe
Office Tele No.: [phone] Cell No.. [phone] Fax No.: [phone]
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 41302012) Page 2

F;
r�
a
a

PROTECTION of h-v `.vdI;s:. .::) sur!`-co water bodies: and (3)
septic systems and associatoc; :>pr< irrigation site:. eia `ahai' :rep,..-within _':�G "eet ofth�pr:)poseri
injection wells will i?e protected during constructii.
Silt tenci'~•g vyiil be used to 'control incf _ DI10- irunoff
:the drillir.a.
J, VARLANCE i'ursuant tr: I ; \C C'6^C .02=1 ?:r:.:ccr r.).—!'!e Dieisior;of Water(duality may grant a
variance from applicable.tiJc l l constniction or )T't'Wide.j that:
(1) use of the welii.$)'wit; not'endanger ........� ile ; l'•:ii'i. ve;l iarc5 or the g;ou 1dv:2ter;and
?) tha?coristnicTion or operation in accarcta :c:e tii�:�;.ai: atcs is 'iot echr: ca?y feasible or the
proposco cons--miction provides.equal r e-,I-r':;;<+iE<.Yi::M pi the grcurn��i'aier.
Any variance.request should accon).l:iary submitta tit n(-,�'-- to expedite cvalu:�tion of the raQuc�st_
The variance.r•::mic4st Corer? .an be accessed onlitic)atiY)/pzrr_;ii-
a �iications
K. SIGNATURES .... The followinc section is to b,:: .:. ?iei.G_! ;,; ':ils.sired bcimv or by chat person's authorized
agent. 15-A N�._.AC i',W S.r.!' el--eq tires signatwe.` az,
(ai . for a Corporatio'!: by a responsibis . rt.'•i]riiii.' .:..? l't;
(b) for a partne-ship of Sole proprieto:s:.lic: gevn 'a i)arll)eI'Jrt}le p-7p:letor, respee;,iveiy;
1-!Ui:i.;ipalit-y' or a state, feder'.. )':lf.'<:=..h!?C agency' by e-itt:er a principal executive
offleer or ranking publicly electec
(di -for all othors; b}'the well owner'
;e) flor any other person authorized To zi . of :, .i':-as: ,vet•the apolic;ant. documentation shay: he
subs-pitted witl-: tho notification char',- ;aenti'fie:- the person. grants ther'1 signanure
authori , a: d is siU*iec and datoc_ 11 r,, .,ri;.
"I herebY ce•e�jv, unde;-Penalty qf law, that (have ,. St)r:li; '. :'.E' Tnined and arrc familiar with the Tnjbrmation
submitted in ihis doczanew and all atia-c hmentc 'iYi''-'_lC :7ve.1 ei7l.ii. t':ase-:l on AZ}' ingzdt ' of those individuals
hnmediatei'y re.sponsibIP jnr Obltilrth7g staftl tinft)Y7YiC%rir;r;. : ?::?n: that .he ?nfb7marion is trite, accurate and
complete. 1 a;n aware (hal rher :t''C:.Sib jrC.a32r f' ?;till%c^t. .<.. !,G ;2f;the -3os.sibilih'o fIres and iTnarisonn,ertt,
J&r subminingJal.5,; in;Orrnatio . i Tree to CO+iSF"':.tt:': :')J)r.?% ;;:::: -„riraai.'t, revair, and f+applicahie, abandon
the injection well and all re lalea appurtenances ZF :'_`C'lrClil'!:::t:'•-,iJrh the 15.4 --V(.AC 01--0200 Rules-
1 •'
nature of Proper?, Ovin4 - Ixripticant
Print or' ypi d!NI:-mL?
t+i nature ofAutlio ized Age ,
Print or T)iDc:i:!!-Num?
llvdaltiEC'lC hosed-.00 <ic vthe-!nai`otifscat��n{its:iced 4r'.i0.`?O]?'.. Pane 3

f -
001110 lBuol as aiiiAagsy
suogwad®leuol€iail t(ileno jeisM
e oil
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NAT RAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE NJEC
These wells are -permitted by rule"and do nat require an individual permit when co t
the rules of 15A NCAC 02C.0200'. This.notice must be subm 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: , 201(0 PERMIT NO. 1}M'0\0 Ot.AZ� (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1). Aqueous(as per 15A NCAC: 02(7 .0222): ✓ Number of wells: C� ( J(00 ,
(2) Direct Expansion(as per 15A NCAC 02(' .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 ow.ner(s). For all others, list name.of the
business,organization,or government agency and person delegated signature authority:
Mailing Address: _�
City. state: N(t, Zip CodeJB753 County:.
Day Tele'No.: __. Cell No.:_,_._
EMAIL Address: Fax No.:
D. PHYSICAL LOCATION OF WELL. SITE i`
(1) Parcel Identification Number('PIN)of well site: G71 8_ '1__ .-1 5 051
County:k�\O,-dks_on
(2) Physical Address.(if differeni-d-ian mailing.address): -.._-.-___-
- _
City: _ _ ..._ State:NCI Zip Code:
DWQ/LJ1C1Closed,Loop Geothermal Notiticatim Mk. ,.:.i +30!20; Page I

. s
E. MAPS,PLANS,AND SPECIFICATIONS
(15 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. Atiach 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 0 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://portal.ncdenr.ora ebtW /apsi�w__Iyo. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Robert Larry Wells
NC Well Drilling Contractor Certification No.: _ 2603
Company Name: AWD Services Inc.-___ Contact Person: Larry Wells
City: Leicester State: NC Zip Code:28748 County: Buncombe
Day Tele No.: 828-683-9223 __• _.. .._. Cell No.:828-215-9334
EMAIL Address: [e-mail]. _ Fax No.: 828-683-9203
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: 2st4
Contact Person: Sash uXh�: ..-... EMAIL Address: -� Stic� Cod by\\rnar
Address:
City: AShe�;N_.... Zip Code:(:2;$RQ State:l&CCounty:
OfficeTeleNo.: 68...._....._CellNo.: 7)01- 714 $8 Fax No : 6,1!458- 106�
i
DWQ/UIC/Closed-hoop Geothermal Notification(Revised 4/30/201 1 Page 2

a � r
e1XI
o
-2-4
1��P7
761 Go
t

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:
c'uc\ . cz a r4Lx�a o�
J. VARIANCE-Pursuant to 15A NCAC 02C .0241 the Director of the Division of Water Quality may grant a
variance from applicable well construction or operation.standards provided that:
(1) use of the well(s)will not endanger human health and welfare or the groundwater;and
(2) that construction or operation in accordance with the standards is not technically feasible or the
proposed construction provides equal or.better protection of the groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation of the request.
The variance request form can be accessed online at http://portal.ncdenr.orWwebfwg/aps/awpro/permit-
applications
K. SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent.: ISA 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 offrnes and imprisonment,
for submitting false information. I agree to crrn.s uct, operate, maintain, repair, and if applicable, abandon
the injection well and all related appurte in acc 'dance with the I5A NCAC 02C 0200 Rules."
d
Signature of roperty Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQ/UIC/Closed-Loop Geothermal Notification(Rcx•iscd 4/30/2017 1 Page 3

so�O
ra OlEuoldab,;ptatlsb
�'f111�nO1ejoM
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT D NATURAL R RW I
NOTIFICATION OF INTENT TO CONSTRUCT OR OI' TE I WELLS !
These wells are 'permitted by rule"and do not require an individual permit when co e 'a ( e with
the rules of I SA NCAC 02C.0200*. This notice must be submitted prior to construc e
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.01S-01 Q,c7 (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per I SA 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._( -- bmit 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. Y
WELL OWNER"!-For single family,residences list the property owner(s). For all others, list name of the
�basiness;organization,or government agency and person delegated signature authority:
e�
r
Mailing Address: !!0 We eK Ha¢2
city: -�� State: ,$'G Zip Code'o?�9tountv:_�fc .vs
Day Tete No.: -3 ,5q Cell No.: D
IJ_MAIL Address: G ..4$e� ,Co Fax No.: ,
ODt PHYSICAL LOCA7 ION OF WELL;SITE.._•'
(1) Parcel Identif cation Number(PIN)of well site: 879-1- L
County:-MA,1)yk,! uC
(2) Physical Address(if different than mailing address): )h�j�jjilJ6 S !!2 1�17
City' State:NC Zip Code:
DWQ/1.1100osed-Loop Geothermal Notification(Revised 4/3MO12)
Page 1
I

N
p
Wc� l

',?k i ,1 y� t ,`S` .fir:`, � � • Oti � , �'
��' -'a '•,����, Qom, ,x ..,` 1'-, �"-`�=;.�-- tG�F�'', / ` ' � \
g • qp ``. a
WOO

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:
0
o p
roposed injection well locations eptic systems and associated spray irrigation sites,
° uildings drain fields,or repa)a7 areas
0
P
roperty boundaries xisting or potential sources of groundwater
° contamination S
urface water bodies
ater supply wells
W
(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 littD:t/-oortal.ncdenr.org/,Aebhv /a s! ro. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification o.: —
Company Nam ' t
�Contact Person:
City: - State: � Zjp Code47 �T3 County:
Day-Tele No.: Cell No.:
1—
EMAIL Address: Fax No.:
H. HEAT PUMP CO tACTOR fOR ATION
Company Name:
Contact Person:
EMAIL Address /J C, 401
Addres . V
City: Zip Code: State: Coun _
ZU ty:
Office Tele No.: _ _— Cell No.: 773 Fax No.:
DW'QAAClClosed-Loop Geothermal Notification(Revised 4/30/2012)
Page 2

I. PROTECTION—Provide a brief description of how(1)water supply wells; (2)surface water bodies;and(3)
septic systems and associated spray irrigation sites, drain fields,or repair areas within 250 feet of the proposed
injection wells%vili be protected during construction of the wells:
51
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 cap,be accessed online at http:!/portai.ncdenr orQ/web/wq/ans/t?woro/uemut
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 cert�, under penalty of late, 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. 1 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 related appurtenances in cordance with the ISA I4'CAC 02C 0200 Rules.
ig atu of Property Omer/Applicant
Wpc 6�'�lJ� ,SG6e�w tT'T
,. Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30t2012)
Page 3

L. SUBMITTAL INSTRUCTIONS=Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Quality Regional Office serving the area in which the injection well facility
will be located:
WINSTOWSALEM r
R -LEIGH
' ASHEVILL WASHINGTON
OREVVIL I
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 71.4 127 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 276994 628
Telephone:[phone]
Fax:[phone]
(2) County Health Department in which the injection well facility will be located. A list of county health
departments can be found online at http://ww-vv.ncalhd.org/county.htm.
I)WQMC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

7/15/2016 Corporation Details
Jon Husted Secretary
Jon Husted &the Office I Elections &Voting Campaign Finance Legislation &Ballot Issues Businesses Records Media Center Publications
$ usinessAr Portal
General Information Business Search UCC Search WTrade Mark I Service Mark Search Prepayment Accounts ' Business Report Download Y Help
I
Business Name Corporation Details
Business Name-Exact
Detailed Business Search
Number Search
Agent/Contact Name
Agent/Contact Name-Exact Corporation Details
Prior Business Name Entity Number 950105
Business Name BALDUS,LTD.
Filing Type DOMESTIC LIMITED LIABILITY COMPANY
Status Active
Original Filing Date 08/06/1996
Expiry Date 10/05/2084
Location: County: State:OHIO
Agent I Registrant Information
CCU AGENTS,INC
225 N MARKET ST
WOOSTER,OH 44691
Effective Date:08/06/1996
Contact Status:Active
Incorporator Information
WOLFGANG R SCHMITT
TONI G SCHMITT
Filings
Filing Type Date of Filing Document Number/Image
ARTICLES OF ORGANIZATION/DOM.LIMITED LIABILITY CO 08/06/1996 5585 1601
AMEN D/ARTICLES-ORGAN IZATION/DOM LIMITED LIAB.CO 10/06/2014 201428000866
Return To Search Page Return To Search List Printer Friendly Report
http://www6.sos.state.oh.us/ords/f?p=100:7:0::N 0:7:P7_C HARTER_N U M:950105 1/1

Moore, Andrew W
From: [e-mail]
Sent: Thursday,July 14, 2016 3:19 PM
To: Moore, Andrew W
Subject: Fwd: Baldus, Ltd
Mr Schmidt, submitted this response yesterday. Concerning ownership of property, see thread below.
I can resubmit drawings if needed,however the measurements off the garage will be 18' and separation
measurements off of the house will be 22 feet
----------Forwarded message ----------
From: Tom Hart<[e-mail]>
Date: Jul 13, 2016 9:17 AM
Subject: Fwd: Baldus, Ltd
To:[e-mail]
Cc:
Let me know if this is what you need.
Tom
---------- Forwarded message ----------
From: Leigh Schmitt<[e-mail]>
Date: Tue, Jul 12; 2016 at 11:34 AM
Subject: Baldus, Ltd
To: Tom Hart<tom e,buchananconstruction.com>
Cc: Wolf<[e-mail]>
Tom,
Wolfgang Schmitt is owner of the LLC, Baldus, Ltd.
Sincerely,
Wolf&Leigh Schmitt
i

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are `permitted by rule"and do not require an individual permit when constructed in accordance with
the rules of 15A NCAC 02C.0200'. This notice must be submitted prior to construction,
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in 15A NCAC 02C.0222 these wells circulate potable water only or a mixture of potable water and
performance-enhancing additives as part of a geothermal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS
As described in 15A NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: �'"� `r 20 PERMIT NO.W 01 y`'I S- (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C,0222): _ Number of wells:
(2) Direct Expansion(as per 15A NCAC 02C.0223) _� Number of wells: _ s
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence ubmit this form two(2)business days prior to construction.
(2) Business/Organization Submit this form 30 days prior to construction.
(3) Government: State Municipal County Federal Pr omr to it his for tr m 30 on.days
C. WELL OWNER-For single family residences list the property owner(s). For all others, list name of the
business,organization,or government agency and person delegated signature authority:
� ' m
Mailing Address: aA '
�n �R ide• ?J County:
City: at T c —
Day Tele No.: Cel No.:
EMAIL Address: Fax o.:
O W ftbr 6�I Mjo1 Regional Operations —/O
D. PHYSICAL LOCATIONAshevilia Regional Office
(1) Parcel Identification Number(PIN)of well site:
County: °S
(2) Physical Address(if different than mailing addressj:
City: t: State:NC Zip Code: l
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4130/2012)
Page 1

E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site-specific map showing the locations of the following:
• 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 All other additives require approval prior to use.
G. WELL DRILLER INFORMATION(if kno� n)
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification qo.. L
Cornpaxiy Name M& Contact Person:
` l
City i d n
State: V tL Zip Code: . 45 County:
Day Tele No.: Cell No.: g�lD—
EMAIL Address: Fax No.:
H. HEAT PUMP CONTRA TOR INFORMATION
Company Name: i
Contact Person: ` c EMAIL Address: C
AddreLl"
r�
City: Zip Code: State: County:
Office Tee No.: Csll No.: ZS 2�Fax Ng.;
MQQUIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

- .ems �• �- �`• '"�" 1 ' •'� Y
rj
yy
4 ni _ •
,Oil
S
aL
IA
77
i. i M(' - j 11f�� • •'^ • .yam'.". y+l'.
i `'�^•...r ; wr ,,� f� >► .y♦ P y�. tip ' `-'i-
r
i _ _r _ �r arc_. -__ __ �._-__.....-__._ __-__.______'__ -. - _�__•_- _ - ��'.

71 ,
eo
Se 4-f L

I. PROTECTION—Provide a brief description of how(1)water supply wells; (2)surface water bodies;and(3)
septic systems and associated spray irrigation sites,drain fields,or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
J. VARIANCE—Pursuant to 15A NCAC 02C.0241 the Director of the Division of Water Quality may grant a
variance from applicable well construction or operation standards provided that:
(1) use of the well(s)will not endanger human health and welfare or the groundwater;and
(2) that construction or operation in accordance with the standards is not technically feasible or the
proposed construction provides equal or better protection of the groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation of the request.
The variance request form can be accessed online at littp://portal.ncdenr.or./web/wq/aps/izwpro�/oermit-
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 1 have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are signicant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all related appurtenances in accordance with the 15-4 NCAC 02C 0200 Rules.t J oonn C5,=, kb� —
"
G
Signature of Properti Owner/A plicant
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/3012012) Page 3

d�
r
ri
d 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
{
RA,LEIGH
E t
A ASHEVILLE WASHINGTON
RE�S�' IL,L
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 hllp-.//wANv.ncalhd.or%z/couniy.htm.
DWQMC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

RECEIVED
Wslon of water Resources
FIB - 1 2017
NORTH CAROLWA DEPARTMENT OF ENVIRONMENT AND NAjM RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE a e a,�°�
io al Office
These wells are `permitted by rule"and do not require an individual permit when construc in actor ante w:t
the rules of 15A NCAC 02C.0200* This notice must be submitted prior to construction:
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in I5A NCAC 02C.0222 these wells circulate potable water only or a mixture of potable water and
performance-enhancing additives as part of a geothermal heating and cooling system.
OR
1
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 ViIl Be Returned As Incomplete:
DATE: . 20_L� PERMIT NO. d ` Z S (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C.0222): y Number of wells:
(2) Direct Expansion(as per 15A NCAC 02C.0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence I/ Submit this form two(2)business days prior to construction.
(2) Business/Organization Submit this form 30 days prior to contraction.
(3) Government: State Municipal County Federal Submit this form 30 days
prior to construction.
�C ' WEL nun For single family residences list the property owner(s). For all others,list name of the
�iSTrgauization,or government agency and person delegated signature authority:
JAI►�Ifz f k mN
Mailing Address:
City: State: Zip Code: County
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
CD-)( PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site: 0 ' —
County_ ur4ca�n g€ //��
(2) Physical Address(if different than mailing address): 3S eH B/1oR4 4AAz-o4,
City: �7ftO ts� ✓ State:NC Zip Code:
DWQIWC/Closed-Loop Geothermal Notification(Revised 4/30/20I2) Page 1

E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site-specific map showing the locations of the following:
• • P
roposed injection well locations eptic systems and associated spray irrigation sites,
• drain fields,or rep*areas
uildings
p
roperty boundaries xisting or potential sources of groundwater
• contamination . S
urface water bodies
W
ater supply wells
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services' Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at htty://portal ncdenr or b/wq/aps/ ro_ All other additives require approval prior to use.
WELL DRILLER INFORMATION(if known
Well Drilling Contractor's Name: P)eimmems
NC Well Drilling Contractor Certification No.:
CompanyNaam EIS "�tL��� (lldedl Contact Person: 1
City: ll�l ,' State:4 Zip Code-, L) 3County M)+ SD
Day Tele No.: Cell No.:—"
EMAIL,Address: Fax No.:
H. HEAT PUMP CONT TOR INFORMATION
Company Name: 1q
Contact Person: EMAIL,AddressL/ ' t '/) �Il C, nppl�
Address
City. Zip Code: s 'd 4 [ State:a' County. L0
Office Tele No.:, Cell No.: L46-0 2813 Fax No.:
MQ/U CIClosed-Loop Geothermal Notification(Revised 4/30)2012) Page 2

i
)4-
EL

211/2017 Madison County,NC
Tasks
_• IF
atGZIOA . , . ; Pant 3
Atfrmuto VL �i� $ Se31ch recalls
Pseud I15A1•,ihrr and ArreA_ a�a - �•
OBJECTm 134232 I • Taskyist
PIN 1676911237O I
Ptl Dent
Ac
res 11.57 I e7eaa12a7a aPf0Ali(61WArt.
Zoning p R-A $mmflOns
SuhdMelon I French Broad Grassing p.e
Phase2
Record of 25835
Account eu■■uilJ�26,„42�9,�,,,,,�
WtPNO Iuri
FlreDl•tAat I a
UndValu o A�OR&9e8
A
muettp I p- I •9
z
NAME oI 6PING
NAMEZ
Al
p PO BO) _
City GUFFe4 CO + ,
Slate 01 VA
ZIP 130320 I
SaeDWe I�'f !!�'t Interest
aw"ounll 62n614000 '6
DeedBook 11�T•�liannPlarnN•m�9
OeedPepe 1248
p Ze &9
Y
■
���/■��&A
. TMCA p USG$ lad
• Aerial Photos
• Gmemt
i
t
W9931p&546914 Y:791558.0988 ft 1 teaeae(e)selected on 1 layer(e) 1: 110&6B89� 713792,91604(fl)
1
1
I
1 I
r
1f
I
iI
f
I _
http.//madisoncountygis.coin/nc/madison/map.htmi 1/2

I. PROTECTION—Provide a brief description of how(1)water supply wells;(2)surface water bodies;and(3)
septic systems and associated spray irrigation sites,drain fields,or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
1
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 litty:I/portalmcdew.org/web/wq/ap o/permit
Splications
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 cent fy, 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 andall rel purtenances in accordance with the I SA NCAC 02C 0200 Rules."
Signature of Property Owner/Applicant
Print or Type Full Name
.s
Si ature of Authorized Agent,if any
Print or Type Pull Name
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4130/2012) Page 3

L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Quality Regional Office serving the area in which the injection well facility
will be located:
{
WINSTON=SALEM -
RALEIGH
WAS HINGTON
ASHEVILLE
- ILL
ORESV
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 ht!p://www.ncathd.org/coun
Pace 4

8�
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by rule"and do not require an individual permit when constructed in accordance with
the rules of 1 SA NCAC WC.0200'� This notice must be submitted prior to constructions.
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 brforination. Illegible Submittals Will Be Returned As Incomplete.
DATE: 2011 PERMIT NO. W:vo ( oon (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C.0222): X Number of wells:(3)wells @ 270'&(2)wells @ 2751
_
(2) Direct Expansion(as per 15A NCAC 02C.0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence_VSubmit this form two(2)business days prior to construction.
(2) Business/Organization Submit this form 30 days prior to construction.
(3) Government: State Municipal County Federal Submit this form 30 days
prior to construction.
C. WELL OWNER—For single family residences list the property owner(s). For all others, list name of the
business,organization,or government agency and person delegated signature authority:
l�v�Nf--Mailing Adddrreesss:� l qb t� b/S i 5_/WOZ "ff/_ 16 D
City: /r`yam YCJ2lL State: PY Zip CodaCel
Coun y: -
Day Tele No.: 9Z 7 7-3 9Z 7-6-2 .
EMAIL Address: C dM Fax No.:
MAY ji
- 2 20D. PHYSICAL LOCATION OF WELL SITEWater CtuRrf{.,F'^-.nior's Q
(1) Parcel Identification Number(PIN)of well site:8788-89-7798 Asflr;ir! r r
County: Madison `
(2) Physical Address(if different than mailing address): 112 Moon Shadow Lane
City: Marshall NC State:NC Zip Code:28753
DWQ/UIC/Closed-Loop Gcothennal Notification(Revised 4/30/2012) ( { r II ! age 1
E .
, Lj

i J
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. Inmost 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, eta 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
ht!p:Hdec nc Qov/about/divisions/water-resources/water-resources-permitshvastewater-branch/ground-water-
protection/ground-water-approved-inj ectants. All other substances must be reviewed by the DHHS prior to use.
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: ��P Vhr1101
NC Well Drilling Contractor Certification No.: —n n
Company Name: r�A W UAR Contact Person: �C' ✓ ��
City: L6 .4..&4'A State: I t C Zip Code:2y Hcounty:rn� ,S 0!J
s
Day Tele No.: Cell No.: 7-2(0- Lo&U
EMAIL Address: �1Z1 G I urn �� r Ga[7r Fax No.:
H. HEAT PUMP CONTRACTOR 1AFORMATION
Company Name:
Contact Person: �'I EMAIL Address:
Address:
City: Prs Zip Code: 19404 State: '` CCounty: �UPI � s
Office Tele No.: Cell No.: -7 40 0 Fax No.:
Closed-Loop Geothermal Well Notification Rev.3-1-2016 Page 2

\� Tosko Platt Mapp
;�w� > _ Q MM x� is �y�,y 1 ,:` sty •���.} a.':�\ �. $a�;:'?SA. � �' si; � M" :R..
It
� � y � r.�+-.�, � i 1, 1 :y w$ -5r,.,�r,� ��0 y�y,r• r��f ° y�'` .,!"
t 3 t
00
Nw
mv
,C
A r ,
r i
,
y
,
a
rT a«
+ � � � ). � - � � .. y _ • Nam`
a-
,
;w .
Y
Al
wjk,

�n
I��, Donn �h► ��I
g7S
PIA MP4 F90 WI
��Wwl

1. 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 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 htt ://portal.ncdenr.org/web/wq/aps/gwpro/permit-
applications
I— 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.
'7 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 sa
�d in I believe that the information is true, accurate and
complete. I am aware that there are si i cant penalties, including the possibility offrnes and imprisonment,
for submitting false information.
r to construct, operate, maintain, repair, and if applicable, abandon
the b jeetion well and all relate tr nances in accordance with the 15A NCAC 02C 0200 Rules."
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Quality Regional Office serving the area in which the injection well facility
will be located:
1 E
~R -
'%`
Wilmington,NC 28405
Asheville Regional Office Telephone:[phone]
2090 U.S.Highway 70 Fax:[phone]
Swannanoa,NC 28778
Telephone:[phone] Winston-Salem Regional Office
Fax:[phone] 585 Waughtown Street
Winston-Salem,NC 27107-2241
Fayetteville Regional Office Phone:[phone]
225 Green Street,Suite 714 Fax:[phone]
Fayetteville,NC 2830I-5043
Telephone:[phone]
Fax:[phone]
Mooresville Regional Office
610 East Center Avenue,Suite 301
Mooresville,NC 28115
Telephone:[phone]
Fax:[phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh,NC 27699-1628
Telephone:[phone]
Fax:[phone]
Washington Regional Office
943 Washington Square Mall
Washington,NC 27889
Telephone:[phone]
Fax:[phone]
Wilmington Regional Office
127 Cardinal Drive Extension
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/3012012) Page 5

3S_0 7�f'bv'�
NORTH.CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
TIFU-ATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
e wells U a ermitted by rule"and do not require an individual permit when constructed in accordance with
® #fides of 15A NCAC 02C.-0200*` This notice must be submitted prior to construction.
N o_ o GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As>edcribe(9nC-ormance-enhancing
A NCAC 02C.0222 these wells circulate potable water only or a mixture of potable water and
r additives as part of a geothermal heating and cooling system.
a)
c 5 C_ OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS
AsscribePm 15A NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
DATE: �e�-u ' , 20 PERMIT NO. LyTo 1 00 S_L5' (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(asper � Number ofwell 3302 t
(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:
Mailin Address: ,
City: UI i State: Zip Coder County: (tit l� C�
Day Tele No.: . Cell No.: 4q
EMAILAddress: C-fh-A Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
1 Parcel Identification Number of well site:
County: M.A i S 0 V\
(2) Physical Address sf;�il
different khan mailing address):
C�LI ^ 18 La s, ��� �Ct
`
City: NV03—- [N gAN State:NC Zip Code:
E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow Attach a
site-specific map showing the locations of the following:
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 1

• 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]=://portal.ncdenr.or web/Nvq/aps/ 3ypro. All other additives require approval prior to use.
F,�A lA i ab �.
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Josh Plemmons
NC Well Drilling Contractor Certification No.: 4137A
Company Name: Clearwater Well Drilling,Inc. Contact Person: Jeff Moore _
City: Hot Springs,__State:NC_ Zip Code:28743 County:Madison
Day Tele No.: 828-776-6526 Cell No.:
EMAIL Address: [e-mail] Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:Bullman Heating&Air
Contact Person: Josh Guthrie EMAIL Address:joshg@.bulhnanheating.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
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

x
o _
J
Q
CRDO�
(1) IhI f

1 1 ArcGIS-Madison County,
County,Madison
' ,' ' ' .4i ,` r� `Af!�t ~ � t •',�r�11�.3a' Y ,i" gtl�:yr_:
` - `` `{4`04�141EA�b�•� �Rp �`� `•'
.
Shows parcels of Madison County,NC
r�rk t lr, � •%.Y A
,,;� � } _`fir' � l � `' '"h, `I �-l 'r•'
Oft
Microsoft
+ 0
1 12 , /
R �

I. PROTECTION—Provide a brief description of how(1)water supply wells;(2)surface water bodies; and(3)
septic systems and associated spray irrigation sites,drain fields,or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
�te� /
V
1
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 htta://portal.ncdenr.org web/wq/aps/ vpro/permit-
apnlications
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 on aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
Signature of Property Owner/Applicant
�MiCtti1 �• ��SC9�
Print or Type Full Name
Signature of Authorized Agent,if any �.
Print or Type Full Name
` MAY 2 0 2020
^late;-QuaI y Regional Operations
i Asi-leville Regional Office
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4130/2012). Page 3

L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Quality Regional Office serving the area in which the injection well facility
will be located:
VONSTOWSALEM"
RALEIGH
WASHNGTOK
, ASH ILLE
0 OR OR,
TAYETTEVILLE
Washington Regional Office
Asheville Regional Office 943 Washington Square Mall
2090 U.S.Highway 70 Washington,NC 27889
Swannanoa,NC 28778 Telephone:[phone]
Telephone:[phone] Fax:[phone]
Fax:[phone]
Wilmington Regional Office
Fayetteville Regional Office 127 Cardinal Drive Extension
225 Green Street,Suite 714 Wilmington,NC 28405
Fayetteville,NC 28301-5043 Telephone:[phone]
Telephone:[phone] Fax:[phone]
Fax:[phone]
Winston-Salem Regional Office
Mooresville Regional Office 585 Waughtown Street
610 East Center Avenue,Suite 301 Winston-Salem,NC 27107-2241
Mooresville,NC 28115 Phone:[phone]
Telephone:[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 htti2://www.ncalhd.orp-/counM.htm.
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4