Rutherford UIC Deemed Permitted 2012

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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are `permitted by rule"and do not require an individual permit when constructed in accordance with
the rules of 15A NCAC 02C.0200*. This notice must be submitted prior to construction.
GEOTHERMAL AOUEOUS 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: 1 July 20_13_ PERMIT NO. (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C.0222): Number of wells:
(2) Direct Expansion(as per 15A NCAC 02C.0223) X Number of wells: 5
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:
Thomas &Beverly Bohle
Mailing Address: 960 Hearthstone Drive
City: Union Mills State: NC_ Zip Code:28167 County: Rutherford
Day Tele No.: 336-785-2252 Cell No.:
EMAIL Address: tbohlel 12(a)gtnail.com Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site:tax PIN #1644353 Hearthstone Ridge Lot No. 112
County: Rutherford
(2) Physical Address(if different than mailing address):
City: State:NC Zip Code:
DWQ/U1C/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page I

E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site-specific map showing the locations of the following:
P
roposed injection well locations eptic systems and associated spray irrigation sites,
• drain fields,or reps$areas
uildings
• • P
roperty boundaries xisting or potential sources of groundwater
contamination S
urface water bodies
W
ater supply wells
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services' Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at http://I)ortal.ncdenr.org web/wq/aps/gwnro. All other additives require approval prior to use.
Water is the only additive used for the bore hole drilling process.Geo Supergrout will be used as the grout for
the installation of the direct expansion earthloops. Please see attached MSDS for Geo Supergrout.
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Joseph G Smith
NC Well Drilling Contractor Certification No.: 3362-A
Company Name: Smith Drilling Services,LLC Contact Person: Joseph G Smith
City: Conyers State: _Georgia_ Zip Code: 30094 County: USA
Day Tele No.: 678-201-9849 Cell No.: 678-201-9849
EMAIL Address: jgsmith42776 gmail.com Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Grovatt Mechanical&HC Heating&Cooling
Contact Person: Ron Jones EMAIL Address:hcheatingcoolingPyahoo.com
Address: 199 League Rd.
City: Simpsonville Zip Code: 29681 State: SC County: Greenville
Office Tele No.: Cell No.: 864-325-8289 Fax No.:
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

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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 Quality Regional Office serving the area in which the injection well facility
will be located:
INSTONrSALEM... I c �
4
w R4EIGH
AgHE,VILLE ?-.' \WASHINGTON
FdY&TEUILLE
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 littp:/hvww.ncal lid.or /cg ounty.htin.
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

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MSDS: GEO SuperGrout
Material Safety Data Sheet
Section 1:PRODUCT AND COMPANY INFORMATION
Product Name(s): GEO SuperGrout
Manufacturers Name: SuperGrout Products,LLC
PO Box 3484
Saginaw, MI 48605
Telephone Numbers: [phone]
Product Use: Thermal Conductive Grout used in geothermal or other bore holes. GEO
SuperGrout is a "single" bagged material when water is added, can be
directly poured,placed or pumped into geothermal or other bore holes.
Section 2: COMPOSITION/INFORMATION ON INGREDIENTS
Component Percent CAS OSHA PEL-TWA ACGIH TLV LDsp(Mouse,
(By Weight) Number (mg/m3) TWA(mg/m3) intraperitoneal)
Portland Cement Proprietary 65997-15-1 15(T):5(R) 10(R) NA
Calcium Carbonate 5-50 1317-65-3 15(T):5(R) 10(T) NA
Calcium Oxide 0-30 1305-78-8 5(T) 2(T) 3059 mg/kg
Calcium Sulfate 1-10 13397-24-5 15(T):5(R) 10(T) NA
Silica Fume 0-10 69012-64-2 NA 2(R) NA
(Amorphous Silica)
Magnesium Oxide 0-10 1309-48-4 1 15(T) 10(T) NA
Crystalline Silica 0-10 14808-60-7 [(10)/(%Si02+2)](R) 0.05(R) NA
[(30)/(%SiO2+2)](T)
Section 3: PHYSICAL AND CHEMICAL PROPERTIES
Physical State: Solid(Powder). Evaporation Rate: NA.
Appearance: Grayish to Tan Powder pH (in water): 12-13
Odor: None Boiling Point: >1000`C
Vapor Pressure: NA. Freezing Point: None,Solid.
Vapor Density: NA. Viscosity: None,Solid.
Specific Gravity: 2.2-2.5 Solubility in Water: Slightly(0.1-1.0%)
Section 4:HAZARD IDENTIFICATION
Geo SuperGrout contains a small fraction of Portland cement and/or Portland cement derivatives which
are fully disclosed in the following Hazard Identification. These factors are clearly defined beginning
with the word "Cement" in the following disclosures. These disclosures are common in ordinary
Portland cement and Portland cement mixtures. The remaining balance of ingredients are inert and
pose no hazard requirements other than silica exposures, which are fully disclosed under the cement
disclosures.
Page 1 of 4

w_S11iPERR® T
MSDS: GEO SuperGrout
Emergency Overview: Cement is a solid, grey, odorless powder. It is not combustible or
explosive. A single, short term exposure to the dry powder presents
little or no hazard. Exposure of sufficient duration to wet cement, or to
dry cement on moist areas of the body, can cause serious, potentially
irreversible tissue (skin, eye, respiratory tract) damage due to chemical
(caustic) burns,including third degree burns.
Potential Health Effects:
Eye Contact: Airborne dust may cause immediate or delayed irritation or
inflammation. Eye contact with large amounts of dry powder or wet
cement can cause moderate eye irritation, chemical burns and
blindness. Eye exposures require immediate first aid and medical
attention to prevent significant damage to the eye.
Skin Contact: Cement may cause dry skin, discomfort, irritation, severe burns, and
dermatitis.
SECTION 5: FIRST AID
Inhalation: Remove to fresh air immediately. If breathing difficulty occurs, seek
medical attention and administer oxygen if coughing and other medical
symptoms persist.
Skin: Wash skin with soapy water and rinse with clean cool water
immediately. Apply moisturizing lotion to dry and irritated skin areas.
Seek medical attention in cases of severe irritation and burns.
Eyes: Immediately flush eyes with large quantities of water, flushing for 15
minutes include under the lids to remove grainy particles. Call a
physician immediately.
Ingestion: Do NOT induce vomiting. If conscious, have victim drink plenty of water
and call a physician immediately.
SECTION 6:HMIS HAZARD RATINGS
Product Rating Scale
HEALTH: =1 Insignificant =0
FLAMMABILTY: =0 Slight =1
PHYSICAL HAZARD: =0 Moderate =2
REACTIVITY: =0 High =3
Extreme =4
PERSONAL PROTECTIVE EQUIPMENT=E Chronic Health Hazard=
(E=SAFETY EYEWEAR, GLOVES, DUST RESPIRATOR)
Page 2 of 4

h
FNORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTIONCD
WELLS o ca
These wells.are 'permitted by rule"rind do not require an individual permit when constructed in p O `�
accordance with the rules of 154 2VCAC 02C.0200. This notice must be submitted prior to s
construction. O O
n
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS CD
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. � QXQQZZA-j to be
completed by DWR)
B.
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL
/T'O BE CONSTRUCTED
(1) Aqueous(as per i 5A NCAC 02C .0222): V Number of
wells: 1
(2) Direct Expansion(as per ISA NCAC 02C .0223) Number of
wells:
B.
C. 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 forms 30 days prior to construction.
1
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=. (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:
-5 L o +• e yr+ S nn
Mailing Address: m p K
City: R V_,t�'e4-4�4]2rt State: JL Zip CodeyIlf•ICounty: ka f'_J
Day Tele No.: 1 g'} '2 y .i - f(a 1 Cell No.: vZ S7 7 q f � q a
EMAIL Address: Fax No::
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site:--/ to I I D
county: A Cou
(2) Physical Address(if different than mailing address):
11b P kol
City: f'ker �k n State:NC Zip Code:a 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
• Buildings
z
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1
• Property boundaries
• Surface water bodies
• Water supply wells
• Septic systems and associated spray irrigation sites,drain fields,or repair areas
• Existing or potential sources of groundwater contamination
(2) Plans and specifications of the surface and subsurface construction details of the well
system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be
used and their 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
litta:/.portal.ncdenr.orgiweb/wq/aps,'�:w•pro. All other additives require approval prior to use.
Fhk"rrona, a00o
a I V►ts -j 4 f
3,Q !� 4% o ►tS f rny rb�%al
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name: Contact Person:
City: State: Zip Code: County:
Day Tele No.: Cell No.:
EMAIL Address: FaxNo.:
3
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H. HEAT PUMP CONTRACTOR INFORMATION ,/� J
Company Name: 1 o res t _ �'-t [-T �• nC� �"1 !
ContactPerson: EMAIL Address:
Address: 4467
Cit, FC r es C L '{" Zip Code: a$0'f 3 state:W& County: -tr�ccL
Office Tele No.: Cell No.:(�� q.2 3o�
4
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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:
-sx t n�
J. VARIANCE—Pursuant to 15A NCAC 02C .0241 the Director of the Division of Water
Resources may grant a variance from applicable well construction or operation standards
provided that:
(1) use of the well(s)will not endanger human health and welfare or the
groundwater;and
(2) that construction or operation in accordance with the standards is not technically
feasible or the proposed construction provides equal or better protection of the
groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation
of the request. The variance request form can be accessed online at
http:!,'i)ortal.nedenr.org/web/wq/aps/gwpro/permit-app 1 i cations
K SIGNATURES — The following section is to be completed as required below or by that
person's authorized agent. 15A NCAC 02C .0211(e)requires signatures as follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner or the
proprietor,respectively;
(c) for a municipality or a state, federal, or other public agency: by either a
principal executive officer or ranking publicly elected official;
(d) for all others: by the well owner;
(e) for any other person authorized to act on behalf of the applicant:
documentation shall be submitted with the notification that clearly identifies
the person, grants them signature authority, and is signed and dated by the
applicant.
I hereby certify, under penalty of law, that I have personally examined and am familiar with
the information submitted in this document and all attachments thereto and that, based on my
inquiry of those individuals immediately responsible for obtaining said information, I believe
that the information is true, accurate and complete. I am aware that there are significant
penalties, including the possibility of fines and imprisonment, for submitting false
5
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information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance ivith the 15A NCAC 02C 0200
Rules."
SignVture of Prooerty OwnerlApplicant
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
6
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Y
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 the
injection well facility will be located:
7.
F4Y�L,L. E J
a �
Asheville Regional Office
2090 U.S.Highway 70
Swannanoa,NC 28778
Telephone:[phone]
Fax:[phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville,NC 28301-5043
Telephone:[phone]
Fax:[phone]
Mooresville Regional Office
610 East Center Avenue,Suite 301
Mooresville,NC 28115
Telephone:[phone]
Fax:[phone]
Raleigh Regional Office
1629 Mail Service Center
Raleigh,NC 27699-1628
Telephone:[phone]
Fax:[phone]
Washington Regional Office
7
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r
943 Washington Square Flail
Washington,NC 27889
Telephone:[phone]
Fax:[phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington,NC 28405
Telephone:[phone]
Fax:[phone]
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem,NC 27107-2241
Phone:[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:i'/,.vwvv.ncalhd.orL,/countv.htm.
8
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Kuthertord County,NU Print Map Page 1 of 2
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1838815
'+1Bi1D35
1849079
1811033
f 1611032
Vu
1�4�II
1SS713$
11a4 1845t'-04
1t345843 58458�5
iA4
Rutherford County, NC
Disclaimer:The Information contained on this page is NOT to be construed or used as a"legal description".Map information is believed to be
accurate but accuracy is not guaranteed.
Parcels
GP1N:1507006815220000 ST SUFFIX:RD Sale Price:46500
Mp Block Lot:641 11 C ST NAME:CAMP Neighborhood Dese:AVERAGE RURAL.
Owners Name1:SAMS EDWARD SCOTr ST NBR:280 Neighborhood Code:A34N
Owners Name2: SAMS RUTH D Census Block: N Deed Bookand Page:5581217
Address 1:280 CAMP RD Road Type:5 Deed Date:4/26/1990
City: RUTHERFORDTON Property Dose:RES SR 1147 Nbr Land Segment:4
Stage:NC Township Code:14 Numb of Bldgs:2
Zip:28139 Account Number.15023567
Bldg Value: 115600 Acres: 13.78
Land Value:58300 Property Address:280 CAMP RD
Total Value: 173900 Tax PIN: 1611033
Stamps:46.50
Attributes at poin ,N:578498, E:1106099
Census Tracts Watersheds Soils Commissioners Fire Service
Tract: 9604 Class: Soil GrE Districts Districts
River Basin: ID: Name: Union District: ORA
Stream Watershed Protection New Name: 34
Name: Area
Voter Districts
Precinct Union
Commission:3
Township: Union
httnl/www.webeis.net Anderson a Associates.Inc. httoi/www.andassoc.com
http://arcgis.webgis.net/nc/Rutherford/prinmble.asp 8/27/2013
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May`Q3 14 08:17p p.1
lk
tr
Green Rive-Well&Pump Co. Phone 82M93-1200
132 Crest d_ Fax [phone]
East Flat Rock, NC 28726
i
T« Andrew Moore .From: Bryant Smith
Fam 828-299-7043 Pages: 5 incl.cover sheet
Phone: Date: 5-3-14
no: Geothermal application for permit CC:
0 Urgent 0 For Review 0 Please Comment ❑Please Reply
Please see the attached application far geothermal permit. Thanks,Bryant Smith
I

May 03 .14 08:17p p.2 ,
Forest City Heating&AC 828-245-2505 p,I
NORTH CAROLINA DEPARTMENT OF IEM-WONVIENT AND NATURAL RESOURCES
rFOT�'I�4�j ION OF Pl'I`ENT TO CONSTRUCT OR OPERATE INJECTION VM LLS
T'h esewdls an permhad by rtde"and do not regafre an fiuGvidualp_m_&n j_u consb tnctad in areor+dmwo with
the of I S.j 'VC4 C 02C.fQ2QQ. Z7tis notice must be subw&W Briar to cora n-
Q7'HEi2D+iAL AQUEOUS CL[Q�SEI3-IA0P WELLS
As desen-bod-in 15 A NCAC 02C. 2 2 91C=wdEs c h-mdue potable wato-ody or a to ofpotable water and
ing additives as part mfa geotbetzz d tioWng and cooling wjs=
• OR
I
GEOTHERMAL DW.C,r EXPA1VSION CLOSED-LOOP M—MLL5
As described in 15 A NCAC WC.13223 obese walls CbMilift a tefrig==PS as part of 8 fiWb inB1 beating and
calling sy►stema.
Print aewiy or Tjptlxfordt a6m nks4w Subwabb FFAU Be-Rmrmied 4s htcnravfd-
DATE_ Zg PERMIT NO.W fQ l b O 2.6'—�k (to be compoled by DW R)
A TYPE OF�EO7IMUMAL CLOSMLOOP WFLL TO BE CONSTRUCTED
(1) d,qizous(as per ISA NCAC 02C.�zt: a
�7( Number of wells:
(2) Direct Expansion(as Per I�SA 13CAC 02C _Ji_L_ Number or welts:�.
B. STATUS OF WELL OWTWX(cttooar ane)
(1) SfMgle Family Rv idencc Sabuii tlua Form two(2)busimess dwp priorto couetteolon-
(2) B Sibmit dtb form 30 days prior to c onsiaxzctiea.
(?) Gov state mmucgnjja County� FederrJ_1_n1 Sabmdt this faun ail daps
prior to construction-
C. WELL OWNER—For s ftk faa'dly residences list the propatyy ov'Dez(s). For a!l OdRM list name of the
business,e%=!=4cn,or gav=mem agency WA person delegmd stgmvze authotzty:
i4iaiil4 Addms• Its Z: -
Cit." a--C�- State: ► C- zip Coda?Z4 y jcouaty:_iE'r.� ,,�.
T*TeleNo.: - 1e Cell No: erzq) QLci - %2fd
EMAII.Address: Fax N o.:
D. pE[ysjcALI ocA.U0N OF WELL SM
(1) Pamol Idtntitc afum Number(PLN- )of well site / 6
County:
(2) Physical Address Cif difletetm than mailing address):
a1r. State:NC Zip Code:
UICdGlaeo�-JAcp GtotL®d mgri=m m(x=scd&W2013) page 1

Z May',03 14 08:17p p.3
Forest Qty Heating dt AL 828-24b-2b0b p.2
I
E.
APS,PL kffli,A"SPECMCATTOM
(1) M2 ps must be scaled or otherwise accurately indicate distances and orknLabons of features located
wil him 250 float of the injection walt(s). ULM a!I features clegrly gad tdu&a vgdbarrow. AtWA u
trap showing the Ioaabons of the fbHowin g:
0 Proposed iIIJeWDn Well locations • Septo sys[ema wW associmd spray iaigWca
• Ruddingc site;+ drain fields,or repair areas
• Property bomtdaries
• Surface wwakT bodies • fisting or potential satuves of groundwater
a Water sup*Was Oantmuinetian
(2) Plabs and specifications of the smfaae aird subsurlimc cons", on details of the well system.
F. TYPES AND CONCENTRAIMONS OF ADDI•tTVES-List an) additives*at will be used and their
cc nccnaz ens.. Only additives that the Department of Health and Human Services"Divisum of Public Health
deacrmines do not adversely affect tunum health shall be used. A list of appoverl additives can be found
online at httzf nudem.orglweblw9 n' ro. Ali otfter additives n quixt appmva prior to uae.
!
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G. WELL DRIIL XER TNFOR.MATION(if lozown)
Well Milling Coulsaator's Name:
NC'Well Dr-Wq tr8LM Cettifica&n No,:
Conway Nave: 17a&k •uir o Ptason: ��� ,r11
City: E ELL Koek State: � Zip co&-20 LCounty: �Fw�r i2 S AstJ
D?av Tele Na.: g ` G 3"l�•OCR Cell No.: %Z C? /
€MAIL Address: �l�ty'r_-"� is�If ,OFyJI SOc ( %�tax Ne.. Tz z ' lI L
FL HEAT PUMP CONTRACTOR ENFORMATION
CompamgName: r t 1
Contact Pelson: t o+�14 Address G u i �o�f�•,e�
Address: li S-7 �• F1 f�� r � �•
ary- _C�_ ZIP COde1 Z Trg"t ,�.,.,_ State-&!.Cottaty: .,4";>1 Lr 4»rj
03ceTelel4o.: C$Z� Z t+�-13?� Cei1PIo._��lLf�'-12�- b51Y3 FaxNo.:
IAClMmxW—P Gmd*zaw No ma PCvisad 8/5=3) Pepe 2

May 03 14 08:18p p.4 m'.
Forest City Heatirg&AC 828-245 2505 p.3
i
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L PROT1vCnON—Prm ids a brit-desc+ipdoa of how(1)water supply walls;(2)s:aface water bodies;and(3)
septic systems and associated spray iirigaton MWs,drain fief,or repair areas within 25Q feel of the Froposed
injecdon wells will be protected doting conbvGtion ofthe wells:
J. VARIANCE—Pwaua„ctto 13A NCAC 02C.0241 the DhccboraftW Division of Nate-Resources may graait
a,,=mcc tram applicable well xrtsirwdon or oparagon standards provided Itot
(1) uwr of the wells)gill not en idk;W human bealth and welfare or 11m grou»dwat~r,and
{2) t;sat construction or operation in ac000dance vdththe standards is not techrfically feasible or the
proposed oorstimton pravxks equal or better protection cfthc gtoundwaler.
Any variance request should accompany submittal of this notification to expedite evaluation of The mq=L
The-yado=r+egueg form can beaccmW cofae at htaa:tFnartal nedenr orgLweb;wa/aoa'Cwuroluerwii-
�nlicatjons '
K. SIGNATURES—Tbf fclloVmg soadon is to be,M mpleted as required below or by that person's am&Orii=d
agaL 15A NCAC 02C.021.1(c)requires sign toresasfatbws:
(a) for a corporation. by a responsible corporate officer;
(h) for a partnership or sole proprietorship: by a genum1 par um or t@te propri r,tcsgectivaly,
(c) for a madckoli!y or a state,federal,or other public agency: by either a grincrpai executive
officer er ranidng Publicly elecmd ofracisl;
(d) for all others: by the well owner.
(e) for any odw person authorized to act on bdaralf of the applicant: docwnentatim shall be
submitted with the notifccation tbi clearly identifies the person, grants fhem signamm
avibority,and is signed and dakd by the applicant.
"I hmvhy caigly,voider penalty of 1m4;Char I ha re personalTy eramined and m,T.fawdwr wirh tke information
.submitted in LWdortmle)tt iurtentr aW all a� Iherety and tha; based on ary Inn �v of:hose inrlividvals
irrvtr zRwely revwxsibic for obtabibW said irfarPoado; I believe that the byfw7nafion it twee, accusate and
comrplete. 1 tin aw4w a that there are sFSn frrxint penak&sti bwjz di rg the p=th ility of fu^.es and iv p uoxmemt,
frr subvniring false it fornranort. I agree to construct;dlw&e, mmwaA repair, and if e*pI cable; abandon
the Wertion weiR and all Fria dd 0jFjxd '=CdS in ccordtmce wino the l5,4 Ar AC 02C 0200 Rates."
Sigos+are of Pro�tq�Svner/Apptie�at
Fruit or IVpc Fall r4 me
Signomm ofAutboihmd Agwk if any
Print ar 7hu Full Name
I
UIGCImed Lacy Gwdc=at Nofi5catim(Revised&5/2013) Page 3

Forest City ieatir-g&AC 628-245-2505 0.1
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05/05/2014 17:43 8286931200 GREEN RIVER WELL PAGE 02
F0r®$t City 4®atirg&,AQ 82$245.2505
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05/05/2014 17:43 8286931200 GREEN RIVER WELL PAGE 01
Green River Well&Rump Company
132 Crest Road
PO Box 204
EaSt Flat Rock,NC 28726
828-693-1200
828-692-6116
r nrlverw 119DkIlsouth.net
DATE: 5/5/14
TO: Andrew Moore
FROM: Bryant
FAX#: [phone]
PHONE#: [phone]
RE; Geothermal well

1 �f
- R� [Cj✓!� SIG �I4G/
NORTH CAROLINA DEPARTMENT OF ENMONMEW AND NATZJRAL RESOURCES
NOTIFICATION OF INTENT TO,CONSTRUCT OR OPERATE INJECTION WELLS
These wells are perrrined by rule"and do not require an indfvidud Nrmd when eked ivr n
ccmdame with
dxndesqfL-_54NCACO2C 0200 _This►gce imut be mimed rwiorto
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described ll 15A NCAC OTC 02'�a_#Nse wells d=1aae.potablc watcro*or a rn�of potable waw,dad
additives as part ofa geothemral heatmg and coofing system.
OR
GE TI ERMAL.!)BW 'EXPANSION CIMED-LUOP WELLS }
As described in 15A NCAC 02C.0223 these wells chcah e a refirigetant gss as pact ofa geothretal heating and
coaling system. l
PdM Clqurfy.or TYPC1nf0rMW & IUegWeSmbe&ffir-WiUBtRMwnedAs incompre&-
©ATE: /I I - 20 /.'Y PERMIT NO.W 10e3 C i (to be completed by DWR)
A. TYPE OF GEOTfIERMA.L cLOSED-LpOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C.:0222): Numberofwells• I
(2) W=d EVansion(as per 15A NCAC 02C.02231 Number.of wells=
B. STATUS OF WELL OWNER(choose }
(1) Singe Family Residence Submit this form two(2)business days prior to conswKfimL
{2) Business/ .Organtz�sn Sebmif.tlYis form days prior
a.
(3): Gores stars M�micipa. �y
Federal 5nbetit tiis.fora 30 days
prior to cosshmcdoo. 4-
C. WELL OWNER For single family residences list the property owners) For all afficts,list Heine of.the
business,019ani2ation,or;government agency.and person delegated signature authorm•:
DL\v ; d � rSK�
Ma7ing AAdre§s- tJw, L9,7
City: state: EL T.ip Code_3-302 Itouw Lf-o t�E�
Day Tele No:: »'.5- 3 z.3- 112(- Cell No.:
EMAIL Address_ C,( l°aAe,Cotax No.:
PHYSICAL LOCATION OF WEL,L'STTE
(1) Paroel Identificatian Number(PIN)ofweII.site:-_ BCD 17,3
(2) 1`103 cal Address(MMm man 1113111l1g address): ITZ Mae f,
City- Stare:NC 2rp Code_.. �2,g .N .
t1IGCksed-Loop Good N*dfi ti a(Revered 8/52013)
Pa6e'1

E. MAPS„PLANS,AND SPECIFICATIONS
(1) Maps most be scaled:or otherwise.acxiaatety mdi :distances and,orientations of features located'
Within feet of the injection,well(s). Label all feataees clearly and include a north arrow. Micah a
sib-�ecific maO.showing the locations ofthe f Mowing.
0 Proposed injection well locatiarns • Septic systems and associated SPA' krwdion
'
Buildings' sibes,.draip fields,or repair arms
• Property boundaries
• Surface wager bodies • Existing or .potential sources of groundwatu .
• Water supply wells contamination
(2) Plaus and spec cations ofthe surface and subsurface construction details ofthe-well system,
F. TYPES AND.COjNCEMMATIONS OF ADDMW S=.List.any additives that will be used sod than
C cenhadioffi, Only additives thatthe Departmft of Health and Human Services'Division of Poh&Health
determines do nut advefwly affax human health shall be used. A list of approved additives can be found
online af:tittp linortat nctienr ark/web/walapsli waro. All other additives reguue-approval pirior t+u use.
En yl.(G►lo f: (S to CoslCe r-T
G: MLL DRILLER INFORMATION(if wn)'Well Drilling_Cantractoes'Nww c. rI7 tIL.
NC WaDn'lling Cerdfic oallo.:
Company}"Name: sori:ContactPer /3I2 'OkJt . V;
City: F. A/rjt R'[7 4C smw:&C zip coaeG Coumy: &-Av����5 eok/
DayG 93 . I oy Ceuxo 572 LI�Y-S?7��i
Teie:No:
EMAR:Address:- &A6 A Fax No:. E 9
H. HEAT PUMP CONTRACTOR INFORMATION
Ca mpany Name:777..Fn Ire s f
ContactPerson: -c.; EMAIL..Ad um t C'�►C' -i. i : 'Sc�(I Ui<�N 7'
Adams:.
City EG C 2 j t i i-V Zip 13 Sta :.&C Corr✓ ' C r'
OiEce. Td[eblo.: Cel1No'; .13 - $�I=GZ�I� r.No.: �l?$- 5--.2 5
[tIGCt° I ooP.Cxathamal Neon(Revised&MO13) page 2
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Forest Cry Heating&AC 828-245-2505 p.i
U PRt]'FF.£rf N-Provide a brfcf dmdptfdm of bow(t)water m**welL,;(2)sm am waW tmd(k
segue Syst=and assocm d splay uttgUn sites,ftin field%or$glee sera$within 250 feet of the p¢
ntjec ion wells w�l be pmemd du rmg o€t€;e trelEm
i
J. VARL4NCE-Pmwj=to 15A NC A C 0-IC_02-i I the Di ecw of the Divisive of Water Resmates may grant
a £Tam appgcab;e well coustnTCE an or aperatim standards provided their
(1) M of tlrc wmll(ss)will sat mdmrw hutnme heW&and welf lra or the 9mmlwatm,-and
(2) ft COMM==Of opcMian in accorcimce with tht standards is mattwkumlly fiaEsi ge or tide
Proper Oodshuctiou provides equal or better protextim of tie groundambu.
AuY Ya3mDQc tegtest stndd acoompaFty submittal offtlris nouftmoa jo expedite evefu>gim oftire
Ih-^v-iaa-1e40=fa m cm be acted otthme ai ttnp:pWaI nadtnr[fir;��eb%%c ins �� ncrnti
a�pl iC2.L•cttta I
K. SiGWATUIM-The solfowatg section is to be cmapleted as requited below or by that pawn's authnd ed
egexn. 02C.021 i r-1 raquLms sjgoSUu=as follows:
(a) far a amporadoo: by a tesponsib{c caqwrate officer,
CO) for a pwmcrship dx Ede WOXkWMW by a 8CI]eMl PWMW OF lb-I KWdCMr,Mp=IiV y;
(c) fdsr a m1micp6lity or a state,fia mat,or other pubi'ec agency: by either a primsipal cm=tm"
ofRcer or raaldmg pabiklY cle cted olTi -d, I
(d) for all ott em- by the wen awoer I
(e) far sev othec person auftri=d to act om•beWf of die applik t= demon shag be �
subs with the ncd&attion that Clearly ideatifim the prrsno, grants thcm sigantdut
autharity,and is signed and damd by ft applies.
I
"t hereby c r6, WUAEr pe=lry r f taw, Nut I kmW fitly mmimd and cmfbmwjdw,urith rF,e n#brrauron
3i[<iitRitt�'in this document and all cPacli we thowo and AA based on my ugvuy of Aram imdrqwFuau
imrne x®jy reTOAMltde fzv o8r'amv said agbmmum I belle-me tkw the itrfarmarim is rslee; arm cmd
coMWWa f ma axara urn AM 42?z stgavfraaV , iaarl:adirrg try POmL&W&y cy'ftm rs ard unprisummit
:a sri& rrrrrrg f�;afOraaamn I agree ro cmcsorc; t vtsafrrtak upon;and if appki aWa ab-ekm
rfre b�tws wr1F and al! �viCir the "
f-v
Print or Type Full Name
154patutre of Asti wimmd Ayent,if any
Prlat or T}pe FU m Mums
JIC1l -ioW Cienftff mg 2:OdG=Vim(Revise£ZWO t3) Pr,gc 3
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