Transylvania UIC Deemed Permitted 2015

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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTICb`3iCAT][ON OF VffUNT TO CONSTRUCT OR OPERATE INJEG'I`ION WEL"
n4?Je wells are permtued rr),,,rule"and Flo rrot regc:iro an individual permit when cOm ucted in accordance;rids
0,-,-ules of ISA�CAC 02C.0200t M notice must be submitted prior to consbuedon.
GEa.F1 RlNAL AOITEOUS CLOSED-LOOP HAU S
As dcscn'bed in 15A NCAC 02C.0222 these wells circulate Potable vwmcr only or a mixmm of potable water and '
performance_c, z=ncn►g additives as pert of a geothermal heating sad cooling system.
OR
GEOTHU MAIL DIRECT EFPANSION CI l4;D-LOOP WELDS
As described in 1 SA NCAC i12C.0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print Clearly or 71 pe Information Illegible Sirbmitfc&WN Be Returned As Inwinplefe:
DATE: 20 (IS aNM NO. NN$ 10 03 (to be completed by DWQ)
A. TYFE OF GEOTEE]1ZI411AL CLOSED-LOOP'NWILL TO BE CONSMUCTED
(1) Aqueous(as per 15A NCAC 02C..0222): . Number of.wells: 3
(2) Direct Expansion:(as per 15A NCAC 02C.0223) Number of wells:
I& STATUS OF VPEI.L 0 V_N=(choose one)
(1) Single Family R sidence X Submit this form two(2)business days prior to construction.
(2) Susiness/Organ m,tion Submit this foram 30 days prior to construction.
(3) Government; Stitt; Municipal County Federal Submit this form 3Q0 days
6tu"�:x `.i.'s:iY:%TY::'c. c�'..•'•':wi+.`:r:r2i^:rG�`:'.Y'1!':..U'`�r'.%!.
I� .T5.3r:Y+.. _.:"�'Y�Cf941}Gi�°�l t99:F1-.:+h• 11raah"u.:_•a�+5:-_+,-
C. WFLI. OWNER—For,;single family residences.list the property owner(s��rY: flr.al?;;�►th :,list;1*0.c,:Pf
business,oanization,o1 government agency and person delegated signati3r
ECENED
y � Division of Water Resources
Eke,I fa 0 r ,
Mailing Address: i; t M A A -
City State: Zip Code: C6us* _
Water Quality Regional Operations
Day Tele No. Cell No.: F"' i
I, 'Regional' TJiiiL`7-
EMAIL Address: Fax No-: r : . ... . 1:... :•,;:... ::,;::.
4.�nar.•-
D. PE fSICAL LOCNTIQN OF WELL SUE
.(1) Parcel identification Number(PIN)ofwell site:
County: Y[ let l+Wtlh
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(2) Physical Address(if different than mailing address): (sale $t(e 11111
Lit AF0. 81ca Kn I
City:- Rt State:NC Zip Code:
I
DwQRnaCtose,& oop Geothermal NBti;cation(Fevised agora 12) Page 1

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T. MAPS,PLATYS,AND Sj(%CIFICATC'IONS
(1) maps muse be soiled or otherwise accurately indicate distances and orientations of featureslocated
within 250 feet gFthe infection weil(s). La]sel all features clearly and includc a north ario . Attach a
site-specific malij showing the locations of the following:
a Proposed inyibcdon well locations o Septic systems and 9mciated spray irrigation
a Buildings sites,drain fields,or repair areas
e Property bo>ndaries
s Surface wathr bodies • Existing or potential sources of groundwater
Water suppl4 r wells contatmmnation
1•
(2) Plans-and specil cations of the surface and subsurface construction details of the well system.
F. TYPES AND CONC 3Td &IIONS OF ADDrr VES — List any additives that will be used and their
concentrations. Only ad,Ifves that the Department of Health and Human Services' Division of public Health
determines do not adv rely affect hurnan health shall be used. A list of approved additives can be found
online at htlgJ/portai.ncd Yrlr otj-WCb/wa/ansIMro. All other additives require approval prior to use.
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C. WELL DRUMM")RM&TION(if known)
Well Drilling Contrami,shame: Robert Larry Wells
NC Well Drilling CDarlator Certification No.: 2603
Company Name: AWDIServices Inc. Contact Person: Larry Wells
City: Leicester �! State: NC Zip Code:28748 County: Buncombe
Day Tele No.: &25-6824223 Cell No.:828-215-9334
EMAILAddre§s: Wel1S2!750549@bellsouthawi FaxNo.: 828-693 9203
H. -HEAT PUMIP COP]IT;&CT018 MOORMATION
Co an Name: y'-J i L` (fo
Contact€'erson Sc e..N EMAIL Address: l lk"'r-c•cra � 4tu, • .ccp,
City: G ''-•v • a-LI3 Zip Code: off -? State: County: f) ­�
(?ifice TeleNo_: 52- �Cell No_: .Z -1-1 �1 ZZ Fax No-:
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DWQ!{ACJclosed-LoW GewhenndN i fieation(ReAsed4MV2012) pzr-Z
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L PROTECTIO.T4—Provide a brief description of hour(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:
(fir« c��� �_ � pis-• p-i i VLc.c.Lssy..r�z
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T. `i1_ARIAI4FCE—Pursuant,-to 1 SA NCAC 02C-0241 the Director of the Division of Water Qualify may grant a
variance from applicable{'well construction or operation standards provided that:
(1) use ofthe woll(s)will not endanger human health and welfare or the groundwater,and
(2) that construction or operation in accordance with the standards is not technical ly feasible or the
proposed construction•provides equal or better protection of the groundwater.
Any variance request shoald accompany submittal of this notification to expedite evaluation of the request"
The vakianc—request form can be accessed online at htw,//oortal_ncdgnr.or1 wehlwo/ans!¢wora/nermit-
aQvlications
i
�t IL SIGNATURES—The tillowing section is to be completed as required below or by that person's authorized
agent 1SA NCAC 02Ci0211(e)requires signatures as follows:
(a) for a cd poraiion: by aresponsible corporate officer,
(b) for a partnership or sole pmprietdrsbip: 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
gfficerpr ranking publicly elected official;
(d) for all others: by the well owner,
(e) for an� other person authorized.to act on behalf of the applicant: documentadon shall be
Sabra* with the notification that clearly identifies the-person, grants them signature
authority,and is signed and dated by the applicant
'•'I hereby certify, wrdk7e►ralty of law,that I have personaNy e mm wed mud am farnilfar with the informat!on
submitted in this•docwhent and all attachments thereto and that, based on my bzquby of those individuals
immediately responsiblg for obtaining said information, I believe that the information is true, accurate and
complete. I am aware#,at there are significant penalties, including the possibility of fazes and imprisomr-en,
for submitting false infai=adon. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and aLI related.appurtenances in acco Fd=ce with the I SA NUC 02C 0200 Rules."
i
t Sigm2tnre of PmpeM.OvvnerlAppticant
s
• i Caiv�a L . ke_4 ovl .
print or Type Full Name
is -
t
Stwiare of Authorized Agent,ifany
�# Printor Type Fall Name
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DWQMIC/Closed-Loop Geothermal Ida!rfrcation(Revised 413D20I2) Page 3

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RECEIVED
CtAsiaa of Water ResoutcM
JUL I :.
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATU. L RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE IN
� �t ereieore�.
These wells are 'permitted by rule"and do not require an individual permit when conrtr cte to [ @ ' 'rill fflC@ �s
the rules of 15A NCAC 02C.020V. This notice must be submitted prior to c
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: July 14 20 16 PERMIT NO.-IN� -0 0 0��(to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOPWELL TO BE CONSTRUCTED .2 @ 350'
(1) Aqueous(as per 15A NCAC 020.0222) X Number of wells: 5 3 Cl 320-
(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 this16em30'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:
The North Carolina C and PSC, LLC
William H Dascombe
Mailing Address: 10 JUdsons Court
City: Savannah State: GA Zip Code:31410Co„nty:
Day Tele No.: ' 912-898-1500 Cell No.: 912-713-2600
EMAIL Address: [e-mail] Fax No.: N/A
D. PHYSICAL LOCATION OF WELL SITE
8592=48-0482
(1) Parcel Identification Number(PIN)of well site:
County: Transylvania
(2) Physical Address(if different than mailing address): 4 Casey Lane
City: Brevard State:NC Zip code: 28712
DWQ/U1C/C1oseNLoop Geothermal Notification(Revised 4/3012012) Page 1

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E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps rrr$st ,te scaled or otherwise accurately indicate distances and orientations of features located
withirL250.feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site-specific map showing the locations of the following:
• Proposed injection well locations • Septic systems and associated spray irrigation
• Buildings sites, drain fields,or repair areas
• Property boundaries .
• Surface water bodies • Existing or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES— List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services' Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at http://portal.ncdenr.org/web/wg/aps/`,awpro. All other additives require approval prior to use.
Glycol
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Robert Lary 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: Bullman Heating & Air
Contact Person: Josh Guthrie EMAIL Address: [e-mail]
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804 State: NC County: Buncombe
Office Tele No.: 828-658-2468 Cell No:: 828-712-7488 Fax No.: 828-658-1001
DWQ/U1C/Cl6sed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

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I. PROTECTION—Provide a brief description of how (1)water supply wells; (2)surface water bodies;'and(3)
septic systems and associated spray irrigation sites, drain fields, or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
Silt Fence will be used to control solids and run off from drilling.
All required set backs will be maintained.
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 I)trp;i/port,ii,nedenr.orWweb/�,\�EiMbiwpl_Q/ eu rniit_
a lications
K SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C.0211(e)requires signatures as follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner or the proprietor,respectively;
(c) for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking-publicly elected official;
(d) for all others: by the well owner;
(e) for any other person authorized to act on behalf of the applicant: documentation shall be
submitted with the notification that clearly identifies the person, grants them signature
authority, and is signed and dated by the applicant.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are 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 1 SA NCAC 02C 0200 Rules."
Signature of Property Owner/Applicant
William H. Dascombe
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

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PRt3TECTION Provide a'brtef description of bow(1)water supply wells, (2)surface water bodies;and(3) .
:. septic systemand associated s ra `trri"`afion sties,drain fields,or'repair areas':witliin 250'feet oftlie.proposed
,x P Y; g
a' - Imection wells will-tie;profected.durii g co nstruciian.of the;wells:
.
;, .
J VA12- CE=Pursuant to BA NCAC 02C.0241 the)irector of-the.-Division of:Water QuaIitymay-grant a
variance from applicable welt construcfion or operation standards;prctuided that
(1} use of the wells}will,no eridat�ger hutran health and welfare or the graundivater,and
., (2) that constntction or opgr 4fi6ri in accordance with the standards"is not technically feasible or the
r., ;,.proposed'.66,'constcuction Pei), r 9 equal or;better protection of the groundwater.
Any vari1.ance request should accompany sub�nittal.of tkis notification.to expedite evaluation of the,request
"The•vartance,request fortn can be accessed online at http:/IpartaLncdenror ?��elily� !a s' rot er"init=
applications ,.
.,
x. .
..,.. .. .
K. SIGNATURES—The:;following section.; to Ge coarpfeted as required below.o`r by thaf~persox's authonzed,.
agent, 15A NCAC 02C :0211,(e)requires sign atures„as follows
(a) fax a1.,corporatton• by a responsible corporate officer,
(b} I for a,parinership or sale propnetorshtp: by a general partner or the proprietor,r r.espccttve r. ly,
(c) for a,municipality,or.a state,.federal,�or bther public agency Ill:by either a principal eaecutave""
officer or�:ranking publicly�elected official;, 1. -
(d) for aT!others: by the well ovner,
(e'11) for any,,oilier`person authorized to act on'"belia7f',of therappltca11.nt:- docum_11e�tatton shalt 6e
sub�itted. with tk.h1.e;notifie_`atton tat'�clearly identifies the person, grants th r.em signature
authority,and is signed and dated by the appitcant 6 j.. _
Thereby certify, under penalty of law, thatl haverper sonally exanzuied'and ani fctrniliar'with the it f�rmatton
, subniit1&d'irz this,doc irnent raid ald attachments thereto and that,'based arr my.nquh7,of those;iradividuals,
r.rmniedaTely responsible,for'nbtainirig said"'ttfaririrtian,;lbelieve'that the rnfor»rativn"is 1ri[e,,.uccurate and;
,', complete.-Jam aware that there are1.s,'1 'nificant pend1 ies, including the possibility offines.and Imprisonment,
, I for submitting false it farmatian. -1" gr 'e'�( constricc , operate, main ain, repair,,and upplicirble; abandon
cirt the inTectian well and all relateda iir6. n ces it1. accordance Wth the°15A NC,C 02C 0200 Rules "
$ignature'of PI.roperty;"Own1.er'/Appliciint
L
`'- I'rmt�or Type!Futl Nine'" ,`
Sigpaturc,,ofAutharize�Ag ent,ifany
PrinE'rnr.Type;Full Name , s
1)WQiPC/C.la ecl-1 oap Ge itherntat.Nattgc"aiion(Revised 4/30/2012) `i'rtge'�"".:

RECEIVED
. , OlNaton d 1wlr Rasp�rq� .
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURA RESOURORS 2 8 2017 Y
NOTIFICATION OF INTENTTO CONSTRUCT OR OPERATE IN CTION WELLS
These wells are 'permitted by rule"and do not require an individual permit when cons tedAleteeQp�ty
the rules of ISA NCAC 02C.0200*. This notice must be submitted YioY td c sutra io�l
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: March 27 20 1 )PERMIT NO. I ��(to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL-TO-BE CONSTRUCTED 2 @ 200'
(1) Aqueous(as per 15A NCAC 020.0222): Number of.wells: . 1 275
(2) Direct-Expansion(as per•15A NCAC 02C.0223) Number of wells:
B. STATUS OF WELL 6VVWER(choose one)
(1) Single Family Residence Submit thiiTorm-two,(2)business days prior to construction.
(2) Business/Organization Submit this fdit 30 days prior to construction.-
(3) Government: State Municipal County Federal Submit this form 30 days
prior to'wnstruction.
C. WELL OWNER—For single family residences list the property ownei(s). For all others, list name of the
business,organization,or government agency and person delegated signature authority:
Guthy William R &Jackson (Guest House)
Mailing Address: 1018 Pamela Drive
City: Beverly Hills State: CA Zip Code:90210 County: Los Angeles
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
D. 'PHYSICAL LOCATION OF WELL SITE
8512-84-2354-000
(1) Parcel Identification Number(PIN)of well site:
County: Translyvania
(2) . Physical Address(if different than mailing address):
74 Red Bird Circle (Sandyland Cove) .
City: Lake Toxaway State:NC Zip Code: 28747
DWQ/U1C/C1ose*Loop Geothermal Notification(Revised 4/30/2012) Page 1

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7E. MAPS,PLANS, 1ND SPECIFICATIONS
:-tn rMapg/m t be scaled or otherwise accurately indicate distances and orientations of features located
a+l4lyo0w, ithin 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 Ilt ._! ortal_nc denc.orweb/ q�`aps/gwnro. All other additives require approval prior to use.
20%Environal
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Lang Wells/David Stratton
NC Well Drilling-Contractor Certification No.: 2603-A/3421-A
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: wells750549@b!gHsouth.net Fax No.:828-683-9203
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:Bullman Heating&Air
Contact Person: Josh Guthrie EMAIL Address:[e-mail]
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804 State: NC County: Buncombe
Office Tele No.:(828)-658-2468 Cell No.: (828)-712-7488 Fax No.:(828)-658-1001
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

I. PROTECTION- Provide a brief description of how ( 1 ; water iupply-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
Silt Fence will be used to control solids and run off from arllling,.--___-_. _•__•,,..
All required set backs wiH be met.
J. VARIANCE—Pursuant to I SA NCAC 02C.0241 the Director of the Division of Water Quality may grant a
variance firm applicable well construction or operation standards provided that:
(1) use of the weIl(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 htiti:/,pot•tal.ncdenr.org/web)wo:'ans/%mroipermit-
applications
K. SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C.021 I(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 owiier, .
(e) for any other person authorized,to act'on behalf of the applicant: documentation shall be
:. ...::..,. submitted t`'ith the notification that clearly identifies the person, grants [here signature
authority,and is signed and dated by the applicant.
V hereby cerfij5; under penalty of law, that I have personally examined and ant familiar with the infonnation
submitted in this document and all attachments they eto and that, based on nay hiquby of those individuals
immediately-responsible for-obtaining said information, 1 believe that the inforniativn is true, accurate and
complete. 1 am aware that there ale sign nit penalties, including the possibility of fines and irnprisoninent,
for subitatting false information. .I agree to construct, operate, maintain, repair, and if applicdble, abandon
the Injection well and all r elated appwien ces in accordance with the 1 SA NCAC 02C 0200 Rules."
Si ature of Property Owner/Applicant
V •_Tt1)
Print or Type Full Name
Hato of Auto ' d Agent,if a
rint or Type Full Name
DWQUC/Closed-Loop Geotiiernal Notification(Revised 41,30 201 1

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CONTOUR INTERVAL•?FOOT Y vJ•

—� RECEIVED
' DivisEon a wear Rosourca�
Aug 18 20
NORTH CAROLINA DEPARTMENT OF ENVIRONMEN.1 A D NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OP RATRsi>)1lIMQ IOIIt> LLS�
These wells are -permitted by rule"and do not require an individual permit when cohstructed 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 I SA 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: AU9USt 18 _ 20 16 PERMIT NO.W0 k _(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: 6 300'
(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 (7ount)- _ 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:
Guthy William R & Jackson
Mailing Address: 1018 Pamela Drive
City: Beverly Hills_ - _ state: _ CA zip c ode 9021 OCounty:. 1-os Angeles
Day Tele No.:
EMAIL Address: _ rax No.:
D. PIIYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site. 8512-84-2354-000
Translyvania
County: _.-..
(2) Physical Address(if different than mailing address)
74 Red Bird Circle _
City:
Lake Toxaway hate:NC Zip Code: 28747
_
Page 1
DWQ/U1C/Close Loop Geothermal Notification(Revised 4/30/2012

f
Y
1
s E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be sealed or otherwise accurately indicatc 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 .ites drain fields, or repair areas
• Property boundaries
• Surface water bodies • 1 \fisting or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications of the surface and Subsurtact ..omstruction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES isl 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 he i.ised. A list of approved additives can be found
online at±'tll? he rta_i r.:cicn: (Irk .eh L1•a.hs/ whr, All other additives require approval prior to use.
20%Environal
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Larry Wells/David Strattor:
NC Well Drilling Contractor Certification No.. 2603-A,."42_i.:A._.
Company Name: AWD Services.Inc.... ontact Person_.._.Larry Wells
City: Leicester State: NC_ /.ip t ode '87748 County: Buncombe
Day Tele No.: 828-683-9223 _.,._.,. c ell Nt, 828-215-9334
EMAIL Address: [e-mail] Fax No.: 828-683-9203
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:Bullman Heating&Air
Contact Person_ Josh Guthrie.__., EMAIL,-\ddress:joshg_nabullmanheating.com
Address: 10 Red Roof Lane
City: Asheville.. ..Zip Code: 28804 State. .N-. ::'ounty: Buncombe
Office Tele No.: (828)-658-2468 Cell No.. _1828.1- I` '488_-_Fax No.: (828)-658-1001
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/201:?. Page 2

Transylvania Cotnty NC WebGIS
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I

a
I. PROTECTION Provide a brief description of how i 1 , water supply wells; (2)surface water bodies;and (3)
septic systems and associated spray irrigation sites. drain tiel&. or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the we,in
Silt Fence will be used to control solids and ruq,yff from.driiJ m&....
All required set backs will be met.
J. VARIANCE—Pursuant to 15A NCAC 02C.0241 the Director of the Division of Water Quality may grant a
variance from applicable well construction or operation standards provided that: z
(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 htit):,1�DUITIII.[1ZdLI)C.Or�T�Ub'�va;`ap !ctwUrafnerniiE-
applications
K. SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .021 1(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 certif}�, udder penalty of law, that I have petwnally&amined and a»r familiar with the inforntatiort
submitted in this document and all attachments thereto and that, based on my inflt hY of those individuals
i innediately responsible for obtaining said a formation, 1 believe that the information is trite, accurate and
e6rrtplete. I am aware that there are sign't nt penalties, including the possibility offines and•intprisminrent,
for stibntitting false it for ination. .1 agree to construct, operate, maintain, repair, and if applicable, abandon
the it jection well and all related appid•tena ces in accordance with rile 15,4 NCAC 02C 0200 Rules."
Si attire of Property owner/Applicant
Print or Type Full Name i•• JJ;"�
gnatur of Au t io ' ed Agent,if a
lint or Type Full Name
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/10/201 ) -

Moore, Andrew W
From: Moore,Andrew W
Sent: Friday,August 19, 2016 8:09 AM
To: 'larry wells'
Subject: RE: Notice of Intent to Construct or Operate Injection Wells
Shannon,
15A NCAC 02C .0241 requires that the well owner or any person authorized to act on behalf of the applicant sign the
application. If a person is signing 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.
It appears that the notification was signed by-Carl Perkins (Estate Manager).Victoria Jackson or William Guthy must sign
the notification or provide documentation that Carl Perkins is authorized to sign on their behalf.
The notification is considered incomplete until this information is provided.
Andrew W. Moore, P.G.
Environmental Specialist—Asheville Regional Office
Water Quality Regional Operations Section
NCDEQ— Division of Water Resources
828 296 4684 office
email: [e-mail]
2090 U.S. Hwy. 70
Swannanoa, N.C. 28778
"Nothing Compares--,-
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: larry wells [mailto:[e-mail]]
Sent:Thursday,August 18, 2016 2:16 PM
To: Moore, Andrew W<[e-mail]>
Subject: Notice of Intent to Construct or Operate Injection Wells
Good Afternoon Mr. Moore,
Please find the Notice of Intent to Construct or
Operate Injection Wells form attached for
74 Red Bird Circle, Lake Toxaway, NC.
i

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
injeetion.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 wells)wilt 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.n.edelinorplweb/wqlaps/�wpro/permit-
applications
K. SIGNATURES—The following.section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C.021 l(e)requires signatures as.follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner or the proprietor;respectively;
'(c) fora 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,
`1 hereby certify, under penalty of law, that I have personally exannned and am fmniliar 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 it formation is true, accurate and
complete. I am aware that there arse significant penalties, including.the_possib lity of fines and irnprisonrnent,
for submitting false information. I agree to construct, operate, maintain, repair; and if applicable, abandon
the injection well and all r•elated.appurten ces in accordance. with the 15A NCAC 02C 0200 Rules."
Signatur ofProperty v er/Applicant
INc 111'q iv1 . C
Print or Type Full Nam
F__ _ECEIVED
;:R�
n o9 Wetw iiesourca
Signature.of Authorized.Agent,if any
1U� 2 2 20
,.
Print or Type Full Name
LWater Quality Regional O
Asheville Regional Offtoe
DWQNIC/Closed-Loop Geothermal Notification(Revised 4/30/2012). Page 3

RECEIVED
' \` NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NA RE R"O"`c"
NOTIFICATION OF INTENT:T.,O CONSTRUCT OR OPERATE I JECTION WELLS
These wells are "permitted by rule"and-do not require an individual permit when const cted in aU daAc8w1N1
the rules of 1.5A-NCAC 02C.0200*. This notice must be submitted priorto onstruction.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLWater Q Regbnat rations
Ashheadyii(e R2dional 01 Roe �
As described in 15A NCAC 02C.0222 these wells circulate potable water only or a mix ur of r ari
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: C n I , 20 1& - PERMIT NO. wTa j 0 D `16(t-' (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: 2 Wells @ 275' each & 2 wells
@ 350' each
(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:
Mailing Address:
City: r• State: Zip Code:5'3?19 County:
"o d
Day Tele No.: _ �""' ��{�C.ell No.:
EMAIL Address: t (kA—kS q Qg C�uC.Os ,Vl ax No.: 826, 1967• '90a 7
D. PHYSICAL LOCATION OF WELL SITE r
(1) Parcel Identification Nu ber(PIN)of well site: �aaa— — a o2�-' 0(50
County: ��S �V
(2) - Physical Address(if erent than mailing address):
, I
City: State:NC Zip Code: CK g7q 7
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/3 /2012) Page-1

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
e-sp6cifld map showing the locations of the following:
p
roposed injection well locations eptic systems and associated spray irrigation sites,
• drain fields, or repaR areas
uildings
• • P
roperty boundaries xisting or potential sources of groundwater
contamination S
urface water bodies
• W .
ater supply wells
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and .their
concentrations. Only additives that the Department of Health and Human Services' Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at http://portal.ncdenr.org/web/wg/aps/gwpro. 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
ENTAIL Address: [e-mail] Fax No.: 828-683-9203
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Bullman Heating and Air
Contact Person: Josh Guthrie EMAIL Address:[e-mail]
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804 State: NC County: Buncombe
Office Tele No.: [phone] Cell No.:[phone] Fax No.:[phone]
DWQ/LJIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

project .
clate /^
tasks
l.
Li
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' t
K

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:
n S Sam k.►
I 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.org/web/w /q aps/ wnro/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 ehected official;
(d) for all others: by the well owner;
(e) for any other person authorized to act on behalf of the applicant: documentation shall .be
submitted with the notification that clearly identifies the person, grants them signature.
authority, and is signed and dated by the applicant.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all rely d urt an e i ordan ith the 15A NCAC 02C 0200 Rules."
Signature of Property-9waeWA_pp1icant
Print or Type F uH Name
Signature of Authorized Agent,if any
Print or Type F uH Name
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

I.
Moore, Andrew W
From: Moore, Andrew W
Sent: Monday, December 19, 2016 2:54 PM
To: 'larry wells'
Subject: RE: Notifications of Intent to Construct or Operate Injection Wells
Shannon,
I will need the following additional information to process the Williams Notification:
1. The Notification is signed by John F. Holbrook.Title 15A NCAC 02C.0211(e) requires that either the well owner
sign the Notification, or any other person authorized to act on behalf of the applicant (i.e. agent). If the agent
signs the form, documentation must be submitted with the Notification that grants them signature authority
from the owner. Please provide documentation from Cliff Williams granting John Holbrook signature authority,
or have Mr. Williams sign the Notification. In the past, DWR has accepted email documentation designating the
authorized agent.
2. Please clarify the distances from the proposed boring locations to the building foundation as required in 15A
NCAC 02C(d)(4)(A).
The Notification is deemed incomplete until this information is received.
Feel free to contact me if you have any questions.
Andrew W. Moore, P.G.
Environmental Specialist—Asheville Regional Office
Water Quality Regional Operations Section
NCDEQ—Division of Water Resources
828 296 4684 office -
email: [e-mail]
2090 U.S. Hwy. 70
Swannanoa, N.C. 28778
Nothing Compares--,—.t.
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: larry wells [mailto:[e-mail]]
Sent: Monday, December 19, 2016 1:04 PM
To: Moore,Andrew W<[e-mail]>
Subject: Notifications of Intent to Construct or Operate Injection Wells
Mr. Moore,
1

NORTH-CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL,RESOURCES
NOTIFICATION OF EWENT TO CONSTRUCT OR-OPERATE INJECTION:W� $
These wells are"permitted by rule"and do not require an individual permit when constructed in accordance with -
the rides of ISA NCAC 02C.0200* .This notice must be.submifted:prior to constmact ori.
GEOTHMMAL AQUEOUS CLOSED-LOOP WELLS
As described in 15A NCAC 02C.0222 these:wells circulate potable water only or a rtiizture of potable water and
performance-enhancing-additives as part of a geothermal heating and cooling.system..
OR
GEOTHERMAL.DIRECT EXPANSION..CLOSED-LOOP WELLS
As descried m 15A NCAC 02C.0223.these wells circulate a refrigeiant.gas a§parE of a.geothermal.heating.snd
cooling:system.
Print Clearly or Type Information. lilegibie SubmittalsWidd Be.Returned As Incomplete.
DATE:__v_?C4w► . 2011—P PERMIT NO: (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
.(1) Aqueous(as per 15ANCAC 02C.0222): X Number of webs 2 wells a 275' each-*'2 wells
@ 350' each
(2). Direct Expansion..(asp15A NCAC C.023) Number of wells:
B.. STATUS-OF WELL OWNER(choose one)
(1.). Single:Family Residence.X_Submit this form two(2)business daps prior to.comstructiont
(2) Business/Organization Submit this form 30 days prior to construction.
(3) Government State Municipal. County Federal . . ..Snbmit:this form.3Q days:
prior f6:constia 6;0.a
C. WELL OWNER-For single.family residences list the property owner(s). For all,:others, list name bf the:
business,organizatioi4 or government agency and person delegated signature authority:.
Mailing Address- ©r b sq
City: State: Zip Coder ffl county;
Day Tele No.•. • .� � Cell No.:
EIVIA]L Address: t. \ 1M$ '81 ax No.: 925, & t5 7
D: PHYSICAL-LOCATION OF WELL SITE
(1) Parcel Identification N. ,ber(PIN)of well site:
County; v�wt
(2) Physical Address(if erent than mulling address):. - : l V&
.
City.: - State:NC Zip Code:-'-,:: 7..
DWQ/UTGClased Loop Geothermal Notification(Revised 4/3 )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-specificmap: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 construetion.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 approvers additives can.be found
online at http://portal:`ncdenr.oralweblwa//apstgmro. 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 dip 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; Bullman Heating.and Air
Contact Person: Josh Guthrie EMAIL Address:josh¢@.bullmanheatmg.com
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804 State: NC County: Buncombe
Office Tele No.: [phone] Cell No.:[phone] Fax No.:f828)658=1 1 . .
D'WQ/WC/Qosed--Loop Geothermal Notification(Revised 4/30t.2012) Page 2

. - r Qom.. . • . _
4 Z: v

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:
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:l&ortal.ncdenr.or web/wgtWs/RmZg "it
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) fora 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.executiv6.
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 tha4 based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true,.-accurate and
complete. 1 can 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 02.00 Rules."
Signature.ofProperty Owner/Applicant
W0rT',,,7e
Signature o Autho Ag t,.if any
Print or Type Full Name
o�l �3llw
MQUC/Closed-Loop Geothermal Noti€ication.(Revised4/30/2012) Page 4

C. =sVc-•D
Division of Wafer Resources
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAI RESOURCES NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE IN TI CON� " .7, 01S
These wells are "permitted by rule"and do not require an individual permil when co d in arc wd
the rules of ISA NCAC 02C.0200el. 77t' ice be ubmkied to
Water Quality negiona Operations
GEOTHERMAL AQUEOUS CLOSED ADOP WELLS Ashevp1 pr`n7p (vrice
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
GEpTHERM"pMCT EXPANSION CLOSEWAM WELLS
As described in 1 SA NCAC 02C.0223 these wells cirvWate a refrigenrt gas as part of a geothermal heating and
cooling system.
Print Cleanly or Type lnfornoarka. lUeebte Srbwksals MY Be Retxrxed As Lncwaplsta
June 22 18
DATE: 20 PERMIT NO. ',�1�-� �00„�y �l G (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSEWLOOP WELL TO BE'CONSTRUCTED
t
(1) Aqueous(as per 15A NCAC 02C.0222): _ Number of wells: (.c�GtCs �(C s
(2) Direct Expansion(as per i SA NCAC 02C.0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence_V Submit this fors two(2)business days prior to construction.
(2) Busintss/Organization Submit this form 30 days prior to c*nArudion.
(3) Government: State Municipal County Federal Submit this form 30 days
prior to oaastnwilloa.
C. WELL OWNER —For single family residences list the property owner(s). For all others, list name of the
business,organization,or government agency ld person delegated signature authority:
Mailing,Address: tC
City: 11/laD 14e Stott: f L Zip Code; c ot�rtty: 'LA_t'��
Day Tele No.. Cell No.:630 c� r �. 1
EMAIL,Address 4 lkXf--0 fl t. CO Fax No.:
M PHYSICAL LOCATION OF WELL SITE
(1) Parcel ldenti&ation Number(PIN)of well site: Dole
County:7i �15'
(2) Physical Address(if different than mailing address):
City: Bee state: iL� zip Code: r- .
DWQA1tC1C1mcd-1.mp Cmo hand naif;ation(Revkod 4/3012012) Page 1

E. MAPS,PLANS,AND SPECIFICATIONS
-a
(1) Maps must be scaled or otherwise accurakly indicate disumces and orientations of features located
within 250 feet of the injection well(s). Label all features cleiarivaad inclWe a r2dh wraw. Attach a
site-specif to map showing the locations of the following:
• p
roposed injection well locations eptic systems and associated agray irrigation sites,
• drain fields-,or repay areas
uildings
• . p
roperty boundaries xisting or potential sources of groundwater
a contamination S
urfnce water bodies
W
ater supply wells
(2) Plans and specifications of the surface and subsurfwe corrsu uction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDMVES — 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 lYttn.f;porfaLncderu.cir to ueblv�EapVMIT o. All other additives require approval prior to use.
20%Environal 80%Water
G. WELL DRILLER INFORMATION(if Mown)
Well Drilling Contractor's Name: Robert Larry Wells
NC Well Drilling Contractor Certification No.: 2603
Company Name: AWD SeMew Inc. Contact Person: Larry Wells
City: Leicester State: NC Zip Code:287d8 County: 1 ww mbce
Day Tele No.: 828-03-92.23 Cell No.:829-215-9334
EMAIL Address: Wells754549@bellsouthaw Fast No.: W-613nM-3
H. RF.AT PUMP CONTRACTOR INFORMATION
Cornpttny Name: Bullmn Hodiig and Air
Contact.Person:_Josh Guthrie EMATL Address:josh lltrru��coot
Address.- 10 Red Roof Lane
City Asheville Zip Code: 28804 State:_NC County: Buocambe
Office Tele No.: [phone] Cell No.:[phone] No,:($ 8)658-1001
DWW1C,fC:1=d-Laop Geothermd Notiftatim(Rovi3c4 4130/2012) Page 2

L PROTECrIQN—Provide a brief description of hm(1)water supply wells;(2)surface water bodies;and(3)
septic systems and ass:ocb to d spray irrigation sites,drain fields,or repair arras within 250 feet of the prupased
injection wells will be protected during construction of the wells:
Silt fencing will be used to control solids and run off from drilling.
J. VARIANCE—Pursuant to I SA NCAC 02C .024.1 the Director of the Division of Water Quality may grant a
variance from applicable well construction or operation standards provided that:
(1) use of the wells)will not endanger human health and welfare or the groundwater,and
(2) that constructim or operation in accordance with the standards is not technically feasible or the
proposed+constntction provides equal or better protection of the grouttwater.
Any variance request should accompany submittal of this notification to expedite evaluation of the re quest
The variance request foam can be accessed online atf rtal:rater . Tfavu =` ro,' xrttit
at�n1 is?n ioto� -
IL SIGNATURES—The following section is to be completed as required below or by that person's authorized.
agent. i SA NCAC 02C.0211(e)requires signawres as follows:
(a) for a corporation: by a responsible czrpomv 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 elsr-d.official;
(d) for all tethers: by the well owner;
(e) for any other pawn authorized to act on behalf of the applicant: docutnemiit on 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, wider penatity of law, that I have persortaily ex=bwd and a7rlt fimillar with the infibma3tion
submitted to this doctaxent and all a rtachnsems thereto and that, based on my koqidry of those individuals
immediately resportsible for obtaining said bybrmation, .I believe dot the bybrrr widn is true, accurate and
complete. I am aware that there are sign f c unt pe- ities, incheding the possibfl#ty cf ?ws and imprisonment,
for submitang false information. I agree to constrwt, operate, mahwa lm repast, and if applicable, abansdon
the injection well and all relKed appurtaurices in awordawe with the 1 art.NCAC 02C 0200 Rules">
of Prraterty O"MWA#pfit*O
Print or Tppe>F'ati Name
Sitta start of Audia od AVK ifs"
Priest or Typo Fall Nausa�
DWC1 WOCImed-t.00p GeoOrtrmat Notirtatiaaa(Revised 4/362912) Page 3

AUG 30 2018
\�la:ar his^� s`easL� l Operatio.gS
North Carolina Departme
nt of Environmental Quality_Division of Water Resources
NOTIFICATION OF INTENT TO CONSTRUCTOR OPERATE INJECTION WELLS
These wells are "permitted by rule"and do not require an individual permit when constructed in accordance with
the rules of Lill NC4C NC.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
i
As described in 15A NCAC 02C.o223 these wells circulate a refrigerant gas as part of a geothermal heating and
coolingsystem. i
print Clearly or Type Information. Illegible Submittals�11 Be Returned As Incomplete
Pr -. �
DATE.
August 30 2018 PERMIT NO.:. `Q D ( be completed by DWR).
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED(select one)
(1) �Aqueous(as per 15A NCAC 02C.0222) Number of wells:. 2
.p
(2) Direct Expansion(as per 15A NCAC 02C.0223) Number of wells:
$, STATUS OF WELL OWNER(S)(choose one) j
(1) [❑Single-Family Residence Submit form two(2)business days prior to construction:
i
(2)- ElBusiness/Organization Submit this form-30 days prior to construction.
Federal* X
(3) Q Government: State Municipal County—Submit this form 30 days prior to construction
y For single famil residences,list all persons listed on the property deed. For all others,
C. WELL OWNER(S).-
list the name of the Business/Agency and person and title with delegated signature authority:
f
i
ational Forests in-North Carolina Engineering Staff Officer
USDA Forest Service,James Barry Jones,N l
a
Mailing Address: 160A Zillicoa St
2as01 Buncombe.
City: Asheville State: NO Zip Code: County:
Day.Te1e No.: 828-267-4200• Cell No.:
EMAIL Address: [e-mail] Fax No.: 1
D. PHYSICAL LOCATION OF WELL SITE
(1} 9999-99-0030-000
Parcel Identification Number(PIN)of well site:
County- Transylvania
11250 Pisgah Hwy
I
(2) Physical Address(if different than mailing address):
x
City: Pisgah Forest County
Transylvania Zip Code: 28768
l
s

f �
i}
E. REQUIRED MAPS,PLANS,AND.SPECIFICATIONS
(1) A site maps must be submitted. It must be scaled or otherwise accurately indicate distances(in feet)
.and orientations of features located within 250 feet of the injection well(s). Label all features clearly
and include a north arrow. Attach the site-specific map showing the wells in relation to the locations of
the following:
• Buildings • Septic systems and associated spray irrigation sites,
• Property boundaries drain fields,or repair areas,if any
• Surface water bodies,if any • Existing or potential sources of groundwater
• Water supply wells;if any contamination,if any
9
(2) Plans and specifications of the surface and subsurface construction details of the,well system.
E
NOTE. In most cases, an aerial photograph and/or plat map of`the property parcel showing property lilies and
structures can be obtained and downloaded from the applicable county GIS website. Typically,the property can
be searched by owner name or address. The location of the wells in relation to property boundaries,houses,septic
tanks and fields, and other wells, etc.'cdn then be drawn in by hand Also, a `layer' can be selected showing
topographic contours or elevation data. g
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
hM://decf.hc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch around-water-
protection/sround-water-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
No additives are injected in.th'ese wells.
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Earth Energy Engineering Inc.
NC Well Drilling Contractor Certification No.:
Company Name: Contact Person:
City: State: Zip Code: County:
Day,Tele No.: Cell No.:.
EMAIL Address: Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
fi
Office Tele No.: Cell No.: Fax No.:
Closed-Loop Geothermal Well Notification Rev.3-1-2016 Page 2

I. PROTECTION—Provide a brief description of how any(a.)water supply wells,(b.)surface water bodies,or
(c) septic systems and associated spray irrigation sites, drain fields, or repair areas within 250 feet of the l
proposed injection wells will be protected during construction of the wells:
Wells were,installed in 1998.
Construction plan shows 19 wells. Only 12 were installed as shown on map but to a depth of_300'.
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 j
(2) That construction or operation in accordance with the standards is not technically feasible or the J
proposed construction provides equal or better protection of the groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation of the:request.
The variance request form can be accessed online at httns://ncdenr.s3.amazonaws.com/s3fs-
public/Water%20 Q uality/Aquifer%2OProtection/GPU/Geotherm alVarianceRequestFormFillable-
20130805.pdf
t
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:
3
(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 l
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 individitals
immediately responsible for obtaining said information, 1 believe that the information is true, accurate and !
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with;t ;N 02C 0 00 Rules.Signature of Pr perty Owner/App
Print or Type Full Maine
Signature of Authorized Agent,if any
Print or Type Full Name
i
Closed-Loop Geothermal Well Notification Rev.3-1-2016 Page 3
t
1

L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The.Division of Water Resources' Water Quality Regional Operations Section (WQROS) Regional
Office serving the area in which the injection well facility will be located:
GH
Xb t�
7 X
..........
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 450 W.Hanes Mill Road
610 East Center Avenue,Suite 301 Suite 300
Mooresville,NC 28115 Winston-Salem,NC 27105
Telephone: [phone] Phone:[phone]
Fax:[phone] Fax:[phone]
Raleigh Regional Office
1628 Mail-S6rvice Center
Raleigh,NC 27699-i 628
Telephone:[phone]
Fax:[phone]
-AND-
(2) The County Environmental Health Department in which the.injection wells.will be located.
Closed-Loop Geothermal Well Notification Rev.3-1-2016 Page 4

U.S. DEPARTMENT OF •NAL FORESTS NORTH .•LINA CRADLEOF •'
FORESTESTRY
• GEOTHERMAL

MInW,Rill atl"p GI�Y 6RNR RCW
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} � ,FF,_ i}. itiD CCbUr1[1ri0R ro cba�NCMM I (,y 'C
JELL FIELD LAYOUTt k—I'9 MIT"
\ p
rn
tµ NOTE
�'.�;•��� 1 .� w
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ero
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w arse #y .t M1N quri,+� Er fCt.a4yalar` 1 '� y,.
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wmwwr
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lon .

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL:RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "Permitted by role"and do not.reyuire an individual permit when constructed in accordance with
the rules of I.SA.NCAC 02C.0200 . .This notice must be submitted prior to construction
GEOTHERIYIAL AQUEOUS CLOSED-LOOP WELLS
As described in 15A NCAC 02C.0222 these wells circulate potable water only or a mixture of potable water and
1 performance-enliancing additives as part of a geothermal heating and cooling system.
C�- OR
G ..GEOTHERMAL;DIRECT EXPANSION CLOSED-LOOP WELLS
G, As described in 15A NCAC 02C.0223 these wells ciTc#dle a refrigerant gas as part of a geothermal heating and
C
Ccooling system.
Print Clearly nr Type Inforfnutian. Illegible Submittals Will Be Returned As Incomplete
BATE: . 2olq PERMIT NO. w y 0 k 0 0 Z�� (to be completed by DVVQ)
V-11Mb
�'e��D
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCLh
Aesource90). . Aqueous(as per 15A NCAC 02C.0222); XNumber of wells:3D.irect Expansion(as per 15A NCAC 02C.0223) Nu -2019 _;:;STAT JS OF WELL OWNER(choose one) ncg!or,•al OReration`s_r;,,.
_. f f..
(1) Single Family Residence tZSubmit:this form two(2)business days prior to construction.` T
(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:
Elizabeth Parker and Margaret Bear
Mailing Address: 675 Seminole Ave, Suite 112
City: Atlanta state: GA zip Code:30307County: Fulton
Day Tele No.: Cell No.: 404-316-2575
EMAIL Address [e-mail] Fax No.:
D. P14YSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site: 8582-01-8723-000
County: Transylvania
(2) Physical Address(if different than mailing addressj: 670 Riverwilde Ln
City: _ Breward State:NC Zip Code: 28768
D%PQlUIC/Closed-Loop Geothermal Notification(Revised 4/i012012) Page I

00'0 . 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 ZZOZ
00'0 00'0 00'0 00'0 00'0 00'0 0010 00'0 00'0 00'0 TZOZ
0010 00'0 00'0 00'0 00'0 00'0 0010 00'0 00'0 00'0 OZOZ
00'0 00'0 00'0 00'0 00'0 00'0 0010 00'0 00'0 00'0 6TOZ
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 8TOZ
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 LTOZ
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 9TOZ
00'0 00'0 00'0 00'0 00'0 00'0 0010 00'0 00'0 00'0 STOZ
00'0 00'0 00'0 00'0 00'0 00'0 0010 00'0 00'0 00'0 VTOZ
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 ETOZ
0010 00'0 00'0 00'0 00'0 00'0 0010 00'0 00'0 00'0 ZTOZ
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 TTOZ
00'0 00'0 00'0 00'0 00'0 00'0 0010 00'0 00'0 00'0 OTOZ
0010 00'0 00'0 00'0 00'0 00'0 0010 00'0 00'0 00'0 60OZ
00'0 00'0 00'0 00'0 00'0 00'0 00'0 0010 00'O 00'0 800Z
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 0010 L00Z
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 900Z
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 500Z
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 ti00Z
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 E00Z
0010 00'0 00'0 00'0 00'0 00'0 0010 00'0 00'0 00'0 Z00Z
00'0 00'0 00'0 00'0 00'0 00'0 0010 0010 00'0 00'0 T00Z
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 000Z
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 666T
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0.-__..- 00'0 .866T
00'0 00'0 00'0 00'0 00'0 00'0 0010 00'0 00 0 d„ „ 0.0,'..0
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'P 0010 966T
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 0010 00'0 S66T j
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00' 6'6T
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 E66T '
It
00'0 00'0 00'0 0010 0010 00'0 00'0 00'0 00'0 I _00'.0 Z6'6T
00'0 00'0 00'0 0010 0010 00'0 00'0 00'0 00'0 00'0
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 - """,`00'0 066T
33W 9H indNI 9H indinO 9H HMW SWVHD 9H
shun TEOD D79I MBN - jnogjjeMeO@W .gad sweiD uz suoissiwa AjnDjaW*
00'0 0010 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 050Z
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 6VOZ
00'0 0010 00'0 00'0 0010 0010 0010 00'0 00'0 00'0 8v0Z
00'0 00'0 00'0 00'0 0010 00'0 00'0 0010 00'0 00'0 LVOZ
s 00'0 00'0 00'0 00'0 0010 00'0 00'0 00'0 00'0 00'0 9t0Z
= 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 5tr0Z
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 trv0Z
00'0 0010 00'0 00'0 0010 00'0 00'0 00'0 00'0 00'0 EVOZ
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 ZtiOZ
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 TVOZ
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 0ti0Z
00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 00'0 6EOZ
00'0 00'0 00'0 00'0 0010 00'0 00'0 00'0 00'0 00'0 8EOZ
00'0 0010 00'0 00'0 0010 00'O 00'0 0010 00'0 00'0 LEOZ
• r

J. MAPS,PLANS;AND.SPECIFICATtON.S .-.
Q). Maps must be scaled.or otherwise accurately indicate distances and orientations of features located
within 250.feet.ofthe.injection well(s); .Label all features clearly and include a north arrow. Attach a
site-specific map showing the locations of.the following:
..
roposed injection.well.locations. ..eptic systems and associated spray irrigation sites,
• drain.fields,or rePek areas.
utldngs
ropt r y boundaries_ :xisting or potential.- sources. of groundwater
...: contamination
5
urface,%vater.bodiesW..
W
atersupply.wdils..
(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.xhat 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 l�tip:ffportal.nedennor�'weti�� lacis��xvpra. All other additives require approval prior to use.
n -
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name:: J 6-41 PI Lom ppll S
NC Well Drilling Contractor Certification No.: —
C lLiY = ;? Contact person: �` R } l© IV
Company Name:(
J
City. 4 T' State-,0.6 Zip Cod4V43County. i cc6i,
Day Tele No.: Cell No.:
EMAIL Address: 571d 9bV144q j r Dl Fax No.:
]L HEAT PUMP CONTRACTOR INFORMATION
Company Name;.Bbilman Heating&Air
Contact Person: Josh Guthrie E1b1AIL Address joshg�rc,,bullmanheating com
Address: 10 Red Roo.f.Lane
City:.Asheville Zip Code 28804_State: .NC County: Buncomne
Office:Tele No.:(828)-658=2468 CeII No.:_(828)-712-7488_ Fax No.:(828)-b58-1001
MQUC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

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L PROTECTION, Provide a brief description.of how(1)'water supply wells;(2)surface water bodies;and(3)
septic systems and associated spray irrigatiorf sites.drain fields,or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the hells:
_
J. VARIANCE Pursuant to 15A NC AC 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 vvell(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.
Anyvariance request should accompany submittal ofthis notification to expedite evaluation of the request.
The variance request form can be:accessed online at htip;hjportal.ncdeimor�:.el�i�gr_4 1permit-
applications
k SIGNATURES=The following_section its to be completed'as required Below or by,that person's authorized
agent.. 15A_:NCAC 02C..02 f I(e)requires signatures as follows:.
-
{a) for a coiporation by a responsible corporate officer; ... .
(ti) fora partnership or sole proprietorship:.by a general partner or the proprietor,respectively;
(c). fora 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;,.:
_.for.any.other:person authorized:to.ad.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#he:applicant.
ill hereby-cert y,:under penalty.of lmv;.that I'have personally examined and ain familiar with the information
submitted in.this document:rind all atfuchments'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 of fines and imprisonment,
for submitting false information::...1.agree to construct;.operate; maintain, repair, and if applicable, abandon
the injection:well and all.related:appurtenances in::accordance with the 15,41VC4C 02C 0200 Rules."
rN
ignature of Property Owner/Applicant
Print or Type;Fail Name
Signature of Authorized.Agent;if any
_ Pr
int, Type Full Name
DWQAJlC[Closed=Loop Geotheimal NuGficadon(Revised 413012012) Page 3

L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Resources' Water Quality Regional Operations Section (WQROS) Regional
Office serving the area in which the injection well facility will be located:
WINSTON-SALEM _
R 'LEIGH
ASHEV,ILLE '' ` WASHINGTON
ORESVIL"L
FAYETTEVILLE
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
FaXetteville,NC 28301-5043 Telephone:[phone]
Telephone:[phone] Fax:[phone]
Fax:[phone]
Winston-Salem Regional Office
Mooresville Regional Office 450 W.Hanes Mill Road
610 East Center Avenue,Suite 301 Suite 300
Mooresville,NC 28115 Winston-Salem,NC 27105
Telephone:[phone] Phone:[phone]
Fax:[phone] Fax:[phone]
Raleigh Regional Office
1628 Mail Service Center
.Raleigh,NC 27699-1628
Telephone:[phone]
Fax:[phone]
-AND-
(2) The County Environmental Health Department in which the injection wells will be located.
Closed-Loop Geothermal Well Notification Rev.3-1-2016 Page 4

i
R)-° S">' 10,�
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 consh•treted in accordance with
the rules of 1 SA NCAC 02C.0200-. 77tis notice Hurst be submitted prior to construction.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in 15A NCAC 02C.0222 these wells circulate potable water only or a mixture of potable water and
performance-enhancing additives as part of a geothermal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS
As described in 15A NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: 20 PERMIT NO. 1-0 k 0 0 577�' (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15ANCAC 02C.0222): �� Number of wells: ®3S�
(2) Direct Expansion(as per 15A NCAC 02C.0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence L,-Submit this form Avo(2)basin rior to construction.
(2) Business/Organization Submit this form 30 days prior t o
(3) Government: State Municipal County it t s t ays
prio o o 0
C. WELL OWNER-For single family residences list the property owner s). IWARIall Th2# st n t e the
business,organization,or government agency and person delegated signature authority:
Sant Cove-, LLtr. ��ater Quality Re i
1 e Regional p � lona�S
Mailing Address: I D1 S �4 • e_Ir_ DL
City: _&-Je l y IYU/5 State: (' Zip Code: 020 County:
Day Tele No.: _ 310 -1/3 2-5!(07 Cell No.: 3Z 3 -(e2,0'- l2$7
EMAIL Address: Fall b> yi�� z(lcz,t�S Fax No.: 310- q32-5528
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site: C8 5(Z— SY-3m'0-000
County:
(2) Physical Address(if different than mailing address): 1 ZS sa�T ee._ LA L-Z"'e
City: [ _'� ,,,y� State:NC Zip Code:
DWQXIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) i �� i Page 1

s �
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 snap showing the locations of the following:
• Proposed injection well locations
o Buildings
o Property boundaries
o Surface water bodies
Water supply wells
o Septic systems and associated spray irrigation
sites,drain fields,or repair areas
• Existing or potential sources of groundwater
contamination .
i
(2) Plans and specifications of the surface and subsurface construction details of the well system.
t
f
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 f
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at http://Portal.ncdenr.org/web/wq/aps/gwpro. All other additives require approval prior to use.
",J
i
i
_ I
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Josh Plemmons
NC Well Drilling Contractor Certification No.: 4137A i
i
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.:
1
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:Bullman Heating&Air
Contact Person: Josh Guthrie EMAIL Address: ioshgna,bullmanheating.eom
I
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804_State: NC County: Buncomne
f
Office Tole No.:(828)-658-2468 Cell No.:_(828)-712-7488 Fax No.: (828)-658-1001
a
i
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2
E

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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:
t ,
iI
I
i
J. VARIANCE—Pursuant to 15A NCAC 02C.0241 the Director of the Division of Water Quality may grant a
variance from applicable well construction or operation standards provided that:
i
(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.nedenr.org/webhvg/aps/gwpro/petinit-
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.
"1 hereby certify, under penalty of law, that 1{rave personally aTamined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all related appurtenances in accordance with the 1 SA NCAC 02C 0200 Rules."
Signature of Property Owner/Applicant
Print or Type Full Name
• • Sign re or Authorized Agent,if,
Print or Type Full Name
MQNIC/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:
S
SS
S
i
HI
}
E Y T IL E
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 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
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
DVPQ/U1C/C1osed-Loop Geothennal Notification(Revised 4130/2012) Page 4

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are `permitted by rule"and do not require an individual permit when constructed in accordance with
the rules of 15A NCAC 02C.0200`F. This notice must be submitted prior to construction.
Cn
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As desJeXin 15A NCAC 02C.0222 these wells circulate potable water only or a mixture of potable water and
® O Operformance-enhancing additives as part of a geothermal heating and cooling system.
CIQ
� F c-
C" o o OR
CM M
z >, e, GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS
=�s descgbi d in 15A NCAC 02C.0223 these wells circulate a refrigerant,gas as part of a geothermal heating and
C cooling system.
m
� Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: lQ - 23 20 PERMIT NO. V,VQ QQ (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:�?9).,06'
(2) Direct Expansion(as per 15A NCAC 02C .0223) Number of wells:
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 Submit this form 30 days
prior to construction.
C. WELL OWNER- For single family residences list the property owner(s). For all others, list name of the
business, organization,or government agency and person delegated signature authority:
Mailing Address: 1000 jfU H �(sja /44/o n ,� y C�/
City: ex- State:n� Zip Code��67/2 County: -r V"-" J / V�
Day Tele No.: Cell No.: BZ6
EMAIL Address: "IIT/ �1 I I , Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site: qs c)
County:
(2) Physical Address(if different than mailing address): LP
City: State:NC Zip Code:
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 1

f q.
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 repay 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
—concenirations. 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 web/wq/aps/g_wpro. All other additives require approval prior to use.
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:[e-mail]
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/IJIC/Closed-Loup Geothermal Notification(Revised 4/30/2012) Page 2

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I. PROTECTION—Provide a brief description of how(1)water supply wells; (2) surface water bodies; and(3)
septic systems and associated spray irrigation sites, drain fields, or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
tP-m oV
1 — f
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.nedenr.or web/wq/aps/awpro/permit-
applications
K SIGNATIURES—The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .0211(e)requires signatures as follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner or the proprietor,respectively;
(c) for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
(d) for all others: by the well owner;
(e) for any other person authorized to act on behalf of the applicant: documentation shall be
submitted with the notification that clearly identifies the person, grants them signature
authority,and is signed and dated by the applicant.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and a ll_re�a t appurt �cesinor ce with the 15A C 02C 0200 Rules."
Signature of Property Owner/Applicant
VA/, '131A,06w4-
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