Yancey UIC Deemed Permitted 2012

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. -�--�1
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 171
performance-enhancing additives as part of a geothermal heating and cooling system. ; 'J
OR cii CIO
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS !,:i� a E�:
As described in 15A NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geothermal heafFig Arid
cooling system. n
.Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete
DATE: J L nb o2 Y 20 // 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) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence Submit lhis'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: C State: Zip Cod 5"00/ County:
Day Tele No.: i y /a 53- Sob Cell No.: aV 77
EMAIL Address: C-',11 Fax No.: i Y 5 3- 3`I1 2-- _
D. PHYSICAL LOCATION OF WELL SITE ✓✓
(1) Parcel Identification Number(PIN)of well site: 02
County:
(2) Physical Address(if different than mailing address): /zS ��v�f c- &
(/ J../hsyrrlc_
City: /�G/►�►Syr'1�� State:NC Zip Code:
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 1

E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations,of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site-specific map showing the locations of the following:
• Proposed injection well locations • Septic systems and associated spray irrigation
• Buildings sites,drain fields,or repair areas
• Property boundaries
• Surface water bodies • Existing or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services' Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at litip://portal.ncdeDr.oriz/web/wq/aaps/aznwpro. All other additives require approval prior to use.
a
0
(o?o
G. WELL DRILLER INFORMATION(if known)
'¢ Well Drilling Contractor's Name: Uca)-- we c✓ w�l r���f�n( �F Or>rTJ,
NC Well Drilling Contractor Certification No.: 7
Company Name: C6 cz✓ wGt-Ge w0U Dr Contact Person:
City: 81& ! lq State: 19L Zip Codea County:
Day Tele No.: P 8 G-V) -7 o c1 D Cell No.: 2,)-9 77te- L,5 akp
EMAIL Address: JI'hLJJR toff Q ADC V,Coo'1 Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: G&'r ktl qc,"k,A6
Contact Person: 6 A i u,5 EMAIL Address: i c<�O
Address: i 00
City: 6 wG n n}r O L- Zip Code: -2$V State: c'County: o,
-& Office Tple Na.: �a� a7�• a 5 aJ 00 14df Fax
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

I. PROTECTION—Provide a brief description of how(1)water supply wells; (2)surface water bodies;and(3)
septic systems and associated spray irrigation sites, drain fields,or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
(100-96)
lJ►nc cfh�,Uenr, cyan�I
J. VARIANCE—Pursuant to 15A NCAC 02C .0241 the Director of the Division of Water Quality may grant a
variance from applicable well construction or operation standards provided that:
(1) use of the well(s)will not endanger human health and welfare or the groundwater;and
(2) that construction or operation in accordance with the standards is not technically feasible or the
proposed construction provides equal or better protection of the groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation of the request.
The variance request form can be accessed online at httpa/Uortal.nctlenr.orh�_eb1�ti /a sl�awpro/permit-
ill icatiorls
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 certfy1 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 tesponsible 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. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all related appurtenances in accordant with the 5A NCAC 02C 0200 Rules."
-.416es Z&- eglgz
Signature of Property Owner/Applicant
'e,f 'kRQ Je
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

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

r , 09/18/2013 09:57 8286656576 MIKES HEATING AND PAGE 02/16
kf101002- r02.
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATIJRAL Rt OURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPEkATE INJECTION WELLS
71mv r welht ara'perrnrrred by rfele"awf do riot require en individua'1 pefmfr when constructed in accordance with
the rules of ISA 1VCAC D20.WOO`, tkknotice must be�gpMlle LLoLjo corrslrrK11 jq,
GEOTHERMAL_AQU.EQUS_CL0SfD-t.002 WELLS
As dtgcribed in 15A NCAC 02C.022.2 fficse w0a circulate potable►voter only or a mixtur¢or potable warer and
Iwrfnrm;mcc-enhtlrtdq additives as part of a genthermal healing and cooling syeaem,
OR
GEOTHERMAL QIREC"C_EXPANSION,CL05ED-LQQF'tNELLS
As described in I SA NCAC b2C.b223 ihEaa wolla circntnte A refrigerant gag ds part of a geotltcrmnl heating and
cooling system.
print Cieaty or Typo Iniprmollon. fflgible Submiflals Will Re Returned&Incomplele.
DATE:9 l 1 o� . _ _ _ - 201; . P E k M I T N0. be eomptcled by DWQ)
A. TYPF OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per l5A NCAC 02C,0:222): X Number of wells:-4--
(2) Direct Expansion(as per 15A NCAC 02C.022_3) Number of wells:_
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Retsidcnec.,X Submit this form two(2)business days prior to construction.
(2) Rusinesvorganieation, Submit this form 30 dayS prior to Construction.
(3) Governmew. State-- Munic iol, Courtty — Federal—Submit this form 30 days
prior to Construction.
C. WELL OWN E R—For single family residences list tilt prnPorty owncr(ts). 'For all others, li"d riarnc of the
husirmss,organisation,or government agency nrld porsna dclegaled siganture nnthor4:
Q>
MailingAddreis;
�p�� W —City: ..��� SiatG���� 'Lip Cnde: �
__)8yFOiE +0.: u %VAS-�rMAr.Address- -�l ` ..fJ..l_f�........•�
t �.e O
iD. PHYSICAL LOCATION OF WELL SITE
(1) Parcel ldemification Number(PIN)ofAeU site_ aDz->
(2) Physical Address(irdifforcnt Than mailing oddress): (u .� "J C� TIl
C hy: Q> sNrc; NC Zip Codc: .�.: L --
pwpN1GL'tnsnl.La.p(ittdtc�mnl i`lotifccntinn(Rnv;�ed 4�O/dal�) tR}T I

09/18/2013 09:57 8286656576 MIKES HEATING AND PAGE 03/16
E, MAPS,Pi.ANS,ANDSPECIFICATIONS
(1) Maps must be scaled or ofllG sc aocu;ately indicate di5tnncey and orienumion-a or rcatures located
within 250 fe0t or the injection well(a). 10k.-1 R features c earl j include a north d,rq�_v, Attn b a
yit03pecifc map Showtnp t1 eC locations of the roilowing,
Proposed injection well loestions + Septic sycterns :md associated spray irrigation
■ $uildinFs sites.drain fields,or mpalr areas
+ Property boundaries
• SUr*t water hodlcs + !Existing ur potential Aources of groundmiler
• Watcr supply wells cen,tnminsttion
(2) Plans and sppcificatiolis orthe Silrfilce and subsurface consiftimion dorails of the Nvcll%r,Lcm,
F TYPES AND CONCENTRATIONS OF ADDITIVES R List any additives that will be used and their
concentrations, Only nddifivtss that tlic.Ocparnnent or tieahh and Human Services'Division of 1lublic.Health
determines do riot advcrscly affect human health shall lie used. A list of approved additives can be Found
online at 1)ttp;;/portai,,t�dsnr-�r rWCnl�Yr,�� l �,�,�, Ali other odditirvar require approval prior to u-ce_
Ethanol 20%
G. WELL DRILLER INFORMATION (ifknown)
Well Drilling Contractor's Name, Robert Larry Wells _
NC Well Drilling Contractor Certification No.: 2603
Company Nome: \8LD SBLV QeS_,—_-.---T Contact Person: Larry Wells
City: Leicester state: zip t od2874r,,,r,ty;_ 31mcombe
Dav Tetc No,;� $ 83-923 „ -------.. . Coll NO.: 82 215- 34
F>4tall,Address: 9 bells�.-,_n-..etFax No,:. [phone]
li. HEAT PUMP CONTRACTOR INFORMATION
.... � -W-QB,_.__.__... 1.lA1 Addre�sronatd(a�mikQsheaUnaaDdcooling.cam
ConlactPer-son; Orl Hach __.��.�_._--.__._
Addrvs.g 329 Dogwood Rd.
city: _Candler _ zip Code; 297-. 5 stateMC-cbtlt)ty:
(}rCicoTele Na.: $2$ T �43-4 cell No.: .^Y _ Fax N,,.[phone]
DWQII llf,!!'lncrr)-Ln.:��ernhrmral Nditicatign(RcriacQ 413�2(I l x) Yngr z

09/18/2013 09:57 8286656576 MIKES HEATING AND PAGE 04/16
Sep 13 13 12:1Sp .lack Gordon 830 798 O2/0 PASep, 11 2013 3 MM lyner Cons) ruchoa Na. iM Y. YI
1. PR TEC TIbN Pravldaa bri;fdescrlyriott onmu(1)waif 3opPly W011t1(2)sudate wales bbaieai and(3)
scptic Wsicros and abocialed apioy lrtigalion pits,drain nelds,or mpair areas wi hin 250 fcel of the proposed
blit00n WAth will be pmlcetcd pugEq consltur tl6n of tilewolis,
$ilt Fend
3. VARLANCE_pnrauaetivlSANCACQ2C.O241thoWncworthrpiySylOnarWpkeyglpritymhy"ta
vntiezce from applirable wcn cormniclion oropernlion slandardspmv"dsd Thal:
(1)It"I)frht W/lt(s)rviA rW cadattgerhureon.htxllb ondwolfttrt;Gr the gr ttmdr gW;mtd
(2y 6al aotleKrar ilon in operntlon in aaeordarna with the acandws is not te0micany fessibtt of ohe
proposed a +rrtiawpmvtde?equal or benqr prmrtcrdon Ortfre grovedwater.
Aiay vodance r Vmm airtrntd accompany submittal of this norifoetlwt ro expedttc a"►uarron orlhe milutst.
Tho volisme reclm a form can be accessed ratline at�1lroY/emtel aCdppr.orrJdteh/weln� t f pc 1.
icatiorrs
K. SIf,NATV R£S -T1pc following p=1jon is to be completd�+11"VM bcldw aT by thta peaaoo's nuthori2.cd
�genl. 15A hT-'AC MC.O211(e)rC areC rlg AtUm$"follows.
{a) 1hr a colporetionz by a rsspoagililp aorpOrllp o(frcaxi
{p) fnr a pa:tocrrh(p or solo p,opeldarahip: by a gctre�l pAtltte[Ot tttO pt�sidor,respecrivellr,
(e) for a Municipolitp or is ttatc,federal,or other pubHz Agentp. by ekhm g;4nt)pnl exectvivo
0"hot a:W011king hubliply eltxacd 9111tlat;
(d) 1•or eliothers: by the well amar,
(6) for my Mhor ptroon autlmtyzc4 tO ept on behalf of the applicnnl: docdroentatiofl eha1l 64
34Nned with 1110 1101►Grarion ihnl dearly ideabfies the person, grants sham eighmurd
®olhorlty,and is bred and dorcd bytho opplicanc
Aoreby�mh:rurdrr�srrn!!r of kr,thin I b6vv person¢exmmri*d and any jox"iffar Itt11b tbx ipirdmV110n
sGDmnitred rum 04 dcumtnl 8nd ell a►dtar,v mis Wrela mad 034.based on my kwfr of Ilratrt lndi'vldrials
lndmedretalp re>y 0Wkyk tpr ob/el»hrg saki kfarblAIM l WktV that Jbr,4rrormpmiemm IS arse, aer&ala and
br subtr:, I ant a,gare!ldbd dhera aura fltanlllcont'gom eE uding the ppolFfbNlty of hrtrs and;mprlsO�nrant;
for sr�bmitdrng falssa rf ra I ogrra to caJtatrrn�frale,mfingefl6 appfrt46k,atiandarl
►Ae injectiarr ttrQA ended rp d ptaunetltes 8t-YCCm eticA 40 the 13A yCA =mm Autos"
5ignaturr of prop.tly otynerlA pplithnt
el
Print or Type f Name
r morn o(Auth rl; J) Of arj
PAnr ov Typb ull Rome -`�'�
nwt�rArmtto,�r-L�ttau+�rmiol Nont-lotion(rudaea ar�anal�l Fayc s

09/18/2013 09:57 8286656576 MIKES HEATING AND PAGE 05/16
L. SlJBMiTTAL INSTRUCTIONS—Submit one copy of lihucomplt:tctlnntilloatinnpackagetotheeochofth,t
following:
(I) The Division of Witter Qunlity Regional QJTpcc serving the area in which the injection well facility
will be located:
IN Ali RS, LEM,
�.,� 15Cr;� vile r� \;__-� I---f- .�/. 1 `•}J�I��H���a�
Asheville Regional Office Washinglon Regional Office
2090 U3.Mgtnvay 70 943 Wa311ingl011 Square Mall
Swannanoa,NC 28778 Washington,NC 27889
Telephone:[phone] Tcicphone.(252)'946-6481
Pax![phone] Fax:[phone]
Fayetteville Regional Office Wilmington Regional Office
225 Green Street,Suite 714 127 Cardinal Drive 1Sx1ett9ioA
Fayeneville,NC 28301-5043 Wilmington,NC 28405
Telephonq;[phone] Telephone:[phone]
Fax:(910)48"707 Fax,(910)350.201
Mooresville Regional Office Winstan•Safem Regional Office
610&,iqf Cotiter Avenue,Stole 30 f 5851Waughlown Sired
Mooresville,NC'281 IS Winston-Salem,NC 27107-2241
Telephone:[phone],699 Phtme:[phone]
Fax:(704)663,6040 Fax:[phone]
Raleigh Regional Office
162Ft Mail Service Center
Raleigh,NC 27699-1629
Telephone:[phone]
Fax:(919)$7T•4718
(2) Ctntuty Health Deportment in which the injection well facility will be located. A list of county health
departmeots can be found online atlttlphtwvy.ncalhd,atic� plTtv,htm,
t5WgrMTCiClwcd-Loop(jewhennni Nolifieption Mvisn14130/2012) Pngc 4

09/18/2013 09:57 8286656576 MIKES HEATING AND PAGE 06/16
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i

Moore, Andrew W
From: Ronald Hathcock <[e-mail]>
Sent: Thursday, September 19, 2013 4:24 PM
To: Moore,Andrew W
Subject: FW: Golden & Reif PIN numbers for NCDENR
Andrew,
Below is the correct PINS for the Golden & Reif Jobs in Yancey Co. (Mountain Air S/D)
Please let me know if you need any additional info.Thanks for your help!
Thanks,
General Manager
Mike's Heating&Cooling
Office:[phone]
Fax:[phone]
Cell:[phone]
ronald(@mikesheatingandcooling.com
M i ke's
Heating & Cooling
Quality. Coinfort. Reliability.
From: Sue Smith [mailto:sue(atynerconstruction.com]
Sent: Thursday, September 19, 2013 2:55 PM
To: Marc Tyner; [e-mail]
Subject: Golden & Reif PIN numbers for NCDENR
OK. For NCDENR.
Golden PIN number: 0708 04 74 8433 000
Reif PIN number: 0709 00 82 6202 000
You can run them all together if you want to.
For me, it is easier to read with a space in.
Hope these are right this time . . .
Thanks @ Sue
1

J 09/18/2013 09:57 8286656576 MIKES HEATING AND PAGE 07/16
YOkf'II(;AR01.lNADF,PAIt•tNVi NI'OPt:*.,\iVIILONA4r:N'1'AN_L)NAI'�JtillE,Kt �i3EJ1CC'Li
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WCLL$
!l:ccc�uwl/s on: "rx�rnitrr.J hp rwle"wrrl rrn)rUr,•i,l�r+rr+,an litdll7llu�!pbrn'lil lNhd)P.r1nSlrUctad In aerArxlnl►ra�Fs+1t!]
the r!1lesof 15A h►r:A6 d2G,0?.lN)'. ThlsRntic.�1T►1lit6a�rr�j1�(1�)rf4.r rb t�l�lr'Orj,
GEOTHERMAL AQUFOUS—C1,OSE;D-L0OP WELLS
As d C',rn;a4luiti w 15A NCA 02r,',p322 I lvw Wells ciroulme penal*Nvowr only m,fe mimurd of i imble water Lind
tk rt'nrtlt.ihCL-C11IIAnG111 additivai aN Jvdrt(/l'n and�c�,li�il; y.9feltr.
on
GEOTHERMAL DIRF.(:i ExPaNslaN Cl,-p$,ED�LOOP WEi,L3
hs dt'S('rihcd In ISA 1vC:,1('ii�r_'.,0�?3 Iftt ir.t�vlls ctiYulrttc a rcdri0enufL�,is t,,�ar1 pl'u gt'OtI1Crnl;tit Iff atin£nn(I
cnoirn);::rl:lum_
F'rirrf rr l��rry dr 1 ypc Irrinrrni3lin,r. lllot7lhle SubrrJl Mals Wlll Be ltp gmad As tC
DATE;. 914 .. ,, 2ol.3. PERMIT NO.AM .- _(tip1+�CnmplOcd by DWQ)
A. TYPE OF OEOTHCRIVIAL CLOSCD•LOO15WELL TO BE CONSTRUCTED
(1) Atlacoas(aq per I.S.A NCAC 02C:.022-,0: x ,Number ol•wutla:_.Q•.
(2) L*CCL 6XI:Mnsinn(n•per 15A NC:AC Q2C.022.3) _ Number orwollc:.. ..,_�._..
S. STATU5 OF WELL OWNER lChbocc one)
(1) Single Ptlmily RCsidel►cc._X Submit this form tyro(2)busin=days prior to construction.
(ti) L�uSisesslf)t tnirtlitn+ Submlttttif;form30 days prior lgconstruciim�:
(3overr(wriv Slaw-_.-, 1,9unit 1pal _ Coumy--,• Lfodcr iI__ 511hr111t this lorm�d da)+:
prior to constfttollnn,
C. WELL OWNER _ Forsingla Rteoily rcsidcn(;t•ti li;•(t ifio pfopertyt:iwncr(s). For all others, list mmw of the
bummm.orgmlirstion,or Gotiernment t ens s(}tt r�ers{�ti{9t le rAtYt tiLenaturC sndflori�';
M14ililing rtitldrCBs;
�!fZ�- yt,tc:/'!�"--• lipCudc: �'1�[;eunlY. Yq:�t��' '
f).1y TL,1c Nn.: f}�/i
liiUflrJL Addre:�,r!?}F-}"^ y t:�►�� !�'� Fif±r No.;,. _/,P//Y1
D, PHYSICAL LOCATION OF WELL SITE
�t
('0 Pf+rucl IdentiliCati'm number(t'I\)t i'a•tfl site: /✓'� r( r��-� .?
Calmly: -f
(?) i'It�t4icpl A(f(tres!;(if diSlcrefrf Ilsnn tnniiinp(Icldresl:;t:�f/,,,-��'�'>'' 7l/�.•�',.•�f��l� J�
ly
L�1yr,lftu(j:T-4ned.laq p(AxIthcfn it Notifleaflnn(r(eei it 41M012) PLipe I
. I

09/18/2013 09:57 8286656576 MIKES HEATING AND PAGE 08/16
j,
E. MAPS,PLANS.AND SPFGIFICATIONS
t 11 r4111+1,;nat+Sl be trulnd m whenv4e.nccmmhl ly indka1e di;:lnnec: and oriculmliorvc of reamm.q loemed
within 230 feet oFrhe iniCtiinu>.vc:ll{S}, 1_Krlml rill fua r tk �k r�v,�,lcl.jp.�(nc�c,a,s rth nrrc>t+,. rluliCh u.
silu�slat:cilic map shafsiny;the;IC+Cillicin,of thr firllc+tivinr;:
• Prmwod irtiC<:rioat uc:ll icx:uixui` • Srplie ,-,yglom-q nod mscx ic*( d spay irrignlmii
• Buildings siWq,drain lichis,or repairaress
• Prnlrcrty hotrndmiev,
Surface waler lm lies l-Ni stingy or pulential Bnnrcos of gmundwa for
11'ltttlrsupply velk conlulnhu,.ritso
{?,.) 11me and spociftcalions nt'16r surface:md strhwurr"re t-kill tilruolon delnilc orilte Wti --Il 5ystrtu_
F, TYp1;S AND GONCENTRATIONS OF ADDITIVES - I.Am 111y addilivos tl,al will be u:wd and lllp+r
concenlrnriow, Only rtddiliwk llttll llle Departmoll of l-leelill and I•f umM Servimt' Divisinn bl'I vNic I Icalth
delumints clD not ;rdver!:aly tdlicf hump hccdth shall lit mcd. A list cif appmved additivec scan (tc 111000
online al ItIIR:e.'„�rp�i.it1_Ifc+,r_carr_;�`,�I,,y:�l_il,i�z;rrhrt�, All oihcr addilivcs require upproal prier Itt utic.
Ethanat •- 20%
�............
G, WELL DRILLER INFORM.ATION01-known}
WiAl Chilling Cbrtiiracft,r'c Namr: _...__ Robert. Larry Wells —�.--
NC W 01 brilfing0intmelr,rC'e INIcafinn N(7.: 2603
(.'on+i,:+nytJame: t:ont;rclr'crton: L_..... rry Wel.1s
City; Lice ter _ Staic: NO %ip C';u4 upntY;gulp„(�roi�i'1bG ---,-.--.�`
Q.3-4•--
F:ft�n1L rlddresc:W�,i.ls75-_45 9CC�k? (Is+,��G1t.k �et1,�r1fa.:...{,8. 8) 683-9203
H. HW PUMP CONTRACTOR INFORMATION
Compnray
1.".Onl:ret Pl:r++Prl;-R—gna1,d-H bL,CC-Ck__...,.•..•., `J �111.Arl,1n�4S �.ClrrtjkeSi�G�tir(aandcQ4Jli�g.corn
Addrp.q :..3.29DO WOpC� ,,,.•.T -
C;iiy; Cpndler ._� Zip cod(!; 28 15� Slam: �••� t:rsunJt: CO
Off ice Tol1•lvo.: (828),665-4343 col No,;
I1WQA;K'r•Invcul-I.,mp ftcnll�Ctln�i r tnlihcrai,xl(Rcvlw.il•N:IN".iai.tl P11tP'

09/18/2013 09:57 8286656576. MIKES HEATING AND PAGE 09/16
11 �
11 PROTECTION—Provide,( 01•11ow(0-miler supply%+ells;().)surrnix ivawr bodies;and(,I)
ty>tic syslo+t++:and acenctylcd spedy hvil;alion-her,drain lirldc,oe within',10 reci ol'the propklsed
injectim)tvclk will bo pt1)k�cled during eutistr%wliAn Ofthew'clie:
Silt Fencil�g W
VA R IANC E—Purronmt to 15A NCAC.42C.1l7+11 the IDirtrctor ol'lho!liviiinn n1'lVatcr Duality nary�rthtt a
;�irinoce from itipplicablc well conslrlicilon or opor-alion sumidirdi provided that:
:1) of ltic tvoll(s)will n01 chd:thger IM111fili blUalth and wcllan:or the grounftuter;atttl
(2,) Civil cowstnidiun of operation in necordatice wilh the s-uullrtls is not Welnticnllu rnAblc or laic
proposed ccln3hlrctinn providor k,,gwil nr ticttor pretceliurl(11'(1t:grpunrinnter,
Any vuriance rcclo(w.shooid rtc:cOmp;lrly rtalmti(taf nrlhis 11411112:1tlAn'10 fKPEtlI(l`CVulult(i(+(1 Orii)c request,
1'hc varlancc ttutlest limn e,pl hey strcc-sed online 01 JltIL_+rL�ll;tf.nc(ic11r;(fat;_�ticl►.'�titt41P '`(:�5'!>la?1(7�?!+it_
1�PI ic;st i(Tp•
K. SI GNATUR ES The toflowing t.;octiotl is ul be utnlplotctl a:;required Wow or by dtnl persnn's au1110d7(rd
eFent_ 15A NCAC;(1?,0.0211('c)rcquires,igtl tiurati as lirlitl\vn;
a! Vir It ctlrporid Ion: by a rc;lpulisihlc corpornia officer,
(h) I)y u goncrai piirtncr or ttic pniprictor_roslwf ivefy:
(c) RV n trtlihifipslily Or Q St-dtt.fcderol,or odtcr public apncy: by Offer:1 prin6pni rxecutivc
ullicer or rnnkfrr publicly vlcc.(cd aliicioi:
(d) fnt'all others: by the wo.II owrlgr.
(e.) for :nty ether perion Utilhoriyod to act oil bchidr of qjo opplienrit: d(tzn111c,11;16(HA shall hc.
;ubrnitRal with rltn nnlilicdfon Iltil•clearly idtWilicti the porson• groins divat signailite
authority,and i;c shoed t(qd dMed by the npplicnnt_
"1lemk)crrf9+, rrrrikrAmalty of low. Null I hors p(tm'rlrmlly urrrrnhwit tr+ulom_forniffor mlith 1k,informannr
wbmlded in this tklamtdfl and all atlachmenb dtcrctp�igt,%dla4 bawd on my inquiry of iftsr In Adduals
immodlarely respoasihle for oGta, ;V sald lnforMalion, I belleve Mot the informfiat is true.arcurate and
coprplate l enr amxe th,?l there Are d fniAtanl pena111es;Incivaing the possiblllty of fines and imprisonmen4
for suhmiffing false lnlorniffi r?. I agree to construct operate mint•rin, repefr, xW it Rpplirable iiftf dop
the injection vmll and all related Apputterranr m in ai=ro, ce ivllh h5e 15A AICAt;OZG 02W Rulas"
rggatureW proptrty caner pliant
"Aria(or Ty ii Full Nam
fl8tur(rM Aar t Agent,II way �
gal-
Print of T**Fall Nair*
t�t>,'t�IUI+':('twu:d-1.+K�p(rC•Jlb�rl7u�l NnrifiGMt+a+(Re�'iu(1lhlftr?n12t refcJ

09/18/2013 09:57 8286656576 MIKES HEATING AND PAGE 10/16
I._ SUBMITTAL INSTRUCTIONS—Submit one oMy of the completed notification paeltagc to the each of the
fallowing:
(I) Tbo Division of Water Quality Regional Office serving the area in which the injection well facility
will be located:
Asheville Regional Office Washington Regional Office
2090 U.S.Highway 70 943 WashiOa oat Square Mall
Swannanoa,NC 28778 Washitagtrfn,NC 27889
Telephone:[phone] Telephone:[phone]
Fax:[phone] Fax;[phone]
Fayetteville Regional Office Wilmington Regional Office
225 CYreeo Street,Suite 714 127 Cardinal D)jvc Eatcnsion
Fayetteville,NC 28301-3043 Wilmington,NC 28405
Telephone:[phone] Telephone;[phone]
Fax:[phone] Fax.-[phone]
Mooresville Regional Office. Winston-Salem Regional Office
610 Feet Center A.veime,Suite 301 585 Waughtown 5ttect
Mooresville,NC 28115 Winstw-Salem,NC 27107-2241
Telephone;[phone] Phone.[phone]
Fax:[phone] Fax.[phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh,NC 27699-1628
Telepbunc:[phone]
Fax:[phone]
(2) County Health Department in whieb the injection well fa01 ty will be located A list of county health
departments can be found online at Http;(Livww,ncalhd.or co mty-11tm,
DWQ0VC1osod-Loop GCOUIEM3.1 NOSficntiao(Rc&cd 030/2p]2} Pogo 4

09/18/2013 09:57 8286656576 MIKES HEATING AND PAGE 11/16
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Moore, Andrew W
From: Ronald Hathcock <[e-mail]>
Sent: Thursday, September 19, 2013 4:24 PM
To: Moore,Andrew W
Subject: FW: Golden & Reif PIN numbers for NCDENR
Andrew,
Below is the correct PINS for the Golden & Reif Jobs in Yancey Co. (Mountain Air S/D)
Please let me know if you need any additional info.Thanks for your help!
Thanks,
Ronaddf{athcock
General Manager
Mike's Heating&Cooling
Office:[phone]
Fax:[phone]
Cell:(8:,$)280-5839
[e-mail]
Mike's
Heating & Cooling
Quality. Comfort. Reliability.
From: Sue Smith [mailto:[e-mail]]
Sent: Thursday, September 19, 2013 2:55 PM
To: Marc Tyner; [e-mail]
Subject: Golden &Reif PIN numbers for NCDENR
OK. For NCDENR.
Golden PIN number: 0708 04 74 8433 000
Reif PIN number: 0709 00 82 6202 000
You can run them all together if you want to.
For me, it is easier to read with a space in.
Hope these are right this time . . .
Thanks @ Sue
1

08/29/2014 10:41
COVED FADE
TO :
FROM : DEWEY WRIGHT
FAX : [phone]
TEL : [phone]
COMMENT :

08/29/2014 10:41 82826461251 DEWEY WRIGHT PAGE 01 `
DEVM WMQFff WEM & P" CO., INS
[phone] Tall free [phone]
105 By Pass (P 0, Box 308)
Boone, North Carolina 28807
FAX COVER SHEET
Fax: [phone]
T
FROM: rr
DATE: a.
PAGES: including fax cover sheet

08/29/2014 10:41 82826461251 DEWEY WRIGHT PAGE 02
.__ .._ .... -, w,:M ,,_ •7tjtJ L^dWG YaU��.l berb� r-
PlORTH CARCjljNa OBP.1 jl'UFKC OF fNV1RUN.MBIVT'AND NATURAL RE330LRC$$
F111rk,d
ION OR!N�'$;VT TO CONSTRUCT OR OpFRATE IN�TE Tj()�i wEX.]<JS �
by rind"aiddo not►�,ulpg a#fndFvfdiial u1es gJ Td d.N_4CiX,020p, Ts Awdmaw P�*';v L3
15A NCA002C.0'22 es. 0 we11e eirqulata pD&b1e %'t0x lly or a mitj olpotabte�iatnr and
'• pdrfnrmancxtnba�xfr g additives as part of d gvut,'ternta'r hegCng 8atd cooli;7g system.
OR
LAs described in SA NCACD2 dI 2 h a wot cam' jr �a�fr; 'Qrn gpa as pa� f r
_. cnautg eystam_ pad 1vaii'g au
/j I'rilu Clearly err 7'W AV orma[lou. Ilksible Smbm4f&&919.RgUti wert,4,1NCwstp(p�T
DATE: .1 PERMIT NO,4 LT 0%q©31,�____t D VVQ)
.—�, ,,, ,, to be cnntpietcd by
A`, TYPE OF GEOTHERMAL C GOt>fi:>a.LOOP WIELL TO DIE CONSTRUCTED
f:1) aqueous(as per 15A NCAC•02C.0222): _
(2) Dim-t Bxpbnsiott(as pa•I SA NCAC 02C ) Number of olk:
• �3 _,, Nurtt6er of we11s:'�'
1t3, STATCFS,01?W9jjL.OWNER 'choose o.7a)
(1) Single Fttrnily Residena•k"Submit this fot411 tern(2)business days prior to constructfor,,
(2) Bu6inasyl0rgenlrAt1b-1.__Sebmlt this form 30,day a prior ro constrtutbx,
(3) Government. State Municipal Counry Federal Subntit th14 form 30 bays
grler to mustructi¢n,
G. WELL OWNER--,Far single i lmily residences list tho prWetty owner(s), Far afi others, !!s1 same o�tea business,orgat,izotto.t,or govern nag genay Mg person delegated signam"au¢hority;
n 4g� 0 N[t3iliug Address: �i/
�L cy �Ca�': r 5ta . l L. 7.ipCocta:Z
V. tp DRY felt No.: e `� tY•—
..�-..1.----.�...��:.._.i..�.��:___.� Cell Nu• T �` " Y-
F,ti•fA1L.A_tidt�ss: Fax?+la.; 2 rC� ,���""�.•^..—_—
00
P1!�SJCAL L0CA r�'jq.N Oy% LL SITE
(1) Idctldficetipn Nutt bet(?IN)of wol'sib:._C) �S''� C���_a J 1. Y�'~'�t.�io-6
County:
V4Y3ic4l A(idr"S(i� ant Ct o milirg address'-:.
Soto;w Zip Code• 2- K
DWQAj!C/C)md-1aDhCJCc�thgrp;ulNotitSCadxr;R;w•Seedat304012) _
Pagc 1

08/29/2014 10:41 82826461251 DEWEY WRIGHT PAGE 03
_ �- you u J• Yl!! r
•1yUJ.=� Sj1"'11�•.12C3v,j ��++ l�r��j r� 13n
1-150 TYJ 02/2il!I174
E. AUPS,PLANS,A""S�F t;p',CCAT1E3Ai5
tl) Mithi muss ae scaled Cr akherWisa &ccurdttl I]ldica.tu disia£p anti rrierNatioas of fedturra iocaud
itV p,250 feet of the G Ig the 1 04tio,). V'tk. fa�,tus igia,���L f h err
sieo�spcoi is rasp shpAVi ig the iooatia.18 of'the fallowing:
• l MPosnd inje4A-iQn VD11 looatiotls
• aui'dings septic systems and A3sooiateo spray irripatior
• ?►uPerly boundaF,'e: shad,drain flelds,ar repair areas
• Surf cu wCor ho,Ie 3
• Watcr s ) �aLs • Ex:stttt� or �oE9�tin' saurces Of groundwater
uFp Y' oanv�minadGn
2) Plane and specifications ofti•eturt'ace and sabdatface 001I8truotion doW:s of'tile well system.
F, TYPES AN13 C0NCEiY1'tiA7 IONS OF Al)V1TtVL » Lie; a s
�Pnoertrrtt_lOrM O NY additivas 1:mt the Deparitrlent of Haatih and Flwyan&Crr e s Jivaliott of Public
e�td their
online at
do nOt dvaa��ly flY xt hut»st+beaftlr shaii be used; A list of approved addifivog caD lbe fou Q
fi n. All other additives requite approval prior to use.
G, WELL DRILLB11 l:VFORMAx(ON(itknown.)
Woll DHillrg Coatmotor'a Nuk1s:
Fr L ��.NC Veil priding CurrtracWr C�1.ikadon .--
Company Name:
4 Intact Nersun:. {� {
tY: F �- �
' 4ur,ty:
G t r Zi Code• d
�i
uay't eie No.: Cell iJe,:
_
lrMAli.Addruss
a� ' c '„ 5 a
tl• HEAT k UMP CONTRACTOR.NFO$HA'Y WN
CompanyName )�•f� Ir 51� -
(-Unte �
Harsott:
Citv,' S Zip Code: ? �'-
'Stator.c, CrL1uaiy;
()�'�/t1f�1C7�e<1•?�,pt,Qco:hGn:ii!tr'o,ifr®tipl(Rx,i�.p136f3U12)
Yogc:'

08/29/2014 10:41 82826461251 DEWEY WRIGHT PAGE 04
p;'Uv(da.$Loaf des�.1ptiolt of'low(1)water snAPf walla;(0)surface water bodies;and(3;,
injAC RYSwclls and hear ed spray
r�.�n'gation sites,dtaln golds,or,epnirllreas within Zit)feet of+he proposed
P artsn•ucilon Uf(he;Weis.
S• VA.RIANCk—Putsoant to 1SA.NCAt'j2C,0141 the Director of the Division of W4ter Quallty MAY graW F
variancr front appileablo WCN eonitrac iort'or operation standards pMividea chat-
(1) u30 Of the WOW will not mdongeritutnen lieldth and we:fato br tho 810011,c3wator;bad
(2) that construction or operatl On in accordance with the standaids is not technically fcasibie or the proposed Ltansttt3oticn pro/ides aqua!or better proteolon of tilt?gnot tdwater,
An)variance request should accompanyiltt$t ofthts nat36cation-0 expedlta tiv$luatlori of the raqunsr, -
The varien3 a sVgst fol tt1,;;n ba:<Cce:sed ontlttG at h � DI�9I'!w�b! /HxY1L'hlil4�t
K. SIGNATURES—The fa;lowilrg soctb in is to be completed as required bGlo1N•�by that persons authrn'lzed
egartt, I SA' CAC 02C.021](a)reyuii as s4naturas�ae fbilows:
(a) for a corporation: by, respon$ibic eorportrte of ter;
(h' cur a partnership ortsa a proptieto[ahi�; by a geaatz(part:,er cT the praprloto_,r�pectiValy:
(cj _pr a rnanlGlpOtity• stilts,federal,or other public agettcy: by either K pringlpai exac(fi vc
officer or ranking p&icb,elected ofMcial;
(u) far all others; by they Falk owner;
C.e) for vl�v other parson wthoNzed to pc:t On bdhalf of;he appl)cant; slooumen%linq shall be
subrr.i Jt d with the .n Xificatior, that clean, ident3fios t1+e person, grants them signat.tre
authority,and is sigtre(.And dated by the applicant.
V hereby cert{f; undv-pa"l;of la% that l have perfOrralld exclMired and am f7t ilar'with the :on
,subr'it,ed 1r1 t/!ls docuwamt and all ativhmon3.t Thermo and that, based a] 7,;y Inquiry of dZ036 h d'>'ldkad
ut,nadiQraly %bspgrrslbie for ahia,migg ;aid 100- radon, I believe that ,he lnynr,radan i$ lr:,d• acourare anti
complefr. ;am Mvzzra that!-here are af;grtllcanr pentilies, lneluding dta pnsrlbiliry of flnas and lire*PsortnerF:,
for sub,nrr,:rtg falss Informalion. I agr 3o to co►utrrtcf, Operate, rtdittlaln,.ntpaar, and iP zppitcab.►e, Rl aria
tits 4ireolton well and all related app:at wamejs jr,accordance,ii1111 rho I5A JV'C.4C 02C koo Rules.
&gnasu•n of pro erCy ner,Appllcant .....--
'*lot or go Pull Naito —' - --
S o atkarleet{rtgont Ifr+ny
ac'lypeNullN9nre4-���—'�"J .
1�'NQ;t�lCiryus U•tAoFC cdillfa',dNalitf.a'.1u-.'Rm($043N20t2)
1'abE

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09/05/2014 12:59 82826461251 DEWEY WRIGHT PAGE 02
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08/29/2014 10:41 82826461251 DEWEY WRIGHT PAGE 06
. �1=oE•i:c9
r. .._. . ., -... �. , ., .©._.- . -..:u ruvta,.��he� r•-.;tea
NOWN CAROLI NA OBPA.RTM:?:T`i11'L'NVJRONA,I3N"['�h(l?Al.�Ti,iY 41,itfiSQUitC:L�
NOTIFICATION 01?INTgNT Ta)CoNSM>LICT+r►R FYI,
lhrrye�vttl/a cre' ,dr►ultlad�t rxla"nod tlp n�r t�gr�p•a ate rndfvlthrai nernai RA I�-INJECTION
WELLS
rho rides of 1$,j NC,4C 02C. t7gN
" ica,rn{:ss,�4_ hrilLef;I.�7r3r�•gpu�1.E1Si!<•
�: c) A C s n-
As dcgcrlbad In I31i NCAC 02C 022Z that a wallb ciroulato xtablc avatar ly o a e�L��
on are ofpotabltr wa r A lc
! Aaifprrrtnca•en7aticiag&�ttit ties$0 p2t"•Gee goothctma'!seating ar;d cooiih&systont,
OR
GEOTNb:r�lutgl, C O- E
As described itti!SA NCAC'42C,Q323 tt1t;=�Wel is oifot3 e a ta5'igcrant gss as part of a geothermei neaung 9nd
...,..� cuoling BysCts:ti.
Prtur C1e0r1y ar Type lltf0r►ggY1,:L. 111001h1gstibmluuls 43'111 Be Rartr::iaJAS Tt�cunrplete.
llAT1L►:�a • --��—, atlld jtlgXtMC'TAlO, Tf3 3lS r
kk ra be completed tay D. tiVQ)
A. 7"Y1PF,OF GEOTHERMAL CMMEJ)-LOOP'WM To BE CONSTRUC1'EI)
11) A q--.&o,s(as per 1 SA NC.AC 0:,C.0222): / Nti�r bor of v.el Is:
(') Direct Erc+arsior.(as per k5A 1 JtvAC 02C.M-3
22. STATUS 01r"WELL OWNER(chcos:orla)
(1) Shield Ffimily Residence ai,tnit thJs farm ttvn(2)ktuak:lofsaap, p:9ar to consrtruct;on•
(�)
(3) Bassirt ti0airniuFlnT" t:rganirekiorl $U 4mIt this form 30 days prior to construclkin.
Slate Mcnicipa!_ County - Peeeral-..._.4abrn4tthis form 3Ddavg
prior to construction.
C. WivCaL C11 ;VE -Per skugic,aml:y.eslrknces list the pt'op�-rty :wrCr(a; y0e all rdlaetT., fiat name or.lie
busfge:s,otgoni7rtiot,,ar guvemfnertt I;@noY Md-person dolegaracl s;6nature au!x)rity:
VluilingAddres<_,
City! f�.�,., � Zip Code:_ Couct: �j --••.--_
y Tole No.: Coil N'J.-
F.A4AlL Address; f- J� . % �•N:I�I+f Pax No.:
{i j parcol tdeallflcation Ntunbet M q)orwdl site;4r'.
(:') Pt•ysica!Address{tf dt ferent th..n mailing addl'ess)• � i=� ,•�`• /'•1�;
City, _�,��' ''..J'..i.•, �---- S,alu:� 2!p,:ode;
Ti11�•IJiG`Gi�snd•:.u�•I,��nEhtmaa?�ctiCctuui(k3:r�r1�50ii.U:2?
Pop I

08/29/2014 10:41 82826461251 DEWEY WRIGHT PAGE 07
i•$h '('r;,.�4ti i) �'-1�t� Plat 0
F. MARS)]PLANS,ANI)SP-E'C(F1CAT 10-NS
(i) Maos musi be sr;aled.r 0010 Age a=,r=.jy indicate distances a
wilhtn 230 t$et of the lnjectip;;well(a). 11q orlentatiors aF feafure9 [acxibd
siiC-s, oitic rntlp t?howi ilte oc fF 111 �j ly_and iL44'1 nore arc w. Attach nK ations orthe following;
• Proposed irtjectipn well lo:atl
Build;ess lolls . septic systems tt�tc essociatea spray itr3gs[Irt�
•
• Properly bp[U[dar1o9 sites,drain rieids,ur repair areas
• Surface water bodies
• Wafer supply we[3s Existing ti p��t�;itiai sources uY gt'ourdwater
contatr�inatlon
(2) Moos and SpeaiGoations oftE,e surAce and sukufraco construa[ian claalls of the well sysiem.
't '3 AN') CONC1v,I+(•1'HATIONS ON, Alal)I7'IVj;S - Wl- any addiiivcs that will be ustd and tileir
coneerrrat[ons. Only additives that the DoNriment of Health and Ht,rran$ttvic03' 1}ivisian of Pcb'ie 2ieaiil
on1!no Tres do not adversely aflbCt human health shall be usad, A list Of approV additives ;,ar, ba faunI
onllrsa:ttc
Ali athor sddiiives regaire approval prior to use.
C. WUL DRILLER INFt?RKATION(:'known)
R'c11 Drilling COniructar'y i�fs<rne: ���- �;• /.,; �
VC�'Vel[Drilling CoNo,(-- ` _
ntmctor Cerlit�catit n �J.
Campdtyy Name:
City; � '�,r .-.., �itH C� y-�- 7,1 •Go e[w i.,
-- •��— � �tt�0ut71y, �yT,
Z IL4— r fl
E3NAI1,ftdd ,;1 --
>I, 1;1EATPUMP CONTRACTOR INFOAMATIOiN
Company 3r•titne' f ',
CilntaCi Porscat_,_
Address;
Lip C jdO;Z--C 1 StatGX -Cotmty:
Cell No.; . ', '
71i'(�/I;IC.JCI�:e�:•[.t4K Gcutiisr'a',n1 Notfl;�;,�u(Revls�cE dJ�Ur0i21
• PaBp

08/29/2014 10:41 82826461251 DEWEY WRIGHT PAGE 08
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1, 1'12UTECTION Providc a bt iaf description of hcw(1)wattsr supply wella,(2)surfaces water bodies,ai:d(3)
septlo systems and aMoaiattd s,ray irrigation sites,draln f olds,or repair areas with in'2K feet of the-.xopcged
injwlior1 wells will be protaetat during construction of the wells,
J. VARTAIYCE-1?urertant to lU XCAC 02C,0241 the Dicevtot of the Division of Water Quality:nay graut a
vadance from appilcablo well c mstructlon or operation standards prmddgd lhat
(1) use of the we11(s)I lilt not endanger human health anal welfare or the grourdwaler;and
(2) trier eott wwtinn o•operation in accordance with the siaudards is not taehriloa!f,fWsible or the
proptaal8d.oarietruc iota provldeaequat of batty proleotlon oftitagroundw;ter•
Any variance mquatat a;7ould ac v apany submittal of this noM41:10 to Nipedite evaaluailart ofthe reglisst.
'rho vatlanoc rvquost fom can 1 ae accessed online a.httn:LIngrml.ncdenr.or�fwebtw�(
K, ts1GNATURU—The followl•ig soetioa is to be xmpleted as ragairral below or by that pecson's sutharixed
agerd, t SA NCAC 02C.0211(.+)requirm signatures as fo?lows:
(a) for x cormati 7 n: by a responsible corporate officer;
(b) for a p4ftore 1p arjsoie pmprietorship; >ay a gerisral panne or the prapriotot,;espectivnly;
(Y) far a manlcipt;lity rr a state,federal,or otter-public agency: by eitber w pr'nclpai axec;idve
ofticor or rant ing p abligly oIcmd 13f3cia 1-
(41 for all Odors; by the well Owner;
00 for•any other pemn uuthorized to act on beba.;f of the appiicant: doer:mentatio-j shall bs
submitted-with the not1fic4don 40•clearly idene.ftas the prawn, grants thtnl'signat.se
authority,and is slated artd dated by eke applicant.
"1 herby certify, under penaA,of law,that 1 have persona:ly examined,wtd.rnn f a?41fae ivitii the:Wformation
submitted In this document aid I all attacharents ihiteio aril that, based do cry Fmgulxy elf hose arrl:vtchaczrs
iMiRdidIR&pCspotrstNe fop of Kaiitfng sald trformdtk !beltew.that the inlfermatioh is trr,e, a4pwate a„.
W,ttpleta. 1 am avare that the-ewe tyitaluding the pg4s1 ltitP of,trfes and buPrlsolrin¢tt,
tor•$ubmi"JNg fala8 lOfortttptto t. 1 ggrse 10 ft mIMI, operrrt,r, matnratn, tuft, and i('appltaahlc, anaxdor
the hlecit;r well and all eclats f appurte>ta,tces to a2aeQrd mce with the JSA NC AC 02C 0200 Rttl n.•'
Bigaataraaf rspartyOwun'Appiicont W
print oa Fall Neme
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09/05/2014 12:59 82826461251 DEWEY WRIGHT PAGE 02
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From: 05/06/2014 09:58 #228 P.001/005
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.
C£EOTHERMAL 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. Dleglble Subminals R?U Be BeturnedAs Incomplde.
DATE: March 1 I 2t) 14 PERMIT NO.W1010 01% -(to be completed by DWG
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per I SA NCAC 02C.0222): x Number of wells:1_
(2) Direct Expansion(as per 15A NCAC 02C.0223) Number of wells-
B. STATUS OF WELL OWNER(choose one).
(1) Single Family Residence_Submit this form two(2)business days prior to construction.
(2) Business/Organization_Submit this form 30 days prior to contraction.
(3) Government: State_ Municipal_ County x 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:
MUland Community College
Gerald A.Hyde
Mailing Address: P.O.Box 547
City: Spruce Pine State: NC Zip Code:28777 County: Avery
Day Tele No.: 828-766-1220 Coll No.:
EMAIL Address: ghydeAgmmaiLeom Fax No.: 828-765-0728
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site:
County: Yancey
(2) Physical Address(if different than mailing address): 107 Wheeler Bills Road
Anspach Advanced Manufacturing School
City: Burnsville State:NC Zip Code: 28714
DWWC/Closed-Loop Geothermal Notification{Revised 4130t2012) Page I

From: 05/06/2014 09:59 #228 P.002/005
E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site-specific map showing the locations of the following:
• Proposed injection well locations • Septic systems and associated spray irrigation
• Buildings sites,drain fields,or repair areas
• Property boundaries
• Surface water bodies • Existing or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES—List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services"Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at Its.//noital.ncdenr.ore/web/wo/aps/gwpra. All other additives require approval prior to use.
None—water only
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Midsouth Geothermal
NC Well Drilling Contractor Certification No.: NCWC 3065-A
Company Name: Midsouth Creothermal Contact Person: Karen Bisso
City: Memphis State: TN Zip Code: 38125 County: Shelby
Day Tele No.: 9017,748-9095 Cell No.:
EMAIL Address: [e-mail] Fax No.: 901-748-9097
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Pyatt Heating 8r Air
Contact Person BiII Pvatt EMAIL Address• email yanheating_net
Address: 1451 Rutherford Read
City: Marion Zip Code: 28752 State: NC County: McDowell
Office Tele No.: 828-652-7747 Cell No.: Fax No
DWQMCIClcm&.00p Geothermal Notification(Revised 4/30/2012) Page 2

From: 05/06/2014 09:59 #226 P.003/005
L PROTECTION—Provide a brief description of how(1)water supply wells;(2)surface water bodies;and(3)
septic systems and associated spray irrigation sites,drain fields,or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
None located within 250'of wellfield
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 hh pp;Itportal nedencor web/wq/aRslg_wpro/permit-
applications
IK 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;
(a) 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,uufer 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. law aware that there are signi#icmrt penalties,including the passibility of frnes and imprisonment
for submitting false b formation. I agree to construct,operate,maintain, repair,and if applicable,abandon
the Injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
+arc C1.64-/�c�-
Signature or Property Oviner/Appliclint
Gerald A.Hyde
Print or Type Full Name
Signature of Authorized Agent,lrany
Print or Type Full Name
DWQ/UIC/Closed-Loop Geothermal Nodrlcation(Revised 4/30/2012) Page 3

From: 05/06/2014 09:59 #228 P.004/005
L. SMN ffTAL 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:
LE _
N.
Asheville Regional Office Washington Regional Office
2090 U.S.Highway 70 943 Washington Square Mall
Swannanoa,NC 28778 Washington,NC 27989
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 28465
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 hM://www.ncalhd.orsyJcounty.htm.
DWQARC/Closedd.00p Geothermal Nod6widon(Revised 4/302012) Page 4

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NORTH CAROLINA'DEPARTMENT OF ENVIRONMENT AND NATURAL 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 I SA NCACO2C.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-waier 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 geothenmal heating and
cooling system. RECEIV D
ources
Print Clearly or Type Information. Illegible Submittals H111 Be Returned As ncomplete.
DATE: March 11 , 20 14 PERMIT NO. (to be co pleted b3i%*QT 9 2014
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTE Water Quality Regional Operations
Asheville Regional Office
(1) Aqueous(as per 15A NCAC 02C.0222): x Number of wells: 11
(2) Direct Expansion(as per 15A NCAC 02C.0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence_Submit this form two(2)business days prior to construction.
(2) Business/Organization Submit this form 30 days prior to construction.
(3) Government: State Municipal County x 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:
Mgyland Community College
Gerald A Hyde
Mailing Address: P.O.Box 547
City: Spruce Pine State: NC_ Zip Code:28777 County: Avery
Day Tele No.: 828-766-1220 Cell No.:
EMAIL Address: ghydeCftzmail.com Fax No.: 828-765-0728
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site:
County: Yancey
(2) Physical Address(if different than mailing address): 107 Wheeler Hills Road
Anspach Advanced Manufacturing School
City: Burnsville State:NC Zip Code: 28714
MQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 1

E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site-specific map showing the locations of the following;
• Proposed injection well locations • Septic systems and associated spray irrigation
• Buildings sites,drain fields,or repair areas
• Property boundaries
• Surface water bodies. . Existing or potential sources of groundwater
• Water supply wells. contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services"Division of Public Health .
determines do not adversely affect human health shall be used. A list of approved additives can be found .
online at http•//portal ncdenr.ora/web/wq/aps/gwpro. All other.additives require approval prior to use.
None—water only
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Midsouth Geothermal
NC Well Drilling Contractor Certification No.: NCWC 3065-A
Company Name: Midsouth Geothermal Contact Person: Karen Bisso
City: Memphis State: TN Zip Code: 38125 County: Shelby
Day Tele No.: 901-748-9095 Cell No.:
EMAIL Address: kbisso(a)jnidsouthgeothermal.com Fax No.: 901 748-9097
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: P,yatt Heating&Air
Contact Person: Bill Pyatt EMAIL Address: email(@pyattheatine.net
Address: 1451 Rutherford Road
City: Marion Zip Code: 28752 State: NC County: McDowell
Office Tele No.: 828-652-7747 Cell No.: Fax No.:
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4130/2012) Page 2

I. PROTECTION—Provide a brief description of how(1)water supply wells;(2)surface water bodies;and(3)
septic systems and associated spray irrigation sites,drain fields,or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
None located within 250'of wellfield
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 hllp://Portal.ncdenr.org/web/wqlaps/g_wpro/»ermit-
applications
K SIGNATURES—The following section is to be completed-as required below or by that person's authorized
agent. 15A NCAC 02C.0211(e)requires signatures as follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner or the proprietor,respectively;
(c) for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
(d) for all others: by the well owner;
(e) for any other person authorized to act on behalf of the applicant: documentation shall be
submitted with the notification that clearly identifies the person, grants them signature
authority,and is signed and dated by the applicant.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct,operate, maintain, repair, and if applicable, abandon
the injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
Signature of Property Owiner/Applickht
Gerald A.Hyde
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQMIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 3

L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water_Quality_R,egional Office serving the area in which the injection well facility
will be located:
LE _
f -
: GA-
' tt16
tAsheville Regional Olfi-W 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 bq://www.ncalhd.orgLcoun!y.htm.
DWQXRC/Closed-Loop Geothermal Notification(Revised 4/302012) Page 4

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