WI0100568_Application_20191104

North Carolina Department of Environmental (duality — Division of Water 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 j,Se,,YLdf QZC . QZQQ. 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.
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS
As described in ISA NCAC 02C .0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: 201_ej�, PERMIT NO.: (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(1) [2/Aqueous (as per 1 SA NCAC 02C .0222) Number of wells: h
(2) ❑ Direct Expansion (as per 15ANCAC 02C �Q223) Number of wells:
B. STATUS OF WELL OWNER(S) (choose one)
(1) ,aliingle Family Residence Submit this form two (2) business days prior to construction.
(2) ❑ Business/Organization Submit this form 30 days prior to construction.
(3) Government: State ___ Municipal _. County __ Federal*
*Submit this form 30 days prior to construction
WELL OWNER(S) — For single family residences, list all persons listed on the property deed. For all others,
list the name of the Business/Agency and person and title with delegated signature authority:
2
Mailing Address: qq1; / ,'�f �' `' r
City: 1,04 t "e PA State: (�14 Zip Code ,5 )� ' ' County:
DavTeleNo.: (�/t�L02 t_`�. Cell No:'�yo Zt-7 -zZZ`f
EMAIL Address: h 7,t Fax No.:
PHYSICAL, LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: (o / 7 5
County: A v /7 r c, r, 9k
(2) Physical Address (if different than mailing address):
z
/-jib �1 Atico. if %� �1�
City: SwAAOJn CountyZip Code:
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 1

E. REQUIRED MAPS, PLANS, AND SPtdifCATIONS
A site mSps must be snbmined. It must be scaled or otherwise accurately indicate distances (in few)
and orientation of features located within 250 feet ofil3c injectiors`Vell(s). Labdl aif features cleanly
aW inchtde a north an ow. _Attach the site -specific rnap showing dte wells in relation to the locations of
the followir
I3izilt • Septic systems and associated spray irrigation sites,
• Property boundaries drain fields, or repair areas, if any
+ Surfer water bodies, if any • Existing or potential sources of grmmdwater
• WSW supply wiei if any contamination, if any
Plans and specifications of the sure and subsurfacc construction details of the well system.
NoT In ears, an photk a�dlor p%t af'rlee� pq! skohrlag pnarperey krtes gntd
$&wc rtres can be o&ained and dow+rtea" vm eke Mpfteahle cmniy GH weWe T jrprcetly, rke property can
be sewrktd by owner, or addresx The kcadon etke wells in rehydon aa properV bouuderks, houses, sepsic
ameb arnd flelafc, and other wefts, efa emr theca be drawn in by hand Afro, a `layer' Cosh be sdectod showbrg
&pojrq *k costoars or elevation data.
F. TYPES AND CONCMRATIONS OF AUll r 1MI -,.List any additives that will be used and their
con�preiiotns. NOTE:'Only injectants approved by t k N16 vision of Public Heaiih, Dint of Health
and Human Services can be' injected: - Approv4l injectan s can- be found online at
•0
All other substances must be reviewed by the DHHS prior to use.
G. WELL DRILLER 114RORMATIQIK
Well Dr fli g C'.antrac#nr's Name: Glint Babbitt
NC Well Miffing Conowtor Certification No.:
}AAA %Veetwate r WOO
Com�r3y �; Pcs'sora
city: Swatinartaa Sto Zip code; 87 ity.
Bunco w
Day Tele No.: 828.298.1117 Cell No.:
ILA i Fax No. �--� kD
It. HEAT PUMP CONTRAl"R ROORMATION
Company Nmrre i i
slit
Contact Per'sotr: 1
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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
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 Resources may grant
a variance from applicable well construction or operation standards provided that:
(1) Use of the well(s) will not endanger human health and welfare or the groundwater; and
(2) That construction or operation in accordance with the standards is not technically feasible or the
proposed construction provides equal or better protection of the groundwater,
Any variance request should accompany submittal of this notification to expedite evaluation of the request.
The variance request form can be accessed online at hU& /lncdenr g3.Alazonaw .eom/s3fs-
publictWater%200u lity/Aquifer%o2OProteeti2n/GPU/GeothermAlVar_and ceReaugstFormFillable-
20130805.vdf
1SIGNATURES — The following section is to be completed as required below or by that person's authorized
71171 agent, 15A NCAC 02C .0211(e) requires signatures as follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner or the proprietor, respectively-,
(c) for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
(d) for all others: by the well owner;
(e) for any other person authorized to act on behalf of the applicant: documentation shall be
submitted with the notification that clearly identifies the person, grants them signature
authority, and is signed and dated by the applicant.
"I hereby certify, under penalty of law, that 1 have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining .said information, I believe that the information is true, accurate and
complete. 1 am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submittingfalse information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordonce with the ISA NCJC 02C 0200 Rules. "
Signature of Property Owner/Applica
Printlor Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Palle 3

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