WI0400530_Application_20191115

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1v0r1n %:arouna liepartment of Environmental Quality — 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 15A NCAC 02C .0200. This notice must be submitted prior to construction.
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.
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As described in 15A NCAC 02C .0223 these wells circulate a refrigerant gas as part of a
cooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
and
DATE: (i ' 2 20� PERMIT NO.:w j_Z)(( 0 D (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
B.
C.
a
(1) [ Aqueous (as per I SA NCAC 02C .0222) Number of wells: A/ eT s S Sr d e e
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
"� VNBftfiiCtlt of
Environmental quality
STATUS OF WELL OWNER(S) (choose one) Received
4 2019
(1) [5Single Family Residence Submit this form two (2) business days prior to construction.
(2) ❑ Business/Organization Submit this form 30 days prior to construction. W(nston-Salon
(3) ❑ Government: State_ Municipal_ County_ Federal*_ PO Tonal Cf ic2
*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:
Gay'ewAlrl Con/frA c! 1 n/c(zev-no('Inen/ Co /N C
Mailing Address: • �) - o Y Z / S-
City: P d A rn (I nl C e, State: ,/✓ C Zip Code:1X of County: C %i 1 d '✓ r—
e
Day Tole No.: 3 3 6- Z 2 6- 9� o 'L Cell No.: 3 3 (- / I Z 6
EMAIL Address: r j M C C. - d h b t $' e r V /C E, c orh Fax No.: 33 t; - 122 1> 14
PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: eF ,? S-15- KO / c5�0 r
County: A L A m A 1V C l
(2) Physical Address (if different than mailing address): 1 f 3 C r A iljc 2n p 7-Z GT,
City: 6t: r 4 1 of C j o r✓ yr County �-G;76» &Mc- B Zip Code: ;7 �7 /s
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 1

E. REQUIRED MAPS, PLANS, AND SPECIFICATIONS
(I) A site maps must be submitted. It must be scaled or otherwise accurately indicate distances (in feet)
and orientations of features located within 250 feet of the injection well(s). Label all features clearly
and include a north arrow. Attach the site -specific map showing the wells in relation to the locations of
the following:
• Buildings • Septic systems and associated spray irrigation sites,
• Property boundaries drain fields, or repair areas, if any
• Surface water bodies, if any • Existing or potential sources of groundwater
• Water supply wells, if any contamination, if any
(2) Plans and specifications of the surface and subsurface construction details of the well system.
NOTE: Inmost cases, an aerial photograph and/or plat map of the property parcel showing property lines and
structures can be obtained and downloaded from the applicable county GIS website. Typically, the property can
be searched by owner name or address. The location ofthe wells in relation to property boundaries, houses, septic
tanks and fields, and other wells, eta can then be drawn in by hand Also, a `layer' can be selected showing
topographic contours or elevation data
F. TYPES AND CONCENTRATIONS OF ADDITIVES - List any additives that will be used and their
concentrations. NOTE: Only injectants approved by the NC Division of Public Health, Department of Health
and Human Services can be injected. Approved injectants can be found online at
hgR://deq.ne.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/around-water-
protectlon/ground-water-approved-iniectants. All other substances must be reviewed by the DHHS prior to use.
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WELL DRILLER INFORMATION
Well Drilling Contractor's Name: 15 S h lz 0% t r T S o i✓
NC Well Drilling Contractor Certification No.: -)-I C / pp
Company Name: 7 r! / L {L i L L C r S I N C Contact Person: _ d o AC o b e r-r S O r,/
City: C- L a (J State: NG Zip Code:2)24-f County: C A S W e t I
Day Tele No.: 3 3 6 - '� 21- 3 51 3
EMAU, Address: -6 r i A rtLL er-f2000 CD GmAIL.
Co,1�
HEAT PUMP CONTRACTOR INFORMATION
Cell No.: 3 3 6- 4 2/_ 3 S/-3
Fax No.: _331; - 9- 2-/- SO �2 S
Company Name: CrALLe -Ser-VICE (:o %;fC
Contact Person: 7 rr, 1 ✓/ 1-4 e r a� EMAIL Address: C re- Re Seryl CC, ru A^,
Address:`f 11 o it i A i L P. A v e,
City: 8 v, r L i N G % 0 W Zip Code: 2IS State:NG County: /91 fi m n rY c
OfficeTeleNo.: 33 E--226-O S CellNo.: 334;- 3?2- 11 Z.{ FaxNo.:33i�- 9-2i-I)��
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
proposed injection wells will be protected during construction of the wells:
Co r, N; cv N e IY D: 8 4 c s w i i L b e ct, s e,
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 https://ncdenr.s3.amazonaws.com/s3fs-
public/ Water%o20Qualiiy/Aquifer%2OProtection/GPU/Geothermal VarianceReauestFonnFillable-
20130805.odf
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 sball be
submitted with the notification that clearly identifies the person, grants them signature
authority, and is signed and dated by the applicant.
7 hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significantpenalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the 15,4 NCAC 02C 0200 Rules. "
Signature of Property Owner/Applicant
1 �.� / 1 rti er�i
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 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:
(2)
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Telephone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5043
Telephone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Telephone: [phone]
Fax: [phone]
Raleigh Regional Office
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
Wilmington, NC 28405
Telephone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
/ Suite 300
�f Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
The County Environmental Health Department in which the injection wells will be located.
Closed -Loop Geothermal Well NotiScation Rev. 3-1-2016 Page 4

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