WI0501035_Permit (Issuance)_20191025

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nunu k,arouna uepartment of Envu•onmentIM Qualily — Division of Water Resources
NOTIFICATION OF ANTE NT TO CONSTRUCT OR OPERATE i'N IECTION WELLS
7hcw wells are "permitied by ivle" and do not require an Jndividmil pel ma when consimc-tad in accordance iverh
the rules of i t 1(:4(_n_i U'J. Thrs notice must he snlnuilted vrrur ao cousfrrrction.
EQ)'F'IIE'9iN1AL Ai➢[JT fBdIS C"LfASEib-LQ}€)P WELLS
As dcsoribed i i 1 �` M- A t ( jii332 these nclls circulate polabL rvutcr only of it mixture of potable �+�a er and
perhammrce-ciilianemg additives as pall of a geothcilnal hcatin", and cooling vstem,
Ho
GE®THERA'dAL ID[RC++� T E#F A SSt� V L I (3SEI>-P i)CP V4 ELLS
As described in IN( '� t t i ?_ thew wells cfruIate a rch iaeruot ga. as part of a im tha-nud Itenting and
umling system.
Print Clearin or Zype In formation. 71!¢gib(c Subnairtrds Will Be Raurned As lywovyrlele.
20 ( PERMIT NO,: V105`0103..5- ---_ ti be complcicd by DWR)
A. TYPE OF GEOTHERMAL CLOSE ID LOOP W EEL TO BE CONSTRUCTED (select one)
Nimtbei of uclistj_
(2) ❑ Direct ENpansion (as per Z_` CAC' t..nz=) Number of ;cells:
B. STATUS OF WELL OWNER(S) (choose one)
(1) OSingle Fanuly Residence Submit this form two (2) business days prior 4n construction.
(2) ❑ Businesslorgtmizalion Sutamit this form 36 days prior to construction,
(3) ❑ Govcnmiont: State _ Municipal _ Couniv Fcderal*
"submit this form 30 days priory to construction
€ . WELL, OWNER(S)— For singlc family residences. list Lill persons listed oil the properly deed. For all othcfs.
list the name of the Business/Agency and person and title witl'i delegated signahnn authority:
Mailing Address: 4-.z-) A- k—,
Cily: _1'� .-�i; cr Stale Zt Codc J 2
Day Telc No. r—`1 % 7 ""3s l' _..._ CeII No.:
EMAIL Address: r r., nI Cc:G:t PaNtio.
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site:
County: _�) _�•.—� 4,'_,
(2) Phrsits] .Address (ir different than mailing a(tditss) ,}
Citt: i _ Conury_ ( - _Zip Codc: ; I , c�
f
IJ`4 -',:_ iktla�l
Closed -!„.op Gaotliwnwl Weil Nwifieafion Rau_ 3-7-2016 40 a-v q Pas-, i
3t'00gS

E. REQUIRED MAPS, PLANS, AND SPECIFICATIONS
(1) A site maps must be subeniitesi. it most be scaled or otherwise accutateiy indicate distances (in feet)
and orientations of features located within 250 feet of the iniection wetl(s). Lapel at! lcatmes cle. arty
and include a nnrih arrow. Attach the site -specific map shots ing lire wells in relation to the locations of
the following:
® Buildings a Septic srstclus and associated spray irrigation sites.
m Propertl, boundaries drain fields, or iCp;m mess. iranv
e. Surface water bodies, if any v Existing, of potent A sourccs of groundwater
>e Watorsupply wells, ifanc conUmivation. ifauv
(2) Plans and specifications of the surface and subsurface construction details of the well systent.
NOTE. Fn maw cases, air aerial plaatagrapb an(Por plat wrap of tFie property prrrceL slunciug property litres and
sn•rucfares can be obhtirred aad drmeclaaderl fraru the applicable eoalliv GIS ir,elkybe.. 7ygricakir, the property can
be searched by mvner narae or arfdresr. 7Ge laeaitan of tfte ivel(s iri :elation Yo proper'Pl' houndaries, luraseg septic
tanks and fields, and other welds, ela can Rhea be drairn irr by hand ALva, a `Paver' call be selected shemjag
topographic Contemn or elevation data.
TYPES AND CONCENTRATIONS OF ADDITIVES List am' additives (hat will be used and their
conecnUations. NOTE. Only iniecLmts approved by the N(; Dhision of Public Health, Dcpamncut ofHealth
and Human seer es can be irtjcolod Approved injectaois can be formd online at
r." y ct All othor subsi mcrs mustbe rwiawed by the BHfIs priorto Ilse.
T� l
G. WELL DRILLER INFORMA'IFON
Well Drilling g Conaactor's Namc:—f-
NC Well DrillingCom'ractorCertification No �,
Cmupan} i me'-� �* Sio-u�: t Zip C_ocfi Pcason.
,let
4
t
Day Pcle No.: —2� - 7 1 Celt No J ..ki' -
f
13MAIL Address: G2 ___Ct i r ; i it �';�F>1 i i r u No
-- —__...
H. HEAT PUMP CONTRACTOR INFORMATION'
CompanyNamc; " � l �
Contact Paso tT'M?I_L Addreas ,n ! v�
Address:
City: li ,:, 0 CtpCode: �' ?" Sim ��� Countg:LtJr
Office "role No.:
'ell No}-----
i
Closed-l..00P Geothermal Ur_71 Noli Ovation Rev. 3-I-201G Tom! �`
Paec 2

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 ISA 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 lr�s:fncdenr.s?,.amazonay�com/s3fs-
a tic/4Vater'/e20pualityj� ri e'+/20Ptntection/GPii/[3eothermal Vari:LceRenuestForrnFillable-
20130805 ndf
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 ranting publicly elected officiid;
(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 certify, under penalty of law, that I have personally examined and am familiar with the information
suimriited in this document and all attachments thereto and that, based on niv inquiry of those individuals
immediately responsible for obtaining said information, I believe that the informaton is true, accurate and
complete. I am aware that there are significant penalties, including the possibility offtnes 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 YCAC 02C 0200 Rules."
"Signature of Propertytfhvner/Applicant
Lealn lO`i
Printor Type u1t.Name
Signature of Authorized Agent, if any
Print or Type fddl Narne -�
Clowd-Loop Geothermal Well Notification Rev. 3-1-2016 Page 3

I,. 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:
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]
-AND-
RALEIGH
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Telephone: (252)t946-6481
Fix:[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
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
(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

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Orange County Environmental Health
5 This map contains paresls prepared for the inventory of real propam, within Orange County, and is compiled from
1 inch = 100 feet recorded deeds, plats and other public records and data. Users of this map are hereby notified that the aforementioned
public primary information sources should be consulted for vam canon of the infomatlon contained on this map. The
0 30 60 120 county and its mapping companies assume no legal reeponslblity for the mformetloo mr this map.
Feet

Orange County
This map contains parcels prepared for the inventory of real property within Orange County, and is compiled from
rem rded deed, plats, and other public records and data. Users or this map are hereby notified that the aforementioned
October 25, 201 S
public primary information sources should be consulted for verification of tha information contained on this map. The
county and its mapping companies assume no logo l responsibility fort he information on Ihis map.
PIN:
9892329381 SIZE: 6.3A BUILDING COUNT:
1
OWNER 1:
COY DERON K DEED REF: 5912167 LAND VALUE:
$182,800
OWNER2:
RATECODE: 09 BLDG_VALUE:
$44,500
ADDRESS 1:
4824 FRIENDS SCHOOL RD DATE SOLD: 02/24/2015 USE VALUE:
$
TOTAL VALUE:
$227,300
ADDRESS 2:
BLDG SOFT: 876
CITY:
DURHAM YEAR BUILT: 1872
1:2,400
STATE, ZIP:
NC 27705 0 0.02
0.04 0.08 mi
LEGAL DESC: 2 DERON K COY P114/53