WI0100567_Application_20191025

R9l o 3T S1 4 b 0 3'
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELL'3
These we/ls are "permitted by rule" and do not require an individual permit when constructed in accordance ❑vit'h
the rides of 15.,INCA C 02C .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 ordy or a mixture at
performance-etrhancing additives as part of a geothermal heating and cooling s} s
3
OR OCT 2 5 2 19
As described in 15A NCAC 02C .0223 these wells circulate a refrigerant gas as part of a
cooling system.
Operations
Office
Print Clearly or TPpe Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: ' U 20Iq PERMIT NO. (to be completed by llWQ)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED
t
(1) Aqueous (as per 15A NCAC 02C .0222): al__� Number of wells: .r1�Dt�3oD
(2) Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER (choose one)
(1) Single Family Residence V 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 3;0 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:
Ik4-_ BY-04-2, -1 �)J_IAInSW
MailingAddress: 61 W0A,6K(ar%,? V-)%ju, Lk,_
Cih: _v✓✓A oJieW State: n,)!_ Zip Code:-ZF213c'County: _Zt)AC01%16
Day. Tele No.: -77E - tq 3t3 Cell No.: 64` 779 --193 S _
EMAIL Address: yl a G 0 10 h�d ,e- t. Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: %7 % -% 3 12,37 _
Count: ,mcaw�ioi
(2) Physical Address (if different than mailing address): (.!�j (A"o,-loi i(,nc1 t4-, _
City: e, w Mw State: NC Zip Code: 7-% ,) 7U
DWQ•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:
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 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 Sen-ices' Division of Public Health
detennines do not adversely affect human health shall be used. A list of approved additives can be found
online at http://portal ncdenr oriz&eb/wg/aos/@wryo. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name:
NC Well Drilling, ICIontracto�r��C""ertifi�c"ati�o�n No.: LA
Company Nanice }�gtn�i, �W,tf Contact Person:
City: } 9 State: AL Zip Code-W143CountyAl
Day Tele No.:
EMAIL Address:
Cell No.:
Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:Bulhnan Heatitur & Air
Contact Person; Josh Gutivie EMAIL Addre jocha'a bulhnanheatine com
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804_State: NC County: Bunconuie
Office Tele No.: (828)-658.2468 Cell No.: _(828)-712-7488 Fax No,: (828)-658-1001
DWQ'UIC Closed -Loop Geothermal Notification (Revised 4/30/2012) Page 2

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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 httn://portal ncdenr ore/web/wa/aps/ oro/permit
applications
X 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.
7 hereby ceri fy, 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 b eve that the information is true, accurate and
complete. I am aware that there are slgntOcan enaltfes luding the possibility offrnes and imprisonment,
for submitting false injormation. I ogre to nstr ict, p rate, maintain, repair, and if applicable, abandon
the injection well and all related appura as;
fr'Ybr ante with the 1 SA NCAC 01C 0200 Rules. "
Na7�en Y!a<Lq
Print or Type Full Name
bignWK9,WAuthorized Agent, If any
_.. 1 cam. 1, 1�G �. � ✓l^
Print or Type Full Name
DWQ/UIC/Closed•Loop Geothermal Notification (Revised 4130/2012) 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 seeing the area in which the injection well facility
will be located:
WINSTON-SALEM
RALEIGH
ASHEVILLE __ -,, 1�- /� /"--' WASHINGTON
FAYETTEVILLE
Asheville Regional Office
Washington Regional Office
2090 U.S. Highway 70
943 Washington Square Mall
Slvannanoa, 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 Sen ice 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 hitp://\vww.ncalhd.org/counb,,htni.
DWQ'UIC Closed -Loop Geothermal Notificalion (Revised 4130'2012) Page