WI0100588_Application_20200623

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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 ISA NCAC 02C .0200*. This notice must be submitted prior to construction
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GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS
desergein 15A NCAC 02C .0222 these wells circulate potable water only or a mixture of potable water and
(D pperformance-enhancing additives as part of a geothermal heating and cooling system.
m �
o OR
in 15A NCAC 02C
cooling system.
gas as part of a geothermal heating and
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: G - 23 , 20 M PERMIT NO. to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED
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(1) Aqueous (as per 15A NCAC 02C .0222): Number of wells: X-l0b'
(2) Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER (choose one)
(1) Single Family Residence ubmit 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.
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:
77�/tiA�SCN;) 0- HCNA �ll bW�
Mailing Address: /il M1 (KL-/C's /C4
City: kr VM�} State: N( Zip Cod
Day TeleNo.: eU2� �r5'Z1S3
EMAIL Address: 14I&P AMILy ,Col
D. PHYSICAL LOCATION OF WELL SITE
Cell No.: 8Z(3 -553 -663s
Fax No.:
(1) Parcel Identification Number (PIN) of well site: 9J 0 3 - o 3 - a / y -UW b
County:
(2) Physical Address (if different than mailing address): rTj LP
City:
State: NC Zip Code:
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:
• • P
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 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://i)ortal.ncdenr.or web/w"s/eworo. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Josh Plemmom
NC Well Drilling Contractor Certification No.: 4137A_
Company Name: Clearwater Well Drilling, Inc.
City: Hot Springs State: NC _ Zip Code: 28743
Day Tele No.: 828-776-6526 Cell
EMAIL Address: [e-mail]_
H. HEAT PUMP CONTRACTOR INFORMATION
Contact Person: Jeff Moore
County: Madison
Company Name:Bullman Heating & Air
Contact Person: Josh Guthrie EMAIL Address: [e-mail]
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804_State: NC County: Buncomne
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 http://portal.ncdenr.or web/wq/aps/gwpro/ ep nnit-
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 certlJy, 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 offines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all. rel to appurt ces in actor rce with the 15AN.C,4C 02C 0200 Rules. "
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Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
or Type Full Name
DWQ/UIC/Closed-Loop Geothermal Notification (Revised 4/30/2012) Page 3