WI0100626_Geothermal Aqueous Closed Loop Well Construction Application_20210826

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NORTH CAROLINA DEPARTMENT OF ENVIRONMTINT AND NATURAL RE�Jj// f, 'J 3' I
NOTIFICATION OF INTF,NTTO CONSTRUCT OR OPERATE INJECTION WELLS Th ese wells tll'e ''pemiitted by rnle" and do not require cm individual pen11it wlle1J com·tructed in accorda11ce with
the 111les of 15A NGA C 02C .0200*. This notice must be s11hmitted prior 10 constrt1cliQ11.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in ISA NCAC 02C .0222 these wells circulate potable water only or a mixture of potable water and
perJbrrnance--cnhancing additives as parl ofa gcothennnl heating and cooling system.
OR
GEOTHERMAL DTRECT EXPANSION CLOSED�LOOP WELLS As described in ISA NCAC 02C .022'.l these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print Clearly fir Type Jrifornu1tio11, Jlleglhle Suhmittals Will Be Ret11r11ed As Incomplete.
DATE: _J_u_n_._9 ______ , 20 � PERMIT NO. WI0100626__ . _ (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1)
(2)
Aqueous (as per l5A NCAC 02C .0222): � Direct Expansion (as per 15A NCAC 02C ,0223) ___ _ Numberofwclls: JftBl/J-�Number ofwells:
B.STATUS Oli'WELL OWNER (choose one)
(l)Single Family Residence 2L_ Submit tbls form two (2) business days prior to construction.(2)Business/Organization __ Submit this form 30 days prior to consh'udion. (3)Government: State Municipal__ County__ Federal __ Submit this form 30 days prior to construction.
C.others, list munc of the
EMAIL Address: [e-mail]
D.PHYSICALLOCATIONOFWELLSITE
WELL business, OWNER organization, -For or single government family agency residences J!!m list person the delegated ptoperty signature ow11er{s).': F�r. 8uih0rity:ol\
Kell Carlson
Mailing Address: 507 Dykeman Trail Rd. (507 Wilma Dykeman Trail)City: Asheville State: NC Zip Code: 28804 County: Buncombe ==-�----
Day Tele No.: ______________ _ Cell No.: ___________ _ Fax No.: ----------
(l)Parce!IdcntiftcationNumber(PIN )ofwcllsite: q.1:1\5:l.�q �'7 OQCO O
Caunty: Buncombe (2)Physicul Address (it' different than mailing address):
City: -----------
l)WQ/U IC/Closed-Loop □eolhcmutl Notincmion (llevised 4/30/2012)
----------
\•' .'r1:s•0 Cil.."c 1,i ·\)' .-.,'::.½' .'V n ·_..,::. S'i"cl.liOllS A:>ilfM1le i�egional OfficG
E. MAPS, PLANS, ANI) SPECIFICATIONS
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:
(1)
Proposed injection well locations
Buildings
Property boundaries
• Surface water bodies
• Water supply wells
Septic systems and associated spray irrigation
sites, drain fields, or repair areas
Existing or potential sources of groundwater
contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and (Ronan Services' Division of Public Health
determines do not adversely affect human health shall he used. A list of approved additives can be found
online at hop://portal.ocdencore/webhadao5/Rwpro. All other additives require approval prior to use.
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G. WELL DRILLER INFORMATIONT(if known)
Well Drilling Contractor's Nomc: V Pi cn Mo4S
NC Well Drilling Contractor Certification No.: 4137A (l )'
Company Noma Clearwater Well Drilling, Inc. Contact Person: St=+)'t yy��a,
City: Hot Springs State: NC Zip Code: 28743 County: Madison
Day Tele No.: 828-776-6526 Cell No.:
EMAIL Address: [e-mail] Fax No.:
II. BEAT PUMP CONTRACTOR INFORMATION
Company Name'. ..AlliVays Heating & Air
Contact Person: Josh Clinton
Address' 80 Old Mars Hill Hwy
City: Wea wnV lle Zip Cude:28787. State NC County: Bun 0E1.0 _
Offee Tele No' [phone] Cell No •1
DWQ/UIC/Closed-Loop Geothermal Notification (Revised 4/30/2012)
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1. PROTECTION — Provide a brief description of !low (1) water supply wells; (2) surface water bodies; and (3)
septic systems and associated spay inigation sitce, drain fields, or repairareas 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 Directorofte Division of Water Quality may giant
variance from applicable well construction or operation standards provided that:
(1) use of the wd(s)w(h 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 Miler protection of the groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation of the molest.
The variance request form can be accessed online at hnn://ynnn).nedenrerg/wch/wq'nns/Rwordpermit-
mmllcalioas
K. SIGNATURES— The following section is to be completed as requited below or by that person's authorized
agent 15A NCAC 02C .0211(e) requires signrautes as follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner r the proprietor. mspectiveiy;
(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 shallbe
submitted with the notification that clearly identifies the person, grants them signature
authority, and is signed and dated by the applicant
"I hereby certI under penalty of law, that I have personally examined and am familiar with the information
submitted in this documentand all attachments thereto and that, bared on my rnquiry of those Individuals
immediately responsible for obtaining said information, I believe Ihat the Wormadou Is true, accurate and
complete I am aware drat their are si truant penaliiev. including the passibility offiner and (nprimrunenf.
for submitting false infarmalk . I a e to coast I. operate. maintain, repair, and if applicable, abandon
the injection well and all related awn Ienanres i rdat e with the ISA NCAC 02CO200 Rules."
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QWQNIC/C1osai-Loop Geothermal Nonfianon (Revisal 4/30R012)
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