WI0700517_Application_20210929

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 15A NCAC 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 only or a mixture of potable water and
performance -enhancing additives as part of a geothermal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS
As described in 15A NCAC 02C .0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: 09/15 , 20 21 PERMIT NO.
(to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED
(1) Aqueous (as per 15A NCAC 02C .0222): x Number of wells:
(2) Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
6
B. STATUS OF WELL OWNER (choose one)
(1) Single Family Residence _x_ 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 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:
Mark Sellers
Mailing Address: P.O. Box 1514
City: Kitty Hawk State: NC Zip Code: 27949 County: Dare
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1)
(2) Physical Address (if different than mailing address):
7012 Currituck Road
Parcel Identification Number (PIN) of well site: 985708985849
County: Dare
City: Martin's Point
State: NC Zip Code: 27949
UIC/Closed-Loop Geothermal Notification (Revised 8/5/2013) 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:
(2)
• 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
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://portal.ncdenr.org/web/wq/aps/gwpro. All other additives require approval prior to use.
Geosafe antifreeze na,15%
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Arthur J. Tatem
NC Well Drilling Contractor Certification No.: 4200A
Company Name: Virginia Energy Services
City: Knotts Island State: _NC
Day Tele No.: 252-455-7710
EMAIL Address:
Contact Person: Art Tatem
Zip Code:27950 County: Currituck
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: North Beach Services
Contact Person:
Address: P.O. Box 181
Ce11 No.:
Fax No.:
EMAIL Address:
252-202-9490
City: Kill Devil Hills Zip Code: 27949
Office Tele No.: 252-491-2878 Cell No.:
State: NC
Fax No.:
County: Dare
UIC/Closed-Loop Geothermal Notification (Revised 8/5/2013)
Page 2

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:
Protection will be provided during the drilling process by containing fluids in a pit or pan and providing silt
fence if run off is a danger. Bore holes will be fully grouted to protect from aquifer cross contamination
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 http://portal.ncdenr.org/web/wq/aps/gwpro/permit-
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 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 significant penalties, 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 itzcco4ge with the 15A NCAC 02C OHO Bulgy
Signature of RroperTy Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Sa =z s
UIC/Closed-Loop Geothermal Notification (Revised 8/5/2013)
Page 3

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
VARIANCE APPLICATION FOR INJECTION WELL CONSTRUCTION STANDARDS:
GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS (15A NCAC 02C .0222) OR
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS (15A NCAC 02C .0223)
This form MUST accompany the Closed -Loop Geothermal Notification Form available online at
http://portalmcdenr. org/web/wq/aps/gwpro/permit-applications#geothermApps
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: 09/15 20 21 PERMIT NO. (to be completed by DWR)
A. 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:
Mark Sellers
Mailing Address: P.O. Box 1514
City: Kitty Hawk State: NC Zip Code: 27949 County: Dare
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
B. PHYSICAL LOCATION OF WELL SITE
(1)
Parcel Identification Number (PIN) of well site: 985708985849
County: Dare
(2) Physical Address (if different than mailing address):
7012 Currituck Road
City: Martin's Point State: NC Zip Code: 27949
C. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Arthur J. Tatem
NC Well Drilling Contractor Certification No.: 4200A
Company Name: Virginia Energy Services
City: Knotts Island State: NC
Day Tele No.: 252-455-7710
Contact Person:
Zip Code: 27950
EMAIL Address: [e-mail]
Kimberly Krinsky
County: Currituck
Cell No.: 252-202-7710
Fax No.:
UIC/Closed-Loop Geothermal Variance Request (Revised 8/5/2013) Page 1

D. REASON FOR VARIANCE REQUEST — Include type of well(s) to be constructed; rule for which the
variance is being requested; description of how the alternate construction will not endanger human health and
welfare and the environment; and reason why construction and/or operation in accordance with the standards is
not technically feasible and/or provides equal or better protection of the groundwater.
See attached page for variance request information.
E. SIGNATURES
Signature,4 Well Driller
Print or Type Full Name
1A),,,c)
Signature of We Owner
n v Ver3 fr%/bfk 5cz_e_E)zs
Print or Type Full Name
Per 15A NCAC 02C .0241 the Director of the Division of Water Resources may require submittal of
information deemed necessary to make a decision on the variance, may impose conditions as part of the
decision, and shall respond in writing to the request within 30 days of receipt of the variance request. A
variance applicant who is dissatisfied with the decision of the Director may commence a contested case by
filing a petition as described in G.S. 150E-23 within 60 days after receipt of the decision.
UIC/Closed-Loop Geothermal Variance Request (Revised 8/5/2013) Page 2

F. SUBMITTAL INSTRUCTIONS — Submit one copy of the completed variance request attached to the
Notification of Intent to Construct or Operate Injection Wells to the Division of Water Resources 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]
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
585 Waughtown Street
Winston-Salem, NC 27107-2241
Phone: [phone]
Fax: [phone]
UIC/Closed-Loop Geothermal Variance Request (Revised 8/5/2013)
Page 3