WI0501131_Application_20231220

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North Carolina Department of Environmental Quality — Division of Water 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 l5A 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.
1C
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.
10-30
Print (Yearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
2023 PERMIT NO.:
(to be completed by DWR)
TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(1) Q Aqueous (as per 15A NCAC 02C .0222) Number of wells: 6
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER(S) (choose one)
(1) X Single Family Residence 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(S) — For single family residences, list all persons listed on the property deed. For all others,
list the name of the Business/Agency and person and title with delegated signature authority:
Joel and Lauren Rutkowski
4 3 0 7- 1 v 1 7 S-T t `
Mailing Address: �
fjIuS6�'�N NC - 2
City. State
Zip Code: County:
Day Tele No.: 5 91(j 2 S S 314:9 Cell No.: '914 S6 4 9ro Q
EMAIL Address: ,i GE' Car\nnENC Ccr-n Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site:9851-12-2128
County: ORANGE
(2) Physical Address (if different than mailing address): 6301 Dodsons Crossroads
City: Hillsborough NC County Orange Zip Code: 27278
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 1

E. REQUIRED MAPS, PLANS, AND SPECIFICATIONS
(1) A site maps must be submitted. It must be scaled or otherwise accurately indicate distances (in feet)
and orientations of features located within 250 feet of the injection well(s). Label all features clearly
and include a north arrow. Attach the site -specific map showing the wells in relation to the locations of
the following:
• Buildings • Septic systems and associated spray irrigation sites,
• Property boundaries drain fields, or repair areas, if any
• Surface water bodies, if any 9 Existing or potential sources of groundwater
• Water supply wells, if any contamination, if any
(2) Plans and specifications of the surface and subsurface construction details of the well system.
NOTE: In most cases, an aerial photograph cool/or plat map of the property parcel .showing property lines and
structures can he obtained and downloaded from the applicable county CIS website. Tipicallt', the property can
be searched by owner name or address. The location of the wells in relation to property boundaries, houses, septic
tanks and fields, and other wells, etc. can then be drawn in by hand. Also, a 'layer' can he selected showing
topographic contours or elevation data.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. NOTE: Only injectants approved by the NC Division of Public Health, Department of Health
and Human Services can be injected. Approved injectants can be found online at
http;//de�c .nc,goy/aho.ut/divis,iori'�/water-resourees/water-resources-,permits/wastewater-branch/ 7round-water-
protection/g ounci .\_ater-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
Water only / closed loop geothermal
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Joshua Robertson
NC Well Drilling Contractor Certification No.; 2461-A
Company Name: Triad Drillers Inc.
City; Elon
Contact Person: Robert Marshall
Zip Code:27244 County: Caswell
Day Tele No.: 336-421-3513 _ _ Cen No.: 336-453-4521
EMAIL Address: triaddrillers2000@gmail-com __ Fax No.:919-779-9294
State: NC
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Bowman Mechanical RDU LLC
Contact Person: Robert Marshall EMAIL Address: [e-mail]
Address: 145 Technical Court [e-mail]
City: Garner Zip Code: 27529 State: NC County:
Office Tele No.: 919-772-2759 Cell No.: 919-427-1424
Wake
Fax No.:919-779-9294
Closed -Loop Geothennal Well Notification Rev. 3-1-2016 Page 2

I. 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 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 htt3s://ncdenr.s3.amazonaws.com/s3fs-
public/W ater%20Quality/Aquifer%2OProtection/GPU/GeothermalVarianceRequestFormFillable-
20130805.pdf
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 oj'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 in accordance with the 15A NCAC 02C 0200 Rules. "
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 3

1
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FUZABETH H MURHEAD ETAL
PIN: 9851-04-2114
D.8. 5472. PG. 291
ZONED: AR
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- - WOWED
MURHEAD FAMILY, LLC
TRACTS 1-3. GRETNA GREEN
PIN: 9851-02-6213
D.B. 1422, PG. 374
ZONED: AR
WOWED
GEOTHERMAL
WELL FlELD
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20" SIDE YARD
WOODED
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WATER SUPPLY WELL
FOR HOUSE AND BARN
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PROPOSED
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SWALE /
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(PS-1)
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WOODED
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96,7-j -o cv5 41 `
&go / 0osse6'v7 p
l-fi[_c.5eo eod7277
EVERETTE AND DALE ANDREWS 1
PIN: 9851-14-2222
D.B. 305, PG. 60
ZONED: AR
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WOODED N
12' —
ACCESS
DRIVEWAY
WOODED
REPAIR AREA FOR ONSITE
WASTEWATER SYSTEM
(14.000 SF SHOWN)
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UTILITY/ACCESS EASEMENT —
P,B, 124 PG 171
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/AREA FOR PRIMARY ONS17E�`
WASTEWATER SYSTEM
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20' REAR
S 89'48'19' E
LAUREN AND JOEL RUTKOWSKI
PIN: 9851-12-2128
D.B. 6780. PG. 701-704
ZONED: AR
PROPOSED
GRASS
SWALE
(PS-2)
HORSE
PASTURE
1.204.21' TOTAL PADDOCK
WOODED
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MECHANICAL ROU ULC
Contact Z p-trsajn; " I - L-
r-ob,er--L-wl,@bowmanmechanic,31servic,.o-,c,.com 919
Address, 6-'501 T)07:)56A1S CF6-55ST6,+7>5,
Well dig mEft"ers- 6". 1.0 BTU thermally enhanced
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grout pumped from'.-Pottorn with "Trimmy" line,
factory instoail,,;,,2d u-bend at ',':)ottom, nominal pipe size
pressu,'!r,Er.sted to 1100 PI an inspected by
jurisdiction as required.

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