WI0100564_Application_20191025

ortbCarolina Department ofEnvironmental Quality — Division 'TNN"at"Resources
3TIFICATION OF INTENT TO CONSTRUCT OR OPERATE INSF-CT'ON WELLS
ese wells are "permitted by rule" and do not require an individual permit when constructed in accordance with
the rules of ILA NCA C 02C .02fJfl. This notice must be submitted prior to comtruction.
C. S CLOSET} -LOOP WELLS
As described in 15A N 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 DIREST L1LPAXSjQN CLOSED -LOOP WELLS
As described in 15A NCAC 02C.=3 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print ( learly or Type bilf,rtnation. Illegible Submillah Will Be Returned As Incomplete.
DATE: 20— PERMIT NO.: (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(1) ,Aqueous (as per 15A NCAC 02C .0222) Number of wells:
(2) Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER(S) (choose one)
(1) Ysingle 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 41-1 persons listed on the property deed. For all others,
list the name of the Business/Agency and person and title with delegated signature authority:
4Y-i-,,j 4 GY;--c4 (4, tf
J
Mailing Address: 2z Arcv%j3A
City: jf1 OA)l k1 State: tkL Zip Code:� t 16 CCounty
Day Tele No.: Cell No.:—Ci0i 41"SC-)
EMAII. Address: JC014Gtyhtl,4 ��fywll,
CL Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 'f72-14z795'300000
P 0
county: _Iync mke—
(2) Physical Address (if different than mail ingladdress): 3TV/ -� ela - 7 e-4 Ll
1;e --
City: A -P 12 county
&101 e- �0^4e_ Zip Code: ZSio�
Closed -Loop Geothermal Well Notification Rev. 3-1-2016
Page I

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). Libel 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, i f any • Existing or potential sources of groundwater
• Water supply wells, if A,ny 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 and/or plat map of the property parcel showing property lines and
structures can be obtained and downloaded from the applicable county GIS website. Typically, 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 be 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
i
nrolr!szrounc water approved-inie. All other substances must be reviewed by the DHHS prior to use.
2 � 14oel
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: dint Babbitt
NC Well Drilling Contractor Certification No.: NC-3556-A
Company Name:AA A Sweetwater Well Contact Person: Danielle or Clint
City: Swannanoa state: NC lip cade:28nOCounty:Buneombe
Day Tele No.: 828,298.1117 Cell No.:
EMAIL Address: [e-mail] Fax No.:828.348.1480
H. HEAT PUMP CONTRACTOR INFORMATION
Company Flame: rr air e 0/"01
Contact Person aanielle {fir Glint E L A suv atwaterwell c' t tail.ec�
Address: Q 7� QQ -- --
City: �E Zip Code: gl State: MC -County: �Iewterso "t
Office Tele No.: Cell No.: Q12�3� d F Nc� 828 34$.1
480
Closed -Loop Geothermal Well Notification R .}$ 3-1-2016 Page 2

PROTECTION — Provide a b description Of how any (a.) water supply wells, (b.) surface water bodies, or
(c.) septic systems and associI'd ray irrigationre
sites, drain fields, or pair areas within 250 feet of the
proposed injection wells will h rotected during
construction of the wells:
J. VARIANCE — Pursuant to 1.9 k`4NICAC 02C .0241 the Director of the Division of Water Resources may grant
a variance from applicable X%,: 1-;struction or operation standards provided that:
(1) Use of the well(, > not endanger human health and welfare or the groundwater; and
(2) That constructio;; aeration in accordance with the standards is not technically feasible or the
proposed consin, a -11, - provides equal or better protection of the groundwater.
Any v:uiancc request should coinpany submittal of this notification to expedite evaluation of the request.
`rhc v,s! i,mce re(west form can be accessed online at h9vs:Hneck nr.s3&MMnaw&Qom/s3fs-
-
20130895.RLf
K. SIGNATURES —The followmig section is to be completed as required below or by that person's authorized
agent. 15A NCAC OX .0211(0 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; documentation shall be
(C) for any other person authorized to act on behalf of the applicant
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,
J;gr submitting false information. I agree to construct, operate, maintain, repair, and ij*applicable, abandon the
injection well and all related appurtenances in accordance with the I SA NCAC 02C 6200 Rules.
4 aoM I -A I/) livard/
Signature IDt Property Owner/Applicant
/Iart \ ° m I I) vw-
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Closed-l-oop Geothennal Well Notification Rev. 3-1-2016 Page 3

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