WV0800231_Application_20191028

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 NC AC 02C .0223)
This form MUST accompany the Closed -Loop Geothermal Notification Form available online at
hhtt ://i)ortal.ncdenr.ora/web/Wg/aps/Rwwi)ro/permit-applications#geothermAnns
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: October 24 2019 PERMIT NO. W10800524 (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:
Mr. Mark Waslo & Mrs. Renn Waslo
C.
Mailing Address: 309 Snowberry Court SE
City: Venetia State: PA Zip Code: 15367 County: Washington
Day Tele No.: 412-400-1638 Cell No.: 703-470-6677
EMAILAddress: [e-mail] Fax No.:
PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 206614446951
County: Brunswick
(2) Physical Address (if different than mailing address): 4439 Midshipman Court SE
City: St James
WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: James L Comette, PG
NC Well Drilling Contractor Certification No.:
Company Name: Applied Resource Management, PC
City: Hampstead State: NC
Day Tele No.: 910-270-2919
EMAIL Address: [e-mail]
State: NC Zip Code: 28461
Contact Person: James L Cornette
Zip Code: 28443 County: Pender
Cell No.:
Fax No.: 910-270-2988
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.
15A NCAC 02C.0222(e)(5)(A) - Two closed loop geothermal wells will be drilled on the
North side of the property. The wells will be approximately 13' from the structure due to
limited property space and CAMA 30' AEC line. They will be grouted along their entirety
and will not present a threat to human health or the environment.
E. SIGNATURES
Signature of Well Driller
James L Cornette, PG, CWD
Print or Type Full Name
Signature of Well Owner
Mr. Mark Waslo & Mrs. Rene Waslo
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. 150B-23 within 60 days after receipt of the decision.
UIC/Closed-Loop Geothermal Variance Request (Revised 8/5/2013) Page 2

D. REASON FOR VARIANCE REQUEST — Include type of wcll(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 bete environment; and reason why construction and/or operation inaccorance with the standards is
not technically feasible and/or provides equal or better protection of the groundwater.
15A NCAC 02C.0222(e)(5)(A) - Two closed loop geothermal wells will be drilled on the
North side of the property. The wells will be approximately 13' from the structure due to
30' AEC line. They will be grouted along their entirety
limited property space and CAMA
and will not present a threat to human health or the environment.
Mr. Mark
Pt
la & Mrs. Rorie Wasto
rype Full Name
the Division of Water Resin

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:
WINSTON-SALEM
ASHEVILLE
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]
RALEIGH
WASHINGTON
FAYETTEVILLE
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

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1Nortn uarouna Lenartment of Environmental vuauty — Division of Water Resources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are `permitted by rule" and do not require an individualpermit 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
M1t
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: February 13 2019 PERMIT NO.: W10800524 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: 5
(2) ❑ Direct Expansion (as per 15A NCAC 02C .02231 Number of wells:
B. STATUS OF WELL OWNER(S) (choose one)
(1) ❑■ 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:
Mr. Mark Waslo & Mrs. Rene Waslo
Mailing Address: 309 Snowberry Court SE
City: Venetia State: PA Zip Code:15asr County: Washington
Day Tele No.: 412-400-1638 Cell No.: 703-470-6677
EMAIL Address: [e-mail] Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 206614446951
County: Brunswick
(2) Physical Address (if different than mailing address): 4439 Midshipman Court SE
City: St James Count} Brunswick Zip Code: 28461
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page t

E. REQUIRED MAPS, PLANS, AND SPECIFICATIONS
G.
(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 wc]Rs). 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 • 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 nrost cases, an aerial photagraph andlor plat map of rile property parcel showing property lines and
structures can he obrained and dmrrdoaded froan Ore applicable coarny GIS website. 7)pkcally, the property can
be searched by owner name or address The location afthe wells in relation to property boundaries, houses, septic
tanks and fields, and other wells, eta can then be drairn its by hand Also, a'layer' can be selected showing
topographic contours or elevation data.
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 Hunan Services can be injected. Approved injectants can be found online at
http:/tdeg.nc.gov/about/divisions/ivater-rescurceshvater-resources-i3emitstwastewater-branch/ round-water-
protectiontground-water-approved-iniectants. All other substances must be reviewed by the DHHS prior to use.
None, water on
WELL DRILLER INIrOR11tATION
Well Drilling Contractor's Name: James L Comette, PG
NC Well Drilling Contractor Certification No.:
Company Name: Applied Resource Management, PC
Contact Person: James L Comette
City: Hampstead State: NC Zip Code: Za"'
Day Tel a No.: 910-270-2919 Cell 1
EMAIL Address: [e-mail] Fax I,
BEAT PUMP CONTRACTOR INFORMATION
County: Pender
Company Name: Fulford Heating & Air
Contact Person: Justin Fulford EMAIL Address: [e-mail]
Address: 3461 Holden Beach Road SW
City: Supply Zip Code: 28462
Office Tele No.: 910-842-6589 Cell No.:
State: NC County: Brunswick
Cinxxi-Loop Geothermal Well Notification Rev 1-1-2v11 G Pige 2

L 1-R07 LC] I01%- pr.nrdC ahrmf aG+n(iunn ei hum pay w 1,. A!",upp$ ,..Ilo- d• , wriac Duna 1+'d'C. ci
is I'trnc sweets and au,+aate6 s rey ur,gat•on atr:. J-arn ricl& of iel-tat a.em...:Clio 2sn feet ,4 d...e
PfaPcseJ m:tamn •'ALIL is A) he luu:CtkJ dm me eemnognnl of flit orlk
No threats
J. VARI.k,CE-Poruant to A*,. .t: +a 11 the Due,tor otlhc Or•n,en al\tau Rc:v; ices oL11 man,
n .a,miac from appbcablc v.sll cnrvaucuen sa arcrauIII aMJIIWn rr+.n IJCd Ilut
I11 Cse A lh: uIII Isl u:❑ no: c•danxr human ocalth and wch'ue of the gtonWadei. and
121 ntat consimcuun of opefeurn m aciJtilantC % Ill. (lie 51anJafJs o IIDnetlunullc Ieasdde ui lie
Proposed o rtilsoclpm n,uvldts equal n; henef prowl,on of the e:oar:Jn +es
Am smmiwe rntucst slim:ld at umtpam subnnaal Of this nnnficahon to espedr.e ct a] action of the icqurst
The tonane request forrncan beacroseJ onlmt al!r:rr.. s'd yr al •'n•o.:n., ;.,.r,'. ^.-
,l
K. SIGXA'rt RES- Me followwa serion Is to ne completed as Icgmled helms or hJ that piraon's aul''ionud
aged I5 \ 4t 11 ni: i lwi requites sl.nm.'v's as fnllom
W her a corporation by a responsible co-polate o0her,
fb) lot a panntrlup of Dote propnus,dup In a gcneml Pammr or lilt pn•r1100% respccuce:p
L4 .1.1 rt u,u,d 1114 . o, a tune. ici<,oi. ut suha pubis eEun-. ', m,iio a piuo'VA cvaenyc
offmn or r-.nhutg puldmly elected mTrc:al.
let for all others by the well owae,,
let for any other person amhomed to act on lichalf of the appheam duamrc:pmion sl'all be
subrnacJ w)Ill the nuidkma+n that cie;1115 Iden!dna Are pesonglans them a_n:mne
autlmnland is signed and dated by the applicant
11""N , nv(I uu;ti r/¢•rndn oI An'. rimy f lrerc pc n.nldfA eumvircd:rnJ our iwn'L✓r nnl, the Lif rmnarnn
u,hmmed ,, tho 'I'Awaraf and 111 .rthahmtun (hrn•hr urr.l Ilml. lanai nn net rnyr«p I A ,, udnxdn,rG
llrnntdroroll r. J"nsfHe 1„r oblummg, said ul/omemnn. / h.i ew dmt the uJnrniaiwn is b;rt «t. Prue and
uanpdtlr two mran ths( Ihrlr err• vt;rnluun ptneftrrc, n¢lndtal; dle i imbri'll of hnn « a,f xn/rrnnrrmorf.
om vrMnnN%CNnc UIpRnL/R4t (J);ra'P tpi,pHMitf.PJ'l'J/t'lll✓n11o"I nplarr,:ni,l Rap110-aph'. ah;nl,Grn(he
nnr..t✓ury 11and011 rrlartJop/mnru✓u rs nr o.rur!✓,rcr auh 1ht 15!'.+ 11 ,r1 n: a'. Abdo
i�� -AAJ
Sn;rammnfM,prnp 0„nerlApphca.I
Mr. Mark Waste & Mrs. Rene VAraslo
P,ipr or Tym Fuil Same
tivrt,fcrrn( AaJ:mnd k—o if —
Pont ar Ttpe Fail Samc
(L,mdd .,p r.n...e a€(Itdrb+•.ir. eomi:e. t-1.:

L. SUBMITTAL INSTRUCTIONS —Submit one copy of the completed notification package to the each of the
followinw
(1) The Division of Water Resources' Water Quality Regional Operations Section (WQROS) Regional
Office serving the area in which the injection well facility will be located:
ASHEVfLLE
Asheville Regional Office
2090 U.S..Highway 70
Snannanoa, NC 28778
Telephone: [phone]
Fax:[phone]
rayetteville 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
!628 Mail Service Center
Raleigh, NC 27699-1625
Telephone: [phone]
Fax:[phone]
-AND-
RALEIGH
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]
`.Vinton -Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
(2) The CountyEnvironmental Health Department in which the injection we) s aitl be located.
Closed -Loop Geothermal Well Notification Rev. 9-i,,w6 Page 4

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LEGEND
Proposed Geothermal Loop Locations
Adapted From Kevin Pfirman Survey C1.0April 10, 2018

2 570'
e Earth
Google �F I It . I/ I $Oft

6" Borehole
a
TITLE: Geothermal Test Loop FIGURE:
Applied Resource Diagram
Management, P. C. JOB: SCALE: I DATE DRAWN BY:
�em�c�+.uczsa4s 4439 Midshipman Court SE As Shown 10/8/18 JMR