WI0100570_Application_20191118

North Carolina Department of Environmental Quality -- Division of Water Resources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by rude" and do not require an individual permit when constructed in accordance wish
the rules of 15A. NCAC 02C .0200. This notice must be submitted prior to construction.
GEOTHERMAL,AQUOUS CLOSED -LOOP WELLS
As described in l 5A "AC 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 -LOOT' WELLS
As described in 15A NCAC 02C_' .a223 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: - AlGy, IG 20 111 PERMIT NO.: (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(1) Aqueous (as per i5A NCAC 02C .0222) Number of wells:
(2) Direct Expansion (as per 15A NCAC 02C .Q223) Number of wells:
B. STATUS OF WELL OWNER(S) (choose one)
(l) 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) ❑ Govemment: 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:
Mailing Address: pie l zpct,. R. AI 7 7 7
City: S r�� f'_ _ State: IVC. Zip Code:aa967/7County: /L.--
Day Tele No.:'7:�% n -7 6 G —7?�9 4-7 ____--- — Cell No.: ----
EMAIL Address:Q W'eg►�e� �,,�� r tr Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 0
7' 101 ` ' 15'A 1
County: tl
(2) Physical Address (if different than mailing address): , `� aY Rok,, V� I .hem--r e
AI Z-77
City: `]f.]t r (ry *. County :' L,-4 S, Zip Code: , 22-7 77
Closed -Loop Geothermal Well Notification Rev, 3-1-2016 Page l

E. MAPS, PLANS, AND SPECIRCATIONS
(1) Maps must be scaled or otber'%vise accurately indicate distances and orientations of features located
within 250 fl ct of the injection ►vell(s). J&hq1 all fea x 4l"rlv afl4hG�tl(�E._ a noritl armw. Attacli a
Site -specific map showing th►: locations of the following.
Proposed injection well locations * SWic systems and associated spray irrigation
■ Buildings SitcS. drain fwkls, or ropair area$
■ Property boundark7s
■ Surface eater bodies a Existing or potential sources of groundwater
■ Water supply wells contarnination
(2) Plans and specifications of the surface and subsurface construction details of the weii system.
F. TYPES AND CONCENTRAT TONS OF ADDITIVES — List any additives that will be used and their
concCntratioAxs, Only additives that thL Department of flealt'h and Human Service~' Division al' Public Hizaltli
determines do not adversely affect liuman health shall be used. A list of approved additives can be .fo-und
amine at h :I't7ortal.ncdenr,ar�lweb.'w Ia .Vgu . All other additives require approval prior to use.
Yl' r `lam'
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11.
WELL DRILLER 11NFORINUA ION 01 knmvn)
Well Drilling C.ontmcior's Nam `���-tC�'_
NC 'WQ11 Drilling Contractor Certifica ian No.: € 3 L.
Company Name: _ 1 1 , Contact Person
City: ke'nn___F _ State: bLt-, Zip Code County: 0' G i
Day Tele No.: � G Cell No.: '" D— -R 7,33D
EMAIL Address: _c� � e� ► r� R x No.:
.HEAT PUMP CONTRACTOR. INFORMATION
Company Name:
Contact Persair -
W]
Address: -' 1 ; .
Ci��i._ lip Code.
State ...County:. "'—
i.... - -
Office Tele No.o - 1� Cell No.R 4 Fax Na.:
R
'[ow)
VICICIosed-L(w 0"tlaCriSlal Nwificatian (revised 8/5120 t 3) 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 https://ncdenr.s3.ama onaws.comis3fs-
nubl ic/Water°/q2Q0uality/Aatiifer°/o2OProtectiou/GPU/Ceotl)emial VarianceReauestFormFillable-
201308i15,pdf
K. SIGNATURES -- The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .02.1 I(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 identities the person, grants them signature
authority, and is signed and dated by the applicant.
"I hereby certify, tender penalty o, f law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on racy 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,
far submitting false informations. I agr e to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all rel01-- spur rxnces 'n accorsdance With the 15A 1yCAC 02C 0200 Rules. "
r perty Owner/Applicant
nt or Type full a
Signature of Authorized Agent, if any
Print or Type Full Name
Clased-Loop Geatltemml Well Notification Rev. 3-1-2016 Page 3

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