WI0800530_Application_20191203

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These hells are "permitted by rule-" and do not require an individual permit when constructed in accordance with
the rules oJ'1 i 1 -WAC 02C.0200. This notice must be suhmitted 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
perfonnancecnhancing additives as pan of a geothermal licating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS
As described in 15A NCA(.'02(.0273 these wells circulate a refrigerant gas as pan of a geothermal heating and
cooling system.
Print Clearly or 7)Te Information. !!legible Submittals W111 Re Returned As Incomplete -
DATE: ( it (� <, =1— 20 PERMIT NO. to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL T CONSTRUCTED
(1) Aqueous (as per 15A NCAC 02C .0222): n Number of wells:
(2) Direct Expansion (as per 15A NCAC 02C .0223) l___, Number of wells: _
B. STATUS OF WELL OWNER (choose one)
(1) Single Family Residence Submit this form two (2) but
(2) BusinesslOrganization Submit thisI -f-o1rm 30 days p�ri-o�1
(3) Government: State Municipal J__t_ County !I
C. WELL OWNER - For single family residences list the property
business, organization, or government agency, and person delegated
Mailing Address: �'', t2 x _L_ `��• ��� _
City: - ti - State: AJC, Zip Cod 2°
Day Tele No.: Cell
EMAIL Address: Fax
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel I e cation Number (PIN) of well site:
County1 I
(2) Physical Address (if different than mailing address):
Cih tr 1 i Sto
LiIC,Closed-Loop Geothermal Notification (Revised 8l5f2013)
Fx
ss days prior to construction.
t 6115tru n.
Fed "era] n Submit this form 30 days

E.
F
MAPS, PLANS, AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of die injection well(s), Label all features clearly and include a north arrow. Attach a
site -specific map showing the locations of the following:
• Proposed injection well locations • Septic systems and associated spray irrigation
• Buildings sites, drain fields, or repair areas
• Property boundaries
• Surface water bodies • Existing or potential sources of groundwater
I wells contamination
• Water supply
(2) Plans and specifications of the surface and subsurface construction details of the Well systcm.
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 Heath
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at htto (!aortal nedenr ore web/wq/gps/gnIQ. All other additives require approval Prior to use.
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Ceaificat
City: t n/ra
DayTeleNa ((�
EMAIL Address: rk 64-'�5 CIQ.pk
H. HEAT PUMP CONTRACTOR INFO
Company Name:
Contact Person:

1.
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:
J. VARIANCE — Pursuant to 15A NCAC 02C .02A1 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 hht p /luorial ncdenr or webfwq/aps(auroro/Dermit-
anolications
K SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .021 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 identifies the person, grants them signature
authority, and is, signed and dated by the applicant.
"I hereby certtfy, 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.mrprisomnent
for submitting false information. I agree to co et, operate, maintain, repair, And if applicahl� aba{7drm
the injection well and all relate rtenan rdancc with the LiA NCAG tl2C Q2t10 Rules
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