WI0700497_Other_20191204

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These Tvells are `permitted by rule" and do not require an individual permitit,hen constructed in accordance 1vith
the rules of This notice must be submitted prior to construction.
GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS
As described in _ _ °, these wells circulate potable water only or a mixture of potable eater and
performance -enhancing additives as part of a geothermal heating and cooling system.
Ws
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS
As described in 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: November 11 t 2019 PERMIT NO. (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED
(1) Aqueous (as per _. ): ® Number of wells: 6
(2) Direct Expansion (as per ) Number of wells:
B. STATUS OF WELL OWNER (choose one)
(1) Single Family Residence _ ✓] Submit this form two (2) business days prior to construction.
(2) Business/Organization 0_ Submit this form 30 days prior to construction.
(3) Goverment: State = Municipal _Q County Federal Submit this form 30 days
prior to construction.
C. 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:
Dewey and Angela Ward
Mailing Address: 8396 Country Life Road
City: Pasadena State: MD Zip Code:21122 Coruat:
Dav Tele No.: 443-459-5372 Cell No.: 724-549-4838
EMAIL Address: [e-mail] Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 080006490913
(2)
County: Dare
Physical Address (if different than mailing address): 101 E. Sandcastle Court
The Village of Nags Head
City: Nags Head
State: NC Zip Code: 27959
UICJClosed-Loop Geothermal Notification (Revised 815/2013) Page 1

E. MAPS, PLANS, AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site -specific map showing the locations of the followI112:
• Proposed injection well locations 0 Septic systems and associated spray irrigation
• Buildings sites, drain fields, or repair areas
• Property boundaries
• Surface water bodies 9 Existing or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. 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 Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at All other additives require approval prior to use.
Geosafe @ 15%
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Arthur J. Tatern
NC Well Drilling Contractor Certification No.: 4200A
COMDativ Name: Virginia Energy Services Contact Person: Art Tatern
City: Knotts Island
State: NC
DaNT Tele No,: 252-455-7710
EMAIL Address: [e-mail]
Zip Code: 27950 County: Currituck
Cell No.: 252-202-9490
Fax No.: 252-648-7000
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: One Hour Heating & Air Conditioning / Franchise 596
Contact Person: Brian McDonald EMAIL Address: [e-mail]
Address: PO Box 2600
City: Kill Devil Hills Zip Code: 27948 State: NC County: Dare
Office Tele No.: 252-441-1740 Cell No.: Fax No.: 252-441-0639
UIC/Closed-Loop Geothermal Notification (Revised 9/5/2013) Page 2

I. 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:
• M • • M-110MORM210a M0191 11MO • • ' l Z 1111910 14110PNIMP201M
from aquifer cross contamination.
J. VARIANCE — Pursuant to 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
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 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 certif ,, under penally 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, ingwly 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 '. _ Rules. "
Signature of Property Owner/Applicant
Dewey Ward
Print or Type Full Name
Signature of Authorized Agent, if any
Arthur J. Tatem
Print or Type Full Name ---- --_—
UIC-,'Closed-Loop Geothermal Notification (Revised 8/5/2013) Page 3

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
VARIANCE APPLICATION FOR INJECTION WELL CONSTRUCTION STANDARDS:
GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS( j'�) OR
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS (-
This form MUST accompany the Closed -Loop Geothermal Notification Form available online at
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: November 11 2019 PERMIT NO. (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
Dewey and Angela Ward
[a
N
Mailing Address: 8364 Country Life Road
Cit.- Pasadena State: M D
Dav Tele No.: 443-459-1919
EMAIL Address: sandcastlecourtggmail.com
PHYSICAL LOCATION OF WELL SITE
Zip Code: 21122 County:_
Cell No.: 724 549-4838
Fax No.:
(1) Parcel Identification Number (PIN) of well site: 0800006490913
County: Dare
(2) Physical Address (if different than mailing address): 101 E Sand Castle Court
City: Nags Head
WELL DRILLER INFORMATION (if kno-mi)
Well Drilling Contractor's Name: Arthur J. Tatem
NC Well Drilling Contractor Certification No.: 4200A
State: NC Zip Code: 27959
t, I
Company Name: 11 Yul 0 HUI Yy VI V►VV0 Contact Person: V; III Uly Krinsky
V L-D
City: Knotts Island State: NC
Day TeleNo.: 252-455-7710
EMAIL Address: [e-mail]
Zip Code: 27950 County: Currituck
Cell No.: 252-202-7710
Fax No.:
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 constriction will not endanger human health and
welfare and the environment; and reason why construction and/or operation i1Y accordance with the standards is
not technically feasible and/or provides equal or better protection of the groundwater.
The structure is on pilings so proximity of bore holes to structure will notbe
E. SIGNATURES
Signature elvell Driller
Arthur J. Tafern
Print or Type Full Name
Signature of Well Owner
Print or Type Full Name
Per the Director of the Division of Water Resources may require submittal of
information deemed necessary to snake a decision on the variance, may impose conditions as part of the
decision, and shall respond in writing to the request within 30 dm,=s 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 _ ,' within 60 days after receipt of the decision.
UIC/Closed-Loop Geothermal Variance Request (Remised 8/5/2013) Page 2