WI0100573_Application_20191220 (2)

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NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by rule" and do not require an individual permit when constructed in accordance with
the rules of 15A NCAC 02C .0200*. This notice must be submitted prior to construction.
GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS
As described in I SA 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.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS
As described in I SA 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 Incorrtprere.
DATE: November 13 2019 _ PERMIT NO. to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED ')�5 @ 2Sot
(2) weds @ 2-s-o' eu.c.�
L/ 4? 301D,
(() Aqueous (as per 15A NCAC 02C .0222):. Number of wells: (i) � vn,(k
(2) Direct Expansion (as per 15A NCAC 02C .0223) Number of well; 1� e 3 pot
B. STATUS OF WELL OWNER (choose one)
(1) Single Family Residence �bmit 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 fconstruction. m30days
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:
Dave Ni hols
Mailing Address: 640 N. Macewen Dr.
City: Osprev State: Florida
Day Tele No.:
Zip Code: 34229 County: SarAs0ta
EMAILAddress: nicholsdl9580.veriZmMLt
D. PHYSICAL LOCATION OF WELL SITE
Cell No.:941.8 Fax No.: 9
DEC 2 0 2019
(1) Parcel Identification Number (PIN) of well site: 9624337322cW#@(1 9 i0
Asheville nalOperatlons
County: Buncombe Regional o
(2) Physical Address (if different than mailing address): 21 Rock Vista Way (fOt3
City: Arden State: NC Zip Code: 28704
DWQMIC/Closed-Loop Geothermal Notiflcadon (Revised 4130/2012) Page 1

E. MAPS, PLANS, AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located I
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach e i
site -specific map showing the locations of the following:
• Proposed injection well locations • Septic systems and associated spray irrigatior, i
• Buildings sites, drain fields, or repair areas
• Property boundaries
• Surface water bodies • 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 theit
concentrations. Only additives that the Department of Health and Human Services' Division of Public HealtF i
determines do not adversely affect human health shall be used. A list of approved additives can be found I
online at litto:/.mortal.ncdenr.org/web/wq/aps/R"-pro. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Josh Plemmons
NC Well Drilling Contractor Certification No.: 4137A
Company Name: Clearwater Well Drilling, Inc. Contact Person: Jeff Moore
City: Hot Springs State: NC _ Zip Code: 28743 County: Madison
Day Tele No.: 828-776-6526 Cell
EMAIL Address: [e-mail] Fax
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:Bullman Heating & Air
Contact Person: Josh Guthrie EMAIL Address: joshi0 bullmanheating.com
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804_State: NC County: Buncombe
Office Tele No.: (828)-658-2468 Cell No.: _(828)-712-7488 Fax No.: (828)-658.1001
DWQ/UIC/Closed-Loop Geothermal Notification (Revised 4/30/2012) Page 2 !

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SUBMITTAL INSTRUCTIONS — Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Quality Regional Office serving the area in which the injection well facility
will be located:
WINSTON-SALEM
RALEIGH
ASHEVILLE t" �C-1/' ' WASHINGTON
FAYETTEVILLE
Asheville Regional Office
Washington Regional Office
2090 U.S. Highway 70
943 Washington Square Mall
Swannanoa, NC 28778
Washington, NC 27889
Telephone: [phone]
Telephone: [phone]
Fax: [phone]
Fax: [phone]
Fayetteville Regional Office
Wilmington Regional Office
225 Green Street, Suite 714
127 Cardinal Drive Extension
Fayetteville, NC 28301.5043
Wilmington, NC 28405
Telephone: [phone]
Telephone: [phone]
Fax: [phone]
Fax: [phone]
Mooresville Regional Office
Winston-Salem Regional Office
610 East Center Avenue, Suite 301
585 Waughtown Street
Mooresville, NC 28115
Winston-Salem, NC 27107-2241
Telephone: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone: [phone]
Fax: [phone]
(2) County Health Department in which the injection well facility will be located. A list of county health
departments can be found online at litti)•//www.neallid.ory/coLiiitN.litiii.
DWQ/UIC/Closed-Loop Geothermal Nalificafion (Revised 4/30/2012)
Page 4