WI0100575_Application_20200212

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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
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 15ANCAC WC.0200*. This notice most be submitted Prior to construction
c GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS
As dicribed in 15A NCAC 02C .0222 these wells circulate potable water only or a mixture of potable water and
n cc� performance -enhancing additives as part of a geothermal heating and cooling system.
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W GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS
As d%iribed 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 Sulo m ils Will Be Returned As Incomplete.
February 7th, 2020 PERMIT NC w'yD, Oa `5� to be completed by DWQ)
TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED
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(1) Aqueous (as per 15A NCAC 02C .0222): Number of wells: Sdf*LS
(2) Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
STATUS OF WELL OWNER (choose one)
(1) Single Family Residence X 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.
WELL OWNER — For single family residences list the property owner(s). For all others, list time of the
business, organization, or government agency and person delegated signature authority:
Mike and Sharon Duke
Mailing Address: 410 Cool Breeze Trail
City: Arden_ State: NC Zip Code: 28704 County: Buncombe
Day Tele No.:
EMAIL Address: [e-mail]_
PHYSICAL LOCATION OF WELL SITE
Cell No.:2393406880
(1) Parcel Identification Number(PIN) of well site: 9633-25-2514-00000
(2) Physical Address (if different than mailing address):
City:
State: NC Zip Code:
DW(lMIC/Closed-Loop Geothermal Notification (Revised 4/30/2012)
�.i J W+ 1 Page t

E. MAPS, PLANS,
(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 following:
• Proposed injection well locations • Septic systems and associated spray irrigation sites,
• Buildings 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 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 http://portal.nedenr.org/web/wq/aps/gwpro. All other additives require approval prior to use.
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G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Josh Plemmons
NC Well Drilling Contractor Certification No.: 41
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 No.:
EMAIL Address: [e-mail] Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:Bullman Heating & Air
Contact Person: Josh Guthrie EMAIL Address: ios azAbullmanheating.com
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804_Smte: NC County: Buncomne
Office Tele No.: (828)-658-2468 Cell No.: _(828)-712-7488 Fax No.: (828)-658-1001
DWQ/GIC/Closed-loop Geothermal Notificafim (Revised 41302012) Page 2

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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:
Silt fencing surrounding the proposed drilling area. Grading and silt fencing away from adjacent drain field.
J. VARIANCE — Pursuant to 15A NCAC 02C .0241 the Director of the Division of Water Quality 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 ht(p://portal.nedenr.oiWweb/wq/aps/gwpro/permit-
applications
K SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .0211(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 certify, 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 imprisonment,
for submittingfalse information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules. "
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Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
DWQ/UIC/Closed-Loop Geothenml Notification (Revised 4/30/2012) Page 3

nuhmimal with Me uothicmion Mat cicerly identifies Ma pence, amen them signature authority,
and n signed and dahed by lire a,,elicam.
"I hereby canh; We, Nuenly f few, +hot I hmx pa.aalb, eannuated and am J4mlllar wish Me oya racoon
subndaw in this document and aft aHa Aeawaa lWaom and that. bated an my "w, of lhme Indrv1dook
immeNmely ,r.Ubfa fw ab+ammg said irllormcewe. d behave Thal the Informonm ie nua, accarme and
mmplefe. I am aware +harThere are slgnglaaenpeaaftla , mciadag the pwasonfif offinar and imprawnrnant far
sabmaung f !se mfornuuion. 1 ¢area w concim, aqua!¢, maintdn, repair, and if applicable, abandon the
hgachan wall endall mlaledn nenaxa,a/naccordaaac Irhrhe!yAAC 03 WMAalex."
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I.. SUBMTTALINSTRU<.TIONS— submit com copy ofeae mmpl.tad notification package to the each of Om
f Ilmving:
(1) Tha Oivialm of Wdw Quality Regioml ORice eenwg Me arcs in which the ir0ecum wall facility will
be located:
Atlee Ma Reglaml Oft.
2090 II.S. Highway 70
Swan... NC 2ans
Telephone: (US) 2964500
Pm: [phone]
FayellavNo ]ggloml Om.
225 (imcn Mrcal, Suit. 714
Fayettavilh,TCUMI-3043
T.lephom:[phone]
Pax: (9m) 496-0707

L. 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:
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]
Fast: [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 littp://www.neallid.ore/county.htm.
DWQNIC/Closed-Loop Geothermal Notification (Revised 4/30/2012) Page 4:'