WI0100563_Application_20191023

North Carolina Department of zuvironmentai wluanty - mivisiun ur vs user ncauux a:ca
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 I SA NCAC 02C .0200. This notice must be submitted for 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
performance -enhancing additives as part of a geothermal heating and cooling system.
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GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS
As described 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 Submittals Will Be Returned As Incomplete.
DATE: IO ` a3 ` 20jj PERMIT NO.: (to be completed by DwR)
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A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED elect of
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(1) a<qucous (as per 15A NCAC 02C .0222) Number of wells:
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells: —I
CD to
B. STATUS OF WELL OWNER(S) (choose one)ca n�i c
cm
(1) mgle Family Residence Submit this form two (2) business dayc"r to construe
(2)- ❑ Business/organization Submit this form 30 days prior to con tiaon.
(3) ❑ Government: State— Municipal_ County_ Federal•3__ —
*Submit this form 30 ilhys prior ction
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 delegates( signature authority:
Mailing Address: lJ ' N IW`W-- ti '''
City: AcLe La 1,.e State:nG Zip Code,9 1 County: �u"
Day Tele No.: Cell No.: —
EMAIL Address: �} rt0111 s ��hr}i �i (C try Fax No.:
D. PHYSICAL LOCATION OF WELL SITE / �y tj
(1) Parcel IdentificationNumber (PIN)ofwell site: W 41eol - 2 % `J- I I `�
County: UA ll
(2) Physical Address (if different than mailing address): 17 le C)61 'V
City: S ounty 9kA Y1 L vl _Zip Code:
Closed -Loop Geothermal Well Notification Rev. 3.1-2016 Page 1

E. REQUIRED MAPS, PLANS, AND SPECIFICATIONS
(1) A site maps must be submitted. It must be scaled or otherwise accurately indicate distances (in feet)
and orientations of features located within 250 feet of the injection well(s). Label all features clearly
and include a north arrow. Attach the site -specific map showing the wells in relation to the locations of
the following:
• Buildings • Septic systems and associated spray irrigation sites,
• Property boundaries drain fields, or repair areas, if any
• Surface water bodies, if any • Existing or potential sources of groundwater
• Water supply wells, if any contamination, if any
(2) Plans and specifications of the surface and subsurface construction details of the well system.
NOTE. Inmost cases, an aerial photograph and/or plat map of the property parcel showing property lines and
structures can be obtained and downloaded from the applicable county GIS websira Typically, the property can
be searched by owner name or address. The location of the wells in relation to property boundaries, houses, septic
tanks and fields, and other wells, e!c can then be drawn in by hand Also, a'layer' can be selected showing
topographic contours or elevation data.
TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. NOTE: Only injectants approved by the NC Division of Public Health, Department of Health
and Human Services can be injected. Approved injectants can be found online at
All other substances must be reviewed by the DHHS prior to use.
G. WELL DRILLER INFORMATION y�
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Day Tele No.: _
EMAIL Address:
H. HEAT PUMP C
Company Name:.
Contact Person:
Address:
City:
Office Tele No.:
State: ML
INFORMATION
Zip Code: LIL&
Cell No.:
C y_ Contact Person:
Zip Code:29'A3 County: MQsoja_
Cell No.:
Fax
State: M C County:
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 2

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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 .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 hhtW://portal.ncdenr.org/web/wg/aps/ewaro/permit-
aonlications
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 certij�, under penally of law, that 1 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 fnes and imprisonment,
for submitting false information. 1 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. "
atureofProperty (Owner/Applicant
Nl Gc Y <� 4 / DyvtS
Print or Type Full Name
Signature of Authorized Agent, If any
Print or Type Full Name
DWQ/UIC/Closed-Loop Geothermal Notification (Revised 4/30/2012) Page 4

L.
SUBMITTAL INSTRUCTIONS — Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Resources' Water Quality Regional Operations Section (WQROS) Regions
Office serving the area in which the injection well facility will be located:
WINSTON-SALEM
RALEIGH
ASHEVILLE t' WASHINGTON
FAYETTEVILLE
Washington Regional Office
Asheville Regional Office
943 Washington Square Mall
2090 U.S. Highway 70
Washington, NC 27889
Swannanoa, NC 28778
Telephone: [phone]
Telephone: [phone]
Fax: [phone]
Fax: [phone]
Wilmington Regional Office
Fayetteville Regional Office
127 Cardinal Drive Extension
225 Green Street, Suite 714
Wilmington, NC 28405
Fayetteville, NC 28301-5043
Telephone: [phone]
Telephone: [phone]
Fax: [phone]
Fax: [phone]
Winston-Salem Regional OMce
Mooresville Regional Office
450 W. Hanes Mill Road
610 East Center Avenue, Suite 301
Suite 300
Mooresville, NC 28115
Winston-Salem, NC 27105
Telephone: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone: [phone]
Fax: [phone]
-AND-
(2) The County Environmental Health Department in which the injection wells will be located.
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 4