WI0700501_Other_20200310

Borth Carolina Department of Environmental t,tuality — litvision of water Kesources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These ivells are "permitted b3, mle" and do not require an individual pevnrit it. -hen constructed in auco►dance with
the rules of 15A NCAC 02C .0200. This notice must be suhmitled 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
performance -enhancing additives as part of a geothermal heating and cooling system.
OR
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 Clearlj, or Type hiformatiou. Illegible Subminals Nilt Be Returned As hicomplete.
DATE: March 10 2020 PERMIT NO.: (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(1) ■❑ Aqueous (as per 15A NCAC 02C .0222) Number of wells: 11
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER(S) (choose one)
(1) Single Family Residence Submit this form two (2) business days prior to construction.
(2) ❑ Bus inesslOrganization Submit this form 30 days prior to construction.
(3) ❑ Government: State Municipal County. _ Federal* _
"Submit this form 30 days prior to construction
C. WELL OWNER(S) — For single family residences. list all persons listed on the property deed. For all others,
list the name of the BusinessiAgency and person and title with delegated signature authority:
Polaris Investment Partners, Inc - Mr. John Parnell
Mailing Address: 735 Johnnie Dodds Boulevard Suite 105
City: Mt. Pleasant State: 5C Zip Code:464 County: Charleston
Day Tele No.: 843-414-4000 Cell No.: 843-810-6001
EMAIL Address: [e-mail] Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of uell site: 8-003-260
County: Craven
(2) Physical Address (if different than mailing address): 528 East Front Street
City: New Bern County. Craven Zip Code: 28560
Closcd-Loop Geothermal Well Notification Rev 3-1-20,'6 Page

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. In most cases, an aerial photograph andlor plat trap of the propertj parcel showing property lutes and
structures can be obtained and downloaded front the applicable county GIS wehsite. Tjpically, the property call
he searched by owner mope or address. The location of the wells in relation to property boundaries, houses, septic
tanks and fields, and other wells, etc. can then he drawn in by haul. Also, a 'layer' can he selected shmving
topographic contours or elevation data.
F. 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
httn://deg.ncaaovlabout/divisions/water-resources; water-resources-permits;wastewater-branchip-round-water-
G.
H.
rotection/ground-water-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
None, water only.
WELL DRILLER INFORMATION
Well Drilling Contractor's Name: James L Cornette, PG
NC Well Drilling Contractor Certification No.: 2424-A
Company Name: Applied Resource Management, PC Contact Person: James Cornette
City. Hampstead State: NC Zip Code:21441 County: Pender
Day Tele No.: 910-270-2919
Cell No.
EMAIL Address: [e-mail] Fax No.:
HEAT PUMP CONTRACTOR INFORMATION
Company Name: Airtech Mechanical
Contact Person: Patrick McKee EMAIL Address: [e-mail]
Address: 153 Two Lakes Trail
City: New Bern Zip Code: 28571
Office Tele No.: 252-636-5841 Cell No.:
State: NC County:
Craven
Fax No.
Closed -Loop Geothermal Well Notification Rev 3-1-2016 Png%: 2

I. PROTECTION — Provide a brief description of how any (a) water supply wells, (b.) surface water bodies, or
(c.) 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:
No threats
J. VARIANCE — Pursuant to 15A NCAC 02C .0241 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 htt s:llncdenr.s3.amazonaws.com/s3fs-
public,'Water°/420QualiiyiAguifer°}a2OProtection�GPUiGeodiermalVariancrRcq€L:stFn mF liable-
20130805.odF
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .021 l(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, [ruder penalty, of lair, that I have petaotaally examined and am familiar with the h formatiotn
submitted in this documew and all attachments thereto and that, based on my inquity of those individuals
immediately responsible for obtaining said information, 1 believe that the information is true, accurate atnd
complete. 1 ant aware that there are significant penalties, including the possibility offtnes and imprisonnietu,
for submittingfalse information. I agree to constructr operate, maintain, repair, and if applicable, abatndort the
injection well and all related appurlettatnces in accordance with the 15A NCAC 02C 0200 Rules. "
Signature of Property Owner/Applicant
Polaris Investment Partners, Inc.
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Closed -Loop Geothermal Well Notification Rev. 3-1-201 G POP 3

1, PROTECTION -- Provide it brief description of how any (a.) water supply wells, (b.) surface water bodies, or
(c.) 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:
No threats
J. VARIANCE— Pursuant tol5ANCACOIC.0241,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 w , o fs-
P t�cWaler%200uality Aquifer'e20Proteri PU Geo than lV ; anceReauestfiormFillable-
20-1301305,nd
IG SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent, 15A NCAC 02Q .M 1 l (O 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 gublicly 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 cert6, under penalo, of late; that I have personally examined and am famlliar with the information
submitted In this document and all attachments thereto and that, based an my inquiry of those individuals
lnrntediarely responsible for obtaining said lrrfwmation. I believe that the hiformation is true; acclurrre and
complete. 1 am aware that there are significant penalties, including the possibility offrnes and imprisonment,
for arrbntittingfalse Igforrnatlon. 1 agree to construct, aperate" ntaintaitt, repair, and Ifapplicable, abandon the
Injection well and all related apEolaris
rdance with the 1 s.l MGIC QZC 0200 Rules. "
nilof Pruperty O�►�ner/Appli ant
nvestment Partners, Inc.
Print or Tjpe hull Name ,
51polure nrAvtherixed Agent, (rang•
!Tint or Type Full Name
Clmd-L wp Gcothcrmat Wcll Nonlinlwn Reti 3-t-20I6 t,,Er )

I— SUBMITTAL INSTRUCTIONS — Submit one copy of the completed notification package to the each of the
following:
(2)
The Division of Water Resources' Water Quality Regional Operations Section (WQROS) Re- ia_onal
Office serving the area in which the injection well facility will be located:
WIN TON-SALEM
RALEIGH
r A
ASHEVILLE WASHINGTON
RESVILL fu
FAYETTEVILLE
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Telephone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 2830 1 -50433
Telephone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Telephone: [phone]
Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone: [phone]
Fax: [phone]
-AND-
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Telephone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Telephone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
The County Environmental Health Department in which the injection wells will be located.
Closed -Loop Geothermal Wcll Notification Rev. 3-1-2016 11W.Re 4

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TITLE: Geothermal Test Loop
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