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HomeMy WebLinkAboutWI0100581_Application_20200430NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS These wells are "permitted hY rile" and do nol require an individual permit when constructed in accordance with the rules of 15A NCAC 02C .0200'. This notice must be subttlilted prior to coltstrucilott. m b i r: GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS c� As described in 15A NCAC 02C .0222 these wells circulate potable water only or a mixture of potap#ater ad performance -enhancing additives as part of a geothermal heating and cooling systemta w OR " a' o d m NO As described in 15A NCAC 02C .0223 these wells circulate a refrigerant gas as part of a cooling system. DATE 10 C. D. Print Clearly or Tt'pe htforntation. Illegible Submittals Hill Be Returned As Incomplete -?0 — , 20�Lb PERMIT NO. (to be completed by DWQ) TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (1) Aqueous (as per I SA NCAC 02C .0222): X Number of wells: 5 wells L 300' each_ (2) Direct Expansion (as per I SA NCAC 02C .0223) Number of wells: STATUS OF WELL OWNER (choose one) (1) Single Family Residence _\_ 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 name of the business. organization, or government agency and person delegated signature authority: City: a55 / AY7 State: Zip Code:VV�t/6 County: 6ttf-k Dav Tele No.: 330%oY 5839 Cell No.: 330, may. sg39 EMAIL Address: rn%p 1414i 61gMcu /. C.'am Fax No.: PHYSICAL LOCATION OF WELL SITE (1) Parcel Identification Number (PIN) of well site: % 9goo 936 6 y00000 County: Slit,'[X00w%10e (2) Physical Address (if different than mailing address): 3G Lake'1own Lavte City: tilo d=e /t State: NC zip Code: c26g0q 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 following: • • r roposed injection well locations eptic systems and associated spray irrigation sites, drain fields, or reps$ areas uildings • • P roperty boundaries xisting or potential sources of groundwater contamination S urface water bodies • W ater supply wells (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 Itttp://Vortal.ncdenr.or web/wq/aps/gwpro. 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 No.: EMAIL Address: jmclrwater70@aol.com Fax No.: H. HEAT PUMP CONTRACTOR INFORMATION Company Name:Bullman Heating & Air Contact Person: Josh Guthrie EMAIL Address: ioshgAbullmanheatine.com Address: 10 Red Roof Lane City: Asheville Zip Code: 28804_State: NC County: Buncomne Office Tele No.: (828)-658.2468 Cell No.: _(828)-712-7488 Fax No.: (828)-658-1001 DWQMIC/Closed-Loop Geothermal Notification (Revised 4/30/2012) Page 2 /-nA,R 1s fee M- I,UOO).S� fj 0 c, 2f'o� 33a -7O� -S-VSq 1'�en�t L4 - gen� �Ressu J44 To )OD �s 1 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 he protected during construction of the wells: J. VARIANCE —Pursuant to I 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 litip://mtrtal ncdenr ore/web/we./ays/gwpro/oermit- applications K. SIGNATURES — The following section is to be completed as required below or by that person's authorized agent. I SA NCAC 02C .021 I(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 cerlih% under penally of law. that 1 have personally examined and mn familiar will; the information suhmined in this document and all onaclunems thereto and that, hared on my inquiry of those individuals immediately responsible for obtaining said information, 1 believe that file information is true, accurate and complete. 1 am uu are [hat there are significant penalties, including the possibility of fines and intpr isonmeni, for submitting false information. 1 agree to construct, operate, maintain, repair, and if applicable. abandon the infection well mid all related appurtemmrces in accordance frith dre 15A NCAC 02C 0100 Rules. " f Signature d.Yropfrty OwnJ"pi9cant J TeVe-As/ wnDe,Av A - Print or Tye Full Name Signature of Authorized Agent, if any Print or Type Full Name 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: WINSTON-SALEM ASHEVILLE Asheville Regional Office 2090 U.S. Highway 70 Swannanoa, NC 28778 Telephone: (828) 296-4500 Fax: (828) 299-7043 Fayetteville Regional Office 225 Green Street, Suite 714 Fayetteville, NC 28301-5043 Telephone: (910) 433-3300 Fax: (910) 486-0707 Mooresville Regional Office 610 East Center Avenue, Suite 301 Mooresville, NC 28115 Telephone: (704) 663-1699 Fax: (704) 663-6040 Raleigh Regional Office 1628 Mail Service Center Raleigh, NC 27699-1628 Telephone: (919) 791-4200 Fax: (919) 571-4718 WASHINGTON FAYETTEVILLE Washington Regional Office 943 Washington Square Mall Washington, NC 27889 Telephone: (252) 946-6481 Fax: (252) 975-3716 Wilmington Regional Office 127 Cardinal Drive Extension Wilmington, NC 28405 Telephone: (910) 796-7215 Fax: (910) 350-2004 Winston-Salem Regional Office 585 Waughtown Street Winston-Salem, NC 27107-2241 Phone: (336) 771-5000 Fax: (336) 7714631 (2) County Health Department in which the injection well facility will be located. A list of county health departments can be found online at htlp://wtv%v.ncalhd.org/county.htn. DWQMIC/Closed-Loop Geothermal Notiflca6on (Revised 4/30/2012) Page 4