WI0100581_Application_20200430 (2)

NORTH 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: [e-mail] 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: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5043
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]
WASHINGTON
FAYETTEVILLE
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
585 Waughtown Street
Winston-Salem, NC 27107-2241
Phone: [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 htlp://wtv%v.ncalhd.org/county.htn.
DWQMIC/Closed-Loop Geothermal Notiflca6on (Revised 4/30/2012) Page 4