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Home My WebLink AboutWI0100587_Application_20200604North Carolina Department of Environmental Quality — Division of Water Resouges NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION ,LS These wells are "permitted by rule" and do not require an individual permit when constructed in accorZ R with the rules oj1 SA NCAC 02C.0200. This notice must be submitted prior to construction. :5. °—'. GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS m As described in 15A NCAC 02C .0222 these wells circulate potable water only or a mixture of potablealU and performance -enhancing additives as part of a geothermal heating and cooling system. = = 00 OR -0 CD ro m GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS 3 As described in I SA NCAC 02C .0223 these wells circulate a refrigerant gas as part of a geothermal heatirT and cooling system. Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete. DATE: �Q4, 20dO PERMIT NO.: (to be completed by DWR) A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one) (I) ❑Aqueous (as per I SA NCAC 02C .0222) Number of wells: (2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells: B. STATUS OF WELL OWNER(S) (choose one) (1) 2/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 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 delegated signature authority: SCdrr d- f15iftx-f m i rnhzL- Mailing Address: :Z 3 P-�,Zk- Rlbtrro- City: /i5N LUC' State: NL Zip Code:_ County: 811Ncoaph Day TeleNo.: (97$ 7117--.81299 Cell No.: (8�) 74-7-9109 EMAIL Address: 6 Smin+e res-1s c)� mar 1- &A, Fax No.: D. PHYSICAL LOCATION OF WELL SITE (1) Parcel Identification Number (PIN) of well site: County: ijv+"&A-$E (2) Physical Address (if different than mailing address): City: County Zip Code: Closed -coop Geothermal Well Notification Rev. 3-1-2016 Page t 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 and/or plat map of the property parcel showing property lines and structures can be obtained and downloaded from the applicable county GIS website. 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, etc. can then be drawn in by hand Also, a 'layer' can be selected showing 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 http://dw, c.goy/about/divisions/water-resources/water-resources-permits/wastewater-branclVground-water- nrotection/ground-water-approved-iniectants. All other substances must be reviewed by the DHHS prior to use. %"1 l (A., „I G. H. WELL DRILLER INFORMATION Well Drilling Contractor's Name: Clint Babbitt NC Well Drilling Contractor Certification No.: NC-3556-A AAA Sweetwater Well Company Name: Contact Person: City: Swannanoa State: NC Zip Code: 287�7 C unty:Buncombe Day Tele No.: 828.298.1117 Cell No.: r/ 4 c7 K I b EMAIL Address: ��y,\I QQ,Y W�I4V y� f �j (I:i � Fax No.: HEAT PUMP CONTRACTOR INFORMATION Company Contact Peron: % i jl L fd J/ EMAIL Address T /u s7r�z r/�(ty6�/7Ar(L Address: /�:-- !J n, nQolt�I /�i ✓tt� A,�2 / City: i%Sek,_ !1 e Zip Code: - State/v�County: .&n e2Q1 Office Tele No.: > �T0��7 Cell No.: fJ�7j£ 3/%�/f! Fax No.: Sr ? --� D37,K Closed -Loop Geothemal Welt Notification Rev. 3-1-2016 Page 2 1. 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: 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 endangef 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 httas://nodenr.s3.amazonaws.eom/s3fs- mrblie/Water%20Ouality/Aquifer%20Protection/GPULGeothermelV -r anceReaue EQmiFillablo- (•33[tltI:itiil�Ii 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, qperate, maintain, repair, and if applicable, abandon the injection well and all related p rtenan e in c or ce with the 15,4 NCAC Q2C Q2Q0 Rules." Signature of Property Owner/Appacant Print or Type Full Name Signature of Authorized Agent, if any or Type Full Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 3 rr , TBM2 - TOP OF IRON ELEV=2,903. 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