WI0100586_Application_20200526 (2)

DocuSgn Envelope ID: D8674D03-55EC4992-BD5D-9FiFBC5ECC29
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "p¢rmirsed by rule" and do aor rarryia w indi.Jd+.at pvmir wham canstruc+¢d rn accordance wi+h
the rules ofl5A NCAC 02C.0200`. 7%s na+ice mist+ be submiaed oriar ro coratruaiarz
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-enhaneitln, 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 pan ofa. geothermal hearing and
cooling system.
Pratt Clearly or Type Information. Illegible Submi+mis Will Be Aena,mad As Incompleas
DATE: UIn - 20_,Li` PERMIT NO. (to be completed by DWQ)
A TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(asper15ANCACO2C.0222): ' Number of wells:
(2) Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER (ehoose�one)
(1) Single Family Residence � Submit this form two (2) business days prior to construction.
(2) Business/Organizadon Submit this form 30 days prior to construction.
(3) Government: Smte_ Municipal_ County— Federal —Submit this form 30 days
prior to construction.
C. WELL OWNER — For single family residences list the property owner(s). For all others, list name of the
business, organization, or governmem agency and person delegated signature authority:
Mailing Address:
Day Tele No.: _
EMAIL Address:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well
County:
(2) physical Address (if differerz than mailing address):
(rS^ k Fo" l' l� r �ri
\\ city: 1. State: 2LC Zip Code:
DR`Q{?[ Lba'FIaa7 C'.yd:G?'3' SodScm �anian::?0]ul]:. _

DocuSign Envelope ID'. D8674M3-55EC4992-8D5D-9F1 FBC5ECC29
E. MAPS, PLANS, AND SPECIFICATIONS
(11 Maps must be staled or otherwise accurately indicate distances and orientations of features locaxed
within 250 feet of the injection weIIla). Label all features clearh anal include a north arrow. Attach a
site -specific map showing the locations -of the following:
• Proposed injection well locations • Septic systems and associated spray irrigation
• Buildings sites. drain fields, or repair areas
• Property boundaries
• Surface water bodies • Existing or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications ofthe surface and subsurface construction details ofthe well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Deparnnent of Health and Human Services' Division of Public Health
determines do nor adversely affect human health shall be used. A list of approved additives can be found
online at .. _ _ _ All other additives require approval prior to use.
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Lam Wells'
NC Well Drilling Contractor Certification No.: 1603-A344*A
Company Name: AWD Services Inc. Cantacz Person
City: Leicester Stan: Lg_ Zip Code: 28748 Counrv: Buncombe
Day Tele No.: 828-683-9223 Cell No.: 828-215-9333
EMAILAddress: g1Sk-L 1,Cc..y c_t llC'C\'P,f, 1l -CC1+, Fax No. 829-683-9203
J
R. HEAT PUMP CONTRACTOR INFORMATION r
Company Name:_
Contact Person: C k C[}Qe e' EMAIL Address: 'r iC�-f�'Iv\Cyt1v}Cti 1'N llV2 iYtG>`Ktl\,!h.l
�i CCrcI
Address: "tee- �•Y' IC✓�
City: PL,'f+ — Zip Code_2:27(\l'•rate: _County: _6't-IGIC
Office Tele No.: L Sti-CCX` \_Cell No.: -I?G " ZZ�
D\t 41 !t" i:used-L.v; Geavna: �.vr.:u:o*. Re+.�u -. i.

DocuSign Envelope ID: D857400&55EC4992-8D5D-9FiFBC5ECC29
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 protec[ed during construction of the wells:
Silt Fence will be used to 0111721 Sands and run offfrom drillin
g.
VARIANCE— Pursuam 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 rntC n;denr.orn�q_r,nJ 2.* tggermii-
K SIGNATURES — The following section is to be Completed as required below or by that person's authorized
agent. 15A NCAC 02C .021 I (e) requires signatures "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:
(a) for any other person authorized to ant on behalf of the applicant documentation shall be
submitted with the notification that ciearlr identifies the person, grams them sigrumure
authority. and is signed and dared by the applicant
"I hereby certify, wider penalty of low, thot I have personally aranined and am familiar with the information
submitted in this doctonem and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information. 1 believe that the information is true. accurate, an,
complete I am aware that there are signiftemu penalties, including the possibility of fines and imprisonment,
.for submitting false information. I agree to construct, operate. maintain. repair, and if applicable, abandon
the injection well and all related ap ourteronces rn accordance with the ISA NCAC 01C 0100 Rules. "
f IGuuL San
Siaoamre WLEWWQM%fffAApjj.m
Eric Rosenberg
Frio[ or Type FuH Dame
Si—oure ofAataodu4 Aaear. if any
Print es Type Full Name
DwQ.,I'ICCimecdo,, Gmmara\"otinmdon ReaiteC—;0'G:' Paccl

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