WI0100600_Geothermal Aqueous Closed Loop Well Application_20201008

North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by rule" and do not require an individual permit when constructed in accordance with
the rules of 15A NCAC 02C .0200. This notice must be submitted 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.
M
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 Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: 9/3 , 20 Lt) PERMIT NO.:
(to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(1) 0 Aqueous (as per 15A NCAC 02C .0222) Number of wells
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of webs':
B. STATUS OF WELL OWNER(S) (choose one)
1 Single FamilyResidence Submit this form two 2 business dvi s rior'to'constructron U '�
(2) ❑ Business/Organization Submit this form 30 days prior to construction
(3) [Z Government: State Municipal County _X_ 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:
Mailing Address: W . /\A (� t 8
City: For e.4- City State: NC, Zip Code: aog3 County: Rtjt"Pie tf ,(i rd
Day Tele No.: 8 2.F3 ZE 9 l P Cell No.:
EMAIL Address:
PHYSICAL LOCATION OF WELL SITE
Fax No.: z El - Z e a _ Z-426
(1) Parcel Identification Number (PIN) of well site:
County: � V `i h r r �.(j r-d
(2) Physical Address (if different than mailing address):
56 1 h oni2spn Root
City: &AeffQ! dt0f` County i� �'''� �`� t' 4`fn r C Zip Code: M 3
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 1

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 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://deq.nc. gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection/ground-water-approved-injectants. All other substances must be reviewed by the DHHS, ior to use.
i @
} '�r
Asheville Regional Office
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: I k ®k\(�ROTG � colC� S f1'1 Q A R
NC Well Drilling Contractor Certification No.: N C, VV C, L44 tJ3 _ A
Company Name: e-OAS' t'�N —fe CA:, Contact Person: Tvs t i 6 G ct Wti ey
City: Er° i 5 Go State: -T'X_ Zip Code:? 5Q Y 6County: Pf
Day Tele No.: _�� S 3 S - 28 (14 Cell No.: 2, . 0
EMAIL Address: iu5fi . ca, �r\P�i SClAe 15Ciiy-J c 1S. Fax No.: 972_)3,`, - R,97
<d ,�
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
Zip Code: State: County:
Cell No.:
Fax No.
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 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:
J. VARIANCE — Pursuant to 15A NCAC 02C .0241 the Directo Me'Division of WateJ gff6W may grant
a variance from applicable well construction or operation standards provided that: Office
(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 https://ncdenr.s3.amazonaws.com/s3fs-
public/Water%20Quality/AcLuifer o20Protection/GPU/GeothermalVarianceRequestFormFillable-
20130805.pdf
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 submitting false information. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the I5A NCAC 02Q200 Rules. "
Signatdre+6f Property Owner/Applicant
1 �io��s �-O�iPr G�S►v\ah
Print r Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 3

L. SUBMITTAL INSTRUCTIONS — Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Resources' Water Quality Regional Operations Section (WQROS) Regional
Office serving the area in which the injection well facility will be located:
(2)
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]
-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.
Rk#TheJdml Cpviltx.
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 4

NOON
00
so
Ego..
0
0 a red' I log I
L........... j I
tu
LU UJ
x
J
Z
8
O uj
UJ
j
MIMI;
eo .-;-:hfl '-n!
21 Ir,
g�g3 se
um
102, U1
I
Hmg Rg -M- z
q g I t s;: vm,
i ?-,--, I 's; I *
mv:v
Mag ij
CHM I H
3
625. �J,X— ec
2291- � 2 1. 9
I Humn Jill'
;
P
V.
I I H
(93)
2026
1fUate U�
Ity Reciic)
kA
T. TA III
w ;
O

r. . . . . . . . . .
ro
20 0
0
20
U/I
j 000 9 1. 1 t P
.. LU 0 ui 0

Rutherford
i
Church of Christ
DeLauters Photography ,�, /` (
t-_ Domtar Paper
Gold Hill Church t Carpenter Design' •
Clearwater Creek POA
Dollar General 6
.S Central High School
4q
564 Thompson Road
f
All Seasons - Automotive ,
and Marine Repair Shop
�......• tyS Hv'164
d
Grace
Bible Church',t` • Knuckles Garage .
- _-...
Recliner Center r f'
1
%„ t�• ,'
ti
MI
Chapel Hill Church't
Scoygin's Seafood y
&Steakhouse Calvary Baptist Church
t t; 'Associated F
G O O J i e r
® � Services
xt' 4r
_ _
g
CF Reece & SonrA