WI0100592_Application_20200825

WI0100592
E. MAPS. PLANS, AND SPECIFICATIONS
i I) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). _ all features cieari_ a3>d_' Judea north arrow. Attach a
site -specific map showing the locations of the following:
(2)
• Proposed injection well locations
• Buildings
• Property boundaries
• Surface water bodies
• Water supply wells
• Septic systems and associated
sites. drain fields. or repair areas
• Existing or potential sources
contamination
spray irrigatior.
of groundwater
Plans and specifications of the surface and subsurface constitution details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES - List any additives that wit' be used and thei:
concentrations. Only additives that the Department of Health and Human Services Division of Public Health
determines do not adversely affec' human health shall be used A list o` approved additives can be found
online at _ +_ r . All other additives require approval prior to use.
20% Environal
G. WELL DRILLER LNFORMATION (if know! l
Well Drilling Contractor's NaJ GL�` tSc X\ /G tnn%U'�
Nam
NC Well Drilling Contractor Certification No.: Xairwi■.9t�4 -l3 ---
Company Name: AWD Services lr.c. Contact Person
City: L eicecter State. NC Zip Code. 28748 County: tiu corLtbe
Day Tele No.: 828-683-9223 Cell Nc.. 828-215-9334
EVIAIL Address. _ Fax No.: 828-68.3-9203
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name! #(1Ltc ( o P2
Contact Person. MO...1 `t1/4%C\ M ltl r, in _ E A i L Addressf L:< tom; iv 1iC '1
Address: ;).7 C �f e City. rC�L (\ Zip Code- \ )L^-htate_ LCounty: 6:•ti'C'Or1‘
Office Tele No.: !,' 7 1 [ - ca% 1 Cell No, S Z 2 Z �•
WA() t IC Closed•Loop Gaoi,rrrnal \otifi�tian : Re% ilia 4 A 2012
cl.t A`ELIcliKa1
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1. PROTECTION — Provide a brief description of how (;) water supply wells; (2) surface water bodies; and (3)
septic systems and associated spray irrigation sites, drain fields, or repair areas within 250 feet oldie proposed
injection wells will be protected during constriction of the wells:
Silt Fong will be to congoisok gfadjw off •-; n mill"
J. vARUNCE — Pursuant to 15A NCAC 02C .024 the Director of the Division of Water Quality may gram 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 opete.don in accordance with the standards is not technically feasible or the
proposed construction provides equal or better protection of the groundwater.
Any variance request shoulc accompany submittal of this notification to expedite evaluation of the request.
The variance request fora. can be accessed online at `ort,:.:icdenr.orp, w_hperm_t-
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent ISA NCAC 02C .0211(e) requires signatures as follows:
(a) for a corporation: by a responsible corporate officer:
(b) far a partner ship or sole proprietorship: by a general parmer 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: doc.umentarfor. shall De
submitted with the notification that clearik identifies the person, grams them signature
authority, and is signed and dated by the applicant.
hereby certify, unaer penalty of law, that 1 have personally examined and am familiar with the irrfcrmarivn
submitted in this document and all attachments thereto ana that oasea on my inquiry of those individuals
immediately responsible for obtaining said Information, 1 believe that the information is true. accurate erred
complete. ! am aware that there are significant penalties. including the possibility offines and imprisonment,
for submitting false information. I agree to construct. operate, maintain. repair, and if applicable, abandon
the injection well and all related appurtenances in accordance with the 154 AVAC 02C 0200 Rules
Signuure Proaarty Owner/Applique
rt LLL-
Pnnt or Type Full Name
Signature of Authorized Agent. tf any
Print or Type Fail Name
DWQ,',. iC:Closd•Loop Geo:acrnai \otir,cation (Rev;xc 410/2012)
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