WI0100593_Application_20200825

WI010059
(2)
S, PLANS, AND SPECIFICATIONS
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:
• Proposed injection well locations
• Buildings
• Property boundaries
• Surface water bodies
• Water supply wells
• Septic systems and associated spray irrigation
sites. drain fields, or repair areas
• Existing or potential sources of groundwater
contamination
Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND
concentrations.
determines do
online at
20% Environal
CONCENTRATIONS OF ADDITIVES - 1"ist any additives that will be used and their
Only additives that the Department of Health and Human Services' Division of Public Health
not adversely affect human health shall be used. A list of approved additives can be found
. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Larry Wells' 1-6"-in`56fl C31t IDShc1
NC Well Drilling Contractor Certification No.:-26^•r. c}Dcj 3 — j9-
Company Name: AWD Services Inc.
Contact Person T m uOr) s; toso 1
City: Leicester State: NC Zip Code: 28748 County: Buncombe
Day Tele No.: 828-683-9223 Cell No.: 828-215-9334
EMAIL Addresses tCw?wl �51i 1c-,1 . cm Fax No.: 828 683 44283
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:" `-; C.1 Cs Sir �L2
Contact Person: r ae" 5-{-j Gl_ l es EMAIL Address:
Address: 3 a Pi r
City: ajry
Zip Code: c state_ VC' County:
Office Tele No.: (v28' (n52 Cell No: - 9zzl
13& Corvbe
DWQ/l IC/Closed-Loop Geothermal Notification (Revised 4/30/2012) Page 2

11.
PROTECTION - Provide a brief description of how (I s 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 protected during construction of the wells:
Silt Fence will be used to control solids and run off from drilling.
VARIANCE - Pursuant to i 5A NCAC 02C .0241 the Director of the Division of Water Quality may grant a
variance from applicable well construction or operation standards provided that:
r 1) use of the well(s) will not endanger human health and welfare or the groundwater; and
(21 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 _ ,_,_. • .
K. SIGNATURES - The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .021 l (e) requires signatures as follows:
tai for a corporation: by a responsible corporate officer:
( b) for a partnership or sole proprietorship: by a general panner or the proprietor. respectively :
(c) for a municipality or a state, federal, or other public agency: by either a principal executi\e
officer or ranking publicly elected official:
(d) for ail others: by the well owner:
e) for any other person authorized to act on behalf of the applicant: documentation shah be
submitted with the notification that clearly. identifies the person. grants them signature
authority. and is signed and dated by the applicant.
"I hereby certity. under penalty of. law. that 1 have ac'rsonalh. examined and am familiar with the :.nformation
submitted in this document and all attachments thereto and that, based on my inquire- of those ind:"v:dua:
immediatel; responsible for obtaining said information, 1 believe that the information is true. accurate and
,omplete. 1 am aware that there are significant penalties, including the possibility• of fines and imprisonment.
for submitting false information I agree to construct, operate. maintain. repair. and tf applicable. abandon
the infection Kell and all related appurtenances in accordance with the 15.a . 'CAC 02C 0200 Rules ..
Si natur o Property Owner'Appican
Print • ype Full Name
Signature of Authorized Agent. if any
Print or Type Full ante
t.)N r.) (t("Closed-I oop Geo:henna: \otidcarion ,Revised 4 30 2C r
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