WI0100605_Geothermal well construction application_20201118

WI0100605
REQUIRED MAPS, PLANS, AND SPECIFICATIONS
(1)
(2)
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
• Property boundaries
• Surface water bodies, if any
• Water supply wells, if any
• Septic systems and associated spray irrigation sites.
drain fields, or repair areas. if any
• Existing or potential sources of groundwater
contamination, if any
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 properly lines and
structures can be obtained and downloaded from the applicable county CGS wehsite. T picalh'. the properly 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 he 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 he found online at
http://dea.ne.aov/about/divisions/water-resourceshvater-r<sources-ncrmits/titastewatcr-brutch 1�round-v.atcr-
protection/grround-water-atwroved-injectants. All other substances must be reviewed by the DHHS prior to use.
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Clint Babbitt
NC Well Drilling Contractor Certification No.: NC-3556-A
Company Name: AAA Sweetwater Well Contact Person: Danielle-'
City: Swannanoa State: NC Zip Code:287'75county. Buncombe
Day Tele No.: 828.298.1117
Cell No.: C 2—S/ 71C 3:3 k?
EMAIL Address: SYge e+vo V Lt6 })yi 1 1 Fax No.: ?2 i n� C' / Li,22 •
J
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Air Excellence
Contact Person: Darrell
Address: 244 Holcombe Cove Rd
EMAIL Address:
City: Candler
Zip Code: 28715
State: NC County: Buncombe
Office Tele No.: Cell No.: Fax NQ •

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:
3 Geo well to be drilled at 320' each for single family residential home. Septic field Located in Back yard.
3. 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 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.corn/s3 fs-
vublic/W ater%20Quality/Aquifer%20Protection/GPU/GeothermalVarianceReauestFonrl illable-
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 sigiature
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 individw*ls
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. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance r�it�i the 15A NCAC' 02C' 0200 Rules."
Sigitdture of property Owner/Applicant
JLISoN t.EtG4-lTO1))4T N11-+
Print or Type Full Name
Cory Wax
Dignsily signed by Coy Was
001e: 2020.11.10 09:51:45 -05`00'
Signature of Authorized Agent, if any
Cory Wax
Print or Type Full Name

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