WI0800544_Application_20201125

North Carolina Department of Environmental Quality — Division of Witter Resources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These walls are "permitted hJ, rrrle"and do not require re an indrridnal per mil it hen constructed in accordance Mite
the Mlles of I Sd C!fC#fN#. This nnr" a nru.r! he suhm ► r'nr in construction.
GEOTHERMAL AOUEO_i,JS CLOSED -LOOP WELLS
As described in I SA NCAC 02C LU222 these wells circulate potable water only or a mixture of potable water and
perrormance-enhancing additives as part of a geothermal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS
As described in II SA NCAC 02C .OZ23 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print Clearly or TSTe hiformadon. 111egihle Snhntirtals Will Be Returned As lncontplete.
DATE: October 29 .2020 PERMIT NO.: (to be completed by DWR)
A.
B.
C.
TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(1) Q Aqueous (as per I SA NCAC 02C .0222) Number or wells: 5
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0233) Number ofwells:
STATUS OF WELL OWNER(S) (choose one)
(1) ❑■ Single family Residence Submit this form two (2) business days prior to construction.
(2) ❑ Business/Organization Submit this form 30 days prior to construction.
(3) ❑ Government: State Municipal County federal' _
"Submit this form 30 days prior to construction
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:
G David Uslar
Moiling Address:
City: Kempton
1220 Old Philly Pike,
State: PA Zip Code: 1"n County: Berk5
Day Tele No.: 610-756-6645
EMAIL Address: [e-mail]
Cell No.:
Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 301311565037
County: Brunswick
(2) Physical Address (if different than mailing address): 184 Station Way
City. Bald Head Island County Brunswick Zip Code: 28461
Ctoscd-Loop Grotharmat Well N01ilie.ptfon Rev ,3-1-20I6 Pa;.c 1
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E. REQUIRED MAPS, FLANS, AND SPECIFICATIONS
(1) A site traps must be submitted. It must be scaled or otlterwise accurately indicate distances (in feet)
and orientations of features located within 250 feet of the injection weil(s). label all features clearly
and include a north arrow. Attach the site -specific map showing the wells in relation to the Iocations 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) flans and specifications of the surface and subsurface construction details of the well system.
NOTE: let most cases, an aerial photograph anUar plat stars of the property parcel shoidug propert, litter and
structures can he obtained and dotvarloaded frost /lee applicable cousay CIS website. Tjplcally, the property can
besearched bj- a►vtter same ar aeldrear. The location tf rite wells in relation to property boundaries, houses, septic
ranks and fields, and other wells, etc. can then be drawrt der by bane. Also, a 'layer' can be selected sharving
topographic contours or eleratlan 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
llttp:! dea,nc,avv?iktro�+tltliviSigrlS'w;ttCr-rc5ouicci�wtiitt-�5[>brces-s�rrtr+ts w�stewntcr-h�rnncisernuatt-water-
c
M.
ItrQtc tiQn(rkround-water-a spmved-Inlectmnt.4. All other substances must be reviewed by the DHHS prior to use.
None, Water Only.
WELL DRILLER INFORMATION
Well Drilling Contractor's Name: dames L. Comette, PG
NC Well Drilling Contractor Certification No.: 2424-A
Company Name: Applied Resource Management, PC Contact Berson:
City: Hampstead State: NC Zip Code: ""' County: gender
Day Tele No.: 910-270-2919 Cell No..
EMAIL Address: Fax No:
HEAT PUMP CONTRACTOR INFORMATION
Company Name: TBD
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
Zip Code: State: County:
Cell No.: _ Fax No.
Closed -Loop Gcothcrmnl Well NntLGratton Rev 3-1-2016 rage {

I. PROTECTION — Provide a brief description ofhow 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:
No threats
J. VARIANCE — Pursuant to 15 I.NCAC.00,0?t the Director of the Division of Water Resources may grant
a variance from applicable well construction or operation standards provided that:
( I) use orthe 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 s:f rr+ a rrl
rattblic 1�,'ater!.i t Ag i{er' # P gt €1.i lttielbCrnssiVariancel2eg 5tFormi•il5able-
20130 0
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A KA !L; 0—)tU } 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 behalr of the applicant: documentation shall be
submitted with the notification that clearly identifies Elie person, grants them signature
authority, and is signed and dated by the applicant.
"I hereby cert05; under penalty of lair, that I have persanallj, e-ranrined and am familiar u-ith the information
,submitted in this docieniew and all attachments thereto and that, based on my hiquirj, of those indiidduuls
inintediately responsible for obtaining said information. I be ieve that the information is true, accurate and
complete. I um airare that there are sign fcaru penalties, including the possibility offrnes and imprisonment.
forsuburittingfalse information. I agree to construct, operate, maintahr, repair; and ifapplicable, abandon the
injection well and all related appurtenances In accordance with the 1,Md CAC 02C 02017 Rules. "
4, t 11,IJ 66&
Sil;nmure of Pruperty Oivnerh%pplicunt
Mr. G David Uslar
11rini ur Type Full Nume
signature orAuthorixed Teent. if any
Print or Type hull Vamc
Clowd•Luup Gcndremml W61 ti'uliGeatian Rcv 3-1-201 G ,!;
QW

L.
SUBMITTAL INSTRUCTIONS -- Submit one copy of the completed notification package to the each ofthe
following:
(1) The Division of Water Resources' Water Quality Regional Operations Section (WQROS) ReLionnl
Office serving the area in which the injection well facility will be located:
VWNSTON-SALEM
RALEIGH
ASHEVILLE r'' _-- ---�-i /`--" WASHINGTON
FAYETTEVILLE
Washington Regional Office
Asheville Regional Office
943 Washington Square Mall
2090 U.S. Highway 70
Washington, NC 27889
Swannanaa, NC 28778
Telephone: [phone]
Telephone: [phone]
Fax; (252) 975 31716
Fax: {828) 299-7043
Wilmington Regional Office
Fayetteville Regional Office
127 Cardinal Drive Extension
225 Green Street, Suite 714
Wilmington, NC 29405
Fayetteville, NC 28301-5043
Telephone: [phone]
Telephone: (910) 433»3300
Fat: [phone]
Fax: [phone]
Winston-Salem Regional Office
Mooresville Regional Office
450 W, Hanes Mill Road
610 East Center Avenue, Suite 301
Suite 300
Mooresville, NC 28115
Winston-Salem, NC 27105
Telephone: [phone]
Phone: [phone]
F= [phone]
Fax: [phone]
Raleigh Regional Office
1628 Mail Service; Center
Raleigh. NC 27699-1628
Telephone. [phone]
Fax: [phone]
-AND-
(2) The County Environmental Health Department in which the injection wells will be located.
Ciuccd-l-mp Geullicrmal Well Nulrticanan Rc%- 3-1-2016 11.1rc a
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TITLE: Proposed Geothermal
Loop Locations
JOB: SCALE: DATE: DRAWN BY_
N 184 Station 1" = 30' 10/29/20 JMR/EMH
LEGEND Way
0 Proposed Geothermal Loop Locations FIGURE:
Note- Adapted from Topographic Survey drawn by Applied nearneResouM
Kenneth W Knott 5/8/2020. Managere"NG P. C.
F1�mpsrad. NC ze"a

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LEGEND
0 Proposed Geothermal Loop Locations
Note: Adapted from Brunswick County GIS.
TITLE:
250' Radius
JOB: SCALE: DATE: DRAWN BY:
N 184 Station 1" = 100' 10/29/20 JMR/EMH
Way _
FIGURE:
Applied Resource
Management, P. C.

Applied Roeourve
Management, P. C.
Hampete,14 NC. ZMWe5
6" Borehole
TITLE: Geothermal Closed Loop
Diagram
JOB: SCALE: DATE: DRAWN BY:
184 Station As Shown 1 10/29/20 JMRIEMH
FIGURE,
3