WI0400308_Application_20210226

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North Carolina Department of Environmental Quality — Division of Water Resou 4 2421
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELL DEOIDV414
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In Accordance With the Provisions of 15A NCAC 02C .07"^
GEOTHERMAL HEATING/COOLING WATER RETURN WELL(S)
These well(s) inject groundwater directly into the subsurface as part of a geothermal heating and cooling system
CHECK ONE OF THE FOLLOWING:
New Application Renewal* Modification Permit Rescission Request*
' ForPermit Renewals or Rescission Request, complete Sections A thru E, and M (signature page) only
Print or Type Information and Mail to the Address on the Last Page. Illegible Applications Will Be Returned As Incomplete.
DATE: reb . 17 , 20 a t PERMIT NO. VJ 10 40 30'(leave blank if New Application)
A. CURRENT WELL USE & OWNERSHIP STATUS (Leave Blank if New Well/Permit Application)
B.
1. Current Use of Well
a. I wish to continue to use the well as 14 Geothermal Well Drinking Water Supply Well
❑ Other Water Supply Use- Indicate use (i.e., irrigation, etc.
b. Terminate Use: If the well is no longer being used as a geothermal injection well and you wish to
rescind the permit, check the box below. If abandoned, attach a copy of the Well Abandonment
Record (GW-30).
❑ Yes, I wish to rescind the permit
2. Current Ownership Status
Has there been a change of ownership since permit last issued? ❑ YES t NO
If yes, indicate New Owner's contact information:
Name(s)
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
STATUS OF APPLICANT (choose one)
Non -Government: Individual Residence V
Government: State
C. WELL OWNER(S)/PERMIT
property deed. For all others,
authority to sign: i 0 n a I d
Mailing Address: 3 L 0
City: beep 64p
Day Tele No.:
Municipal
Business/Organization
County
Federal
APPLICANT — For single family residences, list all persons listed on the
list name of business/agency and name of person and title with delegated
I Hen 25 V\landa D l-Jenrtes
Spencer ;((er 'Rd .
State: (\Ie Zip Code: County: 140- Q
CellNo.: $2.Sf - 773- ,g459
gag- aG4- 3l14
Geothermal Water Return Well Permit Application Rev. 4-15-2016
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EMAIL Address: r t he n r► es e9 y u I.
c o m
Fax No.:
D. WELL OPERATOR (if different from well owner) — For single family residences, list all persons listed on
the property deed. For all others, list name business/agency and name of person and title with delegated
authority to sign:
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Email Address.:
E. PHYSICAL LOCATION OF WELL(S) SITE 1
(1) Parcel Identification Number (PIN) of well site: o� 9 5 0 " `T �'' 7 7 9 7 County: A Cc61,G fJ Q
(2) Physical Address (if different than mailing address):
City: County Zip Code:
F WELL DRILLER INFORMATION
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.:
Company Name:
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.:
Cell No.: Fax No.:
G. HVAC CONTRACTOR INFORMATION (if different than driller)
HVAC Contractor's Name:
NC HVAC Contractor License No.:
Company Name: _
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.:
Cell No.: Fax No.:
H. WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(1) The injection operation? YES
(2) Personal consumption? YES
NO
NO
I. WELL CONSTRUCTION REQUIREMENTS — As specified in 15A NCAC 02C .0224(d):
(1) The water supply well shall be constructed in accordance with the water supply well requirements of
15A NCAC 02C.0107.
Geothermal Water Return Well Permit Application Rev. 4-15-2016 Page 2

(3)
(4)
Property boundaries located within 250 feet of the parcel on which the proposed injection well(s) are
to be located.
An arrow orienting the site to one of the cardinal directions (north, south, west, or east)
NOTE: In most cases an aerial photograph 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, other
wells, etc. can then be drawn in by hand Also, a `layer' can be selected showing topographic contours or
elevation data
M. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211i e; requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by all the persons) listed on the pron err deed.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"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. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
7f/ervi-e140
Signature of Property Owner/Applicant
Ronald I Henries
Print or Type Full Name and Title
Signature of Property Owner/Applicant
v &rda Henries
Print or Type Full Name and Title
5p uSe
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Submit two copies of the completed application package to:
Division of Water Resources - UIC
Water Quality Regional Operations Section (WQROS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Geothermal Water Retum Well Permit Application Rev. 4-15-2016
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