WI0100619_Aqueous Closed Loop Geothermal Well Construction Apllication_20210512

WI0100619
E. REQUIRED MAPS, PLANS, AND SPECIFICATIONS
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:
(1)
(2)
• 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 properly parcel showing property lines and
structures can he obtained and downloaded front the applicable county GIS website. Typically, 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 draivn in by hand. Also, a 'layer' can be 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 be found online at
http •ldeg.nc.govtabout/divi si arts/water-resources/water-resourees-nermitslwastewater-branchlm-ound-wa ter-
proteetionlvround-water-ansrrpved-iniectants. All other substances must be reviewed by the DHHS prior to use.
Envirnol
G. WELL DRILLER INFORMATION
Welt Drilling Contractor's Name: Clint Babbitt
NC Well Drilling Contractor Certification No.: NC-3558-A
Company Name: AAA Sweetwater Well
City: Swannanoa
Day Tele No 828.298.1117
Contact Person: e,flrt Pa
Zip Codc:28d"County:BUrtcombe
CelNo.:
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EMAIL Address: r�a
Fax No.: /Ja j f t-/3 Z
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H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Forest City Heating and Air
Contact Person; Jim Toney
Address: 457 South Broadway Street
City: Forest City Zip Cede: 28043 State: NC County: Rutherford
State: NC
Office Tele No.: 828-245-1379 Cell No.:
Ciused-Loup Gwthurmal Well Notification Rev. 3.1-2016
EMAIL Address:
Fax No.:

1.
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:
J. VARIANCE — Pursuant to I5A 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 httns://ncdenr.s3.amazonaws.com/s3fs-
publi c/Water%200ual ity/Agui fer%20Protection/GPU/Geothermal VarianceReo uestForm Fillable-
20130805.pdf
I{ SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .0211(0 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 signature
authority, and is signed and dated by the applicant.
"I hereby cert, 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 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 I5A NCAC 02C 0200 Rules. "
Signature of Property Owner/Applicant
William Eastman, Jr.
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name

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