WI0800550_Application_20210624

North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
There wells are "permitted hp rule" and do not require an individual perotir it -lien constructed in accordance is ith
the rules of 1 SA IV'AC OIC . A�AD. is tto�ce_musl he suhmilled nrinr Io eorrstruatrnn,
GEOTHERMAL,AQUEQ1IS CLOSED -LOOP WELLS
As described in I SA NCAC 02C .0222 these wells circulate potable water only or a mixture of potable water and
performance -enhancing additives as part of a geothermal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLQSE12;LQOP WELLS
As described in I JA NCAC 02C .Q223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print Clearly or rype h&rutatlon. Illegible 5ubrrduals Will Be Returned As Incomplete.
DATE: June 21 , 20 21 PERMIT NO.: to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(1) 0 Aqueous (as per I SA NCAC 02C .0222} Number of wells: 2
(2) ❑ Direct Expansion (as per ISA NCAC 02C .0223} Number of wells:
B. STATUS OF WELL OWNER(S) (choose one)
(1) Single Family Residence Submit this farm hvo (2) business days prior to construction.
M
(2) Business/Organization Submit this form 30 days prior to construction.
(3) ❑ Government: State Municipal County Federal'
*Submit this farm 30 days prior to construction
C. WELL OWNER(S) —For single family residences, list Li persons listed on the property deed. For all others,
list the name of the Business/Agency and person and title with delegated signature authority:
-Cynthia-Casernyr----... - .
Mailing Address: 5800 NE Island-Cove,Way-Apt 2409 + �„
City: Stuart State: Fl Zip Code:'st"s County: Martin
Day Tcle No.: 301-204-5186 Cell No.:
EMAIL Address: [e-mail] Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PM) of well site: 203809070173
County: Brunswick
(2) Physical Address (if different than mailing address): 1450 Turning Leaf Ln. BE
City: Bolivia County Brunswick Zip Code: 28422
Clascd-Loup Geothermal Well Norifieadon Rev 3-1-20I6 Page I

E. REQUIRED MAPS, PLANS, AND SPECIFICATIONS
(1) 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). LabeLall-reatures clearly
and includq;,north arrow. Attach the site -specific map showing the wells in relation to the locations of
the following;
• Buildings • Septic systems and associated spray irrigation sites,
• Property boundaries drain fields, or repair areas, irony
• Surface water bodies, if any • Existing or potential sources of groundwater
• Water supply wells, if any contamination, if any
(2) Plans and specifications of die surface and subsurface construction details of the well system.
NOTE: It: ►►►ost carer, an aerial photograph and/or plat map of the property parcel sl►owlug property lines and
stmetures can be oblained and downloaded from the applicable county G1S websile. Typicallj,, the prop", can
be searched by owner roan►e or address. The location of the wells in relation to properly boundaries, houses, septic
Yanks and folds, and other wells, eta can then be drawn in bjp hand Also, a 'layer' can be selected showing
topographic contours or eleratlon dal►
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
htw:/-dea.nc.eov'about/divisions,water-resources;water-resources-nermii4; WAStevmter-hr%tnclt.amttnri-wstfwr-
G.
H.
orotectionforound-water-approved-injectants. All other substances must be reviewed by the DHHS prior to use,
WELL DRILLER INFORMATION
Well Drilling Contractor's Name: James L. Cornette, PG
NC Well Drilling Contractor Certification No.: 2424-A
Company Name: Applied Resource Management, PC
City: Hampstead
Day Tele No.: 910-270-2919
State: NC
Zip Code-26""
Contact Person: James Cornette
County: Pender
Cell No.:
EMAIL Address: [e-mail] Fax No.:
HEAT PUMP CONTRACTOR INFORMATION
Company Name: Fulford Heating and Cooling
Contact Person- Justin Fulford_ EMAIL ss. [e-mail]
Address: 3461 Holden Beach Rd. SW
City: SuPPIY Zip Code: 28462 State: NC County: Brunswick —
Offce Telc No.: 910-842-6589 Cell No.: FM No.: -^
Closed -Loup GCothcrmol Well Notification Rev 3-1-2016 t aRr ,

PROTECTION — Provide a brief description of Prow any (e.) water supply weils, (b.) surface water bodies, or
(c.) septic systems and associsled spray Inigation sites, drain fields, or repair areas within 250 feet of the
proposed injection wells will be protected during construction of the wells:
No fhreats
J. VARIANCE-- Pursuant to .15 A N CAC 92C .0241 the Director of tine bivision of Water Resources may grant
a variance from applicable well construction or operation standards provided drat:
(1) use of the weli(s) will not endanger htanan health and welfare or doe 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 nod fication to expedite evaluation of the request
The variance request form can be accessed online atbtt !hjjq¢ &Mj0D v►s.eoa,lx3fsr
WI � 5.14
K. SIGNATURES — The following section is to be completed as required below or by that persan's authorized
agent 15A NCAC {12F, .43 I I [c] regahss 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;
(e) 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;
(a) far 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 doled by the applicant.
"I hereby canny, tuider penalq, of linP. that I have personally axamhred and ant Jam Mar iti th the information
aubutllled ip this darunrent and all attachments thereto and that, based an prop inquiry of those Indic lduals
immadhooly nuponsibla for obtaining said I annation, I believe that the hirarrnadmi Is true, accurate and
complete I ant armm that there are signUkant penalties. including the passibility offines ant! Inpprixonment.
for submitti gfalse hfarnmtlart. I agree to constrict, operate, maintain, repair, and japplicable. abandon the
hilec►ion well and all relaterd trienances in accandanee with the JJA W!C 02C 0200 Rules."
ture of Proprtyispucant
e%Nrf/0, i -g
Arint orT7pt Full Nesne
slinatare or otharked Agent. iratry
Print or Type Fall Name
eiose&t.oW Gcothwa Well Notilico m Rev 3.1.2016 rin�r i

L. SUBMITTAL. INSTRUCTIONS — Submit one copy of the completed notification package to the each of the
following:
(2)
The Division of Water Resources' Water Quality Regional Operations Section (WQROS) Rnional
Office serving the area in which the injection well facility will be located:
RALEIGH
HEVILLE ff /-,, !- WASHINGTON
FAYETTEVILLE
Washington Regional OIIIce
Asheville Regional Office
943 Washington Square Mall
2090 U.S. Highway 70
Washington, NC 27889
Swannanoa, NC 28778
Telephone: [phone]
Telephone: [phone]
Fax: [phone]
Far: [phone]
Wilmington Regional Office
Fayetteville Regional Office
127 Cardinal Drive Extension
225 Green Street, Suite 714
Wilmington, NC 28405
Fayetteville, NC 28301-5043
Telephone: [phone]
Telephone: [phone]
Fax: [phone]
Fax: [phone]
Winston-Salem Regional Office
Mooresville Regional OMee
450 W. Hanes Mill Road
610 East Center Avenue, Suite 301
Suite 300
Mooresville. NC 29115
Winston-Salem, NC 27105
Telephone: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Raleigh Regional Offset
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone: [phone]
Fax: [phone]
-AND-
The County Environmental Health Department in which the injection wells will be located.
Clued-l.mV GcoLhermul Well Notiiicouon Rev 3.1-2016 Va; .0 4

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LEGEND
0 Proposed Geothermal Loop Locations
Adapted from Plot Plan prepared by
Withers Ravenel 3/01/2021
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.LEGEND
1$� Proposed Geothermal Loop Locations
Adapted from Brunswick County O|S 22/2021

Applied Kerource
Management, P7G.
Hempataad, NC 28443 �k
6" Borehole
TIr�E Geothermal Closed Loop
Diagram
JOB: SCALE: DATE: DRAWN BY:
Casemyr As Shown 6/22/21 JLC
FIGURE:
3