WI0100627_Geothermal Aqueous Closed loop Well Construction Application_20210826

� c.37 ''-,,04
NORTH CA ROUNA DEPARTMENT OF ENVIRONlvfENT AND NA ruJtS?ifl)J!dt!J�
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
T!u,se wells are "permilted bi• rule·• and dn not require 1111 indil'idual permit when cn11stn11:ted in accordouce with
1he mies of/ 5A . .VCAC 02C .0200 . This notice must he s11bmi1ted prior w co11s1111ctio11.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
.'\s described in 15A NCAC U2C .0222 lhesc wells circulate potable water only or a mixture of polablc waler and perfonnancc-cnhr111c.;ing adclilives a.� part ofa geothennal healing and cooling system.
OR
GEOTHERMAL DIRECT �XPANSTO� CLOSED-LOOP WELLS
As described in 15A NCAC 02C .0223 tbese wells circulate a re!iigeraut gas as pmt of a geothennal heating aml
rnoling system.
Print Clear(1• o,· (11pe /11for111<11io11. 1/lcgil,{e S11b111ittal.\· Will /Jc Netumetl As /11co111plele.
June 9 DATIE: _______ _ PERMIT NO. -WI0100627---(lo be compkted hy DWQ)
A.TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
Aqueous (as per 151\ NCAC 02C .0222): � / I)
(2)Direct Expansion (as per 15A :--ICAC 02C .0223) __ _
Number of wells: Jifj)__:)3J-'
Number of wells:
B.STATUS OF WELL OWNER (choose one)
( I l Single Family Residence� Submit this form two (2) business days prior to construction.
(2)Busiue5s/Organization __ Submit this form 30 days prior to construction.
(3)Govemmenl: State Municipal___ County__ Federal Submit this form 30 days
µrior to construction.
C.WELL OWNER -For single family residences list the properly owner(s). For all others. lis1 name of 1hc
business. organization, or government agency and person delegated signature authority:
Kevin & Lindsay Giriunas
Mniling Address: 302 Broad Vista Ln.
City: Asheville State: NC Zip Code: 28804 County: Buncombe ..=.c==-"'-'="-------
;.)ay Tele No.: _______________ _
EMAIL Address: [e-mail]
l>. PHYSICAL LOCATION OJ, WELL SITE
C e II No.: _____________ _
Fax No.: _____________ _
( I)Parcel klentification Number (PIN) ol"well site: 91 a Is J 5� S (;, (,()()() (.,
County: Buncombe
(2)Physical Address (if different thnn mailing address):
City:
D\Vl)/Ull'/Closcd-Lonp Geo1he11nal Notilica1ion (Hc,·iscd 4/30i2012)
---------------
State:NC �
Jl� � AUG 2 6 2021
Water Qu.:ility r�eqionAi l ,;,erat,onsAsheviile Regional Office
E. MAPS, PLANS, AND SPECIFICATIONS
Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site -specific map showing the locations of the following:
(l)
•
• Proposed injection well locations
• Buildings
• Property boundaries
• Surface water bodies
• Water supply wells
• Septic systems and associated spray irrigation
sites, drain fields, or repair areas
• . Existing or potential sources of groundwater
contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and human Services' Division of Public Health
determines do not adversely affect human health shall he used. A list of approved additives can be found
online at http://ponal.ncdencorg/.veb/wq'aps/kwpro. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION (,il!Pi till
C�
Well Drilling Contractor's Name: �Ct�►1 / I tJl'1ft OPIJ
NC Well Drilling Contractor Certification No.: 4137A ^^ ss V
Company Name: Clearwater Well Drilling, Inc. Contact Person: C 1i
City: Hot Springs State: NC _ Zip Code: 28743 County: Madison
Day Tele No.: 828-776-6526 Cell No.:
EMAIL Address: [e-mail] Fax No.:
H. HEAT PUMP CONTRACTOR IN FORMATION
Company Name.._QllWays Heating & Air
Contact Person: Josh Clinton
Address: 80 Old Mars Hill Hwy
City; ,ytjgpvPrlie Zip Code: 28787 State NC
County: Bun;Qmbe
Office Tele No.: it281 519-9030 Cell No • - 1
DVQ/UIC/Closed-Loon Geothermal Notification (Revised 4/30/2012)
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i. PROTECTION — Provide a brief description of how (1) water supply wells; (2) surface water bodies; and (3)
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:
Po C )Quo 9
110- byciie
J. VARIANCE — Pursuant to 15A NCAC 02C .0241 the Director of the Division of Water Quality 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 http://poi•tal.ncdet>r.ori;iweb/w.diapslgwpro!permit-
applications
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 signature
authority, and is signed and dated by the applicant.
"I hereby certUY, under penalty of law, that 1 have personally examined and ant familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
irmnediately responsible for obtaining said f Jomation, I believe that the infOr ation is true, accurate and
complete. 1 am aware that there are significant penalties. including the possibility offines and imprisonment,
for submitting false information. 1 agree to construct. operate, maintain, repair, and if applicable, abandon
the injection well and all related
appurtenances in//accordance with the 15A NCAC 02C 0200 Rules.
Signature of Property Owner/Applicant
Lindsay Giriunas + Kevin Giriunas
(-1-\\/CO\ignature
of Authorized Agent, if any
Print or Type Full Nkme
\—\-e'J
Print or Type Full Name
DWQ/UIC/Closed-Loop Geothermal Notification (Revised 4/30/2012)
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