WI0100628_Geothermal Aqueous Closed Loop Well Construction Application_20210901

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North Carolina Department of Environmental Quality-Division of Water Resources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by rule" and do not require an individual permit when constructed in accordance with
the rules of 15A NCAC 02C .0200. This noti'ce must be submitted prior to construction.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS As described in 15A NCAC 02C .0222 these wells circulate potable water only or a mixture of potable water andperformance-enha11cing additives as part of a geothermal heating and cooling system.OR
GEOTHERMAL DIRECT EXPANSION CLOS ED-LOOP WELLS As described in 15A NCAC 02C .0223 these wells circulate a refrigerant gas as part of a geothermal heating andcooling system.Print Clearly or Type lnformatio11. Illegible Submittals Will Be Returned As /11.complete. DATE: 8/27/21 ,20 __ _ PERMIT NO.: _WI0100628_(to be completed by DWR)A.TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED (select one)(1)[i] Aqueous (as per 15A NCAC 02C .0222) Number of wells: _i ___ _(2)0 Direct Expansion (as per 15A NCAC 02C .0223) Number of wells: ____ _B.STATUS OF WELL OWNER(S) (choose one)(1)(2)(3)[i] Single Family Residence0 Business/Organization0 Government: State Submit this form two (2) business days prior to construction.
Submit this form 30 days prior to construction. Municipal--·---County __ . Federal* ___ _ *Submit this form 30 days prior to construction
C.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:Richard Alan Feld and Randy Beth Ziff er Mailing Address: _P�-�O_B_o_x_9_3_7�o�---------�----------�---City: Asheville State: NC Zip Code: 28!15 County:_B_-_u_n_c_o�m_b_e _____ _Day Tele No.: ______________ _850~ 766·3936 Cell No.: ____________ _EMAIL Address: [e-mail] LOCATION OF WELL SITE Fax No.: ____________ _(1)Parcel Identification Number (PIN) of well site:-9_7_-2_-_17_-2_-6_-_18_7_--_0�0~0_0_0 _________ _County: Buncombe(2)23 Bee Ba.Im Way Physical Address (if different than mailing address): ________________ _City: AshevilleClosed-Loop Geothem1al Well Notification Rev. 3-1-2016 County Buncombe Zip Code: 28804
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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-specitic map showing the wells in relation to the locations of
the following:
• 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
(2) Plans and specifications of the surface and subsu
ace construction details of the well system.
NOTE: In most cases, an aerial photograph and/or plat map 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 and fields, and other wells, etc. can then be drawn 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://deq.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection/ground-water-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
None
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Gary Justice
NC Well Drilling Contractor Certification No.:
NCWC 150-A
Company Name: Justice Well Drilling Contact Person: Gary Justice
Marion 2B7 Rutherford
City: Zip Code: 52 County:
Day Tele No.: 828 7 4 454$ Cell No.: 828 442-8720
State:
nc
EMAIL Address: justiceweiidriilingyahoo.com
Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Rosco Jay Green
Company Name:
Contact Person:
Rosco Green
Address: PCB Box 1234
City: Saluda Zip Code: 28773 State: rtc County:
828-702-8629
Office Tele No.: Cell No.: Fax No.:
Closed -Loop Geothermal Well Notification Rev. 3-1-2016
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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:
No surface water within 250'.E✓Z lay style conventional septic system in place withnearest tail line
Nearest tail line approximately 1OO south of well.
VARIANCE — Pursuant to 15A 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 https://ncdenr.s3.amazonaws.com/s3fs-
public/Water%20Ouality/Aquifer%20Protection/GPU/GeothermalVarianceR-• uestFormFillable-
20130805.pdf
K. SIGNATURES — The following section is to be completed as required
agent. 15A NCAC 02C .0211(e) requires signatures as follows:
(a)
(b)
(c)
(d)
(e)
or by that person's authorized
for a corporation: by a responsible corporate officer;
for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
for all others: by the well owner;
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 certify, under penalty of law, that 1 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, 1 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 purtenances in accordan ith the 15_ 02C 0200 Rules."
Signature of Property Owner/Appli
Rico fig6 A v r i/fz•94/py lt/ Z iff "k` '
Print or Type Ful . atne
Signature of Authorized Agent, if any
Print or Type Futl Name
Closed -Loop Geothermal Well Notincation Rev. 3-1-2016 Page 3
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SUBMITTAL INSTRUCTIONS — Submit one copy
following:
he completed notification package to the each of the
(1) The Division of Water Resources' Water Quality Regional Operations Section (WQROS) Regional
Office serving the area in which the injection well facility will be located:
WINSTON-SALEM
• ORESVLL-
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Telephone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5043
Telephone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Telephone: [phone]
Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone: [phone]
Fax:[phone]
(2) The County Environmental Health Depart
Closed -Loop Geothermal Well Notification Rev. 3-1-2016
RALEIGH
FAYETTEVILLE
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Telephone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Telephone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
-AND-
which the injection wells will be located.
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Bee Ba
l
m

W
a
y
N
Property Line
Setback
220 SF
Porch
576 SF
Garage
2,233 SF Conditioned
1,169 Main Level
1,064 Lower Level
17'-83
8"
35'-3 1
16"
27'-11 5
16"
2088
2090
2086
2084
2082
2080
2078
2076
2092
2094
2096
2098
2100
Proposed Septic and Repair
Area .07 Acres
85 SF Deck
90 SF Porch
1,540 SF
Driveway
1.13 Acre lot
.21 Acres
disturbed area
.08 Acres
impervious
surfaces
64'-91
2"
85'-5 7
16"
60°
32'-03
8"
City Water Connection
Proposed
Geothermal
Well location
16' from Garage,
20' from House
Ziffer/ Feld Page 5 Site Plan 1/8" = 1'
16'below grade2 1 14" HDPE pipes to houseTwisty Brand HDPE loop pipePressure tested to 100 psi3 34" HDPE loopsfactory manifolded in wellApproximately 230'GraniteApproximately70' Soil200'Welldepth1.2 BTU thermally enhancedgrout pumped from bottom of well to top.Steel casing removed after grout installGeothermal WellDiagram23 Bee Balm WayAsheville, NC 288042'