WI0100629_Geothermal Aqueous Closed Loop Well Construction Application_20210902

WI0100629
Ir MAPS', PLANS, AND spEcI FICA I IONS
(I)
11+l ips mur.i be scales nr ctJicru•ixe a ratiCly iehdieate dist ane4..artcl u icatatioas { f feJ.i. r Located
within 2.5C1 fc.d. of the inj+xlioa wc:]](s}_ Labe] a]] featur!s c:lrarly .and include a north arrow. Attach a
zte-.dui tic. main showin the locations or the foI1ow•i n8,:
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i
ru pu cd injc.c[ion wdL locatiixs
tiiL4]ir
rupially buundaric�
+ 1'
circle swtcros and acsr iatcd spray irrigation .itc ,.
L]rain LIT repik areas
• I-
xistins ,x potential sources f ..To.tirbclwater
conLaminatiun
UrfarA waterh{Klies
4 W.
tiler supply was
(2) P1 and spuizilit:a ioa! of 1}x: sur a c and subxiurJ:reti. cumitraciicm details of the well sistcm_
F_ TYF"F,R ANI) CONCENTRATIONS OF AI}I}ITIYES. — List any additives that will br used and their
eovrcxaiFnrtiurr3_ °ri]y iw]di[ivc that the I_ cpiirlmerrl of Lkalth and. I lumt,n •ic i' Division Oaf Nblic [iculth
dc1crniinrs rkl not Acivcrseiy affect human IK13.11.h shall us d. A Hsi f approwd additives mar be tou"il
online a[ it 4.rther additives require approval prior lap use_
C. WELL DRILLER INR)]L MATION (ifkwrwn.t
4' 11 ] )r [Eing C Ititr tjr's 1 m -: Josh F7em m n5
Nlv \4'cI 117rilling Cci7Cr;o tc}r Corti fitateen No.: 41374
Company N:tnuu': Clearw:a[tr Well DrilLmg, Inc Contact f m: Je(T Moore
City: Flat. Springs _ Suite: N'(. Zip Code:28743- County: Mjdi cin
Thy Telu Nei_: S28-776--6526 Cell r_: _
EMA11L Address: jmcLrir rF u):xl]_larm 1=aui No_:
H. HEAT PUMP CONTRACTOR INFORMATION
Company m :Bullrliitt & A i r
Contao Elfin; Josh (iLtthrie- ]-:M A IL . Address: jos ii!bul]m: nhcaLino,crrm
Acidres'c: Llk Red Roof Lail'
City: AshoviIle 7ip Celle: 2884)4 date: NC County: Dlioc{rmrui
{)fits; Tele N1i_: (828)-658t2468 Cell No.: _MS-712-74P (32 )415S• L C
I7 'i.J[J1 •tClmed-].ik 1 elf3(1.21ki2) Nee 2

1. PROTECTION — ]'rcvidc a brict`dc lipti Art of I1 {1 } woo. supply wells; (2) surfac4 water txxliit; mad (3)
suplic. systems and WiS4>Liuded spray irriattion citm, drain lieldK or rcrpair arca_g wiRhi n 250 feel of111 proposal
injection wc[[s wi [l be protWeil during cLonstmetion of 11ic
D.„L
, ,t s, tJ1 * L
f Awdit
VARIANCE... — Pursuant to 15A N 'AC: CPC 51.211 the .4 ixee'tur Qf the of WatT Qu: dity rnuy grant a
variamti:e frtnl applicable we.]] construction CTiPpt+raticm standards pxrovid, d that:
(1) u_ss tr[ the weil(s) wi]] ruai endanger hurnaut health ;ind well: .err the groundwater; and
(2} the eonsnotion or operation in accordance +,Minh the stankiards i_s nOt t 015011y feasible or the
proposed construe -lion providti cqua] or Lec.tter prutection ni the groundwai r_
Any varw.nreiiiiia4 should accompany subraillal crf Lhi± notification kr ex.pedite e~rahatdioc oldie rIquniL.
I'hc variznee,1qucsl JutrrJ an amzsed online of h452_: ..rtal,5xdh nr+wZ vec;Ykke,-..ps 23...pro.Nrrn
;a:'heli
S]GNAT!J E — Thu fulLuwing sc:4_ km is Its be com[r1+dcd as r quired bc± w or by that pi. rstm's authorized
agenL ] SA NCAC o2C: _1321 3 (c) requir€ si itturac as teal low:
(a) frpui l uu: by a responsible cfuportat . officer:
(h) fax a pa incnhip or sole prcrtxridxrrnhip: by a. general partner or the proprietor, respectively;
c} for a rr,unieicNility or a state., ti,xleral. or other public agency: by cil]cra lvineip€i] caceculivc
ralTicar or ranking publicly electexl official;
(d) fur all oLhurs: by the well
(a) fax any other person authnri{.cd to act on hchalf'of the applicant: dceumentatinn shall be
submitted with the. rtcrtifttattinn that clearly identifies the person, grants Lht:m !�gnature
indhoriily_ and is si ri d artd 4Jaied by th.e ap9�h aril_
herehy cant., under pe dr).? of i�w, that l have personally examined acid ant 0millar with .0k, Mfg rrr1aarton
sulmiM&i err this dexcurneni and all adfaChmerav !hereto and that, wed on my ingni v of those ircfiwidu:Lc
.ifddrdrtAit i'I err c)#r/ rkting .said illfelPitlarirkn,f helieVe Al/ to tripe datum Lc /Akre, accomeirie ar±d
complete. 1 aFn aware Mat there CDT Ai,��rill:card pcwaltias, including the pr xibthiy of f nex and rrnprisonmc ,
Air srrarnittrng f rrrfonPna/k►ra. f Krirrtrtr re.+ v+ryirma, rnurrrtcarrr. r opair, and r} upplkctht . ahcondcw
the inftc/hrrk 14rli arid all related a rrx7emartecc in accordance with the 114 1 `Af } 02C #21]) h`arles. "
tiigrraLu y t }rreerfApplitartt
Mark Waltrip
Print or Type Tall N,9olc
iigtrslgre or AmihorintflAgeel, ifs
MEd iFr'I';pr Full Nitme
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L. SUBMITTAL INSTRUCTIONS— Nuhrnitone copy al:the Lon5pl.t xl rii tiIiun piu:[r.2.igLhe ea th {�f the
following:
(2}
T Division of Water Quality Regni r:rl 0 MET ser4:mg the arczt in which the injection well facility
will 1will lycIo
W IN TON -SALEM
ASH EVJ L LE
Ashen it k Regional 0Elice
7.0% LI,S_ ! Lighway 70i
Swarnnttnon, NC 2877E
"feel hiinc; (82,8) 2 .4500
Fax: [phone]
ORE1.L
Kayettnv.IIe fir i141url CFiTicsc
225 (irxx, SLrc:42L Suitt 714
tan vial.NC: 2.33O]-5043
Telephone: (91{}) 43 31]U
Fax; (9](I) 4 -0707
Mooresville Regional Oficoe
6LCk I:tCenter Avenuc.Suite 3CkL
Muxares-wille, Nor 28 1.15
elephon4: CM) (i. 3-Ifi9'P
Fax: [phone]
Rs Frigh R t.mi.rl Orfficc.
1 i A�I;kil Soroie. Ccettcp
Raleigh, NC 276 9-1628
T4[tpIKano: (9'19) 79I42(1+9
Fox; (1 9) 5714718
R EIGH
-
WAS H INTO N
FAY ETTEVI LLE
,oec'
Wsshioglon Regiomal Office
9'43 TYV&hington Squaw !quiff
Wnshingion, NC ''F 3 9
114.Thocic: (252) 946-6 8J
Fax: [phone] ] 6
Wilmingtrn Regions.' Orliiice
127 Cardinal I)rivc E.xLinision
Wilnlinglon.. NC 22005
Telephone: [phone]
Fax: 0 1 [I) 350-2OL4
Winston S lem Regional Unice
585 Waughown Street
WIn Lon -Salem, IBC 27] 7-2241
Phone: (336} 77 ]-51][K]
Fax: (336) 771 b3 L
C'ouirtyJ Ioalkh 1)cpark.rnent in %which the i njeeticn u l l faeikiv will Ix located., A list of —county health
J partrounts UM he fcaurw3 suiliru at ht4r:rrti4titiu_n�ttlhl.� ��un3; .horn.
L71f� llJl421:1 +:Li-14.515r CitmlieLwal1+tAIja 1iI'•2D17.
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