WV0800289_Application_20210914

North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These hells are "permitted by rule" and do not require an individual permit ivhen constructed in accordance with
the rules of 15A NCAC 02C.0200. This notice must be submitted prior to construction.
GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS
As described in I5A 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 CLOSED -LOOP WELLS
As described in I5A NCAC 02C .0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: September 08 , 20 21 PERMIT NO.: (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(I) ❑■ Aqueous (as per 15A NCAC 02C .0222) Number of wells:
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER(S) (choose one)
(I) ❑■ Single Family Residence Submit this form two (2) business days prior to construction.
(2) ❑ Business/Organization Submit this form 30 days prior to construction.
(3) ❑ Government: State 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:
Mike Sauer
Mailing Address: 12730 S. Lake Sawyer Ln.
City: Windmere
State: FL Zip Code: 34786 County: Orange
Day Tele No.: 407-388-5030 CeII No.:
EMAIL Address: [e-mail] Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(I) Parcel identification Number (PIN) of well site: 424512964927
County: Onslow
(2) Physical Address (if different than mailing address): 112 Scotch Bonnet Dr.
City: Jacksonville County Onslow Zip Code: 28460
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 1'agc I

E. REQUIRED MAPS, PLANS, AND SPECIFICATIONS
(1)
(2)
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 includg a north arrow. Attach the site -specific 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
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 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 aanre or address. The location of the wells in relation to properly boundaries, houses, sepllc
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
htto:iideo.ne.rowabo tld yiaiar t-e*Qtir£ voter -re I-lietaiitt ValltaiaerbriLrictIJ121.4LICIt, atcr-
protection/nround-water-annroved-injectants. All other substances must be reviewed by the DHHS prior to use.
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: James Leine Corvette, PG, CWD
NC Well Drilling Contractor Certification No.: 2424-A
Company Name: Applied Resource Management Contact Person: James Cornette
City: Hampstead State: NC Zip Code:28443 County: Pander
Day Tele No.: 910-270-2919 Cell No.:
EMAIL Address: [e-mail] Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Fulford Heating and Cooling
Contact Person: Justin Fulford
Address: 3461 Holden Beach Rd. SW
EMAIL Address: [e-mail]
City: Supply Zip Code: 28462
State: NC County:
Brunswick
Office Tele No.: 910-842-6589 CeII No.: Fax No.:
Closed -Loop Geothermal WcII Notification Rev 3-1-2016
I'.Ec2

I, 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 1 SA NCAC 02C .024 I the Director of the Division of Water Resources may grant
a variance from applicable well construction or operation standards provided that:
(I) Use of the well(s) will not endanger human hcaith 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 httos:tlncdenr.s3.arnazonaws.com/s3fs-
publiclWater%200uality/Aauifer"1'o2OPritectiontGPUiGc rmalVarianceReauestFormFillable-
p0130805.pdf
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .02 11(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 stale, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
(d) for all others: by the well o , :ter;
(e) for any other person au oriz d to act on behalf of the applicant: documentation shall be
submitted with the n ificati.n that clearly identifies the person, grants them signature
authority, and is sign'd and ded by the applicant.
"1 hereby certify, under penalty of law, hat 1 rave personally examined and am familiar with the information
submitted in this document and all aua.• try is thereto and that, hosed on my inquiry of those individuals
intnrediaicly responsible for obtaining sal • i formation, 1 believe that the information is true, accurate and
complete. 1 am aware that thenre signify r ni penalties, including the possibility of fines and imprisonment,
for subntiitingfalse informal •.rt. gree to Cstrum, operate, maintain, repair; and ifapplicable, abandon the
itjeclian well and all related enances D ccor dunce with the 1 SA NCAC 02C 02011 Rules."
mature Property Owner1Applieant
Print or 1 ype Full Name
Signature of Authorized Agent, if any
Print ar Type Full Fame
Clased•Lnap Geothermal Well Notification Rev 3-1.2016 i;ajp: 3

North Carolina Department of Environmental Quality (DEQ) — Division of Water Resources (DWR)
VARIANCE APPLICATION FOR WELL CONSTRUCTION STANDARDS:
PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C .0300
WATER SUPPLY WELLS UNDER 15A NCAC 02C .0107
All water supply wells not considered "Private Drinking Water Wells" and including irrigation, industrial, and commercial wells
WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C .0108
Including monitoring and recovery wells.
Print clearly or type information. Illegible submittals will be returned as incomplete.
DATE: September 2 , 20 21
PERMIT NO.: (to be completed by DWR/DPFI)
A. WELL OWNER(S)— For single family residences, list all persons appearing on property deed. For all others, list name
of the business/govemment agency and person and title with delegated signature authority:
Mike Sauer
Mailing Address: 12730 S. Lake Sawyer Ln.
City: Windermere state: FL Zip Code:34786 County: Orange
Day Tele No.: 407-388-5030 Cell No.:
EMAIL Address: [e-mail] Fax No.:
B. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 424512964927
County: Onslow
(2) Physical Address (if different than mailing address): 112 Scotch Bonnet Dr.
City: Jacksonville
County: Onslow
C. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: James Laine Corvette, PG, CWD
NC Well Drilling Contractor Certification No.: 2424-A
Zip Code: 28460
Company Name: Applied Resource Management Contact Person: Jim Cornette
City: Hampstead state: NC Zip Code: 28443 County: Pender
Day Tele No,: 910-270-2919
EMAIL Address: [e-mail]
Cell No.:
Fax No.: 910-270-2988
GW-22V Variance Request Form Rev. 3-6-2017 Page 1

D. REASON FOR VARIANCE REQUEST - Include type of well(s) to be constructed; rule for which the variance is
being requested; description of how the alternate construction will not endanger human health and welfare and the
environment; and reason why construction and/or operation in accordance with the standards is not technically feasible
and/or provides equal or better protection of the groundwater.
TaTelosed loop geothermal well Site Iim tation will not allow for meeting the minimum horizontal separation In (e)
(5) (A) Building perimeters (15'). (B} Septic Systems (50'), and (a) sewer line (15) His proposed that a variance request is allowed for
Building perimeters at 10 • sewer line el 10', and Septic Systems at 30' All geothermal loops will be tremmie pressure grouted along their
entireties. This will prevent vertical minntilon pathways The aubiect site hen a barrier island (Topsail Beach) undsrlaln by salt water
There are no water supply wells present within 1 000 feet Groundwater flaw will be toward the Atlantic Ocean to the southeast
Construction as proposed will pose little to no threat to human health or the environment
E. ATTACHMENTS - Provide the following information as attachments to this application:
(1)
(2)
(3)
(4)
A map showing general location of the pro
key landmarks, etc.) sufficient for findin
Detailed site map with scale showing
foundations, property lines, water bodies,
Submit a copy ofthe local well permit apple
Any other information relevant to the varian
well liner or atypical constructiomaterials me
F. SIGNATURE(S)
ncluding road names, NC State Route Number, distances, any
location.
of proposed well relevant to septic system(s), building
1 sources of contamination, other wells, etc.
and site evaluation map (if applicable).
quest such as a well construction diagram showing proposed
ods.
tur'c(s) ofWCII/Prupert) Owner(a)
C.,6A L7t14M-f
TN VW toQcrt) (hrncr(a)
IVY
Slgnuturc of Person itespansihlc for Well Construction
(T) picelly the flier) l
r
ye Name a of Person Responsible far W ell Construction
(T) pieolly the nett driller)
Signature of County Environmental Health Specialist
Print or Type Full Name lag Title of Count) Entironmcnlal ttculth Specialist
Per 15A NCAC 02C.0118 the Secretary ofthe Division of Water Resources or the Division of Public Health may require
submittal of information deemed necessary to make a decision on the variance, may impose conditions as part of the
decision, and shall respond in writing to the request within 30 days of receipt of the variance request. A variance
applicant who Ls dissatisfied with the decision of the Director may commence a contested case by filing a petition as
described in G.S. 1301i-23 is ithir 60 dates after receipt of the decision.
GW-21 V Vanance Request Form Rev 3-6-20I7
rag; 2

S 6(
rIDE UTILITY EASEM1
112 Scotch Bonnet Dr.
LEGEND
Proposed Geothermal Loop Locations
ST = Septic Tank
PT = Pump Tank
Note: Adapted from previous survey by Charles Riggs & Associates dated June 24, 2002
Applied Resource
Management, F. C.
Hampstead, NC 28443
TITLE: Sauer Home FIGURE:
Proposed Geothermal Wellfield Layout
Onslow County, North Carolina
JOB: SCALE: DATE: DRAWN BY:
16209 1" = 40' 8/03/21 G J/ CDG

Ground Surface
6" Borehole
Thermex
Grout
Applied Resource )k
Management, i' C.
Hampstead, NC 28443
TITLE: Geothermal Closed Loop
Diagram
JOB:
Sauer
SCALE:
As Shown
DATE:
09/08/2021
DRAWN BY:
AAB
FIGURE:
2

LEGEND
Proposed Geothermal Loop Locations
Adapted from Onslow County GIS 09/08/2021
TITLE:
JOB:
112 Scotch
Bonnet Dr.
250' Radius Map
SCALE:
1"=80'
DATE:
09/08/21
DRAWN BY:
AAB
—4444411144,1
Applied Resource
Management, P C.
Hampstead, NC 28443
I.
FIGURE:
3