WI0100630_Geothermal Aqueous Closed Loop Well Construction Application_20210920

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__ N_orth Carolina Department of Environmental Quality-Division of Water ResourcesNOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLSThese wells are "permitted by rnle" and do not require an individual permit when constrncted in accordance withthe mies 0115A NCAC 02C .0200. This notice must be s11bmitte d prior to construction.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS As described in 15A NCAC 02C .0222 these wells eireulate potable water only or a mixture of potable water andperformance-enhancing additives as part of a geothennal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS As described in 15A NCAC 02C .0223 these wells circulate a refrigerant gas as part of a geothermal heating and cooling system.
Print Clearly or Type Information. Illegible Submiltals Will Be Returned As lna,mplete.
DATE:,_ 2if · ,Q..D , 209-1 PERMIT NO.: WI0100630__(to be completed by DWR)
A.
B.
TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED (select one)
Number of wells : ,3@ �-
Number of wells: _____
(1)[3Aqueous (as per 15A NCAC 02C .0222)
(2)0 Direct Expansion (as per I SA NCAC 02C .0223)
STATUS OF WELL OWNER(S) (choose one)
(l)(2) (3)
[jJ Single Family Residence0 Business/Organization D Government: State __
Submit this form two (2) business days prior to construction.Submit this form 30 days prior to comtrnction. 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:
WHITMIRE LYNNE PORTER, WHITMIRE DERRICK LIONEL
Mailing Address: 161 FOUNTAIN FALLS RD
City: WESTMINSTER State: SC Zip Cod�:� County:,_O_co_n_e_e ______ _
DayTeleNo.: (7 0 9) 491-6464 Cell No.:, __________ _
EMAIL Address: [e-mail] Fax No.: ___________ _
D.PHYSICAL LOCATION OF WELL SITE
(1)
(2)
Parcel Identification Number (PIN) of well site::::_9.:.7::.2.:.17:..:3:.1:.:3:.1:.:3:..:0:.:
0:.:0.:..0.:..0 ________ _
County : Buncombe
. ffi •L--.1. ddr )· -2...:.4...:.R.::lv.:.:e::r....:R�u=n:..:.... ________ _Physical Address (1f di erenl twm ma1 ing a cas . _
Lot 9 -Olivette Riverside Com�m�u:.'.n�lty�---------------:-::-:::-:---
c;ty: Asheville county Buncombe Zip Code: 2S804
Page I Qc,w,d,Lwp Owthumal Well Nc,t1ficabu11 Rev 3-l 2016

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