WI0700520_Application_20211103

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E. MAPS, PLANS, AND SPECIFICATIONS
(1) 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:
• Proposed injection well locations • Septic systems and associated spray irrigation
• Buildings sites, drain fields, or repair areas
• Property boundaries
• Surface water bodies • Existing or potential sources of groundwater
• Water supply wells 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 be used. A list of approved additives can be found
online at http://portal.ncdenr.org/web/wci/aps/gwpro. All other additives require approval prior to use.
Geosafe antifreeze n,15%
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Arthur J. Tatem
NC Well Drilling Contractor Certification No.: 4200A
Company Name: Virginia Energy Services Contact Person: Art Tatem
City: Knotts Island
Day Tele No.: 252-455-7710
State: NC Zip Code:27950_ County: Currituck
Cell No.: 252-202-9490
EMAIL Address: Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: OBHC, Inc. dba One Hour Heating and Air Conditioning
Contact Person: Brian McDonald EMAIL Address: [e-mail]
Address: 701 W Fresh Pond Drive
City: Kill Devil Hills Zip Code: 27948 State: NC
Office Tele No.: 252-441-1740 Cell No.: Fax No.:
County: Dare
UIC/Closed-Loop Geothermal Notification (Revised 8/5/2013) Page 2

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:
Protection will be provided during, the drilling process by containing fluids in a pit or pan and providing silt
fence if run off is a danger. Bore holes will be fully grouted to protect from aquifer cross contamination
J. 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 http://portal.ncdenr.org/web/wq/aps/gwpro/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.
`7 hereby certify, under penalty of law, that I 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, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility offines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all related appurt n c s in accordance with the 15A NCAC 02C 0200 Rules."
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Signature of Authorized Agent, if any
Print or Type Full Name
UIC/Closed-Loop Geothermal Notification (Revised 8/5/2013) Page 3

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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.
See attached page for variance request information.
E. SIGNATURES
Signature e11 Driller
Arthur J. Tatem
Print or Type Full Name
Signature of Well r
l (leery IO Gic41 ca rvt I rM
Print Or Ty Full Nalut
Per 15A NG_AC 02C .0241 the Director of the Division of Water Resources 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 is dissatisfied with the decision of the Director may commence a contested case by
filing a petition as described in G.S. 150B-23 within 60 days after receipt of the decision.
UIC/Closed-Loop Geothermal Variance Request (Revised 8/5/2013) Page 2

F. SUBMITTAL INSTRUCTIONS — Submit one copy of the completed variance request attached to the
Notification of Intent to Construct or Operate Injection Wells to the Division of Water Resources Regional
Office serving the area in which the injection well facility will be located:
WINSTO 1-SALEM_
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]
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
585 Waughtown Street
Winston-Salem, NC 27107-2241
Phone: [phone]
Fax: [phone]
UIC/Closed-Loop Geothermal Variance Request (Revised 8/5/2013)
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