WI0800555_Application_20211115

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
VARIANCE APPLICATION FOR INJECTION WELL CONSTRUCTION STANDARDS:
GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS (15A NCAC 02C .0222) OR
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS (15A NCAC 02C .0223)
This form MUST accompany the Closed -Loop Geothermal Notification Form available online at
http://Portal.ncdenr. org/web/wq/aps/gwpro/permit-applications#geothermApp s
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: November 11 2021 PERMIT NO. (to be completed by DWR)
A. WELL OWNER — For single family residences list the property owner(s). For all others, list name of the
business, organization, or government agency and person delegated signature authority:
Mr. John Monteith
Mailing Address: 208 Princess Street
City: Wilmington State: NC Zip Code: 28401 County: New Hanover
Day Tele No.: 910-791-8101 Cell No.: 910-899-7473
EMAIL Address: [e-mail] Fax No.:
B.
C.
PHYSICAL LOCATION OF WELL SITE
(1)
(2)
Parcel Identification Number (PIN) of well sitR06308-008-002-000
e:
County: New Hanover
Physical Address (if different than mailing address):
4 West Atlanta Street
City: Wrightsville Beach
WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: James L Cornette, PG
NC Well Drilling Contractor Certification No.:
State: NC Zip Code: 28480
Company Name: Applied Resource Management, PC Contact Person: James L Cornette
City: Hampstead State: NC Zip Code: 21111 County: Pender
Day Tele No.: 910-270-2919
EMAIL Address: [e-mail]
Cell No.:
Fax No.: 910-270-2988
UIC/Closed-Loop Geothermal Variance Request (Revised 8/5/2013) 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.
15A NCAC 02C.0222(e)(5)(A) - Five closed loop geothermal wells will be drilled on the
south side of the property. Three of the wells will be within 15structure due to
limited property space. They will be grouted along their entirety
and will not present a threat to human health or the environment.
E. SIGNATURES
Signature of Well Driller
Jaynes L Cornette, PG, CWD
or Type Full Name
Sdxn md,14 f j�i�. Well Owner
or Type Full Name
Per 15A NCAC 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 M.G. S. 150E-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:
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) Page 3

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 I5A NCAC 02C .0200. This notice 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 and
performance -enhancing additives as part of a geothermal heating and cooling system.
'JIN
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 Submittals Will Be Returned As Incomplete.
DATE: November 11 2021 PERMIT NO.:
A.
B.
C.
(to be completed by DWR)
TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(1) ❑■ Aqueous (as per 15A NCAC 02C .0222) Number of wells: 5
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells: _
STATUS OF WELL OWNER(S) (choose one)
(1) Al 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 x Federal*
*Submit this form 30 days prior to construction
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:
John Monteith
Mailing Address: 208 Princess Street
City: Wilmington State: NC Zip Code: 28401 County: New Hanover
Day Tele No.: 910-791-8101 Cell No.: 910-899-7473
EMAIL Address: [e-mail] Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: R06308-008-002-000
(2)
County: New Hanover
Physical Address (if different than mailing address): 4 West Atlanta Street
City: Wrightsville Beach
County New Hanover
Zip Code: 28480
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 1

E. REQUIRED MAPS, PLANS, AND SPECIFICATIONS
(1) 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 -specific map showing the wells in relation to the locations of
the following:
• Buildings • Septic systems and associated spray irrigation sites,
• Property boundaries drain fields, or repair areas, if any
• Surface water bodies, if any • Existing or potential sources of groundwater
• Water supply wells, if any contamination, if any
(2) 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 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
httD: Hdea.nc. aov/about/divisions/water-resources/water-resources-permits/wastewater-branch/around-water-
G.
H.
rotection/ground-water-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
None, water only.
WELL DRILLER INFORMATION
Well Drilling Contractor's Name: James L Cornette, PG
NC Well Drilling Contractor Certification No.:
Company Name: Applied Resource Management, PC
City: Hampstead
Contact Person: James Cornette
State: NC Zip Code: 2aaaa County: Pender
Day Tele No.: 910-270-2919
EMAIL Address: [e-mail]
HEAT PUMP CONTRACTOR INFORMATION
Company Name: TBD
Cell No.:
Fax No.: 910-270-2988
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
Zip Code:
Cell No.:
State: County:
Fax No.: 910-270-2988
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 2

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:
No threats
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 https:Hncdenr.s3.amazonaws.com/s3fs-
public/Water%20Quality/Aquifer%2OProtection/GPU/GeothermalVarianceRequestFormFillable-
20130805.pdf
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.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all att chments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining aid information, I believe that the information is true, accurate and
complete. I am aware that there are si icant penalties, including the possibility of'fines and imprisonment,
for submitting false information. I a o construct, operate, maintain. repair, and if applicable, abandon the
injection well and all related appurt q es in accordance with the 1 5A NCAC 02C 0200 Rules. "
Slfn re of Property Owner/Applicant
hn Monteith
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 3

L. SUBMITTAL INSTRUCTIONS — Submit one copy of the completed notification package to the each of the
following:
(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:
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]
-AND-
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]
(2) The County Environmental Health Department in which the injection wells will be located.
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 4

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Proposed Geothermal Loop Locations
Adapted from Plot Plan prepared by
Kersting Architecture 8/06/2021
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Hampstead, NC 28443
4" Borehole
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TITLE: Geothermal Closed Loop
Diagram
JOB: SCALE: DATE: DRAWN
4 West As Shown 11/11/21 JLC
Atlanta St.
FIGURE:
3