WI0100638_Aqueous Closed Loop Geothermal Well Construction Application_20211203

WI0100638
(2)
Physical Address (if different than maiiing address): e,r/y -s4Iw
City: .2-X,r,4.. %77,4i
E. MAPS, PLANS, AND SPECIFICATIONS
State: NC 'Lip Code:
(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 fellow
• Proposed injection well locations
• Buildings
• Property boundaries
• Surface water bodies
• Water supply wells
• Septic *stems and associated spray irrigation
sit• s. drain fields, or repair areas
• lax sting or potential sources of groundwater
co; lamination
(2) Plans and specifications of the surface and subsurface •onstruction details of the well sl stem.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — 1.ist any additives that will he 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 he found
online at htttp:////portal.ncdenr.org/web/wq/apslgwpro. All other additives require approval prior to use.
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G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Josh Plemmons
NC Well Drilling Contractor Certification No.: 4137A
Company Name: Clearwater WWII Drilling, Inc. Contact Person: Jeff Moore
City: Hot Springs State: NC _ Zip Code: 28743 County: Madison
Da), Tele No.: 828-776-6526 Cell No.:
I:MAIL Address: jmclrwater70(ciaol.com
H. HEAT PUMP CONTRACTOR INFORMATION
Fax No,:
I)WQ.t'I1;Closed-tuop(icUt)icrnlal Notification (Kc‘iscd4 ,1)'201?i I'age

Compan, Name:Bulhnan licatirn;& Ai
Contact Person: Josh Guthrie EMAll. Address: joshg' j bullmanheating.com
Address: 10 Red Roof Lane
City: Asheville Zip Code: 2880.4_State: NC Countv: Runcomne
Office Tele No.: (828)-658-2468_ Cell No.: _(828)-712-7488 _ Fax No.: (828)-658-1001
1)\VQ 1 •I(''(i. s d-I ocp (ie.othennal Notification (Re%istd 4 30'.0I2) l'apc

December 3, 2021

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i. PROTECTION — Provide a brief description of hem ( I ) eater supply %yells: (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:
230
J. VARIANCE — Pursuant to ISA NCAC 02C .0241 the Director of the Division of Water Quality may grant a
variance from applicable well construction or operation standards provided that:
(I) use of the well(s) will not endanger human health and welfare or the groundwater: and
(2) that construction or operation in accordance w ith 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 jmp://portal.ncdenr.org/web/wq/aps/gwprQ ermit-
Applications
K. SIGNATURES — The following section is to be completed as required below- or by that person's authorized
agent. ISA NCAC 02C .021 1(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;
(cl 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;
(c) for any other person authorized to act on behalf of the applicant: documentation shall he
submitted with the notification that clearly identifies the person. grants them signature
authority, and is signed and dated by the applicant.
"I hereby certifV, under penalty c flaw. that I have personally examined and am.firmiliar with the infrn•malion
submitted in this document and all attachments thereto and that. based on my inquiry of those individuals
immediately responsible for obtaining said information, 1 believe that the infnrmation is true. accurate and
complete. 1 am aware that there are significant penalties. including the possibility of:fines and impr isonmenl,
for submitting, false information. I agree to construct. operas., maintain, repair. and if applicable, abandon
the injection well and all related appurtenances in accordance will; the I5A NC'AC 02C' 0200 Rules."
l
Sign Lure of Property Owner/
sisePA m
Print or Tope Full Name
Signature of Authorized Agent, if any
Print or Type Fuil Marne
I)WQ,1'I(''('{o.ed-I op Geothermal Notification (Re%iced 4 311 2012) Page .1

L. SUBMITTAL INSTRUCTIONS — Submit one cope of the cc..mpleted notification package to the each of the
following:
(1) The Division of Water Quality Regional Office serving the area in which the injection well facility
Will he 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 281 15
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]
(2) County Health Department in which the injection well facility will he located. A list of count health
departments can be found online at http:i/w'ww.ncalhd.org/countv.htm
IAi Q I I(7Z'tosed I.00p Geothermal Notification (Re%iscd 4.30 201') Page 5