The URL can be used to link to this page

Home My WebLink AboutWI0501088_Application_20220106North 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 1 SA NCAC 02C.0200 This notice must be submitted prior to construction GEOTHERMAL AOUEOUS CLOSED -LOOP WELLS As described in I5A NCAC 02C .022Z 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 15A NCAC 02C .0223 these wells circulate a refrigerant gas as part ofa geothermal heating and cooling system. DATE: 1 /5 Print Clear& or Type Information. Illegible Subndtrtalr Wilt Be Returned As Incomplete 20 22 PERMIT NO.: e O O n (to be completed by DWR) A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one) (1) ❑ Aqueous (as per 15A NCAC 02C .0222) Number of wells: 2 (2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of welts: B. STATUS OF WELL OWNER(S) (choose one) (I) Single Family Residence Submit this form two (2) business days prior to construction. (2) [1 Business/Organization Submit this fbna 30 days prior to construction. (3) 0 Government: State Municipal County Federal* *Submit this form 30 days prior to construction C. WELL OWNER(S) — For single family residences, list g (l persons listed on the property deed. For all others, list the name of the Business/Agency and person and title with delegated signature authority: Glenn Bernstein and Andrea Dubocq Mailing Address: 1608 Ward St City: Durham State: NC Zip Code:27707 County:Durham Day Tele No.: 305 321 0576 Cell No.: 305.321.0576 EMAIL Address: glennb@funix.com Fax No.: D. PHYSICAL LOCATION OF WELL SITE (1) Parcel Identification Number (PIN) of well site: 0832-02-43-9436 County: Durham (2) Physical Address (if different than mailing address): 1100 Edgevale Rd. City: Durham Closed -Loop Geothermal Well Notification Rev. 3-1-2016 County Durham Zip Code: 27101 Page 1 E. REQUIRED MAPS, PLANS, AND SPECIFICATIONS (I) A site maps must be anbmitted. It must be scaled or otherwise accurately indicate distances (in feet) and orientations of features located within 250 feet of the injection well(s). Lailelall features clearly and include 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 (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 properly lines and structures can be obtained and downloaded, from the applicable county GIS website. Typically, the property can be searched by owner name or addles. The location of the wells in relation to property boundaries, horses, septic tanks and fields, and other wells. etc. can then be drawn in by hand Also, a layer' can be selected showing typographic contours or elevation data: F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their concentrations. NOTE: Only injecla nts approved by the NC Division of Public Health, Department of Health and Human Services can be injected. Approved injectants can be found online at htro..dea..ncA,UilboUUdiYisionsiwater-resourtes"water-resaurecs-OerrolislwaStewater-brandantind_waler- prnlet.gerund-water-aolm+.ve iniectant4. All other substances mist be reviewed by the DHHS prior to use. water only C. WELL DRILLER INFORMATION Weil Drilling Contractor's Name: Lake Valley Well CO. Inc., Chauncey H. Leggett NC Well Drilling Contractor Certification No.: #2269 Company Name: same City: Tarboro State: NC Day Te1e No.: 252 823-6311 EMAIL Address: atevab@bowmanmechanicateervices.00m H. HEAT PUMP CONTRACTOR INFORMATION Company Name: Bowman Mehanical RDU LLC Contact Person: Steve Bowman Address: 145 Technical Ct. Contact Person: Steve Bowman Zip Code: 27856 County: Cell No.: 252 450-5110 Fax No.: 919 779-9294 EMAIL Address:sswebotowmanuectianicalsemees.cern City: Gamer Zip Code: 27529 stare: NC County: Wake Office Tele No.: 819 772 2759 Cell No.: 919 427-1425 Fax No.: 919 779-9294 Closed -Loop Geothermal Well Nodlkation Rev. 3-1-2016 Ness 2 L 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: silt fencing .l. 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 hapsvincdenr,s3.amazonaws.com/s3fs- public/Water%20Q4tality/Aquifer°/020Protection/GPIPGeothcr VarianceReouestFormFiIIable- 20130805.odf K. SIGNATURES — The following section is to be completed as required below or by that person's authorized agent. I SA NCAC 02C .021 I (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 certif , under penally of law, that 1 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, 1 believe that the information is true, accurate and complete. 1 am aware that there are significant penalties, including the posslblllry of jinn and imprisonment, for submiuingfaise information: 1 agree to construct operate, maintain, repair, and if applicable, abandon the injection well and all relatedypnurten • in a • r e with the 1,5A NCAC 02C 0200 Rules " store of Property Owner/Applicant Glenn Bernstein Print or Type Foil Name Signature of Authorized Agent, if any Print or Type Fur! Name Closed -Loop Geothermal Wctl Notification Rev. 3-1-2016 Pagel }_ (504.4,Kx fir,; Cc�,�� If1ress //dU & 1/4c-' i2 . V1.L1 I),7 ,!/,C. Z7?d 1 Arze -"evieG cm. isamsoKrn 42.A aHr c q etl rVj cril � Ca 1/5-722 NOLLOnaLSNOO 3V OH M3N 3ON3aIs32i NI3 LSNU38 - 000sna { 7 '1 Pid E 1 L V s ; lig 1: