WI0800558_Application_20220203

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 15A 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.
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 Submittals Will Be Returned As Incomplete.
DATE: January 10
, 20 22 PERMIT NO.: (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: 3
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER(S) (choose one)
(1) I. Single Family Residence Submit this form two (2) business days prior to construction.
(2) n 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
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:
Keith Lane
Mailing Address: 7712 Dunewalk Court
City: Wilmington State: NC Zip Code: 28409 County: New Hanover
Day Tele No.: Ce11 No.: 910-512-8250
EMAIL Address: [e-mail]
D. PHYSICAL LOCATION OF WELL SITE
Fax No.:
(1) Parcel Identification Number (PIN) of well site: R07612-003-033-000
County: New Hanover
(2) Physical Address (if different than mailing address): 5308 Southwind Drive
City: Wilmington County New Hanover Zip Code: 28409
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:
(2)
• 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
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
http ://deq.nc. gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
rotection/ground-water-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
None, water only.
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: James L Cornette, PG
NC Well Drilling Contractor Certification No.:
Company Name: Applied Resource Management, PC Contact Person: James Cornette
City: Hampstead State: NC Zip Code: 28443 County: Pender
Day Tele No.: 910-270-2919 Cell No.:
EMAIL Address: [e-mail] Fax No.: 910-270-2988
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: TBD
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.: 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://ncdenr.s3.amazonaws.com/s3fs-
public/Water%20Quality/Aquifer%20Protection/GPU/Geothermal VarianceRequestFormFillable-
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 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 of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenar1res accordance with the 15A NCAC 02C 0200 Rules."
ure�operty Owner/Applicant
Keith Lane
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

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Proposed Geothermal Loop
Adapted from Lat 34 Engineering, PLLC
Keith and Pamela Lane House Plans
5/20/2021
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Applied Resource
Management, P C.
Hampstead, NC 28443
TITLE:
JOB:
5308 Southwind
Site Map With Proposed
Geothermal Loop Locations
SCALE:
As Shown
DATE:
2/2/2022
DRAWN BY:
JLC
FIGURE:
1

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Applied Resource
Management, 17 C.
Hampotead, NC 28443
TITLE:
250' Radius Map
JOB: SCALE:
5308 Southwind As Shown
DATE:
2/2/2022
DRAWN BY:
JLC
FIGURE:
1

Ground Surface
4" Borehole
Thermex
Grout
Applied IZeSource
Management, F. C.
Hampstead, NC 28443
TITLE: Geothermal Closed Loop
Diagram
JOB:
As Shown
SCALE:
As Shown
DATE:
2/02/21
DRAWN BY:
JLC
FIGURE:
3