WI0100640_Aqueous Closed Loop Geothermal Well Construction Application_20211213

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NORTH CAROLrNA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES v :JCi t J 9, i0NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WF.LLS T/rese 1re//s are "pe1111itte<I by 111/e ·· and do 1101 require an i11di•-id1111/ ,,umit wl,e11 co11st111c1ed i11 accordrmce wirl,
rhe 111/es of 15A NCAC 02C .0200•. 711is notice mmt be s11bmi1ted prior to co11st111ctio11.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS As described in 15A NCAC 02C .0222 these wells circulate potable water only or a mixture of potable water andpcrfonnance-enhancing additives as part of a geolhcm1al beating and cooling system.
OR
GEOTHEUMAL DIU.ECT EXPANSION CLOSED-LOOP WELLS As described in 15A NCAC 02C .022J these wells circulate a refrigerant gas as part or a geothermal heating omlcooling system.
l'r/111 Clearly or Type l11for111fltio11. Illegible S11b111ittnls Will He Nellmted As lnco111plete.
l)ATE: /Z,. -/ 3 • 20..£1..PERMIT NO. _WI0100640____ (to be completed by DWQ)
A.
8.
TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1)Aqucous(nspcr 15A NCAC02C.0222):✓ Numbcrofwclls: � 20� 1
(2)Direct Expansion (as per 15A NCAC 02C .0223) ___Number of wells:
STATUS OF WELL OWNER (cboose one)
(I) Single Family Residence£ Submit this form two (2) busincn d•y• prior to construction.
(2) .Busincs..�Organization __ Submit this form 30 days prior to construcllon. (3) Government: Slate Municipa l__ County__ Federal __ Submit this form 30 dAys prior to construction.
C.WF.LL OWNER -For single family residences list the property owner(s). For all olhcrs. list name of the business. organizalion, or government agency and p erson dclcgoled signature outhorily:
ho,v',o �°'��
Mailing Address: 8 T '-" p<1:. \ O \r \
City: i/slNx• I Ii State: � ZipCodc:�County: �kAC.OM �:,S,
Cell No.: 3 l 1..-307 -9 <.lj <..:, Day Tele No.: _____________ _
EMAIL Address: ___________ _
D. PHYSICAL LOCATION 011 WELL SITE
Fax No.: ____________ _
(I) Parcel Identification Number (PIN) nf well sitc: __ °t�J�Z._\-'--7..._L=--S�t'--'7.,_'7.1-.. _____ _
County: \S\..\•'-C, OM l,,e
(2) Physical Address (if different than mailing address):
City; _____________ _
DWQ/UIC/Close<t-Loop Geo1hcnnnl Notiitca1ion (llcviscd 4/J0/2012}
-------------
Siutc: NC Zip Code: _______ _
Water Qual_ity Regional OperationsAsheville Regional Office
E. MAPS, PLANS, AND SPECIFICATIONS
(I) 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
• Buildings
• Property boundaries
• Surface water bodies
• Water supply wells
• Septic systems and associated spray irrigation
sites, drain fields, or repair areas
• Existing or potential sources of groundwater
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 Ilealth
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at http://portal.ncdenr.oryJwch/w ceapsfawpro. Alt other additives require approval prior to use.
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G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: �� 1 P) tf\tft o/1J
NC Well Drilling Contractor Cettiftcation No.: 4137A
Company Name: Clearwater Well Drilling, Inc. Contact Person: "3—e-,4 ► 'ltiat
City: Hot Springs State: NC _ Zip Code: 28743 County: Madison
Day Tele No.: 828-776-6526 Cell No.:
EMAIL Address: jmcltwater70©aol.com Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name. Ator4,45 -.. %fee •f; A 3 4, r
Contact Person: 5 St1 • A4-aY
Address: 2i3 0 I'> '^'(a' tS 11,111 1-, w y
City; (6e°`Utr✓i c to Zip Cudc: 7Stete f`-1 S�- County: KW.'.,G.?!^
Office Tele No_•B7 Vet 63C-/ Cell No • _ Z$ zoc• ohn
D\Q/111C/Closed-Loop Geothemtal notification (Revised 4/30/2012)
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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 we
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J. VARIANCE— Pursuant to 15A NCAC 02C .0241 the Director of the Division of Water Quality may gram a
variance from applicable well construction or operation standards provided that:
(1) use of the wcll(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 hitpa xtal.ncdcnr.oralwcbAs tilapsigwpro 'pennit-
applicat ions
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)
(b)
(c)
(d)
(e)
for a corporation: by a responsible corporate officer;
for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
for all others: by the well owner;
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 certy, under penalty of law, that 1 have personally eranllned 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 nue, accurate and
complete. 1 am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. 1 agree 10 construct. operate, maintain, repair, and if applicable, abandon
the injection well and all related a rt�tances in accordance with the 15A NCAC 02C 0200 Rules."
Sigma ?e or Propewaer0 ppltcant
Petal or Type Full Name
Slgnaful'f'of Auth- orlgent, If any
� t rhtt o or Full Name
DWQ/UiCJCloscd-Loop Geothermal Notification (Revised 4/30/2012)
Page 3

L. SUBMITTAL INSTRUCTIONS — Submit one copy of the completed notification package to the each of the
following:
The Division of Water Quality Regional Office serving the area in which the injection well facility
will be located:
(1)
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
D W Q/UIC/Closed-Loop Geothermal Notification (Revised 4/30/2012)
Wilmington, NC 28405
Telephone: [phone]
Fax: [phone]
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107-2241
Phone: [phone]
Fax: [phone]
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