WI0100643_Aqueous Closed loop Geothermal Well Construction Application_20220309

Corrected Pin #972152383
WI0100643
E., REQUIRED MANS, PLANS, AND 5I'FCtFICATIONS
(I I A site maps must be submitted. II mint be seated or otherwise accurately indicate distances (in feet)
and oticutations of features located within 230 feet of the Injection well(s), 1,nbeI all features clearly
aud_in iAtui_l1Qrlh mow. Attach Me site. poodle mop showing the wells in relation to the locations of
the Iitllowhtg:
F.
• Handing*
• 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
(21 Plans and specifications of the surface and subsurface construction details of the well systcm.
VOTE: In mart 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 webslte, Typically, the property can
be watered by owner name or address. The location of the wells in relation to property boundaries, houses, septic
tanks and fields, and other Hells, eta can then be drawn In by hand. Also, a 'layer' can be selected showing
topographic contours or elevation data.
TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. NOTE: Only injections approved by the NC Division of Public Health, Department of Health
and Human Services can be injected. Approved in'ectants 'lI e c ov ab at/div'sions! at-resourc s/wa p-re ! can be found online at
t'oteccinn(n..,..nd .._. urces- its/wart w et- ranch! land-water-
."v „cr-n roved-inirr,a.,,�
All other substances must be reviewed by the DHHS prior to use.
Propylene glycol
WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Clint Babbitt
NC Well Drilling Contractor Certification No.: NC-3556-A
Company Name: AAA Sweetwater Well Contact Person: { IYI�' Ul (Q
City: Swannanoa State: NC Zip Code:28778C)unty:
Day Tele No.: 828.298.111711n ! ^ I 1 Ce11 No,: � � �1
EMAIL Address5vie,h\ �i%rY /Lai �w9lmi,4I FaxNo.: 7, 0/
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: StiGkels Service Company, Inc.
Contact Person: Brad Stickels
Address: 2064 US 70
City: Swannanoa
EMAIL Address: offtce(a?stickelsservice.com
Zip Code: 28778 State:NC County: Buncombe
Office Tele No.: 828-417-7186 Cell No.: 828-776-9221 Fax No,:
Closed -Loop Geothermal Well Notification Rev. 3-i-2016
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PROTECTION _ Provide n brief description of how any (a.) wnler supply wells, (b.) surface water bodies, or
(c,) septic systems and associated spray ittigatinn sites, drain fields, or repair areas within 250 feet of the
Proposed iiicetiou wells will he protected during constnictiun of the wells:
VARIANCE, — Pursuant to 5 A 02 024I the Director of the Division of Water Resources 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 with the standards is not technically feasible or the
proposed construction provides equal or better protection of the groundwater.
Any variance request should accom an
The variance mq P y submittal of this notification to expedite evaluation of the request.
nest form can be accessed online at tt s !!n dear. 3.amazonaws.c s fs-
ubadWater" 20 uali IA utter* 20Protection/GPU/GeolhertnalVarianceRe uestFormFi lable-
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SIGNATURES _ The following section is to be completed as required below or b that
agent I SA e_ 02C .o211 a requires signatures as follows: Y person's authorized
(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 appurtenances in • ordance with the 15A NCAC 02C 0200 Rules."
r/Applicant
CL( R 1 "
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
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PIN 8721 43 6685
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