WI0100642_Aqueous Closed Loop Geothermal Well Construction Application_20220208

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3S TJ 30' 4 1 3 3NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL 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 I 5A 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 andperformance-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 andcooling system.
Print Clearly or Type lnformatio11. lllegible Submittals Will Be Returne<I As Incomplete.
DATE: __ :).�-g ____ , 20�PERMIT NO. _WI0100642__ (to be completed by DWQ)
A.TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
B.
C.
D.
(I)(2)Aqueous (as per 15A NCAC 02C .0222): V Direct Expansion (as per I SA NCAC 02C .0223) __ _ Number of wells: s?@]S"'D tNumber of welts: __
STATUS OF WELL OWNER (choose one)� t=✓�\
CT) r' �� (1)(2)(3)
Single Family Residence Vsubmit this form two (2) business days prior to conlrll!,tion. 1 \.�-�:JI
Business/Organization __ Submit this form 30 days prior to construction. � � -r:'(�Government: State Municipal__ County__ Federal __ Submft,@s forn Oday��
prior tQJcR,11structipn. k25::.,Jco <.D ex [-�
WELL OWNER - For single family residences list the property owner(s). For all othe �: fist nam�'of th �::'Jbusiness, organization, or government agency and person delegated signature authority: � ��1 -��;;-tl-4 &.reswc1 � S.-4 &rim i� r�-�
g %::_ 3 (Q
Mailing Addres s: 1.::JJ l�{MSU>ff k1t.L
City: Asb II; /1.1 State: NC-Zip Code: ��,J County: �J a,t,-.,.-,b.f
Day Tele No.: -----:-----------­
EMAIL Address: -J..,....• b_-3_3_2D_�_:_j-+'M�0,.__.1 ....... · /-'-, .... l&..,.»1..__._-
PHYSICAL LOCATION OF WELL SITE
Cell No.: JJ._� -fnf'l _q5c,0
Fax No.: ____________ _
(I)Parcel Identification Number (PIN) of well site:_q_L,_'l_5_3_1',_2Z_Lf_.8_oo_O_'l>_{J ______ _
County: �C(r'l{pe
(2)Physical Address (if different than mailing address): �Z"'--=3 ......7_,Kt---"-'{-'-M.....,S""c,._,Q"-'t'--'-f�L,.--"--',.�U=�----
State: NC Zip Code: _2.'a_&--_o�,'J�----DWQ/UIC/Closed-Loop Geothermal Notification (Revised 4/30/2012) Page I
E. MAPS, PLANS, AND SPECIFICATIONS
(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 following:
• • p
roposed injection well locations eptic systems and associated spray irrigation sites,
• drain fields, or repair areas
uildings
• • p
roperty boundaries xisting or potential sources of groundwater
• contamination S
urface water bodies
• W
ater supply wells
(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 Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at http://portal.ncdenr.org/web/wq/aps/gwpro. All other additives require approval prior to use.
Enviconal 4- wa+Cr
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Josh Plemmons
NC Well Drilling Contractor Certification No.: 4137A
Company Name: Clearwater Well Drilling, Inc. Contact Person: Jeff Moore
City: Hot Springs State: NC Zip Code: 28743 County: Madison
Day Tele No.: 828-776-6526 Cell No.:
EMAIL Address: [e-mail] Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:Bullman Heating & Air
Contact Person: Josh Guthrie EMAIL Address: [e-mail]
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804_State: NC County: Buncomne
Office Tele No.: (828)-658-2468 Cell No.: _(828)-712-7488 Fax No.: (828)-658-1001
DWQ/UIC/Closed-Loop Geothermal Notification (Revised 4/30/2012) Page 2

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I. 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 wells:
No bodies of wa-kv- `45D
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v : 11 Con.-fzt.i A r -Q r-Ft
J. VARIANCE — Pursuant to 15A NCAC 02C .0241 the Director of the Division of Water Quality 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 http://portal.ncdenr.org/web/wq/aps/gwpro/permit-
applications
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. 1 am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. 1 agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all related appurtenances in accordance with the 15,4 NCAC 02C 0200 Rules."
Signature of Property Owner/Applicant
To-(\ r>Lfp
Print or Type Full Name
l
ire of Ai thorized Agent, if any
Print or Type Full Name
DWQ/UIC/Closed-Loop Geothermal Notification (Revised 4/30/2012) Page 3

I. 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 wells:
J. VARIANCE — Pursuant to 15A NCAC 02C .0241 the Director of the Division of Water Quality 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 http://portal.ncdenr.org/web/wq/aps/gwpro/permit-
applications
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 appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
f Property 0 er/Applican
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
DWQ/UIC/Closed-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:
(i)
The Division of Water Quality Regional Office serving the area in which the injection well facility
will be 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 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
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 be located. A list of county health
departments can be found online at http://www.ncalhd.org/county.htm.
DWQ/UIC/Closed-Loop Geothennal Notification (Revised 4/30/2012) Page 4