WI0100651_Aqueous Closed Loop Geothermal Well Construction Apllication_20220510

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NORTH 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 15A NCAC 02C .0200•. Thjs notice must be submitted prior lo construction
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in ISA NCAC 02C .0222 these wells circulate potable water only or a mixture of potable water and perfonnance-enhancing additives as part of a geothennal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS As described in ISA NCAC 02C .0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print aearty or 'lj,pe Information. 1/leglble Submlttals WIii Be Returned As Incomplete.
DATE:_--'-'//J""/�flt'.c.::-_· �- zoJ.l_ PERMIT NO. _WI0100651_(to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(I) (2) Aqueous (as per ISA NCAC 02C .0222): 1,..---"'"
Direct Expansion (as per ISA NCAC 02C .0223) __ _
Numberofwells:�1
Number of wells: __
B.STATUSOFWELLOWNER (chooseone)
(I)Single Family Residence �mit this form two (2) business days prior to construction.(2)Business/Organization __ Submit this form 30 days prior to construction,
(3)Govemmertt! State __ Municipal__ County__ Federal __ Submit this form 30 daysprior to construction.
C.WELL OWNER-For sin gle family residences list the property owner(s). For all others, list name of thebusiness, organization, or government agency !ml person delegated si gnature authority:
D.
Tene-\,.o 1)0,.r,chKov'
MailingAddress: \ild-() L--\<e. IA-v"l\...,;.ec..v-Ln 1�rl1Vld0v\ t='L .'.!,3is'IO
Cl(Y: 1br1A.1"Q()n State: FL ZipCode:0�C\::oun ty: 1-\,', \\�loo-r-a<>szh
DayTeleNo.:R/3-7.fS-�SJ '( fft1d-o Cell No., 813 -'<qS-71 �s ,.J0o<,1Moe,
EMAIL Address: i,cio..riol,,/cov ltql'lfU0f.c,,,.. FaxNo.:, __________ _ Ji 7
PHYSICAL LOCATION OF WELL SITE
(I)Parcel Identification Number (PIN) of well site: 8594-55-4172-000
County: Transylva nia, ________ _
(2) Physical Address (if different than mailing address): 30 Banks Ln, ---�---��-� , , ( r .il/ If :(Ji\111:.:I Clpm;:1lior1'.
City: Brevard
'II; I lrll ,.lfi'ic:L
State: NC Zi p Code: 28712. _____ _
DWQ/UIC/Closed-Loop Oeothennal Notification (Revised 4/30/2012)
(Lot 124 B-R Lake Lane)