WI0100655_Aqueous Closed Loop Geothermal Well Construction Application_20220610

i!'--0 J_ 2.,1 4-� , j � ·­l O 4-0' 77 'JoNORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL I SOURCES
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 11111st 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 andperfonnance-enhancing additives as part of a geothennal heating and cooling system.
OR
GEOTHERMAL DIRECT EXP ANSION CLOSED-LOOP WELLS As described in 15A NCAC 02C .0223 these wells circulate a refrigerant gas as part of a geothennal heating andcooling system.
Print Clearly or Type /11formatio11. Illegible Submittals Will Be Returned As /11complete.
DATE: &� /D -
A.
B.
C.
m Ir20£2,,, PERMIT NO. WI0100655__to be com. pletedl by DWQ) -·1 ,....\. ))
)>� 0...: -·::,TYPE OF GE OTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED �-0 �F S!J
(1) c-·;--��i � lCJL (l) (2) Aqueous (as per 15A NCAC 02C .0222): X Number of wells: 3 wells @ 3.xi0;u:ach�t:l!:;j
0 0 ,,-
Direct Exp ansion (as per 15A NCAC 02C .0223) ___ Number of �l.@ c::;11 it-· �1 � � � ��:-
STATUS OFWELL OWNER(chooseone) ii � Li�] (l) Single Family Residence � this form two (2) business days prior to co�st�ction.1� _ _:;,l(2) Business/Organization __ Submit this form 30 days prior to construction. � � _ / (3) Government: State Municipal__ County __ Federal __ Submit this form 30 days Jlrior to construction.
WELL OWNER -For single family residences list the property owner(s). For all others, list name of thebusiness, organization, or government agency and person delegated signature authority:
Katharine Crawford
Mailing Address: 927 Middle Street ________________________ _ City: Sullivans Island____ State: SC __ Zip Code:29482 County: ________ _ Day Tele No.: 843-364-8471 Cell No.: ___________ _ EMAIL Address: [e-mail] ______ _ Fax No.: ____________ _
D.PHYSICAL LOCATION OF WELL SITE
(I)Parcel Identification Number (PIN) of well site: ____ 9686246301 __________ _County: Henderson __________ _
(2)Physical Address (if different than mailing address): 188 Montgomery Dr,
City: _Saluda. ________ _ State: NC Zip Code: __ 28773 _____ _DWQ/UIC/Closed-Loop Geothennal Notification (Revised 4/30/2012)Page I