WI0100656_Aqueous Closed Loop Geothermal Well Construction Application_20220510

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERA TE INJECTION WELLS ' Thesk1vel/s are "permitted by rule" and do not require an individual permit when constructed in accordance with��; � the rules of 15A NCAC 02C .0200*. This notic e must be submitted prior to construction. r: i a-__ �· oo �I cu co GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS �, {. J As aescnbed in 15A NCAC 02C .0222 these wells circulate potable water on ly or a mixture of potable water and
g> g> perfonnance-enhancing additives as part ofa geothennal heating and cooling system. (Y 0:::
(Y'S .>
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OR
0 55 m �c GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS Asll�scribed in 15A NCAC 02C .0223 these wells circulate a refrigerant gas as part of a geothermal heating and
<� . cooling sys�ein.
Pri11t Clearly or Type /11formatio11. Illegible Submittals Will Be Returned As /11complete.
DATE: _ _____,Jf>l,LL(Yj-"-A,.:..,_;' ___ , 20H I PERMIT �O. WI0100656_____ (to be completed by DWQ)
A. B. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED :l , � 1r 1
J-300(1) (2) Aqueous (as per I SA NCAC 0 2C .0222): �
Direct Expansion (as per I SA NCAC 0 2C .0223) __ _
Number of wells :� "Q)
Number of wells: __ _
STATUS OF WELL OWNER (choose one) (1) (2) (3) Single Family Residence �mit this form two (2) business days 11rior to construction.
Business/Organization __ Submit this form 30 days prior to construction.
Government: State Municipal _·_ County__ Federal __ Submit this form 30 days
prior to construction.
H
C.WELL OWNER -For single famil y residences list the property owner(s). For a ll others, list name of the
business, organization, or government agency and person delegated signature authority:
Ronald Shum
Mailing Address: ___ 4.:...:0�3c..,E=a=s:.:..t =B=o=ar,.,,d'-"w=a=lk""'#"-'8""'0'""6'-'----------
City: Long Beach State: NY Zip Code: 115 6 1 County: Suffolk
Day Tele No.: ______ ..e.N=/A'-"--------Cell No.: 6 31-834-51 82
EMAIL Address: _____ ....:.r"'"on'-"n=i.,.,es""h,.,.um=l�@;,:,,g=,.,m=ai"-'l.-""co"-'1-"-n __ F ax No.: ___ ,!..:N'-'-'/A-'------
D.PHYSICAL LOCATION OF WELL SITE
(I)Parcel Identification Number (PIN) of well site: ___ --'9�6�3�4�03=2=2=5�80�0�0'""0=0 __
County: Buncombe
(2)Physical Address (if different than mailing address): -----=3"-5 ..:.:RA�V,...,E""N...,___,.C=L=IF,._,F'-=LN'--'----
City: _ Arden State: NC Zip Code:
'-E. MAPS, PLANS, AND SPECIFICATIONS "-l '""IUlC/Closed-Loop Geothennal Notification (Revised 4/30/2012)
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287 0 4
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