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Home My WebLink AboutWI0501097_Permit (Issuance)_20220711Firefox about:blanI North Carolina Department of Environmental Quality — Division of Water Resources NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS These wells are 'permitted by rule" and do not require an Individual permit when constntcted In accordance with the rules of IM NCAC OK .0200 nth nonce ntu;Lbe_subndlled odor to construction. GEOTHERMAL 4OUEOUS CLOSED -LOOP WELLS As described in 154 NCAC 02C .0221 these wells circulate potable water only or a mixture of potable water and performance -enhancing additives as part of a geothermal heating and cooling system. OR GEOTHERMAL DIRECJ EXPANSION CLOSED -LOOP WELLS As described in 15ANCAC 02C kaa these wells circulate a refrigerant gas as part of a geothermal heating and cooling system. Print Clearly or Type Iybrmatron. Illegible Submittals 071 Be Retarned.ls Incomplete. DATE: 21 June 2022 PERMIT NO.: baC60/09 7 (to be completed by DWR) A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one) Q (1) ES Aqueous (as per j 5A AC 0 m Ntunber of wells: 2 -- 3 & AJ (2) 0 Direct Expansion (as per Number of wells: B. STATUS OF WELL OWNER(S) (choose one) (I) ® Single Family Residence Submit this form two (2) business days prior to construction. (2) 0 Business/Organization Submit Ibis form 30 days prior to construction. (3) ❑ Government. State Municipal County Federal* *Submit this forth 30 days prior to construction C. WELL OWNER(S) — For single family residences. list all persons listed on the property deed. For all others. list the narne of the Business/Agency Id person and title with delegated signature authority: David Monroe Heath Living Trust Mailing Address: 3006 MarketStreet City: Newport Day Tele No.: _ Cell No.; 252-822-5271 State: NC Zip Code:o County: Carteret EMAIL Address: david@heathoompnies.net Fax No.: D. PHYSICAL LOCATION OF WELL SITE (I) Parcel Identification Number (PIN) of well site:1701439751 County: Wake (2) Physical Address (if different than mailing address): 5013 Cindy Drive City: Raleigh Closed -Loop °eothermal welt Notification Rev. 3-1-2016 County NC Zip code: 27603 Page 1 fd 6/22/2022, 9:27 AM Firefox about: blank E. REQUIRED MAPS, PLANS, AND SPECIFICATIONS (1) A site maps must be submitted. It must be scaled or otherwise accurately indicate distances (in feet) and orientations of features located within 250 feet of the injection well(s). Label all features clearly mid include a north arrow. Attach the site -specific map showing the wells in relation to the locations of the following: • Buildings • 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 (2) Plans and specifications of the surface and subsurface construction details of the well system. NOTE: In most eases, an aerial photograph and/or plat map of the proper°' parcel showing property lines and structures can be obtained and downloaded front the applicable county GIS website. T)plcal#, the property can be searched by owner name or address. The location of the wells In relation to property boundaries, houses, septic tanks and/kids, and other wells, etc can men be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or 'Mellon data. F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their concentrations. NOTE: Only injectants approved by the NC Division of Public Health. Department of Health and Hunan Services can be injected. Approved injects nts can be found online at ; /ft ac tovla4oulidtvisionsiwtde� t13t%tls-r�sot>3cCs-neimitir�lylew�kr le L nd-we2 protectWarousid-wutp-raproved-illiectants. All other substances must be reviewed by the DHHS prior to use. 6(4/ 'F)Z OHh y G. WELL DRILLER INFORMATION Well Drilling Contractor's Name: dr'Ned ✓Q6La/ wtfst Ce. ,2'.✓G . CNAte Ncci L/G(rftt NC Well Drilling Contractor Certification No.: # ► 2 6 7 Company Nance: I AdY! ✓4,4-.1Y £& . G • 1 •• Contact Person: C/I /fit �rvt City: 1.2 e e f G State: +V 4 Zip Code: 27(k 4onnty: P-10+ 14 Day Tele No.: 2 A d { l Cell No.: 1 P)- y r6 'Slf 6 EMAIL Address: Coke a r¢N 2/7 IP C C hvt.Fax No.: ,) .- IV") ' +. ; H. HEAT PUMP CONTRACTOR INFORMATION Company Name:._ e7-•,+'ti^ 4.✓ c.H II Wi c c i AAA < t. C Contact Person:_a'r Vd e wt.+nl !I L : 1-1-4 vF� rA r/Y1 e �llc. y� %j4 fd141, Address: / C Q N/ c.w/ 4.41 City: ls410-411 1.dti Zip Code: Z?t3 i Stater County: } 4 °Td Office Tele No.: 9/ %71.117f9 Cell No.: 9/7 "2' —!y2 Fax Fax No.: / 9 d7 ?1 Closed -Loop Oeothennal Well Notification Rev. 3-1-2016 Pam• 2 Ga M 1 of 4 6/22/2022, 9:27 AM Firefox about:blank I. PROTECTION - Provide a brief description of how any (a) water supply wells. (b.) surface water bodies. or (c.) 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: 5/A14"4/c do y fume of Ot,v ,fit 4IG 5 I 4c7‘fiRl r a S A•ft ef15a. 7 J. VARIANCE - Pursuant to 1 SA NCAC U2C _U241 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 accompany submittal of this notification to expedite evaluation of the request. The variance request form can be accessed online atIgintAcrlextr.s3,amazonaws,cornisift- Eibile/WilterY9200ualila 24130805 pdf — K. SIGNATURES - The following section is to be completed as required below or by that person's authorized agent. 1 SA NCAC 02tC .9211(0 requires signanires as follows: (a) for a corporation: by a responsible corporate officer: (b) for a pamrersli ip 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 prmcipal 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. "7 hereby cert(fi., under penalty of law, that 1ltave personally ermined 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 obtalning said information, 1 believe that the information is true, accurate and complete. I am aware that there are sign(ficaut penalties, including the possibility opines and imprisonment, for subutlttfng false information. I agree ro construct, operate, maintain, repair, and if applicable, abandon the infection well and all related appurtenances in accordance with the hid NC4C OIC 00 Rules." Sign of Property Owner/Appllcant David M Heath Print or Type Fult Name Signature of Authorized Agent, it any Print or Type Fun Name Closed -Loop Geothermal Well Notification Rev. 3-1.2016 Page 3 3 of 4 6/22/2022, 9:27 AM SURVEY FOR AD3 DEVELOPMENT LLC LOT 316. GREENBRIER ESTATES 5013 CINDY DRIVE PIN# 1701.14-43-9751 D.B. 1970. PAGE 602 B.M. 1968r PAGE 74 ST. MARY'S TOWNSHIP WAKE COUNTY, NORTH CAROLINA JUNE 24, 2021 REVISED JANUARY 21. 2022 40 20 0 40 80 SCALE 1 "-40' Et,IR'1°tar N/F ImtEIiLY IL RED OIL 17003 PAM 1700 P6d 1701-13-6252 CWIP CAWIHORNE. MOSS PMICIERA. P.C. Professional Land Surveyors C-1525 333 S. While Street Post Office Box 1253 Woke Forest. N.C. 27588 (919)558-3148 gi ARMREST am-. N AMU MWAT 120.1631311 PACE 2312 M. Inn-03-0525 A111012LIW Io01AT 021.102012 PACE 2312 EIP4b P11f 1701-67-a62b PP ter MP w� •w 11 FF VICINITY MAP EIP - EXISTING IRON PIPE EI8 -- EXISTING IRON BAR BEIP - BENT IRON PIPE BOB - BENT IRON BAR CM - CONCRETE MONUMENT EPIC - EXISTING PK NAIL SPX - SETPKNAIL NIP - NEW IRON PIPE SET R/W - RIGHT OF WAY CAN - CABLE TV BOX EB - ELECTRIC BOX TEL - TELEPHONE PEDESTAL PP - POWER POLE OHL - OVERHEAD LINE LP - LIGHT POLE wM - WATER METER WV - WATER VALVE CO - SEWER CLEAN -OUT MP -MATHEMATICAL POINT IMPERNOUS SURFACE TABLE 3021 v. Naar. 1.e14 sr. 2i3u. swsr. 11111.1. AWL 6214711022 ADA 2437 OT AAEA 12J IQ1�111 Q arlxw0ls AN 0 74,E sr. 20' u11UTY JADES r2P61r1 0J1.16214 PAGE 2230 P0I0 1701-63-1204 I DECLARE THAT TINS SURVEY COMPLIES VIM IRE NORTH CAR0UNA STANDARDS OF MC110E FOR SURVEHNG. (SC11ON 1600) FOR CLASS A SURVEYS NO MAT THE CAI ry>! ATE) RATIO OF P M:IRON BEFORE ADJUSTMENTS IS 1:10.TNERN10RE, PROPERTY CORNERS SHORN ARE TROL 11046I12ENTA110N FOR 1NE RE - EST a T • PROPERTY CORNERS N 1PE ABSENCE OF , -•:. TS Ate 07I1ER S11BOiYlSIOM PROPERTY SURVEY IS NOT TO BE RECORDED T6TM- AUTMORIZATION S7lRVEroR. 5013 Cindy Dr - Google Maps hops://www.google.com/maps/placel5013-1-Cindy+Dr,+Raleigh,+NC+... 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