SW6220802_Response To Comments_20220816

North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION FOR STORMWATER DRAINAGE WELL SYSTEMS
Stormwater drainage wells are classified by EPA as Class V injection wells and do not require an individual
injection well permit when constructed in accordance with the rules of 15A NCAC 02C . 0200.
As described in 15A NCAC 02C .0227 this applies to rooftop runoff infiltration systems and certain other
Stormwater infiltration systems implemented as Best Management Practices designed in accordance with State
stormwater regulations or an approved local government stormwater program.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: PERMIT NO.: to be completed by DWR for new permits)
A. TYPE OF WELL OWNER (choose one)
(1) Single Family Residence
(2) Business/Organization _E
(3) Government: State Municipal County Federal
B. WELL OWNER(S) - For single family residences, list all persons listed on the property deed. For all others,
list name of the business/government agency and person and title with delegated signature authority:
JA c - ev
Mailing Address: :, l do
City: orr ' 1 State: C. Zip Code: ,� %$6b it
Telephone No.: l; 91o 9 8 8 .- 460 tfo( EMAIL: it & 8 7 [ 'n i �. co v►1
C. WELL FACILITY INFO
(1) Name of Facility: -ore
(2) Contact Name (if any):__ Ah i<;-t € ccrg-_ I Phone No.: 0al IFfB - 6 0if
(3) Physical Address (if different than Owner):-... u ►at e
City: 5-T vh e- County: 5g #n e- Zip Code: -Si rat e-
(4) Geographic Coordinates: Latitude: _ _3 -5-. 57i (t, Longitude: 7g.. S 1;Z j9
Reference Datum: Position Accuracy:
Method of Data Collection: �r M p �v �„ f ✓ t'r.1._S
Stormwater UIC Notification Form Rev. 6-21-22 Page I

D. PROJECT CONTACT INFO (generally the environmentaVengineering consultant)
Name: S o nr, Title:_ 1 c,; r- t Er► rl
Company: ' $ ..
Address:--. /\/ ,.-
City: n S Stater Zip: Z 7 SZ._!
Telephone number; 101'7 - 3A 1.a G Email; r J� h ey
fo 0
�Pe '5Ak!a bal �1c cn m
E. WELL(S) INFO - Indicate the number of the we] 1(s) according to the status:
,_Proposed Active Inactive Temporarily Abandoned Permanently Abandoned
F. DESCRIPTION OF UIC STORMWATER WELL S - Attach a site map and schematic of well system
and provide a brief narrative regarding the ose scope, and goals of the proposed injection activi :
r o5erl_J&,.I,6 C e
rr1�Yt i ~i " c ✓1 c i G _s o w r u
W a o
reL41 Lot& j2 ac� G n c e
l�Is°' v �.e r a r c�Gt •, wr � � rS' w ' f � r" -f r' a e
l £�1R o to 'l Gj N u
Stormwater UIC Notification Form Rev. 6-21-22 Page 2

G. SIGNATURE(S) of APPLICANT & PROPERTY OWNER— The following section is to be completed as
required below or by that person's authorized agent. 15A NCAC 02C .0211 d 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.
Well Owner/A licant: "I hereby certify, under penalty of law, that I 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, 1 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. "
Signature of
Print or Type Full Name and Title
Pro e Owner if the.property is not owned by the Well Owner/A licant :
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(ISA NCAC 02C . 0200 . "
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Send one copy of the completed notification package along with an electronic copy on CD or Memory
Stick to:
Division of Water Resources
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Stormwater ti1C Notification Form Rev, 6-21-22
Page 3