WI0501106_Permit (Issuance)_20220921

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 constructed in accordance with
the rules of 15A NCAC 02C .0200. This notice must 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 and
performance -enhancing additives as part of a geothermal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS
As described in 15A NCAC 02C .0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: q` , 202. Z. PERMIT NO.: (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(l) ❑■ Aqueous (as per l5A NCAC 02C .0222) Number of wells: 1 C 3 )
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER(S) (choose one)
(1) ❑!! Single Family Residence Submit this form two (2) business days prior to construction.
(2) ❑ Business/Organization Submit this form 30 days prior to construction.
(3) ❑ Government: State Municipal County Federal*
*Submit this form 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 name of the Business/Agency and person and title with delegated signature authority:
West Forest LLC
Mailing Address: Box 1202
City: Durham
Day Tele No.: 919 422-5773
State: NC Zip Code: 277°2 County: Durham
EMAIL Address: [e-mail]
D. PHYSICAL LOCATION OF WELL SITE
Cell No.:
Fax No.:
(1) Parcel Identification Number (PIN) of well site: 0821-32-86-9036
County: Durham
(2) Physical Address (if different than nailing address): 1050 W. Forest Hills Blvd
City: Durham County Durham
Zip Code: 27707
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page

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
and include a north arrow. Attach the site -specific map showing the wells in relation to the locations of
the following:
S _ Sr-f. !'(ate — (
• 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.
$ t e olo1 w--
NOTE: In most cases, an aerial photograph and/or plat map of the property parcel showing property lines and
structures can be obtained and downloaded from the applicable county GIS website. Typically, the property can
be searched by owner name or address. The location of the wells in relation to property boundaries, houses, septic
tanks and fields, and other wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing
topographic contours or elevation data.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. NOTE: Only injeetants approved by the NC Division of Public Health, Department of Health
and Human Services can be injected. Approved injectants can be found online at
http://deq. nc.gov/aboutld i vis i ons/water-resourceslwater-resources-per nits/wastewater-branchlrround-water-
protectionlground-water-approved-iniectants. All other substances must be reviewed by the DHHS prior to use.
N/A �� 4.0"( V
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: David Brown
NC Well Drilling Contractor Certification No.:
Company Name: Yadkin Well Co. Inc.
City: Hamptonville
2195
3 tiy %t'twl fka-t
2 72 36C
State: NC
Day Tele No.: 336- 96 - 54 rf cl O
Contact Person: Den./ ci /,3 vo W y.
Zip Code: 27020 County: Yadkin
Cell No.: 3363748736
EMAIL Address: AQUI J & n.,". & a ci k.t" EN a (4, Fax No.: 3 2G- S164- i1 1; ca a�
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: N/A
Contact Person:
EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
Closed -Loop Geothermal Well Nolif4caEion Rev. 3-1-2016
Page 2

PROTECTION — Provide a brief description of how ally (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:
NIA Sir✓ Fence i 1' (1(eU i t "P el e4 d fr., /i
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J. VARIANCE — Pursuant to 15A NCAC 02C .0241 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 at https://nedenr.s3.amazonaws.com/s3fs-
public/Water%20Quality/Aquifer%20Protcction/GPU/Geothermal VarianceRequestFormFil lable-
20130805 pdf
K. SIGNATURES — The following section is to becompleted as required below or by that person's authorized
agent. 15A NCAC 02C .0211(e) 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.
"I hereby cerz?fy, under penalty of law, that 1 have personally examined and am familiar with the information
ation
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the it formation is true, accurate and
complete. I am aware that there are significant penalties, including the possibility offrnes and imprisonment,
for submitting false information. 1 agree to construct, operate, maintain, repair, and U.-applicable, abandon the
injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
Leon Meyers Digitally signed by Leon Meyers
Date: 2022.07.06 12:21:03 -04'00'
Signature of Property Owner/Applicant
West Forest LLC I Leon Meyers Project Mgr
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 3

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