WI0100245_Regional Office Physical File Scan Up To 9/23/2022

i, i ( C�-C- � 5
FED 2 7 2CID
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATU L A��Ri &glonal ®fflce-
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJE IY i c fora
-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.
103.1
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: !' 1 w , . 20 /.i PERMIT NO.- to be completed by DWQ)
& TYPE OF GEOTHERMAL CLOSED-LOOP'WELL TO BE CONSTRUCTED
(1). Aqueous'(as per 15A NCAC 02C .0222): 1-,-- Numberof wells:. 7
(2) Direct.Expansion. (as per 15A NCAC 02C .02-23) - Number of wells:
B. STATUS OF WELL OWNER (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 - For -single family residences list the property owner(s): For all others, list name of the
business, organization, or government agency and -person delegated signature authority:
x l �l ®�,r► 6 $ 14. /17 R. S o q
y` Mailing Address:. 3101 C..ke vy GA1g.h /.ir�t✓ c
X City: . A14 kS i State: `Zip Cod — ?County: . %AeWj
`° Day Tele No.: -G 6 -! 2/ Cell No.:-7 13 a .S' 8 L - rY o k
EMAIL Address: Vyh4.r ow /if q Ma, !tea® N, Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel- Identification Number (PIN) of well site: 'a r,t -;3 `I✓�r(�, yla�„� C+,��<<r� /:fL
County.: Jg oks o -n OF
(2) Physical Address (if different than mailing address):
City:
State: NC Zip Code:
DWQ/pIC/Closed-Loop.Geothemial Notification (Revised 4/30/2012) Page 1

E. MAPS, PLANS., AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet- of the injection well(s). Label all features clearly and include a north arrow. Attach a
site -specific map showing the locations of the following:
• P
roposed injection well locations eptic systems and associated spray irrigation sites,
• drain fields, or repaid' areas
uildings
• p
roperty boundaries xisting or potential sources of groundwater
• contamination S
urface water bodies
• W
ater supply wells
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES - List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services' Division of Public Health
determines do not adversely affect human health. shall be used. A list of approved additives can be found
online at htty://i)ortal.n6denr.org/web/wq/aps/Mro.. All other additives require approval prior to use.
G.
H.
G 70 ll%G D V. 6;7,,jL
WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name:. 012 a!`Aed- G�U .-00-L .i
NC Well Drilling Contractor Certification No.: ,) V7/-
Company Name: �f �cf"; y` "I Contact. Person: /foor"7—
City: ; 2�� rl State: /f:� Zip Code3 County:
Day Tele No.: BZ8 . �.?� 69 2- Cell No.: 609 -
EMAIL Address: % m. G C rti oAr % b 0 9/Y0'-d' & No::
HEAT PUMP CONTRACTOR INFORMATION
Company Name: // � !7(
Contact Person: u C-
Address:
City: C�'lutrlc�at
Zip Code: State: NC_County: . U 6•inGz:,,Ati&e-
Office Tele No.: -,�% �/_,� SZ CCell No.: 62 8- 701/. - (U 81 Fax No.:
,6YK
DWQ/UIC/Closed-Loop Geothermal Notification (Revised 4/30/2012) Page 2

cl, -� y LLt �- -eK I/ -
� f �

I. PROTECTION — Provide a brief description of how (1) water supply wells; (2) surface water bodies; and (3)
septic systems and associated -spray irrigation -sites; drain fields, or repair areas. within 250 feet of the proposed
injection wells will be protected during constructionof the wells:
�- �r- �c c • 0-L( Rate : 4tedla-ho �1 -v/�64 -17a'r-e- Icr :fa
J. VARIANCE — Pursuant to 15A NCAC 02C .0241 the Director of the Division of Water Quality may grant a
variance from applicable well .construction or operation standards provided that:
(1) 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 evaluationof the request.
The variance.request form can be accessed online at htty://t;ortal.ncdenr.org/web/wq/aps/R"ro/permit-
applications
K. SIGNATURES — The following section is to be completed 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) fora partnership or sole proprietorship: by a general partner or the proprietor, respectively;
(c) fora 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 certify, under penalty of law, 'that I have personally examined 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 obtaining said' information, I 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 a urtenances in accordance with the I5A NCAC 02C 0200 Rules."
Signature of Property Owner/Applicant
Print or Type Full Name
A. - ?C-
Signature of Authorized Agent, if any
k
Print or Type Full Name
DWQ/UIC/Closed=Loop Geothermal Notification (Revised 4/30/2012) Page 3.

L. SUBMITTAL INSTRUCTIONS —_Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Quality Regional Office serving the area in which the injection well facility
will be located:
Asheville Regional Office
2090 U.S.. Highway 70
Swannanoa, NC 28778
Telephone: [phone]
Fax: '[phone]
Fayetteville Regional Office
225 Green Street; Suite 714
Fayetteville, NC 28301-5043
Telephone: [phone]
Fax:.[phone]
Mooresville Regional Office-
6 1'0 East Center Avenue, Suite 301
Mooresville, NC 28115
Telephone: [phone]
Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center.
Raleigh, NC 27699-1628
Telephone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Telephone: [phone]
Fax:.[phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Telephone: [phone]
Fax: [phone]
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107-2241
Phone: [phone]
Fax: [phone]
(2) County Health Department in which the injection well facility will be located. A list of county health
departments can be found online at httv://www.ncalhd.org/county.htm.
DWQ/UIC/Closed=Loop Geothermal Notification (Revised 4/30/2012) Page 4