Rutherford UIC Deemed Permitted 2015

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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL 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 AOUEOUS CLOSED-LOOP WELLS
___�RECSL LRi ed in 15 NCAC 02C.0222 these wells circulate potable water only or a mixture of potable water and
Division f W r esou perfo ance-enhancing additives as part of a geothermal heating and cooling system.
JAN 2 0 2015 OR
GEOTHERMAL DIRECT'EXPANSION CLOSED-LOOP WELLS
Water Ouslit F ReAlPO 1;MF1VI 5AI NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geotherma[heating and.
AshevillP Regional Office cooling System.
Print`Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: / , 20 )3 PERMIT NO.V 0 3 3J (to be completed by DWQ)
O 0
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
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(1) Aqueous(as per 15A NCAC 02C .0222): L/ Number of wells:_�`�
(2) Direct Expansion(as per 15A NCAC 02C.0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence Ll�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:
.MailingAddress:
City: 144ARolem State: Zip Code; County:
Day Tele No.: ���, Cell No.:_ C
EMAIL Address: ��(,Cl-�lanax No.:
D. PHYSICAL LOCATION OF WELL SITE
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(1) Parcel Identification Number(PIN)of well site:
County:
(2) Physical Address(if different than mailing address):
City: State:NC Zip Code:
DWQ/UIC/Closed-Loop Geothermal 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:
• Proposed injection well locations • Septic systems and associated spray irrigation
• Buildings sites,drain fields,or repair areas
• Property boundaries
• Surface water bodies • Existing or potential sources of groundwater
• Water supply wells contamination
(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 i�ttit: ,.��rt�i_:_ca;n .�� _t� ►�.:,��l_��t�<<<��1 r�. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION(if known) 0--
Well Drilling Contractor's Name: c-DS� +W0
NC Well Drilling Contractor Certification No.: 1 )—►T
Compan Name. l Contact Person_ Alapi
City: i/1_ State: Zip Code;&)A3 County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:
Contact Person: (. tier- — EMAIL Address t aS .� 1( ►�o� � ►�e►�,
Address:
City: _ CX1-0 l e Zip Code: ��JYv State: RvC-County: v nLds k
Office lele No.. Cell No. $,)k 7/2- 7 y,PP^Fax No.: CC-ak—
DWQI000osed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

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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 construction of the wells:
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 evaluation of the request.
The variance request form can be accessed online at littp://p_ortal.ncdenr.ora/web/4s d/ans;gwpro/permit-
a )lications
IC SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent. 15A NCAQ02C .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 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 appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
Signature of Property Owner/A licant
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQMIC/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:
WtNSTON' ALEM
RA
LEIGH
ASHEVILLE - WASHINGTON
ORES, L
FFAYETTEVILLE =
Asheville Regional Office Washington Regional Office
2090 U.S.Highway 70 943 Washington Square Mall
Swannanoa,NC 28778 Washington,NC 27889
Telephone:[phone] Telephone:[phone]
Fax:[phone] Fax:[phone]
Fayetteville Regional Office Wilmington Regional Office
225 Green Street,Suite 714 127 Cardinal Drive Extension
Fayetteville,NC 28301-5043 Wilmington,NC 28405
Telephone:[phone] Telephone:[phone] ;
Fax:[phone] Fax:[phone] f' -
Mooresville Regional Office Winston-Salem Regional Office
610 East Center Avenue,Suite 301 585 Waughtown Street
Mooresville,NC 28115 Winston-Salem,NC 27107-2241
Telephone:[phone] Phone:[phone]
Fax:[phone] Fax:[phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh,NC 27699-1628
Telephone:[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 hiip://www.ncalhd.ora/county.htm.
DWQ/U1C/Closed•Loop Geothermal Notification(Revised 4/30/2012) Page 4

AUG 2 6 2019 E-
NZ7RTFICt�ROT,INElDfaPARTM>;NTE7F.BNVIRQNNJEI�ITAN3N LRESO.t3RCL' rations
NOTIEI'I `ATIOI�T 7[`0 G() +I '7[�ff1C')f"�'HE MMAL CONI�UC V ! ��: ,o
Thermal-conductivity test wells:ar� used to deter'time the amount cif heat"that.Me subsea;f ace way
transrll ft iiz a-giverz.ile��tlt iittei'Va'I f0i`the,j�l/1"t703e Of I�CS�gllitZg geOtltG'7'111a1.�1�Ct�lYt�AI1Cl Gt101119g S}?S�L')T1S,
1?zrrsicarzt to ISA.I+1�ttC�02C:OZ30.ehe�iiidl,cvi2tuctivtty lest tvel�s sha�X be satlJ1ect�o tFae z�egctlata�y `'
r'epirements applicable to geotharrrrat ccqueoux or'aij'eet ezprntslott:,a Wed-loop we designed tv ser ve
sfugfe fandl-y-resfdences..
T11esa welds cwa"peri flood by-rule".and:clo not require an,indivfdital perniftwhen con*wbteclfn
aceor,.'dance with the rules of X 5A 1VCAC 02C,0200
T'hlc-notice mast bo subtrdtled tit least M)o(2 huShiecs ddc.rs pi far to catrsfrircflnrt.:
01711 Cfen)'(Y,`orTi)p L1#Si bmiltah 1011- eltettifiteclrfslttecrrrejrlete,
t
luo": d (to be completed by UW-R)
A. TYPE OT TJEIP..:(tMAL CONDI7CTIVIT:Y TESTVVELL TO BE CONSTRUCTA 0 �
Agcteoim(as per°1.5A NCAG w A222) Nuinbor of welts;
(2)' Direct>Jxpalision(as Per.15A NCAC 02G.U223) _ _ Nulnbe�:gfwells;
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B, STATUS.OF IVVELL-ONM,R,(choose one);
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( ) S.siigle Fairizly Rescieiic@
(2)' 73.usiness/Qxgartization
(3y Government: State Municipul_ CounlyX Federal `
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C. W1uLI.OWN T -For single-family residences list the tope�ty owner(s). For all others,.list.natiio of'die, 1
busluess((organiza&{ ij ugoveinmenf fagefto`y nd pemon delegated signdfure authority::
Iviailuig_Address; �' !n M,r, S'1"
City. cw t✓, L date; . Zip Code .: Couuty: �„ / '%
Day Tale No.: 2 ® 2 lr Ce11,No.:
BMAIL A ddress; Fax No _ .
D. P"% AL LOCATION OF WI Iia ITE
(1)i Parcel Identik catlonNumber(Pn_of well situ; _. . .
County: aQs�nast�_ -
(2) Physical.Address(if'different 41im mailingaddiess}: . !
City. State;INC Zip'Codo: / : 07 I. 3
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r. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately Indicate distances and orientations of features located
within 250 feat of the ft Jection well(s), Label all features clearly and include a north arrow. Alfach a t
site•-specific map showing the locations of the following:
l
)
Proposed injection well locations o Septic systems and associated spray irrigation
a Bitilclings sites,drain fields,or repair areas
Property boundaries e- l
® Surface water bodies S i (Un a L+xisthig or potential sources of groundwater
a Water supply wells contamination I l
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(2) Plans and specifications of the surface and subsurface construction details of the well system. {
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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 (lo not adversely affect human health shall be used. A list of approved additives cat). be found
online at hilp:Npoi-fal.nedenr,or web/wq/Aps/�wpKo, All other additives require approval prior to use.
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G. WELL DRILLER MYORMA.TIO1`1(if known) I
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.: U-7�,Q
Company Name: Ko �k,K I/Je tki - Contact Person: 1
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City: s Ji State: Svc Zip Cocle:217J90County. tf't dry
Day Tele No.: J-7c W"�- � � Cell No, 7g-P'7 3'
EMAIL Address:Dqui d �1.•at�a 4)I aJ ar..W> e4 ,W ex No,;
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1-I. HEAT PUMP CONTRACTOR INFORMATION
Company Name: c1,6�1 +^
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Contact Person:_ EMAIL Address: l
Address: _ l
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.: :
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L PROTECTION—Provide a brief description of how(1)water supply wells;(2)surface water bodies;and(3) j
septic systems and associated spray Irrigation sites,(train fields, or repair areas within 250 feet of the proposed
Injection wells will be protected during construction of the wells: /
j '4"i0.L7'o,,e yA Ma :(, A t j 200 - `F'e G�f Ts yes.ill— C3
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r�r CC u��I C a f: f. (l�l L. p. !.a 6 C16 I
J. VARIANCE—Pursuant to 15A NCAC NC,02111 the Director of the Division of Water Resources may grant j
a variance from applicable well construction or operation standards provided that:
(1) use of the woll(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 orthe j
proposed construction provides equal or better protection of the groundwater. I
Any variance request should accompany*submittal of this notification to expedite evaluation of the request,
The variance request ferin can be accessed online at lax//portal.ncdenr,orp,/tiveb/wq/aps/arvpro/permit- j
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:
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(a) for a corporation; by a responsible corporate officer; j 9
(b) for a partnership or sole proprietorship: by a general partner or the proprietor,respectively; f
(e) for a municipality or a state,federal, or other public agency: by either a principal executive l
officer or ranking publicly elected official; ' x
(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, Wants them signature
authority,and is signed and dated by-the applicant.
"I hereby certVy, under penalty of law, that I have personally examined and mn familiar ivith the information
submitted in this doovinent and all attachments thereto rid that, based on my inquiry of those indfvlduals
inwnediately responsible for obtaining said it fora, believe that the information is true, accurate and
complete. I can aware that there ar-e significant pencluesftncluding the possibility of fines and knprisomnehf,
for submitting false information, I arnyconstr at, g erate, maintain, repair, and if applicable, abandon
the Infection rrell and all related apprr nar ces in cc (dance rvitl7 the 15.4 NCAC 02C 02002ules."
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Si ature of Prop •ty Owner/Applicnnf
8C9 TC a M {
Print or pe Full Mine 1
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Signature of Authorized Agent,if any J.
Print or Type F01 Mine
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