WI0100674_Aqueous Closed Loop Geothermal Well Construction Application_20220525

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 perfonnance-enhancing additives as part of a geothermal heating and cooling system.
OR
GEOTHERMAL DIRECT EXP ANSI ON CLOSED-LOOP WELLS As described in 15A NCAC 02C .0223 these wells circulate a refrigerant gas as part of a geothem1al heating and cooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Retumed As Incomplete.
DATE: $ J Q5 ,20 J.� PERMIT NO.: ________ (to be completed by DWR)
A.
B.
C.
TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED (select one)
(1) �queous (as per 15A NCAC 02C .0222) Number of wells: !). @? 3oD F--f-(2)D Direct Expansion (as per 15A NCAC 02C .0223) Number of wells: ____ _
STATUS OF �L OWNER(S) (choose one)
(1)�ingle Family Residence Submit this form two (2) business days prior to construction. (2)D Business/Organization Submit this form 30 days prior to con5truction.
(3)D Government: State__ Municipal__ County__ Federal* __
*Submit this form 30 days prior to construction
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:
Mailing Address: 304:: fhrooJ V \ Sta Lo..n <. .. City: f\shfM. \l.{ State; �G Zip Code:2i'S-04 County: 8, \hCC\<Y'\ C,, .-e__Day Tele No_: 33D-3l\l ·-d 26 ?-Cell No.; '320 � 39 \ �ooo (
EMAILAddress: i\uh.\:t"tl..@bu;ldw,'!-b laXl«:f, FaxNo.; __________ _
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D.PHYSICAL LOCATION OF WELL SITE
(1)Parcel Identification Number (PIN) of well site: q JJ I L3 lJ7 l-tf g Ooo c) C)County: �l.,hCOM be.,
(2)Physical Address (if different than mailing address): 3o< 0 6 road v; s J.e__.,_ Ln
{\City: JFi;o;; l lL County &, 1 r\CC}rn fa( Zip Code: �g-g-�(
WI0100674