WI0100678_Aqueous Closed Loop Geothermal Well Construction Application_20230307

PocuSi�n _Envelope ID: F100ED19-666B-4D06-9FF4-EB7620EB0583
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERA TE 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 constn1ction.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLSAs described in ISA 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 WELLSAs descri bed in I SA NCAC 02C .0223 these wells circulate a refrigerant gas as part of a geothermal heating and cooling system.
Pri11t Clearly or Type /11/ormatio11. Illegible Submittals Will Be Returned As /11complete.
DATE: 03/07/2023 .20_ PERMIT NO. ________ (to be completed by D WQ)
A.
B.
TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED / (!) Aqueous (as per 15A NCAC 02C .0222): k Number ofwells:3 k,'(,Use .?001 I 13wfiQ
(2)Direct Expansion (as per 15A NCAC 02C .0223) ___Number of wells:__ · -0
STATUS OF WELL OWNER (choose one)
(I)Single Family Residence x_ Submit this form two (2) business days prior to construction.(2)Busin ess/Organization __ Submit this form 30 days prior to construction. (3)Governmen t: State Mun icipal__ Coun ty__ Federal __ Submit this form 30 days
prior to construction.
C.WELL OWNER -For sin gle family residen ces list the property owner(s). For all others. list name of thebusiness. organizati on , or government agency and person delegated si gnature authority:
Monte Dale Rector. Patricia Cooper. Rector Family Trust
Mailing Address: --�1=2=2_C�h=a�tt�oo_g_a�R�u=n�----
City: Hen dersonville State: NC Zip Code:28739__ Coun ty: Hen derson
Day Tele No.: ______________ _ Cell No. :. __ 9"-'7=2'-"-9-'-7.:....9--"-9=86=9 ___ _
EMAIL Address: mon [e-mail]
D.PHYSICAL LOCATION OF WELL SITE
Fax No.: ____________ _
(I)Parcel Iden tification Number (PIN) of well site:_9693441980 _____ _ APR 2 8 ?023
County: Henderson. __________ _
(2)Physical Address (if different than mailin g address): ---"9-"-9 -'-7_,_D=a=n c=i=ng;;,,.=.B=ea=r_,_D=r---#M.o�--��-J-i..C .... Pi-:'4"',11.!t',,SHRS
----------------1.NNWQ;;���
City: Hendersonville State: NC Zip Code: 2879 2 Op�J <i)
DWQ/UIC/Closed-Loop Geothemial Notification (Revised 4/30/2012) Page I
WI0100678