WI0100681_Aqueous Closed Loop Geothermal Well Construction Application_20230510

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&'ZC $7' 04 ,S-'( NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS Tliese 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 no/Ice must be submllled prior to conslruclion, GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS As described in ISA NCAC 02C .0222 these wells circulate potabJe water only or a ntixtu.re of potable water and perfonnance.-enhancing additives as part of a geothennal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS As described in 15A NCAC O2C .0223 these wells circulate a mfrigerant gas as part of a geothermal heating and cooling system.
Pi'lnt Clearly or Type Information, Il1eglhle Submllta/s W1ll Be RelllmedA.s Jncompleie.
DATE: PERMIT NO. _______ (to be completed by DWQ)
A.TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1)
(2)
Aqueous (as per ISA NCAC 02C .0222): � Direct Expansion (as per 15A NCAC 02C .0223) __ _
B.STATUS OF WELL OWNER (ohoose one)
Number of wells: _J__ Number of wells; __
Single Family Residence ✓ Submit tWs form two (2) business days prior to construction.Business/Organization _ Submit this fonn 30 days prior to construction. (I) (2) (3)Government: State_ Municipal_ County_ Federal_ Submit this form 30 daysprior to construction.
c.WELL OWNER - For single family residences list the property owner(s). For all others, list name of tltebusiness, organization, or government agency and person delegated signature authority:·
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Fax.No.:. __________ _
D.PHYSICAL LOCATION OF WELL SITE
(1)
(2)
Parcel Identification Nwnber (PIN) of well site: X'>l'� -C\0-\Co�· ()6()
County: 1'n"'-s'4l\16."'f...
Physical Address (if different than mailing address): / �1' 3 C,t J. Mov...\\.+G. •� {l..a.J..
State:� Zip Code: U 3:tl
DWQ/UIC/Closed-Loop Ooo!hcrmal Notification (Revised 4/30/2012) Pago l
WI0100681