WI0700539_Application_20230815

North Carolina Department of Environmental Quality—Division of Water Resources
NOTIFICATION TO CONSTRUCT THERMAL CONDUCTIVITY TEST WELLS
Thermal conductivity test wells are used to determine the amount of heat that the subsurface may
transmit in a given depth interval for the purpose of designing geothermal heating and cooling systems.
Pursuant to 15A NCAC 02C.0230, thermal conductivity test wells shall be subject to the regulatory
requirements applicable to geothermal aqueous or direct expansion closed-loop wells designed to serve
single family residences,
These wells are `permitted by rude"and do not require an individual permit when constructed in
accordance with the rules of 15A NCAC 02C.0200.
This notice must be submitted at least two(2)business days prior to construction.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: June 27th ,20 23 PERMIT NO. (to be completed by DWR)
A. TYPE OF THERMAL CONDUCTIVITY TEST WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C .0222): X Number of wells: 2
(2) Direct Expansion(as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence
(2) Business/Organization X
(3) Government: State Municipal County Federal
C. WELL OWNER(S)—For single family residences,list all persons listed on the property deed. For all others,
list name of Business/Governmental Agency and name of person and title with delegated authority to sign:
Brian Farley
Mailing Address: 6100 Tower Circle,Suite 1000.
City: Franklin State: TN Zip Code: 37067 County:
Day Tele No.: 850-212-0217 Cell No.:
EMAIL Address: Barrett.smithOacadiahealthcare.com Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site: 89880
County: Pitt County
(2) Physical Address(if different than mailing address): 2820 McGregor Downs Road
City: Greenville County Pitt Zip Code: 27834
E. MAPS,PLANS,AND SPECIFICATIONS
Thermal Conductivity Test Notification Rev.3-1-2016 Page 1

(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 sites,
• Buildings 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 h ://de .nc. ov/about/divisions/water-resources/water- uali -re ional-o erations/ oundwater- rotection. All
other additives require approval prior to use.
Water only.
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: James Laine Comette
NC Well Drilling Contractor Certification No.: 2424-A
Company Name: A lied Resource Management.PC Contact Person: James Comette
City: Hamostead State: NC Zip Code: 28443 County:Pender
Day Tele No.: 910-270-2919 Cell No.:
EMAIL Address: [e-mail] Fax No.: 910-270-2988
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: TBD
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
Thermal Conductivity Test Notification Rev.3-1-2016 Page 2

1. 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:
No threats
J. VARIANCE—Pursuant to 15A NCAC 02C.0241 the Director of the Division of Water Resources 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 h=://deii.nc.gov/about/divisions/water-resources/water-
quality-re 2ional-operations/sroundwater-protection
K SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C.0211 a 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 1 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. 1 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 appurtenance in cordance with the 15A NCAC 02C 0200 Rules."
gnature of P, perty Owner/Applicant
Brian Farley, General Council - Acadia Healthcare
Print or Type Full Name and Title
Signature of Authorized Agent,if any
Print or Type Full Name and Title
Thermal Conductivity Test Notification Rev.3-1-2016 Page 3

L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Resources Regional Office serving the area in which the injection well facility
will be located:
WINSTON-SALEM
-I RALEIGH
WASHINGTONASHEVI -----
0SVILLRE
SJ^
FAYETTEVILLE
Washington Regional Office
Asheville Regional Office 943 Washington Square Mall
2090 U.S.Highway 70 Washington,NC 27889
Swannanoa,NC 28778 Telephone: [phone]
Telephone:[phone] Fax:[phone]
Fax: [phone]
Wilmington Regional Office
Fayetteville Regional Office 127 Cardinal Drive Extension
225 Green Street,Suite 714 Wilmington,NC 28405
Fayetteville,NC 28301-5043 Telephone:[phone]
Telephone: [phone] Fax:[phone]
Fax:[phone]
Winston-Salem Regional Office
Mooresville Regional Office 450 W.Hanes Mill Rd.,Suite 300
610 East Center Avenue,Suite 301 Winston-Salem,NC 27105
Mooresville,NC 28115 Phone:[phone]
Telephone:[phone] Fax:[phone]
Fax:[phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh,NC 27699-1628
Telephone: [phone]
Fax:[phone]
AND
(2) County Environmental Health Department in which the injection well facility will be located.
Thermal Conductivity Test Notification Rev.3-1-2016 Page 4

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5.75" Borehole
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1 1/4" HDPE Loop
Graphite
Grout
TD =400
TITLE: Geothermal Test Loop FIGURE:
Applied Resource Specifications
Management, P. C. JOB: SCALE: 1 DATE: DRAWN BY: 3
Hampsmead,NG28443 230292 As Shown 6/27/2023 BLM