WI0700540_Application_20230816

NORTII CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These fvells are `permitted by rule"and do not require an individual permit when constructed in accordance moth
the rules of 15A NCAC 02C.0200. This notice must be submitted prior to construction,
GEOTII<ERMAL AQUEOUS CLOSED-LOOP WELLS
As described.in 15A 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
GEOT1WRMAL DIRECT EXPANSION CLOSED-LOOP WELLS
As described in 15A NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Pritit Clearly or Type 1i; ormation. Illegible Submittals Will Be Returlled As Incomplete.
DATE: 08/16 . 2023 PERMIT NO. to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C.0222): x Number of wells: 4
(2) Direct Expansion(as per 15A NCAC 02C.0223} Number of wells:
B. STATUS Or, WELL OWNER(choose one)
(1) Single Family Residence_._x_Submit this form two(2)business days prior to construction.
(2) Business/Organization Submit this form 30 days prior to construction.
(3) Goveriunent: State Muu icipal Coiuity Federal Submit this form 30 days
prior to consta uedon.
C. WELL OWNER—For single family residences list the property owner(s). For all others, list name of the
business,organization,or govermnent agency acid person delegated signature authority:
Richard Clark&Kelly Wiley
Mailing Address: 2268 Salem Road
City: _Schulyer State: VA Zip Code:_22969 County: Nelson _
Day Tele No.: Cell No.: 757-6_17-3885___
EMAIL Address: richallenclarlc agmail.com Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site: 891504932571
County: Pasquotank
(2) Physical.Address(if different than mailing address):
199 Dogwood Trail
City: _ Elizabeth City _ State:NC Zip Code: 27909
IIIC/Closed-Loop Geothemil Notification(Revised 8/5=13) Page 1

E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features Iocated
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
O Property botuidaries
9 Surface water bodies • Existing or potential sources of groundwater
• Water supply wells contamiruation
(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 http://port Ll.nedenr.or web/wq/a s/ w_o. All other additives require approval prior to use.
Geosafe antifreeze L&15%
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Arthur J.Tatem
NC Well Drilling Contractor Certification No.: 4200A
Coinpany Name: Virginia Energy Services W Contact Person: Art Tatem
City: Knotts Island State: NC— Zip Code:27950_ County:Currituck
Day Tele No.: _804-749-1962 Cell No.: 252-202-9490
EMAIL Address: Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION -
Company Name: unknown
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Cell No.: Fax No.:
UIC/Closed-Loop Geothermal Notification(Revises{8/51-)M) Paget

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:
_Protection will be provided during the drilling process by containing fluids in a pit or 1)an Ind providing silt
fence if r uti off is a danger. Bore holes will be fully grouted_ to protect fi•om aquifer cross contamination
J. VARIANCE—Pursuant to 1 SA 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 http://portal.ncdenr.or /wg eb/wc aps/Wypro/permit-
applications,
K. SIGNATURES--The following section is to be completed as required below or by that person's authorized
agent. 1SANCAC 02C.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, arnder 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 fnes 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 I SA.NCAC 02C 0200 Rules."
Signature of]'roperty Owncr/A,ppticant
Richard Clark
Print or Type Full Name
Signature ol'Authorimd Agent,if any
Print or Type Full Name
UIC/Closed-L.aop Cecthenrwal Notification(Revised 8/5PM13) Page

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
VARIANCE APPLICATION FOR INJECTION WELL CONSTRUCTION STANDARDS:
Q { (_ 12C.0222}01Z
GEOTHERMAL iJ CLOSE'D- WELLS 15_ 1`i___ (,.
GEOTI ERMAL DIRECT EXPANSION CLOSED-LOOP WELLS 15A NCAC 02C .0223
This form MUST accompany the Closed-Loop Geothermal Notification Form available online at
http://Portal.nodenr.ort;/web/wq/ales/gwnro/permit-applications4geotlierp Apps
Print Clearly or 7:ype dnfbrmation. Illegible,Vubmittals Will Be Returned As lncamplete.
DATE: 08/16 , 2023 PERMIT NO. (to be completed by DWR)
A. WELL OWNER—For single family residences list the property owner(s). For all others, list name of the
business,organization,or government agency acid person delegated signature authority:
Richard Clark& Kelly Wiley
Mailing Address: 2268 Salem Road
City: Schulyer State: VA zip Code:22ss9 County:Nelson
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
B. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site:891504932571
County Pasquotank
(2) Physical Address(if different than mailing address): 199 Dogwood Trail
City: Elizabeth City State:NC zip Code: 27909
C. WELL DRILLER INFORMATION(if known) _
Well Drilling Contractor's Name: Arthur J. Tatem
NC Well Drilling Contractor CertificationNo.: 4200A
Company Name: Virginia Energy Services Contact Person: Kimberly Krinsky
City. Knotts Island State: NC zip Code:27151 County:Currituck
Da.y Tele No.: 804-749-1962 Cell No.:252-202-9490
EMAIL Address: [e-mail] Fax No.:
UIC/Closed-Loop Geothennal Variauec.Request(Revised 8/5/2613) Page I

D. REASON FOR VARIANCE REQUEST — Include type of well(s) to be constructed; rule for which the
variance is being requested; description of how the alternate construction will not endanger human health and
welfare and the environment;and reason why construction and/or operation in accordance with the standards is
not technically feasible and/or provides equal or better protection of the groundwater.
Sea attached page for variance request information.
E. SIGNATURES
Signatnr�►i'Well T)r•]llet-
Print m•Type Tnll Name
Signature of Well(Owner
Richard Clark
Print or Type Full Name
Per ISA NCAC 02C .0241 the Director of the Division of Water Resources may require submittal of
information deemed necessary to make a decision on the variance, may impose conditions as part of the
decision, and shall respond in writing to the request within 30 days of receipt of the variance request. A
variance applicant who is dissaiisfiled with the decision of the Director may commence a contested case by
filing a petition as described in G.S. 15013-23 within 60 days after receipt of the decision.
UIC/Closed-hoop Geothermal Vnriance Request(Revised 8/5/2013) Page 2

PAGE 4 of 4—Clark/Wiley Variance Request
The proposed geothermal aqueous closed loop system for the address listed on
page 1 is in need of a distance requirement variance. The location of the residential
septic system along with the existing CAMA and wetland setbacks, topographic
limitations and proposed residence positioning, are impeding the location of the
geothermal closed loop field to be located within the building perimeter and septic
system setback distances respectively. We are proposing to locate the vertical
bores along the left side of the property. In this manner we can obtain maximum
safety distance from the septic system and achieve a very high degree of human
health and environmental protection. The vertical bores will be grouted from top
to bottom with high quality, low permeability grout using the tremie method to
assure the bore hole will be a solid plug of environmental protection. The bore
holes we construct will be the safest points of ground water intrusion on the
property when compared to the native geology. We will construct triangulated
borehole construction maps for each hole for permanent locating and install metal
detection tape in all of the horizontal connecting trenches to facilitate easy bore
hole locating if ever needed for any reason. Due to the fact a geothermal vertical
closed loop is constructed in the same manner as an abandoned well and does not
move water, does not contain well screens or casing and is not an actual water well,
future service will not be required.