WI0100690_Aqueous Closed Loop Geothermal Well Construction Application_20230822

Ntn1h Carolin:\ l>cpnrtmcnt ofF.nvlronmcntnl Qu11llly- Division ofWutcr Rc�ourcu
NOTIFICA TlON OF INTENT TO CONSTRUCT OR OPERATE IN,JF.CTJON WELLS
Th<\<,' ire/Lr Ill\' "p,:rn1111,•d h, rnl� .. t111</ do 11r11 IW/llill' c,11 /m/11'i<l11t1/ 1x•r111/1 11 /,e11 r,,m/r11,·1cd /11 m:cr,rd1mce 11'/th

the nth•,· ,f /JI . .\C,(<. nx O�l}!J., 11,/s 1wtln• wrm Ii,• .w{lfltll/\'c/ urfw m ,·orn·1me1im1
GF.OTlfF,Rl\1AL AOllf.OUS CLOSEl>-LOOI' Wf.l.LS
As d�s.:ribcd in 15 \ '\;C,\C 0lC ,O�ll these wells circ11l111c potublc water onl y or n mixture or potable waler and
p.:rfon11ancc-cnlrnncing additives as ,,�rt oru gcolhcrmnl hcatlnl( 11ml ,uoling system.
OR
GEOTHERMAL DIRF.CT F.XPANSION <:;I.OSF.D-LOOP WF.LU,
As dcscn"bcd in IS.\ ;-{C,\C 0�C ,022.J these wells circulate a refrigerant gas a5 part of o geothcnnal heating and
cooling system.
Print CJ�11rfy M Typl! lnfomwl/011. 1/1,•g/bll! Suhmltlal.� 11111 Rt' Ne1ur1ml A.� l11compll!lc.
DATE: /r;u, b '].,1,.,- , 20 'l,, 7 PERMIT NO.: _______ (10 be completed by OWR)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO OF. CONSTRUCTED (select one)
t I) �queous (as per 15A NCAC 02C .0:!�1 ) Number of wells: 3 Q 2lJD 1
{:!) 0 Direct Expansion (as per 15A NC AC 0lC .022�) Number ofwi:11s: ____ _
B.ST A TUS OF WELL OWNER(S) (choose one)
Ii] Siniµc: Family Rcsid.:nce 0 Busines!./Org:mization 0 Govemmem: State __
Submit this form two (2) businrss days prior to construction.
S11b111lt this form JO days prlnr to construellon.
Municipal__ c,,unly __ Ftderol• __ •Submll this form JO dA)'S prior to constniction
C.WELL OWNER(S) -For single family r�idenc1.'S, list a!.! pcrnins listed on lhc property d<.-cd. For all others.
liM the name of the Rusincss/Agcncy i!!1l! person and tit I.: with delegated signature authority:
Ellis, Lisa; Christy. Donald
Mailing Address: • 263 Hemlock Loop
C ,ty: -��9� Valley __ S1at.:: NC i'.i 11 Codc:28Z51 Comny: Haywood
IJ;i yTelc: No.: 2B?S:i8::;c;21:l8i!.>3!;j•9;u,2=2::::.4 ______ _
F,MAIL Addre55: [e-mail]
D.l'HVSICAI, U)CATION Of WF.1,1, SITE
(.'ell Nu.: __________ _
fnx No.,:. ___________ _
111 Parcel ldc111ificutio11 Number lPIN) ol'wcll &ite: 9721637286()9000
C'oun1y: -�mbe ____ _
(:?I l'hy1ical Addrm llf ditfcu:nl 1h1111 111ulll1111 oddNn); ___ 8 Aiyer Aun -·----------· ----------·-------
C'ily: Asheville ____ c.·,,ulll)' Buncombe
WI0100690