WI0800567_Application_20231018

North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are `permitted by rule" and do not require an individual permit when constructed in accordance with
the rules of I5A NCAC 02C .0200. This notice must be submitted prior to construction.
GEOTHERMAL 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.
JIN
GEOTHERMAL 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.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: October 17th 2023 PERMIT NO.:
A.
B.
C.
(to be completed by DWR)
TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(1) ❑■ Aqueous (as per 15A NCAC 02C .0222) Number of wells: 10
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells: _
STATUS OF WELL OWNER(S) (choose one)
(1) Al Single Family Residence Submit this form two (2) business days prior to construction.
(2) ❑ Business/Organization Submit this form 30 days prior to construction.
(3) ❑ Government: State Municipal County Federal*
*Submit this form 30 days prior to construction
WELL OWNER(S) — For single family residences, list all persons listed on the property deed. For all others,
list the name of the Business/Agency and person and title with delegated signature authority:
David Dubberly
Mailing Address: 30253 Camp Parkway
City: Curtland State: NC
Day Tele No.: 804-640-0005
EMAIL Address: [e-mail]
D. PHYSICAL LOCATION OF WELL SITE
(1)
(2)
Zip Code: 21111
County: Southampton
Cell No.:
Fax No.:
Parcel Identification Number (PIN) of well site: 539306384053000
County: Carteret
Physical Address (if different than mailing address): 7505 Ocean Drive
City: Emerald Isle
County Carrteret
Zip Code: 28594
Closed -Loop Geothermal Well Notification Rev, 3-1-2016 Page 1

E. REQUIRED MAPS, PLANS, AND SPECIFICATIONS
(1) A site maps must be submitted. It must be scaled or otherwise accurately indicate distances (in feet)
and orientations of features located within 250 feet of the injection well(s). Label all features clearly
and include a north arrow. Attach the site -specific map showing the wells in relation to the locations of
the following:
• Buildings • Septic systems and associated spray irrigation sites,
• Property boundaries drain fields, or repair areas, if any
• Surface water bodies, if any • Existing or potential sources of groundwater
• Water supply wells, if any contamination, if any
(2) Plans and specifications of the surface and subsurface construction details of the well system.
NOTE: In most cases, an aerial photograph and/or plat map of the property parcel showing property lines and
structures can be obtained and downloaded from the applicable county GIS website. Typically, the property can
be searched by owner name or address. The location of the wells in relation to property boundaries, houses, septic
tanks and fields, and other wells, etc. can then be drawn in by hand Also, a `layer' can be selected showing
topographic contours or elevation data.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. NOTE: Only injectants approved by the NC Division of Public Health, Department of Health
and Human Services can be injected. Approved injectants can be found online at
http:Hdea.nc. aov/about/divisions/water-resources/water-resources-permits/wastewater-branch/izround-water-
G.
H.
rotection/ground-water-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
None, water only.
WELL DRILLER INFORMATION
Well Drilling Contractor's Name: James L Cornette, PG
NC Well Drilling Contractor Certification No.: 2424 - A
Company Name: Applied Resource Management
City: Hampstead
Day Tele No.: 910-270-2919
EMAIL Address: [e-mail]
State: NC
HEAT PUMP CONTRACTOR INFORMATION
Company Name:
Contact Person:
James Cornette
Zip Code: 21441 County: Pender
Cell No.:
Fax No.:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
Zip Code:
Cell No.:
State: County:
Fax No.:
Closed -Loop Geothermal Well Notification Rev, 3-1-2016 Page 2

I. PROTECTION — Provide a brief description of how any (a.) water supply wells, (b.) surface water bodies, or
(c.) 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 https://ncdenr.s3.amazonaws.com/s3fs-
nublic/Water%200uality/Aauifer%20Protection/GPU/GeothermalVarianceReauestFormFillable-
20130805.pdf
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 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, under 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 fines 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 15A NCAC 02C 0200 Rules. "
C&&)y T>. Z��&44
Signature of Property Owner/ licant
Print or Type Full Name
Signature of Authorized Agent, if any
Clinton D. Dubberly
Print or Type Full Name
Closed -Loop Geothermal Well 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' Water Quality Regional Operations Section (WQROS) Regional
Office serving the area in which the injection well facility will be located:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Telephone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5043
Telephone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Telephone: [phone]
Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone: [phone]
Fax: [phone]
-AND-
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Telephone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Telephone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
(2) The County Environmental Health Department in which the injection wells will be located.
Closed -Loop Geothermal Well Notification Rev, 3-1-2016 Page 4

BLACK SKIMMER
ROAD
0
QCEAN
DRIVE
—SEA GULL ROAD
— L I VE OAK
STREET
VICINITY MAP N.T.S.
N
#g32
. .'oos•.••• 4 DOWNSPOUT FOw,
ROOF DRAINAGE
" OVERFLOW
�t %�---�" TO RAIN TANKS
OVERFLOW
DOWN SPOUT
(NTS)
tt9 1 9
"X" CUT IN THE INLET/OUTLET
FABRIC TO ALLOW PIPE
PIPE/TANK
INTERFACE EOTEXTILE
FABRIC
!EMEND
Prop oed G e othe rm al Lo op Lo cati
-CORROSIVE HOSE
MP OR TAPE USED TO
TEN LINER TO PIPES
PREVENT BACKFILL
M ENTERING
UCTURE
)TEXTILE
3R I C OVER
INTANK!
WOODEN STEPS EXTEND
2.6' INTO SIDE
SETBACK
k
I
k
k
PLAN --
VIEW
FRONT VIEW
DIMENSIONS SHOWN
ARE ,NOMINAL. REFER
VIEW TO MODULE DATA
GEOMETRY: LENGTH = 26.97 IN. (685 VIM)
WIDTH = 16.06 IN. (408 MM)
HEIGHT = 17.72 IN. (450 MM)
STORAGE VOLUME = 4.22 CIF
VOID INTERNAL'.VOLUME: 95%
PITMISEM
SINGLE MODULE
DATA
LOAD RATING: 34 PSI, (MODULE ONLY) -
H-20, (WITH ACF COVER
SYSTEM)
MATERIAL:
85% RECYCLED
44 RAIN TANKS
TOWN OF r ISLE RUNOFF•CALCULATIONS
• • ! : i I .IA AI M
•:•••mIll M I!Jd,.47A • M: .R III
::7e\LUye\klkfiTwti�����I�L�131f�i1e�3•lf1l : u ►�i6lf�ia� ai &Lidhnj U4e JUG1k! A ; �7i1iT11ktl�Es
e
CONSTnCTION
NORTH
TITLE:
E,
2$ 't
N 23,
N
NCPIN: 539306384053000 '
D.B. 1688 PG. 067
Proposed oth errs aI
LOOP LOcations
J B: SCALE: D I' N ; 'C
7505 cea R
7`4
Hampwr4aol, NC, 2 -Z
iRA1NN BY:
6LM
FiGuRE:

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
VARIANCE APPLICATION FOR INJECTION WELL CONSTRUCTION STANDARDS:
GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS (15A NCAC 02C .0222) OR
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS (15A NCAC 02C .0223)
This form MUST accompany the Closed -Loop Geothermal Notification Form available online at
http:Hdeq.nc. gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection/ground-water-applications
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: October 17th 12023 PERMIT NO.: (to be completed by DWR)
A. WELL OWNER(S) — For single family residences, list all persons listed on the property deed. For all others,
list name of the business/government agency and person and title with delegated signature authority:
David Dubberly
Mailing Address: 30253 Camp Parkway
City: Curtland State: NC Zip Code: 23837 County:
Day Tele No.: 804-640-0005 Cell No.:
EMAIL Address: [e-mail] Fax No.:
B. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 539306384053000
County: Southampton
C.
(2) Physical Address (if different than mailing address):
City: Emerald Isle
7505 Ocean Drive
County Carteret Zip Code: 28594
WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: James L Comette, PG
NC Well Drilling Contractor Certification No.: 2424 - A
Company Name: Applied Resource Management Contact Person:
City: Hampstead
Day Tele No.: 910-270-2919
EMAIL Address:
State: NC
Zip Code: 28443 County: Carrteret
Cell No.:
Fax No.:
Closed -Loop Geothermal Variance Request Rev. 3-1-2016 Page 1

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.
There will be seven closed loop geothermal wells that would come within 10' of the house.
E. SIGNATURES
C2424 - A
Signature of Well Driller and Certification No.
Print or Type Full Name
Signature of Well Owner
Clinton D. Dubberly
Print or Type Full Name
Signature of Well Owner
Print or Type Full Name
Per 1 SA 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
dissatisfied with the decision of the Director may commence a contested case by filing a petition as described in
G.S. 150E-23 within 60 days after receipt of the decision.
Closed -Loop Geothermal Variance Request Rev. 3-1-2016 Page 2

F. SUBMITTAL INSTRUCTIONS — Submit one copy of the completed variance request attached to the
Notification of Intent to Construct or Operate Injection Wells to the Division of Water Resources Regional Office
serving the area in which the injection well facility will be located:
Asheville Regional Office Washington Regional Office
2090 U.S. Highway 70 943 Washington Square Mall
Swannanoa, NC 28778 Washington, NC 27889
Telephone: [phone] Telephone: [phone]
Fax: [phone] Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5043
Telephone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Telephone: [phone]
Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Telephone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
Closed -Loop Geothermal Variance Request Rev. 3-1-2016 Page 3