WV0700173_Application_20230928

NOR•liI CAROLINA DDEPART.WNT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF M1 NT TO CONSTRUCT OR OPERATE INJECTION N%TLLS
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its describedin 15A a iCAC; 02C.0222 tl ev.-e.ILs cir adatepotablevrater oulycra
pedsamar a-mlame rag addi ives aspen of a geodiemsad heating mid
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GECOTBF:'Ik MAL DIRECT EXTANSIt?N CLOSED -LOOP WELTS
A. described in 15ANCAC 02C M23 these vaells coculate a refrigerant gas as part of a geoffiermal hea ing anti
cooling splear,
fvifC"learh'orTips7a,ftraatoafiioax.II111BeRdnowed'AsTncomplel.
DATE-- September 27 - 2023 PERhIIT NO. (to be completed by ID1ti'R)
A. TYPE OF GEM LIERMALCLCDSEIDLCDt7PWELL TOBECONSTRUCTED
(1) Aqueous(asperjANC°ACtl2C.112227: x Number of wells: 17
(2) Direct EzpausimCasper 15ANCA.Ct12C.Ii2233 Number ofwells_
B. STATUS OF VVELL RD'4bNER (slaoose one)
(1) Suagle Family Residence = Sula nit this term two (22) business days prier to eonstmetion.
(2) Ba dumi rgsnization Submit this faun 30 dT sp tior to construction.
(3) Caoveanmeut State_ MumcipaL CounW_ Federal Submitiliaform30days
prior to construction.
C. Iti`E3.•LL OWNER — For single iaudy residences list the property uwner(s). For all others,list name of the
brains, tugamzataon, or gov emment agency and person deltga.ted signature auftnty:
MailiugAdthns: 9100humsRivamatchDrive
City Ridmomi State: VA. Zip Carle 23235 C^atutty:
I3ay Tele No.:
1140 1ltlMICIF.�
D. PHYSICAL LOCATION Or WELL SITE
(1) ParcelIdentifwzhonNumber (PIN)ofweltsite, 9561119M1400
County: _ IDne
(2) Physical Address (if diBarcul than maiiling address):
172 OoemBlvd
City: soutluanShores State:: NC Zip, Code: 27949
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(1) Maps must he scaled or otherwise accurately indim abe distances and. usientatiom of features located
within 250 feet of the injection well(s). Label all features clearly and. include a north srrow. Attach a
site -specific map showing the locations efthe following:
• Proposed injection wclllocations • Septic, systems and associated spray irrigation
• Buildings sites, drain fields, or repair arms
• Property boundaries.
• SYnfacewater bodies • Existing or potential sources of groundwater
q watersupplywas contamination
(2) Plans and specifications of the surface and subsurface eonatruction details of the well system.
F. TIT'ES AND CONCENTRATIONS QF 1AD DI WES — List any additives that will be used and then
conoentrations. Only additives that the Department of Health and Human Services" Division of Public Health
determines do riot adversely affect luiman baatth $ball be used. A list of approved additives can be found
online at lat%'ffportal.siodem.nrglMs of tv grap&tnv we,. All other additives require approval prior to use.
Gewafs antifreeze @Pd 15%
Gt '& IML ID' INFiiP,AUTION (ifkno z)
Well I1rilhug Contractor's Name: Arthur I. Tatem
NC WellDrillmgContractor Csrtifica€ionNo,: 4200A
CoarpanyNarne. Virginia E""egy Serviecs Coutact Person. Art Tatem
City: Knolls Island State: NC_ Zip Code-27954_ County: Cur tmmek
Day Tele Nu.: _ 804-749-1962 _ Cell No_: 252-202-9490,
ENLAiL A ddrem Fax No.:
IL HEAT PUMP CONT1"mACT4ItINFOrdfATION
CnmpanyName: Ne dAr km1
Contect Pessern: He Norris El AEL AMmss: A r+i ni h a9 rnm
Address P 0 Box 217
City: harbinger Zip Cade: 27941 State: NC Comity:
Office Tele Nm: 252A91-2673 Con No.: FamNo_:
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DocuSign Envelope ID: BgC17E67-2EC4-4D5B-A5AD-BC07B66F01 FC
I. 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 pan and providing silt
fence if run off is a danger. Bore boles will be fully grouted to protect from aquifer cross contamination
VARIANCE —Pursuant to 15A NCAC 02C .0241 the Director of the Division of Water Resources may pmmt
a variance from applicable well construction or operation standards provided that:
(1) ruse 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.ncdeni-.or =/wf eb/wg/ans/pwpro/permit-
applications
K. SIGNATURE, S — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .0211(c) 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 penally of law, that 1 have personally examined and ant familiar with the information
submitted in this document and all attachments thereto and that, based on nay 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 offines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if'applicable, abandon
the injection well and all related appurtenancego�ifsSfdX&Jdince with the I5A NCAC 02C 0200 Rules. "
VAa 1-bu�
Si} mlture ofI %pMgY0irJliE rApplicmA
David Traub
Print or Type Pull Name
Signature of Autborimil Agent, if any
Print or Type Pull Name
UIC/Closed-Loop Gconiomml Notification (Revised 8/5/2013) Page 3

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
VARIANCE APPLICATION FOR INJECTION WELL CONSTRUCTION STANDARDS:
GEOTH RMAL 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://portal. ncdenr. org/web/wq/aps/gwi)ro/permi t-applications#geothoml&ps
Print Clearly or I)pe Inforrnatton. Illegible Submittals Will Be Returned As Incomplete.
DATE: 09/27 , 2023 PERMIT NO. (to be completed by DWR)
A. WELL OWNER — For single family residences list the property owncr(s). For all others, fist name of the
business, organization, or government agency and person delegated signature authority:
David 'rrau b
Mailing Address: 9100 James Riverwatch Drive
City: Richmond State: VA Zip Code: 23235
Day Tele No.:
EMAIL Address:
B. PHYSICAL LOCATION OF WELL SITE
C.
Cell
Fax
(1) Parcel Mentiftcation Number (PIN) of well site: 986819701400
County: Dare
(2)
Physical Address (if different than mailing address): 172 Ocean Blvd.
City: Southern Shores
WELL 'D,RILLER INFORMATION (if known)
Well Drilling Contractor's Name: Arthur J. Tatem
NC Well Drilling Contractor Certification No.. 4200A
State: NC Zip Code: 27949
Company Name: Virginia Energy Services Contact Person: Kimberly Krinsky
City: Knolls Island State: NC Zip Code:2795. County: Currituck
Day Tele No.: 804-749-1962 Cell No.: 252-202-9490
EMAIL Address: [e-mail] Fax No.:
UIC/Closed-Loop Geothcvmal Variance Request (Revised 8/5/2013) Page 1

DocuSign Envelope ID: 89C17E67-2EC4-4D5B-A5AD-BC07B66F01 FC
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.
See attached page for variance request information.
E. SIGNATURES
S' nature of Well Driller
Ar-l- LAr e-f Tc+crv�
Print or Type Pull Name
DowGianed by:
VAVJ firms
Signature ( F�wneY:
David Traub
or Tvne Full Name
Per 15A NCAC 02C .0241 the Director oJthe 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. 15013-23 within 60 days after receipt of the decision.
IRC/Ctmod-Loop Goothcmml Variance Request (Revised 8/5/2013) Page 2

PAGE 4 of 4 —Traub 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 proposed
residential structures and the onsite and neighboring operational drain fields are
impeding the location of the geothermal closed loop field to be located within the
residential and septic system setback distance respectively. We are proposing to
locate the vertical bores towards the center 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.