WI0501115_Application_20230627

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North Uarohna Department of Environmeniat vuatity — ulviza i yr rr4rc1 RtcauuKa. a
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by rude " and do not require an individual permit when constructed in accordance trilh
the rules of 15A NCAC 02C .0200. This notice must be submilled prior to construction.
GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS
As described in I5A NCAC 02C .0222 these wells circulate potable wateronly or a mixture of potable water and
performance -enhancing additives as part of a geothermal heating and cooling system.
OR
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 Submiirals�fWiill Be Returned As Incomplete.
DATE: 6/26 2023 PERMIT NO.: A10\rOfi-5�' (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(1) ® Aqueous (as per 15A NCAC 02C .0222) Number of wells: 6-300'
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER(S) (choose one)
(1) 0■ Single Family Residence Submit this form two (2) business days prior to construction.
(2) ❑ Bus inesslOrganization Submit this form 30 days prior to construction.
(3) ❑ Government: State Municipal County Federal*
*Submit this form 30 days prior to construction
C. 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:
l N 00 —E 7`
A
Mailing Address: I M ri QL 1 Q-T-44 LN ry�
City: Apf-x State: #'C Zip Code1162kounty:
Day Tele No.: C n I2A AS S 37 _ Cell No.: S} YA �
EMAIL Address: S-r2 -QA4 Fax No.:
PHYSICAL LOCATION OF WELL SITE
(l) Parcel Identification Number (PIN) of well site: 1718077710
County: Wake
(2) Physical Address (if different than mailing address):
4924 Foxridge Chive
City: Raleigh County Wake Zip Code: 27614
Closed -Loop Geothermal Weil Notification Rc�. 3-12016
Page I
of4 6/27/2023, 10:08 AM

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 clean
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 a 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. Inmost 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
htt :%/de .nc. ov/about/divisions/water-resotirces,,water-resources- erinii /wastewater -branch/ ound-Nvater-
rotection/ round -water -a roved-injectants. All other substances must be reviewed by the DHHS prior to use.
WATER
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Joshua Robertson
NC Well Drilling Contractor Certification No.: 2461-A
Company Name: Triad Drillers Inc. Contact Person: Joshua Robertson/Steve l
City: Elon State: NC Zip Code: 2272-4 County: Caswell
Day Tele No.: 336 421-3513
EMAIL Address: [e-mail]
H. HEAT PUMP CONTRACTOR INFORMATION
Cell No.: 336 453-4527
Fax No.: 919 779-9294
Company Name: Bowman Mechanical RDU LLC
Contact person: Joshua Robertson/Steve Bowman EMAIL Address: triaddrillers2000@gmail, con
Address: 145 Technical Ct. [e-mail]
City:
Garner
Office Tele No.: 919 772-2759
Zip Code: 27529 State: NC County:
Cell No.: 919 427-1425
Wake
Fax No.: 919 779-9294

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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:
Silt fencing in place, with catch basin. No known wells or surface water within 250'.
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, ttpsalnedenr.s3.amazonaws.com.='s3 fs-
pubtic!Water%200uahly%Aquifer,o20Protect ion/GPU/Geothertna[VarianceReguestFormFiltab le-
20130805.pdf
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .021 l(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 penalty of late, that I have personally erumined 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 possibilh), 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 urtenan ?,l accordance with the 15A NCAC 02C 0200 Rules. "
a e of Prope A1fMMk M4----
e5v- C f -sN)wrmQ r4r Low &v pr-�:)
Print or Type Full Name
Signature of Authorized Agent, if any
Closed -Loop Gcothcrmai Wc11 Notification Rev. 3-1-2016
Print or Type Full Same
Page 3
3 of 4 6/27/2023, f 0.08 AM

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:
WINSTON-SALEM
RALEIGH
ASHEVILLE
�1 MQQRE
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]
FAYETTEVILLE
-AND-
WASHINGTON
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

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FOUNDATION MOTE
-THIS SURVEY IS FOR FOUNDATION VERIFICATION ONLY.
1T DOES NOT CONFORM TO G.S.47,30 ASAMENDEfI AND
IS NOT INTENDED TO 6E USED FOR%ONVEYAKE OR
SALE OF THE PROPERTY SHOWN HEREON.`
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