WI0100696_Geothermal Well Construction Application_20230928

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North Carolina Department of Environmental Quality-Division of Water Resources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERA TE INJECTION WELLS
These wells are "permitted by rule·• and do not require an individual permit when construcled in accordance with
the rules of L'iA ,\CAC D1C .01{}Q. This notice must be submitted prior to consq·11ction.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS As described in I SA NCAC 02C .0222 these wells circulate potable water only or a mixture of potable water and peiformance-enhancmg additives as part of a geothcnnal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS As described in 15A NCAC 02C .o223 U1ese wells circulate a refrigerant gas as part of a geothermal heating and cooling system
Print Clearly or Type lnformatwn. lll<->gible S11hmittals Will Be Rebm1e,I As lncompfet&
DATE: 9/28 , 2023 PERMIT NO.: _______ (to be completed by DWR)
A.TYPE OF GEOTHERMAL CLOSED�LOOP WELL TO BE CONSTRUCTED (sclcct one)
(l)[ii Aqueous (as per l5A :NCAC 02C .0222)
(2)0 Direct Expansion (as per 15A NCAC 02C .0223)
.B. STA TVS OF WELL OWNER(S) (choose one)
Numberofwells: 2 @400
Number of wells: ____ _
(I)
(2)
(3)
Ii] Single family Residence 0 Business/Organization D Government: State
Submit this form two (2) business days prior to construction. Submit this form 30 days prior to construction. Municipal__ County__ federal* __ *Submit this form 30 d:iys llrior to construction
C.WELL OWNER(S)-for single family residences, list all person.s listed on the property deed. For all others,
list I.he name of the Business/Agency 1lfil! person and title with delegalod sign ature authority:
Mailing Address: _\L<\.>..:a,.,,_,.(...,.;.........;Q;,=:....,:'-'::,,o-\'e..,!.....e:...,,,__\½......_r:...· • ..... , ¾-=:�n___""""-'-w----"' ........ -,-------------
City: WM"\N\C.o,r State: {\)e_ Zip Code:�'l�ounty:. _________ _
Day TeleNo.: __________ CeJlNo.: {'i1'.\)S<d1 ·· -:)�3'1
EMAILAddress: _____________ fa.,._No.:. ___________ _
D.PHYSICAL LOCATION OF WELL SITE
(I)Parcel Identification Number (PIN) of well site: 9 :J � i G a_ '-l5 D5 C;:ic<::,OO
County: V)'-""�i.'V\ "b-e-
(2)Physical Address (if different than mailing address): :)� � Cppk �: s::l� a._J ·
Closed-Loop Oeor.ltcrrnal WeU Nolificatio11 Rov. 3·1-2016
WI0100696