WI0700546_Notice of Intent to Construct_20231205

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are `permitted by rule" and do not require an individaual permit when constructed in accordance with
the rules of 15A 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.
1j
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
eoohn g system.
Print Clearly or Type Information. IQegible Submittals Will Be Returned As Incomplete.
DATE: 12/5 , 2023 PERMIT NO. (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED
(1) Aqueous (as per 15A NCAC 02C .0222): x Number of wells:
(2) Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER (choose one)
(1) Single Family Residence x_ 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.
C. WELL OWNER — For single family residences list the property owner(s). For all others, list name of the
business, organization, or government agency kind person delegated signature authority:
Susan Carman
a
Mailing Address: 119 Pudding Pan Lane
City: Southern Shores
Day Tele No.:
State: NC
Zip Code:. 27949 County: Dare
✓
Cell No.:
EMAIL Address: [e-mail] Fax No.:
PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) or well site: 986716748767
County: Dare
(2) Physical Address (if different than mailing address):
City:
State: _ Zip Code:
UIC/Closed-Loop Geothermal Notification (Revised 8/5/2013) Page 1

E. MAPS, PLANS, AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site -specific map showing the locations of the following:
a Proposed injection well locations a Septic systems and associated spray irrigation
® Buildings sites, drain fields, or repair areas
m Property boundaries
® Surface water bodies ® Existing or potential sources of groundwater
m Water supply wells contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services' 'Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at http//portal nedenr.org/web/wg/aps/L�vpro. All other additives require approval prior to use.
G.
H.
Geosafe antifreeze @ 15%
WELL DRILLER INFORMATION (if latown)
Well Drilling Contractor's Name:
NC Well Drilling Contractor Certification No.: 4200A
Company Name: Virginia Energy Services Contact Person: Art Tatem
City: Knotts island State: NC_ Zip Code:27950_ County: Curriluelc
Day Tele No.: 252-455-7710 Cell No.: 252-202-9490
EMAIL Address: Fax
HEAT PUMP CONTRACTOR INFORMATION
Company Name: unlmown
Contact Person: E
Address:
City:
Office Tole No.:
Zip Code: State: County:
Cell No.: Fax No.:
WC/Closed-Loop Geothetmal Notification (Revised 8/5/2013) Page 2

SO I' I T 58' W 196. 07'
PUDDING PAN LANE
SITE PLAN
LOT #206 SCALE, 1' = 30' -0'
CHI CAHAUK
SOUTHERN SHORES

/
1, WILLIAM S, JONES. JR., R;L.S., CERTIFY THAT UNDER MY DIRECTION AND SUPERVISION THJS PLAT WAS DRAWN FROM
AN ACTUAL FIELD LAND SURVEY MADE OY ME FROM INEOAMAT11 .. (S �IEFERENCE HEREON ANb THAT THE RAVO OF
PRECISION IS 1J I0,OOO+. WITNESS MY HAND AND SEAL THJS I l�''DAY OF
!'.A °PinAqr
'1'.Wm'Y�c+9vlY�ai^r•ram.Y•-•-w � - A` .l...
VICINITY MAP
N.T.S.
CONC, C, 14MC.W.
7-
LOT Zoe
1YILLIAM J"..JONCS JH( „H.J..J./ML-2232 SEAL S
p ,,,q
L',,,
Septic 6"7"yo roved
L,-2532 s`
Pc ' q9n suriV °e'
y° Dare Caun�
,,�,gM.C..p��,.
Health Department
i}�
M�
Oneett ppyy^9�..�������/��pp���� pp� .��J:9�S/��•±'c./�-�1
"'CaV'IYIiY!'R:�Yil�dp&zAwjm
.
By._
I
�i•' M
GONG.C.MON.
a /
J®��.64
�'
�,®%;wpm �P
'�•..
^..�,
n y
G1
F' GECKS
r-e neca a.
FIRM ZONE­X
PATURAL GROUND ELEV,924.EIa
4IF
/ey1MEJDW�N6
p0.1FIpS II[..—
.
LOT 206
oN Ip'
CONC,. 9cRE
.-...
fit...
�
,•"�' �'
�::
TRfJNSfOxAfEIt
'ME.a A� %6. - 6.5�
C,D,•vC, MON, .
CONC. MOI•I: - 7& °� SEX/ST. /KON P/N
--- — _- - �pp Ne71,1.uu11 PAN. LANE
�r pryt)Uj)le ,p
SURVEYFOR

I, WILLIAM 5. JONCS, JR., P.L.S., CERTIFY THAT UNDER MY DIRECTION AND SUPERVISION THIS PLAT WAS DRAWN FROM
AN ACTUAL FIELD LAND SURVEY MADE BY ME FROM INFORMATION 9,�'"•'R'EFERENCED HER ON, AND THAT THE RATIO OF
' D
PRECISION IS 1: 10,000*, WITNESS MY HAND AND SO —THIS �AY OF '
WILLfA S. JO .. R , P,L '. L•2532 117
a
COMMON ELEMENT pA �
VICINITY MAP
N. T. S.
CONC• MOM, r
prWEEM
li
46
0NlNG M.Cf, � 1
t
'Ex 1.5T.
CONO, A?ON
0.651
SEAL
�? L"2532
CON, MOM.
-•^ I/ E! v p*F �• 94.44r
xl.M a7. D NG PAN LANE �
C(,7NCMOM, lv 1'1 + � i �
V .Tn
SURVEY FOR
LOT 205, CHOCAHAUK
Of AT AAAW 7_ AAP'-g 9
CONC. MON,

7, WfL1lAM S. ✓ONES. JR., R,L,S., CERTIFY THAT UNDER MY DIRECTION AND SUPERVISION THIS PLAT WAS DRAWN PROM
AN ACTUAL FIELD LAND SURVEY MADE BY ME FROM INFORMATI NJ.4�FlEFERENCED EREON. AND Tf T THE RARO or
PRECISION 15 I:Io,v0o+. W/TNESS MY NAND AND SEAL THIS
LOT
1 (bAY OF ,Y�. IS�
4rDT—\�
184 ' LOT I95
-NWit L[AM S. JdN R., R.L.. L 3T
CONC. MON,, •pM.p,� + I -..,.....
:ONc, MON
� C
a4a
r "` R=5.3a.551 '^Ek15r �"t
IRON PIN s '
N �QI t
I $.C45
z S
.s/awLro. VICINITY MAP
1
'� ` SYN44 'jn•• ,v.rs.
t2 STOJL :• .
FFtAME '.. Z
23 `�R
^ *,�pgn4n4rgqrr, OWA'LLINS ,
oN PIL/N�� .`� y�.l� ,i
ZJ 0rx,ry H,o,)M p'/,' M1 4 Sxfs7 d -7
O�•�aQr4y1}S�TE��10
IRON FIN GA4 6
1 L-2532
y ® �qn'.
LOT 187 ' S
Trs-^ e aF a
MOIVVML>NY"
.. v t5
cn
cd
E•xlsT -.. 2Z J®
caNc, Ma/✓ ` / Pa
1
�'q
9 SURVEY FOR I q p JOHN 61 VIRGINIA C®L LIG,AIe
LOT 196, CHICAHAUK
PLAT BOOK r, pAOE S
TOWN OF SOUTHERN "SHORES
DARE COUNTY, NORTH CAROLINA
✓7.94FD! 5-28-9$ SURVEYED 1 - 0 - 9r8
fiEV/aEOr w 3-98 FOUNDATION SURVEY 2-27-98
ma's: AS BUILT SURVEY S- 28- 9s WlLLIAM S. JONES, JR., R.L.5., P.A.
dRM LONE X 2000 CROATAN HIGHWAY
'N # 8O.9@s7(�7457c P.O. Box 2942
•L4, GROUND �� c�& I°Rod'OSEU NDU.5�'� �, 13 KILL DEVIL HILLS, N.C. 27946
^^-�----• 4�15 /A1A) 441.3073
E,1." S •• 9eA ,. SCALE . POLE
bWtd bY.
Plb. 9&Qi