WI0800571_Application Attachment_20240215

North Carolina Department of Environmental Quality — Ulvtsion of Water Resources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These irells ore " perariltrd br rarer " card do not require all individual permit when constructed ill uccordance 11 i1h
the r-rrle,s of ISA NCAC o2C.0200. This notice must be_._submitted prior to con.struclion.
GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS
As described in 15A NCAC 02C .0222 these wells circulate potable water only or a mixture of potable eater 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 Submittaly {Vill Be Returned As Incomplete.
DATE: February 6th , 20 24 PERMIT NO.: (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 «ells:
(2) ❑■ Direct Expansion (as per I SA NCAC 02C .0223) Number of Wells: 4
B. STATUS OF WELL OWNER(S) (choose one)
(1) ■❑ Single Family Residence Submit this form two (2) business days prior to construction.
(2) ❑ Busincss,'Organization Submit this form 30 days prior to construction.
(3) ❑ Govemment: 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 -
Nathan Eta] Bageant
Mailing Address: 1468 Eastbourne Drive
City: Wilmington
Day- Tele No.:
EMAIL Address:
State: NC Zip Code: 2e41t County: New Hanover
Cell No..
Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: R04500-001-047-000
12)
County: New Hanover
Physical Address (ifdifferent than mailing address): 802 Bailey Harbor Lane
City: Wilmington
County New Hanover Zip Code: 28411
Clused-1 oop Geothennal MVI Nouftcation Re% 3-1-2016 Page 1

E. REQUIRED MAPS, PLANS, AND SPECIFICATIONS
(1) A site maps must be submitted. It must be scaled or othen0se 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 tell system.
,VOTE. In most caves, all aerial photograph ondlor plat nutp of Ilse property parcel shoving property Hiles and
structures can he obtained and downloaded front the applicable county GIS website. Typically, the property cast
he searcher! b), owner ttante ar address. The location of the ivells in relationt to property bottntlariev, lsntl.ces, septic
tanks and fteldv, and other welly, etc. can then he drawn in by haunt. Also, a 'layer' can he 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
htto:/ideo.nc.sov/about/divisionsiwater-resources/water-resources-permits/wastewater, branch/around-water-
protection/ground-water approved-injectants. All other substances must be reviewed by the DHHS prior to use.
Norte, water only.
G. 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
Citv: Hampstead
Dav Tele No.: 91 O-270-2919
Contact Person: fames Cornette
State: NC Zip Code :28441 County: Pender
Cell No.:
EMAIL Address: [e-mail] Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: ThermalTran, Inc.
Contact Person: Ryan Mattox EMAIL Address: [e-mail]
Address: 3420 Enterprise Drive
City: Wilmington
Zip Code: 28405 State: NC County: New Hanover
Office Tele No.: 910-444-4877 Cell No.: 910-547-1782
Fax No.:
Closed -Loop Geothermal Well Notification Rev 3-1-2016 l7q;-, 21

I. PROTECTION — Provide a brief description of bow 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 littas://ncdenr.s3.amazonaws.com/s3fs-
puhhe/Water%200ua&/Aquifer%20Protection/GPU/GeothermaIVarianceRequestFormFillable
20130805.�df
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 significantpenalties, 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 ap rienances in accordance with the 15A NCAC 02C 0200 Rules. "
SI-PatarJe o Prop Owner/Applicant
Print or Type FuMZ6une
Signature of Authorized Agent, if any
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:
(2)
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]
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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LEGEND
Proposed Geothermal Loop Locations
Note: Adapted from New Hanover County GIs
on 1/02/2024.
TITLE: Proposed Geothermal
N Loop Locations
JOB: SCALE: DATE: DRAWN BY:
sot Bailey Harbor Lane 1" = 50' 2/6/24 BLM
Applied 12e5ource FIGURE:
Management,kv 1
Hampstead, NC 284h3