WI0800569_Application Attachment_20240215

lvortn [:arolina Impartment of Environmental Vualtty — lltvlslon of Water resources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are "permitted by ride " and do not require an individual permit x-lmn constructed in accordance with
the rules of 15A NCAC 02C.0200_ This notice nrust he 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.
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 Informadvit. Illegible Submittals Will 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 wells:
(2) ■❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells: 2
B. STATUS OF WELL OWNER(S) (choose one)
(1) ❑ Single Family Residence 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(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:
Orton Plantation Holdings, LLC
Mailing Address: 11 Times Square 37th Floor
City: New York State: NY Zip Code: 10D36 County: New York
Day Tele No.: [phone] Cell No.:
EMAIL Address: [e-mail] Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 1440000111
County: Brunswick
(2) Physical Address (if different than mailing address): Orton Plantation PL 231396 and 23114
City: Winnabow county Brunswick Zip Code: 28479
Closcd-Loop Geothermal Well Notification Rev 3-1-2016 Page

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 clearly
an 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 well system.
NOTE: Inmost cases, an aerial photograph and/or plat neap 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, eta can then he 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
htW:).1d%xvi ! v's` �w t r- saurc�s/w ter-r ources- rmi+wastewater- ranchluraunri-wxi
prat ctis grotjttd-wa#cr- roves#-inje:tamis. All other substances must be reviewed by the DHHS prior to use.
None, water only.
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: James L Corvette, PG
NC Well Drilling Contractor Certification No.: 2424 - A
Company Name: Applied Resource Management Contact Person: Jim Corvette
City: Hampstead State: NC Zip Code: 2"43 County: Pender
Day Tele No.: 910-270-2919 Cell No.:
EMAIL Address: [e-mail] Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
rr t
Company Name: NSA r 6+r« vi P�ch-t C 4 i r
Contact Person, _ % G�I o _ _ �V , , ,( EMA_ 1L Address: kktyt o Otrti Sg oice . cc o F.
Address: 5h t L 0 uG 1 n.e.yS Af t 4.4
City: _ I/U e lwtic Zip Code: 4'640S State: AJG County: Nzw n o ✓t•�
Office Tele No.: qq l I I Cell No.: Q Iv Fax No.:
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 2

I. 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:
No threats.
J. VARIANCE — Pursuant to I SA NCAC 02C .0241 the Director of the Division of Water Resources may grant
a variance from applicable well construction or operation standards provided that:
(I) 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 technicaIIy 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
2IJiirlatrUS}elityf,ii r°142i}pratec ign/GPl_#, se t erroa]Vu�ianceequestirm
2 13080 -pdf
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent, 15A NCAC 02C• .021i(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, trader penalty of law, that I have personally examined and am familial 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 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 appurtenances in accordance with the 134 N 'A C 02 7 02 1 Rules. "
Signature of Property OwnertAppileant
Print or Type Full Name
Signature of Authorized Agent, if any
� t Al Sri( D A144 AAA
Print or Type Full Name
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 3

Is. SUBNUTTAL INSTRUCTIONS — Submit one copy of the completed notification package to the each of the
following:
(1)
(2)
The Division of Water Resources' Water Quality Regional Operations Section (WQROS) Re ionaI
Office serving the area in which the injection well facility will be located:
WINSTON-SALEM
ASHEVILLE
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 Offlee
610 East Center Avenue, Suite 30)
Mooresville, NC 28115
Telephone: [phone]
Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone: [phone]
Fax: (9I9)571-4718
RALEIGH
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]
The County Environmental Health Department in which the injection wells will be located.
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Pair 4

N LEGEND
Proposed Geothermal Loop Locations
Please note that wells are spaced at 20' apart.
Note: Adapted from Brunswick County GIS
on 1013123.
TITLE: Proposed Geothermal
Loop Locations
JOB: I SCALE: DATE: DRAWN BY:
Orton Sports 1" = 600' 2/6/2024 BLM
Center
FIGURE:
Applied Resource
Management, P. C.
HampetwW, NC Z8443

6" Borehole
Ground Surface cI
--4'
1 " HDPE Loop
Thermex
Grout
TD = 300'
TITLE; Geothermal Closed LOOP FIGURE:
Applied Resource Diagram
7
Management, P. C. JOB: SCALE; DATE; DRAWN BY:
Hamer NC 2W&4403 Orton Sports As Shown 1013123 BLM
Center