WI0100706_Aqueous Closed Loop Geothermal Well Construction Application_20230512 (2)

g-;2,0 3& 'y�.&// :JS-02,7 's-),9; 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 individual 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 p erformance-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. lllegible Submittals Will Be Returned As Incomplete.
DATE: __ �M=a_._y�l=2 __ �, 20_23_ PERMIT NO. ________ (to be completed by DWQ)
A.TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE CONSTRUCTED
(1) (2)
Aqueous (as pe r 15A NCAC 02C .0222): ✓-Numbe r of wells: .J @3.51> 1
Direct Expansion (as per 15A NCAC 02C .0223) __ _
B.STATUS OF WELL OWNER (choose one)
Number of we lls: __ _
(1)Single Family Residence 0ubmit this form two (2) business days prior to construction.
(2)Business/Organization __ Submit this form 30 days prior to construction.
(3)Governme nt: State__ Municipal__ County__ F e deral __ Submit this form 30 daysprior to construction.
C.WELL OWNER -For single family residences list the property owne r(s). For all others, list name of the
busine ss, organization, or government agency and person dele gated signature authority:
Kathy and Chris Hughes
Mailing Address : ___ 1,..,8'-'S=umm ==er'-'S=t'-------------------
City: Ke nnebunk State: _ME_ Zip Code: 04043_ County: __ Y�o=1=·k ______ _
Day Tele No.: 207-985-1133 Cell No.:207-502-0480 ____________ _
EMAIL Address: [e-mail]�------
D.PHYSICAL LOCATION OF WELL SITE
Fax No.: ____________ _
(1)Parcel Identification Number (PIN) of well site :_962444512700000 __
County: Buncombe. __________ _
(2 )Physical Address (if different than mailing address): 423 Walnut Valley Pkwy _______ _
City: Arden
DWQ/UIC/Closed-Loop Geolhenual Notification (Revised 4/30/2012)
State : NC Zip Code: 28704 _____ _
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