WV0700175_Notification of Intent to Construct_20240123

Nortn l:aro ina Department of r.nvironmentat yuattry — Dtvislon of water 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 suhmilled 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.
10111
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS
As described in 15A NCAC 02C .0223 these wells circulate a refrigerant gas as pan of a geothermal heating and
cooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
23 January 20 24 PERMIT NO.: (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(1) K Aqueous (as per 15A NCAC 02C .0222) Number of wells: 130
(2) ❑ Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
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:
Chowan County, NC: Kevin Howary County Manager
Mailing Address: PO BOX 1030
State: NC 27932 Chowan
City: ate: Zip Code: County:
Dav Tele No.: 252-482-8431 Cell No.: 252-232-8208
EMAIL, Address: [e-mail] Fax No.: 252-482-4925
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 780519714506
County: Chowan t
(2) Physical Address Of different than mailing address): J„ Q, 1AOLNILCJ Yl t OFF S (k10D1r
600 North Broad Street
City: Edenton CountyChowan Zip Code: 27932
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page I

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
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 well system.
NOTE. In most cases, an aerial photograph and/or plat map of the property parcel showing property lines and
structures can be obtained and downloaded from the applicable county GIS website. Typically, the praperty can
be searched by owner name or address. The location of the wells in relation to property boundaries, !muses, .septic
tanks and_jtelds, and other wells, etc. can then be drawn in by hand Also, a `laver' 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
htto://deu.nc.aov/about/d ivi sions/water-resources,/water-resources-perm its/wastewater-branch/around-water-
rotection/around-water-annroved-injectants. All other substances must be reviewed by the DHHS prior to use
100% Potable Water
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Charles Norris Dozier, II
NC Well Drilling Contractor Certification No.: 4088-A
Company Name:
City, Toano
Toano Well and Pump Service, Inc. Contact Person:
Day Tele No.: 757-566-0377
State: VA Zip Code: satss Comity: James City County
Cell No.: 757-784-4941
EMAIL Address:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:
Contact Person:
Address:
City:
Office Tele No.:
Fax
Zip Code: State: _County:
Cell No.:
Closed -Loop Geothermal Well Notification Rev. 3.1.2016 page 2

PROTECTION —Provide a brief description of how any (a.) water supply wells, (b.) surface water bodies, or
(e.) septic systems and associated spray irrigation bites, drain fields, or repair areas within 250 feet or the
proposed injection wells will be protected during construction of the wells:
We are drilling a closed -loop geothermal well field. We are not drilling injection wells.
J. VARIANCE —Pursuant to ) & Ni AC 02L .W?d di the Director of the Division of Water Resources may grant
a variance froin 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) rhat construction or operation in accordance with the standards is not technically feasible or the
proposed consttuction 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 I)twc/,1iLede%r4,3.amaronaws cutnls
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC f12C A21 JLj
, 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;
(a) 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.
1 hereby certify, under penalty, of law, that I have personally examined and am familiar with the information
submitted zn this document and all attachments thereto and that, hayed on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information it true. accurate and
complete. I am aware that there are significant penalties, including the possibility offenes and imprisonment.
for submittingfalse irtfarmcnion. I agree to tonstr t, operate, maimain. repair, and ifapplicahle, abandon the
it jectioa well and all relatee pttrienoncec in dance w' the 15!t N(AC 02C0200 Rvles. "
Print or Type Full Name
SlRnatu ut onzed Agent, It any
Charles Norris Dozier, II
Print nrTypeBull Name
Clased-Loop Geothermal Well Notifieaiion Rev, 3.1.20I0 Pagc 3

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