WI0501141_Application_20240624

mvurtn •>arumia mepartment of l,nvtt•onmentai truauty — Livision of water tcesom•ees
NOTIFICATION OF INTENT TO CONSTRUCTOR OPERATE INJECTION WELLS
7bese mvells a e 'permitted by rule "and do not require an individual permit when constructed in accordance with
the rules o%ISA NCAC 02C.0100. This notice must be submitted prior• to eousu•nction.
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.
IQ V
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 Submittals Will Be Returned As Incomplete.
DATE: 2-Y , 20.Z'� PERMIT NO.: to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
i
(1) D<Aqueous (as per 15A NCAC 02C .0222) Number of wells: l 3 70'
(2) ❑ Direct Expansion (as per l5A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNERS) (choose ore)
(1) 9 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 die property deed. For all others,
list the name of the Bushness/Agency and person and title with delegated signature authority:
S-%eve,,. 4- kiiyn Ari%dyeatAj
Mailing Address: SO 2
be v eYoe
to lC
S f
City: K Rl ei 9 h
State:
jVk-
Zip Code' 6'0 'County: W nt (tiCi
Day Tele No.: Cell
EMAILAddress:9QAArettrAjFax
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well
County: C^Vei n qy -
(2) Physical Address (if different than mailing address): S (X-, 2 ck\
City: [shad f. ( t4l-y l CountyOye, Zip Code:
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page I

C. 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: c$tia- S A-e P ( R ^ G . t
• Buildings . Septic systems and associated spray irrigation sites,
• Property boundaries chain 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.
See D)&yvr, G—Z,
NOTE. Li most cases, an aerial photograph and/or plat utap of the property pareel showing property lines and
structures can be obtained and do loaded fh-on the applicable county GIS website. Typically, the properly cats
be searched by owner name or address. The location of the wells its relation to property boundaries, !houses, septic
tanks and frelds, and other wells, etc. can then be drawn in by hand. Also, a'layer' can be selected shoving
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
http://deo.ne. gov/about/divisions/water-resourcestwater-resources-nemuts/wastewater-branch/ground-water-
Drotection/around-water-approved-iniectants. All other substances must be reviewed by the DHHS prior to use.
G.
LIM
WELL DRILLER INFORMATION
Well Drilling Contractor's Name: CO& P-9 4r - %s65 A
NC Well Drilling Contractor Certification No.:
Company Name: 1n We Ul C'3 ti ,c, Contact Person: Wo i A Q4Dt�{ t 21 9�
City: P ! t a , State:/JC Zip Code:27U21OCounty: YoAk(r
Day TeleNo.: 33C. V-68-- V:�Y��6iD Cell No.: 3i1/- e73C,
EMAIL AddressDa 1.11 d 8*nWr-. e, Y44 k In w e 6I . C-?n,Fax No.:
HEAT PUMP CONTRACTOR INFORMATION
Company Name: f'�oEY �[�o d-kty -, Id' if kl{
Contact Per
Address: C
&- 9Ach i1,co,..
City: rant'( 441 Zip Code: 2-1, k State: County: 0,� e.
Office Tele No.: rf I Q - 3 G 4- o q0Q Cell No.: q 94, , ;; C 3 - 7 SLS gFax 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:
�-v
C.s'A04N C LA'P 1lna i f
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 One
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 https://ncdenr.s3.amazonaws.com/s3fs-
public/Water%20Oualitv/Aquifer%20Protection/GPU/Geothermal VarianceReauestFomtFillable-
20130805.odf
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .021 I f 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 /an ,, 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 indildduals
immediately responsible fo obtaining said information, I believe that the information is true, accurate and
complete. I rum aware that there are signiTcani penalties, including the possibility offnnes and nuprisonnhent,
/or sahmittingfalse information. I agree to construct, operate, maintain, repair, and ifapplicdble, abandon the
injection well and all related appurtenances in accordance with the ISA NCAC 02C 0200 Rules."
Signature of Property OwneiMp-plicant
5'+evc,,. Ar\c4—ea a S
Print or Type Full Name
of Authorized Agent, if any
Print or Type Full Name
Closed -Loop Geothermal well Notification Rev. 3-1-2016 Page 3

N
4E
I
CP
�-
mMu nm Jay Pulkerson, Architect, PLLC (!1�"�t{ill"(��I�C 89
D uv Md ld Residence 2122 Ridgewood Road f{ ;t(� NI i 8�
1 80601dMiLLRoad t tt ii
1 u•• Clw el Hill, NC 27516 �`y' t ;q .7
Chapel Hill, NC 27514 phone/fax [phone] v j''i�jlt�.N�l�
1M

11
�.
iR
A-ij.-._._-._,_._.
y -
'
! j
3 r`i
SS
it
o„
ONk{
it
i
e: i Yr
J
c
@
r ^mess
r
s
9
_—___.._..___.
i
E• Y
�
oao
s agu a r
@
° 113j' I.
o
L
If
e
.._.
jp g
tillD
1Iji3
g
..
°
N
n
.�,•a
rev
Andmaus Residence
80601dMi11 Road
Chapel Iii11,NC 27514
Jay Pulke n, AwWtet, PLLC 1♦
2122 RIdgmvmd Road �'•'t I,.,I it , ,
Cha I0, NC 2751E Illrflfl�{rl�
phone H1/far 919-933-3996 1'''�ll;iilii�
9
S
y
MAI

HDPE
G-�o °cps
P
pi"
pw�ssu�e- Tes-i-ea
40 OP
l oo pS 4
Ie2 Q-�tA
I-Ke.rmully
&(,OVA , PunPeA -CV-m
o S oo-F is o ve. ,o
Suv ace V►t1 f Vlm✓v�y
i I,.,- , Puype wo`4-k
pt s - oh 9voa.' putup
CjSw�L�
31 4. Rook
Z_'7S�
IT-Q
Qep+k