WI0800516_Application_20181019

ivortlr Larouna jumartment of >r:nvironmentai vusaity — lirvls►on 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 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.
M
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: October 8 2018 PERMIT NO.: to be completed by DA R)
A.
B.
C.
TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED (select one)
(1) ❑■ Aqueous (as per 15A NCAC 02C .02221 Number of wells: 5
(2) ❑ Direct Expansion (as per 15A NCAC 02C .02231 Number of wells: _
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
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:
Gilead Corporation - Mr. Jay Jordan
Mailing Address: P.O. Box 98
City: Mount Gilead
Day Tele No.: 910-975-1371
State: NC Zip Code: 27306 County: Montgomery
Cell No.:
EMAIL Address: [e-mail] Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 201506494553
County: Brunswick
(2) Physical Address (if different than mailing address): 403 Ocean Boulevard West
City: Holden Beach County Brunswick Zip Code: 28462
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 1

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 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, etc. can then be 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
htty://deg.ne. gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/uound-water-
Protection/eround-water-approved-iniectants. All other substances must be reviewed by the DHHS prior to use.
None, water only.
G. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: ,lames L Cornette, PG
NC Well Drilling Contractor Certification No.:
Company Name: Applied Resource Management, PC Contact Person: James L Cornette
City: Hampstead State: NC Zip Code: 21441 Count,: Pender
Day Tele No.: 910-270-2919 Cell No.:
EMAILAddress: [e-mail] Fax No. :910-270-2988
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Fulford Heating & Air
Contact Person: Justin Fulford EMAIL Address: [e-mail]
Address: 3461 Holden Beach Road SW
City: Supply
Office Tele No.: 910-842-6589
Zip Code: 28462
Cell No.:
State: NC County. Brunswick
910-270-2988
Closed -Loop Geothermal Well Notification Rev. 3-1-2016 Page 2

I. PROTECTION — Provide a brief description of ]tow 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 httns://ncdencs3.nnm7,onairs.cont/s3fs-
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .0211 te1 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 slate, 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 then, signature
authority, and is signed and dated by the applicant.
"l hereby certf, under penalty of lmn, that I have peisatally examined and ant fa»i/iar 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 beheiv that the Information is true, accurate and
complete. 1 ant moare that there are significant penalties, including the possibility offines and imprisonment,
for subinitting false iitfornhation. I agree to constiztcl, operate, inainlain, repair, and if applicable, abandon the
h jeclion well and all related appur�A?tces i VccolancArith the 15A NCAC02C0200 Rules. "
Gilead Torporation - Mr. Jay Jordan
Print or Type Fall Name
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:
WINSTON-SA
ASHEVILLE C'' f` - WASHINGTON
FAYETTEVILLE
Washington Regional Office
Asheville Regional Office
943 Washington Square Mall
2090 U.S. Highway 70
Washington, NC 27889
Swannanoa, NC 28778
Telephone: [phone]
Telephone: [phone]
Fax: [phone]
Fax: [phone]
Wilmington Regional Office
Fayetteville Regional Office
127 Cardinal Drive Extension
225 Green Street, Suite 714
Wilmington, NC 28405
Fayetteville, NC 28301-5043
Telephone: [phone]
Telephone: [phone]
Fax: [phone]
Fax: [phone]
Winston-Salem Regional Office
Mooresville Regional Office
450 W. Hanes Mill Road
610 East Center Avenue, Suite 301
Suite 300
Mooresville, NC 28115
Winston-Salem, NC 27105
Telephone: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone: [phone]
Fax: [phone]
-AND-
(2) 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
Adapted From James T Tompkins survey 8/1612018
TITLE:
Proposed Geothermal Loop Locations
JOB: SCALE: DATE: DRAWN BY:
403 Ocean 1" = 20' 10/8/18 JMR
Boulevard West
FIGURE:
Applied Resource
Management, P. C.
Hamp.T.", NC 28445

TITLE:
250' Radius Map
I BoBeOvad West SCALE: DATE: DRAWN BY:
ill= 100' 10/8/18 JMR
LEGEND
Proposed Geothermal Loop Locations Applied Resource
Management, P. C.
Adapted From Google Earth 10/29/2016 Hampstead, NG 2843
FIGURE:
2

Applied Resource
Management, P. G
ea .
Hempstd, NL 28448
6" Borehole
TITLE: Geothermal Test Loop
Diagram
Ocean As Shown 10/8/18
i Blvd W
9 ��
FIGURE: