WI0800521_Application_20190123

North Carolina Department of Environmental Quality — Division 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.
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. Illegible Submittals Will Be Returned As Incomplete.
DATE: January 14 2019 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: 5
(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:
Mr. Ryan Mattox & Ms. Nicole Mattox
Mailing Address: 4409 Southfield Court
City: Wilmington State: NC Zip Code: 28405 County: New Hanover
Day Tele No.: 910-547-1782 Cell No.:
EMAIL Address: [e-mail] Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 3282-90-4291-0000
(2)
County: Pender
Physical Address (if different than mailing address): 523 Hughes Road
City: Hampstead County Pender Zip Code: 28443
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 caves, an aerial photograph and/or plat nurp of the property parcel showing property lines and
structures can he ohtained and downloaded from the applicable county GLS website Typically, the properly can
be searched by owner name or address. The location of the wells in relation toproperty 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
httr): Hde(i. nc. aov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
rotection/Uound-water-ai)t)roved-ini ectants. 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 Comette, PG
NC Well Drilling Contractor Certification No.:
Company Name: AppEied Resotttce Management, PC
C
Contact Person: James L Cornette
City Hampstead State: N Zip Code: `..
Day Tele No.: 910-270-2919
EMAIL Address: [e-mail]
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: TBD
County: Pender
Cell No.:
Fax No.:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
Zip Code: State: County:
Cell No.:
Fax No.:
Closed -hoop Geothermal Well Notification Rev. 34-2016 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 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 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 httos://ncdenr.s3.amazonaws.com/s3fs-
publ ic/Water°/n200ual ity/Aquifer%20Protection/GPU/Geothermal VarianceRenuestFormFillable-
20130805.pdf
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .0211(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 certi&, under penalty .of law, that I have personally examined and am fa►ariliar 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 trite, 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 15A NCAC 02C 0200 Mules. "
_V%A (2;0- � ftv
'Signature of Property Owner/Applicant
Mr. Ryan Mattox & Mrs. Nicole Mattox
Print or Type Full Name
Signature of Autlrori wd Agent, if any
Print or Type Full Name
Closed -Loop Geothermal Well Notification Rev. 3-12016 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
Qf ice serving the area in which the injection well facility will be located:
WINSTON-SALEM
RALEIGH
ASHEVILLE t-' ),_� /1 /"'' 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 29301-5043
Telephone: [phone]
Telephone: [phone]
Fax: [phone]
Fax: [phone]
Winston-Salem Regional Office
Mooresville Regional Office
450 W. Manes 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]
Pax: [phone]
-AND-
(2) The County Environmental Health Department in which the injection wells will be located.
Closed -Loop Geothermal Well Notification Rcr-. 3-1-2016 Page 4

HUGHES ROAD
TBM MAG, 60' PUBLIC R\W
NAIL SET
EDGE OF
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-
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DATE 02/16/2007
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7 MARCH 2O17
LEGEND
Proposed Geothermal Loop Locations
Adapted From Site Plan A 1.0 March 7th 2017

LEGEND
0 Proposed Well Locations
Adapted From Google Earth 9/19/2018