WI0800524_Application_20190220

Norm i-arotma Department of r nvironmentai Vuauty— Division of water Resources
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
There hells are ' jvnniued by rule "and do not require an individual pennitwhen constructed in accordance with
the ndes of 1 SA NCAC 02C.0200. Ibis police must be sitbmiiied prior to consturuction.
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 beating 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: February 13 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) Q 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 Susiness/Ageney and person and title with delegated signature authority:
Mr. Mark Wasto & Mrs. Rene Wasto
Mailing Address: 309 Snowberry Court SE
City: Venetia State: PA Zip Code: 15367 County: Washington
Day Tele No.: 412-400-1638 Cell No.: 703-470-6677
EMAIL Address: [e-mail] Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 206614446951
County: Brunswick
(2) Physical Address (if different than mailing address): 4439 Midshipman Court SE
City: St dames County Brunswick zip Code: 28461
Closed -Leap 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 properly parcel sharing proper!), lines and
structures can he obtained Arid datvdoaded from the applicable couin), GbS websita 7)pically, the property wit
be searched by airier 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 drain in by hand Also, a'Ayer' Carr be selected shooing
topographic contours or elerntion 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
litti)://deci.nc. eov/about/d i visions/water-resources/water-reso urces-i)ermits/wastewater-bran! deround-wnter-
orolection/uround-water-aooroved-iniectants. Ali other substances must be reviewed by the DHHS prior to use.
G.
H.
None, water
WELL DRILLER INFORMATION
Well Drilling Contractor's Name: James L Comette, PG
NC Well Drilling Contractor Certification No.:
Company Name Applied Resource Management, PC
City: Hampstead
Day Tele No.: 910-270-2919
Contact Person: James L Comette
State: NC Zip Code: 2"43 County: Pender
Cell No.:
EMAIL Address: [e-mail] Fax No.:
HEAT PUMP CONTRACTOR INFORMATION
Company Name: Fulford Heating & Air
Contact Person: Justin Futford EMAIL Address: [e-mail]
Address: 3461 Holden Beach Road SW
City: Supply Zip Code: 28462
Office Tele No.: 910-842-6589 Cell No.:
State: NC County: Brunswick
Fax No.:
Closed-Lmip Geuthetmal well Notification Rev 3-t-2016 Page 2

PRO I1A110A- Puvlc ss l< Ict 21 +u,, dltm n",pjA- Ji 11, uu4 t>,tes_or
ir. 1 rtic x=stems ad _,S .uteri ,xzr rlcati .n srles d,aw fi Id !a ref-:n, a .uon "I, cca ,-f it
prop+led in mmi arils "ill IV pr •eae3 dmnry Cn s,ca„n "fit" "clis
No tnreats
VARIANCE -Purse i t lu I Sh q> _'I dy the Director co tic Ul. r:cal v1 %l mt , Resoalcca ur<te µrant
a=aam,cu from applicable ucll mr..uvct un nr ape mnm ,tardsms pr.rx Idct, Ihat
t I I Itse or Ile'dilsl,,It nol esdaneer human health and telfare c, the 11 v aid "Icl, and
121 mo eonsimcoon of op�reurn ul atcofdmtce earli the standards is uca Icc'rn1ea111 feaslbte m ti•e
prepused mnstmtti•=a rr' 'Ides corral u, belief nrmect C. l fhte a.onnd111tV
Ang saname rcgnesi should scoompanc subauttul dihas no;dieabor to eap ,hie eeehlauon of the request
The tarmuce request fom can be icceses3 mdme at
Is, SIGVATI'RE5-lie foilowrn section is to be eonirLted w, requued bdo, or h; thui pmon% an mnzc i
ag n I's'.(_v a le tt fquircx menowcs as rnilaa5
(a) to, a corpuretiwf by a resp, na,Wc co polale officer.
(b) for a pannerhlp , slile prepnel'Oop by n general pntnen•r the propnio., fc,pce ,e!,
•.• ,n.,Ji,przidr .. rz yewin a_ by new n pwxryv!i eaca±d!e
ofTictr ar rmakmg puhlydy demcd nfriclsl,i
to) for all corers bt the ,A oeener,
tot for any other perswr auruanzed to act on bellaif of the opnc'ant documenlauan shall be
cubmued unh tltc rmlifi,alion that deailf Idernnirs the person, giants dle.n sigmtave
nuthoniy, and Is signed and dated by the apph-ail
"1 h, wlo <emO. t ndrr pem,111 uJ lml, aituf I hus e l.•rUgruig ecoarnnrd 911.1 J,is lfu!utmr ,ndr tita ii, rindoula
arhmated in di+ J ww"tf tn't 111 oug' lrmeun chow. earl Unn Fmrd un m7 o"pin Id tq: c m.h,Ja,d,
mun,dnnap rtspnrzsih(e Inr ,Iraomkg lard vilonxmwat 1 h hvw tlix the urlirrmalwo is true, enarow and
"'I'll 1, 1 on, "now deut du" 111, vgnlfitoea 1, lul tn•s, nuhe8ng the pmd,fifr of fins mct+mprMi"A trt
p,r talnnnm Izinm i !n,mcli ,o t u rre nI aonfnrt Yrltuc. nmuvam Irpma: and 1/111p9uthle "Immi m O
un,=pnnru••fl mxl efl,n��lgqtt��J uly,`,nrt liar: ziry a!:.mknme!ntla flr t = (', e r .+r, kale,.'
Ir�o�o �csr �o-
51{;rtamre of Pn,prnp OxncrAppf ram
Mr. Mark Waslo & Mrs. Rene Wasto
Pont 1, T, pr Fvil\nmc
�� 9•. em ar A:rth nrrd aim News
Poet yr Ti pe Fuil %time
in:"J-i,rp � 'i I", IIb t -al kcr %I �, ,.r

L. SUBMITTAL INSTRUCTIONS — Submit one copy of the completed notification package to the each of the
followine:
(I) The Division of Water Resources' Water Quality Regional Operations Section (bVQROS) Regional
Office serving the area in which the injection well facility will be located:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Telephone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5043
Telephone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Telephone:[phone]
Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone: [phone]
Fax: [phone]
-AND-
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Telephone:[phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Telephone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
(2) The County Environmental Health Department in which the injection wells Will be located.
Closed -Loop Geotheimat Well Notificaiion 2ev, 3-1-2010 Page 4

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• e.29
LEGEND
- Sanitary Sewer Line
Proposed Geothermal Loop Locations
Adapted From Kevin Pfirman Survey C1.0 April 10, 2018

250
VNI�.,ds'IPman.Gt.SE L�
�.Q
loogle Earth ;y`.

6" Borehole
7
TITLE: Geothermal Test Loop FIGURE:
Applied Resource Diagram
Management, P. C. JOB: SCALE: DATE: DRAWN BY:
Hampstead, NC 28443 14439 Midshipman As Shown 1018/18 JMR
Court SE