WI0300407_Final Permit_20190425 (2)

North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION TO CONSTRUCT THERMAL CONDUCTIVITY TEST WELLS
Thermal conductivity test wells are used to determine the amount ofheat that the subsurface may
transmit in a given depth interval for the purpose of designing geothermal heating and cooling systems.
Pursuant to 15.4 NCAC 02C.0230, thermal conductivity test wells shall be subject to the regulatory
requirements applicable to geothermal aqueous or direct expansion closed -loop wells designed to serve
single fancily residences.
These wells are `permitted by rule" and do not require an individual permit when constructed in
accordance with the rules of15_.9 NCAC 02C .0200,
This notice must be submitted at least two (2) business daps prior to construction.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: April 10 20 19 PERMIT NO. (to be completed by DWR)
A. TYPE OF THERMAL CONDUCTIVITY TEST WELL TO BE CONSTRUCTED
(1) Aqueous (as per 15A NCAC 02C .0222): Number of wells: 2
(2) Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER (choose one)
(1) Single Family Residence_
(2) Business/Organization
(3) Government: State_ Municipal x County_ Federal
C. WELL OWNER(S) — For single family residences, list all persons listed on the property deed. For all others,
list name of Business/Governmental Agency and name of person and title with delegated authority to sign:
City of Charlotte, Jonathan Sossamon, P.E.
Mailing Address: 600 East Fourth Street
City: Charlotte State: NC Zip Code: 28202 County: Mecklenburg
Day Tele No.: 704-432-0406 Cell No.: 704-609-7290
EMAIL Address: [e-mail] Fax No.: 704-336-4554
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site:09722102
County: Mecklenburg
(2) Physical Address (if different than mailing address): 5801 General Commerce Dr.
City: Charlotte County Mecklenburg Zip Code:
'Thermal Conductivity Test Notification Rev. 3-1-2016 Page 1

E. MAPS, PLANS, AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site -specific map showing the locations of the following:
• Proposed injection well locations • Septic systems and associated spray irrigation sites,
• Buildings drain fields, or repair areas
• Property boundaries
• Surface water bodies • Existing or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services' Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found online
at http_/de .iq tc.gov/about(divisionshvater-resources/water-quality-re ioF; ual-oUerat(ors/�roundv.�ater-uroteetion . All
other additives require approval prior to use.
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Yadkin Well Company
NC Well Drilling Contractor Certification No.: 2195-A 2572 A 3036-A 3548-A
Company Name: MidSouth Geothermal Contact Person: Karen Bisso
City: Memphis _ State: IN Zip Code: 38119 County: Shelby
Day Tele No.: 901-748-9095 Cell No.:
EMAIL Address: kbisso(@midsouthgeotltermal.com Fax No.: 901-748-9097
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name
Contact Person:
Address:
City:
Office Tele No.:
Zip Code: State: _County:
Cell No.:
Fax No.:
Thermal Conductivity Test Notification Rev. 3-1-2016 Page 2

PROTECTION — Provide a brief description of how (1) water supply wells; (2) surface water bodies; and (3)
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:
None located within 250'
J. VARIANCE — Pursuant to I -5A 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 hnp:i/deq.nc.eov/about.'divisions/water-resourceshaater-
-qual ity-regional-ooei ations/groundwater-protectio❑
V- 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.
'9 hereby certify, under penalty of law, 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 individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and bnprisonrnent,
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 Rules. "
Signature of Property Owner/Aejilieant
Jonathan Sossamon P.E./ Project Manager City of Charlotte
Print or Type Full Name and Title
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Themtal Conductivity Test Notification Rev. 3-1-2016 Page 3

North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION TO CONSTRUCT THERMAL CONDUCTIVITY TEST WELLS
Thermal conductivity test wells are used to determine the amount ofheat that the subsurface may
transmit in a given depth interval for the purpose of designing geothermal heating and cooling systems.
Pursuant to 15.4 NCAC 02C.0230, thermal conductivity test wells shall be subject to the regulatory
requirements applicable to geothermal aqueous or direct expansion closed -loop wells designed to serve
single fancily residences.
These wells are `permitted by rule" and do not require an individual permit when constructed in
accordance with the rules of15_.9 NCAC 02C .0200,
This notice must be submitted at least two (2) business daps prior to construction.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: April 10 20 19 PERMIT NO. (to be completed by DWR)
A. TYPE OF THERMAL CONDUCTIVITY TEST WELL TO BE CONSTRUCTED
(1) Aqueous (as per 15A NCAC 02C .0222): Number of wells: 2
(2) Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER (choose one)
(1) Single Family Residence_
(2) Business/Organization
(3) Government: State_ Municipal x County_ Federal
C. WELL OWNER(S) — For single family residences, list all persons listed on the property deed. For all others,
list name of Business/Governmental Agency and name of person and title with delegated authority to sign:
City of Charlotte, Jonathan Sossamon, P.E.
Mailing Address: 600 East Fourth Street
City: Charlotte State: NC Zip Code: 28202 County: Mecklenburg
Day Tele No.: 704-432-0406 Cell No.: 704-609-7290
EMAIL Address: [e-mail] Fax No.: 704-336-4554
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site:09722102
County: Mecklenburg
(2) Physical Address (if different than mailing address): 5801 General Commerce Dr.
City: Charlotte County Mecklenburg Zip Code:
'Thermal Conductivity Test Notification Rev. 3-1-2016 Page 1

E. MAPS, PLANS, AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site -specific map showing the locations of the following:
• Proposed injection well locations • Septic systems and associated spray irrigation sites,
• Buildings drain fields, or repair areas
• Property boundaries
• Surface water bodies • Existing or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services' Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found online
at http_/de .iq tc.gov/about(divisionshvater-resources/water-quality-re ioF; ual-oUerat(ors/�roundv.�ater-uroteetion . All
other additives require approval prior to use.
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Yadkin Well Company
NC Well Drilling Contractor Certification No.: 2195-A 2572 A 3036-A 3548-A
Company Name: MidSouth Geothermal Contact Person: Karen Bisso
City: Memphis _ State: IN Zip Code: 38119 County: Shelby
Day Tele No.: 901-748-9095 Cell No.:
EMAIL Address: kbisso(@midsouthgeotltermal.com Fax No.: 901-748-9097
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name
Contact Person:
Address:
City:
Office Tele No.:
Zip Code: State: _County:
Cell No.:
Fax No.:
Thermal Conductivity Test Notification Rev. 3-1-2016 Page 2

PROTECTION — Provide a brief description of how (1) water supply wells; (2) surface water bodies; and (3)
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:
None located within 250'
J. VARIANCE — Pursuant to I -5A 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 hnp:i/deq.nc.eov/about.'divisions/water-resourceshaater-
-qual ity-regional-ooei ations/groundwater-protectio❑
V- 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.
'9 hereby certify, under penalty of law, 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 individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and bnprisonrnent,
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 Rules. "
Signature of Property Owner/Aejilieant
Jonathan Sossamon P.E./ Project Manager City of Charlotte
Print or Type Full Name and Title
Signature of Authorized Agent, if any
Print or Type Full Name and Title
Themtal Conductivity Test Notification Rev. 3-1-2016 Page 3

METALLIC TRACER TAPE-"
ABOVE ALL GEOTHERMAL PIPING
(DEPTH PER MANUFACTURER'S
RECOMMENDATIONS)
EXCAVATED
ROCK FREE
BACKFILL
BACKFILL LOOP BORE HOLE WITH
THERMAL GROUT 1.17 THERMALLY
ENHANCED GROUT
1" HPS & HPR
DROPS
FUSION WELD
PREMANUFACTURED
U-BEND-PHILLIPS
DRISCOPIPE UNICOIL
1-1
m
e;u
MINIMUM
5.5" DIAMETER WELL BORE
or HDPE DR-11 PE4710 GEOTHERMAL
PIPING.

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