HomeMy WebLinkAboutWI0800521_Application_20190513 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 on :VCAC 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-enitancing 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 refrigerate gas as part of a geothermal heating and
cooling system.
Prim 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: 7
(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 tuo(2)business days prior to construction.
(2) ❑ Business/Organization Submit this form 30 days prior to construction.
(3) ❑ Goverment: State_ Municipal County Federal•_
*Submit this form 30 daps 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: thermaltran@gmail.com Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site: 3282-90-4291-0000
Countv: Pender
(2) 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 I
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-speck 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 he obtained and donmdmaded from the applicable coumy GI.S websile Tj pically, 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
hilt://deo.nc,Povlabout/divisions/water-resources/water-resources-nerrnits/wastewater-branch/ground-water-
orotection/cround-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: James L Comette, PG
NC Well Drilling Contractor Certification No.:
Company Name: Applied Resource Management, PC Contact Person: James L Cornette
City: Hampstead State: NC Zip Code:28443 County:Pender
Day Tele No.: 910-270-2919 Cell No.:
EMAli-Address: }Im@armnc.com Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:TBD
Contact Person: EMAIL Address:
Address:
City. Zip Code: State _County:
Office Tele No.: Cell No.: Fax No.:
Closed-Loop Geothefmal Well Notification Res.3-1-2016 Page 2
I. PROTECTION—Provide a brief description of how any(a.)water supply wells,(b.)surface water bodies, or
(cot 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 httos://nederins3.amazonaws.com/s3fs-
nublic/Watera/o20Oualitv/Aauifer%20Protection/G PU/Geothermal VarianceReguestFormFillable-
20130905.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 Le1 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 oflaw, that 1 have personally examined and am familiar with the informatton
submitted in this document and all attachments thereto and that, based on my btquiry of those individuals
hnnnediate(v 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 imprisonment,
for submittingfalse information. I agree to construct, operate, maintain, repair, and ifapplicable,abandon the
injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
Signature of Property Owner/Applicant
Mr. Ryan Mattox& Mrs. Nicole Mattox
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
Closed-Loop Geothermal Well Notification Rer.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-SALEM
RALEIGH
ASHEVILLE WASHINGTON
ORESVILL
FAYETTEVILLE
A
Washington Regional Office
Asheville Regional Office 943 Washington Square Mall
2090 U.S. Highway 70 Washington,NC 27889
Swannanca,NC 28778 Telephone: (252)946-6481
Telephone: (828)296-4500 Fax: (252)975-3716
Fax: (828)299-7043
Wilmington Regional Office
Fayetteville Regional Office 127 Cardinal Drive Extension
225 Green Street,Suite 714 Wilmington,NC 28405
Fayetteville,NC 28301-5043 Telephone: (910)796-7215
Telephone: (910)433-3300 Fax: (910)350-2004
Fax:(910)486-0707
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: (704)663-1699 Phone:(336)776-9800
Fax: (704)663-6040 Fax: (336)776-9797
Raleigh Regional Office
1628 Mail Service Center
Raleigh,NC 27699-1628
Telephone: (919)791-4200
Fax: (919)571-4718
-AND-
(2) The County Environmental Health Department in which the injection wells will be located.
Closed-Loop Geodtennal Well Notirteation Rcv.3-1-2016 Pan 4
250'
11
523
HUghos Rd
LEGEND
Proposed Well Locations
Adapted From Google Earth 9/19/2018
Aw
TITLE:
250' Radius Map
Mpg: SCALE: DATE: DRAWN BY:
Google Earth
523 Hughes Road Approx.
Hampstead,NC 1"= 100, 1/14/2019 JMR
FIGURE:
Applied Resource ^
Management, P. C. L
HAmpeTead,NL 28�4.9
HUGHES ROAD
TBM MAG. 60' PUBLIC R\W
NAIL SET EDGE OF
ELEV. 19.5 PAVEMENT
0.30 OF A MILE Ttl -- 9
E C.M. ."_
THE INTERSECTION OF ' N 600" E C2-rr,.._e..�_C1_ _ _- E.LP.
CENTER DRIVE E.C.M. 0.60' '
- - S�gACK�_ - FLOOD ZONE AE, BASE
FRONT_ --:%-- �'" FLOOD 10.0' TAKEN FROM
�� �.\, MAP 3720/3282, J. EFFECTIVE
•�'. co c ,� // I-'� .i % % 9 \\� PRELIMINARY DATE MAP
MAPS
007
$ J REVISE FLOOD ZONE AE
BASE FLOOD 12.0' & 13.0'
1a Septic Location
/ i' / n .� WETLAND LINE - Q -.-
„_ FLAGGED BY i o
I ' LOT-91'-.'{o % I, i SEGI
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i
124.7 / - 3 LEGEND
51 3¢06a _ , - 6, WETLAND LINE
OTHERS' -- Y sLocations y� <4 6, OT Proposed Geothermal Loop
- - g• ; Adapted From Site Plan A 1.0 March 7th 2017
--- ---- E.C.M. -
,-3-- ,`1.. .. �. .-.-- -- '�...
•-
`- Proposed Geothermal Loop Loca for
JOB: SCALE: DATE: DRAWN BY
523 Hughes Road Approx. 1114/19 JMR
NORMAL HIGH WATER LINE Hampstead, INC 1" = 40'
O SITE PLAN CHANNEL FLAGGED BY
FIGURE:
A sc^`E: ,° - zo FRNM MB 12 PG 1 SEGI Applied Re
A1 source
1 ■0 Management,
7 MARCH 2O17 Hempstead,NG 284h3
6" Borehole
Ground Surface
—4'
1 114" HDPE Loop
Thermex
Grout
TD = 300'
TITLE: Geothermal Loop FIGURE:
Applied Resource Diagram ^
Management, P. C. JOB: SCALE: DATE: DRAWN BY: VS
Hampeta.4,NL 28443 523 Hughes As Shown 1/14/19
Road JMR