WI0501023_Final Permit_20190625

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,Nowraa,r Afeclranical Serviolf# time
145 Technical irourt
Garners NC 17529
(919) 77,E-2759 Offsee
NORTH CAROL1NA DEPAPTM.GNT OF ENVIRONMENT AND NATURAL 01001MM 94 rax
NOTIFICATION OF INTENT TO CONSTRUCT OR UPERA IAWA=W=ate v
Ae a wall r are ' permitted bT ride" and do ni't require an Individual permit when camtrucied 1st accordance'wlth
the rulds of 15A NCAC 02C .0200 t Thl calico n»rs_r lit s t� h�ntlrl�d nrlor � �vrt9lrtt�Ylan,
!QHHAA0V.00U§ !9LOSSV- Y I%LLai
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 s gcothermal Beating And cooling syitam.
OR
SE
M described In t SA NCAC 02C .022,.1' tho$o wolls ciFUuinto a rakiaorunt gas as part orn goothernial (icaling and
cooling system.
"thInve
ices.eom
PNtN Clearly or type Infornmoon. Illegible Subrrrlltaft 0111,00 Rrrluened As hrevnwIck.
LATE: � 2019 PERMIT NO. (to bo completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSE11.L00P WELL T BE CONSTRUCTED
(1) Aqueous (an per 15A NCAC 02C .0222): Number of walls:.
(2) Dlrcel Expansion (a9 per 15A NCAC 02C .0223) Number orwas:
B. STATUS OF WELL OWNER (c{i nc)
(1) Single family Residence .Submit slips earns two (2) husinass days prior to construction.
(2) Busina:ss/Organizotion _ _ : Subnrlt tls4 form 30 days, prior to construction.
(3) Ciovamment: Slate Municipal CountyFederal Submit tins Form 30 days
prior to mastruattan.
C. WELL OWNER -- For single family rcaldenccs Itst tho property owner(s). For all others, Ifst name of the
businass, organization, or government ngoncy 1W person delegated 91gaalure ltuthorlty:
g
Mailing Address:...__
City; , i T G-K stoic; AI �' " Zap coda:9764/ County:
Day Tele No.: Cell No.:.
EMAIL Addms cL w� Q jt Wti+l,� . CvIA Fox No.:
D. PHYSICAL LOCATION OF WELL SITLt
(1) Parcel identification Number (PIN) of well silo:. rf `I .. �.� r
County: �41, k-v
(2) Physical Addrm (ifdlfTarent than mailing address):
City: Statc: j Zip Coda:
DWQ/Ul(' WwA-Loan Ci odwnnal Noilkatkm (Revd 413WO12)
Popp I

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E. MAPSt PLANS, AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of inures locnied
w1tWn 250 &d of the irdr.Qtion wcl((a). Lakl all ftlItUrtA clearly and includa a ng1Jh.MQW. Attach a
site -specific map showing the 1"ationa oit?az 1101113wing:
• proposed injection well locations
buildings
property boundaries
surface winter bodies
•
water supply wells
+ P
saptle systems and associated spray Irrigation sites,
drain fields, or repok areas
P
existing or potential riources of groundwater
contamination S
I,l
(2) Plana and specifications of the surface and, subsurface comlruction dctuils of the wolf system.
P. TYPES AND CONCENTRATIONS OF ADDITIVES — Wet any additives that will he used and their
concentrations. Only additives that lha Department of 111calth and H►imon Scrviccs' Division of Public Health
determines do not Adversely affect human health shall he used. A list of approved additives can be round
online at All ether odditives require approval prior to use.
wn1s�.Ri�lx
O. WELL DRILLER INFORMATION (if 1wown)
Well Drilling Contractor's Name:
NC Wall Drilling Conmicter Cerilf cation No.: #2269_._.. -_.." r.� .... ....
Company Name: Lake Valley Well Co. Inc, Sontact Person Chnuncay LcWtt
City; T"Iboru State; NC Zip Code: Cuunty. Nash
Day Tcic No.: .252823&311 Coil No.: 252 450--511,0
lrMAII. Address; chaunceyleggettgmail.com >:nx Nq.:25641-0241;
H. HEAT PUW CONTRACTOR INFORMATION
Company Name:
Contact Person, • c
Address: 145 T chnl al C.
City:—fiarner.. !6p Code: 27529 _„ Stain_ --k, _County:
Qf'tice Tola No.: (919) 772-646(. _.. ___ Coll No.: -- _ Fps ,_..__(919) 779-9294
DWQ/UTC/CkaedAAiop ClenOmmW NoQfk*don (xaVt,pd 4130f2012j P� 2

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PROTECTION — Provide a brief description of how (() water supply wells; (2) .surface water bodies; and (3)
sepliG systems and associated spiny irrigation sites, drain I adds, or repair areas within 250 feet of the proposed
Injection wells will be protected during construction of the walls:
y. VARLANCE — Pursuant to 15A NCAC 02C .0241 the Dircvtor of the division of Water (duality may grant a
variance from applicable well construction or operation standards provided that:
(1) use of tho well(s) will not endanger human health And welfare or the groundw►atar; and
(2) that constructlon'or operation in accordance with ilia standards is not technically feasible or the
proposed construction provides equal or better prolecl!on of 1he groundwater.
Any variance request should accompany submittal of this notitleation to expedita evaluation of the request.
The va rituice Mgtutst form can be =eased online at lit :gportnl.nadenuort;/web wo/uR;L�ynrolo it
aaa11ct1,lLollll
K. SICNATURES The following section is to be completed as required below or by that person's Authorized
agent. 15A NCAC pai.021 l(a) requims signalum as follows:
(a) for a corporation: by a responsibla corporate officer,
(b) fat n partnership or sole proprietorship; by a general partner or the proprielor, regpe•ctively;
(c) for a municipality or a stMa, federal, or either public Agency: by either a principal executive
of iicor or ranking publicly elected 61Mclal;
(d) ror all others: by the well owner;
(e) for any other persolt authorizca to net on behalf of (lie applicant. documentation shall be
submitted with ' tho nolilicallon that clearly Idealllias Ilia person, grants them signature
authority, and is signed and dated by tho uppilcant.
"I hareby certify, under penalty of Imr, that I have personally examined and am fainlUar with the lnfannallon
submitted in this docutent and all atlachinanls therela mid Iitat, bared an my hiquiry of those lrrdlvtduals
Immediately responsible for ablalning sgtd ItEfomiatton, I believe dint the h1formaddis Is $rue, accurate and
complete. I am atvare that there are slgn(Jlcunl panallles. Inch ding the possibfl%y of nes and Imprlsawosent,
for submitting falsa l►Varmallon. 1 agree to construct, pperala, maintain, repair, and 1(applicablo, abandon
the $Jactla i well ohd all related appurlananras In accat-dance with the 15A NCAC 02C 0200 Rsder. "
sigsAwrior property Ginner/App k�nt
P t op Type J1ult Name
`S*atura of AMI�a�lioA AQenf, tf oily
Pont or Type Nall Na is
DWQMIC/Clawl-Loup Gmiliemirtt Nalltteetlan (ttcklard 41=012) pap 3

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