WI0501029_Permit (Issuance)_20190808

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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NA
Bowman Mechanical Services Inc.
14S Technical Court
Garner, NC 27529
(A//1yy�9�9)�7770-929 4Faxe
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NOTIFICATION OF INTENT TO CONSTRUCT OR OPERAT E IINJCA 11 V1N Vr 111W..
Those wells are "permitted by rule" and do not require an Individual permit when constructed in accordance will,
the rules of 15A NCAC 02C .0200", Th' r race nm (h sub Iced Arlo co n
QEOTN., RF�h1AL OA S CLOSED-LQOP WIEULs
As described in 15A NCAC 02C .0222 thcsethcse wells circulate potable water only Ora mixture of potable water and
performance -enhancing additives as part of it geothermal heating and cooling system.
OR
9LUIEKu a. ... _. _.
As described in 15A NCAC 02C .0223 these wellS Circulate a refrigerant gas as part of n geathermal heating and
cooling system.
Print Clearly or n1i a htformri(IM Illegible Submittals Will Be Returned As Incomplete.
DATE: T 20_ PERMIT NO. _w��to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED
(1) Aqueous (as per I SA NCAC 02C .0222): X Number of wells
(2) Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER (choose one)
(1) Single Family Residence _X_ Submit this form two (2) business days prior to construction.
(2) Business/Organization _ Submit this form 30 days prior to construction.
(3) Government Stare_ Municipal-- county_ Federal _Submit ohis form
30 days
C. WELL OWNER — For single family residences list the property owner(s). For all others, list name of the
business, organization, or government agency and person delegated signature authority:
Richard E qnd Mary E. O'Dor
Mailing Address to r 4n
City: Durham State: _NC_27713_ Zip Code; Coun1y:_PJEhM
Day Tele No.: 919.699-0031 Cell No.: same
EMAIL Address Richard odor(a)gmail com Fax No.: NA
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 9769517598
County: Orange
(2) Physical Address (if different than mailing address): 422 NC S4 West
UWQNIC/Closed-l.onp Ocolhermal Nu0^I^ i fwution (Revised 4/30/2012)
G - Cal 0 V cm.77
35q) 59 _7q,i15`I �q,iiS7
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BOw7na1Technical Conrr
`5 services Inc'
Garner, NC 27329
City: Chapel Hill State: NC Zip Code 27516 "AI�91D � 779,9294 7247S9f ice
bo wrnanm ech an lcal®bellsoH eh'" e f
w , . b o win n ntec It a It ica Lsery lees." In
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 fe tures clearly and include g north arrow. Attach a
site -specific Wrap showing the locations of the following:
• proposed injection well locations septic systems and associated spray irrigation sites,
drain fields, or repaB areas
buildings
� P
property boundaries existing or potential sources of groundwater
contamination S
• surface water bodies
W
water supply wells
(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 All other additives require approval prior to use.
C, WELL DRILLER INFORMATION (if known) '#
A/r�t ✓lJe r F 4 C Q_ rAu�4 y/
Well Drilling Contractor's Name: Cl �
NC Well Drilling Contractor Certification No.: _
-IlGilvK
Company Name: �'�ns'� Contact Person:
City: 7`442d l v State: _NC_ Zip Code: County:-Ut*W
DayTeleNo.: 2,a"g29-9311 CcllNo.: 1.r2 y9G-fNo
EMAILAddreas: as"ti"Y�r�e44PFaxNo.:rx
f7vtran l , G
1�:1E e, r'YNaN 11l 'i EJ 4,e� ••`�r•�
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Bowman Mechanical Services Inc
Contact Person' Steve BOWmall �,„._...F " °�� ass steveb(g,f2owmanmachanicalservices com
Address: 145 Techni-I Court
City: Garner Zip Code: 27529 State: County: Wa)<e
U WQ/UIC/Closed-Loop Geothermal N0107106011(Revised 4/3012012) Pads 2

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Office Tele No.: _(919) 772-6460_Cell No.: Fpx No • (919) 779•9294
Bowman Mechanical Services Inc,
1!5 Technical Court
Garner, NC 27529
[phone] Office
[phone] Fax
bowmanmechanicai®bellsouth. net
www.bowmammeckanicafs!orvicvs.com
D WQ/VIC/Closcd•Loop Gcolhemal Nolika ton (Revised 4/30/2012) Page 3

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+1919M9294 MCE 4/6
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:
use temporary casing and silt fencing while drilling�� rcnrgo Afeeh" r^ t r�..dces hr c.
f�5 7`ecNnJcal Coa�r
772.2759
www. bownlannescea",�..--
J. VARIANCE — Pursuant to 15A NCAC 02C .0241 the Director of the Division of Water Quality 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 http //oortal ncdenr otOweb/wq/aps/gwpro/permit-
aonlicatiots
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .021 l(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.
" / hereby certify, under penalty of late, that l have personally examined and am fannhar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
ilmuedialely responsible for obtaining said information. 1 believe that the information is true, accurate and
complete. I am aware that there are signt/iecuit penalties, including the possibility offnes and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and tf applicable, abandon
the injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules. "
Signature of Properly Owner/Appileant
Richard O'Dor
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
UWQtIIIC/Closcd•Loop geolnmmsl Notiricatinn (Revised 4113012012) Pege 4

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Bowman ;SMec6an''Mal services Inc.
145 7'eabnlca1'CcW1
.I • I Garner, NC 27529
(9I9) 772-2759 Office
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bowmann"[e-mail]
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1019-06-07 07:56 CDT
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Bowman Mechanical Services Ynn
145 Technical Court
Garner, NC 27529
[phone] Office
[phone] Fax
bowmanmechanleal@bellsouth. net
www.bowmonmechanicalservices.com