WI0700493_Other_20190819

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELD
These wells are `permitted by rule " and do not require an individual permit when constructed in accordance wimp
the rules of 15A NCAC 02C .0200. This notice must be submitted prior to construction. ,9
G� k '
41
GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS
As described in 15A NCAC 02C .0222 these wells circulate potable water only or a mixture of ter at%&
performance -enhancing additives as part of a geothermal heating and cooling system?,9
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 Submi t aRls_F ill Be Returned As Incomplete
DATE: Aug. 19 2019 PERMIT NO. V"" O l (to be completed by DWR)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED
(1) Aqueous (as per 15A NCAC 02C .0222): Number of wells: 3
(2) Direct Expansion (as per 15A NCAC 02C .0223) _� Number of wells: _
B. STATUS OF WELL OWNER (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 ]a Federal _a Submit this form 30 days
prior to construction.
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:
Justin McCotter
Mailing Address: 101 Trent Villa Landing Dr.
City: New Bern State: N_C Zip Code:28562 County: Craven
Day Tele No.: 252-671-0756 Cell No.:
EMAIL Address: [e-mail] Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 7-001 -8003
County: Craven
(2) Physical Address (if different than mailing address):
101 Trent Villa Landing Dr.
City:
New Bern
State: NC Zip Code: 28562
UIC/Closed-Loop Geothermal Notification (Revised 8/5/2013) Pagc I

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
• Buildings sites, 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 hgp:Hportal.ncdenr.org/web/wq/aps/gwpro. All other additives require approval prior to use.
G.
None
WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Sanford Sweeting
NC Well Drilling Contractor Certification No.: 2082-A
A 1'ie AD M
Company Name: PP esource anagement Contact Person: Jim Corvette
City: Hampstead State: NC Zip Code: 28443 County: Pender
Day Tele No.: 910-270-2919
EMAIL Address:
Cell No.: 910-512-4890
Fax No.: 910-270-2988
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Climate Control Heating & Cooling Co., Inc.
Contact Person: Mike Hadley EMAIL Address: [e-mail]
Address: 102 Middle St
City: Jacksonville Zip Code: 28546 State: NC County: Onslow
Office Tele No.: 910-353-9040 Cell No.: 910-376-1100 Fax No.: 910-353-1060
UIC/Closed-Loop Geothermal Notification (Revised 8/5/2013) Pale 2

I. 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:
Uncontrolled spoils shall be contained either by berms around the affected area or by silt fence.
A hole dug into the ground at or near the drilling area maybe used to contain drilling/grouting
spoils if necessary.
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 hltp://pL)rtal.ncdenr.org/web/wg/aps/gwpro/Termit-
gpplications
K. 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.
"I 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 offines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all related appurte nces in accordance with the 15A NCAC 02C 0200 Rules.
Signature of Property Owner/Applicant
Justin McCotter
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
UIC/Closed-Loop Geothermal Notification (Revised 8/5/2013) Page 3

L. SUBMITTAL INSTRUCTIONS — Submit one copy of the completed notification package to the each of the
following:
(1)
(2)
The Division of Water Resources Regional Office serving the area in which the injection well facility
will be located:
WINSTON-SALEM
ASHEVILLE
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]
LC
RALEIGH
WASHINGTON
FAYETTEVILLE
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Telephone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 29405
Telephone: [phone]
Fax: [phone]
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107-2241
Phone: [phone]
Fax: [phone]
County Health Department in which the injection well facility will be located. A list of county health
departments can be found online at http://www.ncalbd.oriz/couniy.htm.
UIC/Closed-Loop Geothermal Notification (Revised 8/5/2013) Page 4

Vertical Geothermal Loop Detail
SUPPLY
PIPE
GEOTHERMAL LOOP HEAT
EXCHANGER PIPING MUST
BE PRESSURE TESTED
PRIOR TO INSTALLATION
IN WELL. REFER TO
SPECIFICATIONS FOR
REQUIREMENTS.
L
6°
- --�-- EARTH
BACKFILL
RETURN
PIPE
POLYETHYLENE PIPE
AS SPECIFIED
MIN. BURY DEPTH 3'-O"
6tQQRDMT(xA&RQw3Fc
BOREHOLE- DRILL SMALL AS
POSSIBLE BUT NOT MORE THAN 6"
3ACKFILL ENTIRE BORE
WITH THERMALLY
ENHANCED GROUT AS
SPECIFIED
250 FT. BORE DEPTH
or as specified
JLYETHYLENE FITTINGS
WITH HEAT WELDED
CONNECTION
Climate Control Htg & Clg
Jacksonville, NC
910-353-9040
Mike Hadley CGD CGI

GROUT PUMP
I
SUCTION
NOTES: (GROUT PIPE)
I
10 PRESSURIZED GROUT SHALL BE PUMPED 1
FROM THE BOTTOM TO THE TOP OF
BOREHOLE.
DISCHARGE
(GROUT PIPE)
-----------
7-TRENCH
20 BEFORE GROUTING IS PERFORMED, L
CONTRACTOR SHALL VERIFY WELL DEPTH.
DEPTHS SHALL BE RECORDED BY THE
CONTRACTOR'S QUALITY CONTROL EMPLOYEE,
KEPT AS SEPERATE LOG. IF THE DEPTH IS
NOT AS SPECIFIED, GROUTING SHALL BE r
STOPPED UNTIL WELL DRILLER HAS DRILLED /I
THE WELL TO THE SPECIFIED LENGTH.
O3 GROUT SHALL BE THERMALLY ENHANCED /y .
BENTONITE GROUT, WITH A MINIMUM THERMAL �y'/
CONDUCTIVITY OF 1.0 BTU/(HR*FT* F).
WELL FIELD PIPE_ GROUT METHOD W/ PUMP✓
SCALE: NOT TO SCALE
010
GROUT
BOREHOLE WALL
Mike Hadley, CGD CGI
Climate Control Htg & Clg Co.
Jacksonville, NC
910-353-9040

Proposed Vertical
Geothermal Loop Field
Justin McCotter
101 Trent Villa Landing Dr.
New Bern, NC 28562
Trent River
Min 50' from waters edge
min 20' seperation
\ 0
Proposed Vertical
Loop Field
min 50' seperation
from septic system
Septic Tank & Field
Submitted by:
Mike Hadley CGD CGI
Climate Control Htg & Clg Co
Jacksonville, NC 28546
910-353-9040