WI0100561_Application_20190923

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NORTH CAROLINADEPARTMENT OFENVIRONMENTANIIMATT toAr ucentic,�Uc
"TIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
TQse wells are 'permitted by ode" and do not require an individual permit when constructed in accordance with
,� the ides of /SA NCAC 02C.0200". This notice Hurst be submitted prior to construction
O O
m is GEOTHERMAL AQUEOUS CLOSED -LOOP WELLS
fig dEcribed in 15A NCAC 02C ,0222 these wells circulate potable water only or a mixture of potable water and
performance enhancing additives as part of a geothermal heating and cooling system.
OR
3
GEOTHERMAL DIRECT EXPANSION CLOSED -LOOP WELLS
described in 15A NCAC (A2C ,0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print Clearly or Type information. Illegible Submittals Will Be Returned As Incomplete.
DATE: 4 " 2-3 - • 20 ) 9 PERMIT NO.
be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED -LOOP WELL TO BE CONSTRUCTED
/
(1) Aqueous (as per 15A NCAC 02C .0222): X_ Number of wells lfe AwI eCcC4
(2) Direct Expansion (as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER (choose one)
(1) Single Family Residence i/ 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 _ Federal _ 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:
Ag&pw i Mewl(: Lf►cv
Mailing Address: Z0"%
City: h6te r AvflL. State: NL Zip Code: Z977/ County: OSit
Day Tele No.: 1BU-2-70 -30.39 Cell No.: 8 Z8-Z30- 38 3 j
EMAIL Address: IiflGn M%l.aMKI�ct � CaM7 Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identif cation Number (PIN) of well site: / 6 ? (4V%9 78
County: ZdawleA (� n
(2) Physical Address (if different than mailing address): _ 59 Z JTeQp k7mi
City: Mdefk»1✓I II L State: NC Zip Code: 287q Z
DWQMC/Closed-Loop Geothermal Notification (Revised 4/30/2012)
Page I

E. MAPS, PLANS, AND SPECIFICATIONS
(I) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet dY the injection well(s). Label all features clearly and include a north arrow. Attach a
site -specific map showing the locations of the following:
' • P
reposed injection well locations eptic systems and associated spray irrigation sites,
• drain fields, or repa$ areas
uildings
' • P
roperty boundaries xisting or potential sources of groundwater
• contamination S
urface water bodies
' W
ater 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 http://portal.ncdenr.ore/web/wq/1D%tro. All other additives require approval prior to use.
6
G. WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name:jTS
NC Well Drilling Contractor Certification No.:
Company Name:e-lew►2/.�w U CeP.I Contact Person:
City: i &EJK21 ` StatefiC Zip Code: County
Day Tele No.: �° Cell No.:
EMAIL Address: _ Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name:Bullman Heating & Air
Contact Person: Josh Guthrie EMAIL Address: [e-mail]
Address: 10 Red Roof Lane
City: Asheville Zip Code: 28804_State: NC County: Buncomne
Office Tele No.: (828)-658-2468 Cell No.: _(828)-712-7488__ Fax No.: (828)-658-1001
MQ/U1C/Closed-Loop Geothermal Notification (Revised 4/30/2012) Page 2

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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:
J. VARIANCE — Pursuant to 15A NCAC 02C .0241 the Director of the Division of Water Quality may grant a
variance from applicable kvell 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 htur.//portal ncdem ore/web/wa/apti/ewln•ohxrmit-
implications
K. SIGNATURES — The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C .021 Ile) 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 oj'law, that / have personally examined and am familiar with The infonnallon
.submitted in this doc•toncAu and all attachments thereto and That, based on my inquiry of those individuals
inunediately responsible for obtaining said information, l believe that the information is true, accurate and
complete / not aware that there are significant penalties, including the possibility o(ftnes and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and f applicable. abandon
the injection well and all related appurtenance. ' h accordance with the I5A NCAC 02C 0200 Rales. "
Signature of Proper Owner/Applicant
A•nv Ail, LACY
Print or Ti pe Fall Name
Signature of Authorized Agent, if any
Print or Type Full Name
MQ/UIC/Closed-Loop Geothermal Notification (Revised 4/30/2012) Page ;
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. 1.
L. SUBMITTAL INSTRUCTIONS — Submit one copy of the completed notification package to (he each of the
following:
(2)
The Division of Water Quality Regional Office serving the area in which the injection well facility
will be located: e
WINSTON-SALEM
ASHEVILLE
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 18778
Telephone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5043
Telephone: [phone]
Fax: [phone]
Mooresville Regional Office
610 Fast 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]
RALEIGH
WASHINGTON
E
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Telephone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
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 llttp://www.iicallicl oi,g/county hUn.
DWQ/UIC/Closed-Loop Geothermal Noiilicatlon (Revised 4/30/2012) Page 4