WI0100183_GEO THERMAL_20111027

Permit Number W10100183
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility
Central Files: APS SWP
10/27/11
Permit Tracking Slip
Status Project Type
Active New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Gail Bredehoeft
3080 Halls Chapel Rd
Burnsville NC 28714
Facility Name Major/Minor Region
Steve Bredehoeft SFR Minor Asheville
Location Address County
3080 Halls Chapel Rd Yancey
Burnsville NC 28714 Facility Contact Affiliation
Owner
Owner Name Owner Type
Individual
Steve Bredehoeft Owner Affiliation
Steve Bredehoeft
Owner
3080 Halls Chapel Rd
Dates/Events Burnsville NC 28714
Scheduled
Orig Issue App Received Draft initiated Issuance Public Notice Issue Effective Expiration
10/27/11 10/25/11 10/27/11 10/27/11
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall A'UL°_
Waterbody Name Stream Index Number Current Class Subbasin

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
10/27/2011
Steve Bredehoefl
Gail Bredehoefl
3080 Hails Chapel Rd.
Burnsville, NC 28714
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10100183
3080 Halls Chapel Rd.
Burnsville, NC 28714
Dear Mr. Bredehoefl:
Dee Freeman
Secretary
On 10/25/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met;
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .a213, and
3. The required notification form and associated maps have been completely and accurately submitted,
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2), Additionally, you should contact the Yancey County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Angers at [phone] or Michael.Rotiers:a ncdertr.gov if you have any questions.
Si cerely,
for Debra. ��' efts
Sur ery ,,or
cc: Asheville Regional Office - APS
APS Central Files - Permit No. VM100183
Yancey County Health Dept.
Larry Wells (AWD Services, Inc., 256 North Turkey Creek Rd., Leicester, NC 28748)
John Smith (Burleson Plumbing & Heating, Inc., 141 Highland Ave., Spruce Pine, NC 28777)
AQUIFER PROTECTION SECTION
1536 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Bwlevard Raleian. North Carolina 27604
Phona: 919 733,3221 � FAX 1 919-71s-058a; FAX 2: 919-71M0481 Customer Service: 1.877-623-6748
Internet WWW.r[Mt8r0U311TN.ar7
NorthCarolina
An Equal Opuorwniryl Affirmative Acllon Fmrhyer

NOTIFICATION OF PiT ENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as pert of a geothermal heating and cooling system.
These wells are `permitted by ride" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
W
�1V0 19:t)
Print or Type Information and Mail to the Address an the Last Page.
DATE: OL /d 20_// PERMfT NO. _(to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence Business/Organization
Government: State Municipal County Federal
H. WELL OWNER — For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
Seer r 6 t- e0— is e F 6 d--
t
Mailing Address: 30
C.
D.
City: T� 4 rrt�y r�lle- _ _ State:/lYG Tip Code d � County:
Day Tele No.: 9 Z E— — 9 r Z d Cell No.:
EMAM Address: Fax No.:
LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: County: C
(2) Physical Address (if different than mailing address): aammm �
State: NC Zip Code:
WELL DRILLER INFQRMATION
Well Drilling Contractor's Name: �� �• �/ e_ 11-r
GPUMC 5QW NotiScMim (Realised 311 &201 t )
RECEIVED l ❑ENR 1 DWQ Page I
Agoifef ProtOd;on Sedon
OCT 25 2011

E.
NC Well drilling Contrauctor Certification No.: _ "A -?-
Company Name: 9 WO V C *'&-� tit z7tr r-
I�//
Contact Person a t2f we- l s- __- EMAIL Address:;1/-,6
Address:
City: GGi G eree.k Zip CodeA 2- g�9 State: d—,&-Coumty: d!Ks c u rs
0 M c e Tele No.: TZT"&/LT,j - 724 1_ Cell No.: W ` 2 J.f - _ Vy - Fax No.: "� Z 0
HLAT PUMP CONTRACTOR MFORMATION (if different than driller)
Company Name: as rf� a at p�c. ►•� � ,��� �*. � I� r
Contact Person: .! o rt .J r� �� EMAIL Address:
Address:
City: `s r /C�t Zip Code: Late: County: % Ec IL
Office tole No.: 1 Z P - 74- VQ Y 2- Cell No.: ^L F- I Zf- I t L Fax No.:.91 IF - 7L r- 0
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: -2—Depth of each boring
-3 06
er
* ff existing water supply wells will be used then provide the irrfarnwdion in item (4)
below.
(2) Type of tubing to be used (steel, PVC, etc): ¢
(3) Well casing. Ifthe well(s) will use casing thfiprtb�ride the � (steel, PVC, eta.), diameter, de
and extent of casing appearing above ground: - �d- - C-D e : 6 q
(4) Grout (material surrounding well casing andlor piping):
(a) Grout type: Cement Bentonite** Other (specify)
"= By ackaing bmwnitc souk a vvrU nw is bmby requ� to [ ANC AC 2C .0213(d)(1)(A), whkh ropires a MM grout
(b) Grout depth of tables (reference to land surface): from �0 to 3L D (fee#)
If well has casing, indicate grout depth: from - - to (feet)
G. WELL LOCATIONS- Maps mast be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). babel all features clearly and include a north arrow.
(1) Attach a site -specific map showing the locations of the fallowing:
* Proposed injection wells * Bu ldhW * Property boundaries
* Surface water bodies ' Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Exis ft or potential sou ves of groundwater contamination
d, e.

2 Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name,
NOTE: In most cases, an aerial pholograpk of the property parcel showing property litres and structures can be
obtained and downloaded front the app$eable coon& GIS website. Typleally, the properly can be searched by
owner name or address. The location of the wells In relation to property boundaries, houses, septic Inks, other
wdk, ett can them be drawn In by hand Aho, a `layer' c x be selected showing topographic contours or
eievadon data.
GPUIUIC 5QW Notification (Reriaed 3118R01 I) Page 3

H. CERTIFICATION (to be signed.as required below or by that person's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer,
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner {which means all persons listed on the property deed f.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their hehalt
"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 of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the permit ,
WE
t of Property Owner/Applicant
Print or Type Fall Name
/ X�" "k '4 J- / - '-�- - . - -
. ignature of Property OwnerlApplica
(;A&-- Wr-r—
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RFCEJVED I DENR I ❑INCH
+,infer protection SO,t,,,
GPUARC SQ W Nob 6cadw (Revised 3/1812411) page 4

Printing Layout Page
tMp://mppin&y=eycomtym.gov/layoutaspy
Yancey County - GIS Mapping
1 of 1 10/ 19/2011 11:15 AM

Burleson Plumbing & Heating Inc.
J10.
R SIDENTUL WELL CONSTRUCTION RECORDNorth CarolinaDepartment of Environment and Neural Resources- Division of Water Quality
WELL CUIVTRACTOR CERTmcATTUN a 3500
1. WELL CONTRACTOR:
Chad Sumo
Well ConlI actor (Indlvldual) Nome
AWD Services.
Well Contractor Company Name
255 North Turkey- Qraek Rd,
Street Address
Leicester NC 2 T 8
City a Town SUM Zip Code
[ 28 ] 683-9223
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMI'14 W101 183
OTHER ASSOCIATED PERMrri(irapplitatve)
SITE WELL to t>:{tr appiicawej
3. WELL USE (Check Applicable Box): Residential Water Supply Nr
DATE DRILLFcD 10I31I11
TIME COMPLETED AM ❑ PM W
4. WELL LOCATION:
cITY: Bumsville couNTY Yancev
_ 3080 Halls Chage! Road
{Strut Name, Numbers, Community Svbdivislen, lAt No.. Panxl, ap Code)
TOPOGRAPHIC 1 LAND SETTING: (am& appmpftw ao)y
StSlope ❑ Valley ❑ Flat ❑ Ridge ❑ Other Elev. 2844' _
LATITUDE 35 SO ' 54AOM " DMS OR DD
LONGITUDE 52 10 43.0000 " DIMS OR DD
Latitudellengitude source- Rf,PS ❑Topographic map
(location of well must be shown on a USGS topo wrap andatiached to
this harm if not using GPS)
S. WELL OWNER
5teya Bredehoeft
Owner Name
308o Hal.$ Cha!Q!al Road
f eat Address
Bumsviile NQ 28T1A
City or Town State ZIP Code
8[ 28
Area coda Phone number
6. WELL DETAILS:
B. TOTAL DEPTH- 2-300'
9. WATER ZONES (depth):
Top Bottom
Top BoMDrr
Top Dato
Top Bottom
Top Bottom
Top Bottom
ThIckneeW
7. CASING:
Depth
Diameter Weight Material
Top
eatt rr
Ft
Top
Bemm
Ft
Top
Bottom
Ft.
ft. GROUT:
Depth
Material Method
Top Q
Bottom 2U
Ft_ Bentonite Pour
Top 21
Bottom 3QQ'
Ft. Pea Gravel Pour
Top
Bottom
Ft
9. SCREEN' Depth Diameter
Yap Bottom Ft in.
Top Bottom Ft. in.
Top Bottom FL IR
10. SANDIGRAVEL PACK;
Depth Saxe
Top Bottom Flt
Top Bottom Ft.
Top Bottom Ft
11 • DRILLING LOG
Top Bottom
1
1
1
1
1
1
1
1
1
1
1
(2) Geothermal Bares : 12. REMARKS:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO If
c. WATER LEVEL Be law Top of Casing: (VIA_ FT.
(Use "+' d Above Top of Casing)
d. TOP OF CASING IS -N/A-- FT. Above Land Surface"
'Top of easing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C A118.
Slot Size Material
in. .
In.
in.
Material
Formation Description
I ❑O HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
cklaml-11011
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD tgpmf: NIA _ METHOD OF TEST NIA Chad SulTart
f. DISINFECTION: Type NIA _ Amount NIPS! : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within:30 days of completion to: Division of Water Quality - information PracesWng, Form GW-1a
1617 Mail.onter, Raleigh, NC 27699•161, Phone. (919) 807•6300 Rev. 2N9