WI0100083_Complete Historic File ARO_20220316

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03/02/2010 00:58 919-715-058B NCDE&NR/WATER QUAL PAGE 14
MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H.Sullins Dee'Freeman
Governor Director l Secretary
March 9,2010
Thomas I.Gray
Sharon H.Gray
P.O.Box 1447
Franklin,NC 28744
Subject: Acknowledgement of Application No..WI0100083 I
Thomas lames Gray SFR
Injection Mixed Fluid GSBP Well System(5QM)
Macon
Dear Mr, and Mrs.Gray:
The Aquifer Protection Section of the Division of Water Quality(Division)acknowledges receipt of your permit application and
supporting materials on February 18,2010,This application package has been assigned the number listed above and will be reviewed
by Michael Rogers. {
The reviewer will perform a detailed review and contact you with a request for additional informer on ifnecessary.To ensure the
maximum efficiency In processing permit applications,the Division requests your assistance in providing a timely and complete '
response to any additional information requests.
Please be aware that the Division's Regional Office,copied below,must provide recommendations prior to final action by the
Division.Please also note at this time,processing permit applications can take as long as 60-90 days after receipt of a.complete
application.
If you have any questions,please contact Michael Rogers at 919-715-6166,or via a-mail at [e-mail]. If the
reviewer is unavailable,you may leave a message,and they will respond promptly-Also note that the Division has reorganized.To
review our new.organizational chart,go to hnn•//h2o enr state.nc ug/document-Jt1wq oreehart odf.
PLEASE REFER TO THE ABOVE APPLICATION NUNMER R'&EN NIATCTNG INQUIRIES ON THI PROJECT.
i
Sinc
for Debra J.
Supervisor
I
cc: Asheville Regional Office,Aquifer Protection Section
Christy McClure(Tarheel Water Treatment,Inc.,3494 Georgia Rd,,Franklin,NC 28734) .
Bruce Auld(Andrews Auld Reating 8e Cooling,Inc.,3348 Old Murphy Rd.,Franklin,NC 28734)
EemvFApplicatforiFiPb';WI0100083' I
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AOUIFER PROTECTION SECTION 1
1636 Mail Service Canter,Raley h,Nod Carolina 27699-1636
Lorarpn;2728 Capital Boulevard.Raleigh,Nod Carolina 27604 I ne
Phone;919-733-02211 FAX 1:919-715-0588;FAX 2:919-715-60481 Customer Service;1,877-623,6748 rt �'�Gh.Xl ll:Internet wautnavalerg Ir,�ily om I Nog
An Equal Oppomu,Ap i Affirmative Amion Employer
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03/02/2010 00:58 919-715-0588 NCDE&NR/WATER WAL PAGE 08
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES(NCOPNR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A W ELL(S)FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 50M WELL(S)
New Permit Application OR Renewal(c ED
DATE:_0— O S .. zoo MAR 05 NO
PERMIT NO. (leave blank VNEW permit application)
A. PROPERTY OWNIER(S)/APPLICANT(S) Leville Regional Office
gtlifer Protection
List each Property Owner listed on property deed(if owned by a business or government agency,state name of
entity and a representative w/authority for signature): l A(O rY A S � 5 6'AA 14
5 4AA0 i P• CAI 1
(1) Mailing Address: �1.©- ! n
city: n R State: l\ Zip Code: � � 1 County:
Home/OfficeTeleNO.: 2aR - ' CLlq- 4735 Ce11No.: tf07-22-( 1ZO
EMAIL Address:
(2) Physical Address of Site(if different than above): OuC t n �Qi
city! l( 1\k-V\ State: l.� Zip Code:_ �_ County (r)9 COA
Home/Office Tele No.: Cell No-:
EMAIL Address:
B. AUTHORIZED AGENT OF OWNER,IF ANY(if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City. State: Zip Code: County:
Office Tole No.: Cell No.:
Website Address of Company,if any:
C. STATUS OF APPLICANT
Private: Federal: Commercial:
State:_ Municipal:_ Native American Lands_ RECEIVED I DDNR/DWQ
Aquifer protection Section
FEB 11 20,({
GPU/MC 5QM Well Permit Application(Revised W2008) 8,1

03/02/2010 00:58 919-715-05BB NODE&NR/WATER QUAL PAGE 09
D. WELL DRILLER INF TI N
Company Name: �rL t t'f ea4 1 ge n— J d1 C,
Well Drilling Contractor's Name: _A 1,rr /1 5
NC Contractor Cettification No.: �n yc`Q Li A
Contact Person: �'J_ Yi 5 � n! MAII Address:
Address: ,31I q'"I 1 (7�C�fSi i0� IC(�ll
City: E,(C- `�j . I() Zip Code: _ County: M&Dn
Office Tele No.: /j2Z E nLI^07410 Cell No.: 8 0 _ - A TZ- ( 513
E. HEAT PUMP CONTRACTOR INFORMATION(ifdiffereat than driller)
Company Name: i U
Contact Person: 1 EMA ,Address:
Address:
^ u`
City: Y-j� 4 Zip C//ad--,e: � County: (()
Office Tele No.: & 7i�9 �� ht�Cell No.:�L 2 �] 1 I 2'7i 65
F. INJECTION PROCEDURE (briefly describe how the injection well(s)will be used)
�,e.(M0--1 �1 a � ir�a
G. WELL CONSTRUCTION DATA(Skin to Section H if this is a Permit RENEWALI
(1) Proposed date to be constructed:��j O 1^ 1._��Number of borings:
P
Approximate depth of each boring(feet): 0290
(2) Chemical additives to be used in closed-loop system(only those chemicals indicated have been approved):
R-22 _l,�rcpylene glycol ethanol other(other additives will
need prior approval by NCDPN(Z before use)
(3) Type of tubing to be used(copper,PVC,etc): I ma-1 0D IL/e! e l rV rl-Cl
(4) Well casing. Is the well(s)cased?(check either(a)YES or(b.)(Oelow)
(a) YES if yes,then provide casing information such as type(steel,PVC,plastic,etc,),diameter,
depth and extent of casing appearing above ground: l
11 !I
(b) NO Aoo� _fJ 21
(5) Grout(material surrouading well casing and/or piping) t l 1
(a) Grout type: Cement_ Bentonite Other(specify) Vq Rra,nil�e t4ue I
(b) Grout depth of tubing(reference to land surface): from 0 to 206 (feet)
If well has casing,indicate grout depth: from to (feet)
11 INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing.associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
GPU/UIC 5QM Well Permit Application(Rc isW 712008) Page 2

03/02/2010 00:58 919-715-0588 NCDE&NR/WATER QUAL j PAGE 10
L LOCATION O)F WALL(S)
Attach two copies of maps showing the following information:
(1) Include a site map(can be drawn)showing: buildings,property lines,surfacefwater bodies,potential sources
of groundwater contamination and the orientation of and distances between the proposed well(s) and any
existing wel (s)or waste disposal facilities such as septic tanks or drain fieldsiloeated within 1000 feet of the
geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
J. POTABLE WATER WELL(S)
Are there any potable water well(s)on the subject property or adjacent properties? i! YES NO
If Yes,than indicate location on attached map(s). j
I
IC CERTIFICATION
Note:This Permit Application must be signed by each person appearing on the recorded legal property deed.
"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 tbose 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 imprisonan.ent, 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 th ap roved specifications and conditions of the Permit."
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Signat of Prop weer/Applicant 1
Print or Type Full N e
i
signature of Property Owner/Applic t Print or Type Full Name
Signature of Authorized Agent,if any "
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DRNR-DWQ
Aquifer Pr(ttretion Section
UIC Program
1636 Mail Service Center RECEIVED/DENR I DWQ
Raleigh,NC 27699-1636 Agti'rfer Protection Section.
Telephone[phone] FEB 18 z010
GPU/UICSQM Well Permit Application(Revised7/2008) i Page3
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