WI0100147_Regional Office Physical File Scan Up To 9/14/2022

Permit dumber W10100147 ® 5 2l' lI
Program Category AuhP_v111a I'lOCgiond Office
Ground Water
/aquifer Protection
Permit Type
Injection Water Only GSHP Well System (50W)
Primary Reviewer
midhael.rogers
Coastal SW Rule
Permitted Flow
Facility
Central Files: APS_ SWP_
04/01 /11
it Trackina Slia
St tus
Project Type
A tive
New Project
ersion
Permit Classification
1.00
Individual
Permit Contact Affiliation
Rick Molland
296 Morgan Branch Rd
Marshall
NC 28753
Facility Name Major/Minor Region
Connie Molland SFR Minor Asheville
Location Address County
296 Morgan Branch Rd Madison
Marshall NC 28753 Facility Contact Affiliation P
Owner
Owner -Name Owner Type
6ndividual
Connie Molland Owner Affiliation
Connie Molland
Owner
296 Morgan Branch Rd
Dates/Events Marshall NC 28753
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
03/31/11 . 03/23/11 03/31 /11 03/31 /11
Reaulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Waterbody Name
Stream Index Number
Current Class Subbasin

North Carolina Departme en.t and Natural Resources
Di uality
Beverly Eaves Perdue Dee Freeman
Governor North Carolina Department of¢>avi<Dnment and Natural Resources Secretary
03/31/2011
Connie Molland
296 Morgan Branch Rd.
Marshall, NC 28753
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10100147
296 Morgan Branch Rd.
Marshall, NC 28753
Dear Ms. Molland:
On 03/23/2011, 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 constructionand operation of this type of geothermal injection well system as long as the
following conditions are met: ,
The injection well system contains only potable water,
The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
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 Norih Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Madison 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 Rogers at [phone] or Michael.iSupEerviso
rir.aov if you h v any questions.
pp`
Wa s
cc:=Asheville Regional-Office.-.APS )
APS Central Files - Permit No. WI0100147
Madison County Health Dept.
Von Plemmons (Clearwater Well Drilling, Inc., P.O. Box 71, Hot Springs, NC 28743)
Duane Gentry (Gentry Heating Inc., 100 Buckeye Cove Access Rd., Swannanoa, NC 28778)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919.715-0588: FAX 2: 919-715-60481 Customer Service: 1-877-623-6748
Internet: www.ncwatemualitv.ora
An Equal Opportunity \ Aftirmaiive Action Employe:
P
NOI�1i Caro1l Ii a

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 50W WELL(S)
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Print or type the required information and mail to address on the back page.
DATE: d 11 20//
A.
B.
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
� closed -loop)?
Yes V / Continue completing this form.
No Do Not complete this form.. Complete other UIC application forms for installing
either a 5A7 well (open -loop well injecting potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
PROPERTY OWNER(S)/APPLICANT(S)
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): C
(1)
City: State �- Zip Code:? ,' County:__ / �C
Home/Office Tele No.: ab'_r'O?I-194rl Cell No • -Ak-qj Gj4c4�(p_
Email Address: 0,11 dLL,*Vw91� � Website•
(2) - Physical Address of Well Site (if different than above): --51jl 2
City:
County:
Home/Office Tele No.: Cell No.:
State: Zip Code:
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 Tele No.: Cell No.:
Website Address of Company, if any: KECI'aD
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) MAR 2 � 2011
Page ]

F,
C. WELL DRILLER INFORMATION
Company Name:
Well Driller Contractor's Name:,,v ,
NC Contractor Certification No.:
Contact Person- v, u•
EMAIL Address: n
Address: J
City: fir, Zip Code: '',3 County: /
Office Tele No.: Cell No.: A/
:7-2��F D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:
IC
Contact Person: fco 1 4 EMAIL Address: ac.�
Address:
City: v Zip Code: '� County: oY
Office Tele No.:Cell No.:.���
E. -STATUS OF APPLICANT
Private: Federal: Commercial:
State: Municipal: Native American Lands:
F.- INJECTION PROCED/ RE (briefly describe how the injection well s) will be used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: % L Number of borings:
s
Approximate depth of each boring (feet):
(2) Type of tubing to be used (copper, PVC, etc):
(3) Well casing. Is the wells) cased? (check either (a.) Yes or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: _Jgalvanized steel black steel_plastic other (specify)
Casing depth: From to feet (reference to land surface)
Casing extends to above ground inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Rentonite L -- Other (specify) S91)
(b) Grout placement: Pumping Pressure L--'—' Other
(c) Grout depth of tubing (reference to land surface): from 0 to (feet)
If well has casing, indicate grout depth: from to (feet)
(6 11./
GPU/UIC 5QW Notification of Intent Form (Revised 8/2608) Page 2

K; c I S f L)Dntjrr. I I )OHIMa
to

H. 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.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. 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 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 t Qssibility of fines and imprisonment, for submitting
false information. I agree to construct, operate, m ' am, re i.r, and if applicable, abandon the injection well and
all related appurtenances in accordance with th pprove pecifications and c9nAitions of the Permit."
;fie of PropertyOwner/Applicant
C 44 I CE ),04 xub
Printu11 Namp and title
Signature of Property Owner/Applicant
r, /61—Lo
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center pc�r�l�tDlDlcl; ,�,4�
Raleigh, NC 27699-1636 +C)UIF: I '10 �T''r' �i�'"� '�;�i
Telephone [phone] MAR 2 a 201l
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008)
Page 3