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Home My WebLink AboutWI0100100_GEO THERMAL_20120518NCDENR North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Charles Wakild, P. E. Governor Director May 18, 2012 Stephen and Jayne Cluggish 3101 Churchill Road Raleigh, NC 27607 Subject: Notification of Rule Revisions Affecting Closed -Loop Geothermal Injection Well Permit Holders Permit Number: WI0100100 Dear Mr. and Mrs. Cluggish: Dee Freeman Secretary Our records indicate that you currently hold a permit for a closed -loop geothermal injection well system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative Code Title 15A Section 2C .0200 entitled "Well Construction Standards — Criteria and Standards Applicable Injection Wells" were revised. These revisions affect all permits issued for injection wells including geothermal wells. This letter is also to inform you that your closed -loop geothermal injection well(s) have become "permitted by rule." Therefore, you are no longer required to renew your current permit and the permit will be valid indefinitely as long as the wells are active and are operated in accordance with the revised rules referenced above. Please keep in mind that if you abandon the wells, a record of abandonment must be submitted to the Division of Water Quality. You may view the revised rules on our website at http://portal.ncdenr.org/web/wq/aps. If you have any questions regarding your current permit or the rule revisions, please feel free to contact our underground injection control staff at (919) 807-6464. Sincerely, Eric G. Smith, P.G. Hydrogeologist cc: UIC Permit File AQUIFER PROTECTION SECTION 1636 Mail Service Center, Raleigh, North Carolina 27699-1636 One Location: 512 N. 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Il�Isp,, aFG� a1�F•�I+� avdl llaM. 14w 4Ali mMxu;-724/ /w,°9 alwim Nrmmofbpkmw *o Novo ftwxowik,~rwwm��' in WW Dig - F4N., 119 NN - -��_- -_-,P- ' IL `v4w. 0��,-- .��'----~��'----'--~--- '------'' IL 0OwN-� ftmm---' -`n*+-��--�^�'�.�� | ^m� '---- Fmm AM"" -_�-�--__ ~ ' -'---_--- Central Files: AP5 SWP- 06174/10 Permit Number W10100100 Permit Tracking Slip Program Category Status Project Type Ground Water In review New Project Permit Type Version Permit Classification Injection Mixed Fluid GSHP Well System (50M) Individual Primary Reviewer michaei.rogers Coastal SW Rule Permitted Flow Permit Contact Affiliation Van Plemmons PO Box 71 Hot Springs NC 28743 Facility Facility Dame Major/Minor Region Stephen and Jayne Cluggish SFR Minor Asheville Location Address County 21 Snow Shoe Dr Buncombe Asheville NC 28803 Facility Contact Affiliation Owner Name Owner Type Individual Stephen Cluggish Owner Affiliation Stephen Cluggish Owner 3101 Churchill Rd Raleigh NC 27607 Dates/Events Scheduled Orig Issue App Received Draft initiated Issuance Public Notice Issue Effective Expiration 06129/10 06/02/10 06/29/10 06/29/10 05/31/15 Reriulated Activities Reuuested/Received Events Heat Pump Injection RO staff report requested 06/18/10 RO staff report received 06/22/10 ❑uttall NUL, Waterbody Name Stream Index Number Current Class Subbasin Permit Number WI0100100 Program Category Ground Water Permit Type Injection Mixed Fluid GSHP Well System (50M) Primary Reviewer michael.rogers Coastal SW Rule Permitted Flow Central Files: AP5 SWP 06/22/10 Permit Tracking Slip Status Project Type In review New Project Version Permit Ciasstfication Individual Permit Contact Affiliation Von Plemmons PO Box 71 Hot Springs NC 28743 F aciiit■ Facility Name Major/Minor Region Stephen and Jayne Cluggish SFR Minor Asheville Location Address County 21 Snow Shoe Dr Buncombe Asheville NC 28803 Facility Contact Afflllation Owner Name Owner Type Individual Stephen Cluggish Owner Affiliation Stephen Cluggish Owner 3101 Churchill Rd Raleigh NC 27607 Scheduled Orig Issue App Received breft Initleted Issuance public Notice issue Effective xpira ion 06102110 LQ Ic" v 1 J Reculated Activities F Sour,At d1EWc,-.ived Everts Heat Pump Injection RO staff report requested 06/18/10 RO staff report received 06/22/10 Outfafl NULL Waterbody Narns 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 Dee Freeman Governor Director Secretary June 29, 2010 Stephen and Jayne Cluggish 3101 Churchill Rd. Raleigh, NC 27607 Subject: Issuance of Injection Weil Permit Permit No. WI0100100 Issued to Stephen and Jayne Cluggish Buncombe County Dear Mr. and Mrs. Cluggish: In accordance with your application received June 2, 2010... I am forwarding Permit No. W10100100 for the constriction and operation of a vertical closed -loop geothermal mixed -fluid beat pump injection well system to be located at 21 Snow Shoe Dr., Asheville, NC 28803. This permit shall be effective from the date of issuance until May 31, 2015, and shall be subject to the conditions and limitations stated therein. Please pay special attention to Part 11.1 of the permit. At least forty-eight (48) hours prior to constructing system, the Permittee shall notify the Aquifer Protection Section's Underground Injection Control (MC) Program Central Office staff, telephone number (919) 715-6166, and Jonathan Stepp with the Asheville Regional Office Aquifer Protection Section Staff, telephone number (828) 296-4500 Additionally, per Part VII.2 of the permit, submit copies of the Well Construction Completion form (GW-1) within 30 calendar days of completion of installation of geothermal well(s). In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an application to renew the permit 120 days prior to its expiration date. As indicated in the permit, this permit is not transferable to any person without prior notice to, and approval by, the Director of the Division of Water Quality. If you have any questions regarding your permit or the Underground injection Control Program please call me at (919) 715-6166. Sincerely, Michael Rogers, P.G. & FL} Environmental Specialist cc: Landon Davidson-- Asheville Regional Office Central Office File — WI0100100 Buncombe County Environmental Health Dept, Attachment(s) AQUIFER PP.Q7EC7l4N SECTION 1636 Mai! Service Comer. RaleO. Now Carolina 27699.1636 L=tion: 2728 Capita Soulevard, Raleigh. North Carolina 27604 Phone: 919-733.M1 l FAX I.919.715-058B; FAX 2' 919.71M048 i Customer Serom.- 1•BT7•623-6748 1P of Adl Caro]Ina Intemet: xnr jywatugllall .erg An Equal opptnrawny i A$multi va Asian Employer ovaturallil NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES RALEIGH, NORTH CAROLINA PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable Laws, Rules, and Regulations PERMISSION IS HEREBY GRANTED TO Stephen and Jayne Cluggish FOR THE CONSTRUCTION AND OPERATION OF 4 TYPE 5QM INJECTION WELLS), defined in Title I SA North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop geothermal mixed fluid heat pump system. This system is located at 21 Snow Shoe Dr., Asheville, Buncombe County, NC 28803, and will be constructed and operated in accordance with the application received June 2, 2010. and in conformity with the specifications and supporting data, all of which are fled with the Department of Environment and Natural Resources and are considered a part of this permit. This permit is for Construction and Operation of an injection well and shall be in compliance with Title 15A of the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and Regulations pertaining to well construction and use. This permit shall be effective, unless revoked, from the date of its issuance until May 31, 2015, and shall be subject to the specified conditions and limitations set forth in Parts I through IX hereof. Permit issued this the 29th day of June 2010. Coleen H. Sullins, Director Division of Water Quality By Authority of the Environmental Management Commission. Permit W10100100 UICj5QM Page 1 of 5 ver.03/2010 PART I - WELL CONSTRUCTION GENERAL CONDITIONS The Permittee must comply with all conditions of this permit and with the standards and criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is grounds for enforcement action as provided for in N.C.G.S, 87-94. 2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of this permit, the approved plans and specifications, and other supporting data. 3. Each injection well shall not hydraulically connect separate aquifers. 4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally subject to flooding include those with concave slope. alluvial or colluvial soils, gullies, depressions, and drainage ways. 5. Each injection well shall be afforded reasonable protection against damage during construction and use. PART H — WELL CONSTRUCTION SPECIAL CONDITIONS 1. At least forty-eight (48) hours prior to constructing system, the Permittee shall notify the Aquifer Protection Section's Underground Injection Control (UlC) Program Central Office staff, telephone number (919) 715-6166, and Jonathan Stepp with the Asheville Regional Office Aquifer Protection Section Staff, telephone number (828) 296-4500. ?. The location of each of the system manifolds shall be recorded by triangulation from three permanent features on the site (e.g., building foundation corners) and shown on an updated Site Map. The Permittee shall retain a copy of this record on site. 3. One well identification tag per grouping or 'cluster' of wells shall be permanently affixed to the heating and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g). PART III — OPERATION AND USE GENERAL CONDITIONS 1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as described in the application and other supporting data. ?. This permit is not transferable without prior notice to, and approval by, the Director of the Division of Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a name change of the Permittee, a formal permit amendmeut request must be submitted to the Director, including any supporting materials as may be appropriate, at least 30 days prior to the date of the change. a, The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and all statutes, rules. regulations, or ordinances. which may be imposed by other local, state, and federal agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all regulatonr requirements have been met. Permit WID100100 UIC/5QM Page 2 of 5 per. 03/2010 PART TV — PERFORMANCE STANDARDS ] . The injection facility shall be effectively maintained and operated at all times so that there is no contamination of groundwater that will render it unsatisfactory for normal use. In the event that the facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective actions including those actions that may be required by the Division of Water Quality such as the repair, modification, or abandonment of the injection facility. 2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance requires a reduction or elimination of the permitted activity. 3, The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or ground water resulting from the operation of this facility, PART V — OPERATION AND MAINTENANCE REQUIREMENTS The injection facility shall be properly iaintained and operated at all times. 3. The Permittee must notify the Division and receive prior written approval from the Director of any planned physical alterations or additions in the permitted facility or activity not specifically authorized by the permit. 3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone number (919) 715-6166, Notification is required so that Division staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit conditions. PART VI - INSPECTIONS Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon presentation of credentials, enter and inspect any property, premises, or place on or related to the injection facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or copy any records that must be maintained under the terms and conditions of this permit, and may obtain samples of groundwater, surface water, or injection fluids. '. Division representatives shall have reasonable access for purposes of inspection, observation, acid sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90. 3. Provisions shall be made for collecting any necessary and appropriate samples associated with the injection facility activities. Permit W10100100 UIC/5QM Page 3 of 5 per. 03/2010 PART VII — MONITORING AND REPORTING REQUIREMENTS 1, All required documentation shall be submitted to: Aquifer Protection Section — U1C Program Aquifer Protection Section DENR — Division of Water Quality Asheville Regional Office 1636 Mail Service Center and 2090 US Highway 70 Raleigh, NC 27699-1636 Swannanoa, NC ?8778 Ph# 919-715-3221 (828) 296-4500 ?. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the Aquifer Protection Section Central Office and the Asheville Regional Office within 30 days of completion of well construction. Copies of the GW-1 form(s) shall also be given to the Permittee and retained on site to be made available for inspection. 3. A copy of the site map updated with manifold locations required in Part 11.2 of this permit shall be submitted to the Aquifer Protection Section Central Office and the Asheville Regional Office within 30 days of completion of well construction. 4. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the Division of Water Quality to insure surface and ground water protection will be established and an acceptable sampling reporting schedule shall be followed. 5. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the occurrence, to the Asheville Regional Office, telephone number (828) 296-4500 any of the following: (A) Any occurrence at the injection facility that results in any unusual operating circumstances, (B) Any failure due to known or unknown reasons that renders the facility incapable of proper injection operations, such as mechanical or electrical failures; (C) Any loss of refrigerant in the system, regardless of the origin of the loss; (D) Any recharging of the refrigerant system. C. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any incorrect information submitted in said application or in any report to the Director, the relevant and correct facts or information shall be promptly submitted to the Director by the Permittee. 7, In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such immediate action as may be required by the Director. PART VIII — PERMIT RENEWAL In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall submit an application to renew the permit 120 days prior to its expiration date. Permit W10100100 UIC/5qM Page 4 of 5 ver. 03/2010 PART IX — CHANGE OF WELL STATUS 1, The P ermittee shall provide written notification within 15 days of any change of status of an injection well. Such a change would include the discontinued use of a well for injection. If a well is taken completely out of service temporarily, the Pezmittee must install a sanitary seal. If a well is not to be used for any purpose, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(1). Notification shall be submitted to the addresses given in Part V11.1 of this permit. 2. NVhen operations have ceased at the facility and a well will no longer be used for any purpose, the Permzttee shall abandon that injection well in accordance with the procedures specified in 1 aA NCAC 2C .0214, including but not limited to, the following: (A) All casing and materials may be removed prior to initiation of abandonment procedures if the Director finds such removal will not be responsible for, or contribute to, the contamination of an underground source of drinking water. (13) The entire depth of each well shall be sounded before it is sealed to insure freedom from obstructions that may interfere with sealing operations. (C) Each well shall be thoroughly disinfected, prior to sealing. if the Director determines that failure to do so could lead to the contamination of an underground source of drinking water. (D) Each well shall be completely filled with cement grout, which shall be introduced into the well through a pipe that extends to the bottom of the well and is raised as the well is filled. (E) In the case of gravel -packed wells in which the casing and screens have not been removed, the casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout injected through the perforations. (F) In those cases when, as a result of the injection operations, a subsurface cavity has been created, each well shall be abandoned in such a manner that will prevent the movement of fluids into or between underground sources of drinking water and in accordance with the terms and conditions of the permit. (G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified in 1 SA NCAC 2C 0213(h)(1) within 30 days of completion of abandonment Copies shall be submitted to the addresses given in Part V1I.1 of this permit. Permit W10100100 UIC/5Q.M Page 5 of 5 ver. 03/2010 Rogers, Michael From: Stepp, Jonathan Sent: Tuesday, June 22, 2010 10:30 AM To: Rogers, Michael Cc: Davidson, Landon Subject: RE: W Ig1 OO1 Dg Cluggish 50M Attachments: image001.png Landon is out today, however he did forward these to me so he has looked at the applications. JonathanStepp —Jonathan.Stepp @ ncdenr.pov North Carolina Dept. of Environment and Natural Resources Asheville Regional Office Division of Water Quality - Aquifer Protection Section 2090 U.S. 70 Highway Swannanoa, NC 28778 Tel: 828-296-4SOO Fax: 828-299-7043 Notice: E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and therefore may be disclosed to third parties. From: Rogers, Michael Sent: Tuesday, June 22, 2010 9:55 AM To: Davidson, Landon Cc: Stepp, Jonathan Subject: FW: WI0100100 Cluggish 5QM Landon - Debra wants supervisors to approve these applications. Can we assume if we get an e-mail from Jonathan approving permit issuance that you have signed off on it? Thanks Michael Rogers, P.G. (NC & FL) Environmental Specialist NC Div of Water Quality- Aquifer Protection Section (APS) 1636 Mail Service Center Raleigh, NC 27699-1636 Direct Line (919) 715-6166, Fax 715-0588 (put to my attn on cover letter) E-mail correspondence to and from this address maybe subject to the North Carolina Public Records Law and maybe disclosed to third perties From: Stepp, Jonathan Sent: Tuesday, June 22, 2010 8:26 AM To: Davidson, Landon Cc: Rogers, Michael Subject: RE: W10100100 Cluggish SQM My recommendation is to proceed with permitting. Jonathan Jonathan Stepp —Jonathan .Stepp@ncdenr.Sov North Carolina Dept. of Environment and Natural Resources Asheville Regional Office Division of Water Quality - Aquifer Protection Section 2090 U.S. 70 Highway Swannanoa, IBC 29778 Tel: 828-296-4500 Fax: 828-299-7043 Notice: E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and therefore may be disclosed to third parties. From: Davidson, l-andon Sent: Friday, June 18, 2010 2.25 PM To: Stepp, Jonathan Subject: FW: WI0100100 Cluggish 5QM fyi G. tandrm Davidson. P.G. I,Lr,E1,P E,k 0 Jn it :'; I _I C'0" hh �uIF_I i'r,t__bJnr_ li•,n �. Q _� fJn. I i5 r't �LIR: IYI.JI � i A. A-_ 0IcP, i,n:I rvW. z7?7 US Hrr� �1 ph,,5S,:V ��eb page: hJLa.enr.stute.rrc.u3 Ar+w.html This e-moil contains a public record which is subject to disclosure to third parties and the public pursuant Noah Carolina's Public Records Low. N.0 Gen. Stot. §z32-1, er seq. This e-moil may con roin materiofs prepared during or in anticipation of a Lego! proceeding as port of preporation for that legal proceeding, in which case third party or public access to it is subject to N.C. Gen. Star. §132.1.9 and may be denied until the conclusion of the legal proceeding, including the completion of all appeals and past judgment proceedings, or, in the case where no legal proceeding has been conunenced, upon the expiration of all applicable statutes of limitotions and periods of repose. From: Rogers, Michael Sent: Friday, June 18, 2010 2:23 PM To: Davidson, Landon Subject: WI0100100 Cluggish 5QM Please find attached an application for a 50M well. Please let me know if you wish to conduct a pre - permitting inspection. Thanks Michael Rogers, P.G. (NC 8 FL) Environmental Specialist NC Div of Water Quality- Aquifer Protection Section (APS) 1636 Mail Service Center Raleigh, NC 27699-1636 -Rogers, Michael From: Stepp, Jonathan Sent: Tuesday, June 22, 2010 8:25 AM To: Davidson, Landon Cc: Rogers,. Michael Subject: RE: W 10100100 Cluggish 50M Attachments: imageool.png My recommendation is to proceed with permitting. , Jonathan Jonathan Stepp — Jonathan.Stepp@ncdenr.gov North Carolina Dept. of Environment and Natural Resources Asheville Regional Office Division of Water Quality - Aquifer -Protection Section 2090 U,5. 70 Highway Swannanoa, NC 28778 Tel: 828-295-4500 Fax: 828-299-7043 Notice: E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and therefore may be disclosed to third parties. From: Davidson, Landon Sent: Friday, June 18, 2010 2:25 PM To: Stepp, Jonathan Subject: FW: W10100100 Cluggish 5QM A 'C. Undon Davidson, P.G. ... —.1. rr- r. 4 - - '. _ rt.—A, ,::4Lift _f PIA_'_It JA 5 - - b 494 � R _ iin_ i A1up rvi.J� � F •4all:vfl �: �l'?�QiG.i TIC; N.C. Z8779 �- ph.' S13 Zti6 'S97 � T- 323 _'_+ 7�1 web page, h_.(Tv:(Zh2o.enr.state.nc.usjogw& I This e-mail contains o public record -which issubject to disclosure to third parties and the public pursuant North Carolina's Public Records tow. tv.C. Gen. Star. §132-1, et seq- This e-mail may contain materials prepared during or in anticipation of a legal pror:eeding as part of preparation for that legal proceeding, in which case third parry or public access to it is subject to N.C. Gen. Srot. §132-1.9 and may be denied until the conclusion of the legal proceeding, including the completion of all appeals and post judgment proceedings, or, in the case where na legal proceeding has been commenced, upon the expiration of all applicable statutes of limitotions and periods of repose. -1 From: Rogers, Michael Sent: Friday, June 18, 2010 2:23 PM To: Davidson, Landon Subject: WIOIOO100 Ciuggish 5QM Please find attached an application for a 50M well. Please let me know if you wish to conduct a pre - permitting inspection. Thanks Michael Rogers, P.G. (NC & FL) Environmental Specialist NC Div of Water Quality- Aquifer Protection Section (APS) 1636 Mail Service Center Raleigh, NC 27699-1636 Direct Line (919) 715-6166; Fax 715-0588 (put to my attn on cover letter) E-mail correspondence to and fivm this address may be subject to the North Carolina Public Records Law and may be disclosed [o third parties A, == FA war HCDENR North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Coteen H. Sullins Dee Freeman Govemw Director Secretary June 15, 2010 Stephen Cluggish Jayne Cluggish 3101 Churchill Rd. Raleigh, NC 27607 Subject: Acknowledgement of Application No. W10100100 Stephen Cluggish SFR Injection Mixed Fluid GSHP Well System (5QM) Buncombe Dear Mr. and Mrs. Cluggish: The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and supporting materials on June 2, 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 information if necessary. 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 e-mail at michaei.rogersiwncdenr.gov. 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:llh2o.enr.state.ne.usldocumenWdwci or--,charLpdf. PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT. Sink ely, for Debr . Watts Supervisor cc: Asheville Regional Office, Aquifer Protection Section Von Plemmons (Clearwater Well Drilling, P.O, Box 71, Hot Springs, NC 28743) Duane Gentry (Gentry Heating Inc., 100 Buckeye Access Rd., Swannaooa, NC 28778) Permit Application File WIG 100100 AQUIFER PROTECTION SECTION 1636 Mail Service Center, Raleigh, North Carolina 27699.1636 Location: 2728 Capita! Soulevard, Raleigh, North Carolina 27604 Pl one: 919-733-3221 � FAX 1: 919-715aft FAX 2; 919-715-6W l Cuslomer Servlm 1.877- M-6748 Intemet: www.nrwatemualhv.or� An Equal Opporumrty 1Affirm alive Acrgn Emp6oper NNurally e Carolina NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR) APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WEL14S) FOR I[NJEC' ION VVTM A GECVMRKAL BEAT PUMP SYSTEM FOR: TYPE 5 M WEL 5 VNew Permit Application OR Renewal (cheek one) DATE: , 2AI& PERMIT NOS (lame blank if NEW permit application) A. PROPERTY OWNERMAPPLICANT(S) List Sh Property Owner listed an property deed (if owned by a business or government agency* state namr of emiry and a representative w/sutlt dry for signatum): I S - �-1►�E L-� Is (1) Mallinag Addrm: 31 Q i -c-ti-Lk z uLL- ejn6 D _ City: _ep—,LC--rC, I+ State: W� Zip Code: �_UD-7 County: HomdO fice Tole No.: — ;2 it q4D Cc EMAIL Addrcss: ► 1. (2) Physical Address of Site (ifdifferent than Wxwe). 21 SN 0 -- IkRA VC City: _ swwlug- Store: r. Zip Code: 2= County: ft&ggf"0�r7 Hon KXfice Tele No.: 1 - ZLo- No.: @MAIL AddressSC.i�rs� dia�_ rs�jld�esr� , CLSL� B. r IAVTHDRIZXD AGENT D DWME F ANY (if the Permit Applieamt does not awn the subject property, attach a letter from the property owner authorizing Agent to install and opmft UIC yell) Company Natme: Conmt:t PersonL-- EMAIL ddrrss• Address: City: — State: Zip Code: County: Office Tele No.: _ Cell No.: _ .- -- - - -- -- - Website Address of Company. if any._-... WATUS Of APPLICANT Private: X Federrl L oinrwrcial _ RECEM IDENR I DWD State: Municipal: _ _ Native American Lands: _ A�UI�R` iFr'11f1i�S ['TIDN JUN 0 2 MO D. WELL DRILLER INFORMATION Company Name: ClEAat'1ok7 E�W&.L leiLLauT Weli Drilling Contmetor's Name: Val , ,RMnPAD NC Contractor Certif cat ion No.: 1/0 Contact Person: VDL AzarmACIU S EMAIL Addte§L MaJrlu&kr 7Li 6 -a Dj_. uvi Address: —R D 13n. - 17 _ City: U Zip Code: 2 ri' County; AAA i. Office Tele No.A-A - 6aZ - 7 Z41 Cell No. 4 - LQ I - IGS ZLp E. F HEAT PUMP CONTRACTOR I"RIHATION (if different than driller) Compan Contact Address: I VU %1 S C -4]A4 t City: 5 Dh*)A]A QQ& Zip Code: X ig County: 8LI J2 C)A4 Office Tele No.: 29 - IN- Z4j= - Cell No.: 'q2, -SSA- 14 zl INJECTION PROCEDURE (briefly describe how the injection well(s) will be used) � sZ D - - LD l2 P CP=04.&��l'3� G. WELL CONSTRUCTION DATA (Skip to Section H i<this is 2 Permit RF 'WAL) (1) Proposed due to be constructed: _ 5> - 7- T-_1 ❑ Number of bo� rir: Approximate depth of each boring (feet): " 1 i p I (2) Chemical additives to be used in closed -loop system (only those chemicals indicated have been approved): R-22 - _ propylene glycol ethanol other (other additives will need prior approval by NCDENR before rue) (3) Type of tubing to be used (copper, PVC, etc): _ ? C� 340 "a ^ (4) Well casing Is the wells) cased? (check either (a.) YES or (b.) NO below) lay YES if yes. then provide casing infomtstion such as Dn (steel, PVC, plastic, etc. ), diameter. depth, and e=t of casing appearing above ground: (b) NO� (5) Grout (material surrounding well casing and/or piping): (a) Grout type: Cement—__ Bentonite I Other tspecih-1 , (h) Grout depth of tubing ( reference to land surface): from It s 2— i C) (fret i If ell has casing. indsLaw g!oui depth- Irow It I feel: H. IN.iE:CiTION-RELATED EQUIPMEh-f 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 mar provide supplementary information. L )CATION OP WELI.(S) Attach two won or naps showing the renowing inrormation. ( i) include a silo map (can be drawn) *wwing: buildInIM proper lim surface water bodim potential sourc." or gratandwater aaonteaniraatimn and Gw orienmtion or and distances bntrneen Ilse proposed well(s) and any exisdng wall(:) or waste disposal facilities each as septic lanks or drain fields located within I oco feet orthe goolhetmW had pump wall symm. Label all Mures clearly and include a nortta_arnn�r. (2) Include a topoomphic map orthe area exiending one mile from the property boundaries and indicate the Nallity's location and dw map mama. J. POTABLE!: WATER WELLS) Are there tagy potable water well(:) on the subject property or adjacent ptoperdes'! A_YES viva ICYes, lhan Indicate location an attached ms*). IL CERT111rICATION Note: This Permit Appi cadom =0 be signed by glift panne appearing on the recorded legal property deed. "1 hereby earth, under ponally of law, tbat I have personally examblod emd am familiar with the iaformtation submitted in this document and WI Nachman thereto and that, based an my inquiry of than lttdiarldusls immedWely anponsible ror obtalalr4l; sold Inrorn alloo,1 believe that tho Information is we, accurate and complete. I am aware bast Iltete are siFditanl penalties, including the posslbility or fines and Imprimno nt, ror sabrnirting false infomWom I ngtao to comb% % operate, maalroeln, repair, and irappiirsbie, abandon the irgertien well end all related appurtenanees in accordance wWa the appmved apcdflcatiaras and coatditiiams arts a Paxmic Signaium orProperty OwnerlAppii ant �� LUC�6r act. Print or TM Full Nature j mtu of Property OwnerfAp a i Priol or Type Full Nerne Sigrwtwe orAuthoriacd Agent, Irony Print or Type Full Name Please return two copies ortha compleacd Application pockggc to: North Caroline DEMR DWO Agrsikr Prolection Section UIC Prngraat RECEIVED I0ENR l E"a 1636 Mail Servkc Center A0UIFFq.PR rFr 1nN 1Wfth, NC 27699-1636 SEC77ON Telephone (919) 7IS-6933 `SUN 0 2 2019 W0eR 1� -CV Snoua shoo l� � ScP�t c �� , cre m yew Mal N � Im Web Mapping Application Page I of 2 Buncombe County GIS . .!/* , i; �{ ■ r = f kJ jHelp GIs Home Suffer Pro erty Sales Re art Print earch For• Parcel Search By: r PIN A'i Owner {" Address r Street r Deed Book/Page r Plat Book/Page kduggish f Resuit9 Export to Excel Pri T�hle 4 -- Map Cont£nt9 IF imagery r47 Map (967225.407, 657057-209) (1) 'a F Property ( 1) I=t r MERRILLS PARK FINUI PROPCARD PROPERTY CARD PINNUM 966577205300000 CLUGGISH STEPHEN OWNER CLUGGISH ]AYNE R CONDOBUiLDING DEEDBOOK 4522 DEEOPAGE 1532 PLATSOOK 0062 PLATPAGE 0061 SURNAME MERRLLLS PARK SUBLOT I SUBBLOCK I 1 IL $"r III tiff 4 • http:llgis. buncom becounty.orglbuncom ap/ 6/ 1812010 Web Mapping Application Page 2 of 2 httpalgis.buncombecounty.org/buncomap/ 6/18/2010