WI0100162_GEO THERMAL_20110721

Permit Humber W10100162
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facll.ty
Central Files: APS SWP
07/21 /11
Permit Tracking Slip
Status
Project Type
Active
New Project
Version
Permit Classification
1.00
Individual
Permit Contact Affiliation
Gary Justice
driller
3845 US 70 Hwy
Marion
NC 28752
Facility Name Major/Minor Region
Otis & Ruthene Hill SFR Minor Asheville
Location Address County
210 Mountain Laurel Rdg McDowell
Old Fort NC 28762 Facility Contact Affiliation
Owner
Owner Name Owner Type
Individual
Otis Hill Owner Affiliation
Otis Hill
PO Box 332
Old Fort NC 28762
Dates/Even-
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
07/21 /11 07/13/11 07/21 /11 07/21 /11
Reoulated Activities
Heat Pump Injection
Outfal! NUL-,-
Waterbody Name Stream Index Number Current Class 5ubbasin

Ik 4 a `r
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Govemor Director
712112011
Utis Hill
Ruthene Hill
PO Box 332
Old Fort- NC 28762
Subject: Acknowledgement of Intent to Construct Type 5QW Wection Well System
Permit No. WI0100162
210 Mountain Laurel Ridge, Old Fort, NC 28762
Dear Mr. & Mrs. Hill:
Dee Freeman
Secretary
On 7/13/2011, 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 Admmistrarive Code Title 15A Section 2C Subchapter .0213, and
3. The required notification Form and associated maps have been completely and accuratcly submitted.
failure to comply with all of these conditions constitutes a violation of the Notch Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .021 t(u)(2 ). Additionally, you should contact the McDowell 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.Rogers0vricdenr.Lov if you have any questions,
Sincerely,
cwci�-' 4&x)'�'
for D—ebra Watts
Supervisor
cc- Asheville Regional Office - AP5
APS Cmrral Files- Permit No W tO 1 OU 16?
McDowell County Health Dept.
3w,iicc WelI Drilling, ine (Gary Iusucej
l3tn•lr:'011 Plumbing & l-leattng t`ompank 001ill Smltlr}
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NORTH CAROLNA DEPARTMENT OF ENVTRONM-ENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 1 aA NCAC 02C .0200
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as parr of a geatherrnal heating and cooling system.
These wells are "permitted by rule" sad do not require an tndividual permitwhen they are constructed in
accordance witz the rules of 15A NCAC 02C .420C and this Notice is submitted prior to construction.
Print or Type Information andlMfad to the Addrersbn the Last Page.
DATE: S- jrt'`L-`[ , 2ajL_ PERMIT NO.
A. STATUS OF WELL OWNER (choose one)
lion -Government: Individual Residence
Government: State Municipal
(to be filled in by ❑WQ)
B us i n essfOrgan nation
County Federal
R WELL OWNER — For individual residences, list each owner on property deed, For all others, state name of
entity and name of person delegated audiority to sign or, behalf of the business or agency:
7` RLrri4tP f fk 0-n5 141LL
Mailing Address: ?1 .0 40)c 3 3 7-1-
City: d or-, rt" a-' State: A�C- Zip Code: 2-$ 7 '�O a County: MC DOw;- IL
Day Tele No.: _
EMAIL Address:
$ ;�Ee-(o(a9-Yg7o CeliNn.: Ste- 4170
Fax No.:
C. LOCATION OF WELL SITE— Where the injection wells are physically located:
(1) Parcel identification Number (PIN) of well site: (NOV- Ao- g3' dW74e County: b0
(2) Physical Address (if differcnt than mailing address):
010 !Yl0wN+y') (zP—L- sbr)GS-
City: OL4--) (;0 01 State: NC Zip Code: rr 7
D. WELL DRUAXR LNFORMATIAN
Well Drilling Contractor's Name: GA KY 'J USTIC fr_
NC Well Drilling Contractor Certification No.; ISya -R
Company Name:_ �STtCE 't-+}5.U- -Dizi L - r NC t tiC .
Contact Person: G AIRY 'L U S 71C E EMAIL Address: s itcf
Address: ',$'f S.
City: M r� 2 r.o rj _ Zip Code: '1876 State: ^k_' Coutny: A wS �
OfeeTeleNo.: C-39" 7]Y-49qB CelINo.: 9,g-4y-;I-9'7aa Fax T�ro.:S--71Y-Y54�8
GPiNtlIC 5QW Noiif,cation (lie�iBcd 3l181ZC I ! j
Z'd 9tr9" L-Gzs
Page 1
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E. HEAT PUMP CONTRACTOR MOWMATION (ifdifferenr than drilter)
Company Name: $u4LP-56N LUL,YL34NG & 4tfrTiNiG
Contact Fersarr -D-D1-1 it� EMAIL Address:
Address: IV HtG H_CAN la A ,� E
City: .S p,b_C f p, M1+ £ Zip Code: 777 state: ti tr Catzrlty: _I� e j Tt� _ L L
Office Tele No.: 1�8.7(v51'Y0w'x Cell No, Fax No.:g--�L8-
F. WELL CONSTRUCTION DATA
(1) Numberef borings to be constructed*: �2 Depth of each boring (feet): -300 -rT
* !f existing water supply wells will be used then provide the information in item (4) below.
(2) Type oftubing to be used (steel. PVC, etc): .5e I _
(3) Wei'. casing. If the wel'.(s) will .tse casing then provide the tune (steel, PVC, etc,), giametcr depth,
and extent of casing appearing above ground:
(4) Grout (material surrounding well casing andler piping):
(a) Groul type: Cement Bentonite*Other (specify)
"By selecting bentonm grout, a vari6r cc is herraby requested to 15A NCAC 2C .4Z13(d)1,1)(A), wn;ch requues a cemem lype gwr
(b) Grout depth of tubing (reference to land surface): from -2 to 3 oc7 (feet)
If well has cas! ng, indicate grout depth: from to (feet)
G. WELL LOCATIONS -?Naps must be scaled or otherwise accurately indicate distances and orientations of
features located within Igpq feet of the injection well(s). Label all features clearly and include a north arrow.
(1) Attach a site -specific reap showing the Iocatiom of the following:
4 Proposed injection wells Buildings " Property Boundaries
u Surface water bodies " Water supply wells
* Septic tanks and associated spray irrigation sites, drain Fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Amicb a topographic map ❑f the area extending 114 mile from the injection well site that indicates the
facility's location and the trap name.
NOTE., In most cases, an aerial photograph Of the property parcel showing property lines and strtectkres can he
obtained and downloaded front the applicable county CIS toebsite, Typically, the property can be searched by
owner name or address. The location of rite wells in relation to property boundaries, Awses, septic tanks, oilier
wells, etc. can turn be drawn in by hand Also, a 'Meyer' can be selected showing topograpkfc contours or
elevation data-
OPUMIC 5QW Notification (Revfwd all M0 r 1)
Page 2
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NORTH CAROLINA DEPARTMENT OF ENVIROI:MENT AND NATURAL RESOURCES
NOT91CAT[ON OF INTENT TO CONSTRUCT OR OPERATE IIN,IIECTION SWELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of geothermal heating and cooling system.
These wells are "permitted by rule" and do not rewire 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_
Print or Tvpe Infw-ma n and Mail to the Address on the Lest Page.
DATE: — _ ,7u" , 2011 PERMIT NO. _ .(to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Nori-Government: Individual Residence Susinez/Organixation
Crovemment: State Municipal County Federal
& WELL OWNER -For individual residences, list each owner on property deed. For all others, state name of
entity a d name of person delegated authority to sign on behalf of the business or agency:
Mailing Address_ ?l . ❑ {'30K 3 3'-)-
city: G Lb FD
Day Tele Nc.:
EMAIL Address:
State: rKLZip Code: a$ lip JI County: tbC QDWk L,
_ Cell No.: 9-'VC"
Fax No.:
C. LOCATION OF WELL SITE - Where the. 'injection wells are physically located-
(1) Parcel Identification Number (PIN) of well site: 0&V- 60 9i-711740 County: JK� bo
(2) Physical Address (if different than mailing address): _
010 M 01;-niTI:� tN t A [,, iz Enl-- �Z.+
City: ft State: NC Zip Code: _� S 7 (o 1
D. WELL DR11.1r ER INFORMATION
Well Dri Ili ng Contractor's Name: � r7 Fl R `� � l.x S TdC (
NC Well Drilling Contractor Certification No,:
Company Name: -J1J-S-r1C-V_ W E-LL -bR 1 L.L 1 NG , r 6%! C .
Contact Person; 4 PL-Y '_7US 71 C -P- EMAIL Address: v s +-i ce welt dLr i t l i nc�
Q ,�{Q as . rtovl;
Address: 3S +f 5 l�CS "d � r��S'F' _
City: /)I A 0- to N Zip Code: 'A8'15 x State: NC County: PtZ- 60&UE Lc._
Office Tele No,: %a%- 7J41-451r8 Cell No.: �� 8'• 4 Yam' 8T � Fax No.:Sa4- 7j Y - 49 V F
GPIJAAC 5QW Notif'iration (Revised V1$R011)
LA 819 " ZL-@Zg
Page T
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E HEAT PLMP CONTRACTOR INFORMATION (if different than driller)
Companti Narne: 2)tz4t_ESors >aLU ff�BlNG ff }-firterTfVG
Contact Person: t-4 EK-UL Address:
Address: Ni �4l G H t<rA rlwn A V E
City: ,5 rrr?t.C¢ �rrJ € Zip Code: ;I8 77 7 State: NL County: m i Tit --
Office TeleNo.:2A-746 40ga Cell No.: PaxNo.:8-_18" 7roS_czocol
F. WELL CONSTRUCTION TION DATA
(1) Number of borings to be constructed': a7 Depth of each boring (feet): 300 -n
* If exisring water supply wells will be used then provide the info nwrion in 11em (4) below.
(2) Type of tubing to be used (steel, PVC, etc): -5+-ee �
(3) Well casing. If the weII(s) will use casing .hen provide the tie (steel, PVC, etc.), diameter, degth,
and extent of casing appearing above ground:
(4) Grout (material surrutinding well casing and/or piping):
(a) Grout type: Cement Bentonite**,x' Other (specify)
•i By selecting be" comt[ gm a rariance is haeby requested to 15ANCAC 2C A213(d)(1)(A), which (equims a Cement tyWe gmuL
(b) Grout depth of tubing (reference to land surface): from -2 to 300 (feet)
If well has casing, indicate grout depth: from to (feet)
G. WELL LOCATIONS —Maps rnust be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a notch arrow.
(!) Attach a site -specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Waier supply wells
" Septic tanks and associated spray irrigation sires, drain fields, or repair areas
Existing or potential sources of groundwater contazrination
(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 phonograph of the properly parcel showing propeM lines and straclures can be
obtained and downloaded fr9m dre applicable counry GIS website. Typically, the property cart be searched by
owner name or address. The Location of the wells In relation to properly, boundaries, houses, septic ranks, other
wells, etc. can then be drawn in by hard. Also, a `layer' can be selected showing 10pographlc contours or
elevation data.
GPUMC 5QZV r4o6fica6on (itevised M&2011)
Page 2
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