WI0100177_GEO THERMAL_20111025

e W10100177
Permit Numb r �
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility Name
Mike McCracken SFR
Location Address
170 Ht Dr
Clyde NC 28721
Owner
Owner Name
Mike McCracken
Dates/Events
Scheduled
Orig issue App Received Draft Initiated Issuance
10/25/11 10/17/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name
Central Files: APS_ SWP_
10/25/11
Permit Tracking Slip
Status Project Type
Active New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Larry Wells
Contact Driller Well
256 N Turkey Creek Rd
Leicester NC 28748
Major/Minor Region
Minor Asheville
County
Haywood
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Mike McCracken
170 Ht Dr
Clyde
Public Notice Issue
10/25/11
NC 28721
Effective Expiration
10/25/11
Stream Index Number Current Class Subbasin

AGA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen K Sullins
Governor Director
1012512011
Mike McCracken
170 HT Drive
Clyde, NC 25721
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No, WIO100I 77
170 HT Drive, Clyde, NC 29721
Dear Mr. McCracken:
Dee Freeman
Secretary
On October 17, 2011, the Aquifer Pmtection Section (APS) received notification of your intent to construct a closed -loop water-onk■
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 ,0213, 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 Haywood County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, c-ounty, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Ro_ers amcdenr.eov if you have any questions.
j5�cereky,
U)M4, A - &"
for Debra W atLS
Supervisor
cc; Asheville Regional Office - APS
APS Central Files - Pennit No. W10100177
Haywood County Health Dept.
AWD Services, Inc, (Larry Wells)
Bull man Heating & Air (Joey Bullman)
AQUIFER PROTECTION SECTION
1636 Mall Service Censer, Raleigh, North Carolina 27699-1636
Location: 2728 Cspiwl BoAvard, Raleigh, North Carolina 27604
Phone: [phone] t FAX 1: 919-715-05a9; FAY 2: 919-715-6048 I Customer 5arme:1-877-623-6748
Internet www.ncmt9roa9I r.gre
An Eoual ()=MN1HV; AftmOve++Grin Employer
NorrthCarolina
NIMU,rally

u
NORTH CAROLINA nC� } 7 7011
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIF'1CATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-Q W WELL S )
In Accordance with the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or Tvne in formation).
DATE: -id /, 20 �,.�j ,� k i
A.
Well Type Confrrmratiow 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 w Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (peen -loop well iniectin 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)
PROPEiiTV OWN ER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature):
z-
(f} Mailing Address: /,7+D_ ,�J �y
City: C-/7�C, State: .Zip Cade: �r�7�-I County-W&9Qa
Horne/Office Tele NarZb_j �,� : I,3 V Cell No.:
ii
Email Address: Website:
[2} Physical Address of Well Site (if different than above): ,Q '�►�� _ _ _ _
City_ State: Zip Code; County:
Home/office Tele No,; Cell No.:
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 U I C well)
Company Name.
Contact Person:
Address:
City: - --
State: Zip Code:
EMAIL Address:
County;
Office Tele No.: Cell No.:
Website Address of Company, if any:
GPUltJK' 5QW Notification of Intent form (Revised 8/20081 rage I

C. WELL DRILLER INFORMATION
In
E.
F
Company Name:_ AWD SERVICES. INC.
Well Driller Contractor's Name:
NC Contractor Certification No.: _ 4 as
L.)&13
Contact person: Larr v Wells EMAIL Address: Wells750549-a,Bellsouth.net
Address: 258 North Turke► Creek Rd.
City: Leicester Zip Code: 28748 County: Buncombe
Office Tele No.: 828-683-9223 Cell No.: 828-2I5-9334
HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: �BAI lgjt } Apr,',
Contact Person: _cam v. id�.�tYiC EMAIL Address:
A ddress: f' I
City: :65�kZip Code:_ County -
Office Tele No.: SQ84P52- AP Cell No,:
STATUS OF APPLICANT
Private: x Federal:
Commercial:
State: Municipal: Native American Lands:
IN.IECTION PROCEDURE (briefly describe how the injection wells) will be used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: /+/+ 11 _ Number of borings: Z
Approximate depth of each boring (feel):__ob i
(2) Type of tubing to be used (copper, PVC, etc): _5,�1_1_ ___ 0 i7c <
(3) Well casing. is the weli(s) cased? (check either (a.) Yes or ( No low)
(a) Yes if yes, then provide casing information below
Type: _____galvanized 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 4
P
(a) Grout type: Neat Cement Sentonite Other (specify) ,,2Q�� .570�
(h) Grout placement: Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from to _ (feet)
If well has casing, indicate grout depth: from to (feet)
GPI 1/1 K iQw Notiliration of Intent Fumi (Revised 8/2009)
Page 2

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.
1. 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 wells) and
any existing wells) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system, Babel 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.
"l 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
irninediately 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,;he Permit,"
S/hat�e of Property Owner/Applicant
Print or Type FuII Name and title
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type FulI Name and title
Please return two copies of the completed Application package to:
North Carolina ❑ENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone. [phone]
GPI UtIIC 5QW Notiticarion of Ititunt form (Reviscd 8/2008) Page:

OCT 17 2011
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Bullman Heating & Coaling
�AR.E►SIDENT�A� w>�LL CONSTRUCTION s� rrcriox RFcoRD
North Carolina Department of Envimmnent and Natural Resources- Division of Water Quality
�s
�- wELL CONTRACTOR CERnFicATioN o 3421
1. WELL CONTRACTOR:
David Stratton
Wall Cw&attnr {Indlvtdug Name
Wali Cantractor Ccmpany N a m a
258 North Turkey Creek Rd. _
Street Address
LgiCester _ NC _ 28748
City or Tawn State ZIp Code
8t _ 28 683-9223
Area cede Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# Wi4100177
OTHER ASSOVATED PERMIT#(ff appricabie)
SITE WELL 10 Wappikable)
3. WELL USE (Check Applicable Box): Residential Water Supply J!
DATE DRILLM 1118111 _
IrI:J �eIel.T.l,7ot tRN
AM [I PM
A. WELL LOCATION:
CITY: Civde
170 HT Drive
couwY Havwood
(Street Name, Nnmtera, Cammlurlty, SubdlvWarL Lai Na, Parcel. Zfp Code)
TOPOGRAPHIC/ LAND SETTING:
jche& appmprlaw box?
Slope []Valley ❑Fiat ❑Ridge
❑other Elev.
LATITUDE 35 • 33 ' 510006
" DMS OR OD
LONGITUDE B2 ° 52 ` 16.0000
. DMS OR DD
LatitudeAongitude source: ;tPS
Cropographic map
(location of well must be shown on a
USCS fopo map andattached to
this farm if not using GPS)
5. WELL OWNER
Mike McCracken
owner Name
170 HT Odyne
street Address
Clyde NG
28721
City or Town state
Zip Coda
$�]
Area code Phone number
(2) Geothermal
Bares
s, WELL DETAILS-
a. TOTAL DEM-- 2-300'
b. DOES WELL REPLACE EXISTING WELL? YES ❑
NO if
r:_ WATER LEVEL Below Top of Casing: NIA FT.
(use `-0 KAbove Top of Casing)
g. WATER ZONES (depth}:
Top Bottom
Top Sodom
Top Bottom
Top
Bottom
Tap
Boitam
Top
Bottom
This knesal
7. CASING:
Depth
Diameter Weight Material
Top
Boftrq
FL
Top
Bottom
Ft
Top
BptWm
Ft
B. GROUT:
Depth
Material Method
Tap 0
Bottom 20
FL Bentonite Pour
Top 2
Bottom 300
Ft, Pea Gravel Pour
Top
Bottom
Ft
9. SCREEN:
Depth
Diameter Slot Sires Materiel
Top
Bottom
Ft (n. In.
Top
Bottom
Ft in. in.
Top
Bottom
FL in. in.
10- SANDIGRAVEL PACK
Depth
Sims Material
Top
Bottom
Ft -
Tap
Bottom
Ft. _
Top
Bottom
Ft _
t I. DRILLING LOG
Top
Bottom
Formation Description
1
1
r
1
1
1
1
12. REMARKS-.
I DO HEREBY CERTIFYTHAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS SEEN
PRO)ADED TO THE WELL OWNER.
d. TOP OF CASING is NIA _ FT. Above Land Surface'
'Tap of casing terminated attar below land surface may require T i18111
a variance in accordance with 15A NCAC 2C .Oi 18. SIGNATURE OF GERTIFIE13 WELL CONTRACTOR DATE
e. YIELD (gpm): NIA METHOD OF TEST NIA— David Stratton
L DISINFECTION: T" NIA Amount NIA PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to. Division of Water Quality - information Processing, Form GW-1a
1617 Mall Setvlce Cantor, Raleigh; NC 27"9ml61i Phone :.[phone] Rev.2los