WI0100180_GEO THERMAL_20111027

Bullman Heating & Cooling
r Le .
t RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Enviromnent and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3500
1. WELL CONTRACTOR:
Chad Surrett
Well Contractor (Individual) Name
AWD Services. Inc.
Well Contractor Company Name
258 North Turkey Creek Rd.
Street Address
Leicester NC 28748
City or Town State zip Code
828 683-9223
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT* W10100180
OTHER ASSOCIATED PERMIT#(Napplicable)
SITE WELL ID #(If applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 10/10/11
TIME COMPLETED AM ❑ PM
4. WELL LOCATION:
CITY: Hot SDrinas COUNTY Madison
4625 Meadow Fork Road
(Street Name, Numbers, Community. Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
5181ope ❑Valley []Flat ❑Ridge oother EleV. 2650`
LATITUDE 35 " 4 16•0m " DMS OR DD
LONGITUDE 82 a 5a ' 35.00,00 " DMS OR DC
Latitude/longitude source: StpS Oropographic map
(location of well most be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Michael Tuziw
Owner Name
4625 Meadow Fork Road
Street Address
Hot Sodnas NC
28743
City or Town State
Zip Code
(28 )
Area code Phone number
(3) Geothermal
Bores
s. WELL DETAILS:
a. TOTAL DEPTH: 3-350'
b. DOES WELL REPLACE EXISTING WELL? YES 0
NO d
e. WATER LEVEL Below Top of Casing: N/A FT.
(Use "+" N Above Top of Casing)
d. TOP OF CASING IS N/A FT.. Above Land Surface`
'Top of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2C _0118.
e. YIELD (gpm): NIA METHOD OF TEST NIA
f. DISINFECTION: Type N/A Amount NIA
g. WATER ZONES (depth):
Top `Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
7. CASING;
Depth
Diameter
Weight Material
Top - _ .
Bottom
Ft.
Top
Bottom
Ft
Top
Bottom
Ft
8. GROUT:
Depth
Material
Method
Top 0
Bottom 20'
Ft. Bentonite
Pouf
Top 21
Bottom 350'
Ft. Pea Gravel
'Pour
Top
Bottom
Ft
9. SCREEN:
Depth
Diameter Slot Size Material
Top
Bottom
Ft. in.
in.
Top
Bottom
Ft.in.
in.
Top
Bottom
FL in,
in.
10. SANDIGRAVEL PACK:
Depth
Size
Material
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
Top bottom
r
r
f
f
r
r
1
r
. � 1
/
12. REMARKS:
Formation Description
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
_�,�� 10I10111
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chad Surrett
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Sra6mit-withlr�.30A bf CQmpfett4n.to fllvisfon tsfiWater.Quality lnfaimatlbn Processing, Farm GW-1a
1iB'17 Rilail:3etvlce-center, Raleigh; 1'IC 27699161;:phone=: {9.i9) Bt)7.63t)0 Rev. 2109

Central Files: AP5 5WP
10/27/11
Parmit Number WI0100180
Permit Tracking Slip
Program Category
Status Project Type
Ground Water
Active New Project
Permit Type
Version Permit Classification
Injection Water Only GSHP Well System (50W)
1.00 Individual
Primary Reviewer
Permit Contact Affiliation
eric.g.smlth
Larry Wells
Contact Driller Well
Coastal SW Rule
258 N Turkey Creek Rd
Leicester NC 28748
Permitted Flow
Facillty
Facility Name
Michael & Anna Tuziw SFR
Location Address
4625 Meadow Fork Rd
Hot Springs NC 28743
:■; iTF
MajorlMinor Region
Minor Asheville
County
Madison
Facility Contact Affiliation
Owner Name Owner Type
Individual
Michael Tuziw Owner AfFlllatlon
Michael Tuziw
8 Ascot Point Cir #102
Dates/Events Asheville NC 28803
Scheduled
Orig Issue App Received Draft Initiated issuance Public Notice Issue Effective Expiration
10/27/11 10/20/11 10/27111 10/27/11
Regulated Activities
Heat Pump Injection
Outfall Idl1L_
Waterbody Name Stream Index Number Current Class Subbasin

��V
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H, Sullins
Governor Director
10/27/2011
Michael Tuzi w
Anna Tuziw
8 Ascot Point Circle #102
Asheville, NC -28803
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10100180
4625 Meadow Fork Road. Hot Springs. NC 2,9743
Dear Mr. & Mrs. Tuziw:
Dee Freeman
Secretary
On October 20, 2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onh
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:
The injection well system eontains 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 Weil Conszrtictiou Act and Noun Carolina
Administrative Code Title 15A Section 2C Subchapter 021l(u)(2). Additionally, you should contact the Madison County Health
Department w 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.Roeers:ivncdenr.nov if you have any questions.
Sincerely,
for Debra Watts
Su pern, isor
cc-. Asheville Regional Qffiee - AP5
AP5 Central Files - Permit No, WIU100180
Madison County Health Dept.
AWD Services, NC (Chad Surrett)
Bullman Heating & Air (Joey Butlman)
AQUIFER PROTECTION SECTION
1636 Mail 5arvive Center, Raleigh, North Ca4na 27699.1636
tocatiom 2728 Capital Boulevard. Raleigh, North Carolina 27604
Phone: [phone] FAX 1: 919-715.0588: FAX 2: 919-715-60481 Customer 5euire.1-877-623.6748
Internet: www.ncwatemualitv.org
An ERuel CpMungy 4 Aliirmdve k*xt ErmpoM
North Carolina

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�quiifer Pr ut+ertion Seetian-UJC Fragmto
106 llai! Service Center
RAleigh. NC 276"-1636
'reiephanr (919y 715-69.35

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