WI0100181_GEO THERMAL_20111027

i
Permit Number WI0100181 ,,/
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
Thomas & Linda McCrosky
Location Address
115 Parish Farm Rd
Waynesville NC 28786
Owner
Central Files: APS SWP
10/27/11
Permit Tracking Slip
Status
Project Type
Active
New Project
Version
Permit Classification
1.00
Individual
Permit Contact Affiliation
Jeff Moore
PO Box 71
Hot Springs NC 28743
Major/Minor Region
Minor Asheville
County
Haywood
Facility Contact Affiliation
Owner Name Owner Type
Individual
Thomas K McCrosky Owner Affiliation
Thomas K. McCrosky III
6378 River Rd
Dates/Events Lake Charles LA 70615
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice issue Effective Expiration
10/27/11 .10/25/11 10/27/11 10/27/11
Regulated Activities
Heat Pump Injection
Otitfall I.UU-
Waterbody Name Stream Index Number Current Class Subbasin

A;. �
Aa=
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
10/27/2011
Thomas K. McCrosky IU
Linda M. McCrosky
6378 River Road
Lake Charles, LA 70615
Subject: Acknowledgement of intent to Construct Type 5QW Inlection Well Syswm
Permit No WI0100181
115 Parish Farm Road. Waynesville, NC 28786
Dear Mr. &Fobs. McCrosky:
Dee Freeman
Secretary
On October 25, 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 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, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Roeers,riyncdenr.2ov if you have any questions.
5' cerely,
UJA k
for Debra Watts
Supervisor
or.: Asheville Regional Offiive - APS
APS Central Files - Permit No. W 10I001 R l
1-laywood County Health Dept.
Clearwater Well Drilling (Jeff Moore)
Gentry Heating, tnc. (Duane Gentry)
AQUIFER PR07ECTIQN SECTION
1635 Mail Service Center, Raleigh, North Carolina 27599-1636
Location. 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] l FAX I 919-715-0588, FAX [phone] Gustomer Service: 1-877-623-0748
Internet: www.amateWa1jty,om
North Carolina
Ari Enual Oppmmnrry +Alhrmahve +anon Emprayer

NUR'l I•! C:AROLINA
DFPAK I'MEN-1 t)F FNVIRONMP_'NT AND `9A-1114Al_ itIsSU1_IRC'Lti
NOT] FICATION 4)F IN'TENT 10 C'UNSTRUC'T A CLOSED -LOOP GE"MERMAL
%' %TER-i)NLY IN,iEC'TION WELL SY,S-TFM
In Accordance With thr Pwvisiuns ul tie AC Ville SA 02r .0200
He q to +n .-L,0110 iWOrmajiiun�,l"iu •F0,11 �t11hop'l ', io1e heck +L.
DATE: I � — a C., _ 211J 1_ 1.J�1�� � L 0{0 9 I
Weil Type l hit•, the prupo..-wd system cerctflatc pi?table w,uer an ' t;io addittvus) rrt
c!A111nu0011 Pip IIL; Ihat comp=r1cN skill ws th.: 11trid lctnnl Ili Ulm 11onmcm (i.r_
�Intittl-lutil�}';
Yes c mtrrnu: C0mepletingg tt„ lctrrn
Nu k7t N(lt �awiplcte this kirm. -mpivio Other t.1lC apphcxtrun lcvms tut ussLalling
etthur a 5A7 well [off-I(x)p well i1�pQq,G pz , 4c water initt the aquifer] or s St 1M well lclosed-
iwil well %:011taming add lliycs such n4 H 0h.tit4I Or uther Jilt Ihvc1r car wrr11tiit111 ilthihilors)
PKUYEHT) UWNER(SVAPPL[C AN7ltil
1.na each I ropat) Owncr Ikted tn1 prupert.• deed (If ❑vaned b% a 1]ny11w"S Ruverrrutenp�lats1pency. Maw nail!lu: of
etftity and it rC XC_%C11ta[IVC WMLit 1101'ity lilt ti,gnrtttlre }f .
t•i1y � �°��� Cr,Ufa�f.��S�t:,, �fj-`.�,' t �,�,, ]Q��S__ z tlurtl):�'�ilC��'�LfEI'•
I tumelt)Ff ieC I Clt No.; J J �� !'e)l irtl
L-mail Addrem: _ _ Wut�sitc;
Phy'SiCal .Address Of Well 5ne t I dii'I'trent than aho\t:1.
C i1} zef ,G_--%zl4.zryinle' ,'/ Lip
,7." --77 T -1 ter.
i lnrne/011kc 1-cle Nu � _r _ �- J./ C'rll No.: 3 7 T
11. AU1"HiJ}tilll''i1 AG F,NT I) F U1VNER, IF ANY ti"IILv Pert nit AppIicatt1 dcwt, 11ut own the subjeel properi).
attac11 a lcrrcr 1F0111 tlfe paipully uwncr aathoriciug, Agent W in,,tafl 41W %'PtTatC L 11C tNvlll
C'utnpanSr Name:
Contact person:
Address:
I. 11ti
U2•lice 'fcle .N� .
Website Address t impan, 1 ifl%
C 11-1-1/Uf4r SQW N011k11t1pn 4P AILlll 101111 , 9 1200K1
RECEIVED 1 DENR I DWQ
Aquifer Proteclbn Section
OCT 2 5 2011

Page 2 of 2
payment of the tax.
AM m that this tax payment is not funded by moneys received from a foreign bank
aCCQUnL
M1I� �natt>� �+tll
https:lleservices.dor.nc.gov/nc5/ACHFinal ] 0/18/201 l

C. WELL DRILLER INFORMATION
r� r
Company Name:
Well Driller Contractor's Name: � cv
NC Contractor Certification No.: _ 1
Contact Persoa: _; Il ,: �+� EMAIL Address. 1 Ya Cl& uy+rdrff
Address: �' l t y
City: 'r4 Zip Code: County: --
Office Teie No.: �' ���- �� �1 rf Cell No.. - -
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Le, LEL-
Contact Person_ L ti. -44 71W AIL Adci ess_Address:f ,�,-�41-(_
City: 11Y)�t 1 Zip Code:,Z ty County: c
Office Tele No.: Cell No..
E. STATUS OF APPLICANT
Private! L Federal: Commercial:
State: Municipal: Native American Lands:
F. INJECTI N POCEDURE (briefly describe how the injection wells will be used)
G. WELL CONSTRUCTION DATA ��ryry
(1) Proposed date to be constructed: /V� Number of borings:
r
Approximate depth of each boring (feet):----
(2) Type of tubing to be Used (copper, PVC, etc): J- 0 r ,
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: ___,galvanized steel black steel plastic other (specify)
Casing depth: From to fleet (reference to land surface)
Casing extends ground inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite Other (specify', , 51
4
(b) Grout placement: Pumping _L,--- Pressure Other
(c) Grout depth of tubing (reference to land surface): from �1 to (fcet)
If well has casing, indicate grout depth: from to (feet)
GPU/UIC 5Q W Notification of intent Form (Revised 8R008) Page 2

It INJECTION-FiUATED EQUIPMENI
Attach a diagram showing llic cagineeringt layout of proposed rz oditic:atit111 of the injecticxt cquipmettt and exterior
piping/rubing a;soclared «Ilh the injection nmaiton Hie manufacturer's brochure may provide supplementary
trttornlation.
L LOCATION ATION Uh' NYELL(ar
Attach two ciIpies ufinaps showing the Inllo"-ing nlfi)riitatioIl:
(1) triclude it Site Map win be drawni showing: buildings. prslpurty lities, curtace water bodies, potuntial
suotcts 0t g,ruuttdvWater ctkrtlalt►iatatiUn and the ontmatiun of and distances helween the pripmed well(s) and
a11a existing weI1t,1 ot- u,mw dlsposaI Iitcllilies skIVII ;ia Sept it tams~ or dmirl ticld5 pleated witfliit 00 1eel uf'
tlit-cothel-IlIal lufal pLintp Well ,rtitejlt I Ah(.1 1111 fC4fllrr . r1, •Ai'lt Alid ilk Iitilt .1 ntsrttl.0 t1w
(2) The Site Map IT wo shuv, the stibjeci pvvpert} ill Mlatisti, to the wm-rifttiWing area .� using ill leasl lwo iowd
reterencc points ~hell I road%. streams, an(Vur hkghwa� intersections-
J. CE,R'l'il''tCA I ION
NWv: This Permit kliplic'itlion mwsI be signed by each person Aplxaring on the
recorded Icgal property tired
"I Hereby Wi'tify- i111Ue1 pelmlly ill law. +l+al I have Ill rsunalis evillmled wid ,tut 11kimliar ".1th 111c 111lorI1 alloi1
st11+1tutled it! this Jt1Cun1e111 And all altek:fimo ,, ilivrem ;old 111,11, hasVd Ut1 tit inyunV Of dhl,C 111diviJil;11%
ilnn:esiiatc{y res=hinxihiu ltu nbufill ing said k4ormalion. i heiiest tllttt the 11110FIntlliOlI i:+ trot+ dU uraie and t;omplete.
1 um 3tt,m, that thew art, signilicailt nctl.lhieti. inchidini, 111C {-+tsssil'ilrly (If fiats, 111(1 i)11I]fiSLll}IISL'IFI, fur tiubnlittiI-g
Use information I Agree to c:uttstrucl, orcruw- 1tlaintilin rcpail. xnd 11 3}tplkC!W1k!. tthxrldon the inlection well and
till rrltdutl clrptu�tcls,snres +1� xrtlfr'd:arrre t+,lili llx• tkhlsrin�d til)L'CNil:kFi�kll•.,fIlL1 �Vlldinll!!y Vt t11L' I'ernut ".�_
tiiti'It:lu,rt .�t I'n,I�t•I I� t 1�� i+cs '1ft�Ilrtfrtl
4�. 6 W(',
Print tar 1 yre FI)11 Nnrnc acid title
tits;nLi uI e {ll I'n,}�t•rt. � lt� I Ic r' �1 r1}�] i�,t, kt
A�1- m�s—so—e
hlli;l M- )'pL I'till htWOC iIiid talc o
IL'fl AUT . 11114.1 1 1
I'iease rrttini Iwtk utlples at'the efimpleteci Applrt:ttliun paeftagr u
North Carolina DENR-L)WQ
Aquifer Protection'aection-UIC PrograW
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone ( 919) 7 33-32211 RECEIVED ! DENR ! DVM
Aquifer ProtectionS{e+ction
?(A) IC 10W NtntfiCation M IMLm i nrnk (nevi, eml 90008) OCT 2 5 20l1 1`+4-

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