The URL can be used to link to this page

Home My WebLink AboutWI0100182_GEO THERMAL_20111109Burleson Plumbing & Heating Inc. RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTMCATION a 3500 I WELL CONTRACTOR: Chad Surrett Wall Contractor (Individual) Name AWD Services. Inc. Well Contractor Company Name 20 North TUrke_v Creek Rd. Street Address Leicester NC 28748 City or Town State Zip Code 828 i 683-9223 Area code Phone number 2. WELL INFORMATION: WELL CONSTRUCTION PERMIT# W 10100182 OTHER ASSOCIATED PERMIT#(ir appliceas) SITE WELL ID #(if applicable) 3. WELL USE (Check Applicable Box): Residential Water Supply j( DATE DRILLED-1 1/9/11 J TIME COMPLETED AM ❑ PM L1r 4. WELL LOCATION: CITY: Newland COUNTYAvery 340 Hickory Estates Lane (Street Name, Numbers, Community, Subdivision, Lot No., Parcel. rip Code) TOPOGRAPHIC/ LAND SETTING: (check opproprIate box) StSlope avalley ❑Flat ❑Ridge ❑Other Elegy. 4258' LATITUDE 36 ° a ae.0000 DMS OR DD LONGITUDE 81 ° 54 39.0000 « DMS OR DD Latitude4ongifude source: SOS Dropographic map (location of wall must be shown on a USGS topo map andattached to this form if not using GPS) S. WELL OWNER Fred Davis Owner Name 0 Hi kory Estates Lane Street Address Newland NC 28657 City or Town State Zip Code 8i 28 Area code Phone number 2) Geothermal BOreS 6. WELL DETAILS: a. TOTAL DEPTH: 2-300' g. WATER ZONES (depth): Top Bottom Top Bottom Top Bottom Top Bottom Top Bottom Top Bottom --Thickness! 7. CASING: Depth Diameter Welg1M Matefpal Top Bottom Ft Top Bottom Ft. Top Bottom FIL S. GROUT: Depth Material Method = Top 0 Bottom20y _ Ft Bentonite Pour Top 21 Bottom 3W Ft Pea Gravel Pour Top Bottom Ft. 6. SCREEN: Depth Diameter Slot Size Material Top Bottom Ft. In. In. Top Bottom Ft. In. In. : Top Bottom Ft. in. In. 10. SANDIGRAVEL PACK: Depth Size Material Top Bottom Ft Top Bottom Ft. Top Bottom Ft. 11. DRILLING LOG Top Bottom Formation Description 1 / 1 1 l I I 1 1 1 1 . 1 12_ REMARKS: b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E( I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN c. WATER LEVEL Below Top of Casing: NIA -FT. ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION (Use "+° if Above Top of Casing) STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. d. TOP OF CASING is NIA FT. Above Land Surface" `Too of casing terminated atlor below land surface may require (r 1119111 a variance In accordance with 15A NCAC 2C .D118. SIGNATURE OF CE TIFIED WELL CONTRACTOR DATE e. YIELD (gpm): NIA METHOD OF TEST NIA Chad 5urrett f. DISINFECTION: Type NAA Amount N/A PRINTED NAME OF PERSON CONSTRUCTING THE WELL Su.brrtit within 30 days of carnpiation to Dlr►ision of Water Quality. - Infonmatitin Processing, Form GW-1 a iB17 MailSetult:e:t enter�.:RellelgEt NC 27.699Aiil, ihont3:..(9 9) B07-B300 Rev. 2109 Permit plumber W101 DD182 . Program Category Ground Water Permit Type Injection Water Only GSHP Well System (5QW) Primary Reviewer eric.g.smith Coastal SW Rule Permitted Flow Fac€lltv Facility Name Fred Davis SFR Location Address 340 Hickory Estate Ln Newland Owner Owner Name Fred Dates/Events NC 28657 Davis Scheduled Orig Issue App Received Draft initiated Issuance 10/27/11 10/25/11 Regulated Activities Heat Pump Injection Outfall NULL Central Flies: AP5_ SwP_ 1 U127111 Permit Tracking Slip Status Project Type Active New Project Version Permit Classlification 1.00 Individual Permit Contact Affiliation Larry Wells Contact Driller Well 256 N Turkey Creek Rd Leicester NC 28748 MajorlMinor Region Minor Asheville County Avery Facility Contact Affiliation Owner Type Individual Owner Affiliation Fred Davis 340 Hickory Estates Ln Newland Public Notice Issue 10/27/11 Waterbody Name Stream Index Number Current Class NC 28W Effective Expiration 10/27/11 Subbesin AMA, ==XQ" NCDENR North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Coleen H. Sullins Governor Director 10/27/2011 Fred Davis 340 Hickory Estates Lane Newland, NC 28657 Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System Permit No. WI0100182 340 Hickory Estates Lane, Newland, NC 28657 Dear Mr. Davis: Dee Freeman Secretary On October 25, 2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onli geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An individual permit is not rewired 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 traps 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 1 SA Section 2C 5ubehapter .0211(u)(2), Additionally, you should contact the Avery County Health Department as they may have additional requirements for this type of system- Noncompliance withh applicable state, county, or municipal rules and regulations may result in the assessment of civil penalties. Please contact Mike Rogers at (919) 715-6166 or Michael.Roaersrr�ncdetu.¢ov if you have any questions. Sincerely, &20V� for Debra Watts Supervisor cc: Avery Regional Office - APS APS Central Files - Permit No. WIOI00182 Avery County Health Dept. AWD Services, Inc. (Larry Wells) Burieson Plumbing & Heating (John Smith) AQUIFER PROTECTION SECTION 1636 Mail Service center, Ralsgh. North cams na 27699-1636 Location: 2728 Capital Boulevard, Ra6egh, ND& Carolina 27604 Phone • 919-733-3221 I FAY t 9IS-715.05MI FAX 2, 919-715-6048 +customer Service, 1-877-62�,6748 Internet: V w#'5C91a @AUaL4Y o►4 One NorthCarolina fln Equal Gpportuniry r Afirtmalrve 4a4DD Erno+oye, NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECITON WELLS In Accordance With the Provisions of ISA NCAC 02C .0200 CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS These wells circulate Potable wa= only as part of a geothermal heating and cooling system. These wells are `permitted by rule" and do not require 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. NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES Print or Type Wormation and Mail to the Address on the Last Page - DATE: G t _ _ _ L?. 204 PERMIT NO. %JJI, Q 100 1 Z (to be filled in by DWQ) A. STATUS OF WELL OWNER (choose one) EL C. D. Non -Government: Individual Residence .�L SuusineWOrganization Government: State Municipal County Federal WELL OWNER — For individual residences, list each owner on property deed. For all others, state name of entity and name of person delegated au lhodry to sign on bchWf of the business or agency: reId/ 0,2,rfS Mailing Address: ..5,K0 4Y Yu 7-16. rrj "-a G City: ^/;!ree W I o , Stater Zip Code: gZZ 7 County: Day Tele No.: & b/ JV Cell No.: EMAIL. Address: Fax No.: LOCATION OF WELL SITE -- Where the injection wells are physically located: (1) Parcel Identification Number (PIN) of well si#e&Y70�O/& f 9-r _County; (2) Physical Address (if different than mailing address): _ Q r% City: WELL DRILLER 114FORMATION Well D 11 ing Contractor's Name: State: M Zip Code: GPUMIC 3QW Notification (Revised 311 W011) I RECEryFD j DENR ! Page 1 Aquifer P ecj on Sea OCT 25 2011 E. F. NC Well Drilling Contractor Certification No.: Z � Q 3 Company Name: ^ d wa se aer, 4.c-J y T ►I 4ft- Content Address City: Lef G el k Zip Code: diI Shame: ��-C'oontr: t a w� Office Tele No.: ZZ f-d d3 — ` LZ 1 Cell No.: Z1S,2 �] r _ Fax No.: d 2 I - ,/,D —9't 0 i HEAT P[FIVIP CONTRACTOR UOURMATION {if different than driller) Company Contact Person: Ibhi S to EMAIL Address: 1 k .% 6 i w A Address: W Alil dr,_ City: _ s r e i Zip Code. &W-1-2-10-Ftaie: County: Ion I-C /e l� _ Office lele No.: 12 t - 74r V O V Z Cell No.: 6 L 1-_TE S ,I L Z Fax No.: 8a 1- 7L t �� WELL CONSTRUMON DATA (1) Number of borings to be constru t *: Z Depth of each boring (feet).__ .3 46 * If existing water supply wells will be used then provide the information in item (4) below. (2) Type of tubing to be used (steel, PVC, etc): nc- (3) Well casing. If the wel(s) will use casing them p vi a the toe (steel, PVC, etc.), diameter, depth and extent of casing appearing above ground: f r O e o a f n 5) (4) Grout (material surrounding well casing wWor piping): (a) Grout type: Cement Bernonite** Other (specify) sr Sy sckcdM bmwnite gmuL a vad mod is bmby rcqumtw tot RAC 2C .02 t3(d)(IX& which regains a om mi qW gwa (b) Grout depth of tubing (refbreaoe to land surface): from 19 to -, ,3 0 d` (Feet) if well has cashes indicate grout depth: from to (feet) G. WELL LOCATIONS — Maps must be scaled or otherwise accurately indicate distances and orientations of features located within 1400 feet of the injection weU(s). Label all features clearly and include a north arrow. (1) Attach a site -specific map showing the locations of the fallowing: * Proposed injection welts * 5urbce water bodies * Buildings * Water supply wells * Property boundaries * Sep& tanks and associated spray irrigation sites, drain fields, or repair areas * Existing or potential sources of groundwater contamination .Ael e, 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 photograph of rke property pared showing properly limes and structures can be obtained and downloaded from the applicable county GIS websbr- Ty'pkat&, the property ran be searched by owner name or address. The locadon of the wells in relation to propWy bowndarlm houses, septic tanks, od*er wean, etc. can then be drawn 1n by hand Also, a `layer' can be selecM d showing topographic conAwn or elevadton data GPUIWC SQW Nodficabcs (RcvLqcd 3II B 11) Page 3 IL CERTIFICATION (to be signed as required below or by that person's authorized agent) 15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows: 1. for a corporation: by a responsible corporate officer; 2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively; 3. for a municipality or a state, federal, or other public agency: by either a principal executive officer or ranking publicly elected official; 4. for all others: by the well owner I which means all persons listed on the properir deed). If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the applicant that names and authorizes their agent to sign this application on their behalf. "I 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 immediately 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 the Permit." - Signature of r6peri Owner/Applicant j � � �r¢t.•r � Print or Type Full Name Signature of Property Owner/Applicant Print or Type Full Name Signature of Authorized Agent, if any Print or Type Full Name Submit the complete application package to: DWQ - Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 733-3221 GPU/UIC SQW No0ca6us (Revised 3/18/2011 ) RECEIVED 1 DENR 1 DWO Aquifer probedion SaOon OCT 2 5 201t Page 4 Avery Co. -- Printable Map http://arcims.webgis.netlnc/avery/priiiabl e2.as; Avery County, NC DISCLAIMER: The information contained on this page is NOT to be construed or us believed to be accurate but accuracy is not gua Parcels 1 of 2 1 fl119/2011 11:31 AM