WI0100187_GEO THERMAL_20121123

Burleson Plumbing & Heating Inc.
.RESIDENTIAL WELL CONS RUMON RECORD
x' r ----North Carolina Department of Environment and Natural Resources -'Division of Water Quality
�Y
WELL CONTRACTOR CERTIFICATION # 3500
1. WELL CONTRACTOR:
Chad
Weil Contractor (Individuaq Name
AWD Services: Inc.
Well Contractor Company Name
25allorih 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 PERM IT#WIQ100187
OTHER ASSOCIATED PERMIT#(if applicable) '
--SITE WELL ID *cif appllcabley. - -- .---
3. WELL USE (Check Applicable Box): Residential Water Supply 5(
DATE DRILLED 11I2111 1
TIME COMPLETED AM ❑ PM 3(
4. WELL LOCATION:
CITY: Bumsvilie couNTYYancey
B3 Mica Point Drive
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC/ LAND SETTING: (c hetk appropride boo
IjSlope ❑Valley ❑Flat ❑Ridge ❑otherEley. 3415'
LATITUDE 35 ` 52 39.0000 "DMS OR DD
LONGITUDE B2 a 14 a7.0000 . DMS OR DD
L.atitudeAongRude source: Rf.-PS Dropographic map
(location of woefi must be shown on a L/SGS topo map andattached to
this Form it not using GPS)
S. WELL OWNER
John Preaartner
Owner Name
B3.Mica Point Drive _
Street Address
Burnsville NC 28714
City or Town State Zip Code
8c 28 )
A d Ph ter
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottomssl
Thlckne
: 7. CASING:
Depth
Diameter
Weight Material
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft
8. GROUT:
Depth
Material
Method
Top D
Bottom 20'
Ft Bentonite
Pour37
Top 21
Bottom 5'
Ft. Pea Gravel
Pour
Top
Bottom
Ft.
S. SCREEN: Depth
Diameter Slat Size Material
Top
Bottom
Ft- in.
In.
Top
Bottom
Ft. En.
In.
Top
Bottom
Ft. In.
in-
10. SANDIGRAVEL PACK:
Depth
Size
Materral
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
Top Bottom
1
1
1
1
1
1
r
rea co a one nun
(2) Geothermal Bares : 12. REMARKS:
6. WELL DETAILS:
a. TOTAL DEPTH: 2-375'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I(
c. WATER LEVEL Below Top of Casing: NIA FT.
(L(se "+` if Above Top of Casing)
d. TOP ce CASING is NIA FT. Above Land Surface'
`Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0116.
e. YIELD (gpm): NIA MET140D OF TEST NIA
f. DISINFECTION: Type NIA Amount NIA
Formation Description
I DO HEREBY CERTIFY THAT THIS WELL. WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAG 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
C&axl 11/23112
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chad Surreit
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Summit virithm: 3b.iays; ofornletlon:ta Division of Water Qual.'sty. - Inforrnatiori Processing, Form GW 1a
16f Ajlali',SariiCe Center,; ' gjghj-N . 27699.-16.1.,'�hone (9'19) 807-6300 Rev. able

4
Permit Number WIO'IOO187
Program Category
Ground Water
Permit Type
Injection Water only GSHP Well System (5QW )
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility
Facility Name
John & Sue Pregartner SFIR
Location Address
B3 Mica Point Dr
Burnsville NC 28714
Owner
Owner Name
.loon Pregartner
Dates/Events
Central Flies: APS SWP
11/16/11
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
Yancey
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
John Pregartner
4705 Essex Dr
Doylestown
PA 18902
Scheduled
Orlg Issue App Received Draft Initiated lasuance Public Notice Issue Effective Expiration
11/15/11 10/28/11 11/15/11 11/15/11
Regulated ► ctivities
Heat Pump Injection
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin

A�
KDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H, Sullins
Governor Director
11/16/2011
]olin Pregartner
Sue Pregartner
4705 Essex Drive
Doylestown, PA 189021
Subject: AcknowledgemeAt of intent to Construct Type 5QW Injection Well System
Permit No. W10100187
B3 Mica Point Drive, Burnsville, NC 28714
Dear Mr. & Mrs. Pregarmer:
Dee Freeman
Seuretery
On October 28, 2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onl•
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 Nonh Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Yancy 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 gagers at [phone] or N ichael.Rouers,uinedenr.gov if you have any questions.
Sincerely,
joy -Debra Watts
Supervisor
cc: Asheville Regional Mce - APS
APS Central Files - Permit No. WI0100187
Yanry County Health Dept.
AWE Serviced, im. (Larry Wells)
Surieson Plumbing Er. Heating, Inc (John Smith)
AQUIFER PROTECTION SECTION
1636 !Nail Service Center, Raleigh, North Cardlrna 276S9-1632
Locatim 2728 CaptI Boulevard, Raleigh, North Carolina 27604
Pnone M-733.3221 l FAk 1: Bi9.715-0588. FAX2: 919-715-60481 Customer Service: 1-877-62U70
internal-' www.nma ernu®Iftprp
An Equal UpportuMy iAtrrreBve Ann Emdoyo-
One
NmthCarolina
Naturally

NOTIFICATION OF 114TENT TO CONSTRUCT OR OPERATE INJECTION WELLS
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 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 Information and Mail to the Address on the Last Page.
DATE: Or- t I I . 20-ff PERMIT NO. LKMQ I 00 R' to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence,k--' Business/Organization
Government: State Municipal County Federal
EL WELL OWNER - For individual residence, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
S4 it Pre CAP'1&ner
Mailing Address: J eX '0' I r e
City: ,�� �d W d State: t& Zip Code: % 00' id 2--County: UC S
Day Tele No.: _. Cell No.: E57 - Q4'Y - 9 L -r-7
EMAIL Address: ' q�k !VJ' r#e-T-)JM QMft"ax No.:
• A3 iT
C. LOCATION OF WELL SITE - Where the injection weIIs are physically located:
(1) Parcel Identification Number (PIN) of well site: D % yf Ood 9/9 Z,Y County: n
(2) Physical Address (if different than mailing address): c err e� J -f Ie 1
ct t if"-.� �r G[rr t a Cola41�r 4 eL 11
City: 13f, r,-A., v 4rIle State: h& Tip Code: Z 871 yf
IG i (-A Tb) ,OT DP11}�, *9UEI^sv► t W
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: 4fr II.r _
Aquifer Prc?'e�+ion Serrlan
GPURnc SQw r�ofts�.t� (l��d sit sr2ar t ) Pas 1
OCT 2 8 2011

E.
F.
NC Well Drilling Contractor Certification No.: Z V"03
Company Name: wo '�er_I, t rr T,rh f-
Contact
Address
f�. me t
City: G j c- F Zip Code 2-1 77I r State: &4 County: &u+r c a ^ J
OfficeTele No.: TLJ-d - 724 Cell No.: F11- US"-2. ,] f� , Fax No.: dZI4
HEAT PUMP CONTRACTOR INFORMATION (if different
than driller)
Company Name: _5-4 Kle Un ?AJ ►•J �" V-- !Y rA &A 5 T
Contact Person: : e i w .Sr,) �� EMAIL Address: A a -1,0 J a n 12AA i th. AD 4�I r� a@
Address: Z! % ! 4. _
City: 5V&W&fr e ` e Zip Code: x0 Ftate:1YC-Cuunty: %�%I f�10 l�
Ofisce ele No.: W-Ter Ya Kz Cell No.: L F-.3 - C L 4 z Fax No.:,92- d -
WELL CONSTRUCTION DATA
(1) Number of borings to be constructed': Depth of each boring
(feet): 3 7.r-
* If existing water supply wells will be used then provide the tnormatian in item (4)
below.
(2) Type of tubing to be used (steel, PVC, etc):
(3) Well casing If the well(s) will use casing then pro ide the tie (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground_ ! r O Ca a ,' n
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite** Other (specify)
•* By selecting beatonite grvar a variance is hereby mquested to 15a NCAC 2C .6213(d)(i)(A), which requires a cement type grout
(b) Grout depth of tubing (reference to land surface): from Q to ,37s (feet)
1f well has casing, indicate grout depth: from to (feet)
G. WELL LOCATIONS - Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1040 feet of the injection wells). Label all feattm clearly and include a north eumw.
(1) Attach a sit. -specific map showing the locations of the following:
* Pmposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contarnination
GPUMIC 5QW Notifiratiao (Revised 3/1812Q11) Page 2

Z AHach 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 the properly parcel showing property lhm and structures can be
obtained and downloaded front the applicable cotnry GIS webstle. 7)plcalty, the property can be searched by
owner name or addresx IWe location of the wdb In relation to property boanrdarles, loses, septbc tanks, other
wells, or- can than be drawn In by hand Also, a `layer' can be selectedshowing topographk co mars or
elevation data.
GPUJUiC 5QW Notification (Rr.Ascd 3/18/2011) pap 3

EL 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 � which means all parsons listed on the property 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.
N 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"
gC��N�,
Signature ofPmpaity wnerlApplicant
Print or Type Full Name
X
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 [phone]
r
REr,VVED I DENR I DM
Aquifer Proledlw Section
GPUIUIC 3QW Notification (Revised 3/18/2011) Page 4

Prinfmg LaYoTA Pap
hV://mapping yz ►ceWo m*=.Epv/lay+outaspa
Yancey County w IBIS Mapping
of 1 10/19/20I1 11:23 AM