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Home My WebLink AboutWI0100191_GEO THERMAL_20121123dsrar�� jj]] Bullman Heating & Cooling RESIDENML WELL CONSTRUCTION RECORD z = North Carolina Department of Environment and Natural Resources- Division of Water Quality y WELL CONTRACTOR CERTIFICATION # 3421 1. WELL CONTRACTOR, David Stratton Well Contractor (individual) Name A_WD Services. Inc. Well Contractor Company Name 258 North Turkey Creek Rd. Street Address. — — Leice3ter NQ 2748 City or Town State Zip Code 828 6 3-9223 Area code Phone number 2. WELL INFORMATION: WELL CONSTRUCTION PERMIT# W 101 00191 OTHER ASSOCIATED PERMIT#(if applicatle) -SITE WELL ID #(ff applicable) S. WELL USE (Check Applicable Box): Residential Water Supply ilk DATE DRILLED 1 1I21I11 TIME COMPLETED AM ❑ PM W 4. WELL LOCATION: CITY: Fairview COUNTY Buncombe 31 Bleeker Lane (Sheet Name, Numbers, Community, Subdivision, lot No., Parcel, Zip Code) TOPOGRAPHIC/ LAND SETTING: (check appropriate bcoo IvlSlope ❑Valley ❑Flat ❑Ridge ❑otherEley. LATITUDE 35 ° 31 34.0000 ^ DMS OR DID LONGITUDE 82 ° 21 54.0000 " DMS OR DID Latitudellongitude source: Gt�PS ❑Topographic map (looatron of well must be shown on a USGS topo map andattached to this ibrnr if not using GPS) 5. WELL OWNER Michael Bradlev Owner Name 31 Bleeker Lan Street Address Fairview NC 2$730 City or Town State Zip Code $[ 28 ) Area c de Phone number g. 'WATER ZONES (depth): Top Bottom Top Bottom Top Bottom Top Bottom Top Bottom Top Bottom Thickness! 7. CASING: Depth Diameter Weight Mlaterlal Top Bottom Ft. Top Bottom Ft. Top Bottom Ft 8. GROUT: - Depth Material Method Top 0 Bottom 20' Ft. Bentonite Pour Top 21 BottorrL260` Ft. Pea Gravel Pour : Top Bottom Ft 9. SCREEN: Depth Diameter Slot Size Materialm Top Botto 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 f I 1 1 1 0 (2 ) Geothermal BoZ'ES 12. REMARKS: 6. WELL DETAILS: a. TOTAL DEPTH: 2-260r b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Rf c. WATER LEVEL Below Top of Casing; NIA FT. (Use °+° if Above Top of Casing) d. TOP OF CASING is NIA FT. Above Land Surfae 'Top of casing terminated atlor below land surface may require a variance in accordance with 15A NCAC 2C .0118. e. YIELD (gpm): NIA METHOD OF TEST NIA NIA nt NIA Formation Description I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NGAG 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. 11/23/12 SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE David Stratton PRINTED NAMtw OF PERSON CONSTRUCTING THE WELL f.. DISINFECTION. Type Amou 5ubink withln 30.'days of r-orrrp(atton to Dl:.vislon Of. Water Quality - .Information Processing, Form GWAa 1617 Allatlerutce`Center, Raleigh; NC 27595161;. PhaYte [89.9) 807-6300 Rev. 2109 Permit Number W10100191 , Program Category Ground Water Permit Type Injection Water Only GSHP Well System (50W) Primary Reviewer eric.g.smith Coastal SW Rule Permuted Flow FSCi I itv Facility Name Michael Bradley SFR Location Address 31 Bleeker Ln Fairview Owner Owner Name Michael Dates/Events NC 28730 Steven Bradley Central Fifes: APS SWP 11/23/11 Permit Tracking Slip Status Project Type In review New Project Version Permit Classification Individual Permit Contact Affiliation Larry Wells Contact Driller Well 258 N Turkey Creek Rd Leicester NC 28748 MajortMinor Region Minor Asheville County Buncombe Facility Contact Affiliation Owner Type Individual Owner Affiliation Michael Steven Bradley 31 Bleeker Ln Fairview NC 28730 Scheduled Orig Issue App Received Draft Initiated Issuance Public Notice Issue 11ro7111 equlated Activities Outfall DULL Effective Expiration Waterbody Name Stream Index Number Current Class Subbasin YK_ WA �. NCDIENR North Carolina department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Coleen H. Sullins Govern , [Director 11/23/2011 Michael S. Bradley 31 Bleeker Lane Fairview, NC 28730 Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System Permit No. W10100191 31 Bieeker Lane, Fairview. NC 28730 Dear Mr. Bradley: Dee Freeman Secretary On November 7- 2011. the Aquifer Protection Section (APS? received notification of your intent to construct a closed -loop water-unh 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, 'The injection wet] 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 Art and North Carolina Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Buncombe County Health Department as they may have additioaaI 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 (919) 715-6166 or Michae1.Rnuers:&ncdenr.uov if you have any questions. S' cerely, 0WkAAWQ." Debra Watrs Supervisor cc: Asheville Regional Office - APS APS Central Files - Permit No. W10100191 Buncombe County Health Dept. AWD Services, Inc. (Larry Wells) ❑ullman Heating & Air (lacy flullwany AQUIFER PROTECTION SECTION 1636 NtaII Service Center, Raregh. North CarDIIna 27694-1636 Locabon. 2728 CapltaI Boulevard. Raregh Nonh Camina 27604 Phone 919-733.32211. FAX',: a15 71r Q59f FAX 2. 91f-715.60461 Gt si0MV 5eruica:1-87-a?'0-674B Internet: wvry .Tsmatetmalk .o-- do Ecual (rpponunrla I ArrrmTive Ac11dr. Ertrplayc- Dn; No th Carolh--1a �. t all, NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR) NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM: TYPE 5-!QW WELL(S) In Accordance with the provisions of NCAC Title 15A: 02C.0200, please complctc this notification and rraiI to address on the back page (please Priiii or'Iype information). DATE: t& VY :2- _, 20 11 � ❑ 1 ❑019 ! I !1 A Weft Type Confirmation: Does the proposed system circulate potable water onnll rr (no additives) +n continuous piping that completely isolates the fluid from the environment (i.e- closed-loop)? Yea Continue com letina this form. p a No ___. Do Not complete this form. Complete other UIC application forms for installing either a 5A7 well (off -loop well injecting potable water into the aquifer) or a 5QM well (closed - loop well containing additives suA as R--22, ethanol, or other antifreeze car con-osion inhibitors), PROPERTY OWNER(S)IAPPLICANT(S) List each Property Owner fisted on property deed (if owned by a business or government agency, state name of entity and a representative wlauthority for signature): (1) Maiiing Address: 3 1 L e e kef?, L d`-3 b Cit;l: 79 sR V-1B+.�tate: WC.�ip Cnde:Z9%�� County-tt ti+w3 ruDri►t 4et />1 BRRC1 `ig �p get 15❑ 1:it3iiii i I Address:_ --- - - - — ------.r_..1 a si le,-- - -- --- _- ----- -- --__ (2) Physicat Address ❑I' Weil Site (ifdifierent than above); City. State: _ Zip Code: Co.Unty: Home/Office'Fele No.: Cell No.: AUTHORIZED AGENT OF OWNER, IF ANY (ii-the Pennit 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 Namc: Contact Person: EMAIL Address: Address: City: State: Zip Code: County: Office'fele No.: Cell No.: Website Address of Company, if any: KtC Is�rll�f. � k1±r,ir�rr OV07�Qf c;l'4fll�lC' i[?W M1�atiticatinn of Intt�z! i�nrrn (1tG.�itic�i H!7{11YR] C. D. E. WELL DRILLER INFORMATION Company Nama: AWD SERVICES. INC. WeII I:)JIler Con tracTor's Natnc: C %'r-k -6u-rr e.Ar-1- NC Contractor Cerlilication No.: 3 S v o Contact Person: Larry Wells EMAIL Address: Welis750549(a-).Be11south.net� Address: 258 North Turke. Creek Rd.. City: Leicester Zip Code: 28748 County: Buncombe Office 'Fete No.: 828-683-9223 Cell Xlo.: 828-2I5-9334 H EAT P{IMP CONTRACTOR IN FORMATION (if different than driller) Company Nance: a.,� I(non�z Contact Person: c�, —VL1_�Yi�t'i_` ___ EMAIL Address: Address: l City: f�SI,P.Ui� Q. Zip Code: � rlbCounty:'BAOGC Q. Office Teie No.: i8-(58- MY Cell No.: - — STATUS OF APPLICANT i�rfYliL': x Nederal: Commercial: Native American I ands: IN.IEC" ION PROC FDURE (briefly describe stow the injection weII(s) will be used) G. WELL CONSTRUCTION DATA - -r (I ) Proposed date to be constructed; ► , :lfp;:-lr [.I►NUrn ber ❑Fborings: Approximate depth of each boring (feet): . u (2) Type of tubing to be used (copper, PVC, etc); E, 6imii (1) 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: _�alvaiiiTed steel black steel___plastic_`other (specify) Casing depth: From to feet (reference to land surface) Casing extends to above ground inches (b) No t% (4) Grout info (matCrial surrounding weft casing and/or piping). (a) Cirout type: Neat Cement— Besntonite rhy Crow plricemeot: Pumpin4,-____ Pressure _ (c) (Prout depth of tubing (reference to land surface): From I well has casisig, indicate grout depth: from ___ 9— Other(specify) r -je ] ' Other Tbp a t .1p 20% 50 lia.S to (fleet) to __ -__-{ Feet) ONO JIC 5QW NrAiFication [)I'{ntent Form Wevkod 9/2009) Pngc 2 If. 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. LOCATION OF WELL(S) i%uach two copies of maps showing the following Irifurrnation 1 1) include a Site Map (can tie drawn) showing: Nlildin()s, property fines, surface water bodies, patentRil sources nfgroundwater contarninatinn and the orientation ai'and distances between the proposed well(s) and any emsting or waste disposal facilities such as septic tanks or drain fields located within 200 feet of the geothermal heat pump well system. Label ail features clearly and include a north arrow, (_J The Site Map Ii}itst show the subject property in relation to the surrounding area by using at least two tied reference points SUCK as roads, streams, and/or highway intersections. I. CERTIFICATION Nate: This Permit Application must he signed by each person appearing on the recorded legal property deed. I rcrtify, undcs' penally cal- law, that I have personally cNamined and am tamiliar wadi the inibrmaJori submitted in this document and all attachments thereto and that, based on my inquiry of those individuals immediately responsihic for obtaining said iriformaiion, I believe that the information is tree, accurate and wrnpletc, I am aware thal there are significant penalties, including the possibility of tines and imprisonment, for sublr.ining false information. l 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 Property OwnerlApplicant Phnt or Type Full Name ail title Signature of Property Owner/Applicant Print or Type Full Namii and title Signature of Authorized Agent, if any Print or'Type Pull Name and title Please return two copies of the completed Application package to: North Carolina DENR-DWQ RECEIVED i QENR D'I1Q Aquifer Protection Section -[TIC Program A0UTCFR'Pl?')rFf'7ln)" Vr?ION 1636 Mail Service Center NOV 0 7 mi Raleigh, NC 27699-1636 Telephone (919) 715-6935 ( Pill I i/[ I I C 5Q\Y Ncotificatian nI' Inrenl Fomi (Revised 812008) page 3 i 1 i Buncombe County Tax Lookup - Property Card Page 1 of 2 , y COUNTY OF BUNCOMBE, NORTH CAROLINA r ti .f Web Property Record Card 9696-83-9488-00000 Date Printed: 11/8/2011 Owner Information Parcel Information Total Property Value: 213.100 Status: Active Owners: MICHAEL S BRADLEI' .account: 8047954 %ddress: Deed Date: 7/10/1991 31 BLEEKER LN Deed Book/Page: 1657 / 0280 FAIRVIEW NC 28730 Plat Book/Page: 0000 / oaoa Property Location:31 BLEEKER LN Legal Reference: WARRANTY OR SPL/COMP TRANSFER Ta.adng Districts Location: 31 BLEEKER LN (Class: RESIDENTIAL County: Buncombe County eighborhood: FVW-GARREN CRKAREA City: Subdivision: Fire: FAIRVIEW FIRE Sub Lot: School: Zoning: Conservation/Easement: N Flood: No Owner History Ownership History Assessment History Year Account Acres, Land i B1dgs Other Assessed Desc I Exemptions Deferred Taxable 2011 18047954 3.09 168,6ov1z39,900 4,600 1213,100 10 0 213,100 2010 18047954 3.09 68,600 L39,9D0 4,6o0 1213,100 1 Io io 1213,1ao 2009 2008 18047954 18047954 3.09 168,600 3•09 168,600 139,900 139,9o0 4,600 4,6o0 i213,100 213,1a0 0 ]o 0 E0 213,100 1213,100 12007 18047954 3.09 68,600 1139,900 4,6o0 1213,100 10 l o 1213,100 2oo6 18047954 3•09 168,600I139,90014,6o0 1213,100 10 0 I 1213,100 f 2005 18047954 3.09 141,900 i 112,900 4,6o0 1159,400 10 0 1159,400 2004 18047954 18047954 �3-•09 I3.09 L41r9aa 141,90fl ri2,gaa 112,9o0 4,6o❑ 4,600 159,400 159�400 1 o 10 o 10 159,400 159,400 2003 ,2002 180471954 3.09 41,900 112,900 4,6o0 159,400 1 10 10 1159,400 12001 18047954 3.09 i28,500183,30012,200 1114,000 1 10 10 114,000 l Data Total Acres: 3.09 Land Value: Other Im irovements Acres 68.600 Segment# I Units Description 1.00 Each [HOME SITE Vable.. _4_600 Improv* Description Year Units 1 IPOOL,VINYL Ix988 Fee Square Acres 1CLASS 1 Building Structures Res. Building Style Sq Bsmt Bsmt Year ID Feet SgFt Finished Built 1 RANCH 1604 1604 a 1964 Grade Condition Value C N IR9000 http://www.buncombeta.x.org/PropertyCard-aspx 11 /8/20 11 Buncombe County Tax Lookup - Property Card Page 2 of ? Refinenient Description Built-ins Units Foundation CONVENTIONAL Full Bath(s) 1 Roof TV/MT HIP W/ COMP. SHOL. Half Bath(s) I Roof Structure WOOD MOIST Bedrooms%, !S Floor Finish (SOFTWOOD Basement Cr # Cars 3 Interior Finish DRYWALL/SHEETROCK Heating 1 FORCED AIR Air Condition NONE(NO CENTRAL A/Q Section SgFt # Stories 700M BASE ART 1604 t.00 SAS fi'ERRACE k o 11.00 Total Building Value: 139,900 http://www.buncombetax.org/PropertyCard.aspx 11 /S/? Q 11