WI0100192_GEO THERMAL_20120124

Central Files: APS SWP
01 /24/12
Permit Number WIO1OO192
Permit Tracking Slip
Program Category
Status Project Type
Ground Water
Active New Project
Permit Type
Version Permit Classification
injection Water Only GSHP Well System (5QW)
1.00 Individual
Primary Reviewer
Permit Contact Affiliation
eric.g.smith
Jeff Moore
Coastal SW Rule
PO Box 71
Hot Springs NC 28743
Permitted Flow
Facilit
Facility Name
MejortMlnor
Region
Jeffrey & Jennifer Budai SFR
Minor
Asheville
Location Address
County
621 S Phillips Rd
Polk
Columbus NC 28722
Facility Contact Affiliation
Owner
Owner Name
Owner Type
Individual
Jeffrey Budai
Owner Affiliation
Jeffrey Buda!
621 S Phillips Rd
Columbus
NC 28722
Dates/Events
Scheduled
Orig Issue App Received Draft initiated
Issuance Public Notice issue
Effective Expiration
01/24/12 12/02/11
01/24/12
01/24/12
Regulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name
Stream Index Number Current Class Subbaein

A, A
n. s
1` LOL1` K
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor Director
1/24/2012
Jeffrey Budai
Jennifer Suded
621 S. Phillips Road
Columbus, NC 29722
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No, WIO14U 192
621 S. Phillips Road, Columbus, NC 29722
Dear Mr, & Mrs. Sudai:
Dee Freeman
Secretary
On December 2, 201 I, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onlr
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
ixidivi.dual pernut 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 contains only potable water,
2. The injection well system is constructed in accordance with well cwLstruction standards specified in North
Carolina Administrative Code Title 15A Section 2C Suhchapter .4213, 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 Wei Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Polk 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.
PIease contact Mike Rogers at [phone] or Michael.RQggrs;C[tin denr.�ov if you have any questions.
Sincerely,
Jor Debra X atts
Supervisor
cc: Aslieville Regional Office - AP5
AP5 Central Files - Permit No. W1010014?
Polk County Health slept.
Clearwater Well Drilling, Ins:, (lefrMoorc)
Gentry Heating, Inc. tDuane Gentry)
AQUIFER PROTECTION SECTION
1636 Mali Servlce Centar, Raleigh, North Carolina 27699-1636
Location: 512 N. 5allsbury 31, Raleigh, North Carolloa 27604
Phone: 91M07-6464I FAX [phone]
inIVT)et: www-n terqualitY.Or4
Na thCaroiina
An Equal 4pporluno i Aff ffn9w Action Employar

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
I' 1 1 MEW 1 i
W&JI&QMY UUWn0NW r
TYPE row wMu(s)
to Accol low wish the Provisions ofNCAC TWO 1SA 02C,0200
Prw or We the mgs&ed trp*ormet cw and wd to addm an the back page-
DATE: /a - 5-K 20
a 1 a) tqt�
Wag 7jjx Cai n: noes the proposed systan cimulate potable Mgff C (no odors) in
rontinuous piping that camphftiy isolates dw (fluid from the environment (i.e.
clos"W �?
Yea L---�Carrtinuc eaanpleting this fortis.
No -Da Not complete this form. Complete ad= UIC applicadon fanny for installing
either a 5A7 well (ppwioop well jU potable water into tho aquifer) or a SQM w+eH (closed -
loop well camaining such as R 22, ethanol, or other anti.Grea n or oornasioe k&Ra xrs).
A. PROPZRTY OWNER(SYAPPLICANT(S)
List qKh Property Owner listed on property deed (if owned by a business or ernment ageney, state Wne of
eotitf and a representeaive wlauthmity for sigr►s hm):
(1) Mailing Address:'94
City: State• Zip Code:.._�vi Caeaaty:
Home/Office Tale N Cell No.•
Ems! Addpm:' Weft:
W i la�.lt!
(2) PhysiQd Address of Well Site (if dim than above):
City: gam• zip Code: —County:
Home/Moe Tele No.: Cel Mn .:
B. AUTBORMED AGF'.rl'I' OF OWNER. fF ANY (if the paW Applicant d= sown the subject propeaty,
838cbi a lettff fsvm the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact 1L ddress: -
Addrass-
City. Stye: Zip Cade: County.
Office Tale No.: _ Cell N .:
Website ► 4dress of Company, if any:
Rgl�rfvr �rote+rt �� ��
cPuAAC 5QW rat of Wed. Fwm.(Fxvixod arMW DEC a
CUfl

C. WELL DRAPER INFORMATION
Company Name:_'_ - _! lf"��L.�I _ _ ��'i.._ Well Driller Contractor's Name:
NC Contractor Certification No.:
Confect Person: S r-? J i �t E f �� "7_�_ �`�'�►HCo� EMAIL Address: _ C.i t: �!� ►i '+ l�� y
Address:
City: 42a± ;O Zip Cade: �&7Lf County: �.
Office Tale No.:7Celt No.: 1�y
D. HEAT PUMP CONTRACTOR INFORMATION (ddiffrereat than drilkr)
Company Name: iJ r
Contact Person FIA
Ail Address:
Address:
City: - L -' �a i Zip Code: joyCowity:
Office Tele No.: _; ' `y7L 9r] X Cell No. - - W-Sr-1 j �I
E. STATUS OF APPLICANT
Private: Fedesel• Commercial:
State: Municipal: Native American Lands-
F. INJECTION P'ROC ll[JRE (hri fly describe bow the injection well(s) will used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: —• `)S-- Nurp� ofboa-ings:
ApproAnale depth of each boring (feet):
(2) Type of tubing to be used (upper, PVC, eta): �Q 1 _ q0k1
(3) Well casing, Is the well(&) eased? (check either (a.) Yes 2E (b.) No below) - -y-
(a) Yes if yes, then provide casing information below
Type: ---Pvan>zed steel black "!cl`pJwbc other (specify)
Casing depth: Fmm to feet (tefraence to land surface)
Cuing extends to above d inches
(b) No
(4) Grout Info (material surrourXEM Well casing M&or piping):
(a)
N
(c)
J �.Other (specify)
Grout placement_ PUMPing_ - Pre&qum _ pdr
Grout depth of tubing (referenec to land surface): f m _ to (feet}
If well has casing, indicate grout depth: fiam m ( )
Grout type: Nag Cement Bentonite --
GQUAJIC 3QW Nvtifiratim of bu= Farm (Revised VM8) Pup 2

H. INMAMON-MICI ATED EQUEPWMNT
Aftech a diagram showing the engi wffing layout or proposed Modification of the injection c"prnerd and exterior
pipit tubing amciated with the bdection operation. The manttfacturWs. brochuie may provide mppkmentarY
infbIrmation.
LOCATION OF WELL(S)
Attach two copies of maps showing the finllowing WMmadon:
(I) Include a Site Map {can be drawn} dawinF buildings, pro" lines, s+afaoe waW bodies. Potential
sources of VmW wuW amamination and the onion of and distances between the proposed well(s) and
any eacisang well(s) or waste: disposal facilities such es septic to b or drain fields located within 200 fact of
the geothermal bed pump wail systaera. label all features dearly w4 include a worth arrow.
(2) The Site Map must show t#te subject property in relation to the mumunding area, by w&W at least two fixed
reference points -such as roads, streams, andlor hghway moons.
L CERTIFICATION
Nate: This Packk Appikeden mast be aiped by V_qk person appearing on the
recorded iepl property deed.
"I hereby comfy, under penalty of law, dw I have pally examined and am famaiUaar with the information
submitted In this docsnnent and all attachments thueto and ,trot, based on my inquiry of tlrou individuals
i nmedialeiy responsible for o1naining said informs M I believe drat the information is tote, aec rename and deplete.
I am aware then them are slofcant peraltIM including the possibility of fines and imprim meet. for submitting
Mse lydwriu ym I agree to construct, operate, maintain repair. and if apphoubb% abandon the injection well and
all related Wurftaaoes in accordance with the approved spedficafioets and conclitions. of rile Permit."
Signatttim 6f Property OwnerlApplk=
V �f',VN laxll;1O., T3�!
Print or Type Fuli Name and title
Signature a soperty OrvrrerlAMi�irant
`r • a
..,1 e A. Bj
Print or Typo Full Name and tide
Signatures of Authorized Agent if any
Print or Type FlI N me and tttle
Pieme "t= two oapies of the completed Application package to:
North CaroHm DENR DWQ
Aquifer Protection Section-i]IC Program RECEl1 M I DENR 1 DM
1636 Mad Service Centex' Aquifer Preipction "'On
Raleigh, NC 276WI636 DEC p 2 2011
Telephone (919) 733,U21
GPUAW 3Qw NoriS=dm of )W& Fear (Rarieed 9020M PVW 3