WI0100193_GEO THERMAL_20120124

t
Permit Number WI0100193 '
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Central Files: APS SWP
01/24/12
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
Facility Name Major/Minor Region
Mooreland Farms LLC Minor Asheville
Location .Address County
308 Sassafras Jackson
Cashiers NC 28717 Facility Contact Affiliation
Owner
Owner Name
Mooreland Farms LLC
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated issuance
01/24/12 12/02/11
Regulated Activities
Heat Pump Injectlon
Outfall NULL
Owner Type
Unknown
Owner Affllation
Anthony Zande
10530 Savannah Dr
Vero Beach
Public Notice Issue
01 /24/12
FL 32963
Effective Expiration
01 /24/12
Waterbody Name Stream Index Number Current Class Subbasin

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Chaves Wakild, P.E.
Governor Director
1 /24/2012
Moureland Farms, LJ,C
Anthony L. Zande
Lynne Zande
10530 Savannah Drive
Vero Bcach, FL 32963
Subject: Acknowledgement of Intent to Construct Type 5OW injection Well System
Permit No. WIQ 100193
308 Sassafras, Cashiers, NC 28717
Dear Mr. & Mrs. Zande;
Dee Freeman
Secretary
0n December 2, 2011, the Aquifer Protection Section (APS) received notification of your intent to cownruct a closed -loop water -only geoWermal
injection well system for the operation of a ground-souree 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 weal system is constructed in accordance with well consuuc;ion standards specified in North Carolina
Administrative Code Title 15A Section 2C Subchapter .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 Wall Construction Aet and North Carolina Administrative
Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Jackson County Health Department as they Wray have
additional requirements for this type of system. Noncompliance with applicable state, county, or municipal rules and regulations may result in the
assessment of evil penalties.
PIease contact Mike Rogers 8t [phone] or Michael.Rogersla.ncden,.Lav if ,you bave any quesrons.
674 6 - t4Q
for Dcbru Watts
Su pervisor
cc: Asheville Regional Ofte - APS
APS Central Files - Permit No. W10100193
Jwkson County Health Dept.
Clewwaler Well Drilling (Jeff Moore)
C.cntry Heating, inc. (Duane Gentry)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Catalina 27699.1636
Loralton: 512 N. SalIsbury St., Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone]
Internet www n
An Equal pppodunky lAffirmative Acllan Employer
I�e Carolina
QVr261Y

NORTH CAROLINA
0FpARTH3NTOp ENVIRONMENT &ND'NATURAL RESOURCES
r40TWIcATION OF INTENT TO CMWMUCT A gL9=-JA= GEOTHIZrSMAL
W►tyTSR4NLY EKjwCTJ0N WM L SYSTEM
1' PE JQW MTk& 8J
In Acsa�&Ljwe With tha Provlalotta of NCAC'ritla 15A 02G0200
Friar ar W rim rer)r+kwd kl/F maikv? rr+ulemil to oddrNO ort dw back Page.
DATIL- ) " 1 d- -- aQja_ O 1 DPI- 3
A.
K
Well 7) pa Corljli►Nallon: Does tite pinpomW systeat Wroubde potable water [(no additives) in
conlikummis piping dL%t completely laolates the fluid (rnm the wivironment (i.e.
9252d-1m)?
Yea L-- Contimie completing this fang.
Na Do Nat complem this forn). Complete otltor UIC aplrlication fortes %r tttslaiiing
either a 5A7 well (Opp,+ -loop well 101NO potable ?vnter into the aquifer) ova SQM twolt (olosed-
loop well containhig atlditrnes such ae R 22, elhnnol, or other notif we or cormslott inhibitws)-
PROPERTY OV01911{S)IAr MICANT(S}
r"ltliy tmd a mpmegn%live wlnttthmily far signature);
City: State: 5if- Zlp Code: ,,3I;�'9 +3 _ Countr.Z�
Honw/OFlTco Tole No.:
8ttt911 Address:-ZA-A
D - .2S3 74
C2) Physiml Addren of Well Site (if0lbrent ilrsn shave]: 3
aty: _,'_"- State: 'tL Zip Code: Z 10 t _i Couliv.
HomdOfflee Tele No.:
Cell o.;
AUTHORIZED AGENT OF OWNXR, IF ANY Of 1he hermit Applb=nt dM OW own the subject property,
attach a lolte r Rain the pr+opeity o►vnor suthwixiag Agent to WSW and opamte LnC wall)
Comimny Flame:
Contact Person-
-Address:
city: —_
Oil'iev Tee No.:
F-MAIL Address:
State: Zip Cade: Cntutty:
Wobsite Address ofCompany, ifauy;
OPUM1C SQW NollkwIrbi oClMml boron [RWANd BrW" Aau el mterr �► '
O' C Q t 2011 iw8 ► pniS loppolzi
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dw.zo C l 6Z RON
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C. WELL DRILLER INFORMATION
Company Name: ys . t. s .LU ry WLIXt,14)(11
Well Driller Contractor's Name: R(, f 1
NC Contractor Certification No.:-
_f=�= EMAIL Address: tj1 I, Contact Person : _
Address:
City: I Zip Code: �"7_ County:
Office Tele No.: ��� �� � � Cell No.:
D, HEAT PUMP CONTR.aCTOR INFORI ATlON (If dill rent than driller)
k �
Company Name:—
Conract Person: A' r y EMµAIL Address: k_���„i
Address: r�LH�`��:�-:_
City: -� L+A, �-�J- - Zip Code: �� �� ;�, (County: _ _ - } L -
Office Tele No,:
E.
F
16
STATUS OF APPtj(:ANT
Private: �� Federal:
Commercial:
State: Municipal: Native American Lands:
INJECTION PROCEDL ) tE (briefly describe how the injection well(s) will be used)
WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: i �--- �-#umber of borings:
I
Approximate depth of each boring (feet): `
2 e of tubing to be used (copper, PVC etc):
(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 feet (reference to Iand surface)
Casing extends toabo ground inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement . 13entonite _�
(b) Grout placement: Purnpin vg Pressure t:
(c) Grout depth of tubing (reference to land surface): from
If well has casing, indicate grout depth: from _
Other (specify)
Other
to (feet)
to (feet)
GPU/LJIC 5QW Notification of Intent Form (Revised 8/2008) Page 2

H, YNMCnOW-RELATED E+QVtPMNT
Attach a diagram showing t6 et 0needng ]gyout or pmposed modificeflon of the Wootlon agttipnient end axterlo
pipingltubing aaeoelawd with the i1dwian opgrmlon. The maiwfecturees broehure may provide eapplen>entar.
inform lon,
L LOCATION OF WBLd.(Sj
Attach two copies of maps sMwlag the following inlbrrnadion:
(t) Include a Site Map (can be drawn) ahowlitg: buildiar, PM00 llM% surface water Wdk% pobaetlai
:ounce* of swmidwawr codttan+tmdon and the arlawation of ad distances benmen ft F%Wjcd walls} and
tiny tudeting weil(e} or "M dlspml fhclikke wok as aeptk Lanka or drain fl" tocamd within 200 that of
the grwhermai beat pump well system. Label ali fbatures clearly and include a_nontli
(2) 'nw Site Map aaast *how The subject pzoperW in relaft to the simrtmnding am by using at teat two fixed
mhr enca points sucit as made, streatt% and/or ittgiim lnmemedions.
J. CWr1F1CA7WK
Notes Thle Permit Applteafien muust lie agned by =k pessou Appearing en the
recorded lept pt�oporty dead.
.it ii�t�i� * �1i , ustder panaity of Igw, that i have peraottally examined and stn fiuniiiar ►ddl ft k4br istion
Ruby 4 'r doomwM and all atiaoltmw is tharaio and that, based on my inquiry of those individuals
IvM • +ft1ble bar obtaltting aid infamatim l believe dmt the Infont ibm Is am, accurato Brad complete.
f M Aft am aignilieent patastics, irtoludhig the possibility of fines and Impdsortmernt, fbr submi thig
�Mr rw r agree to eonshwL opera% ah tat ti, n�aix, estd If appilcahire, abanda+t mite iedection well acid
rr oW4es in accordance with the, :pr�vcr sP�Ldons and oarAl loin of the Permit,"
Print ourType Full dame and title
f a of Arapc vdAppihwt
hJtJ Rr /�"�l��
PrW erTypa ltuilNattte attd title
SNxialrcofAuftwind A", ifegy
Prim or Typo Poll Nam and title
WON return two copies of the canpiefod Applicatlon package to:
North Carollan DFXJWDWQ
AgailDir ProfeWon Section-UTC Program
11636 M%R SWYke Cep
Raleigh, NC 27699q69
Wepbaue (919) 733-32211
liMMC NW Nadfcadw orinkt pony (tta w tt mD
Cd 999L L gUL
RECEIVED f ❑E1YR, fiv�o
Aquifer PrWFVinn So- Wn
DEC 4 S 2011
x" Apn1S aP901d deb:Z0 11 6Z AON

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