WI0100198_GEO THERMAL_20120202

Central Files: APS SWP
02/02112
Permit Number W10100198 `., 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
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility Name
Charles M Kuzell SFR
Location Address
673 Wickhams Fancy Dr
Candler
Owner
NC 28715
Permit Contact Affiliation
Charles M. Kuzell
Owner
Cmr 450 Box 456
Apo AE 09705
Major/Minor Region
Minor Asheville
County
Buncombe
Facility Contact Affiliation
Owner Name Owner Type
Individual
Charles M Kuzell Owner Affiliation
Charles M. Kuzell
Owner
Cmr 450 Box 456
Dates/Events Apo AE 09705
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
02/02/12 01/05/12 02/02/12 02/02/12
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall MULL.
Waterbody Name Stream Index Number Current Class subbasin

...... d
NCDEE R
North Carolina Department of Environment and
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor Director
02/02/2012
Charles M Kuxell
Patricia L xuzell
CMR 450 Box 456
APO, AE 09705
Natural Resources
Subject: Aclmowledgemew of Intent to Construct T)qx 5QW Injection Well System
Permit No. WI0100198
673 Wickham's Fancy Dr.
Candler, NC 28.715
Dear Mr. Kuxell.:
Dee Freeman
Secretary
On 01/0512012, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop watermanly
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 is 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 North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Buncombe Counry 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 Rogers at [phone] or Michael.lkoeers rr ncdenr:i o►r if 1you have any questions.
5 i cerely, 1
fOr De "aam
Supervisor
APS central Files - Permit Nn, N190100198
Bunccinbe County 1Tcaiti Dept,
Jeff 1"loore (Cicalwatci '�YU1I DI-Iili,ld Inc.; f'.0r 13DX 71, 1J0SP1111g5, \C 2E')d;)
Duane Gentry (Gentry Heating Inc., 100 Buckeye Cove Access Rd., Swannanoa, NC 28778)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St„ Raleigh, NoM Carotene Z7604
Phone: 912W-6 s4 � FAX: 91W7-6496
Intarnet www.nm%MueGiv.ara
An Equal OpporhrMty%ARkm*eeAftn EmPbyer
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NORTH CAROL.INA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
I+TOTICF'1(CATION OF WTENT TO CONSTRUCT A (74OSED-LS YOP GXDTE[ 'RMAL
WATER-Oir'I.Y INJECTION VnrLL SYSTEM
T�rgw 5��W WELL�SF `
In Accordance With the Provisions ofNCAi: Title 15A 02C.0200 1
Prim or type the required f> formatron and mail 1c; address on the back page,
DATE: 1� r 21) Id,
rAd
We!! Type Confirmadon: Does the proposed system circulate pomble water only lrxo addiCryes) in
continuous piping that completely isolates the fluid from the environment (i_e,
closed -low)?
Yea "ti oe vampleting this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (opcn-loop well injecting potable water into the aquifer) or a 5QM well (closed -
loop well containing additivos such as R-22, ethanol, or other antifreeze or corrosion inhibitars).
PROPERTY OWNEH(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or goverment agency, state name of
entity Ew a rove W/Kdhodty for 34pwft):
CNHr�1.65 ^1 � P6TR1C14
L- hti 0Z E i-L
(I) 111ading Address: C!2a r. -A 5 0 _ f3 cx, -k 5 i0
co, It 00 sm, &E Zip trade: O9 ,70 5 co
Horne/Office Tele No.: 3 g `_ 4�7 5 �ellNtr.: _
Email Addiass: CAMWebsite:
(2) Physical Address of Well Site (if diffe=t than above): :S W i C KH 14 M IS t:W1V L Y )� R
city; C ANDI-isk _ St9e: t1 C zip Code: AS -115 Cry:
HomdOffice Tak Na: Cell No.:
AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a Jew from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Conttwt Person: Er iL A
Address:
City:
Smte: Zip Code;
County:
Office Tele No_: tom.
Website Address of Company, if any: G `
QPUIU1C 5QW Nvtdficatian oflaupuFaQm {Revised Mo09) IMF I

C
'WELL DRMLER WFORMATION
Company Name: �° 1•� ��'_ �� '� 1 �- -
Well Driller Contractor's Name: �, L 1', r� ► �LU>S _ _
NC Contractor CertificRtion No.: U3 7 — r l _
Contact Persc-. '� 'kGE�!r
Addre
City:
Office
Zip Code: ak�_Z___ Comty:
-i ►--- Cell No.: 44 9M— ]1_1_�
D. HEAT PUMP CONTRACTOR INFORMATION (if differe t than driller)
Company Name: 1 k g _
Contact Parson . SvIAfT. Address: c' �.+c.� era _ c :,,�- s .�� i�iGCp►''!
Address:
City: c�2ritp Code: At?-9— County
OfficeTeleNo.: 5:+a_'��fT� t13�-� Cell No.. _Z — — 5�
E. STATUS OF APPLICANT
Private: L_ Fedrrel: Cnmmemial-
Stele: Municipal: Native American Lands:
F. INJECTION PROCEDURE (bpefly descnbc haw the inJec-non weIl(4) wi 11 be used),
G, WELL CONSTRUCTION DATA
(1) Proposed date to be constructed_ j — —C( ± Number of borings: W
Approximate depth of inch boring (feet):��(]
(2) Type of tubing to be used (copper, PVC, etc): Lit '�
(3) Well casing. Is the well(s) cased? (check either (a_) yea a (b.)140 below)
(a) Yes if yes, then provide casing information below
Type: _gAlwanized steel truck steel— plastic other (specify)
Casing depth: From to feet (reference to lend mzfeee)
Casing Wmends to above ground inches
(b) No K
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement
BetttQnito V Other (specify} —
(b) Grout placement: Pump1ng_1e- Presstm
(c) Grout depth of tubing (reference to lend =-face).- from_ - to2. 6, (feet)
If well bas casing, indicate grout depth: Erom to (fiW)
GPtJMC SQW Notification oflrihcat Form (Revised 820081 P"m I

Page 3 of 4
H. 1NSRCTION-RELATBI) EQUIPMENT
Attach a diagram showing the engineering layout or proposed modifearion of the injection equtpment and exterior
piping/tubing associated with thin injection operation. The menuiaotaror's brochure may provida supplementary
information.
I LOCATION OF WELQS)
Attach tyro copies orRiaps showing the following information:
(1) Include a Site ,Map (ean be drawn) slowing buildings, property Imes, surface Aaler bodies, potential
sources of drouirdwater comamrn1160i, and the orientation of and distance between the proposed wr_ll(s) at Id
any existing weil(s) or waste disposal facilities such as septic tvnks or drain fields located within 2.00 feet of
the goo thuripal heat pump well system. Label all features clearly and incl41d1agrd mow.
(2) The Site Map must show the subject property in relation to 11ic surrounding area by using at least two fixed
reference points such as roods, streams, and/or highway intersections.
.1. CLR11F1CATION
Note: This Permit Apptecadon must he stgned by Lath person apptsrhig on the
recorded legiti property steed,
"1 herebv cool/}, under penalty of taw, that f hvve personally examined and am familiar with the information
submitted in this document and all attachinetm hereto and that, based on my inquiry of those individuals
immediately responsible for abtuining said information, I bcIieye that the Inforn141ian is true, accurate and complete.
I am awere that There are signiFicarnt penalties, including the possibilYty o;• fiines and imprisoliment, far submitting
false inFnrrnatinn, I agree to construct, operate, maintain, repair. and If applicable, abandon the injectiaii well and
all related appurrentinces in accordance witiz tit ed specifications an •conditions of the Permit.,
Signature of Property Owner) licatrt
eA44R 4rv*S M , td rz-e=G �—
Prlrtt or Type lull Name and title
Sigtumue of PtOp"UM Own 1r Applicant
00,0? l 0A L , Al I7r-- Gc�
Print orTYpe FulI Marne and title
5iviz=e ofAuthorized Agent, if any
Print or, Type Full Name and title
Please Mum two copies at the completed Application package to:
No rtb Carolina DENR-DW Q
Aquifer Protection Section-U1C Program
1636 Mali Se±-viee Canter
Raleigh, NC 27699-1636
Telephone [phone]
GP01)C 5QW Notifirstian of ]plan[ Form fReviud IV20081
12/29/2011

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