WI0100175_GEO THERMAL_20120523

Beverly EavesPerdue
Governor
A~/tr · EjLj¥~~ -
MCDENlt
North-Carolina-Department-of E-nvironment:and-Natural-Resources
Division oLWatei:.Quality..-.
CharlesWakild~ P~ E.
Director
May 23, 2012
Donna_Cox Rus_ch
110 Concorde Place
Mandeville, LA 70471
Subject: Notification of Rule Revisions Affecting
Closed".'J,.oop _Ge<>.tb,ermaLinj ection_Well-Permit-Holders-•-
Permit Number: WIOlOOl 75
Dear Ms. Rusch:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefmitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http://portal.ncdenr.org/web/wq/aps.
If you have any-.questions-regarding. your current-permit-or the rule-revisions;-please· feel free to-·
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydro geologist
cc: UIC Pennit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterouality.org
An Equal Opportunity\ Affirmative Action Employer
One ·
North Carolina
JVaturnll!f
2t0/0t0d S~d 8N30 :JN E0Z6E89828 -WOH~ 00 :tt Zt,-80-20 CI3AI3~38
R ESIDENTIAL WELL CONSTRUCT.JON RECORD
North Carotbla Depamnem of.~1wlronmont and Nat\&r&I R.csou~-Division ofWm,, Qulllity
W8LL CONTRA.CTOR CERTlJIICA.TION d _1_4._'21:c,_ ______ _
1, WEI.I. CONTRACTOll:
David Stratto n
Well Connctor (Individual) Name
AWD Sea,ices. Inc.
W•II Contractor Company Name-
258 North Tyrke v Creek Rd.
Sttaet ACIC!ress
Leicester
CityorTown
c,J28 > 683-9223
Ates cooe Pl'tol'le number
~WELL.INFORMATION :
NC
State
WELL CONSTRUCTION PERMIT# WIO1 00175
28 748
Zip Coda
OTHER ASSOCIATE0 PeRMIT#(ifappttcable) ______ _
IITE WELL ID#('tfapptlCIIIII._ _____ ~---
•• WELL USE (Check Appttcable BOX); Resldtmial Watar Supply 0
1
" OATEORILLEO j0/21111
TIME COMPL.ETeO. ______ AM CJ PM~
'-WEI.I. I.OCATl9N:
c1TY: Mars Hill· couNrv Madison
2314 Hamburg Road
(Strwt ~ine, Numbell, Cornmunity, Sulldlviaion, Lot No .. Parml, Zlp coda)
TOPOGRAPHIC/ ~0 SEn'ING; (Qlleek •PP!!r'llle bOll)
litSIOpe OVaUI) cl'lat CRldge CJOthor._~:;..a.ev~·-----
LATITUCi ,A__•~• 38.0000 "·DM60R ____ Ol>
LONGITUDE~0 2S '41.0000 "DMSOR ____ oc
Lltit\ldllllongltude 1ourc:e: ifopg CJTc;pographlc map .
(/00&1/ion of well must b9 snown on a USGS ropo mrip andettsohlffl to
this form ff not using GPS)
i. Wlt.L OWNER
Donna C-Ox Rus ch
0wnerN1me
23 14 Hamb uro Road
street AddreM
Ma rs HIii ·
City~rTown
c828 I Arn cooe -=Pl'l=-one--nu~m-:-be_r ____ _
NC
State
28754
Zip Code
e. Wl!LL DITAILS: ( 5) Geotherma.1 Bort!S
a, TOTAL DIPTM 1__,.3:..:0:..:0'-' ___ _
b, 000 Will.\. RIPI.ACE IXlfllNO W!I.L? YES Cl NO □
a. WA1'E~ L!V&I. Below Top of Casil\g : NI A FT.
' (Use ••• 11 Above Top of Casing)
d. TOP OF CASING 1& NIA FT. Above Land Surface•
"Top of caslng terminated eVor be1ow land surface may require
r varianc:t in 2,cc(lrd '.l nce w:'h 15.1' I\ICt-C 2 r. .01 16.
9, WATE~ l0NES (deplh):
Top Botro111 Top Bottom
Top Botro"' Top Bottom
Top Bottom Top Bottom
Thlckn.&/
7, CASING: Deptft Dlill'll9ter Weight Mat.rial
Top_ Bottom_ Ft.
ToD_BOt11lm_Ft. -Top_BCIUl:lm_Ft. -
8. GROUT: Ooplh Material
Top.Q__ Bottom~ FL Bentor,lte
Top~ BottornlQ[_ Ft. Pea Gravel
Ma1hod
Pour
Top_ Bonom_ f!t., ____ _
Dlametar Slat llta
Top_Bottom_Ft. __ ln. _In. ___ _
Top_BoftOm_Ft._ln. _In. ___ _
TOJ>_Bottom_Ft._ln. _In. ___ _
10. SAND/GRAVEL PACK:
Depth Size Maer1a1
Top ___ .8ottom_J:t .. __________ _
~P--~~tton,_Ft. __________ _
Tcp, ___ Bottom_Fl. __________ _
11. DRILLINO LOG
Top Boaom Fonnation Detortption ,
I
---'----__ _,/ ___ _
---='-------'----__ _,! ___ _
I __ _,, ___ _ __ ...,, ___ _
---'----
: 12.. , REMARKS:
II:
I 00 Hl!Rl;BY CER111'Y THAT THIS WELL WM CONSTRUCTED IN
ACCORDANCE'. WITH 15A N'CAC 2C, WELL CONSTRUCTION
Sf.AN0AROS, ANO THAT ,t.. C0PV OF THIS RECORD HAS BiiiN
PROVIDED TO THE WELL OWNER.
£lcu,-/d ~ ti.?-n-2-2-12
SIGN/ITIJRf OF CE RTIFIED WELL CO NTRACT OR DATI:
e. YIELD (gpm); NIA MITH00 OF TEST N/A David Stratton
f. DUIINFECTION: Typ• NIA _ Amount N/A ~PRJ:.::.:.:NT-=-EO=NA:::.:.::::M~e-o..,,/!=p1;=R.,..so~N-::c-=-o .,..,Ns=m"""""'u-=-cn=-:-:-NG=TH-:-:li=-aW--:-:El=:-:-L--
•:·~J.,d:~it,\¥ttl1i'1 ··30•dajs of aompt~tfan to: Dlvlllion of Water Quality • 1'1form~on ProCH1ln9, Fo1m GW-ia
:'.)fs~?..°tw.R~ice -Can,,Jr, Rafefgti, NC 27699•161, Phone·: [phone] Rev. 2109
ONI S30!~35 OM~ €0Z6€898Z8
Permit Number WI0100175
P rogram Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facllity Name
Donna Cox Rusch SFR
Location Address
2314 Hamburg Rd
Mars Hill
Owner
Owner Name
NC 28754
Donna Cox Rusch
Dates/Events
Orig Issue App Received
10/05/11
Reg ulated Activities
Heat Pump Injection
Outfall NULL
Draft Initiated
Scheduled
Issuance
Central Files: APS_ SWP_
10/18/11
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit C o ntact Afflliatlon
Major/Minor
Minor
Region
Asheville
County
Madison
Facility Contact Afflllatlon
Owner Type
Individual
Owner Affiliation
Donna Cox Rusch
110 Concorde Pl
Mandeville LA
Public Notice \o'(,;' l' Effective
Rea uested/Received Events
RO staff report requested
RO staff report received
70471
Expiration
q_\~\ l\o
10/1 3/11
10/1 7/11
Waterbo dy Name Stream Index Number Current Class Subbasln
PA
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Division of Water Quality
Coleen H. Sullins
Director
October 18, 2011
Donna Cox Rusch
110 Concorde Pl.
Mandeville, LA 70471
Ref: Issuance of Injection Well Permits WI0I00175
Issued to Donna Cox Rusch
Mars Hill, Madison County, North Carolina
Dear Ms. Rusch:
Dee Freeman
Secretary
In accordance with the application received on October 5, 2011, I am forwarding permit number WI0100175 for the
construction and operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well system to be
located at 2314 Hamburg Rd., Mars Hill, Madison County, NC 28754. This pennit shall be effective from the date
of issuance until September 30, 2016, and shall be subject to the conditions and limitations stated therein, including
the requirement to install well identification tags as specified in Part ll.3 and to submit w.ell construction
records as specified in Part VII.2. Be sure to read the entire permit to ensure that you are aware of all compliance
requirements of the permit.
You will need to notify this office at least 48 hours prior to beginning construction and operation of the injection
well' system! In order to continue uninterrupted legal use of the injection facility for the stated purpose, you must
submit an application to renew the pennit 120 days prior to its expiration date. This permit is not transferable to
any person without prior notice to and approval by the Director of the Division of Water Quality.
Please contact me at [phone] or michael.ro!lers(aJ.ncdenr. 20v if you have any questions about your permit.
cc: Landon Davidson, Asheville Regional Office
W10100175 PennitFile
Madison County Environmental Health Department
Michael Rogers, P .G. (NC & FL)
Larry Wells, AWD Services Inc., P.O. Box 125, Leicester, NC 28748
AQUIFER PROTECTION SECTION
1636 Mall Seivice Center, Raleigh. North Carolina 27699-1636
Location: Z728 Capita l Boulevard, Rale~h. North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588: FAX2; 919-715-6048 \ Cusiomer Servlce: 1-817-623-6748
Internet: www.ncwateroualliv.or;:i
A~ Equ.1 Opponunir; I Afiil!tlat1ve Action Ell)ploye,
Oneth J' N~{ Caro ma
;vaturalfll
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21 , Chapter 143 ; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Donna Cox Rusch
FOR THE CONSTRUCTION AND OPERATION OF 5 TYPE SQM INJECTION WELL(S), defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at 2314 Hamburg Rd., Mars Hill, Madison
County, NC 28754, constructed and operated in accordance with the application received October 5, 2011, and
in conformity with the specifications and supporting data submitted, all of which are filed with the Department
of Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation of an injection well and shall be in compliance with Title 15A of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws., Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until September 30, 2016, and shall
be subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 18th day of October, 2011 .
~ j . Wcl{s
~~oleen H. Sullins, Director V Division of Water Quality
By Authority of the Environmental Management Commission-.
Permit #WI0l00l 75 UIC/SQM
ver. 03/2010
Page 1 of 5
PART I-WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Inj ection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N .C .G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not b e located in an area generally subject to flooding. Areas that are generall y
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART Il -WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing system, the Pennittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
nwnber 919 715-6166 and the Asheville Regional Office Aquifer Protection Section Staff, telephone
number 828-296-4500.
2. The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation corners) and shown on an updated Site Map. The Pennittee
shall retain a copy of this record on site.
3. One well identification tag per grouping or 'cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g).
PART III-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volwne of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and app roval by, the Director of the Division of
Water Quality (Director). In the eveht there is a desire for the facility to change ownership, or there i s a
name change of the Pennittee, a formal permit amendment request must be submitted to th e Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The i ssuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies , which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
Permit #Wl0100175 UIC/SQM
ver. 03/2010
Page 2 of 5
PART IV-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the tenns and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3 . The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
ground water resulting from the operation of this facility .
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Pernrittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number 919 715-6166. Notification is required so that Division
staff can inspect or otherwise review the injection facility and detennine if it is in compliance with permit
conditions.
PART VI· INSPECTIONS
1, Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Division representatives shall have reasonable access for purposes of inspection, observation., and
sampling associated with injection and any related facilities as provided for in N.C.G .S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
Permit #WI0100175 UIC/SQM
ver. 0 3/201 0
Pa ge 3 of 5
PART Vil -MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section -me Program
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
Asheville Regional Office
2090 US Highway 70
Swannanoa, NC 28778
828-296-4500
2. A completed Well Construction Record (Form GW-1 ) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Asheville Regional Office within 30 days of completion
of well construction. Copies of the GW-1 form(s) shall also be given to the Permittee and retained on site
to be made available for inspection.
3. A copy of the site map updated w ith manifold locations required in Part TI .2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Asheville Regional Office within 30
days of completion of well construction.
4. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection will be established and an
acceptable sampling reporting schedule shall be followed.
5 . The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Asheville Regional Office, telephone number 828-296-4500! any of the fo ll owing:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, s uch as mechanical or electrical failures;
(C) Any loss ofrefrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refriger~t system.
6. Where the Perm.ittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permitte~.
7. In the event that the permitted facility fail s to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIll-PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
Permit #WI0100175 UIC/SQM
ver. 03/2010
Page 4 of 5
PART IX -CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injecnon
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Pennittee must install a sanitary seal. If a well is not to be used
for any purpose, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l).
Notification shall be submitted to the addresses given in Part VII.1 of this permit.
2. When operations have ceased at the facility and a we11 will no longer be used for any purpose, the
Pennittee shall abaJ.1.don that injection well in accordance with the procedures specified in ISA NCAC 2C
.0214, including but not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if the
Director finds such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water. ·
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may intexfere with sealing operations.
(C) Each well shall be thoroughly disinfecte~ prior to sealing, if the Director determines that failure
to do so could lead to the contamination of an underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the well
through a pipe that extends to the bottom of the well and is raised as the well is filled.
(B) In the case of gravel-packed wells in which the casing and screens have not been removed, the
casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout
injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the tenns and conditions
of the permit.
(G) The Pennittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII. l of this permit.
Permit #WI0l00l 75 UIC/SQM
ver. 03/2010
Page 5 of 5
Rogers, Michael
From: Stepp , Jonathan
Sent:
To :
Subject:
Monday, October 17, 201 1 3:22 PM
Davidson , Landon ; Rogers, Michael
RE : WI0100175 Rusch SQM
Attachments: Dohha Cox Rusch_W l0100175.pdf; WI0100175Map.pdf
Please find additional map submitted by Larry Wells (driller) attached. My recommendation is to proceed with
permitting. Mr. Wells will be receiving a NOV on this one because he began work without a permit (m ix-up between
SQW and SQM). I have asked Mr. Wells to postpone the rest of the work until he receives a permit. Please expedite this
permit ... Mr. Wells has equipment o n site and would like to complete this job so he can move on to others. Please call or
e-mail with questions.
Thanks,
Jonathan
Jonathan Stepp -Jonathan.Stepp@ ncdenr.gov
North Carolina Dept. of Environment and Natural Resources
Asheville Regiona l Office
Division of Water Quality -Aquifer Protection Section
2090 U .S. 70 Highway
Swannanoa, NC 28778
Tel: [phone]
Fax: [phone]
Notice: E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and
therefor e may be disclosed to third parties.
From: Davidson, Landon
Sent: Friday, October 14, 2011 8:36 AM
To: Stepp, Jonathan
Subject: FW: WI0100175 Rusch SQM
For review.thx
:G. L,'-nd~n ciavid i.on, P,C.
M:t,£11.P tli~i,iu11 uh•,:1,.:-rC'ur fi tv
:quikr r r:it:.~uJn ~~~tiun f: ;{{00.·1 '\fl! ~up~•,.,'i,o,
\.h ,.ii 1-: P :::i4tr.1 otti.,_,
2:::1:.•'.) 11.1.!. H.., • ,o
·.£;,f:~n:,n~: t,.C. 2ll"n
ph,: 62.5 Ulii '50:l
web page: http://portat:ncdenr.org/web/wg/aps
Email con·espondence to andfl'Om this addre.vs is subjecr to
the Norrh Caro/111a Pt.tblic Records Law and may be dlrclosed
to third parties 1111/ess the r.ontell/ is exempt by stawte or
other regulalio11 ,
From: Rogers, Michael
Sent: Thursday, October 13, 2011 4 :48 PM
1
To: Davidson, Landon
S ubj e ct: WI0100175 Rusch SQM
Please find attached a residential SQM geother mal permit ap plication for your review. Please let us know if you wish to
conduct a pre-permitting inspection or not.
T hanks
Michael Rogers, P .G . (NC & FL)
Environmental SpeciaHst
NC Div of Water Qualify. Aquifer Protection Section (APS)
1636 Mall Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://portal.ncdenr.org/web/wq/aps/qwpro/permit-applications#qeothermApps
&mail correspondence to and from this address may be subject to /he North Carolina Public Records Law and may be d isclosed to third parties
2
Madison County, NC Parcel Number: 9786291121 Deed Book: 380
Record Number: 5122 Deed Page: 485
e Owner Name: WINDRUSH FARMS; LLC Notes 1: REF;174/66;269/511 ;DAVID RUSCH;NAME CHANGE OR(
PROPERTY MAP Owner Address: 110 CONCORDE PLACE Notes 2: PER DB 380/485 ~ Owner City, ST: MANDEVILLE, LA SCE-Land Value: 134200
Owner ZIP: 70471 Building Value: 102700
OisdcwMr; Owner Account: 5902 Total Value: 236900 Th& dala provided on thle map ere Pffipered for the lnw.~ af n,ol propet'ly found within
Mlldiaon County, NC aod ere compiled from 1'900fded plats, doech, and other pwic n,cords Owner Zip: 70471 Sale Date: 11202000
ond o,i.. This data ie f« infonnetionel pxpoeoe onty end shoud not be IUl>duted Deed Book: 380 Sale Price: 165000 One Inch = 170 Feet for• trua title ...-rdl, property eppnriNI, .......,y, or for mnlng wrWkatlon. Deed Pa e: 4
s~~~
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~lt-1~~
,Joo <~ ::i-o,.
;;i-6 ' 15" .G .,,L~
o)P~ .5J.'/)-' ~';\,c.
Susan Rector
Register of Deeds, Madison County, NC
Consolidated Real Estate Index
O'ltllria -Given Name1 donna Lut Name: nlSd1 GrantN/Grantar: Either From Date: 01/01/1.995 Party Type: Either
Date: 11/02/2000 Doc No: 225260 Kind: DEED llool<: 269 Page: 511 DMc: TP#'I 68,33 ACRES lERRYS FORK Tix: $330.00
c.r.nlDl'S Grantee&
M,AYENCE, ~ R RUSCH, DAVlD
MAYENCE, PAULA A RUSCH, DONNA
Date: 10/16/2001 ooc No: 229763 Kind: R/W Boole: 2n P;age: 757 o.c:
c.r.ntors
RUSCH, DAVID W
RUSCH, DONNA COX
Ollt'e: 09/22/2003 l>oc: No: 239980 Kine!: R/W 8ook: 303 Page: 78S O.Cr
Granton
RUSCH, DAVID W
RUSCH, DONNA C
GnmlNS
FRENCH BROAD ELECJlUC MEMBERSHIP CORP
Grantaes
FRENCH BROAD ELECTRIC MEMBERSHIP CORP
Data: 01/19/2006 Doc: No: 25-4026 kind: DEEO Book: 380 Pagel 485 O.C: 1l'#4 MAOISON CO AND MITCHEU CD 2 TRAC!S
Granton Grant.NI
RUSClt DAVlO WINDRUSH FARMS UC
RUSCH, DONNA
Diita: 09/02/2011 Doc No: 304407 Kind: PLAT Bookl 7 Page: 294 Due; HAMBURG ROAD 3.00 AC PORTION OF DB 380/485 Ta: $0.00
Gnmtors Grantmu
WINDRLJSH FARMS U.C WINDRUSH FARMS UC
RUSCH, DONNA COX RUSCH, DONNA COX
O.tll: 09/12/2011 Doc: No: 304473 Kind: OEEO 8oDlll 521 Paga: 560 Duel BEECH GLEN HAMBURG RD 3:00 W:. PORTION OF BK 380/485 Tax: $0.00
GrantDn Grantees
WlNDRUSH FARMS UC RUSOi, DONNA COX
Date: 09/26/2011 00c No: 304678 Kind: 0/T llookJ 522 Page: ◄09 Dae: Tax: $0.00
GrantDn
RUSO!, DONNA COX
RUSO!, DAVID WIUlAM
Gran1-
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bttp://216.27.81.171/Madisonncnw/realestatesearch.asp .
Page 1 of 1
10/13/2011·
Madison County, NC
PROPERTY MAP
OiK:1aimer:
Tho doa. ~ on th:0 mep t10 FN9p111nKI b-the lnwnby of "'•I prgperty found within
Mtdleon County, NC •nd we compllod ~ NCOrded p• dtedt, end other pubic reoocds
and deta. Tl\ls data b: for lnfoonatlonel ~ only and lhoutf not be M.U:uted
fof • lrm We aearch, pn,,porty apprelaal, aurvey, or fof" llOning Yefffication. One Inch = 1076 Feet
PA
NCO
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beve rly Eaves Perdue
Go \lemor
Donna Cox Rusch
110 Concorde Place
Mandeville, LA 70471
Dear Ms. Rusch:
Coleen H. Sullins
Directo r
October 11 , 2011
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. WI0100175
Donna Cox Rusch SFR
Injection Mixed Fluid GSHP
Well (SQM) System
Madison County
The Aquifer Protect ion Section acknowledges receipt of your permit application and supporting
documentation received on October 5, 2011. Your application package has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Asheville Regional Office staff will perform a detailed review of the provided
application, and may cont act you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information request s.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail].
Sincerely,
0\l½· IA.~
for DebraJ. Wa~
Groundwater Protection Unit Supervisor
cc: Asheville Regional Office, Aquifer Protection Section
Larry Wells-AWD Services, Inc.
Brad Stickels -Stickels Service Co., Inc.
J>ennit File WIOl 00175
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard , Raleigh . North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588 : FAX. 2: 919-715-6048 \ Customer Service : 1-877-623-6748
Internet www.ncwatergua lity.org
An EQual 01>.oonunny \ Affimla11ve Aclioo Erooloye r
Ni¥th Carolin a
Jvatura!l!I
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S} FOR
INJECTION· WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE SOM WELL(S)
_...,/ __ New Permit Application OR ____ Renewal (check one)
DATE: ';;,r..~~'-o~-C ~r"\ • 20~
PERMIT No. '1il'.Q \ 00 \1S (leave blank if NEW pennit'applieation)
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): ________________ _
(1)
\ft,v-. "'o... ~ V-~"' ~c_~
Mailing Address: \ \~ ~"' ~~~ \ \..
~ .... ,;~
City: ~~~CLv, \ \ ~ State: \_,-.. Zip Code: "'\. 0 '-'. '\ \ Geunty.:
Hoine/OfficeTeleNo.: °\,\S · ~L\S \~'a~ CellNo.: 11\.'b'S· -~~
EMAIL Address: ~~~\A.s.&Q' \otl.\ s.~-...."(\..,. "'u
(2) Physical Address of Site (if different than above): ~.':> \ l\ \"'\. ~ '-o v..~c~ \l..~
City: M~ \~\\ State: N~ZipCode: _____ County: ~~\~~""
Home/Office Tele No.: Cell No.: '\.~S -\c,~~ C'\\.o~
EMAIL Address: ~c_"'-'""-'!:.~0 W\ S.o\.o.~ "'-~'-
B. AUTHORIZED AGENT ()F' OWNER, IF ANY (if the-Pennit Applicant does not own .the subject property.
attach a letter from the property owner authorizing Agent to instaJI and operate UIC well)
CompanyName~----------------------------
Contact Person.__: ____________ --=E=M..::..A=J=L..:..;A=d=dr=es=s"--: _________ _
Address: _____________________________ _
City: ________ State: __ Zip Code: _____ County: ______ _
Office Tele No.: Cell No.:
Website Address of Company. if any: _____________ _
C. STATUS OF APPLICANT
Private: ~x_
State:
Federal:
Municipal: __
GPU/UlC SQM Well Permit Application (Revised 7/2008)
Comm~rcial:
Nati-ve A.mericanLands:
Page 1
D. WELL DRILLER INFORMATION
Company Name: A WD Services, Inc.
F.
G.
Well Drilling Contractor's Name: =Larry------~W-e-lls~---
NC Contractor Certification No.: 2603
Contact Person=-: =Lar='-ry._____,_,W~e=lls=---=Em=ai~I =A=ddr=es=s~:W~. e=tl=s~75~0~5~49~@_..tl3=e=Il=so~u=th=·=ne-t
Website: www.appwelldrilling.com
Address: PO Box 125
City: Leicest.er, NC Zip Code: 287 48 Cowuy: Buncombe
Office Tele No.: .828~683-9223 Cell No.: 828-215-9334
BEAT PUMP CONTRACTOR INFORMATION (if dfflerent than driller)
Company Name: Si, J.u.-\> ~<...L Lo i 1""''-
c::>
r:M
r--> c::> --
ContactPerson: \>t""'-~ S:\i c..~ EMAILAddress: S-\,c..k.. • e rhl'J$pfi'D .COM
Address: 3 '2.. Pi ,u.. 'r\.: \\ ~ ·-.
City: Ye;,,.\ f ~ ~ Zip Code: ~ 1~o County: --=f>c..:~::.._=-="--'' ....,,_._.b..,c..__ _____ _
Office Tete No.: 22.i t-l.j 'lf.S'l.. Cell No.: <l~i' 11 C. 'i 211. 1
INJECTIO~ PROCEDURE (briefly describe how the injection well(s) will be used)
f :\olc... Ce,..otbt~\ (.)~l\) C \6~d loof
WELL CONSTRUCTION DATA (Skip to Section H if this is a Permit RENEWAL)
(1) Proposed date to be constructed: _ when permitted Number of borings: Fi UL
Approximate depth of each boring (feet):_=3~00~-----
(2) Chemical additives to be used in closed-loop system (only those chemicals indicated have been approved):
___ R·22 )( propylene glycol __ ethanol ________ other ( other additives will
need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc): __ -=tt..~P"--"l)=-. -'M ___________ _
(4) Well casing. Is the well(s) cased? (check either (a.) YES Qt (b.) NO below)
(a) YES ___ if yes, then provide casing infolJllation such as~ (steel, PVC, plastic, etc.), diameter,
rum!;b. and e]'tent of casing appearing above ground: --------------~-,--,,,,c..~~-
(b) NO ~ l 1iJt r
(5) Grout (materi:i surrounding well casing and/or piping): ;)-D r:-_ O
/(~~ (a) Grout type: Cement__ Bentonite -1{_ Other (specify) ~ --,>"-,,.._ ____ _
(b) Grout depth of tubing (reference lo land surface): from O to~ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
H. INJECTION-RELATED EQUJPMENT
OPU/UIC 5QM Woll Pamit Application (Revised 7/200S) Page2
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.
L LOCATION OF WELL(S)
Attach two copies of maps showing the following infonnation:
(1) lnclude a site map (can be drawn) showing: buildings, property Jines, surface water bodies, potential so~
of groundwater contamination· and the orientation of and distances between the propose<t weU(s) and atir
existing well(s) or waste disposal facilities such as septic tanks or drain fields 1.ocated within 1000 ket Q.fthe ,
geothermal heat pump well system. Label all features clearly and include a north arrow. .,... ~
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
J. POTABLE WATER WELL(S)
Are there any potable water well(s) on the subject property or adjacent properties? __ YES _x_ NO
lfYes, than indicate location on attached map(s).
K. CERTIFICATION
-1 ~l!J
~ ~~
I'.:) -:::>$
~ z-=-~51
~a
Note: Tbis Permit ApplicatioJI most be signJld by each penon appearing on the recorded legal property deed.
"I hereby certify. under penalty of law, that I have personally examined and am familiar with the infomiation
submitted in this documen t and all attachments thereto and that, based on my inquiry of those individuals
immediately responsib1e 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 fmes and imprisonment, for submitting
false information. l agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance wi the approved specifications and conditions of the Permit.,. ~----~ "-\\.-.. .. ~
Signature of Property Owner/ AppJicant
\Jc,\,,\/'\°'-c:..o~ ~ v. ~~
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature ef Authorized Agent, if any
Print or Type Full Name
Please retum two copies of the comf,}leted Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UICProgram
1636 Mail Service Center / .._ b
Riift. •~ h N c. l-7 l,,f 'J -'-7
GPU/UIC SQM Well Pennit Application (Re¥ised 712008) (ti l'f ) J "1 I~ .-~'f 3S-Page3
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