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Home My WebLink AboutWI0400227_GEO THERMAL_20120523Beverly Eaves Perdue Governor A~A~ ~j;,-~~ NC-D EHR-_ North Carolina Department of Environment and Natural Resources -- Division of Water Quality Charles Wakild; P. E. Director -- May 23, 2012 James Carneron- 3293 NC Highway 87 N Sanford, NC 27332 Subject: Notification of Rule Revisions Affecting Closed-Loop Geothermal Injection Well Permit Holders Permit Number: WI0400227 Dear Mr. Cameron: 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 ://p ortal.ncdenr.or g/web/wq/ap s. If ymi nave any questions regartling ·your current permit-or the-rule revisions,.please .feel·free-to contact our underground injection control staff at (919) 807-6464. Sincerely, Eric G. Smith, P.O. Hydro geologist cc: UIC Permit File AQUIFER PROTECTION SECTION 1636 Mail Service Center, Raleigh, North Carolina 27699-1636 Location: 512 N. Salisbury St., Raleigh, North Carolina 27604 Phone: 919-807-6464 \ FAX: 919-807-6496 Internet: www.ncwaterguality.org An Equal Opportunity\ Affirmative Action Employer Ni~hCarolina Naturally Permit Number WI0400227 Program Category Ground Water Permit Type Injection Mixed Fluid GSHP Well System {5QM) Primary Reviewer michael. rogers Coastal SW Rule Permitted Flow Facilit Facility Name James McKay Cameron SFR Location Address 1513 Flat Top Rd Blowing Rock Owner Owner Name James Dates/Events NC 28605 McKay Cameron Scheduled Orig Issue 1.2/09/11 App Received Draft Initiated Issuance 11/21/11 Central Files: APS_ SWP_ 12/13/11 Permit Tracking Slip Status Active Version 1.00 Project Type New Project Permit Classification Individual Permit Contact Affiliation Major/Minor Minor Region Winston-Salem County Watauga Facility Contact Affiliation Owner Type Individual Owner Affiliation James McKay Cameron Contractor Heat Pump 3293 NC 87 N 'Sanford NC 27332 Public Notice Issue 12/09/11 Effective 12/09/11 Expiration 11/30/16 Regulated Activities Re ouested/Received Events ---------------------- Heat Pump Injection RO staff report requested RO staff report received Outfall N;..JLL Waterbody Name Stream Index Number Current Class 11/22/11 11/28/11 Subbasin Permit Number WI0400227 Program Category· Ground Water · Permit Type \ \ Injection Mixed Fluid GSHP Well System (501\'1) Primary Reviewer michael .rogers Coastal SW Rule Permitted Flow Facility Facility· Name James McKay Cameron SFR Location Address 1513 Flat Top Rd Blowing Rock Owner Owner Name James Dates/Events NC 28605 McKay Cameron Scheduled Orig Issue App Received Draft Initiated Issuance 11/21/11 Re g ulated Activities Heat Pump Injection Outfall f\~ULL. Central Files: APS_ SWP_ 12/06/11 Permit Tracking Slip Status In review Project Type New Project ·Version Permit Classification Individual Permit Contact Affiliation Major/Minor Minor Region Winston-Salem County Watauga Facility Contact Affiliation Owner Type Individual Owner Affiliation .James McKay Cameron . Contractor Heat Pump ·3293 NC 87 N Sanford NC Public Notice Issue Effective Re guested/Received Events RO staff report requested RO staff report received 27332 Expiration 11/22/11 11/28/11 Waterbody Name Stream Index Number Current Class Subbasin AWA •. ;~~ NCDENR North Carolina Department of Environment and Natural Resources Beverly Eaves Perdue Governor James McKay Cameron 3293, North Carolina Hwy. 87 N. Sanford, NC 27332 Division of Wate·r Quality Coleen H. Sullins Director December 9, 2011 Ref: Issuance of Injection Well Permits WI0400227 Issued to James McKay Cameron Blowing Rock, Watauga County, North Carolina Dear Cameron: Dee Freeman Secretary In accordance with the application received on November 21, 2011, I am forwarding permit number WI0400227 for the construction and ·operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well system to be located at 1513 Flat Top Rd., Blowing Rock, Watauga County, NC 28605. This permit shall be effective from the date of issuance until November 30, 2016, and shall be subject .to the conditions and limitations stated therein, including the require~ent to install well identification tags as specified. in Part II.4 .and to submit copies of well construction records as specified in Part VIl.2. Be sure to read the entire permit to ensure that you are aware of all compliance requirements of the permit. NOTE: If temporary surlace casing is· left in the borehole during the drilling/installation process for longer than 5 days, it shall be grouted in accordance with 15A 2C .0213( d). 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 permit 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 (919) 715-6166 or michael.ro e:ers<a2ncdenr.gov if you have any questions about your permit. cc: Sherri Knight, Winston-Salem Regional Office WI0400227 Permit File Appalachian District Health Dept. Bes.tRegards, ~ .~ ~ Michael Rogers, P.G. (NC & FL) Dewey Wright, Dewey Wright Well and Pump Co., 1856 NC Hwy. 105 Bypass, Boone, NC 28607 AQUIFER PROTECTION SECTION 1636 Mail Service Center, Raleigh, North Caroiina 27699-1636 Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604 Phone: 919-733-3221 \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748 Internet: www.ncwaterquality.org An Equa! Opportunity \ Affirmative .~ctio_n Employer .NOnetl C 1· or 1 aro in.a ~Vatural!lf 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 James McKay Cameron FOR THE CONSTRUCTION AND OPERATION OF 3 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 1513 Flat Top Rd., Blowing Rock, ·watauga County, NC 28605, and will be.constructed and operated in accordance with the application received November 21, 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 ·lSA of the _North Carolina Administrative Code 2C .0100 arid .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 November 30, 2016, anq. shall be subject fo the specified conditions. and limitations ·set forth in Parts I through IX hereof. Permit issued this 'the 9th day of December, 2011. ~J -~ ~leen H. Sullins, Director -~-Division of Water Quality By Authority of the Environmental Management Commission. Permit #WI0400227 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 Injection Wells (1 SA 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 inje9tion well shall not hydraulically qonnect separate aquifers. 4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally 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 II -WELL CONSTRUCTION SPECIAL CONDITIONS 1. At least forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the Aquifer Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone number 919-715-6166 and the Winston-Salem Regional Office Aquifer Protection Section Staff, telephone number 336-771-5000. 2. If temporary surface casing is left in the borehole during the drilling/installation process for longer than 5 days, it shall be grouted in accordance with 15A 2C .0213(d). 3. The location of each · of the system manifolds shall be recorded by triangulation from three permanent features on the site ( e.g., building foundation comers) and shown on an updated Site Map. The Permittee shall retain a copy of this record on site. 4. 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, volume 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 approval by, the Director of the Division of Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a name change of the Permittee, a formal permit amendment request must be submitted to the Director, including any supporting materials as may be appropriate, at least 30 days prior to the date of the change. Permit #WI0400227 UIC/SQM ver. 03/2010 Page 2 of 5 3. The issuance .of this permit shall not relieve the Pennittee 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. PART IV-PERFORMANCE STANDARDS l. 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 ip.cluding 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 ~hall be required to comply with the terms 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 Permittee must notify the Division ~d 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 determine 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 injectfon 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. p·rovisions shall be made for collecting any necessary and appropriate samples associated with the injection facility activities. Permit #WI0400227 UIC/SQM ver. 03/2010 Page 3 of S PART VII -MONITORING AND REPORTING REQUIREMENTS 1. All required documentation shall be submitted to: Aquifer Protection Section -UIC Program DENR-Division of Water Quality 1636 Mail Service Center and Raleigh, NC 27699-1636 Ph# 919-715-3221 Aquifer Protection Section Winston-Salem regional Office 585 Waughtown Street Winston-Salem, NC 27107 336-771-5000 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 Winston-Salem Regional Office within 30 days of completion of well construction. Copies of the GW-1 form(s) shall also be given to the Pennittee and retained on site to be made available for inspection. 3. A copy of the site map updated with manifold locations required in Part 11.2 of this permit shall be submitted to the Aquifer Protection Section Central Office and the Winston-Salem 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 Winston-Salem Regional Office, telephone number 336-771-5000, any of the following: (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, such as mechanical or electrical failures; (C) Any loss of refrigerant in the system, regardless of the origin of the loss; (D) Any recharging ofthe refrigerant system. 6. Where the Permittee 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 Permittee. 7. In the event that the permitted facility fails to perform satisfactorily, the Pennittee shall take such immediate action as may be required by the Director. PART VIII -PERMIT RENEW AL In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Pennittee shall submit an application to renew the permit 120 days prior to its expiration date. Permit #WI0400227 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 injection 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 Permittee 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 .02-13(h)(l). Notification shall be submitted to the addresses given-in Part VII.I of this permit. 2. When operations have ceased at the facility and a well will no longer be used for any purpose, the Permittee shall abandon that injection well in accordance with the procedures specified in 15A 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 interfere with sealing operations~ (C) Each well shall be thoroughly .disinfected, 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. (E) 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 int~als not exceeding 10 feet, and grout injected through the perforations. (F) In those cases when, as a result of the injection operations, a sub_surface cavity has been cr~ated, 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 terms and conditions of the permit. (G) The Pennittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified in ISA NCAC 2C .0213(h)(l) within 30 days of completion of abandomnent. Copies shall be submitted to the. addresses given in Part VII.1 of this permit. Permit #WI0400227 UIC/SQM ver. '03/2010 Page 5 of 5 Rogers, Michael From: Mitchell, Patrick Sent: Monday, November 28, 2011 12:54 PM , f To: Watts, Debra Cc: Rogers, Michael; Knight, Sherri Subject; RE: W10400227, Review Request Attachments: W10400227 Application.pdf; W10400227 Review Request.pdf Debra, 1 have reviewed the parcel on the Watauga County GIS. I will not be making a site visit inspection. Please proceed with issuing Permit W10400227. Let me know if you need anything further Thanks, Patrick Patrick L. Mitchell, LSS NC DENR - DWQ Aquifer Protection Section Winston-Salem Regional Office 585 Waughtown Street Winston-Salem, NC 27107 Phone: (336) 771-5285 FAX: (336) 771-4631 E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties. From: Knight, Sherri Sent: Tuesday, November 22, 2011 2:54 PM To: Mitchell, Patrick Subject: FW: W10400227, Review Request Sherri Knight, PE NC DENR Winston-Salem Regional Office Division of Water Quality, Aquifer Protection Section 585 Waughtown Street Winston-Salem, NC 27107 Voice: (336) 771-S280 FAX: (336) 771-4632 E-mail correspondence to and from this address may be Subject to the Worth Carolina Public Records Law and may be disclosed to third parties. From: Watts, Debra Sent: Tuesday, November 22, 2011 1:28 PM To: Knight, Sherri Cc: Rogers, Michael Subject: WI0400227, Review Request Sherri Attached is a SQM for review. Also attached is our request for a staff report. If you feel you need to do an inspection, please send your staff report to Mike Rogers (I'm just filling in while staff is out). Otherwise, let me know you DO NOT plan to do an inspection, and we'll go ahead and process. Thanks! djw Debra J. Watts. Supervisor Groundwater Protection Unit Aquifer Protection Section 919-715-6699 DISCLAIMER: Per Executive Order No. 150.all e-mails sent to and from this account are subject to the North Carolina Public Records Law and may be disclosed to third parties. 2 A QUIFER PROTECTION SECTION APPLICATION REVIEW RE QUEST FORM Date: November 22 , 2011 To: □ Landon Davidson, ARO-APS □ Art Barnhardt, FRO-APS □ Andrew Pitner, MRO-APS □ Jay Zimmerman, RRO-APS □ David May, WaRO-APS □ Charlie Stehman, WiRO-APS [8] Sherri Knight, WSRO-APS From: Debra Watts , Groundwater Protection Unit Telephone: 919-715-6699 Fax: (919 ) 715-0588 E-Mail: debra.watts(@ ncdenr.gov A. Permit Number: WI0400227 B. Owner: James McKay Cameron SFR C. Facility /O peration: [8] Proposed D Existing D Facility D Operation D. A pp lication: 1. Permit Type: D Animal D Surface Irrigation D Reuse D H-R Infiltration D Recycle D I/E Lagoon D GW Remediation (ND) 1ZJ UIC -(SQM) closed loop mixed fluid geothermal __ For Residuals: D Land App. D D&M D Surface Disposal D 503 D 503 Exempt D Animal 2. Project Type: [8] New D Major Mod. D Minor.Mod. D Renewal D Renewal w/ Mod. E. Comments/Other Information: D I would like to accompany you on a site visit. Attached, you will find all information submitted in support of the above-referenced application for your review, comment, and/or action. Within 30 calendar days, please take the following actions: [8] Return a Completed Form APSSRR. D Attach Well Construction Data Sheet. D Attach Attachment B for Certification by the LAPCU. D Issue an Attachment B Certification from the RO*. * Remember that you will be responsible for coordinating site visits, reviews, as well as additional information requests with other RO-APS representatives in order to prepare a complete Attachment B for certification. Refer to the RPP SOP for additional detail. When you receive this request form, please write your name and dates in the spaces below, make a copy of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person listed above. RO-APS Reviewer: __________________ _ Date: _____ _ FORM: APSARR 02/06 Page 1 of 1 A~A CDE R North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Governor Coleen H. Sullins Director Dee Freeman Secretary November 21, 2011 James M. Cameron 3293 NC 87 North Sanford, NC 27332 Dear Mr. Cameron: Subject: Acknowledgement of Application No. WI0400227 Jaines McKay Cameron SFR Injection.Mixed Fluid G~HP Well (SQM) System Watauga County The Aquifer Protection Section acknowledges receipt of your permit application and supporting documentation received on 11/21/2011. Your application package has been assigned the number listed above, and the primary reviewer is Michael Rogers. Central and Winston-Salem Regional Office staff will perform a detailed review of the provided application, and may contact 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 requests. Please note ~at 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 (919) 715-6166 or michael.rogers@ncdenr.gov. ~O (l Acerely, 1 _ .// e--,.. .;;pllnd• .. ,, J;J5nGJlt~> for Debra J. ~ atts Groun ter Protection Unit Supervisor cc: Winston-Salem Regional Office, Aquifer Protection Section Dewey Wright-Dewey Wright Well & Pump Co.1856 NC Hwy 105 Bypass, Boone, NC 28607 Permit File WI0400227 AQUIFER PROTECTION SECTION 1636 Mail Service Center, Raleigh, North Carolina 27699-1636 Location: 2728 Capita! Boulevard, Raieigh, North Carolina 27604- Phorie: 919-733-3221 \ FAX 1: 919-715-0588: FAX 2: 919-715-6048 \ Cusmme, Servic6 : 1-877-623-6748 Internet: www.ncwateroualitv.o ro An Equal Opportunity \ Afficmative Action Employer · r-~One. C 1. 1\J orth : .. aro. .1.na ~Jvatu.ratfu LTl1n q-" ri A nl1T TAT A rlTIM A n'M A'C"Lrr !1V =kT[ rrn fNkTTL SIOWT'r ALTr► WT A'M Tn AT nT Ci-NI I r•r.c APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS In Accordance With the Provisions of 15A NCAC 02C .0200 CLOSED -LOOP MIXED -FLUID GEOTHERMAL INJECTION WELLS These wells circulate fluids other than potable water as part of a geothermal heating and cooling system (check one) , New Application Renewal* Modification Print or 4pe Information and Mail to the address on the .Lust Page. Illegible Applications Will Be Returned As Incomplete, DATE: A %z!/ Y , 2da PERNHY NO. (leave blank if New Application) A. STATUS OF APPLICANT (choose one) Nan -Government: Individual Residence Business/Organization Government: State Municipal County Federal B. PERMIT APPLICANT — For individual residences, list each owner on property deed. For all others, state name of entity d name of person delegated authority sign on bel!alf of the business or agency. Mailing Address: City: 0- k State: Zip Code: County._ Day Tele No.: Cell No.: EMAIL Address: �J � %�i s 1 Fax No.: C. LOCATION OF WELL SITE — Where the injection wells are physically located: (1) Parcel Identification Number (PIN) of well site: Z?f f2$14�4?OO6 County: `4�`�4 (2) Physical Address (if different than mailing address): r . � ezr'�';C C1 � City: '45�-- State: NC Zip Coder 1 GPU/UIC 5QM Permit Application (Revised 1/24/2011) Page 1 D. WELL DRILLER INFORMATION , a Well Drilling* Contractors Name: ►' zo �- G E. NC Well Drilling Contractor Certification No.: Company Name: r` 1 4.0-- G Contact Person �-�� - �� ' EMAIL Address: Address: �J / `' •• /[' �7 �I`f S� City. 2 Zip Code:ZL State:&CCounty c� � 2 4c5' Office Tele No.: — Cell No.: Fax No.: HEAT PUMP CONTRACTOR INFORMATION (if different than driller) Company Name: 0 Contact 1we ,-, 1' Address: 3 V- 9 3 AJ C F7 /V-, /Z, City. A-+n F Zip Code: Z 7S Y State: Ak'-County: L� Office TeleNo.: �/o k,6 m Cell No.: Fax No.. F. WELL CONSTRUCTION DATA (1) Number of borings to be constructed*: _ J Depth of each boring {feet}: _6 * If existing water supply wells will be used then provide the information in item (4) below. (2) Chemical additives to be used: R-2-2 Propylene glycol Ethanol Other (other additives will need prior approval by NCDENR before use) (3) Type of tubing to be used {copper, PVC, etc}: _ !. _-- { -- - �t GPUIUIC 5QM Permit Application (Revised 1/24/2011) Page 2 (4) Well casing. If the well(s) will use casing then provide the type (steel, PVC, plastic, etc.), diameter, dam, and extent of casing appearing above ground: (5) Grout (material surrounding well casing and/or piping): (a) Grout type: Cement / Sentotaite** Other (specify) ** By selecting bu-ntonite gout, a variance is hereby requested to 15A NCAC 2C Mi 3(d)(l)(A), which requires a cement type grout (b) Grout depth of tubing (reference to land surface): from _ to (feet) If well has casing, indicate grout depth: from C; to �a (feet) G. WELL LOCATIONS — Maps must be scaled or otherwise accurately indicate distances and orientations of features located within 1000 feet of the injection well(s). Label aU features clear]v and include a north arrow. (1) Attach a site -specific map showing the locations of the following: * Proposed injection wells * Buildings * Property boundaries * Surface water bodies * Water supply wells * Septic tanks and associated spray irrigation sites, drain fields, or repair areas * Existing or potential sources of groundwater contamination (2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the facility's location and the map name. NOTE. Inmost cases, an aerial photograph of the property parcel showing property lines and structures can be obtained aced downloaded from the applicable county GIS website. Typically, the property can be searched by owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other wells, etc. can then be drawn in bu hand. Also, a `layer' can be selected showing topographic contours or elevation data GPU/UIC 5QM Permit Application (Revised 1/24/2011) Page 3 H. CERTIFICATION (to be signed as respired below or by that person's authorized agent) 15A NCAC 02C .0211(b) requires that all permit applications small be signed as follows: 1. for a corporation: by a responsible corporate officer; 2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively; 3. for a municipality or a state, federal, or other public agency: by either a principal executive officer or ranking publicly elected official; 4, for all others: by the well owner (which means all persons listed on the Mpggy deed). If an authorized agent is signing on behalf of the applicant, them supply a letter signed by the applicant that names and authorizes their agent to sign this application on their behalf. "I hereby certify, under penalty of law, that 1 have personally examined and am familiar with the information submitted in this document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible for obtaining said information, 1 believe that the information is true, accurate and complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting false information. I 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." _-J j ter• �- J Sid ature of Property Owner/Applicant C-411,fes' I�'' Print or Type Full Name Signature of Property 0 nerlApplieaut Print or Type Full Name Signature of Authorized Agent, if any Print or Type Full Name Submit two copies of the completed application package to: DWQ - Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 733-3221 GPUMC 5QM Permit Application (Revised 1/24/2011) Page 4 'atauga County, NC Page 1 of 2 Summary Prone owner sales Residential Commercial o13r Land Sketch Full Legal Agriru{tural Map Parcel Freya Values Comments Property Records Owner Address PARID-2818392676000 T-1 SHUFORD FOMISTEN Map C' ..-Aer' . Parcel Selection - Map Layers * Parcel Map + Schools * Communities * Pa rks Sanitation + Highways + Blue Ridge Parkway + Roads * County Grid + Contours 5ft - Contours 2Oft Zoned Areas * Fi re t Vote + Township il Census Blocks 2011 + Protected Ridges + Protected WatershE * - Flood Hazard * Farmland Preserval i + PIN# -- Aerial nrthophotog *Red: Band_1 WGreen: Band_2 w'Blue: Band 3 _ * Parcel ID County Border r RKEIVED r or-NR � Dwa AQU1F9R'PR0Trrr10N RFC;ION NOV 2 12011 Parcel ID Advanced Map Search EDMISTEN, JOE -g�jr2 �W;;�'VJ,) 21'i�;- !i; ?-o-/,'i')'f j .. a� 3H.- '. 76 114 152 Fed _ is Data Copyright Watauga County, NC [Privacy Policy] Last Updated: 11 tp:llwww.wataugacounty.orgliaslarcgistnataslarcizisma-odatalet.ast)x?sIndex=2&idx =1&LMnareni*--- 11 /19/2011 atauga County, NC rage t o i CONTACTUS { HELP Watauga County Fosse - _d Propery Records Owner Address Parcel1D Advrinced [dap span': Map Contents ' Parcel Selection ; Map Layers ' I j ,<SParCei Map F "Schools - F LCommunities E; Parks X ElSanitation + :J Highways- + R'; Blue Ridge Parkway +1 Roads i `Y + County Grid i :}Contours Sft .: ` * _j Contours 26ft Ar'r�' f Zoned Areas:'; • J Fire Vote 4. > t''Townshlp Census Blocks 2010 a Protected Ridges F' ' Protected Watershed; �� Y a :.iFlood Hazard OFarmland Preservatic, PIN# . LAerial ❑rthophotogral Parcel IiJ I ' + R�-County Border F r - Boone Layers •.�'- 44LL4 1 i' •r' �. � •• 1 71 Data Copyright Watauga County, NC [Privacy Polity] Last Updated: 10/1312011 Site Design Copyright 1999-2009 Akanda Group LLC. Ail rights reserved. ip:llWww.wataugaeounty.orgliaslaregismaps/arcgismapadvanced..aspx 1 QII4120 Watauga County, NC Page I of 1 •.7 � 3apli Prppa rty Rewrda Pwner Address ParW 2P Aw. anpd MaP Scx rh pngsty; '�xy28 S5u8n R11 M.p Contents � i eCl:-3>=i•F]h�YL' 's3'1 r ?.sYp 7W3 Parcel Selection Map Layers Parcel Map �] . 7 5chools E -Communities wParks �•;� __ -.-Sanitation „li•r:; ,,� 7 Highways --Blue Ridge Parkway Roads County Grid Contours 5ft Contours 20ft Zoned Areas y Fire Vote Township '-'Census Blocks 2010 :Protected Ridges :Protected W atershedl —;Flood Hazard Farmland PreservaticF'''��'�r'''y PIN# :. Aerial Orthophotogra Parcel I❑ :IP>fr„r2 r•„1 ,_County Border • "Boone Layers i33J-'1:•73i�44L �w CPn11ACP11S i HELP vlatavpa C—tv Komi LAMEA0hi. 2AF1kS n xs13 FLAT Te1G an a;F�tfF•4.4vL -- �� avrrer warm pImpetty Remm Cam sumrnarr .. ze1a2a1acaiaao _ zoiz _ .1513 FLIT TOP RD - 0327 • EUtH15rEN f ROAD AAEA _ 28IH-28-MO.004 64700 CAMERON, 1AMCS M 3293 NC HIGHWAY 87 IN SANFORD, NC ., __ 27332 • _ •__ 03 e F22 - 190 A.ATTOP RD Burr TOP RD ise Data COPYHpht Watauga county, NC [Privacy PO6[y} Last updated: 11J19J2011 Site bealgn Copyright 1949-2009 AFanda Group LLC. AR rlghC reserved. http:llwww.wataugaeounty.orgliaslarcRismapslaregismaT)datalet.asDx?sIndex=2&idx= 1 &.-. 11 /19/201 > Watauga County, PVC Page 1 of 1 Iva AiNIA! vi�' s7� lid u r PrupLr" Records _ - -- Owner Address Parcel IFS AdVaneed Map Search Summery prdrle Owner Sales Residential Commurcm; 013Y Lena sketch Full Legal Agricullursi Parral irfr- .omment3 PARip:281S28166SU00 FLAT TOP RA ++ 7.. Fir �► i� Map Confents - Parcel Selection - Map Layers + Parcel Map + Schools :- Communities + Parks Sanitation - Highways + Blue Ridge Parkway + ` Roads + County Grid * Contours 5ft + Contours 20ft } Zoned Areas * Fire + Vote + Township + Census Blocks 2010 * Protected Ridges + Protected Watershed + Flood Hazard + Farmland Preservatic * E;PIN # + Aerial Orthophotogra + Parcel ID + County Border Boone Layers 0 CA] r Feet Data Copyright Watauga County, NC {Privacy Policy] Last Updated: 111 - Site Design Copyright 1999-2009 Akanda Group LLC. All rights reservr http:llwww.wataugaeounty.orgliaslaregismapslaregismapdatalet.aspx?slndex=2&idx=1 &... 11/19/2011 `atauga County, NC Page 1 of 2 Parcel Selection Map Layers + Parcel Map t Schools Communities Parks } Sanitation Highways Blue Ridge Parkway Roads * County Grid 4. Contours 5ft - Contours 20ft Zoned Areas Fi re Vote } __-Township - Census Blocks 201t T Protected Ridges T Protected WatershE * Flood Hazard Farmland Preserval PIN# Aerial Orthophotog -Red: Band-1 Green: Band_2 Blue: Band 3 Parcel ID T County Border ., J�y>wfy+yiy F+1 p ..,19•.3$- 75 114 152 Feet J 4• Data Copyright Watauga County, NC [Privacy Policy] Last Updated: 11 too-llwww_watauizacouuty_orgliaslarcRismayslarceisma-DdaWet.asvx?slnde�2&idx=1&LMnarent 11/19/2011