WI0100262_Injection Event Record_20130912

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HEATING & COOLING
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COMMERCIAL RESIDENTIAL >��«s
BBB GENERAL
Qualify. Comfort. R¢liahility. -----*
xrreo�lxcr rR►Gee
329 Dogwood Road 2018 Dellwged Road
IC Candler,NC 28715 Waynewille,NC 28786
Omee:[phone] Ofpce;[phone]
Fax: [phone] Fax: [phone]
www.mlkoshcalingandcoolln(�.com
TO: FROM:
COMPANY: wQky,4Na1,- DATE'
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NORTH CAROI.NA DEPARTNEF.NT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCTOR OPERATE INJECTION WELLS
These welb me'permined by ride and do not require an im Wa?js1 petmfr u'leen canstfuctad in aecofdanav Wirli
Me fd1e3 of T5A NCAC D2C.0T00', rfi dCe r1lrzs16@ Ef!lf�lo CO/f.Sll/JGIiIR,
GEOTH£R,MAlA0UE0USCLOS:EO•L00P WELLS
At dascrrsed in 15A NCAC 02C.0222 rllese wens'ejroV)atc potable water only or a mb uire of potable warer and
perfnrmanceenholxing additives as pan of a gemhennal healing and sealing syateni,
OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS
As described in lSA NCA�U2C.022S Ihssu wyllsciropinioa refng�Tam gasesP art nfa and
P,nu11"runl heatin g
coolih}r eystcnr.
Print CfOPM'of Typa I00r'm0110r1. d'legible Anbminals Will Re Returned A$Incomplele. ~
DATE, 20U., P E R M I T N O.�a„Q\O.A_j aZ. fro be compietod by DWQ)
A. TYPE. OF GEOTHERMAL CLOSED-LOOP WELL TO 8E CONSTRUCTED
(1) Aqueous(as per f 5A NCAC 02C,0222): X Number of wens:4
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(2) Direct Expansion(as per 15A NCAC 02C.0221) ... ..._........ Nil mber of woils:,-
a. STATUS OF WELL OWNER(chooseone)
(1) Single Family Residence_,X_Submil this form two(2)business days prior to tonstruction.
(2) TInsiness/Orgonrea lion__Submit this form M days prior 100011strbctlon.
(3) Croyemmene State__----- Munjripel CounlY __ Fadaral Submit this farm 30 days
prior 10 construction.
C, WELL OWNER—.Por single family residences list the property owner(s). For all ancct3, liar name of the
husincsa,organization,or gmraanment ageney MI person ddcgaled signature nwhority;
�. u �_)
IIi City: .]Q,�`�, .\tJ..CIG�� p Slarc�yi Zip Codc;+t r1,aibG Connly:, —T 1 S ��
L)ay'i'ala No.! ._` {�.._ Cl L} �1 .......... Call No.'z )1 -Sz
FMAIL Address, ;iY'y�S(i .r���[C f6, CSC.�CS�rlraallo.; .3U n
s cT
0. PHYSICAL LOCATION OF WELL SITE 070 9 OBE - 1A vies 000
(1) Part al ldenlification Number(P IN)of avlI sire;
county:.._,`I,CM.,C. `..L....-.
(2) Physical Address(ifdiflrreni than mailing address):
.-'Stare NC L'ip Cody,
1riVgNIC,'fLYoewl.Lwp G>!elhsnnnl NolfOcalian(Revises 40012011)v i 'ram i 7� I'n1.wl
1 SEP 18 20!1
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E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otlxerwisc accurately indicate di5tancea and orientation or features located
within 250 feet of tits injection welt(s). I„gI,g,((„f-canueg c earl n anIJude a north err0)_v,, Attach a
site specifne mnp showing the locations of the following:
. Proposed injection well!captions Septic systems and aswaiakd Spray Irrigation
I'I . Buildings sites,drain fields,orrepoirnmas
NNProperty boundaricx
• Sar*e water)YAIca . P.xisting ar potential srnuues of groundweler
• Water supply wells contamination
(2) Plans and specifications orthe surface anti subsurface conatruCliort details of the well%ricm,
Y F. TYPES AND CONCENTRATIONS OF ADDITIVES •- List any additim that VdIl be used And thoir
mmccntratitms, only ndditives that the hcpment of Health antl Human Services'Division or Puhlic Health
determines do out adversely street human health shall be trgod. A list of approved additives can be found
r online nl btipt(Por611 ncdenr.oalwrb/wA(?125/.G.YL>fbL All other additives require.approval prior to use.
Ethanol »20%
G. WELL DRILLER INFORMATION (ifkaown)
Well Drilling Contractor's Nome; Robert L_........a!rY Wells
NC Well Drilling Contractor CeniFcalion No.: 26d3
1 Company Nome.: �1WlJ SErV10ES __.__ ._,. Contact Perann; Lryarry Wells
City: Qt(�E Stir state: NC Zip Code2-$74a D aunty: unixi lTbe_.. .. ...
Day Telc No,:{. aLw3m 6.z-3— Cell Nn.;-48-2t 21u--93ya _ __..__ _...
FMA]i.Addless:l�" FJQ st24d1.<.Ci4'�FaxNn.:... ��$�-� d3 --
H. HE AT PUMP CONTRA CTO R IN F OR MAT ION
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Coaled Pcrson.,. Q � ��( _„ _ ___ FMnl.t, nddn�sn±Wald(o'Ztnikflsheatingafrdcooling.cam
Address:. 326 [)t7.0wood Rd.
Shy: Candler GG zip Code: 28715 -_ state:NC—counly:
Uf7iccTole No.: (WLB)Y.y. .:. 43 C,:OII No.: .......,.., F:rx Noi(828,.,) 665N6576
DWQ/1Il(,'rt•In.ey-t.•:p!}r,annmial NainpntMn(Rrvirra J/7M2nlx) - pnpr�

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Sep 131312,19p Jaok Goldnn 8307iag 02?0 PA
Seq. 11 2013 1 'Mij lyner Unslruul ;mi 4n. [1!5 Y. l✓�
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1. PROTECTION Psovldtsa brief desedygM,bnw(1)suer,,lopplywclla;(2)atdacv Water bndita;endo)
asptic aysteeps and aarodaled spray 1r igation sites,drain adds,or repair arcae Wisbin 730 Cvcl of die pmpostd
hlfeolinn Wa(1s Will be prnlcctat durhrg ommotion of lie Wo(Ist
$lit Fpnch
J. UAit.LANCE_panvanrtoISAlsC,lC42C.07.4ItbDFjincrorortheptylsyonorWaler()uelityrnny grant a
vnlieoaCfirornnppltpableracffCDWFWtionoropwplioosfondards Pm videdOrel:
(1)I'm Ofdro Wali(a)wig not mdaagerhumaaboob ond"Ifare of the Safi hdwoxs;and
P (2)dial Equor eahx,wapcmiion in accordomc�ilh Ore standards Ie eel lachnleolly feasible or g,e
propastd avnspnrtiow prvvtdea egnai or betltr proreerion v[the groslpdfvater,
Apy vedunca rcquasl andnld aerampany subasibol of tbig AcelOcatloa fo C><padttc eeal,mdan of the rggtscst.
The variance regueat foray can be accessed online alj;dt}I,yfQggpi,,aedeo,.vranurn,..r� � it,
EP.Flirndona
fI K. g!p NATU R CS�7ho fallowlgg 5ccthpn la ro bd wmplettd xs rbnVilRd beltsnr m by Ihm pegaen's nutherinxd
fII dgent 15A h�AC11ZC.tl211(e)rtgo,res slgsprureg as fotlerea;
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(a) for a cotpocariar.qy a rcgpnagibla vorpo"O off=i
(p) rng apnMcrrhlp arsab ptapdgmahlp: byagvmaol patlarr of the ptupdaor,4capectivefy,
(e) for a r"niaipobty w n Sea*fedwl,Or tlhpr public aRadeq, by emog a pfibe)pal e=mAvo
ug'irpr of rpnR'M&ImbGolyallxdcd Pliklpl;
1� foCnliothcrs: by lie wellwmew,
(e) for my a(hvr phpon autha4m3 to avl on bel elf of fbe applkaal; do0nowtation ehou ba
sublaiNed with Iho noliftcatien tWl Clearly ideatihes the pexron, gmntg Outgo aighabart
i� ®nlharAy,and ig signed and duttd bythe applicant,
"1 Aereby cero,fwdor pwmby oflom.fhw I hm a perawrm/r A�.�atwri ertddnr faMidklr 10h the lryfdrrrarllpn
apAt W 1W fare'dpral m arrd all al7af blr m S$&raft and 1bsf,Iw,ad va'my)rirprl/y OI llAMr 2gdW/d/H/5
hamedla'fif raApW"k for dblrldArg said lafdryrl011 t I bdk&'bar Ma hrbrrmphiM&&W. OeMAU and
uaap/afa. Inawj*(h rhareSRffgnl/ftPnrpa4axdfeLbscMdinglg# uffil0ffivol and:mprlsp4xnenl
lorsvbmdfAg rape ft a /agar ro rMslmr§ arroraie,r»arbrsttJL rapNr,and p appJiGapk ,tpendtln
IAPJnjarlian wsp amfgdf d�pwrrnagtas at aetwtlanco wlM lba f;SA NpACd�C pgO6 RW1ae
Signasura ofProprrtY nvmarfAppfiaant "-'""'""
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PrMaa Type ryt Name
B , tlnre,a-i1�A^UIh f G it any
yPrinl er iypp ull Name
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DWp/tn[y[IprM-Loop OraAemial NtaCseean plaNfetlJr3afJnln-)
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I-. StJ8M ITT A 1, INSTRUCTIONS—Submit one copygf the cnmplrmtl nntificmion package l u thevoch ll
following:
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(1) The Division of Water Quality Regional QYiec serving the urea in which the injection well facility
will be located:
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Ashevilla Regional Office Washington Regional Office
2090 U.S.Flighway 70 943 Washington Square Mall
Swannarl Ill 2877E Washington,NC 27889
Telephone:[phone] Telephone:(252)'946.6491
Fax:[phone] Fax [phone]
Fayetteville Regional Office Wilmington Regional Office
225 Omen Street,Suite 714 127 Cardinal Drive F,x'ienafon
Fayetteville,NC 28301-5043 Wilmington.NC 28405
Telephoncl(910)433.33t10 Telephone;[phone]
Pax:[phone] Fax,(910)350400A
Mooresville Regional Office Wins3on•5alerrl Regional Office
610 E,asl Center Avenue,Suite 301 985 Waughtown Street
Mooresville,NC 291 IS Winston-Salem,NC 27107-2241
Telephone:[phone] .Phol(336)771-SO00
Fax:[phone] Pax: 336 171.4631
Ilkl Raleigh Regional Office
1623 Mail Scrvica Center
1Gdcigh,NC 27699-1628
•ralcphonc:[phone])
Pox-(919)SIT•4718
(2) County Health department in which the injection well fatality will be Iocntcd. A list of county health
departments can be round online at h})lli:www.nralhr ikh,•g}1litv'll
OWpgnCXla rd-Loop 6m1hennni Tnlincatjpn tF{cl 030,12012) paw p

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Moore, Andrew W
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From: Ronald Hathcock <[e-mail]>
Sent: Thursday, September 19, 2013 4:24 PM
To: Moore, Andrew W
I] Subject: FW:Golden & Reif PIN numbers for NCDENR
Andrew,
Below is the correct PINS for the Golden & Reif lobs in Yancey Co. (Mountain Air S/D)
Please let me know if you need any additional info.Thanks for your help!
Thanks,
�orucLiL�fat3�cork
General Manager
Mike's Heating&Cooling
Office:(828)66.5-4343
Fax:(&8)665-6,576
Cell:(81,8)280-,5839
ronald(r)mikesheatinaandcoolina.com
Mike's
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Pleating & Cooling
Quality. Comfort. Reliability.
i
From: Sue Smith [ma!Ito:sue(altynerconstruction.com]
r Sent: Thursday, September 19, 2013 2:55 PM
i' To: Marc Tyner; ronald(aOmikesheatingandcooling.com
Subject: Golden & Reif PIN numbers for NCDENR
I OK. For NCDENR.
Golden PIN number: 0708 04 74 8433 000
Reif PIN number: 0709 00 82 6202 000
You can run them all together if you want to.
For me, it is easier to read with a space in.
4` Hope these are right this time . . .
Thanks O Sue
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