WI0300183_Regional Office Historical File Pre 2018

tit Number '10300183
Central Files: APS SHIP
09/14/11
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (50W)
Prirnary Reviewer
michael,rogers
Coastal SW Rule
Permitted Flow
Facility Name
Shawn A. McMillan SFR
Status Project Type
Active New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
IShawn A. McMillan
}eOwner
241 Edgewood Rd
harlotte
NC 28208
Major/Minor Region
Minor Mooresville
Location Address County
1241 Edgewood Rd Mecklenburg
Charlotte NC 28208
Owne r
Owner Name
Shawn A
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Shawn A. McMillan
Owner
1241 Edgewood Rd
Charlotte
NC 28208
Orrg Issue
09/14/11.
,Ap Received
09/14/11
ted Activities
Draft initiated
Scheduled
Issuance
Public Notice issue Effective
09/14/11 09/14/11
Expiration
Heat Pump injection
ence, single farniiy
Waterbody Narne
Stream Index Number Current Class Subbasin

NCDENR
North Carohne artment of Environmen and Natural Resources
Division of Water Quality
Bever Eaves Perdue Oojeen H. SuVwuns De. Freeman
Governor rector Seo etary
0t
Shaun A. Mcl" lllan
241 Edgewood Rd.
Charlotte, NC 2S208
4'2011
Subject: Acknaw°ledgemem of Intent. tt Construct Type 5QW Injection 'Well Sys
Permit No, W103001 S3
1241 Edgewood Rd,
Charlotte, NC 28208
Dear Mr. McMillan:
On 09/14"/2011, the Aquifer 'Prom ct€o:n Section (A..PS) received notification of your intent to construct a closed -loop water -only
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 peothemxal injection well s flstetn as long as the
following conditions are met.
1. The injection well system contains only potable water,
?. The injection well system is constructed in accordance with well construction standards specified i North
Carolina Administrative Code Title 15A. Section,2C Subchapter .0213, and
3, The required notification form and associated maps have been completely and accurately" su.brnitted.
Failure to contply with all of theseconditions cons trtutes a. skiolation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 1 5A Section 2C Subchapter .021. 'it `l, Additionally, you should conta.c-t the Mecklenburg County 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 (919) r 15-6166 or Michael Roaers,'ir;;l
Dbm atts
Sup
t°e anv questions"
cc: Moores' 'ille Reionai Office - APS
APS Central Files - Pernitt No, W103001 Sal
Mecklenburg County Health Dept.
Chad. Mullis (Mullis Well Inc.,Dril''ling.9200 Surface Hill Rd., Charlotte,?3C: 2822)
Mike Geddings (Panther Heating & Cooling. Inc., P.O. Box 3587. Rock Hill, SC 29732)
AQUIFER ;TE:T',w)VS_:''1:P

VvPL63
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed In
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Print or Type Information and Mail to the Address on the Last Page.
DATE: 6(a°T6pf ,?2 2- , 2t1L
PERMIT NO. (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non-Govenunent: Individual Residence 1 Business/Organization
Government: State Municipal County Federal
B. WELL OWNER — For individual residences, list each owner an property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
SMOW A. I lCPI/LL,4g
Mailing Address: 1 Z L S7G E GJpo.P 129
City: %1-1,4 a1.—oTT7 State: /VC Zip Code: 2? Za P County: BergL r4c�
Day TeleNo.: 70L1—q 0 23 l Cell No.:7011—`" 1 37 S
EMAIL Address: 51MciillillavlC jq140oCoim Fax No.: 70V — 376 i62g
C. LOCATION OF WELL SIM,— Where the injection wells are physically Iocated:
(1) Parcel Identification Number (PIN) of well site: 054 0 f 321 County: fre-Ckt6.rg1
(2) Physical Address (if different than mailing address): 54,416
City: State: NC Zip Code:
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: /newS W! .PgZ/L2./N6 f / NC. / S /1411 _ U
NC WeIl Drilling Contractor Certification No.: 20,?
Company Name: / aL1-!S Wu- D r[.L/M4, (^1C..
Contact Person: GI{,/s #W U L4-(5 EMAIL Address:
Address: qt 2.00 ,Sl. g /act 1-1 I L L 112 .
City: Cl•1Kco 7T4 Zip Code: 2$227 State: R!C County: MK-012A415,14gL
Office Tele No.: 7,>`1--SYS- S•4(f CellNo.: FaxNo
RECEIVED / DENR / DWQ
Aquifer Protection Section
SEP 14 2011

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: PA V.4Et2 146/4-1IPIX .- Coot./tit C, i Are.
Contact Person: MIKE (6'9/k) E EMAIL Address:
Address: Cip.5 W . {Ylk/N 54-• Po 31t g5-$ 7
City: Po c K FI/LC- Zip Code: 7.197. 2- State: 5C County: ?fo Kg
Office Tele No.: Sty- 327.- o o CeII No.: Fax No.: $U 3 - Z'_ 0266'
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: z. Depth of each boring (feet): Zoo
* If existing water supply wells will be used then provide the information in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc): P LYt<TFW Y e ii 5�2- -1 1 ff 51/LQT
(3) Well casing. If the welt(s) will use casing then provide the type (steel, PVC, etc.), diameter, depth,
and extant of casing appearing above ground:
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite** i Other (specify)
" By selecting bentonite grout, avariatce is hereby requested to 15A NCAC ZC .02I3(d)(I)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from O to 2.c'o (feet)
If well has casing, indicate grout depth: from to (feet)
G. WELL LOCATIONS — Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within I00D feet of the injection well(s). Label all features clearly 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: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS webtsite. Typically, the properly can be searched by
owner nine or address. The location of the wells In relation to property boundaries, houses, septic tanks, other
wells, etc. can then he drawn in by hand Also, a `layer' can be selected showing topographic contours or
elevation data.

H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shalt 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 an the property deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"l hereby certify, under penalty of law, that I 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, I 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."
Si of Property Ownerr/A pticant
Sliet ,4-, Mc. M //amm
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED I DENR ! DWQ
Aquifer Protection Section
SEP 14 2011

BASIS OF BEARINGS
----OHU
DB 24787 PG 16
C. WAYNE KEY
DB 3327 PG 263
PARCEL ID 059-013-04
LOT 5 BLOCK 1
MB4PG151
PP-21960-7y or
1 z4'-! J) )Co.D
� � ,Wc 2Yza
J
0
OD
EASEMENTS RECORDED IN
DB 24747 PG 983
TIE UNE
N 04'50'59" E
•
NPS
DB PG
0 0 a
• OHU
OD
r
10.05'
0.2
an
S 0455'24' W 50.00'
MB 4 PG 151
AREA
0.183± ACRES
LOT 6 BLOCK 1
MB 4 PG 151
PROPERTY OF
M.E. DODGE
6 .1 w5 0
7.
TEMPOR !
ARY CONSTRUCTT
ON
EASEMENT
OS17 or w 50 00'
•
=EWAW AN u0 -A-ND ..�,
EASEMENT m
LI 1 25.52'
N 04446'52' E.50.00' TOTAL'
LEGEND
PROPERTY IJNE
11E LINE
ADJOINING PROPERTY UNE
TEMPORARY CONSTRUCTION EASEMENT
EXISTING 3/4" IRON PIPE
NPS
NO POINT SET
DEED BOOK do PAGE
SIDEWALK & UTILITY EASEMENT
FENCE
UTILITY POLE
OVERHEAD UTILITY LINES
PARCEL ID 059-13-08
LOT 11 P/P LOT 12 BLOCK 1
MB 4 PG 151
S 04'55'24` W 49.98'
AREA
0.183± ACRES
LOT 7 BLOCK 1
MB 4 PG 151
PROPERTY OF
M.E DODGE
J
HUD
DB 26136 PG 839
PARCEL ID 059-013-05
LOT 7 BLOCK 1
MB 4 PG 151
23'01"W 50.02' _
TEMPORARY CONST
EMPORARCONST UCTION
EASEMET
_ S O511'36W 50ti —
SIDEWALK AND UTILITY
EASEMENT
NUMBER
DIRECTION
DISTANCE
L1
S 0511'52" W
16.57'
TIMOTHY J. KEI
DB 25701 PG
PARCEL ID 059—
LOT B BLOC
MB 4 PG 1
GRAVEL DRIVE
ENCROACHMENT
TIE UNE
S 0514'40" w
49.69'
NTS RECORDED 1N
740 PG 16
NUMBER CHORD DIRECTI
C1 N 05'17'48' E
C2 N 05'53'23" E
ON
RADIUS ARC LENGTH
1679.51
483.85
6.43
1.48
CHORD LENGTH
6.43
1.48
AccuTech Surveying & Mapping, LLP 1 BOUNDARY/LOCATION/CONVEYANCE
546 Newell a
Street >, W ppnpFRTY [whir p• HUD
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