WI0300190_Regional Office Historical File Pre 2018

Central Riles; AP SWP
03/07/12
Permit Number
00190 Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Perm-itfed Flow
Facility
Status Project Type
Active New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Chad Mullis
Driller Well
9200 Surface Hill Rd
Charlotte
NC 28227
Facility Name Major/Minor Region
Cory Frank SFR Minor Mooresville
Location Address
151' 6 Lynway Dr
Charlotte NC 28203
Owner
Owner Name
Cory
Dates/Events
County
Mecklenburg
Facility Contact Affiliation
Owner Type
Individual
Frank Owner Affiliation
Cory Frank
1516 Lynway Dr
Charlotte NC 28203
Scheduled
©rig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
03/07/12 03/05/12 03/07/12 03/07/12
Regulated Activities
Heat Pump injection
Outfall NULL
Waterbody Name
Stream Index Number
Current Class
Subbasin

NCDENR
North Caroina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, PE. Dee Freeman
Governor Director Secretary
March 7, 2012
Cory Frank
1516 Lynway Drive
Charlotte, NC 28203
Subject; Acknowledge.me.nt of Intent to Construct Type 5QW Injection Well System
Permit No. W10300190
1516 Lynway Drive,, Charlotte, NC 28203
Dear Mr, Frank:
On March 5, 2012, the Aquifer Protection Section (APS) 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 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 in North
Carolina Administrative Code Title 1.5A. 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 .021 i(u)(2). Additionally, you should contact 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 [phone] or Michael.Rqgcrsgncdenrvy if you have any questions.
Jr Debra
Supervisor
cc: Mooresville Regional Office - APS
APS Central Files - Permit No, W10300190
Mecklenburg County Health Dept.
Chad Mullis -- Mullis Well Drilling, Inc.
Mike °Wings Panther Heating &
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.ncw iio
An Equal Opporleriffy Affirmative Action Employer
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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Previsions or 1 SA NCAC ow .0200
CLOSEX]_tOO1LWAT R OM V GEOTT%Pfla XNI CTLON WELLS `;
Tifesc was circulate potable water only as part ors geothermal heating and cooling system.
These wells arc "permitted by rule" and do not require on indivichnil permit when they are contuuctcd In
accordance. with the rules of 15A NCAC 02C .020n and this Notice is. submitted prior to conatructian,
DATE: (l c..,
4e
print or Type f iforrnarion and Man to rice Address cm ncm Last Pape.
, 201PERMIT NO.\ 030D 19 0 (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose onc)
Non -Government: Individual Residence ►/ business/Organization
Government:
State
Municipal County Federal
B. WELL OWNER — For individual residences, list owner on property deed. For all others, stow name of
entity iu, name of person delegated authority to sign on behalf of the businem or ugenoy:
MailingAddreses: 15 110 Lc. 11 L 44 r�
city: theft—it+i+ e,, . . S n0_ p �� 03 County;_ (Y e 1.rt1�:�v..r'J
Ci � fate; f Cede:
Day TeleNo,: - CelLNo,;
BMAI,L Address: fruc.No,:
C, LOCATION OF WELL SITE — Where the injection walls arc physically located:
(1) Parcel identification Number (PIN) of well site; t fj I 0 i = % 3 County: me 641.a.e%burr
(2) . Physical Address (if different thanmailing uddress): .j4tVI e, _
City: State: IX Gip Code:
D. WELL DRILLER INFORMATION
WcH Drilling Contractor's Name: (Y) u t ei 1 1 e
NC Well Drilling Contractor Certification 0 32).
Company Name: in 1.4 f I S L)00,4j T C. It
Contact Pcraon:, /nu i j i $
Address: `61Doe sV ra,c..q -PIi11
City: Ck. e r! '.[ p Code:,IP5L3.71 State:1County: 1Yi e a't` &
Office Tele No.: . -5 /-J Cell No,:
E. HAT PUMP CONTRACTOR INFORMATION (if different than driller)
r r
Company Name; Qf..r 4,,, +tQ
4PU/U1C SQW Notification (Revised 3/16I2011)
RECEIVED 03-02-' 12 17 : 33 FROM -
Pagel
TO- NC DENS P&S
P002/A05

r
03 02 2012 18: 55/ST, 18: 54
P003
Contact Person:, M K-47— 42if1reV3
Address: go 3 . Moin
City; frC L. I Zip Code: .41 • Coun
OfEcTe1eIJo,:
WELL CONSTRUCTION DATA
(1) Number of borings to bc constructed':
• if exi.sting water sup
(2) Type of tubing to be used (steel, PVC, etc):
(3) Well casing, if the well(s) will use casing then
and rjacz of casing appearing above ground:
glutATI Adds
Depth of each boring (feet):
.rctl thenproviae the informal!
J-Drz7
vide the ecl„ PVC, etc,), diameter,
...141111160..,
(4) Grout (materiel surrounding well casing 5nd/or piping);
(a) Grout type; Cement Bentonite" ,
•• Dy tioletAing bentonite grout, a variance hntaby requested to I5A NCAC 2C
(b) Grout depth of tubing (reference to land surface): from.
Ifwell has casing, indicate grout depth: from
(feet)
G. WELL LOCATIONS — Maps must bc scaled or otherwise turazIy ndiczt dtance.indicate and oriinitkrns of
realties located within 1000 feet of the Injection well(s).
(1) Attach a sitc-speciric map shown g the locations of the following:
• Proposed injection wells • Buildings Property bountioric
• Surface water bodies Water supply Wc415
• Septic tanks and associated spray irrigation sites, drain fields, or repair areas
• Existing or potential sources of groundwater contamination
t.
(2) Attach a topographic map of the area extending 1/4 mile from the injection well alto ttliit indicates the
facility's location and the map name,
NOTE: In Hunt eases, an aerial photograph of the property pared Yllowing property lines and structures can
be obtained and downloaekti front the applicable county GIS WebSite. Typically, the property can be a'etarcheri
by owner name or address. The locarion of the wells in relation to property boundaries, houses, septic tanks,
other isicits, etc. can then be drawn in by hand. Also, a 'layer' can be selected ,showing topographic contours nr
elevation data,
GRUNIC 5 QW NOMICatiOn (Revited 3/11/201 t) Prtgo 2
RECEIVED 03-02-12 17:33 FROM—
TO— NC MR PR,S

rliUM , • 03 02 2012 18:56/5T, 18:54 NUU4
11 CERTIFICATION (to be signed as required below or by that person's authorized agent)
ISA NCAC 02C .0211(b) requires that all permit applications shall 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 Cwhieh means all persons fisted ()who ptopsry 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,
"I.hereby certify, under penalty or law, that I have personally cxttrnincd 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 signileant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair. and it applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and condition of
the Permit."
Signature of op rty Owner/Applicant
Pr__r t1i
nIr 1' a
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any '
Print or Typo Full Namc
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mali Service Center
Raleigh, NC 27699.1.636
Telephone (919)'1'r
col, v30 l
OPUNLC SQW t4ot111cntlon (RoulActI 1/102011) Aaae 1
RECEIVED 03-@2-' 12 17:33 TO- NC DENIM P&S PAG14/1Ata;

FROM
03 02 2012
P005
1 Stephen B. Mu;IPn% Certify that an the ,1.,. Pay of 5FP
Ihle map wog drown under my auperWDIQn from on actual au
my super l I ; that this survey woe performed to qo.m A VA
stonooram, that tIQ rail* or preclsron Is 10041O0, and there aro
ancroachrhonts either way °CroDQ p llne4 e>to•pt p apc. rt
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N,.CkP.L,S. L-3059
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ENCROAC1 uNG
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LOT 23
CURVE RADIUS LENGTH TANGENT CHORD BEARING DELTA
C'1 1467.09 5.79 2.90 5.79 S2810'42"E 0'13°39"
PHYSICAL SURVEY
LOT 22, BLOCK 2, CUMBERLAND PARK
CITY OF CHARLOTTE
MECKLCNBURG CO,, NORTH CAROLINA PREPA
STfEET ADDR( 5:1516 EYNWAY DRWE STEP.
TAX PIN:15101223
OWNED 1UY; ESTHER L FISMEt.
CONVEYED TO:CORY & CARRIE FRANK
RECORDED IN HAP 004f< 4 — PACES
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REAR 35°
MIN OPEN SPACE 5574
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001-0 EACI.ETON DO`rPNS DRIVE
P1NEVILLE° FI.0 261.34.
(704)5BD-1 B00
[phone]
RECEIVED 2- 2-"12 17:33 FROM-
TO- NC D
P 05/005

FROM
03 02 2012 18:54/ST.18:54 P001
Post Office Box 3587
Rock Hill, SC 29732
Phone: [phone]
Fnu q0'.3329.O266
'To: Tanya - NCDENR
Panther Heating .&
From: . Cheryl Geldings
Fax: [phone] Date: 3/2/12
Phone: [phone]
IN Mk
Pages: 4 to follow
Re: Notification of Intent to Construct or CC:
Operate Injection Wells
Urgent For Review Rlease Comment Please Reply Please Recycle
•CoMmcnts: If you need additional information, please let me know. 1 will drop
the original and two copies of this in the mail. Thank you.
RRCETVFD 02-02-'12 17;33 FROM-
TO- NC DENR P&S P001/005