WI0100134_Regional Office Physical File Scan Up To 9/14/2022

Permit Number W10100134
RE C E�VE[a
EEC 23HID
Program Category AsIlnvillel Rcf j onal O'i'fiCO
Ground Water _ /Isu.fl f.)r Pi°€:�teiAol9
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility
Central Files: APS_ SWP_
12/21 /10
Permit Tracking Slip
I
Status
Project Type
fn review
New Project
Version
Permit Classification
Individual
Permit Contact Affiliation
Gary Justice
driller
3845 US 70 Hwy
Marion
NC 28752
Facility Name Major/Minor Region
Joseph & Catherine Thomas SFR Minor Asheville
Location Address County
1660 Plantation Ct Burke
Morganton NC 28655 Facility Contact Affiliation
Owner
Owner Name Owner Type
Individual
Joseph C Thomas Owner Affiliation
Joseph C. Thomas
1660 Plantation Ct
Dates/=vents Morganton NC 28655
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
11 /30/10
Regulated Activities
Out all NULL
Waterbody Name
Stream Index Number Current Class Subbasin

E
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Faves Perdue Coleen H, Sullins
Governor Director
1.2.121/2010
Joseph C. Thomas
Catherine R. Thomas
1660 Plantation Court
Mor_Tanton. NC 25655
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WIO100134
1660 Plantation Court. Morganton. NC 25655
Dear Mr. & Mrs. Thomas:
Dee Freeman
Secretary
On 11/30/2010, 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:
The injection well system contains only potable water,
The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
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 .0211(u)(2). Additionally, you should contact the Burke 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.Rogers(itmcdenr.00v if you have any questions.
Sincerely,
_ itL-
jor Debra Watt
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Pen -nit No. W10100134
Burke County Health Dept.
Justice Well Drilling; Inc. (Gary D. Justice)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: 919-733 �221 \ FAX 1: 919-715-0588: FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6746
Internet: www.nmraterguality.org
An Enual Opportunity t Anirmarive Action Employer
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 50W WELLS)
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Print or type the required information and mail to address on the back page.
DATE: It- 211- 20AQ ) (00.�
Well Type Confirmation: Does the proposed system circulate potable water only (no additives)�n
continuous piping that completely isolates the fluid from the environment
closed -loop)?
Yes Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well iniectinn potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNERS)/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): Joseph C. Thomas and wife, Catherine R. Thomas
(1) Mailing Address: 1660 Plantation Ct.
City: Morganton State: NC Zip Code: 28655 County: Burke
Home/Office Tele No.: 828 433-9207 Cell No.: 828 448-5517
Email Address: [e-mail] Website:
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code:
Home/Office Tele No.: Cell No.:
County:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
State: Zip Code: County:
Cell No.:
Website Address of Company, if any:
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008)
Page 1

C. WELL DRILLER INFORMATION
E.
F.
Company Name: 1 UST! CE kytl (C, _09-1 L 1,1 nl 6--
Well Driller Contractor's Name: CAM _ J c7) 66
NC Contractor Certification No.: f& W C _ ;-7 / S0 - A
Contact Person: To S'� L C EMAIL Address:
Address:
nI
City: ► 9 (� o iJ i J ( Zip Code: .S­ Z County: 110 F C,L
Office Tele No.: '3 ��y - i SLj' Cell No.: II'l L4 (42, Zb
HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Compan
Contact
Address: t 03 C, d.:L AL S4
City: NVLAGn,Zip Code: PJ C, County:
Office Tele No.: J,12A -4-5 Cell No.:
STATUS OF APPLICANT
Private: x Federal: Commercial:
State: Municipal: Native American Lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
&50111ELMA' NZ-Ar,1l& / A)► _
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: 11-• 6 - 10 Number of borings:
Approximate depth of each boring (feet): goo
(2) Type of tubing to be used (copper, PVC, etc): -) P F
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: _galvanized steel black steel plastic other (specify)
Casing depth: From to
Casing extends to above ground
(b) No X
_feet (reference to land surface)
inches
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite _X_ Other (specify)
(b) Grout placement: Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from �_ to (feet)
If well has casing, indicate grout depth: from to (feet)
GPU/CTIC 5QW Notification of Intent Form (Revised 8/2008) Page 2

H. INJECTION -RELATED EQUIPMENT
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.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I 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."
OgjaL C-7-
Sign e ofi3roperty Owner/Applicant
Joseph C. Thomas, property owner
Print or Type Full Name and title
(112& ilA-1�
Signature of Property Owner/Applicant
Catherine R. Thomas, property owner
Print or Type Full Name and title
Signature of Authorized Agent, if any
,s
C-3
Print or Type Full Name and title
`
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008)
Page 3

Burke Co., NC -- Printable Map
Page 1 of 2
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RES7DEIVTIAL WELL. CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division
WELL CONTRACTOR CERTIl! ICATION # 2150
1. WELL CONTRACTOR:
Gary D. Justice
Well Contractor (Individual) Name
Justice Well Drillina. Inc.
Well Contractor Company Name
3845 US Hwv. 70 West
Street Address
Marion NC 28752
City or Town State Zip Code
828) 724-4548
Area code Phone number
2. WELL INFORMATION: t'
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#Qfapplicable)
SITE WELL ID ftf applicable) `Z
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED
TIME COMPLETED AM ❑ PM ❑
4. WELL LOCATION:
CITY: /'Ytp l I'JTDi\j COUNTY RI.L(� )c L .
iIOIOO I?lA(J%ATI N c- 1ho(L&lNZ1N Ne-a9&S5
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope []Valley A Flat ❑ Ridge []Other
LATITUDE 103<! 4R' q 3 " DMS OR 3X X*0000= DD
LONGITUDE A.&/"/f 01 " DMS OR 7X.X)00000= DD
Latitude/longitude source: BPS propographic map
pocafion of well must be shown on a USGS topo map andaitached to
this form if not using GPS)
5. WELL OWNER
7DSE-P-M ATl+�2�n�4 T6famtt5
Owner Name
I(�(a� P�nr►,4-no� e.r
Street Address
City or Town State Zip Code
&4 ' 33-- 11a7
Area code Phone number
S. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS O FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): O METHOD OF TEST O
f. DISINFECTION: Type Chlorine Amount 0
nrCre" oVE0
rzB 012v;1
' •�:�ae�i,lie i�'� �i 4c:
g.
WATER ZONES (depth):
Top
/ j_eo`tto'rn`rL_'iwCfi23"n
-
Top
Bottom
Top
O Bottom
Top Bottom
Top
Bottom
Top Bottom
Thickness/
7. CASING: Depth
Diameter Weight Material
Top
Bottom Ft.
Top­_D
Bottom Ft.
Top
Bottom Ft.
8. GROUT: Depth
Material Method
Top Bottom
Ft.
Topes_ Bottom qoQ t. /
Top Bottom
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top Bottom
Ft.
in. in.
Top Bottom
Ft.
in. in.
Top Bottom
Ft.
in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
Top Bottom
Ft.
Top Bottom
R.
Top Bottom
Ft.
11. DRILLING LOG
Top Bottom
Formation Description
�I lOs%
:
/
/
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIPIED TO THE WELL OWNER.
91, �- k QZ=-3i-5 l lk-1f
SIGNATURE CERTIFPIP-D WELL CONTRACTOR DATE
Gary D. Justice
PRINTED NAME OF PERSON CONSTRUCTING THE WELL

North Carolina Deparhnent of Environment and Natural Resources- Division
WELL CONTRACTOR CERTMCATION # 2150
Quality
REM 01 20'11
r�GHoville Regional Office
1. WELL CONTRACTOR:
g. WATER ZONES (depth):
A c�if2r rQ1RCtiorl
-opottom
Gal'V D. Justice
Top Bottom---- —� _ __
Well Contractor (Individual) Name
Top Bottom Top Bottom
Justice Well Drilling. Inc.
= Top Bottom Top Bottom
Well Contractor Company Name
Thickness/
3845 US Hwv. 70 West
7. CASING: Depth Diameter Weight Material
Street Address
Top Bottom Ft.
Marion NC 28752
Top & Bottom Ft -
City or Town State Zip Code
Top Bottom Ft.
8( 28) 724-4548
Area code Phone number
8. GROUT: Depth Material Method
2. WELL INFORMATION•.
Top_!a___ Bottoms Ft.'riclsi�c
``�, LL
WELL CONSTRUCTIONPERMIT# W 1 0 IyV l 3 �[
= Top Bottom Ft.
-.
OTHER ASSOCIATED PERMIT#(ifappGcable)
Top Bottom Ft. -
SITE WELL ID #(d applicable)
= 9. SCREEN: Depth Diameter Slot Size Material
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
Top Bottom Ft. in. in.
DATE DRILLED - J g > / l
Top Bottom Ft in. in.
= . Top Bottom Ft. in in.
TIME'COMPLETED AM El-.,' PM ❑
_. _
4. WELL LOCATION
10. SAND/G RAVEL PACK: - -
Depth Size Material
CITY: Q�%,w--_ COUNTYt?
Top-'Bottori► _- _;Ft = - --_- --
`r'ilirtaN Ne.?g5s
Too,_Bottom
�' YhbA't+lN,
_1lPSOQ
(Street Name iNumbe Commundyj+Subdivision .Lot No., Parcel, Zip Code)
Top' ^ Boiom - - -,Ft1
TOPOGRAPHIC(LAND SETTING �(checkappmpriatebox)
"
OG -: ,}
1'I DRILLING, C,
❑Slope pL(alley, Flat vd e r Other
_ ❑R
- - l ._ 9 ❑
. .
Top " ^Bottom �,. _ Fommra#on Description -;
LATITUDE A3 - 9 % "DMS OR 3X.)000OOOtSOC DD
_
LONGITUDE; y/ s „ DMS OR 7xxX*000= DD
/
Latitude/longitude source: [•BPS ❑ropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
l
/
5. WELL OWNER a'
/
�seP44 toT14sA,tic fiHamAS-
/
Owner Name-
1 L ti(7 PGAN°iAT16AJ Cr,
/
Street Address
/
Ned "A l'-eN 'e NC )81P 5 S
I
City or Town State Zip Code
_ / -
c Rai 433-qZo�
/
Area code Phone_number'
12. REMARKS:
6 WELL DETAILS
g0 -
a TOTAL DEPTH:
b DOES WELL REPLACE EXISTING WELL? _YES ❑ NO p_'
= I DO HEREBYCER11FY THATTHIS WELLWAS CONSTRUCTED IN
VIIATER LE1/EL Below TopofCasing - + • % FT.
ActORD_AN10EWITH 15A NCAC 2C, WELL CONSTRUCTION
RDS, AND THAT A COPY OF THIS RECORD HAS BEEN
-,--- Sii,
- a THE1NEtCOWNER:- — -- -- - - — - - - --
E�)T
.:
`dTOPOF CAS tNGIS- ` ' tI ° FT. Above.lnnd Surface'
_ - -- ---_Top
UGf
of casing'terminated-at/orbelow land surface- may requirevariance
-
in accordance with 15ANCAC 2C `91 I BRE`
CERTIFIW WELL CONTRACTOR DATE
_ L . METHOD OF TEST
e. YIELD (9Pm)=_
J
Gary D; Justice
-f." 'DISINFECTION: Type ChIOfICIe " Amount : 0
PRINTED NAME OF PERSON CONSTRUCTING THE WELL