WI0100162_Regional Office Physical File Scan Up To 9/22/2022

Permit Number W10100162
QVF0
2�
Program Category p Ground Water Ai.,hevilla Regional Office/
anl.flfor Protection
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility
Central Files: APS SWP
07/21/11
it Tracking Slip
Satus
Project Type
AItive
New Project
Version
Permit Classification
1.00
Individual
Permit Contact Affiliation
Gary Justice
driller
3845 US 70 Hwy
Marion
NC 28752
Facility Name Major/Minor Region
Otis & Ruthene Hill. SFR Minor Asheville
Location Address County
210 Mountain Laurel Rdg McDowell
Old Fort NC 28762 Facility Contact Affiliation
Owner
Owner Name
Owner Type
Individual
Otis Hill
Owner Affiliation
Otis Hill
PO Box 332
Old Fort NC 28762
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance
Public Notice Issue Effective Expiration
07/21/11 07/13/11
07/21/11 07/21/11
Reaulated Activities
Heat Pump Injection
Outtall NULL
Waterbody Name
Stream Index Number Current Class Subbasin

i �®s
MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
7/21/2011
Otis Hill
Ruthene Hill
PO Box 332
Old Fort, NC 28762
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100162
210 Mountain Laurel Ridge, Old Fort, NC 28762
Dear Mr. & Mrs. Hill:
Dee Freeman
Secretary
On 7/13/2011, 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 15A 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 .0211(u)(2). Additionally, you should contact the McDowell 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(&,ncdenr.Qov if you have any questions.
Sincerely,
for Debra Watts
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. W.1.0100162
McDowell County Health Dept.
Justice Well Drilling, Inc (Gary Justice)
Burleson Plumbing & Heating Company (John Smith)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard. Raleigh, North Carolina 27604
Phone: [phone] FAX 1: 919-715-0588; FAX 2: 919-715-60481 Customer Service: 1-877-623-6748
Internet: www.nmateroualitv.org
An Equal Opportunity \ Afnrmative Action Emplover
IOne
gor t€Carolina
�zfklrallff

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT A ---,ID NATURAL REg01JRCPS
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of I5A 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: J!" �`'`�"`� 20 YI PERMIT NO. (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence Business/Organization
Government: State Municipal County Federal
B. WELL OWNER - For individual residences. list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
Rt ik F-N E. 1F, 0Tt5 t-l-Iu-
Mailing Address: 7 b ?3C�c 3 3 �-
City: bL- 2 i ` State: /VC Zip Code: a -a 7 ea -) County: MC Dowi 1,1.
Day Tele No.: is (o q5 7y Cell No • 9-*- (p 9-- tl 17 7 D
EMAIL Address: Fqv XTn
C. LOCATION OF WELL SITE - Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 0&5q- 00 8}-dY7-re County: ��
� O
(2) Physical Address (if different than mailing address):
010 010 VP,�1' (N �Flt�2�L rZri���
City: D C • State: NC Zip Code: 7 G Z
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: �7� l2 `i Z3 ILSTIC
NC Well Drilling Contractor Certification No.: 15,0 - R
Company Name: -SUS TLC1; WE L 2J6ZI LLi NCB , l 04C- .
Contact Person: G k '-TU5 TIC EMAIL Address: jLA s i-ice we.l(ckri tI i n
Q=-.t4� ac.Ccir-
Address: 3S If S s - 0 w,tS �
City: M 6 rL �o tJ Zip Code: 'AS 75 a State: NC County: MC D o urs Q-
OfficeTeleNo.: CelINo.: 8;.8-'tq�;l-F'7ao
Fax No.: g-;19 " 7-' Y. - qS �8
GPUIUIC 5QW Notification (Revised 3I182Dl1} Pale 1
Z'd 8b9b-�ZL-8Z8 1`' 9011sn0 eLZ:80 Cl Inf

E. BEAT PU_VIP CONTRACTOR INFORMATION (if different than driller)
Company Name: 94t2(_ES6N 'rPLLQrL8iNG g �l}�ttti"C
Contact Person: __T�i-1 tJ EMAIL Address:
Address: _ i Y! )+L G H C_rt N 6 A) F_
City: 5 P11UC_ f Pf N £ Zip Code: --IS 7 -7 7 State: Ne
Gounty: __/Yt i 7"Gl>t ti t- L
Office Tele No.: 3a8 - 765- qo y -A Cel I No.: Pax No.:g-_18-
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: a? Depth of each boring (feet): 3oo -�7 .
* If existingr water supply wells will be used then provide the information in item (4) below.
(2) Type_oftubing to be used (steel, PVC, etc): 5-hee i
(3) Well casing. If the well(s) will use casing then provide the type (steel, PVC, etc.), diameter, death,
and extent of casing appearing above ground:
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite* *,>.-� Other (specify)
*" By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(1)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from - to 3 o D (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 1000 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 114 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 front the applicable county GIS websile. Typically, the property can be searched by
owner name or address. The location of the wells in relation to properly boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand Also, a `layer' can be selected showing topographic contours or
elevation data.
GPUtU[C 5QW Notification (Revised 3/18/201 1)
Page 2
C-d 2tstl_tlzL_2ze eoilsnr eLZ:80 Ll, Cl, Inf

H.. CERTMCATION (to be signed as required below or by that person's authorized agent)
15ANCAC 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 (which means all persons listed on 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.
"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 inLecorclance with the app oved specifications and conditions of
the Permit." -
Signature of Pr e y Cwner/Applicant
5 � . " l- - I �.
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 Ser-vice Center
Raleigh, NC 27699-1636
Telephone [phone]
W.
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01 'r
GPU/UIC 5QW Notification (Revised 31182011)
Page 3
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MCDOWELL COUNTY
TAX MAP
The data provided cn this map am prepared for the tmentoty of teal property found Wihin
N%I)a +ell Cmmty. NC and are compiled !ram recorded plats. deeds. and other public records
and tlata. Thls data is for ln'armatl:nal purposas only and should not be substItu:e7
rarairue We acamh.prapady appraeml. smrv.y. ar far—ie9 r ieaabae. One Inch =100 Feet

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water
WELL CONTRACTOR CERTIOH'ICATION # 2150 A
RECEWE®
,a,, E'J L 2 1 2 U 19
f` shovillo Regional Office
Apulfer Protection
1. WELL CONTRACTOR:
9. WATER ZONES (depth):
Gary Justice
Top. Bottom Top Bottom
Well Contractor (IrKrmk uaq Name
Top Bot6om Top Bolcom
JUStICe Well drillina
Top Bottom Top Bottom
Well Contractor Company Name
Thickness)
3845 US 70 West
7. CASING: Depth Diameter Weight 111laterial
Street Address
TOP Bottom Ft
marion nC 28752
Topes._ Bottom 0 Ft
City or Town State Tap Code
Top eottnm Ft
8t 281 724-4548
Area code Phone number
D ��0 /! r
8. GROUT: Depth Material Method
lIf �J
2. WELL INFORMATION: � �l �b�
WELL CONSTRUCTION PERMIT# ��
: Top Bottom Ft
= Top _ Bottom 00 Ft
OTHER ASSOCIATED PERMR#('dapp►kxble)_�—
Top Bottom. Ft -
SITE WELL ID#(dapp
9. SCREEN: Depth Diameter slatSizeMaterial
& WELL USE (CheckAppliclable Box): Residential Water Supply ❑
Top Bottom Ft in. in.
DATE DRILLED r`y'
' �bI
Top Bottom Ft in. in.
l
- Top_Bottom Ft in. in.
TIME COMPLETED AM ❑ PM ❑
4. WELL LOCATION:
= 10. SANDIGRAVEL PACK-
� L � �-r-d— i� ~�r31�
Depth Size Material
CITY.
: Top Bottom Ft
,� (b Iylt� l d�il � 1 1.i�Iwg
Top Bottom Ft
(Street Name, Numbers, CoTmrmdy, Subdiv7sft Lot No.. Parce4 Zip Code)
Top Bottom Ft
b
TOPOGRAPHIC LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
11. DRILLING LOG
Top Bottom Formation Description
LATITUDE tZ 3S' 4I _Gs "DMS OR DD
= /
LONGITUDE VS t2 " tO ' OGG .ill " DMS OR OD
Latitudefiongbde source: LJrS propographic map
/ ®; E 2GG
(location of Weil must be shown on a USGS tope map andattached to
this form ffnot using GPS)
/
S. WELLOWNER
Owner Name
'2/6 �?o�N�ir`m L4&-te6(- 2r06€
V.
Street Address
/
�a> (02'�` fvc 2 �7(� z
/
CiCy oarTown —. -- - — — State -- - ZIP Vie. -
--- -- — _.-. -- - —
Area code Phone number
= 12. REMARKS:
S. WELL DETAILS:
a. TOTAL DEPTH: 0 O
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
= i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT.
: ACCORDANCE WITH 15A NCAC 2C. WELL CONSTRUCTION
(Use'+' if Above Top of Casing)
: S_TAN AND THAT A COPY,OF THIS RECORD HAS BEEN
P l� TO THE WELL OWNER.
d. TOP OF CASING IS FT. Above Iagd:Surface'
�WELLCONTRACITOR-'D
'Top of casing terminated at/or below land surface may require
r
a variance in accordance with 15A NCAC2C".0918.
TH'
GNATURE OF CER IED A
e. YIELD (gpin): '—' NIE TROD OF TEST—.L—
Gary D. Justice
f. DISINFECTION: Type' '^ Amount __..
: PRINTED N, AME OF PERSONCONSTRUCTLNG THE WELL
Submitwithin-30 days of completion to,.Division of.Water. Quality:W Information Processing, Form GW-1a
1617 Mail Service Center, Raleigh, NC 27699461, Phone: (910)
807�100 . Rev.2109

- n H-SMENTIAL WELL CONSTRUCTION RECORD
g North Carolina Department ofEnvuenment and Natural Resources- Vivision of Water Quality
W
�� J12
WELL CONTRACTOR CERTIFICATION # 2150 -Ait - .
AshavjI..I R �,1cbna! Office
r
1. WELL CONTRACTOR:
Gary.Justice
Well Contractor (Individual) —Name
Justice well drillina
Well Contractor Company Name
.3845 us 70.west
Street Address
marlon nc 28752
City or Town State Zip Code
828 7244548
Area code Phone number O� �6 � *f�
2WELL INFORMATION: O l
WELL CONSTRUCTION PERMIT#���jC
OTHER ASSOCIATED PERMI HWapplic0le) _
SITE WELL ID " applicable)
g. WATER ZONES (depth): t1Cid
Top Bottom Top Bottom--
Top Bottom Top Bottom
- Top Bottom Top Bottom
Thickness)
7. CASING: Depth Diameter Weight Material
Top Bottom Ft —
TOP (2 Bottom �D Ft.
Top Bottom Ft
8. GROUT: Depth Material Method
Top Bottom Ft- %
Top O Bottom_O Ft
Top Bottom Ft
9. SCREEN: Depth Diameter SlotSae Material
3. WELL USE (Check Applicable Box):
Residential Water Supply ❑ -
Top
Bottom
Ft in.
DATE DRILLED 7 /3^ 2C*Top
Bottom
Ft in.
Top
Bottom
Ft in.
TIME COMPLETED
AM ❑ PM ❑
=
10. SAND/GRAVEL PACK:
4. WELL LOCATION:
/�
Depth
Size
my. O,(..d Oya-
COUNTY/q�1�Jb�3
Tap
Bottom
Ft
b� 10 1,4 uVA-1 A-►-3
bA1 JV fiL �� ���
ToP
Bottom
FL
(StretName, Numb—. Community, Subdivision. Lot No., Parcel Code)
Top
Bottom
Ft
TOPOGRAPHIC t LAND SETTING: (ehe& appropriate box)
11. DRILLING LOG
❑Slope ❑Valley ❑Fiat ❑Ridge ❑Other
Top Bottom
LATITUDE 36 35' " 3 (0•±I.2j _ DMS OR ' DD
/
LONGITUDE 75 U(i ^ l0 ' �o ` " DMS OR DD
/
/
Latitudellongihmde source: PS propographic map
pocaSon of well must be shown on a USGS topo map andattached to
= Q —Ji 129 42
this fain ifnot using GPS)
5. WELL OWNER
-
Owner Name
/
Street Address
p (-1) i AAA -19 7 do 2
/
/
City -or -`rows—
Area code Phone number
12 REMARKS:
S. WELLDETAILS:
a. TOTAL DEPTH: 3,00
b. DOES WELL REPLACE DOS llNG WELL? YES ❑ NO ❑
c. WATER LEVEL Below Top of Casing: F1- _
(Use W' if Above Top of Casing)
d. TOP OF CASING IS . <�� FT. Above Land Surface
'Top of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): ^� ®METHOD OF TEST �
f. DISINFECTION: Type Amount
in.
in.
in.
Formation Description
WIMZWW �
t DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
ST ARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PRO ED TO THE WELL OWNS
77
- J TE !
IG RE FD WELL CONTRACTOR A
Gary D. Jus 'ce
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days.Of completion td.- Division of Wittier Quality Information Processing, Form GW-1a
161T Mail Service Centel, Raleigh, NC 27699=151; fmhone : (919) 8D7-6300 _ _ " Rev. 2109