WI0100177_Regional Office Physical File Scan Up To 9/22/2022

r Central Files: APS SWP
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10/26/11
Permit Number W10100177 Pick P q ?r : a / Permit Tracking Slip
Program Category. v Status Project Type
r sheville, Regional Office
Ground Water AquiferteC�iCn Active �� New Project
Permit Type version Permit Classification
Injection Water Only GSHP Well System (5QW) 1.00 Individual
Primary Reviewer Permit Contact Affiliation
enc.g.smith Larry Wells
Contact Driller Well
Coastal SW Rule 256 N Turkey Creek Rd
Leicester NC 28748
Permitted Flow
Facility
Facility Name Major/Minor Region -
Mike McCracken SFR Minor [Asheville -
Location Address County
170 Ht Dr Haywood
Clyde NC 28721 Facility Contact Affiliation
Owner
Owner Name
Mike
Dates/Events
McCracken
Scheduled
Orig Issue App Received Draft Initiated Issuance _
10/25/11 10/17/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Owner Type
Individual
Owner Affiliation
Mike McCracken
170 Ht Dr
Clyde
Public Notice Issue
10/25/11
Waterbody Name Stream Index Number Current Class
NC 28721
Effective Expiration
10/25/11
Subbasin
Le� T 2 3 2r
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North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
10/25/2011
Mike McCracken
170 I -IT Drive
Clyde, NC 28721.
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100177
170 HT Drive, Clyde, NC 28721
Dear Mr. McCracken:
Dee Freeman
Secretary
On October 17, 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 Haywood 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.Roaers(cuncdenr.eov if you have any questions.
!!Si�cerely, e
for Debra Watts
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. W101001.77
Haywood County Health Dept.
AWD Services, Inc. (Larry Wells)
Bullman Heating & Air (Joev Bullman)
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.ncwaterouality.org
One
NortbCaroiina
An Equal Opportunity \ Affirmative Action Employer

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NORTH CAROLINA d� V 0, Q 17 2011
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-OW WELL(S)
In Accordance with the provisions ofNCAC Title 15A: 02C.0200, please
complete this notification and snail to address on the back page (please Print or Type information).
DATE: /6 20_ �_k3 j �� � ��
A.
60
};Nell Type Confirtnatiom Does the proposed system circulate potable water one (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.-
closed-ioW)?
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 in'ectin 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).
PROPERTY OWNER(S)/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):
(1) Mailing Address: f .7 D &A-eJ nn
City: — State: Zip -Code:_ 7Z County��c�OL,
Home/Office Tele NA4 1,3 5% � Cell No.:
Email Address: Website:
(2) Physical Address of Well Site (if different than above):
City. State: Zip Code: County:
Horne/Office Tele No.: _ Cell No.:
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 Te.le No.:
State: Zip Code:
Website Address of Company, if any:
Cell N
County:
GPLliUK' 5OW Noii(ication ol'Intent Fonn (Revised 8/2008)
Pagc i

Fe
WELL DRILLER INFORMATiONj
Company Name: AWD SERVICES, INC.
cJ,Ir�
Well Driller Contractor's Name:
NC Contractor Certification No.: z 4 as ;
Contact Person: Larry Wells EMAIL Address: Wells750549 anHellsouth net I
Address: 258 North Turkey Creek Rd.
City: Leicester Zip Code: 28748 County: Buncombe
Office Tele No.: _828-683-9223 Cell No.: '828-215-9334
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Bbkl Iman fl, c ;W of Ig �-
Contact Person: at" ltt EMAIL Address:
Address:
City:' e'viI I pp��Zip Code:
Office Tele No.: -ws2- d 9147 Cell No.:
County: �Buncam�p,
E. STATUS OF APPLICANT
Private:_ Federal: Commercial: -
State: Municipal: • Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: /, J, t/ Number of borings:
Approximate depth of each boring (feet): 3G?9
(2) Type of tubing to be used (copper, PVC, etc): ,F m ) (
(3) Well casing. is the well(s) cased? (check either (a.) Yes or ( Plow)
(a) Yes .,_ if yes, then provide casing information below
Type: galvanized steel black steel plastic other (specify)
Casing depth: From to _feet (reference to land surface)
Casing extends to above ground inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping) 2D
(a) Grout type: Neat Cement Bentonite Other (specify) „-760A 5'ell
(b) Grout placement: Pumping Pressure Other _ f,�&010 `
(c) Grout depth of tubing (reference to land surface): from
If well has casing, indicate grout depth: from __
_ to __ (feet)
to _(feet)
U'lUIJW 5QW Notification of Intent Form•(Revised 8/2008) Page 2

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H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterjor
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplemei
information. o
1. LOCATION OF WELL(S)_ f
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 we]I(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.
"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 condition/otf lie Permit."
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Property Owner/Applicant
Print or 'type Full Name and title
Signature of Authorized Agent, if any
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]
GPII/IIIC 5QW Notification of Intent form (Revised 9/2008) Page 3

_CTION
OCT 17 2011
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