WI0100180_Regional Office Physical File Scan Up To 9/22/2022

_ Central Files: APS_ SWP_
® 10/27/11
Perinit Number-W10100180 , ✓ Permit Tracking Slip
Program Category
i Status Project Type
Ground Water
Auhovill0 RGl10.nal OffIC8Active New Project
Permit Type
- Version Permit Classification
Injection Water Only GSHP Well System (5QW) 1.00 Individual
Primary Reviewer
Permit Contact Affiliation
eric.g.smith
Larry Wells
Contact Driller Well
Coastal SW Rule
258 N Turkey Creek Rd
Leicester NC 28748
Permitted Flow
Facility
Facility Name
Major/Minor Region
Michael. & Anna Tuziw SFR
Minor (`Asheville
Location Address
County
4625 Meadow Fork Rd
Madison
Hot Springs NC
28743 Facility Contact Affiliation
Owner
Owner Name Owner Type
Individual
Michael Tuziw Owner Affiliation .
Michael Tuziw
8 Ascot Point Cir #102
Dates/EventsAsheville NC 28803
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
10/27/11 10/20/11 10/27/11 10/27/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name
Stream Index Number . Current Class Subbasin
Ashnv1110 M3091011al 0�"Ce

T k '7 IV
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
10/27/2011
Michael Tuziw
Anna Tuziw
8 Ascot -Point Circle #102
Asheville, NC 28803
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100180
4625 Meadow Fork Road, Hot Springs, NC 28743
Dear Mr. & Mrs. Tuziw:
Dee Freeman
. Secretary
On October 20, 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 Madison 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(a—),ncdenr.sov if you have any questions.
Sincerely,
()U_JA-J\- kovv
for Debra Watts
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. W10100180
Madison County Health Dept.
AWD Services, NC (Chad Surrett)
Bullman Heating & Air (Joey 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.nmatemuality.oro
An Equal Opportunity 1 Affirmative Action Employer
One
NorthCarolina

NOR111 CAROLINA
IR.ONMEW AND NNATURA-1. RFS0UR(1---S kNMENR.)
NOTIFICAT'llON'OF INTENT TO CONSTRUCT A CLOSED-1-001 GPICY111ERMAL
WATE,R-ONLY INJECTION wrn,L SYSTEM:
TYPE 5-( UW WELUS)
III Accordanci: whM tht- provi�inns of\,"CAC Tide 15A: VX.0200. p!asc
h -np wti-,�.,- nol;fication and 11-vil lo �Icldrass'on th!- back navc mic-ast, Pr
. - . . - Mi
GG I
Well Y*Vpe Cartfritratiam Doc.ithe
contifluml, pipinv that wiliplelely isolaics tine fitlid i�rcmn the clivirmill-tclit: (i.c.
-)III, UlCap, lication fiorms for instaihn�-
No Do'-:�tc, plew this form.. (7cmplei�2 oihc�,
either 7 %;cll weli il the aqUi4 Tj j\,j tv,ijj4 1
loop well containim: eddiuves such any R-22, othanol, or offier antifire�!.zc or corrosion 111hibifors'l-
A, PROPERTY
List each Prop,.!rtv (mncr fisted on pi-qpemy d&cl -0 Fowned by a htjsiness (jrroven rnent. agrency.
eniii v and a reprLsent-ativc w1atithority for signature):
1-11'.Agkvv; lie 0 to Z-9903 Counn;', puma"ke
(2) -Phyicai Address W'Well Site (Wdifi&cna thall abovt):
It Zipcodc-2-97((S c Ufl!". M &.4,
It. 'I -11� N'v-cLjl No -
A 11110 14 1 4EI ) A G VNI' () F MY N F R. I PA N V i i (I i1w Permit Applicai v , dpqnot, i y !iw, , Ll hic i p vA: ri
-Wad;:1 iciler from 01C vrope0v Agcct.! to install and openif-e 111C
------
Contact !1r;;om:
I' MAIL,
C, i tv
Stale:. Zip Code: Couniv-:
Of CE
0, C T 2 0 2011

"`E[J- DRILLER INFORMATION
Naini-,:_ ANVI INC.
1Vtli i i `uttrtc:
. . . . . . . . . .
3Sov
PonL(im Larr, Wells,.
254i CretkA(l.
/ii) <'o(iQ: 2-'� 13 i4S
828---6S,3AZ23 828-215�9134
H EAT PUM P C BNTRA NIFORMATION (if different than drillier)
Conn paw, Nnnie:
City:
zip("wic
lr ca Nmv
ry
OF APINACANYr
C
Sun., NATive Amtrican F. ijMhOn W12% WHI hC LMOd)
"e'FAA, CONSTRI �CVJON DATIA
Pvo*pfv�vaw J r 'I " w 1` �
A &Nh of Lodi bn6n; CQCI,)7
1:n i n. C o FY pt! r,
1 cashg. IN dw M) cused? (check, Omer (V-)Ws PLr (1}455 baiowj
ualva
mind steel (specify'i
-Cming dyS From . _ to fCCt (reforence to land surface)
lo mov�e groundl
chi No
frojr,­
11-�S Casing. gmlu, ch:pth: firom

Auactt a di :.+`.'_C. ni Aiowill^_ 1n: CS1k1.in 'rilif: lc14f}Eit or llrilpand n wdtik 'aic-n E?i, the liljection s=tji ipm nt and etiel•iar
3S.ATc,.r cd, tvitl tS ;'.. ilt cc!i n [ iT- riaiiiin. t li: ilianutact -er'S hrtl:hain', !nag provide supplementary
,i!3iti:k! to'''tl 01'!;?.}l)5.lvnt'itlg 0 -,, 1*6ilowin!'. ira {3E`rwitte'tn'
(1 t ln.Oudc a Witte Nla p (can N! drawn) i wl"Ving-. buildinpi, k_.rOtnaty luics. surKacc. : ntei• l'E?dies. potential
sourwi of rrptitiewater confit'minattion and tlge orientation a,17and disiancey,, i-,ieiwiccn flit': proposed tv'eil(ss mid
any C. dstii'li'_ wull(i) ol, Nast, dispcisal taciliitic'�c Such as SClitic tanks or drain Yields located within '200' Ifect o'
Hw ':wiilCCi al heat pwrip well system, Libel all features clei?rll mid include ki._iiort 1_:it'Ct)i1.
l i-ic, sits Ntlap must Show fli:.' slthjeci pt:opermow` in rCliiiion tc ills surrt'•E311 ling avea tiy ushi,4 at lkmsi two l:iY CI
ref,crenc:t•. points tiuch as roads, s'Ircanist ancUor fitgirvay IntcmcCtioni -
.4. ClZi`f'lfrlt:.`A'CF�t3'�
i'4L e: This Pernik ^`L"pplicatian must lie signLd 111y elicit pft r lls 'fiipc.,tring, on t€ke
r€'+•Qs';sd dtgw fi_rnii"q tlE_ d.
-! hCrCl-l`, tiLrlil % Under (?enally of jaw. that l have lgru'rscni ll i ex,,,in iince, and am, Rwilihar wiili the i!ilormation
SL'bmilted in this doctEinent and all atta'chincills titercto and that, Based on my, nitliiii- rt` tili,'ose irdiV:idualS
inlmediateL rE-4;.po ESiliic for obtaining, said inforinat'ion. l beiiave that the iEntiii-nation is true. ilcc rat` and mnpletc.
t a ni wware tl!iii. art: Si tiitiCs711t renaltl'.s, tnelftdin'•? ili: SC,44ileLlllV of itne& and EEili rE3t7nt}ltrti., {Ell` 5tilitiilil7n
fEElse, infornialkin. f , g.= to constrUCt. OpCrate. ntrsirtt&M rellA and tl'arRti tl,1 ; abandon the iiiiedtion'Fell and
ill rE-lateLt s�f?ultinances inP eordance %,ith the ah�Et�veci sn ti�#i atiir s:zni.en,ii turn rzftilc fcrinit_'°
St 3.11 .aAI
Print or 1";•Ile; Rill Nanw alit`;
xz
Sis!nsture' cll'11toperty C)wneriAppliciinf
.� 1_
l'rl:�i Ear t`ti lic• Hill �rnrli• as;ci Ei;:le.
___ ....._ .._ _._.._.
`� _.iltli(,`. li ?t.ltil4 ff kLC[c �_:�lt., tS iitii
l'lm1 el 'I',,i f�uli'vatailaltEl title
Pleat- return two cal"nes of ivita. c-pniplated Application f',:t,`iiltge to:
North Carolina DEN-, R-DWQ
Aquifer Prartertion ISPCt iii-l_)'IC Pr091-ilill
1636 Mail Service Center
RAcinh, NIC ? 7699-lfi:3fr
Telephone (9 i 9) 715-6935
. a't _. �t i11 ' ,.,iiic.ati+.�u �,f to=t:�a+;. J.'l,•.ri �}t.evt•;:Ei `ra°Y;;Nf:
�f""il/` ; t'
i:_vf=t ED ! � li;:Nli
Wwwww a 1

m
/20 10,
mv)48�
Mi
k-