WI0100181_Regional Office Physical File Scan Up To 9/22/2022

Central Files: APS SWP
10/27/11
Permit Number W10100181
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.,smith
Coastal SW Rule
Permitted Flow
Facilit
Permit Tracking Slip
Status
Project Type
Active
New Project
Version
-Permit Classification
1.00
Individual
Permit Contact
Affiliation
Jeff Moore
PO Box 71
Hot Springs
NC 28743
Facility Name Major/Minor Region,
Thomas & Linda McCrosky Minor Asheville --
Location Address County
115 Parish Farm Rd Haywood
Waynesville NC 28786 Facility Contact Affiliation
Owner
Owner Name
Thomas
Dates/Events
K McCrosky
Scheduled
Orig Issue App Received Draft Initiated Issuance
10/27/11 10/25/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Owner Type
Individual
Owner Affiliation
Thomas K. McCrosky III
6378 River Rd
Lake Charles LA 70615
Public Notice Issue Effective Expiration
10/27/11 10/27/11
Waterbody Name Stream Index Number Current Class Sruurbbasin
`a EP
CCT 2320
Asheville Regional ®slice
A.auifer Pratecti®n

4
MNCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H, Sullins
Governor Director
10/27/2011
Thomas K. McCrosky III
Linda M. McCrosky
6378 River Road .
Lake Charles. LA 70615
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100181
115 Parish Farm Road, Waynesville; NC 28786
Dear Mr. & Mrs. McCrosky:
Dee Freeman
Secretary
On October 25, 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.Rogers wncdenr.eov if you have any questions.
Si cerely,
d
for Debra Watts
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. W101001,81
Haywood County Health Dept.
Clearwater Well Drilling (Jeff Moore)
Gentry Heating. Inc. (Duane Gentry)
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
NorttiCarofna
An Equal Opportunity 1 Afirmative Action Employer

f3EPAftTMLNt7 0f l iRt3Nfvl> i } ,J 3.Ni\'CIJi Ai.. iZt Sof.1KCL5
N.:
NOTIFICATION t:)F FN TV
ENTTO CONSTIJUCT A CLOSE-1,00IX iEcileR
!LhWHR-ONIA, INJ�7ION WFT51SIEM
11E - Q{ �LL,IS
in Accordance W"11) the Provisions o('NL'A(' Ville 15A O2(1.'.O20O
Print ur t,),I)e thr infi rrnatiora and rncui iu
uchl)•e.cs „rr ;iubcrcn icw.
00
We// Thpl, t'nrrjcPrnlctrf ) It),. pr•c)pvsed systen) circulate potable wTtter oily ("n(; adiiitives) in
rr)ntirn+arr'> Arpin,.; that comploick i, atc., the f1l, front the c.nvironrnent'(i.c.
Lisp _I_uu}?1')
` CS V (r)tttit)tu, cc)rrt . fetin
p , thts iurrn.
No Uo Not complete ihis form. unr ica ,
either -a well o)en-loop well in ectim, p ` <thcr (_fi(• application li)rrns fur installing
(_" iia f-]__--_,, pc)tabie water into Nee aquifer) or a SQM well (closed-
lool) well citnt<tinin, aciditi,}e such :ts R_22., eth;rrtc)l, or other atttiiNei.e Or a)rrosicm inhibitors).
PROPERTY OWNER(5)/APPLICAN?'(8)
l.isf c:ich Property Ut ner listed r.)n )ro c rt�
F p" . deed (ir owned by a ixrSir)ess ar' �overrnncnt a�� entity ant\ :: repres t ,_utc'Y. sulle name of
cr tativc w/authr?rfty ii,r sinrticu'e): _
'.77!%-
1XI Lit,
f iu.tn::i()flicc i cic No.: j,Y/j 7 h `�
-..- .. �`�.� " (.ell No.:
Ismail Address:
W el)site:
(2) Physical Address o! \bell Site (it'dit3'erent than aiwvc}.
C.�Stale: �U�� Zip C due: i ��r �, ✓��'�1
f (r)mc,(Jf(ice l'cli <o :
. �r..... _._.. C:aunty:
>-
i > ('e'll No.: > f /- .ZZ'C',
F3. A. U'I'tI6D18rlfi;r} Air ,
fr T OF' OWNER, IF ANY 6 tltc 1 ermit Applicant tiueL. t)o( own tf-ie subject proper!;.
attach a Ic=ttcr fi9m the -property <)tivner authari�ing Awc:nt to intai! ,tnii r,prraic O!(' c+elli
C:onlparty Name:
f 'fvi ;l i r
_____
Address: _ _...__._-------------_—_
-._
State: lip Code: -
lhiebsitc Address oi(ompan=,.
wntirrcut)on Vi I111CUt Form (Itn.iscd W200x)
RECEIVED 1 DENR / DWG
Aquifer Protection Section

C. WELL DRILLER INI
Company Name: A I&Af&2 (/Lkp,U Q ,yjl L,
Well Driller Contractor's Name: R-0.V
NC Contractor Certification No.: 2 ��
Contact Perso • E
Address: +
City:
Office Tele.No.:
D. HEAT PUMP C
Company Name:.
Contact Person:
Address: I h 0
E.
F.
6 W- �5 - �� �/ / Cell No.:
AIATION (if different than driller)
n9.4 L
City: /j._ / MM Zip Code:,;4y�/
Office Tele No.: j �7� -�5� Cell No.:
County:
STATUS OF APPLICANT
Private: L/ Federal: Commercial:
State: Municipal: Native American Lands:
G. WELL CONSTRUCTION DATA /
(1) Proposed date to be constructed: V� � - I l Number of borings:
Approximate depth of each boring (feet):_
(2) Type of tubing to be used (copper, PVC, etc):
(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 feet (reference to land surface)
Casing extends to above ground inches
(b) No P f
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Eentonite Other (specify),
(b) Grout placement: Pumpingy�. Pressure Other
(c) Grout depth of tubing (reference to land surface): from to �0 (feet)
If well has casing, indicate grout depth: from to (feet)
GPU/JIC 5QW Notification of Intent Form (Revised 8/2008) Page 2

(1. INJEM'JON-RELATED EQUIPMLNT
Attach a diagram showing the ettginzering
pipinghuhing associated wilayout or proposed modification of the injection equipment and exterior
th the injection operation. "fhe manufacturer's brochure may provide supple star
information.
LOCATION OF Wfr:lrl,(ti)
AHach two ccil:rfcS of nt:aps, showing the Iiolio
N inh inlitt'ntatiun:
I) Include d Site Map 'Carl he drawn) showing:
sources of rouneJwa! ftuildin s• lines, surface Miler ?� ter contantinatiott anti the orienlatiutt of andJtdistartcrs henveen ihcpral cued welll(s}tatnd
ant c�istin� evelf(} or waste dispusa! facilities such as septic tanf , or dr;rin (iclds located within 200 feel (tf,
the ;eotherrnai heat pump well system. Label ali textures c ir'tfli and rncluilr a north located
.
:irrow
(?) -1'ite Site: Map must shoev the subjecr properry in rci<•rtioti tit the urretundittarea �t b_y using al least two fixedreference tiuints urcFi as roads. streanis, and/or highway ihterseclinns.
CERTIFICATION
Nolt': This de(i let ;�ppiirrlio
recorticd c1 ►nest be sned igby cads person rrppeurinti on the
hat property deed.
•`I milted Certify. utxlcr penalr i of, lava• that I have prrsonal(� cs:rmined and unt familiar with the inlimnation
suhmitrnd in this dot untent and all attachtituttts therelo and th.it_ base<i un ntv inl"lia will"
those individuals
inuneiiiatc y rc,puttsihic fire obtaining >aic{ inlbrnialion. ! helieac that the iniormatiim is true, accurate and complete,
l ant aware that there are s ,
false: inibrination.- 1 agree to tconstruCI, operate N. irtn fitintrain.trepeiiaarufttif appfline., altcaba prisonrl jell
intecijr 'uhntitlirtc.
all related appurtenances in aCC rdance with the appnrved speciiic<ttiunz and utndilions of the l'errnit." ._
I ton well and
?+. 4
5ignauirc of 1'rolwrty Oavnrr/.Applicant
Prim or "l) pc f u(i Larne artci title -----.-._
:i�na urc crl I'rcrperty t iu•nrr••�phlic:rnt _ � ----
Pritil of l'ypc Pull iVrunc art<1 title __ o`L
Signature. trf'Atilhorizccl , cttt. it anv `
Print or'I-ype full IVame antJ ti[fr-
PIcasc return !WO copies of the cnnthletca Application package tie:
!forth Carolina DENR-1m1Q
Aquifer" Protection :Section-tJiC !'rof;r-arn
1636,Mail Sen'ice Center
Raleigh, NC 2.7699=1636
Telephone [phone]
RECEIVED / DENR / DUVQ
ON Y01C 5(-)W Notifrcatttrn ()f trrterrt t orrri (kcvised t mm.) Aquifer Protection Section
OCT 9, 5 2011

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