WI0100182_Regional Office Physical File Scan Up To 9/22/2022

- Central Files: APS SWP
10/27/11
Kermit Number W10100182
Permit Tracking Slip
Program Category
Status Project Type
Ground Water
Active 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
256 N Turkey Creek Rd
Leicester NC 28748
Permitted Flow
Facility
Facility Name
Fred Davis SFR
Location Address
340 Hickory Estate Ln
Newland
�i'
NC 28657
Major/Minor Region.
Minor 1 7-Asheville -
County
Avery'
Facility Contact Affiliation
Owner Name Owner Type
Individual
Fred Davis Owner Affiliation
Fred Davis
340 Hickory Estates Ln
Dates/Events
Newland NC 28657
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
10/27/11 10/25/11 10/27/11 10/27/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
J
QrT 23 2r*1
Asheville regional Office
Aquifer Protection

Y..i
.amp
MCDENK
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H, Sullins
Governor Director
10/27/2011
Fred Davis
340 Hickory Estates Lane
Newland, NC 28657
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100182
340 Hickory Estates Lane, Newland, NC 28657
Dear Mr. Davis:
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 Avery 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.Rosers(rvncdenr.sov if you have any questions.
Sincerely,
,For Debra Watts
Supervisor
cc: Avery Regional Office ­APS
APS Central Files - Permit No. WI01001821
Avery County Health Dept.
AWD Services, Inc. (Larry Wells)
Burleson Plumbint, & Heating (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: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwateraualitv.om
An Equal Opportunity \ Affirmative Action Employer
One Nor, hCaroiir.a
NaTt rZ

PIV llirYl A11UN -ur 1N 1r:N l ru UONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A 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.
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
Print or Type Information and Mail to the Address on the Last Page.
DATE: 44 q 20// PERMIT NO. O 100 ( Z (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:,
re J 10 a Ifs
Mailing Address: 3r d/ ��fC /.-, oi-
City: State:,ZYe- Zip Code: Z t1.,' % County:
v r
Day Tele No.: 7.37 F `1 I Cell N0
EMAIL Address: Fax No.:
C. LOCATION OF WELL SITE - Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site; 9!V7/j,30 f Z % 9s' County: Le
(2) Physical Address (if different than mailing address): ,..
City: State: NC Zip Code:
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: a Cel Gl
GPU/UIC 5QW Notification (Revised 3/18/2011) RECEIVED / DENn / Page'
Aquifer protection Se do n
OCT 25 2011

NC Well Drilling Contractor Certification No.: Z 0
Company
Contact
Address
Is
9. ne
City: l of G es tee l' Zip Code: 2- 8 7 State: �%C County: _&eg c a
Office .Tele No.: �Z ��'� (f j - f 22--1 Cell No.: J,?- ? S--?M K Fax No.: 12 t - zg j - '?z o 3
E. HEAT FLTMP (CONTRACTOR FORMATION (if different
than driller)
Company Name: =18 !1/d!f .3 ow Ply MJ � A M a- Ad e n a
Contact Person: .!/a f�/n Sh 1 �� EMAIL Address:
Address: / y� f{1 y h /a J
City:
S .-
e P'C�JrA a
Zip Code: AM9Lr2,0 tate:ZYe-county: I'%i fCI e
Office
lele No.:
d 2 .- 7(S-
yo y 2- Cell No.: 6 2�+5 [ L L 2- Fax No.: 9Z B - 7,1r
E. . WELL CONSTRUCTION DATA
(1) Number. of borings to be constructed*: 'Z Depth of each boring
(feet): .3 o d
* If existing water supply wells will be used then provide the information in item (4)
below.
(2) Type of tubing to be used (steel, PVC, etc): h�
(3) Well casing. If the well(s) will use casing then p A e�the tyre (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground: VO L p .3 be
(4) Grout (material surrounding well casing and/or piping):
(a) . Grout type: Cement Bentonite** Other (specify)
'x By selecting bentonite grout, a variance is hereby requested to I A NCAC 2C .0213(d)(1)(A), which requires a cement type grout
(b) Grout depth of tubing (reference to land surface): from 0_ to .306 (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
6

Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE. Inmost cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and. downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, eta can then be drawn in by hand Also, a `layer, can be selected showing topographic contours or
elevation data.
GPU/U1C 5QW Notification (Revised 3/18/2011) Page 3

H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 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 propei1y 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 arWdware-that there are-significarit 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."
Signature of Prope Owner/Applicant
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 Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notification (Revised 3/18/2011)
RECEIVED / DENR / DWQ
Aquifer Protection Section
OCT 925 2011 .
Page 4

34
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