WI0100192_Regional Office Physical File Scan Up To 9/23/2022

Permit Number W10100192
r Central Files: APS SWP-
01/24/12
JAN 9 6 ,P17 Permit Tracking Slip
Program Category
Ground Water
Stitus
%-�s�ville Regional Office Active
Project Type
New Project
Aquifer Protection
.
Permit Type
- �/erslon
Permit Classification
Injection Water Only GSHP Well System (5QW) 1.00
Individual
Primary Reviewer
Permit Contact
Affiliation
eric.g.smith
Jeff Moore
Coastal SW Rule
PO Box 71
Hot Springs
NC 28743
Permitted Flow
,mob
Facility
Facility Name
Major/Minor
Region
Jeffrey & Jennifer Budai SFR
Minor
tAeville7 .
Location Addreas
County
621 S Phillips Rd
Polk
Columbus NC
28722 Facility Contact Affiliation
Owner
Owner Name Owner Type
Individual
Jeffrey Budai Owner Affiliation
Jeffrey Budai
621 S Phillips Rd
Columbus NC 28722
Dates/Events
Scheduled
Arlg Issue App Received Draft Initiated Issuance
01 /24/12 12/02/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Public Notice Issue Effective Expiration
01/24/12 01/24/12
Waterbody Name.' Stream.lndex Number Current Class Subbasln

,V
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor Director
1/24/2012
Jeffrey Budai
Jennifer Budai
621 S. Phillips Road.
Columbus, NC 28722
Subject:. Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No.. WI01001.92
621. _S. Phillips Road, Columbus, NC 28722
Dear Mr. & Mrs. Budai:
Dee Freeman
Secretary
On December 2, 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 standard's 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 Polk 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 (919) 807=6406 or Michael.Rogers cr ncdenr.gov if you have any questions.
Sincerely,
® ' A ,M
for
Debatts
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. W10100192
Polk County Health Dept.
Cleanvater Well Drilling, Inc. (Jeff Moore).
Gentry Heating, Inc. (Duane Gentry)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 21699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone]
Internet: www.ncwatercivality.org
An Equal Opportunity 1 Affirmative Action Employer
One.....::
NorthCarolin.a
Nature"

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT .AND NATURAL; RESOURCES
OP NQTIFICATION OF INTENT TO CONSTRUCT
WELL S0--W GE
OTHERMAL
WATER ONLY INJECTION
TYPE 5QW WELL Sl
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Print or type the required information and m�toddress o�tWlac�k.
DATE- •
201 /
Weu Type Con, jlrwWon: Does the proposed system circulate potable water on1 (no additives) in
continuous piping that completely isolates the fluid from the environment-(i.e.
CIO sed-1oo ?
Yes V Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
_ well in'ectin table water into the aquifer) or a SQM well (closed -
either a 5A7 well (oven loop __)_ __ 9
loop well containing add_ itiyes such as It 22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List ee ,i_ic Property Owner listed on property deed (if ownne��d by a business or government.ageney, state name of
entity and a representative w/authority for signature):
.n . 1
(1) Mailif
City -
Home
Email
(2) Physical Address of Well Site (if different than above):
City: _ State: Zip Code: . ---------,.County:
Home/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: State: Zip Code: County:
Office Tele No.:.. Cell No •
Website Address of Company, if any: R1 .01
aquifer ProteDSection EN/
GPU/UIC 5QW Notification ofintent Form.(Revised 8/2008) - �EC O
Page 1
2 2011

C. WELL DR- LLER INIA MATION
Company Name•
Well griller CoNractoes Name:
NC Contractor Certification No.: ^' I -?MA _
Contact Person: S co1,gAi40 1 EMAIL Address: (J
10
Address: 17p
. S r Zip Code: —%�.3 County: %��•.y,�11rp�
City: ---- -2g - 7
Office Tele No.: - �'^ 2` 7�1 j r — Cell No.:
D. MEAT PIJIIliP CONT CTT IP+ F ON (ef different then driller)
Company Name:
L,
Contact Perso` U EMAIL Address:
n:
Address:
Zip Code. County.
City;
Office Tele IVo. � o `�� L �' M CellNo.:
b �o
E. sTATus OF APP ICANT
,private: Federal• Commercial:
State: Municipal: Native American Lands:
P, INJECTION PR(C 'b • y describe how► the injection well(s) will used)
G. WELL CONSTRUCTION DATA c� �
(1) Proposed date to be constructed: "/� ` I 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: ____gaivanized steel black steel____ Plastic other (specify)
Casing depth: From to feet (reference to land surface)
Casing.extends to above inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Ce
ment Bentonite Other (specify) V `
(b) Grout placement: Pumpmg��PressureOther • P,r
(c) Grout depth of tubing (reference to land surface): from L./ to (feet)
If well has casing, indicate grout depth: from to
GPURRC SQW Notification of Intent Form (Revised 8/2008) Page 2 oh 0 ty

K ` INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
L LOCATION OF WKUI.(S)
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 well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields Imated 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.
"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 in accordance with the approved specifications and conditions of the Permit."
Sig a# Property Owner/Applicant
Print or Type Fug Name and title
Signature o roperty Owner/Applicant
t
1. -A. -&4'
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]
RECEIVED / DEN R / DWQ
Aquifer Protection Section
DEC 0 2 2011
GPU/UIC 3QW Notification of Intent Form (Revised WON) Page 3

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