WI0100193_Regional Office Physical File Scan Up To 9/23/2022

� MVED
i
Permit Number W10100193 i JAN 262,012
Program Category,
. l!! , �e ions! Oilice
. Ground Water � � °�S'� `-� ' �
Permit Type -d " Protection
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility
Central Files: APS_ SWP_
01/24/12
it Tracking Slip
tatus
Project Type
ctive
New Project
Version
Permit Classification
1.00
Individual .
PermifContadt
Afflllation
Jeff. Moore
PO Box 71
Hot Springs
NC 28743-
Facility Name Major/Minor Region
Mooreland Farms LLC Minor Asheville
Location Address County
308 Sassafras Cashiers
--
Cashiers NC 28717 Facility Contact Affiliation
Owner
Owner Name
Owner Type
Mooreland Farms LLC
Unknown
Owner Affiliation
Anthony Zande
10530 Savannah Dr
Vero Beach FL 32963
Dates/Events
Scheduled
®rig Issue App Received Draft Initiated
Issuance Public Notice Issue Effective Expiration
01/24/12 12/02/11
01/24/12 01/24/12
Regulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name
Stream Index Number Current Class Subbasin

�7k
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor Director
1 /24i2012
Mooreland Faris, LLC
Anthony L. Zand.e
Lynn Zande
10530 Savannah Drive
Vero Beach, FL 32963
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100193
308 Sassafras, Cashiers, NC 2871.7
Dear.Mr. -& Mrs. Zande:
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 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 Jackson 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@nedenr.g_ov, if you have any questions.
for Debra Watts
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. WI0100193
Jackson County Health Dept.
Clearwater Well Drilling (Jefflvfoore)
Gentry Heating, Inc. (Duane Gentry)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N..Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone]
Internet: www.ncwatemuality.org
No thCarolina
e'�
An Equal Opportunity 1 Affirmative Action Employer

G
NOit 11-1 CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL. RESOURCES
NOT1ICATION OF INTENT TO CONSTRUCT A CLOSM140OP GEOT ERMAL
W&T-1 MR -ONLY INJECTION WELL SYS , M
xxPl; 5ow WEILUS)
to Accordance With Ilia Provisions ofNCAC Title I5A 02C,0200
Prhit or t1 pe the required h1formamm and mad to attilress au the back prige,
it✓ell 41)0 Cot1trnn!lon: Does the proposed system circulate potable water oEflX (no additives) in
eantinuous riiping that completely isolates the fluid from the environment (i.e.
closed -loom)?
Yes Continue completing tills form.
No Do Not cvmActe tills form. Cotnplete otltor Ule application forms for hlstaflitlg
either a SA7 well ('open -loop well inletinlot ill notable water into the aquifer) or a 3QM well (closed-
toop wefl.containing additives such as It 22, ethanol, or othermrtifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPL1CANT(S)
List g o i Property Owner listed on property deed (if owned by a bushiess or government, agell , state t ine of
t'ntfty and a repiVsentative w/autltarity for signature):
_DaZr4NA _A2►'ES Lt '. Ax.n�,,. %ea,.�_
(I) MalluigA,ddress:_ AT50 �Amyyj d4tY -Dr&
City: State:Fa— Zip code:_:3,2%3 Coimty:T..�iAAiU %Zldy►�t•
1HalnelOftice Tele No.:
13111ail Address: ZA,u
(2) Physicat-Address of Well Site (Ndlffewnt gialt above).._
City: 4a::E tt r c Siatc: -"JL, Zip Code: Z "i t ` —counly.3� ..
HOtnelOfflee Tele No.:
R. AUTHOItLZFtD AGENT 01► OWNER, jr, ANY (if the Perinit Applicant does not Own the subject property,
attaelI a letter from the ptapel'ty owner authorizing Agent to Instal) and opetnte UIC tvell)
Company Name:
Contact Person: EMAIL Address:
Address:
City: State: - —Zip, 6oda: Conn
Oftiic'
c Tole No.:
Wcbsite Address of Company, if any:
urv�ute sQ�v Notiticntlan of t��te�it l�nnn (Rc�isect 812Q08) RECEIVED I DENR I DVVQ
Aquifer Protection Suction
Z-d . DEC 0 2 20jj xm_q Apnls eppol: d8t,:Z0 �6 6Z AoN

C.
La
E.
F.
WELL DMLLER IIXFOti2MATION
Company Name: CjanAAj4, ())jo (',
Well Driller Contractor's Name: 903
NC Contractor Certification No.:
Contact Person:
Address:
City: �
Office Tele No.: f'n�
HEAT PUMP CONT CTOR (INFO TON (if different than driller)
Company Name:_�.�+�r�'��l =
Contact Person: " oN EMAIL Address:
Address: IN) n n M 0
City: ✓ 8zip Code:` / /d Cou"nty�: _ I
Office Tele No.: �, _ �] �-� —=Cell No.: %RA� 1vy a, `) 4
STATUS O!Federal:
APPL�ANT
Private: Commercial:
State: Municipal: Native American Lands:
INJECTION PROCEDUIE (briefly describe how the injection well(s) will be used)
e -
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: z' `umber of borings: ....... )D
I
Approximate depth of each boring (feet):
(2) Type of tubing to be used (copper, PVC, etc): } PE — 3� 0 ^�
(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
(4) Grout Info (material surrounding well casing and/or piping):
C
(a) Grout type: Neat Cement Bentonite Other (specify)
(b) Grout placement: Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from ' to ov/ (f et)
%voerso­'
If well has casing, indicate grout depth: from to (feet)
1/�i /mac i
GPII/UIC 5QW Notification of Intent Form (Revised 8/2008)
Page 2

-
Piping adiagram showhlg tl►e engltteering layout or pl�posed modification -of the injectlon equipment and exterlo
piping/tnbing assoeiated with. tho iiuection operation. The manufacturer's brocliu,'e may provide sttppleinentar;
information.
L LOCATIO 1T QIr'VVL+'IiL(S)
Attach two copies of neaps showing fhe following information..
(l) include a . Site Map (can be drawn) showing: buildings, property lines, surface water bode
sources of groundwater contamination and the orientation of and distances between the proposed well $)rand
Any existing Nvell(s) or waste disposal facilities such as septic tanks ar drain fields located within 20() feet of
the geothermal heat pump Avell system. Label all features clearly and include a north ro1v.
(2) The Site Map must show the subj
reference points such eet property IIIrelafion to file surrounding area by using at feast two fixed roads, streams, and/or highway intersections.
J• CERTIFICATION
Nate: This Perinit Application must besigned by ae l operson appearing on the
recsrrded legal property doed,
"I h � 'Y +55% under penalty of law, that I have personally examined and ,ant familiar with the Information
subr `'i r Of and all attaohments tlte,�eto and that, based on m in to of (hose individuals k bible for obtaining safcl information, i believe that the inforinatiou is fire accurate slid complete.
are significant penalties, includilig the possibility of fill es and imprisonment, far com leA
' he- agme to construct, operate, aint, a�epsir, and ifappticesa abandon the imprisonment,
for
g
des in accordsnoe with ti,e (cations and oonditious of the pe►7tt,t," injection well and
or Type Full am
e and title
1 a }ofProper neriApp)icant
Prin or Tppe pull Name altd title
Signature ofAutltorized Agent, ifany
print ar p a p'pIl Natne attd title
Please return two copies Of the coinpleted Applioatiolt package to:
Nartlr CarQl'UH DrNR.DWQt
Aquifel- PrOtectlon Section.Ulepro
1636 Mail Semite Center �'ata RECEIVED-1
Raleigh, MC 276994636 Aquifer ?rO*tiotn Se� on
-Telephone [phone] DEC 0 2 2011
(""1111[C $Q%V Notifceation ofInleat Pam, (Roviscd 8Q008) .
£*d5s1
xo_ Apn1S epiaol� d6b:Zo 66 6Z AoN .

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