WI0100194_Regional Office Physical File Scan Up To 9/23/2022

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Permit Number WI0100194
E.
INN 27 2012
Program Category Asheville Regional Office
Ground Water A hider Protection
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary.Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Central Files:.APS SWP'
01/26/12
ermit Tracking Slip
St�tus Project Type
Adtive New Project.
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Chad Surrett
driller
258. N Turkey Creek Rd
Leicester NC 28748
Facility Name Major/Minor Region
Cynthia Buff SFR Minor Asheville
Location Address County
30 Thousand Oaks Blvd Buncombe
Fairview NC 28730 Facility' Contact Affiliation
Owner
Owner Name Owner Type
Individual
Cynthia Buff. Owner Affiliation
Cynthia Buff
30 Thousand Oaks Blvd
Dates/Events
Fairview NC 28730
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
01/26/12 11/15/11 01/26/12 01/26/12
Regulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin

NCDENR
North Carolina Department of Environment and
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor Director
1/26/2012
Cynthia Buff
30 Thousand Oaks Blvd
Fairview, NC 28730
Natural Resources
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100194
30 Thousand Oaks Blvd; Fairview, NC 28730
Dear Ms. Buff.
Dee Freeman
Secretary
On 11/15/2011, 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 Buncombe 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.Rogersnncdenr.gov if you have any questions.
- - S' erely,
for Debra atts
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. WIO100194
Buncombe County Health Dept.
AWD Services, Inc (Chad Surrett)
Bul lman Heating & Air (Joey Bul lman)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone; 919-807-64641 FAX: [phone]
Internet: www.nrwaterauality.org
An Equal Opportunity 1 Affirmative Action Employer
One
NorthCarolina
Natu-paliff.

i
NORTH C:AROLINA.
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOT' GEOTIiERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5-OW WELLS)
In Accordance with the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or'I'_vpe information).
Well Tyi3e Corafr -maliom Does the proposed system circulate potable water and (no additives) in
continuous piping that completely isolates the flttidfrom the environment (i.e.
- closed-logR)?
Yes V Continue completing this form.
No _ Do Not complete this form. Complete.other UiC application forms for installing
either a 5A7 well (o e_n-loop well iniectinpotable water into the aquifer) or a 5QN,1 well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROI'ERTY OWNERS)/APPLICANT(S)
List each Property Owner listed on property deed (if owned y pa. `I files or gover Went agency, state name of
entity and a representative w/authority for signature):
(1) Mailim, Adch•css: 0.-_T_ 4fl'J6 B�1 or'v� G(u�
_ 111nC�tri L
City: �Gtr(('�l)'eW State:jIC7_ip Code;_,��.3_ Count y:..-� b
I lone/Office Tele No. j2t:_aS3-0 Cell No._ _—___.----._----
Email Address:---- - ---- Website;_._...__—. - --- -=--- --
(2) Physical Address of• Well Site (if different .than above): _
City._ . State: Zip Code: County:
Home/Office Tele No.: _ Cell No.:
B., AU` BORIZED 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:___--
RFCEM—D I D`NR i DVVQ
cfi�:?1`t �J�cli�ti
( WH1,1ll(' 50W Notification ol'intent Dorm (Revised 3/2008) A(�tiife?'!7i't��t?Page t
NOV 1.5 mil

El
C. WELL DRILLER INFORMATION
Company Name: AWD SERVICES. INC. _
Well Driller Contractor's Name:
NC Contractor Certification No.:_ 3
Contact Person: 'Laraly Wells EMAII., Address: WellS7505490).Bellsouth.net
Address: 258 North Turkey Creek Rd.
City: Leicester — Zip Code: 28748 County: Buncombe
Oflicc 'I'ele No.: _82.8-683-9223 Cell No.: 828-215-9334
1).
E.
a
G.
HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
C'()lilpally Name:6vn)f 4
Contact F
Address:
City: A , - e I Q; l�Lip Code: t County: aAncarn1 o'
Office Tele No.: SQ8� 459�c?YW Cell No.:
STATUS OF APPLICANT
Private: x_ Federal: _ Commercial:
Stale: f\luiiicipal: Native American I..ands:
INJECTION PROCEDURE (briefly describe how the injection wells) will be used)
WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: tiketl-_Pe_,rn�; L Number ofborinols: 3
Approximate depth of each boring (feet):_ 3 u C
(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 __ ifyes, then provide casing information below
.Type: galvanized steel — black steel— ^plastic 1^other.(specify)
Casing depth: From _ to - —feet (reference to land surface)
Casing extends to above ground inches
(b) No V
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite —_ Other (specify). �v-�a--
(b) GT'0U1 pla.ccn)ent`: F'uml)ing - Pressure Other �a'P �i ��Gjo 50�iCij
(c) Grout depth of tubing (reference to land st.nface): tiom_ to u
- -------(feet)
117well has casing, indicate grdut. depth: from.__.
U'U/I It(: _5Q\N Notification of Intent Form (Revised 8/2003) Page 2

IZ I, I
I
I

1 Buncombe County Tax Lookup - Property Card
rage i of z
COUNTY OF BUNCOMBE,
NORTH CAROLINA
Web Property Record Card
9695-87-8995-00000
Date Printed: 11/15/2011
Owner Information
Parcel Information
Total Property Value: 583,500
Status:
Active
Owners:
CYNTHIA S BUFFAccount:
8156229
Address:
Deed Date:
1/6/2005
107 BREVARD RD
Deed Book/Page:
3890 / 0028
ASHEVILLE NC 288o6
Plat Book/Page:
0059 / 017o
Property
3o THOUSAND OAKS
Legal Reference:
WARRANTY OR SPL/COMP
Location:
BLVD
TRANSFER'
Taxing Districts _____ __ - _ ____ _- _
Location: _
3o THOUSAND OAKS BLVD
_
Class:
RESIDENTIAL
County:_
Buncombe County
Neighborhood:
RES/AVG/UNPLAN 20
City:
Subdivision:
GLEN T HIGGINS '
Fire:
FAIRVIEW FIRE
Sub Lot:
2
School:
Zoning:
Conservation/Easement:N
Flood:
Ownershiu History
Transfer
Price
Legal
Deed
Qualified
Vacant
When
Account
Seller
Date
Reference
Book/Page
Sold
Names,
MCCARTHY
WARRANTY OR
ROBERT P
of/o6/05
$325,000
SPL/COMP
3890 / 0028
No: X
No
8072967
MCCARTHY
TRANSFER
-
KIMBERLY
ANN
Assessment History
Year
Account
Acres
Land
Bldgs
Other
Impr
Assessed
Desc
Exemptions
Deferred
Taxable
2011
8156229
1.49 - .
65,200
502,500
15,800
583,506
0
0
583,500
2010
8156229
1.49
65,200
452,600
o
517,8o6
0
0
517,800
20o9
8156229
1•49
168,200
452,600
0
1517,800
0
0
517,800
20o8
8156229
1.49
65,200
452,600
o
517,800
0
0
517,800
2007
8156229
1.49
165,200
452,600
0
517,800
0
0
517,800
2oo6
8156229
1.49
165,200
452,600
o
517,800
0
0
517,800
2005
8072967
1.49 -
44,200
293,100
0
337,300
0
0
337,300
2004
8072967
1.49
44,200
366,400
0
141o,600
0
0
410,600
2003
8072967
1.49
44,200
366,400
0
410,600
0
0
410,600
2002
8072967
1.49
44,200
366,400
0
410,6o0
10
0
410,600
2001
8072967
1.49
120,100
240,500
0
26o,600
10
10
26o,600
Land Data
Segmen
Total Acres: 1.49
AnrpQ
Land Value: I Other Improvements
fir,_200
t# .
Units
Description
1
l.00 Each '
HOME SITE
Value: 15,6001
Improv#
Description
Year
Units
1
GARAGE
2010
70 Square
Feet
http://www.'buncombetax.org/PropertyCard.aspx
11/15/2011 .