WI0100197_Regional Office Physical File Scan Up To 9/23/2022

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FP3 02 2612
Permit Number WI0100197
Program Category p+ Ui e'r
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer .
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Central Files: APS_ SWP_
01/31/12
rmit Tracking Slip
S tus Project Type
tive New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Larry Wells
Contact Driller Well
258 N Turkey Creek Rd
Leicester NC 28748
Facility Name MajorlMinor '_Region
Paul R Farago SFR Minor Asheville
Location Address. County
Fontana Lk Estates Lot 4-1 Swain
Bryson City NC 28713 Facility Contact Affiliation
Owner
Owner Name
Owner Type
Individual
Paul R Farago
Owner Affiliation
Paul R. Farago
Owner
PO Box 8907
Asheville NC 28814
Dates/Events
Scheduled
Orig Issue. App Received Draft initiated
Issuance Public Notice Issue _ Effective Expiration-
01/31/12 12/13/11
01/31/12 01/31/12
Regulated Activities
Heat Pump Injection
Private residence, single family '
Outfall NULL
Waterbody Name
Stream index Number Current Class Subbasin

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.. -
Governor Director
01/31/2012
Paul R Farago
Michelle T Farago
P.O. Box 8907
Asheville, NC 28814
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100197
Fontana Lake Estates Lot 4-1
Bryson City, NC 28713
Dear Mr. Noble:
Dee Freeman
Secretary
On 12/13/2011, 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 Swain 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.Rol [e-mail] if you have any questions.
SS'erel�, rr �
for DebtWa
Supervi
cc: Asheville Regional Office - APS
APS Central Files - Permit No. WIO100197
Swain County Health Dept.
Larry Wells (AWD Services Inc., 258 N. Turkey Creek Rd., Leicester, NC 28748)
Joey Bullman (Bullman Heating & Air, 10 Red Roof Ln., Asheville, NC 28804)
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.ncwaterguality.oro
..One ....:::::...:::
North6r6lina
An Equal Opportunity l Affirmative Action Employer

NORT11 C:ARi, L NA
Ot•_P,aR't'M)r:Nl• O1` ENVIItONMEN'C AND -NATURAL. RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUiC°C A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTU)NI WELL SYSTEM':
TYPE 5-OW ��LL S
In Accordance with the provisions of NCAC Title 1:5A: 02C.0100, please
complete this no0fiication and mail to address on the back page (please nriiit or' ipq information).
)Ye11 1'q e Cotifirrrrrrtion: [does the proposed system circulate potable wetcr onl (no additives) in
continuous piping that comalr,ely isolates the fluid from the environment (i.e.
closed-lloop)?
Yes V (;tliti►lue completing this form.
No _ Do Not complete this form, Complete other UIC application fonns fior installing
either a 5A7 %yell (open-loup well l'niect.ing>potable water into tile, aquifer) car a 5QNI well (closed -
either %veil containing additives such as R-??, ethanol, or other antifreeze of corrosion inhihitars).
A. PROPERTY OWNr!,R(S)/APPLICANT(S)
1•,ist esch Property Owner listed on property deed (if o,wn.d by a business or government agency, state name of
entity and a representative w/authority for signature):.—_. --- ----
(1) Mailim, Address:__�rJ__I✓t?T^ iJ
City:(Q'
knivil Address:. Wel:�:itc:._ ...___.... ....:......._........._._ _._._.__.__._
(2) Physical Address al' wen Site Okfil'1'erent than nbove): �o -4_%na
City§_ � atc: L _lip Code: 24 7 13 County: 5 („rn •i
Home/Office Tele No. —v_ ___ Cell No._• 5 2_, _%�d
13. AUTH01111ZED AGENT OF OWNF,R,1F ANY (F tlI Permit Applicant does nat oWn the suhjecd property.
attach a letter rrom the property owner' uthorizing Agent to install and operate, UIC' well)
Company Name:
Contact Person_ _ _ _ .—._ _.EMA,IL Address,_-----•-.-----.__�_
Address -_—•- _ _ __ ._.___�__.
City:. —_.— — State: Zip C:odt-: _ ('aunty:
U1110c l'elc: No.: __ __ _ ---. Cell No.: �.�_...•_ ._ ....�_ _,___
Website Address of•C'ompanv, iPany:------_--•...._. _.__ .____, w.._.._ _..._._
(Plll:I!IC j0W yolitication oNj1 UIL Fonn (RcvisctI g/7(t(11) RECEIVED i D i�t\ / Eml�lUt�
Aquif r D.romr-fi.,,I f
DEC 13 N11

C. WELL DRILLER INFORMATION
Company Namc:­AWDSERVICES. INC..
\.Vcl[ Di-illet, Contrucior's Name:
NC Conlraclor Certification
Contact Person: Larry Wells EMAIL. Address: Wells?
Address: 258 North Turkey Creek Rd.
City: Leicester zip code: .2-8- 48 COUTIN1
. : Buncombe
Off-ice'l-cle No.: 828-683-9223 CeU 1\1).: 828-21-5-9334
I . *,AT PUMP CONTRACTOR INFORMATION (ifdIffe-rent than driller)
Company Name-.
ContactPerson- `j.9"1 1011A.
Address: JDS-4j-PLU Lri
City: -�4r,.(A Zip Code:
0 trice Telc No.: —Cell No.:.
E. STATUS OF APPLICANT
I:ederal:
!M till ic ip-a! Native American 1.,ands:...
P. IN.11',CLION PROCEDURE (briefly describe 110W the OjeCtioll Well(S) Will be used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed -41-Number or borings:
Approximate depth ol*each boring (leet):--.-A',&L-
(2) oj'tubing
to be uses! (copper. PVC, etc):
(3) Well casin,,- Is the well(s) ca.--,cdT(chccor (b.) No bellow)k either (a.) V —
(a) yes if yes, ffen provide casing, irit"cl-mation below
Type; ---galvanized steel black steel pl:isl her (specit*y)
pl:isl pl:isl
Casing depth: From. to __feet (refercilce to land surface)
Casing extends to above ground inches
(b) No
(4) Grout into (material %uri-01,111ding well casino alld/or:p PhIM:
Crow type: Neat Cement (Spe-cil'y)
(b) (ji-cii.11 plilC0111CIII.- PLIMping,
(C) (jj,nLlj t1eplil ofitibing (rellerence to lall( . I st rfilce)' I'l-0111 (feel)
ll,well lias.casing, indicate ri-Mit dmth:
5(.,W Notification olAmel'i Dunn (Ruvised .4.12008) 1
th

H_ INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering )tryout or prof
pipirig/tubing associated with tiie injection operation.
information.
osed modification of the injection equipment and exterior
"he manufacturer's brochure may provide supplementary
t. LOCATION OF WELL(S)
Attach twit copies of maps showint; the following inform ition:
(l) _ Inelude a Site Map (can be drawn) showing: Wildings, property lines, surface water bodies, potential
sources of groundwater contamination and the.orkcitation ofand distances between the proposed well(s) and
any existing well(s) or waste disposal facilities stt:h as septic tanks or drain fields located within 200 leer of
the ,cotliermttl heat. pump well system. Label +atl :caroms clearly and include 8 north__M?A.
(2) The Site Map must show the subject property in elation to the surrottndin` area by ltsin�ll at lCaSt two fixed
reference points such as roads, streams, and/or`hi;.,hway intersections.
J.- CERTIFICATION
Note: This Permit Application must he signed by. ett h person appearing on the
recorded legal property deed.
-I hcrchy certify. under penally of law. thal I have p rsonally examined and, am familiar with the information
suhmitled in this document and all attache :to and thal, based on illy inquit_y of those individuals
immediately responsible lix obtaining said information, I believe that the information is True, accurate and complete.
I am aware that there are significant penahies, ineJudin the possibility of fines and imprisonment, for submitting
false information. I* agree to construct, operate, maintait, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approvei I specificalions and conditions of the Permit."
Pratt or Typc
Sionaturc of
Print or `i %ip(
at wand tilt
operty Owner/ licant
,(,E 1- 1- Apj
ull Name�nd title
Signature ctf , ,uthorixed Al,ent. if any
Print 01-'1'ypt: Rill Namcand title RECEIVED/ DEj RIDWO
Please return two copies of the caret feted Application package rqdtfer f'ttctefton Section:
North Carolina )FNR-DWQ DEC 13 2011
Aquifer Protection Section-UIC Program
1636 Mail Sere ice Center
Raleigh, NC` 2 1699-1636
Telephone [phone]
(wi vi!Ic 50w Noliftrtlion sir 1111etit Dorm (Revised 5/300ic) !'age ;

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