WI0100198_Regional Office Physical File Scan Up To 9/23/2022

A M .
NCDENR
North Carolina Department of Environment
Division of Water Quality
Perdue Charles Wakild, P.E.-
Director
02/02/2012
Charle109705
Kuzell
PatricKuzell
CMR Box 456
APO,
C11 FE V F
F"B 22 2G12
J
Asheville Regional Office
AaLlifer Protection
Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10100198
673 Wickham's Fancy Dr:
Candler, NC 28715
Dear N2 Kuzell.:
Freeman
Secretary
On 01/1 /2012, the Aquifer Protection' Section (APS) received notification of your intent to construct a closed -loop water -only
geothe al injection well system for the operation of a ground -source heat pump located at the address -referenced above. An
individ ' permit is not required for the construction and operation of this type of geothermal injection well system as long as the
follow 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 a comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Adminiftrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Buncombe County Health
DepartJ ent as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municiA 1 rules and regulations may result in the assessment of civil penalties.
Please )ntact Mike Rogers at [phone] or Miehael.Rogeersna,ncdenr.gov if you have any questions.
5' cerely,
for De a atts
Supervisor
cc: A eville Regional Office - APS
APS Central Files - Permit No. 100100198
Du coribe County Healhh Dept.
Jcj 0;L>o;r ( lc iarii%atcl ldel[ :J�illiiig Inc.,:P:C:13ar: ;1, Il�t. Sl?rings, la: 23'7?_J
Du, ne Gentry (Gentry Heating Inc., 100 Buckeye Cove Access Rd., Swannanoa, NC 28778)
AQUIFER.': ROTECTION SECTION
1636 Bail ervice Center, Raleigh, North Carolina 27699-1636
Location: 4 2 N. Salisbury St, Raleigh, North Carolina 27604
Phone: 91 807-M41 FAX: [phone]
Internet .nowatemualitv.ora
..One ... ...... :.......
NofthCarallna
An Equal O*rtunity 1 Affirmative Action Employer

ASI.lT►ENT ML WELL CONSTRUCTION RECORD
Natural Resources- Division of Water Quality
North Carolina Department of Environment and
CERTIFICATION # /37
WELLCONTRACTOR _q
i
1 WELL
ONTRtACTOR: g. WATER ZONES (depth):
J}i
Sh Top Bottom Top Bottom
WeII t
ntractor (Individual) Name Top Bottom Top Battom
Top Bottom Top Bottom
)ntractor Company Name Thickness/
Well
7. CASING: Depth Diameter Weight Material
ddress ^ !' Tap Bottom FL
�113
Streel
/ Vd , c Top Bottom FL
State Zip Code0-7 Top Bottom FL
Phone number 8. GROUT: Depth Material Method
City offowh
Area cod
l
2. WELL
FORMATION: : Top /W0 Ft. i 6 Y7{7r ✓
WELL C
_Bottom
p
STRUCTION PERMIT# 1A110' 00 167 QTop Bottom Ft_
OTHERIL
OCIATEO PERMIT#(ifappiicabte)�7zfp Ali, / !1 s Top Bottom Ft
SITE W
ID #(if applicable}
9. SCREEN: Depth Diameter Siot Size Material
3. WELL,
11
SE (Check Applicable Box): Residential Water Supply ❑ Top Bottom Ft. in. in.
DATERILLED
— / `/ Top Bottom Ft in. in.
Top Bottom Ft in. in.
TIME l,!OMPLETED
AM ❑ PM ❑
a `�I
4.1NELL11
10-SAND/GRAVEL PACK:
LOCATION:
r A Depth Size Material
CITE
COUNTY ; Top Bottom Ft
Top Bottom Ft-
me, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) Top Bottom Ft
IRAPHIC
(Streel
TOPO
/ LAND SETTING: (check appropriate box)
❑SlopDValley
❑Flat ❑Ridge []Other 11.DRILLING L•OG
Top Bottom Formation Description
i
LATIT��
v N
DE XQ0' S% - qqW" DMS OR 3X.XXXX)00= DO
LONGFUDE
D�F�°3�' (qQW "DMSOR7X.X)oOM0=DD
Latitud
longitude source: '1216PS Qropographic map
flocatf
of welf must be shown on a USGS topo map andattached to
this fo
if not using GPS) J
1 /
5. tNELU
31111NER /
4ame /
Owns
7
cS J
J
Streeli,Address
AILI 0(�p 7/.5 /
Town State Zip Code /
City o
Area cod
Phone number 12. REMARKS
6. WELL;
ETAILS:
a. TOE
l r
AL DEPTH:
b. DO
SWELL REPLACE EXISTING WELL? YES ❑ NOg : I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
C. WA
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
ER LEVEL Below Top of Casing: STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN
,,
(Use °+° if Above Top of Casing) : PROVIDED TO THE WELL OWNER-
d. TO
"
OF CASING IS FT. Above Land Surface'
below land require Z/ ! J 1 L
Eop of casing terminated atlor surface may . CJ���
variance in accordance with ISA NGAC 2C .0118. : SIG`NATURE OF CERTIFIED WELL CONTRACTOR DAitt
e. YIE
J'
D (gpm): METHOD OF TEST
f. DI t
FECTION: Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
i
(fir
a 'p y..,^'6 ;' sit +.. v� ' x N'MAIR-1
,y�
[t - itQ>? S+xt�coSSi Form GW Rev. 2109

�iESIDE11l�'IAi WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL IONTRACTOR;
h
W
Well ntractor (individual) Name
_-Amu Dn
Well )ntractor Company Name
dtheel, ddress !Vd ll
City o I Tow Stab
Area coi
2. WELI
WELL C
OTHER
SITE WI
3,
DATE
TIME
Phone number
g. WATER ZONES (depth):
Top
Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
7. CASING:
Depth
Diameter
Weight Material
�����Top
Bottom t F
Top
Bottom Ft
_
Zip Code
Top
Bottom Ft
8. GROUT:
Depth
Material
Method
Top_
Bottom / FU Ft 7r Arf
3TRUCTION PERMIT# [6f l o I oo �
Top
Bottom
Ft
�"f��,, / j
IOCIATED PERMIT#(ifapplicable) hi
Top
Bottom
R.
ID #(if applicable)
9. SCREEN:
Depth
Diameter Slot Size Material
E (Check Applicable Box): Residential Water Supply O
Top
Bottom
Ft. in. in.
`10 l
Top
Bottom
Ft in. in.
ILLED o�
Top Bottom Ft in. in.
AM PM [I
10. SAND/GRAVEL PACK-
A.
OCATION:
i- Depth Size Material
I-
t�f COUNTY
ClT
_ _ —f- Top Bottom Ft
Top Bottom Ft
(Scree
Name, Numbers, Community, Subdivision, Lot No., Parcel, Tip Code) Top Bottom Ft.
F
TOPO
roRAPHIC / LAND SETTING: (check appropriate box)
11. DRILLING LOG
❑Slap
❑Valley ❑Flat EIRidge ❑Other Top Bottom Formation Description
N
LATITI
�l ' " DMS OR 3x x*mx xxx DD
LONGI
jjDE
WDE � ° 37' y { qD(_J " DMS OR 7X.x70 XXXXX DD / / YQ ���z jr F
Latitude'longitude
source: '[36PS []Topographic map /
pocaud
i of well must be shown on a USGS fopo map andattached to l
this fo
I if not using GPS) l
1 /
5. WELL
WNER j
I
Owners
ame j
Street
ddress /
a
p
All l O 5 /
City o;
Town - State Zip Code /
i
/
Area cod
t
Phone number
- 12. REMARKS:
6. WELL
i)ErAILS:
a. TO'
1
DEPTH: ! 40
b. DOS
_
WELL REPLACE EXtSTiNG WELL? YES ❑ NO(I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
C. WA
'
ER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
4
(Use °+° if Above Top of Casing) = PROVIDED TO THE WELL OWNER.
d. TO,
"
OF CASINO IS FT. Above Land Surface'
land U�(J Z f / /
p of casing terminated atfor below surface,may require -- .-
variance in accordance with 15A NCAC 2C .0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIE
D (gpm): METHOD OF TEST
f. DI `i
FECTION: Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1�;�..@,.J,� ��
k t3
��n?ar_ma.,.
E���)$n���iP`5ii'�xa *"�`m''sF L 1w,Y,+�"�Y`_y?',lv:�• .. �� � : A'ii.Y <.-.. ,Fwr-¢ !K
t{[{ k iliS ot1 O a�e� to ~ o � c Srl1 Form GWA a
c+J.,x•,,;3:` ... ,."�'�syuY �,„.r;R���n 7t�•t7�"nesa .��, tt�` �?' ., � - _ ,� `�� �,.� Rev. 2/09

E
aILL,S'IIII�ENTIf�L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
(Individual) Name
Well R ntractor Company
In —
Streeti�j kddress
lot
City o ow
Area coi
2. WELI
WELL C
OTHER
SITE W
%/i Vo7 — % -7 4/
Phone number
'3
3TRUCTION PERMIT# 1n 1 01 �0�0 1 `f W� /
tOCiATED PERMITI if applicable) b
ID #(if applicable)
State Zip Code
3. WELL • SE (Check Applicable Box): Residential Water Supply ❑
DATE RILLED �2 —
TIME OMPLETED AM ❑ PM ❑
t
4.IlVEL OCATION:
CITY'.' , COUNTY
1
(Stye Name, Numbefs, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPO RAPHIC / LAND SETTING: (check appropriate box)
❑Slop; ❑Valley QFlat ❑Ridge pOther
LATIT' DE XOa5�81-'&VfN" DMS OR 3X.)oo0cMXXX DD
LON UDE 7Z0F,�° &? ti 1 qV k) ° DMS OR TX.X)O000tJO X DD
Latitud ` ongitude source: )&PS QTopographic map
(JocatJ , of well must he shown on a USGS topo map andattached to
this fo if not using GPS)
i
S. WEL WNER
Ownedd ame
rj C kS 7
jSt:ree,-�address G
O 71
City 0
1 Town State Zip Code
Area coc I Phone number
6. WELL ETAILS: _
a. TO DEPTH:
f`
b. DC { SWELL REPLACE EXISTING WELL? YES ❑ NOI
1
c. W rER LEVEL Below Top of Casing: FT.
(Use °+° if Above Top of Casing)
d. T OF CASING IS FT. Above Land Surface"
op of casing terminated atlor below land surfaee,may require
variance in accordance with 15A NCAC 2C A718.
e. YIE D Win). METHOD OF TEST
f. DI , NFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
7- CASING: Depth Diameter Weight Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
8. GROUT: Depth Material Method
Top_ Bottom /� Ft
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Diameter
Slot Size Material
Top Bottom
Ft
in.
in.
Top Bottom
Ft.
in.
in.
Top Bottom
Ft
in.
in.
10. SAND/GRAVEL PACK:
Depth
Size
Material
Top Bottom
FL
Top Bottom
Ft
Top Bottom
Ft.
11 _ DRILLING LOG
Top Bottom
Formation Description
1
/
1
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
: ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER_
SI ATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
r
Form GW-1 a
Rev. 2/09

J S���IdTfAL WELL CONS t MUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # L —-
1 WELL hONTRACTOR:
Mp .
Weli ntractor (individual) Name
a
Well i ntractor Company Name
Stree ' dress
f Ald
City o 9 Towh
State Tip Code
Area cod' Phone number
2. WELL
WELL C
OTHER
S(TE WI
3. WELL
DATE
TIME
A. WELL
CIT1��
(Strei
TOPC
❑ Slop
LATIT
LONG
Latitua
{/ocati
this fa
5. WELL
3TRUCTION PERMITH
iOCIATED PERMIT#(irapplicable) r�Q
ID #(if applicable)
(Check Applicable Box): Residential Water Supply ❑
g. WATER ZONES (depth):
Top
Bottom Top Bottom
Top
Bottom Top Bottom
Top
Bottom Top Bottom
Thickness/
7. CASING:
Depth Diameter Weight Material
Top
Bottom Ft
Top
Bottom Ft
Top
Bottom FL
8. GROUT:
Depth Material Method
Top_
Bottom % WO Ft IrYYI�t /�--cSCG�
Top
Bottom Ft -
TOP.
Bottom FL
9. SCREEN:
Depth Diameter Slot Size Material
Top
Bottom Ft in. in.
Top
Bottom Ft in. in.
TRILLED a �-j l
Top
Bottom
Ft in. in.
DMPLETED AM O PM O
OCATION•
10. SAND/GRAVEL PACK:
Depth
Size Materiai
(f1�OX COUNTY
Top
Bottom
Ft
Top
Bottom
Ft
Name, Numbers, Community, Subdiivision, Lot No., Parcel, Zip Code)
Top
Bottom
Ft.
;RAPHIC / LAND SETTING: (check appropriate box)
11. DRIVING LOG
DValley pRat ORidge pother
Top
Bottom
Formation Description
o
DE 3 c3I ' 4q V " DMS OR 3x.XXX 000XXX DD
=
f
uDE jZQF),-3?' 1 q I g014) DMS OR 7X.xroo =XX DD
longitude source: V6PS Dropographic map
i of well must be shown on a USGS topo map andattached to
ri if not using GPS)
l
1
J
)WNER
/
�enss 51- 0/1hzi!6a—
dame
/
�Ilr`�lC�)�trJs - lk-7
l
kddress U
J
Town State Zip Code
j
-
f
Area �co , Phone number 12. REMARKS:
l
6. WELL]ETAILS: r r
a. TOTAL DEPTH;
i.�
b. DQ S WELL REPLACE EXISTING WELL? YES O NO101 ; I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
C. W R LEVEL Below Top of Casing: Fr, ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
(Use "+° if Above Top of Casing) STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
d. TO+ OF CASING IS Fr. Above Land Surface"
op of casing terminated at(or below land surface,may require
variance in accordance with 15A NCAC 2C .0118. SI NATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YI D (gpm)t METHOD OF TEST
f. DI NFECTION: Type Amount PRINTED NAME OF PERSON CONSTRUGTING THE WELL
`►lit3�ttff )Sift R1s Dts�ss)t9sr Form GW-1a
Rev.2/09

RERDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Div'iission of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL
OCTOR: g. WATER ZONES (depth).
— !(1�j_),
)okb!�:," : Top Bottom Top Bottom
Well Ci
ntractor (Individual) Name Top Bottom Top Bottom
Top Bottom Top Bottom
Well
7 ntractor Company Name Thickness/
7. CASING: Depth Diameter Weight Material
Stre_eti
ddress Top Bottom FL
I
!/
/� J V� /71 Top Bottom Ft .—
,I ow State Zip Code Top Bottom FL
M
a
Area cod
Phone number 8. GROUT: Depth Material Method
2. WELL
FORMATION: ; Top_ _ Bottom % FQ FL
WELL C
f f p
- NSTRUCTION PERMIT# [8 f I D 100 O Top Bottom Ft
Top Bottom Ft.
OTHER
} OCIATED PERMIT#(ifapplic�le) f.7 l��1'�
SITE WE
L ID #('d appUcabie1 = 9. SCREEN: Depth Diameter Slot Size Material
3. WELL
i JSE (Check Applicable Boxy Residential Water Supply [ITop Bottom Ft in. in.
DATE
RILLED 2— tl — 0/ : Top Botbm Ft in. in.
Bottom —Ft —in. in.
TIME
f OMPLETED AM ❑ PM [ITop
' 4.1�fIEa
OCATION: 10. SANDIGRAVEL PACK:
L+
Depth Size Material
" "
CITE
COUNTY 7op Bottom Ft.
Top Bottom Ft
(Strel
Name. Numbers. Community, Subdivision, Lot No., Parcel, Zip Code) Top Bottom Ft
TOPO
RAPHIC ! LAND SETTING: (check box)
appropriate
[]Slop
❑Valley ❑Flat ❑Ridge 001her DRILLING LOG
Top Bottom Formation Description
LATIT
i DE O35a3//'� ' q wN " DMS OR 3XJOIX7000= DD = f
�
LONG
UDE��A'3?9� ° DMS OR 7X.XXXX)OCXXX DD D I f FD hyn2o z k s �
19aPS
Latitud
j longitude source: y,❑ibpographic map /
(locati
of well must be shown on a USGS topo map andattached to !
this fo
'""7 if not using GPS) /
l /
5. WELL
WNER /
Ownef
ame /
r %
s : /
Stree
I Diddress a/
' 75 /
i
City ag
Town State Zip Code /
Area co
Phone number
12. REMARKS:
6. WELL
a. TO
ETAILS: 1 p�1 s
DEPTH: I Q D
b. D
/ .
SWELL REPLACE EXISTING WELL? YES ❑ N01�J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. W
R LEVEL Below Top of Casing: FT_ ACCORDANCE WITH 1SA NCAC 2C, WELL CONSTRUCTION
= STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
(Use °+° if Above Top of Casing) PROVIDED TO THE WELL OWNER.
d. TO
"i
OF CASING IS FT. Above Land Surface`
terminated atfor below land surface may require W� Z Z
op of casing
15A NCAC 2C CONTRACT 1 OR DA i C
variance in accordance with .0118. SIGNATURE OF CERTIFIED WELL
e. YIE
D (gpm): METHOD OF TEST
DI
i NFECiION; Type AmCUnt : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
9qf.
I$Llb�tf
. .. i$ at...�+
ZRN.i'�'„ ..yr 14vy�`t7''e' 9 y%%z 5.c rm-'.' 2�a ;7
' $11i16f`(})1_M' A DSO t$al�'� tlfl 3ceSi 4, FormGW-1a
.''YW. Y'q, ft i� { ii •q `,.yam fY1 1 .� [.7 Z Y yD-iF
i,.x. e+�v>. Rev. 2109

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WEL ''
CONTn ACTOR.
17 /�fl%r / tt�nsS
g. WATER ZONES (depth):
Top Bottom Top Bottom
Well
ontrador (Individual) Name
Top Bottom Top Bottom
1
1
Company Name
Top Bottom Top Bottom
/�Wellj;ontractor
Thickness)
L
J l
Address t L'
Towh State Zip Code
7. CASING: Depth Diameter Weight Material
To Bottom FL
Top Bottom Ft
Street
City •
+�
Top Bottom FL
117
�D 07 — 7Gi `1
a Phone number
8. GROUT: Depth Material Method
Area co0a
2. WEL
INFORMATION:
Top_ c i Bottom/
WELL Cl
/
NSTRUCTION PERMIT# n / 0 00 l
Top Bottom FL
OTHER `
�""l� )
SSOCIATED PERMIT#(if applicable) ( E( r U f� / 1 S
Top Bottom R.
SITE W
LL ID #(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3. WELI
USE (Check Applicable Box): Residential Water Supply El
Top Bottom FL in. in.
i
DAT
DRILLED - U%
Top Bottom FL in. in.
TIMEff
OMPLETED AM ❑ PM ❑
Top Bottom FL in. in.
4. {IVEL tI
LOCATION:
10. SAND/GRAVEL PACK -
CITY
COUNTY
Depth Size Material
��i'
Top Bottom Ft
__ r
Name, Numbers, Community, Subdivision, Lot No.. Parcel, Zip Code)
Top Bottom FL
Top Bottom FL
(Stree"
TOPO
33RAPHIC / LAND SETTING: (check appropriate box)
[]Slop'
❑Valley []Fiat []Ridge ❑Other
11.DRILLING LOG
LATI ;
V
DE Q 5 81. W f " DMS OR &.)oc3Qt70oCXyC DID
Top Bottom Formation Description
LONG!
UDE j4°,Hy ` 141 Oil) a DMS OR 7X.=WDD= DID
Latitud)I/longitude
source: °LD6PS OTopographic map
/
(locatiN
of well must be shown on a USGS topo map andattached to
this fo
n if not using GPS)
/
5. WEL
l
3WNER - -
/
flame
Owne
u2 `7
G�11'�a�hoi`rrts faj) Onil
ddress U
/
,
/
Street'
^' 871-5
own I State Zip Code
,
/
—city o'I
Phone number
Area co
;
12. REMARKS
6. WELL
)ETAILS:
a. TO
t C
DEPTH. / C}
V0
b. DO.
S WELL REPLACE EXISTING WELL? YES ❑ NO'p/
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WA
ER LEVEL Below Top of Casing FT.
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
(Use °+^ if Above Top of Casing)
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED T THE WF_LL OWNER.
d. TO.
OF CASING IS FT. Above Land Surface'
'.
p of casing terminated atfor below land surface may require
variance in accordance with 15A NCAC 2C .0118.
S GNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. Y19
D (gpm): METHOD OF TEST
f. DIS11
IFECTION: Type Amount
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 a
Rev. 2109

r
RECEIVED
Permit Number WI0100198 FEB O 6 2M
,I.sheville Regional Office
Program Category e��il Pif&31' Protection
Ground Water -..�
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Central FIIes: 'APS_ SWP_
02/02112
it Tracking Slip
Status Project Type
ctive New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Charles M. Kuzell
Owner
Cmr 450 Box 456
Apo AE 09705
Facility Name Major/Minor Region
Charles M Kuzell SFR Minor Asheville
Location Address County
673 Wickhams Fancy Dr Buncombe
Can NC 28715 Facility Contact Affiliation
Owner
Owner Name
Owner Type
Individual
Charles M Kuzell
Owner Affiliation
Charles M. Kuzell
Owner
Cmr 450 Box 456
Dates/Events
Apo AE 09705
Scheduled
Orig Issue App Received Draft Initiated
Issuance Public Notice Issue Effective Expiration
02/02/12 01 /05/12
02/02/12 02/02/12
Regulated Activities
Heat Pump Injection
Private residence, single family
Outtall NULL
Waterbody Name
Stream Index Number Current Class Subbasin

NCDENR
North Carolina Department of Environment and Natural Resource_ s
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman
Governor Director Secretary
02/02/2012
Charles M Kuzell
Patricia L Kuzell
CMR 450 Box 456
APO, AE 09705
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10100198
673 Wickham's Fancy Dr.
Candler, NC 28715
Dear Mr. Kuzell.:
On 01/05/2012, 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 [e-mail] if you have any questions.
jSerely, ^
for De a atts
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. MTIO100198
Buncombe County Health Dept.
Jeff Moore (Clearwater "'ell Drilling Inc., P.O. Box 71., Hot Springs, IBC 2043)
Duane Gentry (Gentry Heating Inc., 100 Buckeye Cove Access Rd., Swannanoa, NC 28778)
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.ncwateraualitv.org
An Equal Opportunity 1 Affirmative Action Employer
..One ....::.::...
NorthCarohna
N;k `!1 �1

LINA
DEPARTMNT OF ENVIRONMEN T�
ED NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTIMRAIAL
F�'VATER-ONLY INJECTION WELL SYSTEM
TYPE 5®'W WELLfSI
In Accordance With the Provisions ofNCAC Title 15A 02C.0200
Print or type the required information and mail to address on the back page.
DATE: �= 7 "" 20
Yell 4Pe Confirmation: Does the proposed system circulate potable water onlX (no additives) in
continuous piping that completely isolates the fluid. in the environment (i.e.
clos_ ed-loop)?
Yes VContinue completing this form.
No Do Not complete this form. Complete other UIC application fords for installing
either a 5A7 well (open -loop well in'ectin loop wepotable water into the aquifer) or a 5QM well (closed-
ll containing additives such as R 22, ethanol, or other antifreeze or corrosion inhibitors).
. PROPERTY 0"ER(S)IAPPLICANT(S) ,
List each Property Owner listed On
property deed (if owned by a business or government agency,
entity and a representative w/authority for signature): state name of
H�-i i ES r- P(+ i R i C1 L. ►� �'ZEr it
(1) Mailing Address: C
4 56
City: > 140 State: AC Zip Code: Vit �� Home/Office Tete Na.: i o :3-- q "7 5 County:
jt
Email Address: KJ2ctr 4 Cell No.;
- (2) Physical Address of Well Site (if different than above): 607,� uO i C KH 14nn5 r4,rV L y
City: State: /Y �
Zip Code: ' � Q 7 s� County:
Home/Office Tele No.:
Cell No.:
$' AUMORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject attach a letter from the property owner authorizing Agent to install and operate UIC well) t property,
Company Name:
Contact Person
Address:
City.
Off ce Tele No.
State: Zip Code;
County:
W'Osife Address of Company, if any:
GPU/UIC SQW Notification of Intent 1:0rm (Revised 8/2008)
. C v

C• WELL DRILLER IN ORMATION
Company Name:—L
Well Driller Contractor's Name:.
NC Contractor Certification No.:
Contact Pers
Address:
City:
Office Tele No.:
�a
Zip M
Ar& u
iCell o r
i ur
D. HEAT PUMP CONTRACTOR MORIiMATIOIIIN (if difi'erent than driller)
Company Name r
Contact Person: f e IdA Ila 4--
E.
F.
G.
City' tQ°� Zi Code:
Office Tele No.. _ P �-Ou�
STATUS OF APPLICANT
Private: t / Federal:
Commercial:
State: Municipal:
Native American Lands;
INJECTION PRO EDURE (b efly describe how the injection well(q) will be used),
WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: — �')
Number of borings: (D
Approximate depth of each boring (feet):
(2) Type of tubing to be used (copper, PVC, etc):
(3) WelI 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 plc others ci
Casing depth: From C � �)
to feet (reference to land surface)
Casing extends to above ground inches
(b) NO
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat cement'
I3enfanite t✓ c i �i Sf1
.. (b) , Crrovf placement: PiOther (specify)unpin , �„-•,
g —( Pressure Other
(c) Grout depth of tubing (reference to land surface): from from
If well has casing, indicate grout dep' rh; - to `— 06' (feet)
to -----___(feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8@008)
N" 's
a
Baal
1

Page 3 of 4
F. INJECTION-RELATEM EQU PMENT
Attach a diagrmii 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.
1. LOCATION OF WELL(S)
Attach hvo copies of maps showing the following information:
(1) include a Site lvlap (can be drawn) showing: buildings, property lines, surface a:ater 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 sucli as septic tanks or drain fields located 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. CERTWICA.TION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby aeitify, under penalty of law, that 1 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. 1 agree to construct, operate, ma in, repair, and if applicable, abandon the injection well and
all related appurteriances in accordance with tie d specifications an deconditions of the Pen -nit."
Signature of Property Owner/ licant
Print or Type Full Nat» a and title
Signature of Property Owne'r/Applicant
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-JDWQ
Aquifer Protection Section-Ule Prog�ra>n r`v
1636 t'ATail 5erviee Center
Raleigh, NC: 27699-1636 :a
Telephone (g19) 733-3221
CD
MADC 5QW Notification. orintent Form (Revised 812008)
CD - C!
Ci
12/29/2011

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