WI0100203_Regional Office Physical File Scan Up To 9/23/2022

Permit Number W10100203
F E la n ,, [0 Central Files: APS_ SWP_
lrtl �� �Uf [� 04/10/12
A��19 ,)r;� Pe mit Tracking Slip
Program Category
Status
/ash Bvllle Regional 1ve
Project Type
Ground Water
officc-Ac
New Project
B'f � '�I®D��/elion
Permit Type
Permit Classification
Injection Water Only GSHP Well System (5QW) 1.00
Individual
Primary Reviewer
_ Permit Contact Affiliation
eric.g.smith
Bret Hartzog
Coastal SW Rule
132-B Third Ave
E
Hendersonvlle
NC 28792
Permitted Flow
Facility
Facility Name
Major/Minor
Region
Asheville
David & Patricia Wyche SFR
Minor
Location Address
County
33 Bear Flower Trl
Buncombe
Arden NC
28704 Facility Contact Affiliation
Owner
Owner Name
David Wyche
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance
04/10/12 04/08/12
Regulated Activities
Heat Pump Injection
Outfall NULL
Owner Type
Individual
Owner Affiliation
David Wyche
15 River View Ln
Marion MA 02738
Public Notice Issue Effective Expiration
04/10/12 04/10/12
Current Class Subbasin

A
NCDENR .
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor Director
April 11., 2012
David Wyche
Patrick Wyche
15 River View Lane
Marion, MA 02738
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10100203
33 Bear Flower Trail, Arden, NC 28704
Dear Mr. & Mrs. Wyche:
Dee Freeman
Secretary
On April 3, 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:
The injection well system contains only potable water,
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
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.Ro ers@ncdenr_gov if you have any questions.
Sincerely,
0 1—o , 6Aqx(�,
-
a• Debra
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. W10100203
Buncombe County Health Dept.
Glenwood Custom Builders (Bret Hartzog)
Clearwater Well Drilling (Jeff Moore)
Air Excellence, Inc (Darrell Bedwell)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St, Raleigh, North Carolina 27604
Phorm: 919-807-64 64 1 FAX: [phone]
Internet: www.ncwaterguality.org
An Equal Opportunity 1 Affirmative Action Employer
NorthCarolina
;Vatt(mll� J

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 50W WELL(S)
-In Accordance With the Provisions of NCAC Title 15A 02C.0200
Print.or type the required information and mail to.address on the back page. APR ® 3 2012
DATE: o, _ 20 �o 00�,03
Section
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes " Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well injectin potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature):
C,
(1) Mailing Address: a' t
City: State: ffl Lip Code: -
county-Home/Office Tele No.:� �C/�i Cell No.:
Email Address: Website:
(2) Physical Address of Well Site (if different than above): ZL N'-�-
City: &_J21_� State: f)C-, Zip Code: %� County: 1411' '
Home/Office Tele No.: Cell No.:
B. 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)
Compan
Contact
Address
City: ILIAState: NL Zip Code:zS� 6-1/ County:
Office Tele No.: `bZ q Z- Al i Cell No • 3(Z;r- l `13�Z�7Q
Website Address of Company, if any:
GPU/UIC 5QR' Notification of Intent Form (Revised 8/2008) Page 1

n
C. WELL DRILLER INFOPIATION
Company Name:
Well Driller Contractor's Name:
NC Contractor Certification No.:
Address:—,'21
City: Zip Code: County: 4
OfficeTeleNo.: Cell No.:
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:
Contact Person: -D,,+ rrc-LL- 1?,, Awe-LL-- EMAIL Address: 1 igrr-e-LC RCX00—L4e re tip• CG
Address: �j0 hjy WAois/s j de- 7"Q.
City: no )J /L Zip Code: MPI County: iguriconvbe
Office Tele No.: �9 T (a 6-V 113 Cel] No.: 'g,2 �- % 0 - $'7 y -7
E. STATUS OF APPLICANT
Private: Federal:
State:
F. INJECTION
Cep
Municipal:
(briefly
WELL CONSTRUCTION DATA
Commercial:
Native American Lands:
how the injection well(s) will be used)
(1) Proposed date to be constructed: �-12 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: _galvanized steel black steel plastic other (specify)
Casing depth: From to feet (reference to land surface)
Casing extends to above ground inches
(b) No L-­­
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement BentoniteOther (specify) r /r L 56 h
(b) Grout placement: Pumping_ Pressure Other
(c) Grout depth of tubing (reference to land surface): from 0_ to 3 -D (feet)
If well has casing, indicate grout depth: from to (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 2

H. 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.
I. LOCATION OF WELL(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 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. 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."
J
cp��A_P_
Signature of Property ner/Applicant
Print or Type Full Name and title
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of A
c
or Type Full Name
if any
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 MaiI'Service Center
Raleigh, NC 27699-1636
Telephone.[phone]
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008)
RECEIVED/DENR/M
APR 03 201
Aquifer Protection Section
Page 3

-ID

k'IP ti v 12 iji
(bOF3'- 748-1583
Bret I lartzog — Project N4anagler
Glennwood Custorn 3uilders
132-B Third Avenue Eas_
Hendesrsanville NC 28192
S28 692 8191 phone
828 692 0052 fax
emaill
June 16, 2011.
Attn: Permit Center
P,e: Authrorized Agent letter
`o Whom It rVUiy Concert:
q&
GLENN-WGDD
C u_to:,i ht3,jdC:TP
'With .his letter, I, Tricia Wyche, authorize you to woonize Bret Hartzog with Glerinwood
Custom Builders as my Agent, anc _ycting in my behalf may sign for pern;its for construction at
33 Bear Flower Trail, Arden, NC L8?04_
Sir nature . ;r
Name
0
Date
RECEIVE®ID PMQ
APR 03 201
Aquifer Protection -Section

Buncombe County Tax Lookup - Property Card
Page I of I
COUNTY OF BUNCOMBE, NORTH CAROLINA
Web Property Record Card
Go. 9623-69-3077-00000
Owner Information
C DAVID WYCHE
PATRICIA L WYCHE
15 RIVER VIEW LN
MARION MA 2738
Location:33 BEAR FLOWER'
Taxing Districts
Buncombe County
SKYLAND FIRE
Date Printed: 4/10/2012
Parcel Information
Total Property Value: 618,000
status:
Active
iccount:
8251418
)eed Date:
9/29/2011
)eed Book/Page:
4918 / o884
'lat Book/Page:
0102 / 0197
.egal Reference:
WARRANTY OR SPL/COMP TRANSFER
,ocation:
33 BEAR FLOWER TRL
;lass:
RES BUILDING LOT
leighborhood:
WALNUT COVE
ubdivision:
THE CLIFFS AT WALNUT COVE
ub Lot:
11
zoning:
'onservation/Easement:N
Ownership History
Transfer
Date
Price
Legal
Reference
Deed
Book/Page
Qualified
Vacant
When
Account
Seller Names
Sold
WARRANTY
CLEAR
09/29/11
$230,000
OR SPL/COMP
4918 / o884
Yes
Yes
8213154
DEVELOPMENT
TRANSFER
INC
WARRANTY
THE CLIFFS AT
07/28/o6
$625,000
OR SPL/COMP
426o / 1523
Yes
Yes
8166269
WALNUT COVE
TRANSFER
LLC
Assessment History
Year
Account
Acres
Land
Bldgs
Apr
Assessed
Desc
Exemptions
Deferred
Taxable
2012
8251418
1.28
618,000
o
0
618,000
0
0
618,000
2011
8213154
1.28
618,000
o
0
618,000
0
0
618,000
2010
8213154
1.28
618,000
o
0
618,000
0
0
618,000
20o9
8213154
1.28
618,000
o
0
618,000
0
0
618,000
2oo8
8213154
1.28
618,000
o
0
618,000
0
0
618,000
2007
8213154
1.28
618,000
o_
0
618,000
0
0
618,000
(Land Data Total Acres: 1.28
Acres
Land Value: Other Value: o
618,000 Improvements
ption
Segment#
Units
Descri
1
1.28 Acres
LOT
Total Building Value: o
http://www.buncombetax.org/PropertyCard.aspx 4/10/2012