WI0100187_Regional Office Physical File Scan Up To 9/23/2022

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Permit Number W10100187
D —F®
L i
NOV 17 2011
Inwo
Central Files: APS_ SWP_
11/16/11
Permit Tracking Slip
Program Category
Status Project Type
Ground Water
Active New Project
Permit Type
Version Permit Classification
Injection Water Only GSHP Well
System (5QW)
1.00 Individual
Primary Reviewer
D
Permit Contact Affiliation
eric.g.smith
R-6E C
LarryWells
Contact Driller Well
Coastal SW Rule
NOV 2 $.2�} I I
256 N Turkey Creek Rd
Regional Ofiiice
Leicester NC 28748
Permitted Flow
A sheviile
.�1L6ilE?r prote✓C$IOn
Facility
Facility Name
John & Sue Pregartner SFR
Location Address
B3 Mica Point Dr
Burnsville NC 28714
Owner
Owner Name
John
Dates/Events
Pregartner
Scheduled
Orig Issue App Received Draft Initiated Issuance
11/15/11 10/28/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Major/Minor Region
Minor ;Asheville_ 1
County
Yancey
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
John Pregartner
4705 Essex Dr
Doylestown
PA 18902
Public Notice Issue Effective Expiration
11/15/11 11/15/11
Waterbody Name Stream Index Number Current Class Subbasin

.4
il;�. AW
WMENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
11/16/2011
John Pregartner
Sue Pregartner
4705 Essex Drive
Doylestown, PA 18902
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100187
B3 Mica Point Drive-, Burnsville, NC 28714
Dear Mr. & Mrs. Pregartner:
Dee Freeman
Secretary
On October 28, 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 Yancy County Health
Department as they mayhave 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 Mlchael.ROeerSla.ncdenr.eov if you have any questions.
rSincerely,
for Debra Watts
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. WI010018 7
Yancy County Health Dept.
AWD Services, .inc. (Larry Wells)
Burleson Plumbing & Heating, Inc (John. Smith)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604 oRC
Phone: [phone] FAX 1: 919-715-0588: FAX 2: 919-715-60481 Customer Service:',-877-623-6748 On-, � �
Internet: www.ncwatergualitv.oro r
An Equal Opportunity 1 Affirmative Action Employer" �'i

J,
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSET) -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potablewater only as part of a geothermal heating and cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
Print or Type Information and Mail to the Address on the Last Page.
DATE: Oc t l �% 20-ff PERMIT NO. U—Tl—(D I C)O (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence "ate :Business/Organization
Government: State . Municipal County Federal
D. WELL OWNER — For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
e
Mailing Address:
City: o State: Zip Code:, °%'� Z County: �4CKC'
Day Tele o.: — .�� �. — Z G Z 2 = Cell No.: 90 Y Z s-7
.EMAIL Address: y ?V64e'Qz M f G),1WCet1*ax No
1)
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PIN.) of well site: 0 7411000 9/9 2- 3 County: � h
(2) Physical Address (if different than mailing address):
es �� 7Ze G(ra_c
City: U 4vni lv 4le- State: NC Zip Code: Z � f
AA RA P j D?-N&� *guk), S.4 MC
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: L ¢ 111-1-
GPU/UIC 5QW Notification (Revised 3/18/2011)
AaLiifer .PiotPCtlt'?o'i S+rlaCtiCri Page 1
OCT 2-8 2011

NC Well Drilling Contractor Certification No.: Z .0 3
Company
Contact
Address
t -ncl
City: l of G e1eep Zip Code 2- 8 7r State: �LCoun ty: 9u4 cv r,
Office Tele No.: F-Z T - y/ b - 2�2-2, - Cell No.: 94� - US'—� 33 f Fax No.: 12.1- g - 9?L 0 7
E. HEAT PUMP CONTRACTOR INFORMATION (if different
than driller)
Company Name: 18 c4 ✓le s aw Nu m+ k n a et N a E ih w � e
Contact Person: n s 6`EMAIL Address: l4 s, bh w
Address: 1
City: r e 6A e Zip Code: 1Z4G'tate:/VC-County:
Office lele No.: 82 74, V0 y 2- Cell No.: _d Z 8- 3 �,� I Z L L Fax No.: ?A 1- 7L f-
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: 2 Depth of each boring
(feet): .3 7-r
* If existing water supply wells will be used then provide the information in item (4)
below. `
(2) Type of tubing to be used (steel,. PVC, etc):
(3) Well casing. If the well(s) will use casing then pro 1de the type (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground:
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite** --a4-- Other (specify)
** By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(1)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from _� to .3 �, r (feet)
If well has casing, indicate grout depth: from to (feet)
G. WELL LOCATIONS - Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1) Attach a site -specific map showing the locations of the following:
* Proposed injection wells
* Surface water bodies
* Buildings
* Water supply wells
* Property boundaries
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
GPU/UIC 5QW Notification (Revised 3/18/2011)
Page 2
f, c,

M
2 Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE. Inmost cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS websita Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, eta can then be drawn in by hand Also, a `layer' can be selected showing topographic contours or
elevation data
GPU/UIC 5QW Notification (Revised 3/18/2011)
Page 3

H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
I5A NCAC 02C .021 l(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official; -
4. for all others: by the well owner (which means all persons listed on the prope deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf:
"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
com lete I am awaTe'thaf there afe'`si cant "en ' ties' includingthe possibility of fines and imprisonment
t p gm p .. P tY
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."
t�
Signature of Prop wner/Applicant
C°'
Print or Type Full Name
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636 . RECEIVED / DENR / DWQ
Aquifer Grctertio i Section
Telephone [phone] OCT 28 2011
GPU/UIC 5QW Notification (Revised 3/18/2011) Page 4

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