WI0100118_GEO THERMAL_20100908

Permit Number W10100118
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (50W)
Primary Reviewer
michaei.rogers
Coastal 5W Rule
Permitted Flow
icy lty
Facility Name
105 Forest Knoll Place
Location Address
105 Forest Knoll PI
Weaverville NC 28787
Owner
Central Files: APS SWP r
09/08/10
Permit Tracking Slip
Status
Project Type
Active
New Project
Version
Permit Classification
1.00
Individual
Permit Contact Affiliation
Von Plemmons
PO Box 71
Hot Springs
NC 28743
Major/Minor Region
Minor Asheville
County
Buncombe
Facility Contact Affiliation
Owner Name Owner Type
Individual
Dee Dee Anders Owner Affiliation
Dee Dee Anders
105 Forest Knoll PI
Weaverville NC 28787
Scheduled
Orig Issue App Received Draft initiated Issuance Public Notice Issue Effective Expiration
09/08/10 09/08/10 09/08/10 09/08/10
Reculated Activities
Heat Pump injection
Outfall N1%JL!
Waterbody Name Stream Index Number Current Class Subbasin

NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
9J8'2010
James T. Anders
Dee. Dee Anders
105 Forest Knoll Place
Weavervill.e, NC 28787
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10100118
105 Forest Knoll Place. Weavetville, NC 28787
Dear Mr. 8t Mrs. Anders:
Dee Freeman
Secretary
On 918/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onh
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.RoBers,a)ncdenr.gov if you have any questions,
Sincerely,
r
,for Debra Watt_-,
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. W10100118
Buncombe County Health Dept.
Clearwater Well Drilling — Von Pierrunons, PO Box 71, Hot Springs, NC 28743
Bulllnan Heating and Air — Tom Trantham, 10 Red Roof Lam;, Asheville. NC 28814
AQUIFER PRDTECTIDN SECTION
1636 Mall Service Center, Ralaig . North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, No Rh Carolina 27604
Phone; 919.733-33221 I FAX t 919-715-0588: FAX 2: 919-715-BW i Customer Service: 1-877 623-5748
Internet. www,neytratergua_111+1_D
Arr Epual Opperturiiq %Arfirrnalk Atuarr Employer
One
No tb Carolina
;Vawl'a,14i

09/08/2010 05:57 FAX
Q 002
NORTI.1 CAROLINA
DbPARTMENT OF ENV] RONMENTAND NATURAL RESOURCES
NOTI.14CATION OF INTENTi TO CONSTRUCT A CL0rLD-L0_0P GEOTHERMAL
WAT_ E&QNLYY INJECTION WELL SYSTEM
TYPE SOW WI;L S
In Accordam With the Provisions ofNCAC Tido 15A 02C,0200
Print or type the ramped Wormatiom and mall to mMrws an the back paga
DATE; L�r� , 20 s' Ila: C) l C�
WaA YjPe Cmirarnfadox: Daea the proposed system circulate potable ytrataroily (no additives) in
continuous piping thm completely isolates the fluid from the environment (i.e.
clo - ?
Yes Continue completing this form.
No Do Not complete this form. Complete other UIC application forma for installing
either a 5A7 well CqM-loop well .n •ti potable water into the aquifer) or a 5QM well (closed -
loop well cominingaddifi such as R 22, ethimol, or other antifreeze or oormslon lnhlbim)•
A. PROPERTY OWNER(S)IAPPLICANT(S)
List gash Piaperty fawner listed on property deed (if owned by s business or gov t tray, state game of
entity and a representative wtauthority far signature): Some-& _ -T � /) a ❑e s Pe e fit) deal.?
(1) Mailing Address: J 1 •
City: i stag: f)L Gip Code: County: r G'n►M
Horne/Office Tole No.:
Email Addness: _
(2) Physical Address of Well Site (if different than above):
City: — State: Zip Code: County: w
HometOfi;re Tele No.: Cell No.:
R. AUTHORUMD AGENT OF OWNER, IF ANY (if the Permit Appiioant does cot own the subject property,
attach a letter from the property owner authorizing Agent to install and opewlie UIC well)
Company Name:
Contact Person: A [ Address:_
Address:
City: State Zip bode-, County:
Office Tele No.: Celt No.•
Website Address of Company, if any:,
REC1r1VEO I DENR t D*Q
OPO/01C 5uw mats time nr rnum Form (Revised 0008) Aqufiieer Protection SeAW t
SEP 0 8 nin

09/08/2010 05:57 FAX
IM003
C. WELL DRILLER ]l VORMATI<ON
Company Name:
Well Driller Contwtor's Name:
NC Conmmr Cerdfication No.:
Contact person
Address
City:
�,-f
OfficeTeie No
0. HUT PUMP
Company Nan
Contact Person
aQ—&, Zip Code: W�3T Couattiy:
Cell No. �k—,M __-
WIPORMAT)ION (if difl�erat then drll1w)
11 1 A r
Address+: S Q��,
City: C- Zip Code. 90 — County:
Oifce Tele No.: -� � �I� , Cell No.: -'7
L. STATUS OF APPLICANT
Privets: Federal: Commercial:
SUM: Municipal; Native American Lands:
P. D1.FEGTIDN RUCEDU (br}efty osoribe Crow the Ir�cc#ion c i �e} will b�uftd)
G. WELL CONMUCTION DATA p
(1) Proposed date to be constructed: f ! 7 Number of borings:
Approximate depth of each boring (fit); a",, _
(2) Type of tubing io be used (copper, PvC, ow): 4 -
(3) Well casing. Is the well(s) caseV (check either (a.) Yee u�r (b.) No below)
(a) Yes if yes, then provide ming isfbrmation below
Type: ___0v%niard steel btuelL steel__plagtia other (specify)
Casing depth: Prom to _fhet (reference to land sarNco)
Casing axWWs to above ground _ inehes
(b) No !l�
(4) Grout info (material surrounding well casing andfor piping}_
(9) GMUt type: Nest cement— 9entonite �Othar (specify) %X-441
(b) Ormt placement: Pwnping-� Ptessurc Other
(c) Grout depth of tubing (refemnee to land surface), from to -� (fact)
If well has casing, indicate grout depth: from to (feet)
•coiJi
�'Ma 401
GPUIElIC SOW NutiRcation of I&r Form (ROYIW 8rlo08) Pap 2

00/08/2010 03:58 FAX
Im 003
n. INJECTION-RXI ATW EQUIPMENT
Attach a dhWim showing the englnearing layout or proposed modification of the ir31ection equipment and exterior
piping/tubing zsaciated with the irja 6w operation. The manufacturer's brochure may provide supplementary
infarmatl(m.
I. LOCATION OF W EILIA
Attach two copies of maps showing the foilowing Information:
(1) Include a Site Map (tan be drawn) showing: bulidir4m property lutes, surface v6ater bodies, potential
sources of groundwater contamination and the orientation of and distances between tho proposed weri(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fleids lowed within 2W feet of
the geothermal heat pump well system. LoW all features clearly and include a firth BIM.
(2) ne Site Map must show the subject property in relation to the surrounding area by using at toast two fixed
reference points stitch as mods, streams. and/or highway inm sections.
J. CERTiFICATIOM
Note: This Permit Application most be signed by oath 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 infcnmation
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said inhrmation, I believe that the information is true, sioeurahe and complete.
i am aware that there am 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 thqApproved specifloado4s and oondidoiz ofthe Penult"
Of
'Jan1" � .. Ate
Print or Type W- 1 Name mW We
,tore of Property Owner/Api
D-e _, -D ec,
or Tyne Full Name and title
SignaWsa of Authorized Agent, if any
Print or Type Pull Name and title
Pieest return two copies of the completed Application package to -
North Carolina DLNR-DWQ
Aquifer /protection Sectlon-MC Program
1636 Mad Service Center
Rx1eW NC 27699-1636
Telephone [phone] RECEIVED I QENR i DWQ
Aquifer Protedlatl Section
GKI/01C 3QW Notiiiagon of Irma Fenn tRevism R=8y S E P 08 2{119 Pop 3

09/08/2010 03:38 FAX
191004

09/08/2010 05:57 PAI
Q 001
Clearwater Well Drilling, Inc.
P.O. Box 71
Hot Springs, N.C. 28743
828-622-7421 828--776-6526
Fax: [phone]
To: Mike Rogers, NCDENR
From: Jeff Moore, Clearwater Well Drilling, Inc.
Subject: James Anders 5QW Permit Request
Pages: 5 Including Cover
Note:
Any further questions, please give me a calf.
r4,r60rIVt:►J 1 LJLiVtt ► uvvt1
MOW Pratectipr Section
SEP 0 8 2010