WI0100146_GEO THERMAL_20110331

Permit Number WIOIOO146 �r
i
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (50W)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Central Fifes: APS SWP
03/31 /11
Permit Tracking Slip
Status
Project Type
Active
New Project
Version
Permit Classification
1.00
Individual
Permit Contact Affiliation
Julie Jensen
Owner
130 E John Carpenter Freeway
Irving TX 75062
�ri�41
Facility Name Major/Minor Region
Echoview Community Mill Minor Asheville
Location Address County
76 Jupiter Rd Buncombe
Weaverville NC 28787 Facility Contact Affiliation
,)weer
Owner Name
Julie Jensen
Dat
Scheduled
Orig Issue App Received Draft Initiated Issuance
03/31 /11 03/28/11
Rer,ulated Activities
Commercial or industrial, other
Heat Pump Injection
Out -fall
Owner Type
Individual
Owner Affiliation
Julie Jensen
Owner
130 E John Carpenter Freeway
Irving TX 75062
Public Notice Issue Effective Expiration
03/31 /11 03/31 /11
Waterbody Name Stream Index Number Current Class Subbasin

Ak7VXy1_9A;?WFA
RCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly raves Perdue Coleen H. Sullipl-
Governor Director
03/31/2011
Julie Jensen
130 E. Johri Carpenter Freeway
Irving. TX 75062
sill jest: Acknowledaemew of Intent to Construct Type 5QW Injection Well 5ysiem
PermitNo w10100146
Eclin iew Community Mi1l
76 Jupiter Rd.
Weaverville, NC' 28787
Dear Ms- Jensen.
Dee Freeman
Secretary
On 03128-12011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
gvothernial injection well system for the operation of a ground -source heat pump located ai the address referenced above An
individual permit is not required for The construction and operation of this type of geothermal injection well 6vstem as long as the
tollowina conditions are met:
1 The injection well system contains only potable water.
2, The injection well system is constructed to accordance with well construction standards specified in North
Carolina Adniin] suatii-e Code Title 15A Section 2C Subchapter 0'. 13, and
The required notification form and associated maps have been completely and accurately submitted
Failure to comply with ali of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter 02-1 l(u)(2) Additionally. you should contact the Buncombe County Health
De-panmem as they may have additional requtrements for this type of system. Nnncomphance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at (919) 7 15 -6166 or Michael.Rot-,ers a mcdent.-ov if you have ally questions
r.
for Debrd Warts
Supervisor
cc: Asheville Regional Office - APS
APS C=nirai F•iies - Permit No. W1010014
Buncombe County Health Dept.
Von Plemmons (Clearwater Well Drilling, Inc., P.O. Box 71, Hot Springs, NC 28743)
Duane Gentry (Gentry Heating, Inc., 100 Buckeye Cave Access Rd.. Swannanoa, NC 28778)
AQUIFER PROTECTION SECTION
1636 Mat, Service Center, Raleigh. North C.am1irra 27699-163t
Location 7 7728 Capilal Bouievarc, Raleigh. Norill Garoikna 27604 Une
Phone; 919-733-3221 � FAX [phone]. FAX [phone]­�04 C.ustarier Se, 1-P'• -z�� 7kF.
Intemer Y.o www ncwatemualitra 1\ Oirt1iaFG1lllu
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP_ GEOTHERMAL.
WATER -ONLY INJECTION WELL SYSTEM
TYPE 50 W WELL
In Accordance With the Provisions of NCAC Title l 5A 02C.4200
Print or type the required information and mail so address on the back page.
DATE: J - 3) 200
Well Type Confirmation: Does the proposed system circulate potable water onl,, (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-Iopp)?
r—
Yes y` Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (Wen -loop well in' in 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)IAPPLICANT(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): JL{%R yOe n
(l) Mailing A ddress:
City. _r_ V k �'\c State: 1)� Zip Code:_ County: ! Gt
Home/Office 7 N z 0 2- 1 US aY. _ Cell No.: ;-o 2
Email Address: _=-`---� ' Website_ rrC ti b V i e- c:: �'+- = m t 6 vY_1
(2) Physical Address of Well Site (if different than above): _ _ . _� _ _ �t_ + i - Y A
City: W P V zv'V l 1 k f_ Slate: h LZfp Coder County: ^+Y1 0►�' �'�.
Home/Office Tele No.: �� 6 �� Cell No-: 51x-►yr-�—
B. AUTBORIZED 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)
Company Name:
Conact Person: EMAIL Addrnss:
Address:
City: State: Zip Code: County:
Office Teie No.: Cell Nn.•
Website Address of Company, if any: _--
GPUMIC 5QW Notification of buent Form (Revised 812008) Page t

C.
E.
WELL DRILLER
Company Name: L t 0-ew z+w Lya by *, w
Well Driller Contractor's Name: Vb►r-
NC Contractor Certification No.:
Contact Person; A1L1a-P101An(+0&S- #i _� e-��- µoars EMAIL_Addmns_ ,1 PAC. Ly � U- 0,c( 1 D@
Addim: T-b - i� a1- 11
City: 5 Zip Code: t4 C- County: )mac I J'i S WX
Office Tele No.: _ : Cell No.: (oq t -U S2-(v 7-7U-(052AP
HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Comnanv Names -,e v LAvi.! ��Ctz•Tti�4 �
Contact Person: �Aplw ,c I._, C* t -' EMAII. Address:
Address: _
City: Zip Code: County:
Office Tele No.: �n-` tq w 2.5Z0 Cell No.: '�52-% -552- H 2-1
STATUS OF APPLICANT
Private: Federal: Commercial:
State: Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA
(1) Proposed daft to be constructed: Number of borings: LQ
Approximate depth of each boring (feet): ;
(2) Type of tubing to be used (copper, PVC, etc): , ] F — _ -
(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. lJgalvanixed steel black steel plastic other (specify)
Casing depth: From to
Casing extends to above ground
(b) No
_feet (reference to land surface)
inches
(4) Grout Info (material surrounding well casing and/or -piping): ! �+
(a) Grout type: Neat Cement Bentonite Other (specify),5r+ / is -y
(b) Grout placement: Pumpin ze-r Pressure Other Ew - 4+/k, �'
(c) Grout depth of tubing (reference to land surface); from o 0-4 to 37 S (feet) C. ' "'
If well has casing, indicate grout depth: from to (feet)
GPUIUIC 5QW Nodfim ion of InUxU Form (Revised SnO08) Page 2

IL 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.
L LOCATION OF WEWS)
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
Dote: This Permit Application most be sighed 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."
Sivature otfrope-rN OwnevApplicant
Print or Type Fun Name and -title
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authori zed Agent, if arty
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUMC 5QW Notification of k t = Form (ttw;sed W2M) Pop 3

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