WI0100147_GEO THERMAL_20110401

` Central Files: APS SWP
04/01 /11
Permit Number W10100147 ,./
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (50W)
Primary Reviewer
michael.rogeis
Coastal SW Rule
Permitted Flow
Permit Tracking Slip
Status
Project Type
Active
New Project
Version
Permit Classification
1.00
Individual
Permit Contact Affiliation
Rick Molland
296 Morgan Branch Rd
Marshall NC 28753
Facil'm
Facility Name Major/Minor Region
Connie Molland SFR Minor Asheville
Location Address County
296 Morgan Branch Rd Madison
Marshall NC 28753 Facility Contact Affiliation
Owner
Owner Name Owner Type
Individual
Connie Molland Owner Affiliation
Connie Molland
Owner
296 Morgan Branch Rd
Gateslynts Marshall NC 28753
Scheduled
Orig Issue App Received Draft initiated Issuance Public Notice Issue Effective Expiration
03/31 /11 03/23/11 03/31/11 03/31 /11
Renuiated Activities
Heat Pump Injection
Private residence, single family
Outfall h -1111—..
Waterbody Name Stream Index Number Current Class Subbasin

North Carolina DepartmeKHR
I &ent and Natural Resources
-Eiever{y Eaves Perdue _ :ality
Governor North Carolina Department of[Em>attnment and Natural Resources
03/31/2011
Connie Molland
296 Morgan Branch Rd.
Marshall, NC 2R753
Subject! Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10100147
296 Morgan Branch Rd.
Marshall, NC 28753
Dear Ms. Molland:
Dee Freeman
Secretary
On 03/23/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -on]
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 ig conwucted in accordance with well construction standards specified in Noah
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 Madison 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.Rogers a)ncdcnr.«ov if you h� v f any questions.
Sin rely, '
for Debra Wags
Supervisor'
cc: Asheville Regional Office - APS
APS Central Fife- - PArm11 NC! W191001s'
Madison County Health Dept.
Von Plemmons (Clearwater'Well Drilling, Inc., P.G. Box 71, Hot Springs, NC 28743)
Duane Gentry (Gentry Heating Inc„ 100 Buckeye Cove Access Rd., Swannanoa, NC 28779)
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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 50NY WELLS51
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.
DATE: , 20D _
Well Type Conflrmadon: Does the proposed system circulate potable water ortly (no additives) in
continuous piping that completely isolates the fluid from the: environment (i.e.
closed-lvou)`t
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 iniectin 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, Mate name of
entity and a representative wlauthority for signature): J r f r 1
! (1) Mailing Address: f� c'1_J—`�C-��_ � ;�`�,.-�.c , -- -
City: f° State�Zip Code: County:_
Home/Office TeleNo.: -r
Cell No.:��
Email Address: f 'c i o Website:
(2) Physical Address of Well Site (if different than above): -54q }v
City:
State: Zip Code: County:
Home/Office Tele No.: Cell No.:
H. 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)
Company Name:
Contact Person: EMAIL Ad s:
Address:
City:
State: Zip Code:
County:
Office Tele No.: Cell No.:
Website Address of Company, if any:
GPUMC 5QW Notihcadan of Intent Form (Revised W008) MAR 2 3 2011 Page t

C. WELL DRILLER INFORMATION
Company Name:
Well Driller Contractors Name:4���i L -
NC Contractor Certification No.:
Contact Person,' r 1{ t,.+=-.-'v>�( EMAIL Address: �'•s�'�;�r� e;�' --'�+:,�+ �► �C7't7
r
Address:
it .}
City: -f,`}' a- i Zip Code: County:' rr __,
II
Office Tele No.: 7 s A,- �— Cell No.:
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:'-�-
Contact Person; _�,;��s_i L� - j _ EMAIL Address_ x �� y t- C007
Address:t;;—
City: —��.i +�s� Zip Code: �, County: --
Office Tele No.: �4 Cell No.: 1 —
E. STATUS O"LICANT
Private: Federal -
State; Municipal:
F. INJECTION PROCEDURE
Commercial:
Native American Lands:
describe how the injection well 9will be used)
CL�-t- C: ". 7ta'
G. WELL CONSTRUCTION DATA J f
(1) Proposed date to be constructed: ? y 1 ' r _ Number of borings:
Approximate depth of each boring (feet): Lic L
(2) Type of tubing to be used (copper, PVC, etc):--
(3) Well casing. Is the well(s) cased? (check either (a.) Yeas 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 Hentonite L - Other (specify) Shn
(b) Grout placement: Pumping Pressure L-"" Other
(c) Grout depth of tubing (reference to land surface): from 0 to (feet)
If well has casing, indicate grout depth: from to (feet)
GPUARC 5QW Notification of Lntent Form (Revised 8/2008) Page 2

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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.
L 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. t..abel 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.
1 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 tti� pu;sibiIity of fines and imprisonment, for submitting
false information. I agree to construct, operate, m3ia n, rep+iir, and if applicable, abandon the injection well and
all related appurtenances in accordance with thk npproveo specifications and cl�r►ifitions of the Permit."
-
tore of Property Owner/Applicant
Print o Y J ype ull Nainw and title
`J
r—
Signature of Property Owner/Applicant
Axe
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-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center A�� ►0,4- Rloft
Raleigh, NC 27699-1636 t*0mr.1m 31,f
Telephone [phone] "AR 2 S 2011
GPU/UIC SQW Notification of Intent Form (Revised MOOR) -erw 3