WI0100166_GEO THERMAL_20110812

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Central Files: APS— SWP_
08/12/11
Permit Number W10100166 Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility Name
Margaret Moss SFR
Location Address
86 Larchmont Rd
Asheville
NC 28804
Status Project Type
Active New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Randall Cutter
6105 Rest Home Rd
Claremont NC 28610
Major/Minor Region
Minor Asheville
County
Buncombe
Facility Contact Affiliation
Owner Name Owner Type
Individual
Margaret Moss Owner Affiliation
Margaret Moss
86 Larchmont Rd
Asheville NC 28804
Oates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
08/12/11 07/25/11 08/12/11 08/12/11
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name Stream Index Number Current Class Subbasin

Aki M. P FA
zv-l;.r
NCDEN
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor director
811212 011
Margaret V. Moss
86 Larchmont Road
Asheville, NC 29804
Subject: Acknowledgement of Intent to Construct Type 5QW injection Well Systern
Permit No. WIO100166
86 Larchmont Rd, Ashville, NC 28804
Dear Ms. Mass:
Dee Freeman
Secretary
On 7/25/2011, 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 .G211(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_erROmcdenr._ov if you have any questions.
Sincerely, -
/or �ra Watts
Supervisor
cc: Asheville Regional Office - APS
AP5 Central Flies - Permit No, W10 100166
Buncombe County Health Dept.
Asbevliie Geothermal. Inc. (Rick Chnnenti)
Go! Green Drilling, Inc. SRandai Cutter]
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Ralegh, North Carolina 27699-1636
Locatimn 2728 Capltai Boulevard, Raleigh, North Carolina 27K14
Pnone 919-733-3221 I FAX 1: 919-715.0588, FA}: 2. 919.715-6048 � Customer Service 1-877-623-6748
lnremet; www.nMiterpuality.o'a
An �Qllal Clpponunq ti A5 native Paoli Employer
One
North C3r0)1T1a
s 'fd► u alfi,,,

NORTH CAROLI.NA jI I� o ?►►+�
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTLFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELLiSl
In Accordance with the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the hack page (please Print cr Type information).
DATE: July 22 , 20 11
A.
FVell Type Confirmation. Does the proposed system circulate potable water onI\, (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes _X— Continue completing this Form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (L)pen-loop well inj_ectinl 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).
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 represe=tive wlauthority for signature):
(1)
(2)
Margaret V. Moss f PIN 9740-20-6917)
Mailing Address: 86 Larchmont PA
City: Asheville State: NC Zip Code: 28804 County: Buncombe
Home/Office TOe No.. 828-774-4242 Call No.: 828-774 4242
Email Addmw-. uunossgunca.edu_ Website:
Physical Address of Well Site (if different than above):
City:
State: Zip Code:
HomelOffice Tele No.: CCU No..
County:
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; Asheville Geothermal Inc.
Contact Person: Rick Clemenzi
Address; Pa Box I8 57
EMAIL Address: info a shevill�eothermaLcom
City: Asheville State: NC Zip Code: 28814 County: Buncombe
Office Tele No.: 828-712-6786 Cell No.: 828-712-6786
Website Address of Company, if any. www.asheyille_eothermaLcom
GPU/UIC 5QW Nc6ficafen of Intent Form (Revised 9/2008) Page I

C.
D.
E.
F.
IVELL DRILLER INFORMATION
Company Name: Go! Green Drilling,_ Inc. Well Driller Contractor's Name: Randall E. Cutter
NC Contractor Certification No.: 2818-A_
Contact Person: Randall Cutter EMAIl, Address: rand\ Ev uo,reendrilli�.com
Address: 6105 Rest Home Rd.
City: Claremont Zip Code: _ 28610 County: Catawba
Office Tele No.: 828-367-1293 Cell No.: 828 228-1695
HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Nam: Asheville Geothermal Inc.
Contact Person: Rick Clemens i FAIA L Address: infat!asbevillegeotherntal.com
Address: ?0 Box 18757
City: Asheville Zip Code: _28814 County. Buncombe
Office Tele No.: 828-712-6786 Cell No.: 828-712,6786
STATUS OF APPLICANT
Private: X Federal: Commercial:
State: Municipal: Native American Lands:
INJECTION .PROCEDURE (briefly describe how the injection well(s) will be used)
Geothermal Heat Pump, Closed Loop
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _about 811111 Number of borings:
Approximate depth of each boring (feet):_225'
(2) Type of tubing to be used (copper, PVC, etc): HDPE
(3) Well casing. Is the wells) 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 X
(4) Grout info (material surrounding well casing andlor piping):
(a) Grout type: Neat Cement Bentonite X Other (specify)
(b) Grout placement: PumpinV,-X Pressure Other
(c) Grout depth of tubing (reference to land surface): from_U to 225 (feet)
1f well has casing, indicate grout depth: from _ _ to (feet)
GPUJ IIC 5QW Notifiraticn of Intent Form (Revised KnO08) Page 2

JUL 1! 6 11"
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
pipingitubing associated with the injection operation. The manufactwer's brochure may provide supplementary
information.
1. 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 204 feet of
the geothermal beat 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 most be signed by each person appearing on the
recorded legnI 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."
Sigmt= of Property Owner/Applicant
Print or Type Full Name and title
Signature of Property Owner/Applicant
Print or Type Full Name and title
7C�
Signature of Authorized Agen�-any
Rick Clemenzi. President
Print or Type Full Name and title
Pleasc return. two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-LIIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone (9I9) 715-6935
GFUrU1C SQW Notification of Intent Farm (Revised 9/2008) Page 3

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The informatfon provided is based on the best available data at the time of cuorency for ab datasets. ft is the requestoes responsibility to verify any information derNed from She G I S data
before making any decisions or Taking any adions based on the intonation. Buncombe County shall not be held Gable for any errors in the GIS data. This indudas ennrs of omission,
cam miss on, errors conceming the content of the data, and relative and positional accuracy of the data.

1 %
NORTH CAROLM A
DEPARTMENT OF ENVIRONMENT AND NATURAL. RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELLS i
In Accordance with the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or Tye information).
DATE: July 22 . 20 11
Well Type Confirmation: Does the proposed system circulate potable water opl\ (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loos,)?
Yes _2t_ Continue completing this form
No Do Not complete this form. Complete other UIC application forrus for Iiistallizig
either a 5 A7 well (9pen-hoop well injectin}, potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or ether 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 wlauthcrity for signature):
Margaret V. Moss (PIN 9740-20-69171 _
(1) Mailing Address: 86 Larchmant R.d.
City: Asheville State: NC Zip Code: ! 2.8904 County: Buncombe _
HomelOffice Tele No.. 828-774-4242 Cell No.: 828-774-4242
Email Address: mnnassitrunca.edu Website:
(2) Physical Address of Well Site (if different than above):
City:
HomelOfEce Tele No.:
State: Zip Code:
County:
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 U1C well)
Company Name, Asheville GeatheruW Inc.
Contact Person: Rick Clernmzi EMAIL Address: info a asheville geother nal.com
Address: PO Box 19757
City:
Asheville
State: NC Zip Code: 28814 County: Buncombe
Office Tele No.: 828-712-6786 Cell No.: 828-712,6786
Website Address of Company, if any: _ www.ashevilleLeothermal.com
GPUIUIC 5QW Notification of Intent Form (Revised 812008) Page 1

C. WELL ❑BILLER INFORMATION
Company Name: Go! GreenDrillinb, inc.
Well Driller Contractor's Name: Randall E. Cuter
NC Contractor Certification No,: 2818--A
Contact Person: Randall Otter EMAIL Address_randvia aojeendrillin�_com
Address: 6105 Rest Home Rd
City: Claremont Tap Cade: _ 28610 County: Catawba
Office Tele No.: 828-367-1293 Cell No.: 828-228-1695
D. HEAT PUMP CONTRACTOR INFORNIATION (if different than driller)
Company Name: Asheville Geothermal Inc.
Contact Person: Rick Clemenzi E AIL _Address- infoasbeviile!eothermal.com
Address: PO Box 18757
City: Asheville Zip Code: 28814 County. Buncombe
Office Tele No.: 828-712,6786 Cell No.: 828-712-6786
E. STATUS OF APPLICANT
Private: X Federal: Commercial:
State: Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Geothermal Heat Puntp, Closed Laop
G. WELL CONSTRUCTION DATA
(1)Proposed date to be constructed: about 811111 Number of borings; 2
Approximate depth of each baring (feet).- 225'
(2) Type of tubing to be Used (copper, PVC, etc): HOPE
(3) Well casing, Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes if yes, then provide casing informtation 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 X
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite X Other (specify)
(b) Grout placement: Pumping_X Pressure Other
(c) Grout depth of tubing (reference to land surface): from. 0 to ?25 (feet)
If well has casing, indicate grout depth: from to (feet.)
GPUIUIC 5QW Notification of intent Farm (Revised 8/2009) Page 2

H. INJECTION -RELATED EQULPMENT
h411 ?N?
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. LOCATTON OF WELLS)
Attach two copies of maps showing the following information:
(1) Include a Site Map (can be drawn) showing: buildings, property tines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing weli(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 feattures 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 higbway 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, atud if applicable, abandon the injection well and
ail related appurtenances mi accordance with the approved specificatiomr_s and conditions of the Permit."
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Property Owner/Applicant
Print or Type Full Name and title
Sigua=tee of Authorized Agelv�`if any
R_ick_Clemenx-i. President
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section -UDC Program
1636 Mail Service Center
Raleigh, NC 27699-I636
Telephone [phone]
GPU/UIC 5QW Notification of Intent Form (Revised VMS) Page 3

Buncombe 'County Neap
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The information provided is based on the hest available dale at the lime of currency for all datasets. It is the requestor's responsib i ty to verily any information derived from the CIS data
before making arty decisions or taking any actions based on the information. Buncombe County shall not be held liable for any errors in the CIS data- This includes errors of omission,
commission, errors concerning the content of tha data, and relative and posit ion at accuracy of the data-

Asheville
Geatherrrial
ft.
To: NC Department of Natural Resources .
Re: Geothermal Well Permit
PIN: I]YQ -20-- 611 7-00000
Dear Department of Natural Resources:
I/We hereby authorize Asheville Geothermal Inc., a licensed NC HVAC contractor, to sign and
otherwise speak for us with regard to obtaining a permit from the NC Department of Natural
Resources (DENR) for ethanol antifreeze protected Closed -Loop Geothermal Wells on our
property at the above Property Identification Number (PIN). We ask that Asheville Geothermal
Inc. be allowed to sign and submit the Geothermal Well application, and that a representative
of Asheville Geothermal Inc. be allowed to speak with DENR on our behalf in this regard as
further needed.
Sincerely,
V f a33
Signature of Property Owner
Printed Name
Date
Signature of Property Owner
Printed Name
Date
Signature of Property Owner
Printed Name
Date
Signature of Property Owner
Printed Name
Date
[e-mail] 828-712-6786 www.ashevillegeothermal.com

Asheville JUL ) 5 7n'�
geothermal
If,,
To: NC Department of Natural Resources
Re: Geothermal Well Permit j
PIN: �[ r} (,i c - .20 w 6 � / 7' n 0
Dear Department of Natural Resources: �' 401-
A
I/We hereb authorize Asheville Geothermal Inc., a licensed NC HVAC contractor, to sign and D
y n
otherwise Speak for i jr, with -rpon -0-- l to nhtaininu a 1nP —rm - frnm t..- Ali f7vnartmPnT of NatUral
Resources (DENR) for ethanol antifreeze protected Closed Loop Geothermal Wells on ow: —
property at the above Property Identification Number (PIN). We ask that Asheville Geothermal
Inc. be allowed to sign and submit the Geothermal Well application, and that a representative
of Asheville Geothermal Inc. be allowed to speak with DENR on our behalf in this regard as
further needed,
Sincerely,
MLk�r�� a1�r t
V-
Signature of Property Owner
Printed Name
Date
Signature of Property Owner
Signature of Property Owner
Printed Name
Printed Name
Date
Date
Signature of Property Owner Printed Name Date
[e-mail] 828-712-6786 www.ashevillegeothermal.com