WI0400117_GEO THERMAL_20120517

ffA .
~' -a __ _
NCDEHR-~-
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue----
Govemor
Jeremy Fox
294 Horseshoe Drive
Boone, NC 28607
Division of Water Quality
Chartes-Wakild; P. E
Director
May 17, 2012
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
_ P~rmit Number: WI0400117
Dear Mr. Fox:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system . .This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title I SA Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also t.o inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit wi•l be valid indefmitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Diyision of Water Quality. You
may view the revised rules on-our website at http ://p ortal.ncdenr.org/web/wq /ap s.
If you have any questions regarding your current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely, a ~tt
Eric G. Smith, P.G.
Hydro geologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: 919-S07-6464 \ FAX: [phone]
Internet: www.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer
One North Carolina
;Vatura/l!f
_06/28/2810 15:06 8282E59585
MGT DEPARTMENT
PAGE 02
Ricalaari1AL v yew c
Nardi Caroline DeparnerMt of Erivironeldit mid Natwa! ReeOEu ' Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818
1. WELLCONTRACTOR:
Weil Comer (individual) Name
via Contractor COmPlInY Narr10
Sheet Address
Earemont NC 28610
City or Town �5%lia lip Cade
8211-) 228-1 95
Ares cods Pons minim-
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT* WI0400117
OTHER ASSOCIATED PERMITAN apply )
siT WELL ID +rnr apparehlao GL_2
3. SMELL ME (Check Applicable : Reeder West Sueflph 0
DATE ORILLED11 /20/09 J.
TIME COMPLETED 3:,1Q AM p PMEI
M. WELL LOCATION:
Crrr: Boone cowry Watauga
294 Horseshoe Dr.2Bfi07
(Street Name. kmt era Comex*. StOdvieicn. Let No.. Penal. To case)
TOPOGRAPHIC 1 LAND SETTING' (check eencenele nevi
ISSiops p VIy 0 Flat ED Ridge pOther
L.ATrnJDF 36 •1 t 13JeiO0 • MS oft 3Xxcosszim co
LONG TUDE 81 _■ +o • Waco • tabs tea huccvaaoocx ix,
L.HprdMer de source: iiittiPS C]iopopraphic map
(location dr Marmu be erxmat on a USGS kpa map endaltedied b
trey lbrmrm if eta! using GiM
5. WELL aarlIER
Jeremv Fox
Oen& Nano
294 Horhae Dr.
stroet moon
Boone NC 28607
City or Town State Zip Code
(820 )773-8636
Area code Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 150'
b. DOES WELL REPLACE EATING WELL? YES 0 NO
c. WATER LEVEL Dela" Tap of Caeins: None Fr.
(Use "+" ITAbove Top of Celina)
d. TOP OF CASING IS NIA Fr. Above Land Surface -
"TOO of Ming taminaled dills below lend surface may r*atire
a rename In ecccrdence with 15A NCAiC 2C .0115.
▪ YIELD (Damp _NIA fathom of TEST NIA
f. DISINFECTION: Type N/A Amount
s. WATER ZONES (MOO: Top'
TvP�— $°^"
Top n Top Bottom_
Seaton Tog - _Bottom_
%4_� Thickness/
dal
7. CASING: Depth Diernete►
Top Norte Bosom_. R�—
Top tom. - fT
Top Bottanl FL
Weight Mete
S. GROUT' C$pN Material Method
Top 0 Bottom150 Ft_Bantonite Pumped
Top Bottom_ -_ F. _
Tap Bottom , FL -
a ! oasts otwnetsr Slat ate
Top NIA Bottom_ _ Fk in. in.
Top ,Bottom Ft_it
Top Boulam Pt kt. in.
10. 5ANDIGRAVEL PACK!
p„prp nap Material
Top NIA Bodoni_. Ft
f op FL.
Top &Worn Ft.
i 1, DIMING LOG
Top sotiom
0.0 / 8.0
Folvricoon Deecrtptiof
Sandy Gay WI broken rock
8.t7 / 50.0 sand stone rick
1
1
1
r
1
12. REMARKS:
ThIS i8 It_GtoOtherrne1 Closed laoo well. Water Onty No
precise cuttings 1 sample& taken.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 1SA MAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF 7 18 RECORD HAS BEEN
PRoViDEb TO THE WELL OWNER.
er.'7 /Atilep,
S TIRE OF CERTIFIED WELL CONTRACTOR DATE
Randall E. Cutter
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit wtthlrr 30 days of completion to: Division of Water Ouallty - information Processing.
78i7 Mail Service Cantsr, Raleigh;, NC 27111116.181, Phone : pie) 8074300
Poem GW-le
Rev. 2R19

a6/281;2010 16:06 8282658605 MOT DEPARTMENT
PAGE 03
RESIDEIVIIAL WLix OASTRUCTION RECORD
North Craolma Dopes of Environment sad Neural Rceowvee- DiviSios of Water Qusltty
WELL CONTRACTOR CERTQFCATION 0 2818
1. room c0NTRAC OP
Randall ESutter
MR Contractor (Indtviduai) Nam
Innovative Environmental Qrilline
WeII Cwit ctor Company Name
_al Adtst Horne Rd.
s
Claremont NQ. 28
City or Town Srsee Zip Cade
( 828) 226-1695
Area Lode Phone minter
2. WELL INFORMATION:
WELL CONSTRUCTION PERIArT/ W1Q430117
OTHER ASSOCIATED P AITsI[Ireppecie+ta)
arts WELL ID trappezecire GL-1
3. WELL USE (Chao( ApOlkaate Bo : Resklerrtiai Wow 8t01:4 CI
DATE DRILLER 11 /191Q9
my COMPLETED 5:00 AM 12 PM 11
4. WE L LOCATION
CRY: Boone
COUNTY Watauga
294 shoe Dr. 28607
(swat Neve When, Comiviur r. SubdhUkn. Lot era,, Pnoel, Al Cols)
TOPCGRAPHiC i LAND SETTING: Kowa appreprr hog
orSlopo ©viy OFiat Cl Rifts dog
LA11TL0E 36 • 12 ' 13.e000 " g DR 3XJ00000:100t CO
Lomor uoe 01 ' /6 . 5e.2000 " c s& ORa7[.x xxxo00t DD
L a iaideltvrpidsie source: f+i ❑rcpagraphic reap
{Vlaoetion oboe/ must to shown are a IISGS tom map a datiodwci ip
V s form A'not using GPS)
S. WELL OWNER
Jet emv Fox
ovinmainsi
294 Horseshoe pr.
Street Address;
Boone NC 28fx07
City or Town State Zip Code
828 773-8636
Area cods Phone number
e. WELL DETAILS:
a. TOTAL DEPTH: 150'
b. ODES WELL REPLACE EXISTING WELL? YES cl NO if
c. WATER LEVEL Beep" Top Carder lone FT_
(Use `+` S A4Wre Tap c4 C q)
A. TOP or Gnome W N/A Fr. Abaft Lurid Surface"
"Top of casing terminered SSVor phew Iresd surface may regain
a vartainc, In accordance w i 1SA NCAC2C .011S.
e. YIELD (gm): NIA . METHOD OF Thar NIA
f. DISINPECTiow TypeJlf/A Amount
R. WATERZONE1 td r
Top Norte Bortern
Top BMW_ _
Tap Radom Top _ Bottom
Top Bottom Top Bottom
Thickness,
7. CASING: Depth DWneter Weight Material
ropes.. F
Top BOOM Ft
Top Idiom Ft.
s. OROW% DeDfh IAassrtal
Top 0 Bottom 150 FL Bentonite
Top Bottom --__ FL -- -
Top Bottom FL
Method
Pumped
f. SCPIEEN: Depth os Busier Nat. St= aleteriel
Top NIA Bober FL in. in.
Tap BOSOM FL n. lil.
Tap Balrxn FL. in, In.
/O. SAMDIDAAVEL PACK:
Depth Size Weft
Tap N/A B am FL
Top
Top aottom tt
11. DRILLING LOGI
Top Bottom Forrnativn Dlec(ptiari
0.0 /8.0 sandy Clay w/ broken rock
8.0 1150- 0 sarsd stone/rock
1
1
1
1
1
1
f
1
— 1
1
12. REMARK
This is a Geothainal o swell. No precise cuttings 1
sarrs�les taken_
I DO HERESY CERTIFY THAT THIS WELL WAS coNSTALICTED tN
ACCORDANCE MTN 1I,A NCAC 2C. WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD WAS BEEN
TO THE 7.7,1ER
NATURE OF CERTIFIED WELL CONTRACTOR DATE
Randall E. Cutter
PRINTED NAME OF PERSON CONSTRLlCTINO THE WELL
Submit within 30 days or compiefon to: Division of Water Qutllty - Information Procassing,
1E17 Mail Service Center, Ririoigh, i$C 2NN-111i, Pharos :1119j 801-4300
Form GW1a
Rev. 2/09

'61281T810 16:06 6282658685
MGT DEPARTMENT PAGE 61
DEPARTMENT OF MANAGEMENT
Thelma Raley Hall
Boone, North Carolina 28608
[phone]
I281 265-8685 FAX
Appa1achin
STALE UNIv$RSITY
BOONE, NORTH pAROLINA UGO
FAX
DATE: TIME:
TO: G 7FROM:
organization: PHONE:
PHONE: ' / FAX:
FAX: r EMAIL:
REGARDING: 0
(cK In
Number of pages including cover sheet
Message
Yjo4 00v,
cfril4r sir vv,e
64/44- e.
CJ FoX_
�y� T)3 5f63-4

AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Jeremy and Josephine Fox
294 Horseshoe Drive
Boone, NC 28607
Dear Dr. and Ms. Fox:
Coleen H. Sullins
Director
November 17, 2009
Dee Freeman
Secretary
Subject: Issuance oflnjection Well Permit
Permit No. WI0400117
Issued to Jeremy and Josephine Fox
Watauga County
In accordance with your application received October 23, 2009, I am forwarding Permit No. WI0400117
for the construction and operation of a vertical closed-loop geothermal mixed-fluid heat pump injection-
well system located at 294 Horseshoe Drive, Boone, Watauga County, NC 28607. This permit shall be
effective from the date of issuance until October 31, 2014, and shall be subject to the conditions and
limitations stated therein.
Please pay special attention to Part I. 7 of the permit and submit copies of the Well Construction
Completion form (GW-1) after construction. Please submit all data within 30 calendar days ofreceipt of
this letter to the address below:
Aquifer Protection Section (APS)
Underground Injection Control (UIC) Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
Additionally, your UIC system is subject to inspection by the APS and at the time of the inspection must
display a permanently affixed identification plate in accordance with requirements of2C .0213(g). Please
insure this is completed in accordance with permit condition Part 1.6 of this permit issued November 17,
2009.
In order to continue uninterrupted legal-use of this well for the stated purpose, you should submit an
application to renew the perinitthree months prior to "its expiration date. As indicated in the permit, this
perm.it is not transferable to any person without.prior notice to, and approval by, the Director of the
Division of Water Quality. If you have any questions regarding your permit or the Underground Injection
Control Program please call me at [phone].
Sincerely, , ~u~
1;1/"John McCray, 7
v Environmental Specialist
cc: Sherri Knight -Winston-Salem Regional Office
Central Office File -WI040011 7
Watauga County Environmental Health Dept.
Mark Evans -Evans Heating and Cooling, Inc.
Enc: Permit WI0400117
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143. and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Jeremy and Josephine Fox
FOR THE CONSTRUCTION AND OPERATION OF 2 TYPE 5QM INJECTION WELLS, defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed -loop
geothermal -mixed -fluid heat pump system. This system is located at 294 Horseshoe Drive, Boone, Watauga
County, NC 28607. and will be constructed and operated in accordance with the application dated October 23,
2009, and in conformity with the specifications and supporting data submitted, all of which are filed with the
Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation only, and does not waive any provisions of the Water Use Act or
any other applicable Laws, Rules, or Regulations. Operation and use of an injection well shall be in compliance
with Title I5A North Carolina Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until October 31. 2014, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the t\ day of , 2009.
014,
oleen H. Sullins, Director
Division of Water Quality
Hy Authority of the Environmental Management Commission.

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
6. Each geothermal injection well system shall have permanently affixed an identification plate on a nearby
building or other permanently fixed structure indicating the location and presence of underground UIC
wells according to 2C .0213(g).
7. A completed Well Construction Record (Form GW-1) must be submitted for each injection well to:
Aquifer Protection Section -UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section -Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27669-1628
[phone]
GW-1 s must be submitted within 30 days of completion of well construction. Copies of the GW-1
fonn(s) shall be retained on-site and available for inspection.
8. Well construction records must also be submitted for the existing water supply wells on-site as well as a
site map showing any water supply wells on adjacent properties as specified in NCAC .021 l(d)(l)(D).
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing system, the Pennittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number [phone] and the Winston-Salem Regional Office Aquifer Protection Section Staff,
telephone number [phone].
WI0400117 2
2. Boreholes shall not connect separate aquifers which have differences in water quality ( e.g.) shallow
surficial aquifers, saprolite, fractured bedrock, etc.) as specified in 15A NCAC 2C .0213(d)(8)(C) and
shall be filled with bentonite grout from the lowermost water bearing zone to land surface as specified in
the permit application.
PART III-OPERATION A.l\ID USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Perm.ittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the dat~ of the change.
3. The issuance of this permit-shall not relieve the Permittee of the responsibility of complying with any and
· all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
PART IV -PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of 'groundwater th~t will render it -unsatisfactory for normal use. In the event . that the
facility fails to perforni satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immedi~te corrective
actions including those actions that may be required by the Division of Water Quality such as· the repair,
modification, or abandonment of the injection facility.
2. The Pennittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted ac~ivity.
3. The issuance ofthis perm.it shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART V -OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
. planned physical alterations or additjons in ·the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injecti_on Control (UIC)
Program Central Office staff, telephone number (919) _715-6166. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
WI0400117 3
PART VI -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Winston-Salem Regional Office, telephone number [phone], any of the
following:.
(A) Any occurrence at the injection facility that results in any unusual operc1:ting circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application. or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART IX -CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well
Construction Standards.
WI0400117 4
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Perinittee shall abandon that injection well in accordance with the procedures specified in 1 SA NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each·well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination ·of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a . pipe which extends to the bottom of the well and is raised as the well is
filled. .
(E) In the case of gravel-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite · the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
(F) In those cases· when, as a result of the injection operations, a subsurface cavity has been
created, each well sliall be abandoned in such a·manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit,
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(l). within 30 days of-completion of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
WI0400117
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
5
s0 ,. Cry
FT 62. a/ AI 0400 r r 7
g4)41r 914i 7/ Coffer
(504,-)
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, poleatial soirees
of groundwater contamination and the orientation' of and distances between the proposed weii(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 1000 feet of the
geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's Location and the map name.
J. POTABLE WATER WELL(S)
Are there any potable water well(s) on the subject property or adjacent properties? YES }( NO
If Yes, than indicate location on attached map(s).
K. CERTIFICATION
Note: This Permit Application mast be signed by each person appearing on the recorded legal property deed.
"I hereby certify, render 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 inqu y 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 • ibility - d imprisonment, for submitting
false information. I agree to construct, • ' - . t maintain, .. i r, a if .. ie, .. don the injection well and
all related appurtenances in accordance ith the ' proved sp ."f • ns eni ;�j cliti. . e Permit"
Sipa
Print ' Type Full Name
4
Signature of Itrapeny Owner/Applic {
► JO YI �1+ 1�, .r0g-
Print or Ty Name
Sim of Authorized Agent, ifany
f r4c4 tic
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
i3IC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GFU/[]IC 5QM Well Permit Application (Revised M9Qn)
RECEIVED i OENR
AQUtFPR PRnTFr:TinN SECTION
OCT 2 3 2049
RECEIVED ► U€NR 1 Drill
AQUIi`rR ertinN VCTION
NOV 1 9 Nog Page'

..ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Qualit}CEIVED r DENR
WELL CONTRACTOR CERTIFICATION # 2818 Aquifer Protection section
1. WELL CONTRACTOR:
Randall E. Cutter
Wet Contractor (Individual) Name
Innovative Environmental Drilling
Well Contractor Company Name
6105 Rest Home Rd.
Street Address
Claremont NC 28610
City or Town
c 828) 228-1695
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10400117
State Zip Code
OTHER ASSOCIATED PERMlT#(if applicable)
SITE WELL ID #(if applicable) GL-1
3. WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 11/19/09
TIME COMPLETED 5:00 AM D PM It
4. WELL LOCATION:
CITY: Boone COUNTY Watauga
294 Horseshoe Dr. 28607
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
UTSiope ❑ Valley 0 Fiat ❑Ridge D Other
LATITUDE 36 • 12 • 13.800a " DINS OR 3x.xx xCx ccxx DD
LONGITUDE 81 •40 55.2000 "DINS OR 7xJao0Oouooc DD
Latitude/longitude source: W6FS l]ropographic map
(location of well must be shown on a USGS topo map andatteched to
this form if not using GPS)
5. WELL OWNER
Jeremy Fox
Owner Name
294 Horseshoe Dr.
Street Address
Boone
NC 28607
City or Town State Zip Code
(828 j 773-8635
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 150'
b. DOES WELL REPLACE EXISTING WELL? YES D NO gg
c. WATER LEVEL Below Top of Casing None FT_
(Use `+" if Above Tap of Casing)
d. TOP OF CASING IS N/A FT. Above Land Surface*
"Top of casing terminated atior below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top None Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom _ Top _ _ _ Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top None Bottom Ft.
Top Bottom FL
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom1550 R. Bentonite Pumped
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Siot Store Material
Top N/A Bottom FL in. in.
Top Bottom FL in. in. Top Bottom Ft in. in.
10. SAND/GRAVEL PACK:
Depth
Top N/A Bottom Ft.
Top Bottom Ft.
Top Bottom R.
Size Material
11. DRILLING LOG
Top Bottom
0.0 18.0
8.0 / 150.0 sand stone/rock
Formation Description
sandy clay w/ broken rock
/
/
/
/
12. REMARKS:
Thus is a Geothermal loop well. No t7r 1tiggs
samples taken.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDETO THE WELL OWNER
12-7?Atek"‘":7°;--- • - -
StGNAIURE OF CERTIFIED CONTRACTOR ATE
Randall E. Cutter
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of compietlon to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2► 9

��CStD NTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818
1. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (Individual) Name
Innovative Environmental Drillina
Well Contractor Company Name
6105 Rest Home Rd.
Street Address
Claremont NC 28610
City or Town State Lip Code
c 828) 228-1695
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W104001 17
OTHER ASSOCIATED PERMIT#(ifappticable)
SITE WELL ID #(if applicable) GL-2
3. WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 1 1 /20/09
TIME COMPLETED 3:30 AM ID PM Eft
d. WELL LOCATION:
CITY: Boone COUNTY Watauaa
294 Horseshoe Dr. 28607
(Street Name, Numbers, Common ty, Subdivision, Lot No., Parcel, Dp Cade)
TOPOGRAPHIC / LAND SETTING: {check appropriate box)
wfSlope ❑Valley
LATITUDE 36
LONGITUDE 81
❑ Flat
• 12
a40
p Ridge ❑ Other
13.8100 " DMS OR 3x.?UOOocCxXX r
55.4000 - DMS OR 7x.)OO000000( DO
Latitude/longitude source: 3PS propographic map
(►acabon of well must be shown on a USGS topo map andattached ka
this form if not using GPS)
5. WELL OWNER
Jeremy Fox
Owner Name
294 Horseshoe Dr.
Street Address
Boone NC 28607
City or Town State Zip Code
1828 ) 773-8636
Area code Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 150'
b. DOES WELL REPLACE EXISTING WELL? YES p NO
c. WATER LEVEL Below Top of Casing: None F r.
(Use •+• if Above Top of Casing)
d. TOP OF CASING IS N/A FT. Above Land Surface'
"Top of casing terminated at/or below sand surface may require
a variance in accordance with 15A NCAC 2C 0118.
e. YIELD (gpm): NIA METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top None Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom
RECEIVED I DENR I DWC
Aquifer Protection Section
DEC 07 2009
Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Materiel
Top None Bottom FL
Top Bottom Ft_
Top Bottom FL
8. GROUT: Depth Material
Top 0 Bottom 150 Ft. Bentonite
Top Bottom Ft.
Top Bottom Ft,
Method
Pumped
9. SCREEN: Depth Diameter Slot Size Material
Top NIA Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top NIA Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0.0 18.0 sandy day wi broken rock
8.0 1150.0 sand stone rock
1
r
1
1
1
1
12. REMARKS:
This is a Geothermal dosed Iona well. Water Only. No
precise cuttings / samples taken.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE W L OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Randall E. Cutter
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mali Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2109

gitAndi3aor1e ,git [ Image, 5851635 pixeL_ htip://vialaugaccutyrc.goNl rrcio
.Ps r/i�440CAVA lI I f5

Permit Number WI0400117
Program Category
Ground Water
Permit Type
Central Files: APS_ SWP_
11/19/09
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Mixed Fluid GSHP Well System (5QM)
Version
1.00
Permit Classification
Individual
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
294 Horseshoe Dr. SFR Geothermal
Location Address
294 Horseshoe Dr
Boone
Owner
Owner Name
Jeremy
Dates/Events
NC 28607
Fox
Orig Issue
11/17/09
App Received Draft Initiated
10/23/09
Re gulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name
Scheduled
Issuance
Permit Contact Afflllatlon
Major/Minor
Minor
~egion
Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Jeremy Fox
294 Horseshoe Dr
Boone
Public Notice Issue
11/17/09
NC
Effective
11/17/09
28607
Expiration
10/31/14
Stream Index Number Current Class Subbasln
Permit Number WI0400117
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Jeremy Fox
Location Address
294 Horseshoe Dr
Boone
Owner
Owner Name
Jeremy
Dates/Events
NC 28607
Fox .
Orig Issue App Received Draft Initiated
10/23/09
Re g ulated Activities
Outfall NULL
Scheduled
Issuance
Central Files: APS_ SWP_
11/03/09
Permit Tracking Slip
Status
In review
Version
Project Type
New Project
Permit Classification
Individual
Permit Contact Afflllation
Major/Minor
Minor
Region
Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Type
Individual
Owner Afflliatlon
Jeremy Fox
294 Horseshoe Dr
Boone NC 28607
Public Notice Issue Effective • Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NA
, NCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Jeremy and Josephine Fox
294 Horseshoe Drive
Boone, NC 28607
Dear Dr. and Ms. Fox:
Coleen H. Sullins
Director
· November 17, 2009
Dee Freeman
Secretary
Subject: Issuance of Injection Well Permit
Permit No. WI0400117
Issued to Jeremy and Josephine Fox
Watauga County
In accordance with your application receiyed October 23, 2009, I am forwarding Permit No. WI0400117
for the construction and operation of a vertical closed-loop geothermal mixed-fluid heat pump injection
well system located at 294 Horseshoe Drive, Boone, Watauga County, NC 28607. This permit shall be
effective from the date of issuance until October 31, 2014, and shall be subject to the conditions and
limitations stated therein.
Please pay special attention to Part I. 7 of the permit and submit copies of the Well Construction
Completion form (GW-1) after construction. Please submit all data within 30 calendar days ofreceipt of
this letter to the address below:
Aquifer Protection Section (APS)
Underground. Injection Control (UIC) Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
Additionally, your UIC system is subject to inspection by the APS and at the time of the-inspection must
display a pennanently affixed identification plate in accordance with requirements of 2C .0213(g). Please
insure this is completed in accordance with permit condition Part 1.6 of this permit issued November 17,
2009.
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit three months prior to its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Quality. If you have any questions regarding your permit or the Underground Injection
Control Program please call me at [phone]. ·
Sincere!~. ,· .... ;$-~:i_;
11/J~hn McCr~y, 7
v' Environmental Specialist
cc: Sherri Knight -Winston-Salem Regional Office
Central Office File -WI0400117
Watauga County Environmental Health Dept.
Mark Evans-Evans Heating and Cooling, Inc.
Enc: Permit WI0400117
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Jeremy and Josephine Fox
FOR THE CONSTRUCTION AND OPERATION OF 2 TYPE 5QM INJECTION WELLS, defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed -loop
geothermal -mixed -fluid heat pump system. This system is located at 294 Horseshoe Drive. Boone. Watauga
County, NC 28607, and will be constructed and operated in accordance with the application dated October 23.
2009, and in conformity with the specifications and supporting data submitted, all of which are filed with the
Department of Environment and Natural Resources and are considered a part of this permit.
. This permit is for Construction and Operation only, and does not waive any provisions of the Water Use Act or
any other applicable Laws, Rules, or Regulations. Operation and use of an injection well shall be in compliance
with Title 15A North Carolina Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until October 31, 2014, and shall be
subject to the specified conditions and limitations set forth in Parts I through Ili hereof.
Permit issued this the f day of , 2009.
oi,J2
v41,
oleen H. Sullins. Director
Division of Water Quality
By Authority of the Environmental Management Commission.

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
6. Each geothermal injection well system shall have permanently affixed an identification plate on a nearby
building or other permanently fixed structure indicating the location and presence of underground UIC
wells according to2C .0213(g).
7. A completed Well Construction Record (Form GW-1) must be submitted for each injection well to:
Aquifer Protection Section -UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section -Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27669-1628
[phone]
GW-ls must be submitted within 30 days of completion of well construction. Copies of the GW-1
fonn(s) shall be retained on-site and available for inspection.
8. Well construction records must also be submitted for the existing water supply wells on-site as well as a
site map showing any water supply wells on adjacent properties as specified in NCAC .021 l(d)(l)(D).
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number [phone] and the Winston-Salem Regional Office Aquifer Protection Section Staff,
telephone number [phone].
WI0400117 2
2. Boreholes shall not connect separate aquifers which have differences in water quality (e.g.~ shallow
surficial aquifers, saprolite~ fractured b~drock, etc.) as specified in ISA NCAC 2C .0213(d)(8)(C) and
shall be filled with bentonite grout from'· the lowermost water bearing zone to land surface as specified in
the permit application.
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Pennittee, a formal perm.it amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be ·imposed by other local, s~ate, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
"regulatory requirements have been met.
PART IV -PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of 'groundwater that will render it -unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a r~duction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART V -OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection· facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight ( 48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injecti_on Control (UIC)
Program Central Office staff, telephone number [phone]. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
WI0400117 3
PART VI -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and ·any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART VII-MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Winston-Salem Regional Office, telephone number [phone], any of the
. following:
(A) Any occurrence at the injection facility that results in any unusual opera#ng circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
3. Where the Pem1ittee becomes aware of an omission of any relevant facts in a pennit application, or of any
incorrect information submitted in said application. or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII-PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well
Construction Standards.
WI04001 l 7 4
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled. .
(E) In the case of gravel-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit!
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
WI0400117
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
5
Mccray, John
From:
Sent:
To:
Subject:
Attachments:
Dear Ms. Knight,
Mccray, John
Thursday, November,12, 2009 11 :51 AM
Knight, Sherri
SQM permit application
WI0400117p091112.pdf; WI0400117App_RevReq.doc
Attached you will find an application for geothermal permit WI0400117. This is a closed Loop Single System in Boone.
Please let me know if you have any issues with issuing this permit.
Best Regards,
John McCray
DISCLAIMER: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina
Public Records Law and may be disclosed to third parties.
1
.AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
November 3, 2009
Jeremy Fox
294 Horseshoe Drive
Boone, NC 28607
Subject: Acknowledgement of Application No. WI0400117
Jeremy Fox
Injection Mixed Fluid GHSP Well System -SFR
Watauga
Dear Mr. Fox:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on October 23, 2009. This application package has been assigned the number listed above and will be reviewed
by John McCray.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 -90 days after receipt of a complete
application.
If you have any questions, please contact John McCray at 919-715-6168, or via e-mail at [e-mail]. If the reviewer is
unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To review our
new organizational chart, go to http://h2o.enr.state.nc.us/d.ocuments/dwg ornchart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
o~~
for Debra J. Watts
Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
Mark Evans (Evans Heating & Cooling -2297 Rich Hill Rd, Glade Valley, NC 28627)
Permit Application File WI0400117
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard , Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588 ; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity \ Affirmative Action Employer
None C lin orth aro a
/Vaturaltu
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 50M WELL(S)
New Permit Application OR Renewal (cheek one)
DATE: &C 4 Ie r .,7 / , 20 CY?
PERMIT NO. _ (leave blank if NEW permit application)
A. PROPERTY OWNER(S)f
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlau hority for signal): SG rG r'+ / 5
(1)
(2)
Mailing Add :. CO 7 NO[t545,72,L Are -
City: /6 AC Stape:AGT.p Code: i 6*7 7 amity: z.4447 1410,9
Home/Office Tele No.: ? 2 8 ) 7
EMAIL Address: •#7
Physical Address of Site (if different than above): 1-7 /4a u.'
City: state: Zip Code: County:
Home/Office Tele No.: Celt No.:
EMAIL Address:
B. AUTHORIZED AGENT OF OWNER, re ANY (iftbe Permit Applicant own the subject property,
attach a letter Rom the property owner authorizing Agent to install and operate UIC well)
Company Name: ..Z 12 r/r9712.4r sr cfFi9L i2 a .11;CC
Contact Person: / 9 C r (7‘,"77-74VC EMAIL Address ivk .
Address: fo f.9f /t S47 frlo ,
City . State:. G Code:01-e'CF-42 County: C r g d4
Office Tele No. 8.28 22f -/b9 Cell No.: S -J.25' /4 5' 5—
Website Address of Company, if any: 141t;,44.J. I-v�r.Y4. / , -7 ,
C. STATUS OF APPLICANT
Private: X Federal: Commercial:
State: Municipal: Native American Lands:
RECEIVED / fENR I DWG
Aou FPR'PPf]'fFC.TWIN SECTION
OCT 2 3 2009
GPU/WC 5QM Well Permit Application (Revisal 7t2OO8) Pale 1

D. WELL DRILLER INFORMATION
Company Name: 1.447r ?-' Frru, ?ei0A/, 7d rrY 9i��
Well Drilling Contractor's Name:
07,44:41.:91L G� . re...•-r-T,e�
NC Contractor Certification No.: o241
Contact Person:
Address: i '/OS ,& .4i'-e /€
City: [:'� r9/�1iyf Code:A' County: et' f "4
Offs a Tele No.: ,;'J f -. -%.6 S'j Cell No.: ...142J S
F HEAT PUMP CONTRACTOR INFORMATION Of different than driller)
Company Name: &.-W crs t�a.4i.V;, �C
Contact Person: 7 7.4.Ae y.✓5 EMAIL Addae s:02 s t •r ,4'y sr Gen
Address: 0Z2 %r'7 ,E''A-
City: QL •tA F �• ze.er Zip Caie J 6v?7 Ccuady: .4Azeisw 9.'
Office Tele No.; 94 - 4$T J'9.23 Cell No.;aids -AS? 7f .? Z
F. INJWHON PROCEDURE (briefly describe how the injection well(s) will be used)
oleo //ter-ftr- -L £lase 4/4 h 9 r fir' - 7 .
G. WELL CONSTRUCTION DATA (Skin to Section H if this is a Permit RENEWAL)
(1) Proposed date to be caked: 4--e9l) Number of borings:
Approximate depth of each boring (feet): J� 5 '
(2) Chemical additives to be usedinclosed-loop system (only those chemicals indicated have been approved):
It 22 glycol.. ethanol /7+ ,,L other (other additives will
need prior approval by NCDENR before use) : - ad"(► t / ' p
(3) Type of tubing to be used (copper, PVC. etc):' /1)Jo /'yG >dG. ee.
(4) Well casing. Is the wells) cased? (check (a.) YES or (b.) NO below)
(a) YES if yes, then provide casing hifc mafioii such as Wm (steel, PVC, plastic, etc.), diameter,
nth and extent,ofcasing appearing above ground:
(b) NO
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite
(b) Grout depth of tubing (reference to land srmface from 0 to D (feet)
If well has cam indicate grunt d *OM to (feet)
H. INJECTION-RFLATED EQUIPMENT
Attu a diagram showing the engineering layout or proposed niodification of the injection equipment nod exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
GPUI[]1C 5QM WdI Peamiit Application (Revised 7t2OO) Page 2

11/16/2009 14:17 8282558685
MGT DEPARTMENT
PAGE 01
J O Cry
144 ell 7i6cz(
L LO.ATION OF WELI.(S)
Attach two copies of reaps showing the following information:
(1) Include a site map (can be dracwn) showing: buildings, Icy lines. surfaos water badses, polcalid sources
of groundwater contamination and the orientation of and di Lances between Ibe proposed well(s) seed any
eeclsting well(s) or waste disposal facilities such es septic twin or drain fields located within 1000 feet of the
geothermal heat pimp well system. Label all features clearly mid inclu4e a WWI an w.
(2)
bell e a topographic map of the area extending one mile from tbre propetty boundaries and
indicate die facility's location and the map name.
J POTABLE WATER WELL(S)
Are there may potable water well(s) on the subject property or adjacent properties? YES , N]
If Yes, than indicate location on attached map(s).
K. Cat IFICAT1ON
N. This Permit Apldtiryrtiess, mast he steed try mg perm appearing as the molded legal property deed
"I hereby certify, under pen*1ty of law, that 1 have personally eacamiaed and am tmntilar with the information
submitted in this document sod all ellachments thereto and that. based co nay *airy of those individuals
immediately rea ponsible for ob pining said information, I believe that the 1n is true, accurate end complete.
1 am *ware that there art significant paucities, irscitditrg the isiiity • �� . imprisonmentfor deg
false information. I agree to oonsirue t, �'"?'. ran, , if the injection well and
all relatedappuramances iniceoniunee . ., ..-,•-, i r:ii 11-.-+1�.Aj4, $ $ , e it."
1 4��� . Permit."
"..„--
..,
Print •` Type Full Name
inttp LLRA
SignstuTe of>iiuperty Owner/Appli
PrintFull Name
Sire of Authorised Agent, if any
Print or Type Full Name
Please return two copies of the completed d Application package to:
North Caroline DFNR-DWQ
Aquifer Protection Section
UJC Program
1636 Mail Service Center
Raleigh, NC 37699-16U
Telephome (9I9) 715.6935
RECEIVED i Dan (Lin
acxi R1/Rrrrr-r1C!N x,,64
NOV I P. 7Af9
RECEVED f DENR ! DWQ
AQUIFER annTFi:TICIt<t SECTION
OCT 23nog
GI'[YU!C 50M well P* nppiineio►a (therhsed MOOS) Pew 3

L LOCATION OF WELL(S)
Attach two copies of maps showing the follovering 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 MOO feet of the
geothennal heat pump well sysienrt. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
J. POTABLE WATER WELL(S)
Are there any potable water wel(s) on the subject property or adjacent properties? YES NO
If Yes, than indicate location on attached map(s).
K. CERTWICATION
Note This Permit Application meet be signed by 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 lion, I believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the ", ibili1y • : • s imprisonment, for submitting
f dse information. I agree to construct, maintain, if the injection well and
all related appurtenances in accordance .' t e : +'roved s _ ' :�• ., ��,�... . a Permit."
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Armed Age if arty
� CL eiiarretzre.
Print or Type Full Name
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]
RECEIVED / OENR i DWG
ADufFFR-PROW(i 1ON SECTION
OCT 232009
AMC 5QM Weil Permit Appliratim (Revised 70.O011)
paw

gaAndliaaee 40{c,11 Imam 51 i1ri p xcL _ ittp://wateasscoutympav/ArcIMSOulpal/WataummAndnexine_arct
10/20/2009 R:43

gaAMUoone arpn I3Y'2lb32333Wl.gIt((ill' Image, 585x5135 pt.._ :/Avww.walgov,ne#1 W arrai l
2900-8$080$000
2900-834532-100
$
2900-83-5500 000
2900-83-7860.000
0 mi
-2900-83-7528-000
.45,0e...-re 4./6_ ea 7
10/21,2009 1:1 S

%bap County.Praperty Cord Informatics
PAYS. DATA
LAND mamas
PIN Tills
ACCOUNT #
MAP SHPFi
ASSESSED
ACREAGE
SEGMENT TYPE
STYE
APPRAISEDVALUE
PRiMARYRES sm..89
47400
2900-83-5883-000
1510815
2900-16
A000
BURDERIEURDIARY
ZONE �LA�ID'USE
TYPE
DESCRIPTION
APPRAISED VALUE
BOONE SINGLE FAMILY RES
SAL 1 FAMILY
RESIDENTIAL
HOME
L 160900
PROPERTY ADDRESS
NEIGHBORHOOD
BOWIOOD
294 HORSESHOE DR
POPLAR IULL AREA
PROPERTY DESCRIPTION
POPLAR HILL
OWNERSHIP AND MAILING ADDRESS
FOX, JEREMY AND JOB
294 HORSESHOE DR
BOONE, NC
TOWNSHIP
TAX CODES
TAX RATE
NEW RIVER
GENERAL COUNTY
BOONE
.370
.3I3
SALES DATA
DATE SALE PRICE
DEED 1 NA]RMATION
BOOKJPAGE
DATE RECORDED
DOCUMENT TYPE
STAMPS
0971748
06/23/1981
III
90
IEGAL DESCRIPTION
0.849 AC N RIVER
GRAN oRs
VALUE S,••••■•Y
B
FOX J SEPHINE B
LAND
BUILDING
TOTAL
WATTS TIMOTHY J05Fd�°S IIIFOXJEREMY
47400
160900
208300
BUDDING INFORMATION
DURUM 1
BLELDDIG1 SUMMARY
BUILDING
Tpo
USE
--) -- --- - ---1
l
HOME
Rom.
Sg[,TIOT�
• UNFFS
PHYSICAL %GOOD
t
I
1
i
3
1
78
AREA
HEATED AREA
2988
1840
MATH AREA
DATA
NUMBER OF Sl[ RBIS
1.0
IIDflER OR WALLS
HOU
STYLE
Itmaai
ROOF COVER
ASPWA89BSICE SHINGLE
YBARIU.T
196S
VIARREMOVELED
—
FOUNDATION
COHEI :IOW WAIL
BASEMENTTYPE
CRAWL
MAT RATING
OH$TLitAL
HEATT iG FUELT3PE
OH.
IiEA11M3 SYS1I MTYPB
EDT WATER
NUMBER CFROOMS
7
LNUMBER OF BEDROOMS4
FOIL HAIM
2
}HALF HAM
AEIIXI NAL FL:MIRES
2
ATTIC TYPE
NONE
AREA
1840
View Detailed Sketch
GRADS FACTOR
C+
CbCI_
GOOD
MEEER FEATURES
FINISHED BASEMI3NTLIVING
AREA
RICROOM ARRA
MASOONtYSTActa
1
MASONRY
1