WI0100166_Regional Office Physical File Scan Up To 9/22/2022

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818 A
1. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (Individual) Name
Go! Green Drilling. Inc.
Well Contractor Company Name
615 Rest Home Rd.
Street Address
Claremont NC 28610
City or Town State Zip Code
828 367-1293
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10100166
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #C'dapplicable) GL-1
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 8/17/201 1
TIME COMPLETED 4:30 AM ❑ PM
4. WELL LOCATION:
ciTY- Asheville COUNTY Buncombe
86 Larchmont Rd. 28804
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley 5fFlat []Ridge ❑Other
LATITUDE 35 ^ 37 ° 25.9100 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 82 " 33 ° 32.2000 " DMS OR 7X.XXXXXXX)O( DD
Latitude/longitude source: SJJ�PS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Maroaret V. Moss
Owner Name
86 Larchmont Rd.
Street Address
Asheville NC 28804
City or Town State Zip Code
8( 28 ) 774-4242
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 150
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO R(
C. WATER LEVEL Below Top of Casing: None FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS NSA FT. Above Land Surface -
'Top of casing terminated at/or below land surface may requi
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
Ft.
: Top Bottom
Ft.
8. GROUT: Depth
Material Method
Top 0 Bottom 150
Ft. Benetonite Thermal
Top Bottom
Ft.
Top Bottom
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top N/A Bottom
Ft
in. in.
Top Bottom
Ft.
in. in.
Top Bottom
Ft.
in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
Top N/A Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
11. DRILLING LOG
Top Bottom
Formation Description
0 / 12
Silty
Sandy Clay w/boulders
12 / 62
Gray
Rock
62 / 64
Brown Rock-
64 / 76
Gray
Rock
76 / 77
Brown Rock
77 / 90
Gray
Rock w/Quartz
90 / 150
Gray
Granite
/
/
e�t FT
12. REMARKS:
Information Processing �lnit
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
PROVIDED TO THE WELL OWNER. - i
e. YIELD (gpm): NSA METHOD OF TEST NSA
Randall E. Cutter '
f. DISINFECTION: Type NIA Amount NIA : PRINTED NAME OF I
Submit within 30 days of completion to: Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161,.Phone : [phone]
WELL
I
Information Processing,
7 �P 2 6 r
L2v•ol
DATE
WELL
GW-1 a
2/09

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818 A
1. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (Individual) Name
Go! Green Drillina, Inc.
Well Contractor Company Name
615 Rest Home Rd.
Street Address
Claremont NC 28610
City or Town State Zip Code
828 367-1293
Area code Phone number
2: WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10100166
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) GL-2
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 8/20/201 1
TIME COMPLETED 12:00 AM ❑ PM J(
4. WELL LOCATION:
CITY: Asheville COUNTY Buncombe
86 Larchmont Rd. 28804
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley PfFlat ❑Ridge ❑Other
LATITUDE 35 ° 37 25.9100 " DMS OR 3X.XXXXX)o(XX DD
LONGITUDE 82 ° 33 32.0000 " DMS OR 7X.XXXXXXXXX DO
Latitude/longitude source: RrGPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Margaret V. Moss
Owner Name
86 Larchmont Rd.
Street Address
Asheville NC 28804
City or Town State Zip Code
8( 28 ) 774-4242
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 150
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 9(
c. WATER LEVEL Below Top of Casing: None FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS NIA FT. Above Land Surface'
`Top of casing terminated attor below land surface may require
e. YIELD (gpm): NIA METHOD OF TEST NIA
f. DISINFECTION: Type NIA Amount NIA
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
Ft.
Top
Bottom
Ft.
8_ GROUT:
Depth
Material Method
Top 0
Bottom 150
Ft. Benetonite Thermal
Top
Bottom
Ft.
Top
Bottom
Ft.
9. SCREEN:
Depth
Diameter Slot Size Material
Top N/A
Bottom
Ft. in. in.
Top
Bottom -
Ft. in. in.
Top
Bottom
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material,
Top N/A
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
Top
Bottom
0
/17 .
17
/66
66
/68
68
/80
80
/82
82 /85
85 /150
12. REMARKS'
Formation Description
Siltv Sandv Clav w/boulders
Gray Rock
Brown Rock
Gray Rock
Brown Rock
Gray Rock w/Quartz
Gray Granite
SEP' 0
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
PROVIDE0*f0 THE WELL_OWNER.
CERTIFIED
Randall E. Cutter
'-X�W" 8/29/11
CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING'THE WI
r-
r-
Submit within 30 days of completion to: Division of Water Quality - Information Processing,.
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: [phone] h!
GW-1 a
2/09

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2818 A
1. WELL CONTRACTOR:
Randall E. Cutter
Well Contractor (Individual) Name
Go! Green Drillina. Inc.
Well Contractor Company Name
615 Rest Home Rd.
Street Address
Claremont NC 28610
City or Town State Zip Code
828 367-1293
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10100166
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) GL-3
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 8/24/201 1
TIME COMPLETED 5:30 AM ❑ PM
4. WELL LOCATION:
CITY: Asheville COUNTY Buncombe
86 Larchmont Rd. 28804
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley UfFlat ❑Ridge ❑Other
LATITUDE 35 ^ 37 25.9100 ^ DMS OR 3X.XXXXXXXXX DID
LONGITUDE 82 ^ 33 31-8000 " DMS OR 7X.XXXXXXXXX DID
Latitude/longitude source: VGPS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPSI
5. WELL OWNER
Maraaret V. Moss
Owner Name
86 Larchmont Rd.
Street Address
Asheville NC 28804
City or Town State Zip Code
8( 28 ) 774-4242
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 150
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO St
c. WATER LEVEL Below Top of Casing: None FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS NSA FT. Above Land Surface`
`Top of casing terminated at/or below land surface may require
e. YIELD (gpm): NIA METHOD OF TEST NIA
f. DISINFECTION: Type NSA Amount N/A
g. WATER ZONES (depth):
Top None Bottom
Top Bottom
Top Bottom
Top
Top
Bottom
Bottom
Top
Bottom
Thickness/
7. CASING:
Depth
Diameter Weight Material
Top None
Bottom
R.
Top
Bottom
Ft.
Top
Bottom
Ft.
8. GROUT:
Depth
Material Method
Top 0
Bottom 150
Ft. Benetonite Thermal
Top
Bottom
Ft.
Top
Bottom
Ft.
9. SCREEN:
Depth
Diameter Slot Size Material
Top N/A
Bottom
Ft. in. in.
Top
Bottom
Ft. in. in.
Top
Bottom
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
Top N/A
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
Top
Bottom
0
/24
24
/73
73
175
75
/86
86
/88
88
/95.
95
/150
12. REMARKS:
Formation Description
Siltv Sandv Clav w/boulders
Gray Rock
Brown Rock
Gray Rock
Brown Rock / Fractured
Gray Rock w/Quartz
Gray Granite
r�kf��
SEP 0 cs Dui
infOrmation Ar
3ce557114 (Jnjs
DINrn/Rn,
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
PROVIDEDJO THE WELL OWNER.
Randall E. Cutter
PRINTED NAME OF
Submit within 30 days of completion to: Division of Water Quality - Information_ ProcessF. A
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: (919)' 807-6300 ,. e l 2U I
WELL
GW-1 a
2/09

Margaret V. Moss
86 Larchmont Rd.
Asheville, NC 28804
HVAC Contractor. Asheville Geothermal
NC State Permit# WI0100166
GPS coordinates for Geothermal Loops
GLA 350 3T 25.91" N 820 3V 32.20" W Back comer = 36.T
GL-2 350 3T 25.91" N 820 33' 32.00" W Back comer = 42.9
GL-3 35" 3T 25.91" N 820 33 31.W' W Back comer = 52.8'
Front comer = 43.7'
Front comer= 36.6'
Front comer = 37.2'
".'P:
information Processing Unif
Go! Green Drilling, Inc. 61058 Rest Home Rd. Claremont, NC 28610 828-367-1293
J

/
Permit Number W10100166 l'"1G 1
Program Category ip:u,iC�°i)jS RcjpPPO ®jCC
Ground Water A'If_ i•ieo pmt-actic n
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
Central Files: APS_ SWP_
08/12/11
Permit Tracking Slip
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, CAshevlll�
County
Buncombe
Facility Contact Affiliation
Owner Name Owner Type
Individual
Margaret Moss Owner Affiliation
Margaret .Moss
86 Larchmont Rd
Asheville NC 28804
Dates/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 NULL
Waterbody Name Stream Index Number Current Class Subbasin

Aff 711
AM
HNR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
8/12,12011
Margaret V. Moss
86 Larchmont Road
Asheville. NC 28804
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100166
86 Larchmont Rd, Ashville, NC 28804
Dear Ms. Moss:
Dee Freeman
Secretary
On 7/25/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as -the
following conditions are met:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Buncombe County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Rogers(c—vncdenr.aov if you have any questions.
(Siinncerely,
or Debra Watts
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. WI0100166
Buncombe County Health Dept.
Asheville Geothermal, Inc. (Rick Clemenzi)
Go! Green Driliin„ Inc. (Randal Cutter)
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-'i5-0588; FAX 2: 919-715-6048 , Customer Service: 1-877-623-6748
Internet: www.ncwaternualitv.oro
An Eaud Opponunit \ Affirmative Action Employer
One
NorfiiC ff..O-lIna
t

NORTH CAROLINA JUL _2 5 m
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-OW WELL(S)
hz 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 Type information).
DATE: July 22 , 20 11
Well Type Confirmation: Does the proposed system circulate potable water only (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 (open -loop well injecting 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)/APPLICANT(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):
Margaret V. Moss (PIN 9740-20-6917)
(1) Mailing Address: 86 Larchmont Rd.
City: Asheville State: NC Zip Code: 28804 County: Buncombe
Home/Office Tele No.: 828-774-4242 Cell No.: 828-774-4242
Email Address:_mmossAunca.edu Website:
(2) Physical Address of Well Site (if different than above):
City:
State: Zip Code: County:
Home/Office Tele No.: Cell No.:
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 UIC well)
Company Name: Asheville Geothermal Inc.
Contact Person: Rick Clemenzi EMAIL Address: info(cbashevillegeothermal com
Address: PO Box 18757
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.ashevillegeothermal.com
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 1

C. WELL 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: randy@gogreendrilling com
Address: 6105 Rest Home Rd.
City: Claremont Zip Code: 28610 County: Catawba
Office Tele No.: . 828-367-1293 Cell No.: 828-228-1695
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Asheville Geothermal Inc.
Contact Person: Rick Clemenzi EMAIL Address: info(a)ashevillegeothermal 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 Pump, Closed Loon
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: about 8/1/11 Number of borings: 2
Approximate depth of each boring (feet): 225' _
(2) Type of tubing to be used (copper, PVC, etc): _HDPE
(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: _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 225 (feet)
If well has casing, indicate grout depth: from to (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 2

JUL LU
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.
I. 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 systein. 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 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, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications 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
d, e c : �_ R
Signature of Authorized Agent any
Rick Clemenzi 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-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 3

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The information provided is based on the best available data at the time of currency for all datasets. It is the requestor's responsibility to verify any information derived from the GIS data
before making any decisions or taking any actions based on the information. Buncombe County shall not be held liable for any errors in the GIS data. This includes errors of omission,
commission, errors concerning the content of the data, and relative and positional accuracy of the data.