WI0100053_GEO THERMAL_20070913

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
September 13-, 2007
Mr. Tom Osterhoff
202 Creek Side Drive
Warner Robins, GA 31088
Subject: Acknowledgement of Intent to Construct Type'5QW Injection Well System
Permit No. WI0100053
85 Ladys Fern Trail, Hendersonville
Henderson County, North Carolina
Dear Mr. Osterhoff:
In accordance with the application submitted to the Underground Injection Control (UIC) Program that
was received on August 30, 2007, the Aquifer Protection Section (APS) acknowledges your intent to
construct a closed -loop geothermal water -only injection well system for the operation of a ground -source.
heat pump. This system is located at 85 Ladys Fern Trail in Hendersonville, North Carolina.
This system is deemed permitted by rule (North Carolina Administrative Code Title .15A, Subchapter 2C,
Section .021 l(u)(2)). However, it is recommended that you contact the Henderson County Health
Department, as they may have additional construction or permitting requirements for this type of system.
If you modify your system at any time, including the addition of antifreeze, corrosion inhibitors, or any
other substances to the circulating fluid, you must contact the APS to verify compliance with applicable
rules.
Thank you for submitting this notification. Please call me at [phone], or email me at
au. i a,ncmail.net if you have any questions regarding geothermal heating or injection well rules and
regulations.
Sincerely,
Qu Qi
Aquifer Protection Section
F-nclosures
cc: Asheville Regional Office - APS
APS Central Files - Permit No. WI0100053
Grace Home Builders — PO Box 2779, Hendersonville, NC 28793
Aquifer Protection Section 1636 Mail Service Center
Internet: www,ncwaterquality.or Location: 2728 Capital Boulevard
An Equal OpportunitylAffrmative Action Employer— 50°% Recycled110% Post Consumer Paper
I�0�h Carolina
11Vaturallb
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

Petmil Number WIOI00053
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (50W)
Primary Reviewer
qu.gi
Permitted Flow
Facillt
Central Flies. AP5 SW P
09/12/07
Permit Tracking Slip
Status Project Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Facility Name MajorlMinor Region
Tom & Dianne Osterhoff Minor Asheville
Location Address County
85 Ladys Fem Tr! Henderson
Hendersonville NC 28739 Facility Contact Affiliation
Owner Name Owner Type
Individual
Tom Osterhoff Owner Affiliation
Tom Osterhoff
202 Creekside Dr
Warner Robins GA 31088
Scheduled
Drig issue App Received Draft Initiated Issuance Public Notice Issue
08/30/07
ulated Activities
3utfail NULL
Waterbody Name
Effective Expiration
Stream index Number Current Class Subbasln

Application Reviewer: 0 k :� ,
Pre -Review: Conducted? Y Yes ❑ No
O.K. to Process? ['`Yes ❑ No
If No, What Action Is Needed? ❑ Pre -Review Return
❑ Hold, Pending Receipt of Addinfo.:
NameJAffiliation of Person Contacted:
Dates) ofContact:
Owner: ❑ Existing ❑ Unknown Owner Type
Facili tvlOperation:
Regulated Activities:
2-1proposed ❑ Existing
W -r- 01000 s3
❑ By Phone ❑ By E-Mail ❑ By Letter
2--Non-Gov't ( nd or ❑ Org) ❑ Gov. -Municipal
❑ Gov. -County ❑ Gov. -State ❑ Gov.*ederal
❑ Facility ❑ operation
Applica tionlPermit:
Fee Category: ❑ ND Major (New $1090, Major Mod $325) ❑ ND Minor (New $675, Major Mod $205)
❑ Sewer Ext. ($400) ❑ SFR (New $50, Major Mod $15) ❑ Recycle ($300) ❑ Other
`j Permit Type: ❑ Sewer Ext. ❑ Collection System (O&M) ❑ Pump & Haul
❑ Surface Irrigation ❑ Surface Irrigation - SFR ❑ Reuse
❑ High -Rate Infil. ❑ Recycle ❑ Infil./Evap. Lagoon ❑ G W Remediation (ND)
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal ❑ Animal
❑ 503 ❑ 503 Exempt
Project Type: ❑ New ❑ Major Mod. ❑ Minor Mod. ❑ Renewal ❑ Renewal wl Mod.
Notes: _ . �.� c k 0 e' is AI-F-�
t =%a
FORM: BIMS 04/02/18
dU

08/15/2007 10:35 8266931200 GREEN RIVER WELL PAGE 02
NORTH CAROLJNA
DEPARTMENT OF ENVIRONNZNT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP
GEOTHERMAL WI&BB -ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
IjW saw wdl«
In Aconrdapm with the WvWms of NCAC Title I SA-, 02C.0200
Cmnplete eppliatiun wA mail to addrm on the hack pa fe.
This Is mItbe proper form sa bur reed fiw kimcdor wells i■ ar roo�pRe"h ermal system.
gLgLIM tits bm for syrh ms twee eisvebte asrr ateltedaaen other A111 now -
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: d 20-0
A. SYSTEM CLASSIFICATION Dws the propaoed system dmulate p ouble water in continuous
plpinS duet ownphnely isolsks flee fluid from due envimmmt?
YES Vel,if yea, thm axaWw caimpkting this form.
NO If na, do not complete this farm. Form GW-57 HP, Application For
Pepwit T'o Canrrras l And1Or Use A Well fs) ,Far Infecdor With A Hear
Pr ww weer, should be completed
H. SYSTEM FLUID Will any wMfivea be inb+odwed to the rystesn'a circulating bm transfer
fluid? This includes, but is not limited to cmrosion inhibitors wKVor antifreezes.
Yl?S If yea, da not oomom this form. Pam GW-57 HP, AppikaHo►r For
Permit Ta Cderrrrspl AmdADF Use A Wall(s) For Injection With A Hera
Pre w *tiemk should be colttpIdW.
NO V If me, then cartimue cangged" this fomu.
C. PROPOtTY OWNER
Nacre: 4 0f" + D i inns—
Addt"s, 2-L-'- ' 'etL SIDE DR k(E
City; U LnErc. tbe'r ns, State: C-,L4__ Tip Code: o jS"-
County: U.,5 PrTglepbaft, I 1 9a�T55
D. STATUS OF PROPERTY OWNER
Private: Federal: CSn woucial:
State: Municipal: Nadve Am4icm Leads:
Revised 7/05 OW/iIIC-37 Ct. Peas 1 of e

081'15i2$07 10:35 8206931200 GREEN RIVER WELL PAGE 03
E.
F
G.
FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owoar is Federal, Steve, Municipal or Commercial).
Nume of Du3iness or Facility:
City; Stde: A/cF Zip Code: , �_ Couruy;
Telephone: Comet Person:
Standard IrkdtsMW Code(sN SIG, which describe* cammer081 faci#fty:
HEAT PLfW CONTRACTOR DATA
Nurse: f,o1� f : '�.!' , 1Ae L+t n, 4- Ate,. ne -
Address- 1' U 66%- , ; t i
City; _ .1-1re'ri tic State: Y'L- Zip Cede: f) 18 a1�Cowaty: U'_ -A
Te#epltane: g = a4+o 8 Contact Parsan: - t Oe , W_JKL'T} �. 4, _ L_ --
CONS11RUCT ION DATA (check ono)
EXISTING WEi„l,{S) being prvltosed for use as a ground -coupled heat pump
well(s). Provide the irdormetiaa in (1) through (3) below to the beat of your
knowledge. Atwch a copy of Farm OW-1 (Well Const -action Record) If
available.
X _ PROPOSED WELL(S) to be eooswucW for use ay ■ grawW-coupled heat pump
well(s). Provide the hdb msdon in (1) through (3) below as PROPOSED
owam ctioe specifications. Submit Form GW-1 after contraction.
(1) Well Miling Contrsr:tar's Nurse: di'1 Y r i% -6V&*1K 0`
NC Convactor Certification ou;mber: as 7 i
(2)
(3)
NOTE.
Reviled 7/06
Date to be c4mro4ucted:
A,pproximde depth of ewh basing (feet):.
Number of borings; al
Well casing: Is the we11(s) cased?
(a) YES if yea, diva ptavide the casing infcrrnaticm below.
Type; Galvanized steel Black, steel Plastic Orbear (specify)
Casing depth: Roar to
Casing extends shave ground
(b) NO *
ft. (rarbU ao to land stwfaee)
inches
Grout (grout the ►►ethical Intro ofthe borehole to a ttiWrnum depth of 20 feet b.l.s.):
(a) Grout type: Cwnertt Berrlortile tin Other (specify)
(b) Grouted awface and grout depth (refamw to laced surface):
amused closed loop piping; fi m to (feat).
around well ceasing; from to (fret).
TM WELL ML LINo G*NTRACIGR CAN MMY THE DATA FM Er MER UMSnNG GR
MO"E0 WELLS rFIM FWOtLMATM 13 UNAVAALABLEBYOTWAMEANS.
OWMC-s7 CL
PuEe Z of 4

08/15/2007 10:35 8286931200 GREEN DIVER WELL PAGE 04
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the mainaering layout of the injection equipment and estterior pipingftnsbing
associated with the iriEja dm opention. Ilse manoraeturer's bmochue may provide supplementary
inforreation.
LOCATION OF WELL(S) Attach two maps.
(1) Include a site map (can be drawn) showing: buildings, property Ibm suface water bodies,
potential sourcies of groundwater contaatination and the adentat6m of and distances between
the pmpaaed well(s) and any cxistlang wall(s) or waste disposal facilities such as septic tanks
or drain fields located within 20D (bet ofthe Smud-aupled hest pump well system. Label all
features clearly and include a north arrow.
(2) location map referencing the site to two nearby perrrranent refQerace paw (such as roads,
strearrss and highway irntWWOdona).
PERMIT LIST: Attach a list of all permits or can tyuetion oppmals that are related to the site.
Examples Include:
(l) Hazardous Waste Management program permits under RCRA
(a) NC Division of Water Quality Nor-DiscImp permit
(3) Sewage Treatment earl Disposal Permita
K. CERTIFICATION
"I hereby certify, under penalty of law, tho I have personally examined and am familiar with the
informasion submitted in this document and all ataaciaruenw Owsto and thK based on M inquiry of
those ivdividuWs immediately reawopossible for obtaining said informatiom, I believe that the Womneition
is true, accurate and complete. I err► aware that Once are slgaificrost penaltim, including the possibility
of lines and imprisonumt, ror atsbtmitting false iefonnetioen. I agree to consaw, operate, maintain,
repair, and if applicable, abardan the groua&source but pump system and all related maces in
accordarme with the app mrved nwifscations and coaditioms of the Permit,"
Wgr►st� Well Owner or Audwdzcd Ag t)
1f authoriized agent is acdrrg on beharlf of dse wet! owner,
please supply a raper sop rd by the owrrwer
awhorfift the above agent.
Ravised 7/W OWAJW-57 CL Pie 3 0!0

0g11512807 18:35 i32B6931200
GREEN RIVER WaL PAGE 05
�. CONSENT OF PROPERTY OWNER (Owner meam my persan who holds the fee or other property
rights in the well being constructed. A wall is rod propcity seal its omst uction on lmd rests
ownership in the landowrmr in dw sixence of conh ly egrmmmt in writing.)
If the property Is owned by sommoc other than the a"lican% the property owner hereby comerm to
allow the applicant to conmuct each injection well m outlined in this application and that it shell be
the responsibility ofthe applicant to ensure that the groundyounm beat pump rfstem's well(s)
confmme to the Well Construction Stmdards (Title ISA NCAC 3C .0200)
(SipxhAm Of Property 0w mJr If Diffme+en From Applicant)
Please return two copies of the completed Applium6an pwkAge to:
UIC Program
Aquifer Protection 5e9f s
North Cs+lrt mm DENR DWQ
1636 Mail Service Center
Raltigh, NC 276"-1636
Telephone [phone]
page 4 of 4
Revised 7106 OWMC•57 CL

07 12: 37PM Grace !-lame Builders,
Inc. 1-829-698-6984 P•1
nut i-7
GRACE HOMES
Send to: [ Prom: f l�j
Attention: Date:
Office Location
Fax #:
Urgent Please Review
Reply ASAP For Your Information
Please Comment
Total pages, Including cover page
Comments:
PO Box 2779 Hendersonville, NC 28793 [828)598.6888 Fax - (828)69"84
grace hb Ob ell s o+uth. near

Rur�_P7 2,007 12:37P11 Grace Home Builders, Inc. 1-628-698-6884
88/15/2087 10:35 B286931200
GREEN RIVER WELL
PACE 62
p.2
NORTH CAROLI?aA
0EPAIRT%CD?T OF EWA001ENT AM NATL►RAL RESOURCES
NOTMCA770N OF INTENT TO CONSTRUCT A 0&SLRt1AUP
GEOTHERMAL NA3M zp= INJEC 70N WELL SYSTEM
(GROUND COUPLED HEAL' PUMP)
Type SQW Wells
1n Av=dww whh tha porbksr of NCAC Tkk I5A: 02r—OM
Conipkw awiwtion and motto halt on dw back pale.
IMin to AgLibe peum form m be rd br kajortim ..dhr in as-1M2jpotba *I rph m.
Do gs th k !bras for srla that dremitm -llishnft� other Reny *our.
TO: DIRECTOR, NORTH CAROLINA DIVINON OF WATER QUALITY
DATE: flu - ' 70-01
A. SYSTEM CLASSIFICAT014 DM the prop=W ■ wW m daukte petabk water 1A 0on inuato
piping drat a mpkt * isohfts dta fluid f w die emv4v mr7
YES v Byes, then OWAISOC aotrWWng this Form.
NO If ne, do net compicto this ii+ 7m Fam OW-57 HP, App&-attar For
Powit ro Cmw wc(,fmd/Or Vae A welffs) For bordcn l 70* A Heat
P mwp ypleru, should be "avow.
B. SYSTEM FLUID WiA *M add t1ycs be head to ft rysrspa`a ci�cviatiraa ltcae uertafer
fluid? This hwludea, but is not XM1%d to awmion dtibitom mWor =tif .
C.
YES If yen dro mm camph" this form. Farm OW-57 HP, A00ca fon ,Pbr
,P~ To Carr bwO AM&OF use A Weir() For Injeaton With A Elea
Ptmmrp 4whs r, should be compieRed.
NO if mo, than 000dwe amwktirtR %No fom;r.
PROPMTY OWNER
Name. -Om `-" D iGnfle.. Gs+tef hOW-
AddrW.' 2D2 C'_1Feegt &oE v %ir
City; _k ex- gz�43 i n s. Stm: rx Pr Zip Code: a 5
CapAnty: _ U-S Pr Tnlapbm. 4 - j 4 - ja;- hf!J
STATUS OF PROPERTY OWNER
Mwate: I- pedemi:
Steve:
Mttnidpw.*
Comme:sia]:
Native Aawrkw Laoda:
Rerirad 7AX (iW/UIC•57 CL Pw t of e

Aug,27 2R07 12:37PM Grace Home Builders, Inc. 1-828-699-6884
a311512097 10:35 8295931200 GREEN RIVER WELL
PAGE 63
P- 3
E. FACILITY (SITE) DATA
(Fill ants ONLY ifthe 8tMe of Ow,w is Padaad, 51aoe, Municipal or Caatrneasia
Nameof Business or Facift:
Addmn;
City: Stile: Zipcodr: County.
Tel"Aaw Coaitae poson:
Standard IrAaaaW Coda(sj SIC, wh :h darcribn commcacW fhcilib:
F, HAT PUW CONTRACTOR DATA
Noma: _ A a Lt.LI AJWL -):AW+nrGjl f'rk +�.�
Address: 9b & Yx _12 11A -
City: snare• yx- zip coda. a r s I coursy:
Telephone: 8 as r a4ty S Cock Persaa:
O. CONSTRUCTION DATA (chock am)
EXISTIM0 WELL(S) being ptr wwd for use ae a grvtad-ooY W heat pump
well(sk Provide the inSrrana. on is (1) duough (3) blow to the beat of Your
WwwkdSe. Ankh a coPy of Fauns OW-1 (Weil CanovWon Record) i C
evallabhL
x PROPOSED WMUS) to be aoastnicted for Yee ao a gtwUad- "lad beat pump
wwtKsj Pe Aft die kdmw don bt (1) tl mlb (3) below as PROPOSED
ce�trmvcRiva sped&ndc . sb rFantr vw-I altetr oonetrttcdna. j]
(ly vYra] Orlllirig Carmac�o�'. T�lamey �ar+__ �_�� �► �dt -Pk � r� i
NC Cantractar Catifie ddon t Mdw- �
Date to be i m budod• l+ wkber ofba 6W.- d�
Appfoxkmste d0F* of each baring(001):
(2) Wed) wing: Is the wetl(s) eased?
(a) YSS if yaa, draft prM% i& the raft'Faesaaeia4 bekrw.
Type, Odvmfmd steal Black creel Plrek Odw (spo d fy)
Casing depth: Ftvm m lt. (rdwxm to lad stofatx)
Caaing ext mft ebm Darned inches
(b) NO x
(3) Grout (grvtd tine mtr&d bwob of the >domboie so a atWmum depth of 20 feel W-%):
(a) craw type: cane" b%*MM ro Other (specify)
(b) O mutxl stu fwx wd gn M depth (mina oe to land staflrae):
wound ckm d bap piping; fro m (fbst�
$Mwdweil ea8irw Sam too {fart),
NOTE- TIN WELL DMtLJMo CONVRACMR CAN SUPPLY 771E DATA PM ssras M sZIM40 OR
PIKAFLBM WELLS IF T*M INPOIKAYM It UNAVAILAK8 aY a7M MtAN3.
Rarlsad 7M QWMC-57 CL ftga 2 of 4

Rug P-7 2Q07 12:37PM Grace Home Builders, Inc. 1-828--698-6884 p.4
0(?11512897 12+:35 9286931280 GREEN RIVER WELL PAGE D4
H. 04JECTION-RKLATEI) EVENT
Attach a disgracer snowing the ssgkowing iayow of the injeajoez egt;i wam and em m or piphg0tubing
aswwAsted vwielt the Injecdon opersdiod The rasnafdume's bsvehem mey provide suppler riwaary
tafermwdon.
LOCATION OF WkLL(S) Attach two nips.
(1) Include a Bite w ap (cm be drawn) dwvK g, buildbgw Popwby lines n6wo crater bodies,
polrsntial sources of paapradwater aonaninWon =W to oriamWon of w d dlstswes betrweep
do psaapveed welks) sad a" sodaficpg well(s) or n= disp=W f c Brea such as septic tanks
or dada fwldk loud wkbin 20D fim ardw pawad-PoWie+d hem pwowp well syssm. Gbei all
feettree Ilea ft and irsclt�ds a tnoffh an[ttw.
(2) iacatiarer map the site to two rreaeby psaronaeretft refs paitees (fruch as made,
sbwu sod bighwag imeraeciians).
PERhUT LIST: Aetwb a No of all psrmita or consrruueiaa opprvwls that art; related to the site.
Ennarnples iechuh:
(1) Hsard&m Wasta Mmagomad prsgrartt pwmits uWw RCRA
(2) NC Division of Wow Quality Noib-Db� pmais
(3) St3wege Tr a rneot rand Ensl oral Ptxenito
K. CEATIPICATION
"I hereby certify, urWer pmWd of low, dace I have pera wAlly =wntinad nerd am 1lanilbor with the
infbnrnrtian er6mitted lw Ws daaowwK nerd all stuchmentr *moo artd t1rs. based oar w bgwy at
those iDdIvidush Wonediataely mopa>cnible ibr obtaining said mftmm}an. I belim tort the inPorion
is true, accurate add complasw I on mw Ow d we we Wpifieaert pepAhia4 including the poasibMW
of fbw wW inter amment, for ffAw tang Mae kdbc rrtkm. I #Sw to oostatr wk op puk, mointairy
mpsir, wed if a WkW) e, sbser I the troua:�-sowce bee posse my - and all misted epp urkmnow in
wcordsae with Ilse wprorad spscukefiew and 000dwms of d* Permit'"
(P ignatu�►—#rlr Well Oww cr Aude dwd Ageht)
1f awhorAwd wnt w ov ft one AtWf of the well awrser,
please shy a kew algrasd by thr ownser
asap: fg dw above agog
gs+riaed 7196 Gw► nr'57 Cl. YOW 3 of 4

19ug 27 20,07 12:37PM Grace name Builders, Inc. 1-820-696-6884 P.5
09t1512@07 10:35 9286931208 GRE
EN RIVER WELL PAGE 05
Lr CCNSENT OF PROPERTY OWNER (Owner mama any lx= who holds rite fm or ottw property
rights In the well bob* ooMvvetrd` A pied is teW p opw red its amwb vdm an lard MM
awnenhip in the teribwrRw in dt0 abpeasoe ofeoettrary armwo in wtfift)
If the pM10M is owend by fanowe 0dw thwk tba appl6eri e, lie propmV ovum bweby oaemmw to
show Ow appliraat to oonrinx t each lnjwdm whit ee acded In thin appllartioei toad theet it sWI be
the €e9pDD2M ity ofdte epp kAM to Mtn" that tt g OUM640 tme beat PUMP *WOWS we#t(e)
oaofor M to the Wall Comtrt cd m 64ddera (Me 1 SA MCAC 2C .0200)
(5iP Owea If Oiffemd Frvtts Applieant)
plerae retmo twn Copiaa of Lbe cm*tvW App liw: an ped eae to:
UIC Pragrw
AgwUlp r Proteebm 5etetioo
Tiorth CMnAkzo DEMR•DWQ
1636 Mt;R Servke Center
Rsk116,14C 376 M6M
Tekpbme (919) 715-6"5
pt�e 4 0! 4
p.&v;eee 7V6 0WAY[C•57 CL

GoMAPS - Henderson county NC Public Access
c(
.fic
IF
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1 ~rALAURLL PARK
1
4
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w
***WARNING-. THIS IS NOT A SURVEY!***
This neap is prepared For the inventory of real properly found Nvithi n this jurisdiction, and is compiled from recorded
deeds, plats, and other public records and data. Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map. The
County and mapping company assume no legal responsibility for the information contained on this map.
LEGEND
C7 ...
Apf�as.l
r� MAT ROM
'rTucs
hi`.SEl80CY y.F
SAL:, ]A
Wednesday. September 12 2007
N

GoMAPS - Henderson county NC Public Access
LAKJDJA
Sky TPL s�IST
e
IF AT
M 51(Y`YAY DR RD
❑GOB [ �(0 ' LAUREL PARK 'r
r qP
f { CLAYS GQ P
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raYTe -'A'q c r�
m R�yR,.� aulL �� yly r
Pit *�fu
t) p=2277R Ln,►ru�,�,,x
***WARNING: THIS IS NOT A SURVEY!***
This map is prepared for the inventory of real property found within this jurisdiction, and is compiled from recorded
deeds, plats, and other public records and data. Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map. The
County and mapping company assume no legal responsibility for the information contained on this map.
LEGEND
Caryl "1
�nr woc�c
e�+oE�esurr-�
L�l.A.Ei iJIEp[
1-" -V-
axv�a
Monday, December 14 2007