WI0100070_GEO THERMAL_20090519

Central Files: APB— SWP_
05119/09
Permit Number W10100070 `' Permit Tracking Slip
Program Category Status Project Type
Ground Water In review New Project
Permit Type Version Permit Classification
Injection Water Only GSHP Well System (5QW) Individual
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility Name
Southwestern Comm College -Jackson Campus
Location Address
447 College Dr
Sylva
NC 28779
Permit Contact Affiliation
Kevin W. Brock
PE
PO Box 540
Waynesville
NC 287860540
Major/Minor Region
Minor Asheville
County
Jackson
Facility Contact Affiliation
Owner Name Owner Type
Individual
George Stanley Owner Affiliation
George Stanley
Construction Manager
447 College Dr
Sylva NC 28779
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
05/15/09
Regulated Activities
Outfall NULar
Waterbody Name Stream Index Number Current Class Subbasin

... &'A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
5/19/2009
George Stanley, Construction Manager
Southwestern Community College
447 College Drive
Sylva, NC 28779
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10100070
447 College Drive
Sylva, NC 28.779
Dear Mr. Stanley:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (UiC) Program that was received on
05/15/2009, the Aquifer Protection Section (APS) acknowledges your intent to construct a closed -loop geothermal water-
on�l rr in well system for the operation of a ground -source heat pump located at 447 Collage Drive, Sylva, Jackson
County, NC 2 87 79. This system is deemed permitted by rule (North Carolina Administrative Code Title 15A, Subchapter
2C, Section ,0211(u)(2)).
However, it is recommended that you contact the Jackson 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. If you have any questions please call me at [phone].
Sin rely,
for Mich Rogers
Environmental Specialist
GPU-Aquifer Protection Section
cc: Asheville Regional Office - APS
APS Central Files - Permit No. W10100070
Jackson County Health Dept.
Reece, Noland & McEirath, Inc. (Kevin W. Brock, PE, P.O. Box 540, Waynesville, NC 28786-0540)
Mid -South Geothermal, LLC (Scott Triplett, 8275 Tournament Dr., Suite 185, Memphis, TN 38125)
AQUIFER PROTECTION SECTION
1636 Mall Servlae Center, Raleigh, North Carolina 27699.1636
Locatlon, 2728 Capital Bouievard, Raleigh, North Carolina 27604
nB
Phone: 919-733net: 3221 1 FAx 1: 919.715- 588; FAX 2: 919-715-6048 l Customer Service; 1$77-62M748
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An Equal Qpporhink 1 A16mm*e Act& fmporer

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ENGINEERS
REECE, NOLAND & WELRATH, INC.
409 North Haywood Street • P.C. Box 540
Waynesville, North Carolina 28786-0540
Waynesvil:e 828-456-9851 e Asheville 828-253-3280
Fax B28-456-6205 . www.rnm-enLinears.com
May 13, 2009
North Carolina DENR-D WQ
Aquifer Protection Section — LIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
RE: Type 5-QW Injection Well System Permit
Southwestern Community College
14004 nuuJ-.Ubd-bJ11WV
0MQ r NN30 I C13A 33V
Enclosed please find two copies of Type 5-QW permit application for Southwestern Community
College.
Please don't hesitate to contact me if you have any questions.
Sincerely,
REECE, NOLAND & McELRATH, INC.
Kevin W. Brock, PE
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Y:ISCC - Administrative - Bookstore 2009066.001Cor espondence\TrammitW lest well permit. doc

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NOR'm CAROLINA MAY 16 2009
DI; PARI'MEN'I'OF ENVIRONMENT AND NATURAL RESOURCES (NC DEN [d)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER-ONLN INJECTION WELL SYSTEM:
TYPE 5-Q W WELLS
In Accordance with Ilse provisions ofNCAC Title I5A: 02C'.0200, please
complete this notiticalion and mail to address on the back Page (please Print or 16N information).
DATE: V, , 20%[..`
Well Type Confirmation' Dries the proposed system circulate potable wateronly (no additivcs) in
conliiluauS piping that crnMpletely isolates the fluid from The environrnem (i.e.
ciasesl-LgQ0;'
Yes Continue cornplei ing this form.
No _ _ Do Not complete this farm, Complete other UIC application firms liar installing
either a SA 7 weil (DpCrl-hoop well in eetctin}; potable walur inlo the aquifer) or n 5QM well (closcd-
luop well comaining additives such as R-22, ethanol. or caller a n 6 fireczc or corrosion in hi hilors).
A. PR0pEIR'l•Y OWN ER(S)IAPPLICANT(S)
List each Property Owner listed on properly deed (ifowned by a business or government agency, slaw name of
entity and a representalive w/authority for signature):
(I) Mailing Address: L! 14 ' �' le C I )t r t" r-
T_
' . r
City: '.J ��ti•'�`>< State: tL Zits Code:' 7 I � `_County
Hamel[}Ftice Tele Nn.: Sry:;' �� ". J�( tl�'� [] f Cell No.: ft
:mail Address:
t2 y Physical Address of Well Site (if dilTerent than above): ►`? 01 C--
City: _ Slate: Zip Code: __—,__C'ounty:
Home/OlTice Tele No.: _ _.. Cell No.:.
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does fiat own the subject prolerly.
attach a letter from the property owner authnriring Agent to install and operate UIC well)
Company Name. _ �� f /Z/M.
Comael Person: EMA IL Address:
Address:
C'ily:
O ice 1'ele No.:
Slate: Zip Code:
Webnile Address of Company. if any:
Courtly:
Cell No.:
j 6111 A 4C 50W NniiGenikin of latent l sinn (Revised $1200H) Page
D�0

C. WELL DRILLER INFORMATION
C'otnpany Name: f! It + �� _, [ �71.
Well DriIler Conlractar* & Name: j_ j {' L,L-s
NC Contractor CrtiItent ion No.: :'��r � )`q . U y *
Contact Pcrson�t `l_ t'-� 1Lt a'�i +i✓ L A�i, Address'
- s-
Address:._:� L1 (4 {_- t'l_ , : - J ^r(•. t✓ _
City: ~'�V oy t '1 �C t t l Zip Code: `�' County:
Of ice Tele No.. 4.� L -. ilc��- C~ � ��} Cell No.;
1). HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Narne:� C- (1` t V C. ' '' u l L _t__ '_
Contact Person:, �L't_7E �'-- F:i��,dr9re�s:� _ yG �- -
Address: -- lL:�� lc l'k mil,• r_�115 t� - —' 14 1��_.,, .- -��
r
City: i.�..t<�-�.� ��s. � _lip Code::^�i �'-_�- �.�, C�umy: 1-�tj:�
Mice 1•ele No.:I`Ll . I I (J x�_ Cell No.:, 1l
F. STATUS OF APPLICANT
Private: Federal: Commercial:
Slate; Municipal: ff- Native American Lands:
F. iNJECTION PROCFDURt. (trriclly describe how the injection well(s) will he used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: 1?l C1 �� Number of borings: i
7
Approximate depth of each boring (feet): � f'
(2) Type of tubing to he used {copper. PVC, etc):
(3) Well rising. Is the well(s) cased? (check either (a.) Yea or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: ___galvanized steel black steel plastic other (specif} )
Casing depth: From to feet (reference to land surface)
Casing extends to above ground inches I
(b) Na _-fit tom.{�i.�ttt >t �� �li� +C:C•. �' ksl �u: '�� ty_, 1 I�I���'Uc�i.
(4) Crow Info (material surrounding ►aeil casing and/or piping):
(a) Grout type: Nea( Cement_ Bentonite � Other (specify)
(b) Grout placernent: Primping Pressure Other
(e) Grout depth of tubing(reference to land surface): front (')— to feet)
II' well has casing. indicate grout depth: from _ to —( feel )
61`1 /1,1C 5OW NEnificaliem ttr Intent Moroi IRevisvd RI21108) vagv

H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification or the injection equipment and exterior
piping/tubing associnted with the injection operation. The munul`acturer s brochure may provide supplementary
information.
1, LOCATION OF WELL(S)
Attach two copies of maps shoving the following infonnation:
(1) Include a Site Map (can be drawn) showing: buildings, properly lines, surface water bodies, potential
sources of'gmuridwaler contamination and the oriental ion of and distances between the proposed wclltsl and
any existing, well(s) or waste disposal facilities such as septic tanks or drain gelds located within ?pp feet of
time geothermal heat pump well system. Label till features clearly and include a north arrow.
[2) The Site Map must show the subject properly in relation to the surrounding area by using at Imst two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
!Vote: This Permit Application most be signed by each person appearing on the
recorded legal properly deed.
" l hereby certify. Linder penalty of low, that I have personally examined and am familiar with time inlarination
submitted in this doctiment and all atlachments thereto and that, based on my inquiry of those individuals
immediately responsible foi• obtaining said information. I believe that the informatim is true. accurnle and complete,
t am aware that there arc significant penalties. including the possibility of fines and imprisonment. fur submitting,
false. information. I agrce to construct, operate. maintain, repair, and il' applicable, abandon the in well and
all related appurtenances in accordance with the appjn A specificay qns avid conditions of the Pennit."
Signature ofPropcTly Owner/Applicattl
RECEIVED / DENR aCII�II FORnT � 6 ec , r �� �f f ' r .=�c:� �c , rr ` c� �1 ill. t w ,�:
SAY Y
Print or Type frill Nanw and Mille
�i 2��g
Signature ❑rPrWriy Owner/Applicant
Print or Type Fu11 Name and title
Signature o1'Atlthorized Agent. il'any
Print or Type Full Naive and title
Please return Iwo copies of the completed Application package to;
North Carolina DENR-DWQ
Aquifer Protection Section-UiC Program
1636 Mail Service Center
Raleigh, NC 276"-1636
Telephone [phone]
( il'i'!l It' 5OW M1rtliCicalion of Initin l~um I -krixd 812MR) I'aw 3

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