WI0100075_GEO THERMAL_20091012

d�p5L47Ea
RESIDENTULi watt coNsmucrioN RwoRD
North Carolina Departcnertt of Travirommeat antdNatural Resources- Division of Weft Quality
* WELL CONTRAC M]PIL CERTMICAnCIN # 3421
1. WELL CONTRACTOR --
David Stratton ---
Well Contractor (Individual) Name
MD SeLvices.1nc.
Well Contractor Company Name. - - —
258-NortbIuds-e-vCneekRd.
Stnaat Address
Leicester _ NC 28748
City or Town State Zip Code
828 ti 683-9223
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERwro WIQ100075
OTHER ASSOCIATED PERMITORapprxable)
SITE WELL IDAQfapplicablel -- J
3. WELL USE (Check Applicable BOA: Residential Water Supply N
DATE oRiLLE.D 9/28/09
TIME COMPLETED AAA ❑ PM D(
4. WELL LOCATION:
crrr: Asheville
coumwBuncombe
290 Vanderbilt Road
(Street Name. Numbaia, Comnwft, SubdRrialan, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC/ LAND SETTING:
(rhedkappmprisee boo
=lope ❑Valley .OFIat ❑Ridge
❑Olher.Eley-
LATITUDE 36 �'
" DMS OR DD
LONGITUDE 82
" DUS OR DD
Lalltudellongitude source: RfJPS oropographic map
(focaflon of we#must be shown on a USGS fnpo map andaffeched to
this form ff not using GPS)
8. WELL OWNER
Owner Name
290 Vanderbilt Road
Street Address
Asheville _ NC 28803
City or Town State Zip Code
a(28)
Area code Phone number
e. WELL DETAILS. (4) . Geothermal Bores
s. TOTAL DEPTH: 2-325' 2-260'
b. DOES VVELL REPLACE EXISTING WELL? YES ❑ NO Si
c. WATER LEVEL Below Top of casing: NIA FT.
(Lisa W if Above Top of Casing)
d. TOP OF CASING IS NIA FT. Above Land Surfaoe
Top of casing terminated atfor below land surface may require.
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): NIA METHOD Of TEST NIA
f. DISINFECTION: Type NIA Amount NIA
g. WATER ZONES (depth):
Top
Bc#Du
Too
Botb3m
Top
Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness!
7. CASING:
Depth_—
Diameter --Weight-- Maloria€-
Top
Bottom
FL
Top
Bottorrr
Ft.
Top
Bottom
Ft
S. GROUT:
Depth
Material
Method
= Top
Bottom2(1' _-Et_Bentonite
Pour
Tap 21'-Botmrr1325'
=
Ft Pea Gravel -
Pour
Tap 21'
Botiorn 260'
Ft. Pea Gravel
Pour
S. SCREEN:. Depth
Dlameter Slot
Size Allstarlal
Top
Bottom
Ft_r_jn.
In.
Top
Bottom
Ft- in.
in.
Top
Bottom
Ft in.
In.
= 10. SANDIGRAVEL PACK:
Depth
Size
Material
Top
Bottom
Ft
Top
Bottom
RL
Tap
Bottom
Ft
11. DRILLING LOG
Tap Bottom Formation Description
1
I
Ji
1
1
1
1
1
12- REMARKS:
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.
�Q.1�� [1 ,�.�j2,, ii11912008
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
David Stratton
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
:: it i%ij riff in:3 ;,#ai sof�gri�' leti� toC..:. DiYisiof� of �lll.9er Quality - Infann0onf Fro Soft; Form GW-1a
p
>1 AAa(t SeiaGal� Fi<a�lf�.'171��l t?lotie (9'f 9) :807-30D Rev. 2109

Permit Number W10100075 ►�
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facial
Facility Name
William C. Burgin SFR
Location Address
290 Vanderbilt Rd
Asheville NC 28803
owner
Owner Name -
William
C Burgin
DateafE►rent+s
Scheduled
❑rig Issue App Received Draft Initiated Issuance
10/02/09
Resaulated Activities
Outfall NULL
Central Files; APS SWP
10/12/09
Permit Tracking Slip
Status _ Project Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
William C. Burgin
Owner
PO Box 5571
Asheville NC 28813
MajorlMinor Region
Minor Asheville
County
Buncombe
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
William C. Burgin
Owner
PO Box 5571
Asheville
NC 28813
Public Notice Issue Effective Expiration
Waterbody Name Stream Index Number Current Class Subbasin

KIA
CCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Govemor Director
10/12/2009
William C. Burgin
P.D. Box 5571
Asheville, NC 28813
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10100075
290 Vanderbilt Road
Asheville, NC 28803
Dear Mr. Burgin:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on
l OI0212009, 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 located at 290 Vanderbilt Road, Asheville,
Buncombe County, NC 28803. 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 Buncombe 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].
Sinryerely,
for Michae Rogers
Environmental Specialist
GPU-Aquifer Protection Section
cc: Asheville Regional office - APS
APS Central Files - Permit No. W10100075
Buncombe County Health Dept.
Richard Fulbright (Bullman Heating & Air, 10 Red Roof Ln., Asheville, NC 28804)
AQUIFER PROTECTION SECTION
1636 Mai Service Center, Ralegh. North Garollna 27699-1636
t_ocabon. 2728 Caprtal soulevard, Raleigh, North Carolina 276(9
Phone: [phone] I FAX 1: 919.715-0585; FAX 2: 919-715-6W81 Cuslorner Service: 1-877-523�748 TOn az�l.iJ S�y R�
IATUnOt WWW.ncwaterotualitv.om 1 V
An Eau Opportunity 1 Alflrrlolive A,cbw Employer ;Vaturalt�

RECEIVES J DENR I iDW O
A2J1M'M FrTTN !lFC.T0
NORTH CAROLINA OCT 4 2 2009
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NC DEN R)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE S-Q W WE
LL(Sj
In Accordance with the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or Tie information).
DATE: [T -It _, 204"
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 , Continue completing this form.
No Do Not complete this form. Complete other [U IC application forms for tn;;talling
either a 5A7 well (open -loop well injecting potable water into the agttifcr) or a 5QM Kell (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPi+:RTY OWNER(S)/APPLICANT(Sj
List each Property Owner listed on property eed (if owned
--by a business or government agency, state name of
entity and a representative wlauthority for signature):-_ W 1 �! A m C. __E r e r in
(1) Mai ling Address: _ P 036 x _5- 5- W
City: jrd4111 StateA""_GZip Code: 42M 3_-_ _ County: ~ e4j"
Home/Office Tele No.: ���-a7�"7 ��� Cell N 9 9 30
Email Address:b+ J t kv 4 e in Websrte: _
d . C don
(2) Physical Address of Well Site (if different than above): P-g0 Llo z,� erb+ )+-ODc.�_
Ci e"rne- State: G Zip Code:°$BCounty- 13uRLD'h be,
borne/Office Tele No,: Cell No.: w�
B. AUTRORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not awn the subject property,
atrach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person:
Address:
City:
EMAIL Address:
State: Zip Cade: _County: ___
Office Tele No.: Cell No.:
Website Address of Company, if any —
011RU1C 5QW Notification of lntcot F'omi (Revised 812008) Page I

C. WELL DRILLER INFORMATION
Company Name: AWD SERVICES INC.
Well Driller Contractor's Name: Dave Stratton
NC Contractor Certification No.: 3421
Contact Person: Larr► Welfs EMAIL Address: Wells758549 rr Beilsouth.uet
Address: 258 North TurkeN Creek Rd.
City: Leicester Zip Code: 28748 County: Buncombe
Office Tele No.: 828-683-9223 Cell No.: 828-215-9334
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: �W- �'/ ►1.- - yy��.�Gt i �'- + Y'
Contact Person: � fGj+]r�
Address; _, o f� �jaj- h tl tl Q e Ca m
City: As it P.t•i ue-: 'Lip Code:a t$q�L_ County:
Office Teie No.: f" — (o5r— 2 W CCell Na.:
E.
F
STATUS OF APPLICANT
Private: x
State:
Federal:
Municipal:
Commercial:
Native American Lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
_ n15S&d Jan
G. WELL CONSTRUCTION DATA
(I) Proposed date to be constructed: 4--4aJ T4wA-ht' d-2- Number of borings: 27
Approximate depth of each boring (feet):?
-eT,
(2) Type of tubing to be used (copper, PVC, etc).
(3) Well casing. Is the well(s) eased? (check either (a.) Yes or (b.�elow)
(a) Yes if yes, then provide casing information below
Type: �galvanized steel black steel Dlastic other (specify)
Casing depth: From to feet (reference to land surface)
Casing extends to above ground inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite A/
(b) Grout placement: Pumping_ _ Pressure
Other (specify)
Other
r cA, I&�,A
(c) Grout depth of tuning (reference to land surface): from to _ _ _ (feet)
Iwell has casing, indicate grout depth: from to (feet)
GPUMIC 5QW Notification of Intent Foms 4Revised 8/2008) Page 2

H. INJECTION -RELATED EQUIPMENT
RECEIVED DENR?D WO
A0UIF;R-PRATr-r,nrN * Tm
OCT 0 2 2009
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 wells) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections,
.I. 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 farniliar 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 atn 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."
-- G C_
Signature of Property Owner AI ant
Print or Type Full Name and. title
Signature of Property Owner/Applicant
Print or Type Full Name and. title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Caroling DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GMUIC 5QW Notification of Intent form tRevised 8/2008) Page 3

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Rogers, Michael
From: BILLBURGIN@aol,com
Sent: Tuesday, October 06, 2009 11:20 AM
To: Rogers, Michael
Cc: [e-mail]
Subject: Re: geothermal wells Burgin Site
Michael,
The following information was faxed to me from the well driller:
2 goo wells 325 feet In depth:
325 feet to 20 feet from surface - pea gravel,
20 feet to surface - 20 % solids Bentonite.
2 geo wells 260 feet In depth.
260 feet to 20 feet from surface - pea gravel.
20 feet to surface - 20 % solids Bentonite.
Thanks,
Bill Burgin

Buncombe County Property Report
Page 3 of i
GIS
Parcel
Record
Report
PIN OWNER MAILING SiTUS ACRE DEED PLAT VALUE
NUMBER ADDRESS ADDRESS
9647-75- BURGIN
04-7500 WILLIAM ASHEVILLE NC
C
9647-75- BURGIN
44-2000 WILLIAM ASHEVILLE NC
C
2396/0501 12/29/2000 0008/0048 0
1891 /0108 02102/1996 0008/0048 0
http:llgis.buncombecounty.❑rg/website/sid311report_process.asp?PINNUM=964775442000000„964775047500000, 10/5/2009