WI0100104_GEO THERMAL_20120518

AJL'A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P. E.
Governor Director
May 18, 2012
Robert Stolz
Post Office Box 18509
Asheville, NC 28814
Subject: Notification of Rule Revisions Affecting
Closed -Loop Geothermal Injection Well Permit Holders
Permit Number: WI0100104
Dear Mr. Stolz:
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 15A 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 to 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 will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised runes referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http://portal.ncdenr.or�web/wc /ads.
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,
Eric G. Smith, P.G.
Hydrogeologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636 One
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604 North Carolina
Phone: 9IM07-6464
water FAX: [phone]
Internet: www,ncwateraualitv.am
An Equal Opportunity 1 Affirmative Action Employer

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Central Files: APS SWP
07/22110
Permit Number WIOIOO104 Permit Tracking Slip
F
5
Program Cate ory Status Project Type
Ground Wateo Active New Project
Permit Type Version Permit Classification
Injection Mixed Fluid GSHP Well System (50M) 1.00 Individual
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facillt•.
Permit Contact Affiliation
Kevin Ward
503 Old Farm Ln
Marshall NC 28753
Facility Name Major/Minor Region
336 Barnard Ave Minor Asheville
Location Address County
336 Barnard Ave Buncombe
Asheville NC 28804 Facility Contact Affiliation
Owner Name Owner Type
Individual
Robert Stolz Owner Affiliation
Robert Stolz
1100 Delaney Ave
Orlando
Scheduled
Orig Issue App Received Craft Initiated Issuance
07/22/10 06/08/10
ReF;uiated Activities
Hest Pump Injection
❑utfall
FL 32806
Public Notice Issue Effective Expiration
07122/10 07122/10 06/30/15
ReL:uested]Received Events
Region comments on draft received 07/14/10
Region comments on draft requested 0711 F4110
Waterbody Name Stream Index Number Current Class Subbesin

-All
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
July 22, 2010
Robert and. Pat Stolz
1100 Delaney Ave. Apt. F100
Orlando, Fl. 32806
Dee Freeman
Secretary
Subject: Issuance of Injection Well Permit
Permit No. WIOIOOI04
Issued to Robert and Pat Stolz
Buncombe County
Dear Mr. and Ms. Stolz;
In accordance with your application received June 8, 2010, l am forwarding Permit No. W10100104 for
the construction and operation of a vertical closed -loop geothermal mixed -fluid heat pump injection. well
system located at 336 Barnard Ave., Asheville, Buncombe County, NC 28804. This permit shall be
effective from the date of issuance until June 30, 2015, 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 of receipt 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 of 2C .0213(g). Please
insure this is completed in accordance with permit condition Part 1.6 of this permit issued Juiy 22, 2010.
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 li&ction
Control ProExam please call me at [phone].
Sincerely,
Y John McCr
Environmental Specialist

cc: Landon Davidson — Asheville Regional Office
Central office File - W10100104
Buncombe County Environmental Health Dept.
Kevin Ward -Southeast Ecological Design, Inc.
Enc: Permit WI0100104

NORTH CAROLINA
ENV RONMENTAL MAINAGEMENT COMNUSSION
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
Robert and Pat Stolz
FOR THE CONSTRUCTION AND OPERATION OF 3 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 336 Barnard Ave., Asheville, Buncombe
County, NC 28804, and will be constructed and operated in accordance with the application received June S.
2010, 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 June 30, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the a)- day of . 2010,
06" --�. VA
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
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 (I5A 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 2.7699-1636
and
Aquifer Protection Section -- Asheville Regional Office
2090 U.S. 70 Highway
Swarmanoa. NC 28778
(8281 296-4500
GW-1 s must be submitted within 30 days of completion of well construction. Copies of the GW-1
form(s) shall be retained on -site and available for inspection.
8. Well construction records trust 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 .0211(d )(1)(D ).
PART II — WELL CONSTRUCTION SPECIAL CONDITIONS
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 Ashvvillc Regional Office Aquifer Protection Section Staff. telephone
number (K28) 296-4 00.
WIOI OO104

2. Boreholes shall not connect separate aquifers which have differences in water duality [e.v.. 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 pen -nit 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 Permittee, 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 date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsihility 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 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 reduction 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
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 iJnderground Injection 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.
WIOl OO104

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 Asheville Regional Office, telephone number (528 ) 296-4500, any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating 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.
The Permittee shall, at least 120 clays prior to the expiration of this permit, request an extension.
PART IX — CHANGE OF WELL STAT U S
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)(1), Well
Construction Standards.
W10100104 4

? 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 gout, 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,
T) 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 m 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)(1) within 30 days of completion of abandonment.
?. The written documentation required in Part IX f 1) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
WIOIOO104 5

Central Files: APS SWP
07/22/10
Permit Number W10100104 Permit Tracking Slip
Program Category Status Project Type
Ground Water In review New Project
Permit Type Version Permit Classification
Injection Mixed Fluid GSHP Well System (50M) Individual
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Permit Contact Affiliation
Kevin Ward
503 Old Farm Ln
Marshall NC 28753
Facilit■•
Facility Name Major/Minor Region
336 Bernard Ave Minor Asheville
Location Address
336 Barnard Ave
Asheville
NC 28804
County
Buncombe
Facility Contact Affiliation
Owner Name Owner Type
Individual
Robert Stolz Owner Affiliation
Robert Stolz
1100 Delaney Ave
GateEl arils Orlando FL 32806
v
Scheduled
Aria Issue App Received draft Initiated Issuance Public Notice Issue Effective Explretion
06/08/10
Reo_u_lated_Activities ftQ estFd/Receivo-dEYer'is
Heat Pump Injection Region comments on draft received 07/14/10
Region comments on draft requested 07/14/10
❑utfall A•ISLL
Waterbody Name Stream Index Number Current Claus Subbasln

Central Rea: APS SWP
0711 4110
Permit Number W10100104
Permit Tracking Slip
Program Category
Status Project Type
Ground Water
In review New Project
Permlt Type
Version Permit Classification
Injection Mixed Fluid GSNP Well System (50M)
Individual
Primary Reviewer
Permit Contact Affiliation
john.mccray
Kevin Ward
Coastal SW !Rule
503 Old Farm Ln
Marshall NC 28753
Permitted Flow
MIR
Facility Name
336 Barnard Ave
Location Address
336 Barnard Ave
Asheville
NC 28804
MajorfMinor Region
Minor Asheville
County
Buncombe
Facility Contact Affiliation
Owner Name Owner Type
Individual
Robert Stoltz Owner Affiliation
Robert Stoltz
1100 Delaney Ave
Orlando FL 32806
Dates/Events
Scheduled
Drig Issue App Received Draft Initiated Issuance Public Notice Issue EfFective Expiration
06/08/10
Reaulated Activities
Outfall Nil1 i
Waterbody Name Stream Index Number current Glass Subbasin

MGGray, John
From: Davidson, Landon
Sent: Wednesday, July 14, 2010 4:05 PM
To- MCcray, John
Subject: RE: 50M geothermal application
We went by the site today and saw no obvious problems, Please issue. Thanks
Landon
G. Land6n Davlclsori . P. C.
NCEIEhF rri,;t,l'Jn ul ::. t r CU. tit,
t4nit_I Prst__ti.aus-_tiu;l r
F ion. I .sir pup. r•,i �r R
�e:_nti-n3:, h.C.Z9
gli.. 925 39L '503
web pane: httL.'rr. _hZo.enr.state. nc.uslggw.html
This e-m oil contains a public record which is subject to disclosure to third
parties and the public pursuant North Corolino's Public Records Low. N.C.
Gen. Sta-L §132.1, etseq. 'This a -moil rrrnoy contain moterfols prepared
during or in aaticlpation of o lego) proceeding as port of preparation for that
lego I proceeding, in which case third party or public access to it is subject to
N. C. Gen. Stat. §132-1.9 and may be denied until the conclusion of the legal
proceeding, including the completion of all oppea}s ondpas t judgment
proceedings, or, in the case where no legal proceeding has been commenced,
upon the expiration of all applicable statutes of limitotions and periods of
repose.
From: MCcray, John
Sent: Wednesday, July 14, 2010 8:51 AM
To: Davidson, Landon
Subject: 5QM geothermal application
Mr. Davidson,
Attached is a copy of a permit application for a 5QM system located at 335 Barnard Ave., Asheville. The application was
emaiied to me but unfortunately the server directed it to my Junk e-mail. I tracked it down this morning and the Admin
staff has not entered it into RIMS, therefore it has no permit number. If possible could your office provide me with an
opinion as whether it is ok to proceed with issuance or not?
Best Regards,
Jahn McCray

Buncombe County Tax Lookup - Property Card
http://www.bmcombetaxorg/PropertyCard.aspx
A property %vith WORK IN PROGRESS is currently- being m iewed by the Buncombe County tax department. This
re-.iew could include a tranfer of ownership, a split parcel, a combined parcel, and acreage adjustment, etc.. For
these properties, you will see thevalues which were last approved before the revie►+, began. Be ai Tare that these valuers
could change once the re%iew is complete. if a parcel is new, you wzll have access to limited property data until the
review is complete and values have been approved.
COUNTY OF E��IVCOMEE, NORTH AROLII�T 3
ra Web Property Record Card
9649-09-7799-00000
Date Printed: 7/21/2010
This parcel is currently being reviewed. Values may change.
Owner Information
IOwners:
�Address:
I
Property
ROBERTSTOLZ
PAT STOLZ
1100 DELANEY AVE APT
Fioo
ORLANDO FL 32806
Location. 336 BARNARD AVE
j Ta_Aing Districts
ICoun.ty: Buncombe County
City: City of Asheville
Fire:
'School: ASHEVILI.g SCH.
Transfer price
Date
11/05/09
Parcel Information Total Property Value: 27,200
1Status:
Active
(Account:
8239776
heed Date:
11/5/2009
Deed Book/Page:
4737 / 1193
Book/Page:
0000 / 0000
(Plat
Legal Reference:
WARRANTY OR SPL/COMP
TRANSFER
Location: 3
Class:
!Neighborhood: H
ubdivision:
!Sub Lot:
!Conservation/Easement: N
Ownership History
36 BARNARD AVE
RESIDENTIAL VAC/LOTS
YANNIS ACRES
Deed Vacant
Legal Reference Book/Page Qualified When
Sold
WARRANTY OR
$65,00o SPL/COMP 4737 / 1193 Yes Yes
TRANSFER
Account I Seller
Names
FOTOS NICK
81g3$46 G
F
MARTIN DR
WARRANTY OR
J PAUL
09/20/05
$110,000
SPL/COMP 4108 / 0883
No: A
Yes
8145581
I
(MARTIN
TRANSFER
ENANCY O
ELMS JOE D
WARRANTY OR
ELMS
04/19/00
$20,000
SPL/COMP
2264 / 0341
Yes
Yes
1969goa
TRANSFER
SUZANNE E
IM
Assessment History
Year
Account
Acres
Land
Bldgs
Other
pr
Assessed
Desc Exemptions Deferred Taxable
2010
8239776
0.38
27,200
a
0
27,200
10 j 0 127,200
2009
8153846
10.38
127,200
0
0
127,200
j 0 l a , 27,200
2008
181,53846
0.38
27,200
0
l0 127,200
10 j 0 j 27,200
2007
18153846
0.38
27,200
0
0
127,200
0
10 127,200
2006
8153846
0.38
27,200
0
0
127,200
0
0 j27,200
I of 2 7/21/2O 10 4.55 PM

Buncombe County Tax Lookup - Property Card
hrtp:Ilwww.bimCombetax-org/PropertyCard.aspx
2005
8145581
10.38
24,500
0
0
124,500
0
0
24,500
2004
18145,581
0.38
24,500
0
0
24,500
0
0
24,500
2003
8145581
0.38
24,500
0
0
24,500
0
0
24,500
2002
8145581
0.38
24,5000
118,50010
0
24,500
0
0
24,500
2001
8145581
0.38
10
18,500
i]
0
18,500
Land Data Total Acres: 0.38 Land Value: Other
Acres 27,200 Improvements
Segment# lMits Description
1 o.38 Acres ILOT
Value: ❑
1
Total Building Valuer o
2 of 7/21/20104:55 PM

Map
http://gis.buncombecounty.org/aspnet_c1ient1ESRJ/WebADFJPrintTask-..
Map
5076 ;.
i'940 g $
8121
27615 � �,`� , 1820 477 4
7662
Own
t �+14J
5112 3127
��- -- ice`
3829 59$1
!••' ` � � 973'.' it
377 3
j L 5428
4103 ' 7385
a
H23s' if
I
Property Property Street Centerline
'I
0142
456 7
1 of 1 7/21/2010 4:55 PM

HCDEHR
North Carolina Department of Environment and Natura
Division of Water Quality
Beverly Eaves Perdue CNeen H. Sullins
Governor Director
July 14, 2010
Robert Stoltz
Pat Stoltz
1100 Delaney Ave
Apt F-I 00
Orlando. FL 32806
Subject: Acknowledgement of Application No. WI0104104
336 Barnard Ave
Injection Mixed Fluid GSHP Well System (5QM)
Buncombe
Dear Mr, & Mrs Stoltz:
Resources
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on June 8.2010. 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 organizat;onal chart, go to httr:J/h-)c.enr.state_nc.us/docurnents/dwc or_chamndf
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQU RIES ON THIS PROJECT
Sincerely,
UU—iZa, , &e��
for Debra J. Watts
Supervisor
ec: Asheville Regional Office, Aquifer Protection Section
Southeast Ecological Design, Inc (Kevin Ward - 503 Old Farm Lane, Marshall, NC 29753)
Permit Application File WIG 100104
AQUIFER PROTECTION SEG T IGN
1636 Mad Service Center, Raleo h. Worth Carolina 27699.163(1
ocatlon, 2723 Capital Boilavard, Raleigh, North Carolina 27604
Phone. [phone] I FAX V 919-715.0588; FAY, 2, 919.715$0481 Customer Service )-877-623-6748
latemer. WWY1.ncwatemu8fitY-flag
One
North Cal-olina
An Equal Uppormr,ily Afirmalive Amu Em 151over

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPUCATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELLS) FOR
INJECTION WITH A GEOTMMMAL HEAT PUMP SYSTEM FOR -
TYPE 50M WELLS)
V/ New Permit Application OR Renewal (check one)
DATE: _ 5 -' V ;1 g - .? b 1 . 2QJ .
PERMIT NO. V I () C W 10� ([ease War& if NEW permit application)
A.
a
PROPERTY OWNER(SYAPPILICANT(S)
List mh Property Owner listed an property deed (if owned by a business or govemment agency, state name of
entity and a representative wlaudwrity for signature):�y—Oat—M t.-rL
(1) Mailing Address: T 110n �3 r-L- A Q O f
City:.Q P-t_ 62 M0_ State: f—L zip
Home/Office Tele No.: Lj d - - D-D S4 Cell No.:
EMAIL Address`
(2) Physical Address of Site (if different than above): 6 Ar na -t A UA ,
City: As �W-Vt L State: WG Zip Code: 29 �M� county: _ &&n C�1L�
14=00ilice Tele No.: LA 0-1 P-2-!94 Cell No.:
EMAIL Address:
AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant dgjg no own the subject property.
attach a letter from the property owner authorizing Agmt to install and operate UlC well)
Company Name: 1%r��Ht=SST - E COt C?jL_ _ PEStC-7ANC
Contact Person: - N�l,V 0 WAP-D - - --EAA-1.. Address: -Ve�! n C'V 0� �+ar C�tS+�'r m f
Address: _5D QZ D E,4P L �1FL-]
City. N �P- A __ Statcj ]C Zip Code: Z!g County: }A.F DI 50X)
Office Tele No.: - � tt �Z4 I __ Q01 No.:
Website Address of Company. ifany:_w_
C. STATUS OF APPLICANT
11'rivste: Federal. _ - Commercial' _
State: Municipal: Native American IAtds-
RECEIVED 10ENR,'0VQ
Aquifer Protection 5e MOA
JUN 08 2010

D.
E.
F.
WELL DRD.LER INFORMATION
Company Name: IC- e- tucTL L --P1? t[_ -jAii
Well Drilling Conbactor's Nestle: _ U DO ?LQVl q AbN_ S _
NC Contractor Certification No.: C� 1 1 _ a
Contact Person -MOO EMAIL Address: JA-&rU-Q4i-y 2Q & 4Q-•C01
Address: 7 z) - f3aX r7
City: lkm �tCLS_ Zip Cadet$ r N 3 County: AIULSZ)ti7-
Office Tale No4.2 �- [a22- r724 1 Ceti No.: 13 I - 'a
HEAT PUMP CONTRACTOR INFORMATION (if dlft mot than driller)
Compan
Contact
Address;
City: Qaly1 V\6- ho Q, Zip Code:1 l�� County: 1�) 4 rQ Q r►1 lLQ— _
OffiiceTeleNo:: 18-a'74-.1S'.-)o CellNo.: -2- a— IW2-1
fNdECTION PROCEDURE (briefly descn'be how the injection well(s) will be used)
a WELL CONSTRUCTION DATA (Skip to Sectfan H If this is a Permit RFMWALI
(I) Proposal date to be consrructcd: -11- Zd Ili Number of borings:
Approximate depth of each boring (flea): �QQ /
(2) Chemical additives to be used in closed -loop system (only those chemicals indicated have been approved):
propylene glycol ethanol other (other additives will
need prior approval by NCDENR before use)
(3) Type of tubing to be used (copW, PVC, etc): 0
(4) Well casing. Is the well(s) cased? (check either (a) YES 1(b.) NO below)
(a) YES if yes, then provide casing information such as to (steel, PVC, plastic, etc.), di
depth and Mot of casing appearing above ground:
(b) NO .�
(5) Grout (material surrounding well casing and/or piping):
{a) Grow; type: Cement Sentonite Other (specify)
(h) Grout depth of tubing (reference to land surface): item iJ to 2= ( feet I
11' welt hw• casing. indicaic grout depth 1h)w is [ test I
H. iNJE:C11ON-RELATED F.QIJIPIHM
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
pip'utgi tubing. associated with the injection operation. The manufacturer's brochure may provide supplamenbu-y
information.
IRC
nbrn

L. LOCATION OF WE11(5)
Attach two copies or maps showing the following information:
(1) Include a site map (can be drawn) showing: buildings, property fines, surface ewer bodies, potential sourew
or groundwater contarnitudion and the arletstation of mid distances bmwern the proposed walks) and arty
existing weli(s) or wane disposal facilities such as septic tanks or drain fields located within 1000 feet of the
geothnrmel heat pump well rystem. Label dl remum clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile f mm the property boundaries and
indicate the lbeiiity's location and the map name.
L POTABLE WATICR WKU49)
Are there any potable water walks) on the subject property or adjacent propetties7 YFS ,&NC
If Yes, than indicate locctlon on stteched mep(g).
X CERTlRICAT1ON
Nolen This Formit Applicadoo must be slgoed by nc_h perm xppmriog on the recorded legal property deed.
"I hereby cam, under penalty or law, that I have pamonaliy examined and am familler with the information
submitted in this document and e11 adechments thereto and t4 based on my inquiry or those individuals
immediately responsible ror obtaining staid Inforrnalion, I believe that the information is true, accurate and camplew.
t am swam that there are significant penalties* including the possibility of Rases and imprisonment, for submitting
false information. 1 Ww to constmat, operated maintain, repair, and irapplicable, abandon the injection well and
all related appurtenances in amordanee with the approved specifiatdions and conditions orthe Pc=IV
signature or Property Owner/Appliamt
Print or Type Full Name
signature orPropem OwnedlAppiicam
Print or Type
,F�ull I Name
k4l" -
5igrratune of A utisorlrtied Agent, if arty
KEYW R. WARO, SOUTHMT E00I.WCAL DESIGN. W-
Print or Type Full Name
Please return two copies of the completed Application package to:
Worth Caroline DRNR-DWQ
Acialter Protection Section
UIC Program
1636 Mail Service Center REC;EJVED / DENR I DM
Raleigh, NC 276"-1636 Aquifer Protection Sec#lon
Telephone (919) 71S-b93S
MAY 2 9 201D

May 15. 2010
To Whom 11 May Concern:
'[iris letter is intended to verify th:et Kevin Ward. tin behalf of 5outhl:ast L•cologicul
Cksign, Inc. is an agent authorized to sign permit applications for our propeny
improvements and mom specifically fur the gcothe:rmaI wells being drilled. The propeny
location is 336 Barnard Avenue, Asheville NC. 28804.
Sincerely
bert Slot
Pat Stolz
1100 Delancy Ave Apt 0 rlando Fl 32906
[phone]

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