WI0100114_GEO THERMAL_20100825

Central Files: APS_ SWP_
08/25/10
Permit Number W10100114
Permit Tracking Slip
Program Category
Status
Project Type
Ground Water
Active
New Project
Permit Type
Version
Permit Classification
Injection Water Only GSHP Well System (50W)
1.00
Individual
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility Name
Kevin McRae SFR
Location Address
68 Gladly View Dr
Candler
NC 28715
Permit Contact Affiliation
Kevin McRae
Owner
PO Box 698
Enka NC 28728
MajorlMinor Region
Minor Asheville
County
Buncombe
Facility Contact Affiliation
3
Owner Name
Owner Type
Individual
Kevin McRae
Owner Affiliation
Kevin McRae
Owner
PO Box 698
Enka NC 28728
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance
Public Notice issue Effective Expiration
08/25/10 08/24/10
08/25/10 08/25/10
Reaulated Activities
Heat Pump Injection
Private residence, single family
Outfall
Waterbody Name Stream Index Number Current Class Subbasin

Affil I- ; VA
WDERR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
8/25/2010
Kevin McRae
P.O. Box 678
Enna, NC 28728
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100114
68 Glady View Dr.
Candler, NC 28715
Dear Mr, McRae:
Dee Freeman
Secretary
On 08124/2010, the Aquifer Protection Section (APS) received notification of your intent to consuruct a closed -loop water -only
geothermal injection well system for the operation of a ground -source beat 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 injecrion well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Suhchapter .0213, and
3. The required ootification 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 Tile 15A Section 2C Subcbapter .0211(u)(2), Additionally, you should contact the COUNTY 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.RoLers+�-i ncdenr.i,,oy if you have any questions.
sin 1
for Debra
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. W10100114
Buncombe County Health Dept.
Voo Plemmons (Clearwater Well Drilling, Inc., P.O. Box 71, Hot Springs, NC 28743)
Duane Gentry (Gentry Heating, Inc., 100 Buckeye Access Rd., Swannanca, NC 28778)
AQUIFER PROTECTION SECTION
1636 Mail Servim Center, Raleigh. North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] I FAX [phone]t588; FAX [phone] I CustornerService. 1-877-623-6748 �hCarolina
Internet: www,ncwatearslairhr.arc ����������
An Equal Opponunily + Afirmative Parlor mployw

06,/24/2010 17:21 FAX
IM 001
Clearwater Well Drilling, Inc.
P.G. Box 71
Hot Springs, N.G. 28743
828-533-7431 828-776-6526
Fax:
August 24, 2010
To:
Mike Rogers, NCDENR Raleigh
From:
Jeff Moore, Clearwater Well Drilling, Inc.
Subject:
Mcrae permit
Pages:
5 Including Cover
Note:
Any further questions, please give me a call.
RECEIVED I DENR I DWO
AQUIFFR-pRn F(,tnO N SECTION
AUG 242910

0&124/2010 17:22 FAX
VvTo
Q 002
NORTH CAROLINA
DEPAATM.ENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTEPICATION OF INTENT TO CONSTRUCT A CWSED-LOOP GEOTEMtMAL
WATER -ONLY INJECTION WELL SYSTEM
In Accordance With the Prevision of NCAC Title l SA 02C.0200
Prier or type the required information and Grail to address on the back page.
DATE: K - _ I_ ;� , 201jb-
WeH Type CorvJJrmaslori: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolaws the fluid from the environment (i.e.
�ciosed-n )7
Yesy Continue completing this force.
No Do Not complete this form. Complete other U1C application forms for installing
either a SA7 well CO-M-loop well injecting potable water into the aquifer) or a SQM well (closed -
loop well containing fir such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. . PROPERTY OWNER(S)IAPPLICANT(g)
List eagh Property Owner listed on property deed (if owned byla business or government agency, state name of
enclty and a representative wlauthority for signature): I e [1► ,,I C. X4 i°
(1) Mailing Address: C .ow &9
City: 1n 94- -- State: �C Zip Code; O County: G1 �d ►t!
Home/oftice 'i'ele No.. Y" -
Email Address:
wo
+ 60 7
(2) Physical ddress of Well Site (If different than above): _,. __ u 1 `
City: State: /k. Zip Code: S County:
HorncJQffce'l'cic- No.: Cell No.:
AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter Jiom the property owner autlwrixiM
Agent 10 install and operate UIC well)
Company Name:
Contact Persona
EMAIL Address:
Address:
City: State Zip
Code: County:
Office Tale No.: _.
Cell No.:
Website Address of Company, i Party:
RECEIVEDI DENR I DVVQ
GPU/UIC SQW Notlflcetian of laumi l:unn iRtvlBcd 8/2009j
Ri�irGP �
AQl11pFR,PRnTFrnnN SECTION t

08/24/2010 47:22 FAX
11003
L?
WRLL DRELLER INFORMATION
Company Name:
Well Driller Comrecwr's Name; _ Oe& , P— } rvy+#✓�
NC Cozift for Certification No.: [� w
Contact Pe 1
A e-406U L Address: ^ 1 G hl
Address..:,,� 11
City. l7O.rT Zip Code: �43_, , County:
Offlae Tele No.:�CelI No.: D9/— � 2 G `
HEAT PUMP
Company Nam
Contact Person
TION (1f different tbun OrMar)
A,v, , -rrl C.
City: Zip Code: ,^ County:
OflSce Tele No.:
L STATUS OF APPE�:AP I'
Private: U, Federal:
State; Municipal:
F. INJECTION PROCRO RE (briefly
Commercial:
Native American Lands:
how the injection well[$) will be used)
G. WELL CON9MUCi'ION DATA
(1) Proposed date a be conamted: — � — Number of borinp:
Approximate depth of each boring (fit):
(2) Type of tubing W be used (copper, PVC, etc): T
(3) Well casing, is the well(s) cased? (check either (a.) 'Yea a (b.) No below)
(a) Yes if yes, theft provide casing information below
Type: __galvanized steel filack steeiTplastic other (specify)
Casing depth; From to Stet (referenw to land surface)
Casing extends to shove d Incises
(b) No
(4) Grout Info (material surroundiog weft casing and/or piping):
(a) Grout type: Neat Cement Bentanito Other (spealfy)
(b) Grout placement PumpIng�^ PressureOther
(c) Omut depth of tubing (reflrrence to land surface): fivm to_(feet)
If wall has casing, indicate grout depth: fbrn to (red)
L-D ►*
rnC-,40
aPtlrUIC 5QW NW[imila„ of Lnomr Form (Revised 6/2009) ftm 2

08/24/2010 17:22 FAX
IM 004
N
T
("pi )lUlC SQfvl Wall PeWt AppiicaUoil (i;Lvin[1 MOOS)
Raleigh, NC 27699-1636
Telephone [phone]
Page 3

Za05
0/24/2010 17:22 FAX
Attach a diagram showing the engineering Iayout or proposed modification of die injection rcluipment and exterior
pipirigltuhing associated with die injection operation. The manufacturer's brochure may provide supplenicritary
il!t"oCallatlom
LOCATION OF WELL(Sj
Attach two copies of reaps showing the fallowing information:
(1) Include a site map (can be drawn) sliowing: buildings, property lines, surface water bodies, potential sourves
of grouruiwater contauii:ration and the orientation of and distances between the proposed well(s) and any
existing weil(s) or waste disposal facilities such as septic tanks or drain Relds located within I000 feet of aic
geothermal Beat pump well system. Label all features clearly and include a north nrrow.
(2) Include a topographic neap ofthe area extending one mile from the pmpeity boundaries atld
indicate the facility's location and the map name.
J. POTABLE WATER WELL(S)
Are there any pot -Able water wrll(x) on thu subject property or adjacent properties? tl YES NO
If Ycs, than indicate location ail attached map(s).
K. CE RTUICATION
No to: This Permit Appiicatlan must be Signed by each parson appearing on the recorded Icgal property deed.
"I hereby certify, under penalty of Iaw, that I have personally examitied and am flimiliar with the inforntutlon
submitted in this document and all altzehments thereto and that, based on my inquiry of those individuals
ittmmedietely responsible for obtaining said itifarniatiou, I buIieve that the inforrnation is true, accurate and complete,
I am aware that tIlete are significant penalties, including the possibility of fines and imprisonment, for submitting
false infonaarion, I agree to ccilstruct, operate, maintain, repair, and if applicable, abalidon the injection well will
all related appurtenances inaccotrla.nce with the approved specifications and conditions of the Permit."
5igziature of Property OwnerlApplicprtt
Print or Type Full Name
Signature of Property Owncr/Applicant
Print or Type Fail Name
Signature of Authorized Agcnt, if ally
Print or Type FuiI Name
tftit:lV�I7 ! i3E�iR I �WQ
l'lestsc return two eopies of the ovtimpleted A}rpticutioli package to; At]L1t�pR >�RI��F.�T1rfN'FCT104
North Carolina DEMR-DWQ AUG 2 4 N10
Aquifer Protection Sectiou
UIC Program
1636 Mail Service Center
GPUIUIC sQM well PermirApptieaeioa (KovWed 72098) tx-jg%; 4

] MUL I ANIXUR USE A WELL(S) FOR INJECTION WITK A GEOTHERMAL I-EEAT PUMP SYSTEM FOR:
WML$L `
,NORTH CAROLINA
'enn it Application OR DEPART9WzW"ff&WdKQNWNT AND NATURAL RESOURCES (NCDENR)
th the provisions of NCAC Title 15A: 42C.4200
tion and mail to address on the back page (Please Print or Type Informaiion)
RECEIVED I DENR / Qwo
AQ IFFR PROTl^CTIONSEN
DATE. 24_LO
PERMIT NO. (leave blank if NEW permit application)
A. PROPERTY OWNERS)/APPLICANT(S)
List each Property Owner listed on property deed (if awned by a business or government agency, state name of
!` l
entity and a representative w/authority for signature): &x P-
(1) Mailing Address: + + n Cl
City: l State: Y)C. Zip Code: oV 79;� County:
Houle/Office Tele No.-09 ` (a :' _ Cell No.: "'T
EMAIL Address: t-d LW Im J. Vlj, aL�. , . C r�
(2) Physical Address of Site (if different than above):
City: State. f)C- Zip Code: Aj 1 County:
Home/Office Tele No.: N- Cell No.;
EMAIL Address:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property
attach a letter front the property owner authorizing Agent to install and operate UIC well)
Company Name;
Contact Person: EMAIL Address:
Address:
City:
State: Zip Code: County:
Office Tele No.: Cell No.
Website Address of Company, if any:
I. STATUS OF APPLICANT
Private: Federal: Commercial-.
State: Municipal: Native American Lands:
`i
GPU/UIC 301A Well PenniI Application (Revised 7/2008) Page I

C. WELL DRILLER
Company dame: C
kl�'D I.-)
Well Drilling Contractor's Name: [�11
NC Contractor Certification No.:
Contact Person46'_J1 k ti
Address: ' 0
3tn J
City: j) Zip Code:
Office Tele No,:''��'>`�'��
1 EMA I L Address: 4 I ' __W&kGo � C�
�^ County:
CeII No.: 4 `�4_ _
D. HEAT PUNIP CONTRALTI )R INFORMATION (if iifferent than driller)
3 ,
Company Name: �
2A!-"14
� rrLL
Contact Person: ► t. ►'i si r i
_ 40 EMAIL Address: r I GG rru
ll �
Address: fL.
City: Zip Code: Ong— - �� �cws m
❑ffice Tele No.: A `� 6 — Cell No.:
E. INJECT I 1N PR CEO) RE (briefly}jescribe how the injectitm well(s) will be used)
G. 4VELL CONSTRUCTION DATA (Sk_ Its to Section H if this is a Permit RENEW At.}
7
(1) Proposed date to be constructed: Number of borings:
Approximate depth of each boring (feet): _�
r
(2) Chernical additives to be used to closed -loop system (only those chemicals indicated have been approved):
R-ZZ —propylene glycol ethanol other (other additives will need prior
approval by NCDENR before use)
(3) Type of tubing to be used (copper, P%'C, etc is ".
(4) Well casing. Is the well(s) cased? (check either (a.) YES or (b.) NO below)
(a) YES if yes, then provide casing information such as We (steel, PVC, plastic, etc.), diameter,
devti,, and extent of casing appearing above ground,
(b) NO �
(5) Grout (material surrounding well casing and/or piping}: r
(a) Grout type: Cement Bentonite Other (specify)
(b) Grout depth, of tubing (reference to land surface): from 0_ _ to 40 0 (feet)
If well has casing, indicate grout depth: from to (feet)
H. INJECTION -RELATED EQUIPKENT
GPU/UIC 7QM Well PeMVL Application (Revised 1/20091 Page 3

N
Raleigh, NC 27699-1636
Telephone [phone]
9-1
GPU/U IC 5QNl Wei[ Permit Application {Revised 712 00 9) Page 5

Attach a diagram showing the engineering layout or proposed modificaElon of die injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplemenwy
information.
I. LOCATION OF WELLS)
Attach hvo copies of maps showing the following infonnatton:
(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 w6l(s) and any
existing well(s) or waste disposal facilities such as septic tanks or drain fields located within tOOO feet of the
geothermal heat primp well system. Label all featuth°s clearly and include a north avow.
(2) hhchide a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
J. 110TABLE WATER WELLS)
Are there any potable water wetl(s) on the subject property or adjacent properties? ,' YES NO
If Yes, than indicate location on attached tYiap(s),
K. CERTIFICATION
Note: This Permi t Ap plica tion most be signed by each person appearing on the recorded legal property deed.
"I hereby certify; under penalty of law, that I have personally exainined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
irrimediately responsible for obtaining said infothnation, I believe that the infomiation is trite, accurate and coinplete.
1 atn aware that them are significant penalties, including die possibility of fines and imprisotunent, for SUbnutting
false information. I agree to construct, operate, maintain, repair, said if applicable, abandon the injection well and
all related appurtenances la accordance with the approved specifications and conditions of the Permit "
RECEIVED i DENR I DWQ Signature of property Owner/Applicant
A0l11FrMR PPnTFCT10N
A U G 1$ 2010 Print or Type Full Name
Signature of property Owner/Applicant-
Print or Type Full Name
Signature of Authorizer! Agent, if any
Print or 1pe Full Name
Pleas4 return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
GPtJ/111C 5QM Well Permit Appikation (Revised 712008) 4

, J-1%iv,+, iu k.vir�! stUL ► ANDeUX USE A WELLS) FOR INJECTION WITII A6EOTFiERMAL HEAT PUMP SYSTEM FOR:
- ,,NORTH CAROLINA
-crinit Application OR ❑EPARTWxWa(*1fi&&B0NM1ENT AND NATURAL RESOURCES (NCDENR)
th the provisions of'NCAC Title ISA: 02C.0200
ttan and mass to address on the back page (Please Print or Type Information) (��
JeDIDENRIDWQ
1 r"U1 FF PgnTF"CIV S=K
AUG 16 291a.
DATE: F r' X , 20L
PERMIT NO. (leave blank if NEW permit application)
A. PROPERTY OWNER(S)IAPPLTCANT(S)
List each Property Owner listed on property deed (if owned by aC business or government agency, state name of
entity and a representative wlautlzority for signature): 7� ^ �-;� J �1
(1) Mailing Address: - RL. r r
City: State: Y)C. Zip Code: on% ? County.
Home/Off ce Tele No.-) Cell No.:
EMAIL. Address: rz i IU U4
(Z) Physical Address of Site (if different than above): CL b •�` i L.
City:State: OC. Zip Code: -County:
' t
i F 1.4•.rf
. _��Y� 1_ -- I
Home/Office Teie No.: Y—a ( 11-y.) - �, _ _ Cell No.:
EMAILAddress:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant ves :3at own the subject property
attach a letter From the property owner authorizing Agent to install and operate U1C well)
Company Name -
Contact Person; - _ __- _ - AILAddress:
Address:
City:
State Zip Code:
Office Tele No.: CeRN
Website Address of Company, if any:
1, STATUS OF APPLICANT
Private: Federal: Commercial:
State: Municipal: Native American Lands:
County:
GPWUTC 5Q1b[ Wc11 Perinit Application (Revised 712008) page I

C. WELL DRILLER
Company
Well Drilling Contractor's Name:
IBC Contnictor Certification No.:
_LL 1
(1111
Contact Person; � v►�4 �[, +� �} ,rC _ EMA1LAddress:
Address: - J_ C}-
1
City: r� Zip Code; County:
Office Tele No.: `7A1 Cell No.: ,�LAt-& .'
D. HEAT PUMP CONTRACTOR INFORMATION (if ifferent than driller)
5 r
Company Name -
Contact Person:
Address:
City: _ _ Zip Code:
Office Tele No.: A `,W-6 Cell No.:
t x ,'o(4jj_ 1 �oe7
2�& - (Psn-L
EMAIL Address: by 47w';
E. INJ'ECTI N PR( CED .'RE (briefly lescribe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA (Skij to Section H if this is a_Permit RENEWAL)
(1) Proposed date to be constructed: `" 1 tP'� b Number of borings: j
Approximate depth of each boring (feet):_.( &C r
(2) Chemical additives to be used in closed -loop systetm (only those chemicals indicated have been approved):
R-22 _Propylene glycol ethanol
other (other additives will need prior
approval by NCDENA before use) W 0 r jL,
(3) Type of tubing to be used (copper, PVC, etc:: T Or
(4) Well casing, Is the well(s) cased? (check either (a.) YES or (b.) NO below)
(a) YES if yes, then provide casing information such as We (steel, PVC, plastic, etc.), diameter,
depth, and extent of casing appearing above ground:
(b) NO
(5) Grout (material surrounding well casing and/or piping -
(a) Grout type. Cement Bentonite L Other (specify)
(b) Grout depth of tubing (rcference to land surface): From () — to &V 0 (feet)
If well has casing, indicate grout deptlr. from to (feet)
H. INJECTION -RELATED EQUIPMENT
GPUIU IC 5QM Well Peniiit Application (Revised 7/2008) Page 3

N
Raleigh, NC 276994636
Telephone [phone]
1
r
rr
S
I
GPU/UIC 5QN1 Well Permit Application (Revised 712008) Page 5

Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
pipinaltabing associated with the injection operation. The manufacturer's brochure may provide supplementary
iiiforination.
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, stirface 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 1000 Feet of the
geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
J. POTABLE WATER WELL(S)
Are there any potable water well(s) on the subject property or adjacent properties? YES NO
1f Yes, than indicate location on attached map(s).
K. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the recorded legal property deed.
"I hereby certify, udder penalty of law, that I have personally examined and am familiar with the information
submitted in tlus document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said itifoimation, I believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the possibility of fines and imprisorunent, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurteriances in accordance Nvith the approved specifications and conditions of the Permit."
Signature of Property Owner/Applicant
AUG 16 2018 Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Nano
Phrase return two copies of tine completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UtC Program
1636 Mail Service Center
GPUIU IC 5 Q M Well Permit Application (Revised 7/2008) F'+ige 4