WI0100115_GEO THERMAL_20100830

Central Files: APS_ SWP_
08/30/10
Permit Number W10100115 Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (50W)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility
Status
Project Type
Active
New Project
Version
Permit Classification
1.00
Individual
Permit Contact Affiliation
Facility Name Major/Minor Region
21 McKinnish Cove Rd Minor Asheville
Location Address County
21 McKinnish Cove Rd Buncombe
Asheville NC 28806 Facility Contact Affiliation
Owner Name Owner Type
Individual
Barbara Thompson. Owner Affiliation
Barbara Thompson
21 McKinnish Cove Rd
Asheville NC 28806
DatestEvents
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
08/30/10 08/27/10 08/30/10 08/30/10
Regulated Activities
Heat Pump injection
Outiall NUL!
Waterbody Name Stream Index Number Current Class Subbasin

K kvxwj
I *� AW
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
8/30/2010
Barbera Thompson
21 McKinnish Cove Road
Asheville. NC 28806
Subject: Acknowledgement of intent to Construct Type 5QW Injection Well System
Permit No. WI0100115
21 McKinnish Cove Road. Asbe►viVe, NC 28806
Dear Ms. Thompson:
Dee Freeman
Secretary
On 8/27/2010, the. Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -on]"
geothermal injection Well system for the operation of a ground -source heat pump located at the address referenced above. An
indivviduai 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 injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code: Title 15A Section 2C Subchapter .0213, and
3. The required notification 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 Title 15A Section 2C Subehapter .Q211(u)(2). Additionally, you should contact the Buncombe 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.Rov ersfa)ncdenr.vov if you have any questions.
Sincerely,
for Debra W atts
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. W10100115
Buncombe County Health Dept.
Geotherm Loop Services — Steve Deweese -- PO Box 5411, Asheville, NC 28913
Gentry Heating, lac. — Duane Gentry — 100 Buckeye Access road, Swannanoa, NC 28778
AQUIFER PROTECTION SECTIDN
1636 Mail Service Center, Ralegh, North Carmilna 27699.1636
l.oration: 2728 Capital Boulevard, Raleigh, North Carolina 77604
Phone: [phone] I FAX 1: 919.71 "588: FAX 2: 919-715.60481 Custamer Service:1-877.623.6748
Internet www.nmatelaualtN.om
pn Enual Oppahuney I Af it nahve Acbcn Employer
ne
cor Carolina
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RECEIVED I DENR I DWI]
NORTH CAROLINA AOUIFFR PRf1TF{'.I rw SECTION
DEPARTMENT OF ENVIRONMENT AND NATURAL. RESOURCES AIJC 27 2010
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5QW WELL(Sy
In Accordance With the Provisions of NCAC Title 15A 42C,0200
Print or type the required in formation and mail to address on the back page.
DATE: 20� '�`qQ0 k
Well Type Confirmation. Does the proposed system circulate potable water onl\ (no additives) in
continuous piping that completely isolates the Fluid from the environment (i.e.
closed -loan)?
Yes ZConttnue completing this form.
No Do Not complete this form. Complete outer UIC application forms for installing
either a 5A7 well (open -loop well in— iecting potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)IAPPLICANT(S)
List each Property Owner listed an property deed (if ow by a business or lzovernment agency, state name of
entity and a representative wlauthority for signature}:
(1) Mailin- Address: 1_ "—Ful tSCity:�7 L5tatet� Zip Code: 2 ID �o County: Oryl 1:1 e
Home/Off ce Tele No.: y 1 Cell No.: I 1:3 "'q-Szg- I
Email Address: }-+* OY`Ck-%ty'81 ebsite + CQ �
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code: _ County:
Home/Officc Tele No.: Cell No.:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from 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.: Cei] No.:
Website Address of Company, if any:
GPUMC 5QW Notification of Intent Form (Revised 8/2008) Page I

H. INJECTION -RELATED EQUIPMENT
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,
1. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(l) 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 well(s) 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 roust 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.
1 hereby certify, under penalty of law, that I have personally examined and am familiar 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 am 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 thfi"pproved specifications and conditions of the Permit."
Signature of Property Owner/Applicant 44
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 Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center RECFIVE ] I DENR t DWO
Raleigh, NC 27699-1636 QQtjlFPP PRnTFrn0N SFC7M
Telephone [phone] AUG 2 7 mo
CPU/U1C 5QW Notification oflntent Form (Revised a/2008) Page 3

C. WELL DRILLER INFORNNATION
Company Name: _yY- tom a Y' J r _
I-
le.
— -
Well Driller Contractor's Nav.L.,.., __ zz-
NC Contractor Certification No.: -;M +�
Contact Person_ Z=>- ]J¢ � _SC"' EMAIL Address:,S Cu
s
Address: `R � L - j
City: r.�7�����kpCode: �-S Count��:
ty � $ l 3
Office Tele No.:<gZT •-
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:.�� 5'�1 _'�+ (%Z
Contact Person: u` .�-2-erlAEMAIL Addres wo, r7
Address: n,lr4�
1
City: �ILctrptOC&)!!?Q—ZipCode; `� � County: �-- 1, z
Office Tele Noll-%- MQ14 —7 ZQeII No.:
E. STATUS OF APPLICANT l
Private: —Lz� Federal: Commercial:
State: Municipal: Native American Lands:
F. INH,,CTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA
(1 )Proposed date to be constructed: Q�2� Number of borings: _
Approximate depth of each boring (feet): -5> d e-1 l
(2) Type of tubing to be used (copper, PVC, etc): �► D pE' _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes of o below)
(a) Yes if yes, then provide casing information below
Type: �gal�anixed steel black steel plastic other (specify)
Casing depth: From to feet (reference to land surface)
Casing extends to above ground inches
(b) No _ L
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite Other (specify) 1 V NQ Ar�X
(b) Grout placement. Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from C> to ZCM' (feet)
If well has casing, indicate grout depth: from to (feet)
GPU/UIC SQW Notification of Intent Form (Revised 8/2008) Page 2

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DATE:
A.
H.
RECEIVEO I i7ENR l nwp
A4UWR PPnTFr'rnn1 SFCit0N
NORTH CAROLTNA AUG 2 7 2010
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
Z]
TYPE 5QW WELDS)
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Print or type the required information and mail to address on the back page.
20�
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 V Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well ❑ en -loop well infecting potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
PROPERTY OWNER(S)IAPPLICANT(5)
List each Property Owner listed on property deed (if ovfjd by p. business or government agency, state name of
entity and a representative wlauthority for signature):
*� (1) Mailin -Address: Z I
City: State Q�Zip Code: 'Z_'64�9 D (In County:
Home/Office Tele No.: ?5!�--?may I _ Cell No.: _
LLam�-, t r TO ° ►r �--�
Email Address: TT� qr ,tebslte:
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code: County:
Home/Office Tele No.: Cell No.:
AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name
Contact Person:
Address:
City:
Office Tele No.:
EMAIL
State: Zip Code:
County:
Le
Website Address of Company, if any;
GPUIUIC 5QW Notification of Intent Form (Revisrd 8/2008) Page I

H. INJECTION -RELATED EQUIPMENT
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 well(s) 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.
J. 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 familiar 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 am 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 th pproved specifications
and conditions of the Permit."
Signature of Property Owner/Applicant
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 Carolina DENR DWQ
Aquifer Protection Section-UIC Program REC I p/pEIRIDVVp
1636 Mail Service Center AQ PR!]Tp��0M SFC71
ON
Raleigh, NC 27699-1636 AUG a i 2010
Telephone [phone]
GPUMIC 5QW Notification orintent Form (Revised 812008) Page 3

C. WELL DRILLER INFORMATION
Company Name:��_ �'►�� _ � � k�1'V{ r
Well Driller Contractor's Name:
NC Contractor Certification No.: 1!N T,
I1!
E.
Contact Person:
Address:� X Z—I> 0���� L
City: �'tS '7�? �Nl �P�ip Code: ZS g 13County:
Office Teie No.: ZS —2.0r}g f1G'tell No.: S 01 ) � g
HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: '-i rL} N�µ
Contact Person:
Address: j 44 __►� �'
City:l J, �eat� W70 i cA—Zip Code: County:
Office Tele hio. 3— - �-�e11 No.:
STATUS OF APPLICANT
Private: _V­ Federal:
Commercial:
State: Municipal: Native American Lands:
7
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
close d\., cn ,��4-e rr d nLe l- rr )ea'. t) c �v
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: 212711 D Number of borings:
Approximate depth of each boring (feet): �Q_eL1
(2) Type of tubing to be used (copper, PVC, etc). iL P E
(3) Well casing. Is the well(s) cased? (check either (a.) Yes RKSINO below)
(a) Yes if yes, then provide casing information below
Type: _galvanized steel black steel plastic_other (specify)
Casing depth: From to feet (reference to land surface)
Cej�- • Cu
qa'4 05
3N t—%• CA i
Casing extends to above ground inches
(b) No lZ
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite Other (specify) VmEinJv Ar jr
(b) Grout placement: Pumping Pressure Other
Grout depth of tubing (reference to land surface): from d to �Qo� (feet)
II well has casing, indicate grout depth: from to _ (feet)
GPU/UtC 5QW Notification of Intent Form (Revised 9/2008) Page 2

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