WI0100116_GEO THERMAL_20100830

Central Files: APS— SWP_
08/30/10
Permit Number WI0100116 Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility Name
77 Pine Forest Drive
Location Address
77 Pine .Forest Dr
Weaverville NC 28787
Status
Project Type
Active
New Project
Version
Permit Classification
1.00
Individual
Permit Contact Affiliation
Von Plemmons
PO Box 71
Hot Springs
NC 28743
Major/Minor Region
Minor Asheville
County
Buncombe
Facility Contact Affiliation
Owner Name Owner Type
Individual
Derek Lee Edwards Owner Affiliation
Derek Lee Edwards
77 Pine Forest Dr
Weaverville NC 28787
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
08/30/10 08/23/10 08/30/10 08/30/10
Regulated Activities
Heat Pump Injection
Outfal l N; II i
Waterbody Name Stream Index Number Current Class Subbasin

Ai;_7:A
RMENP.
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
8/301201.0
Derek Edwards
77 Pine Forest Drive
Weaverviile, NC 28787
Subject: Acknowledgement of Intent to Construct `type 5QW Injection Well System
Permit No. WI0100116
77 Pine Forest Drive, W eaverville. NC 28787
Dear Mr. Edwards:
Dee Freeman
Secretary
On 8/23/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onl\
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
individual permit is not tcquired for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met:
The injection well system contains only potable water,
The injection well system is constructed in accordance with well consmrctton standards specified in NurLh
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
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 Subchapter .0211(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.Ra<cers;a7ncdenn uov if you have any questions
Sincerely,
�
,for Debra Wat s
Supervisor
cc: Asheville Regional Office - APS
APS Central Files -Permit No, WIU 100 116
Buncombe County Health Dept.
Clearwater Weil Drilling — Von Plerrunons _ PO Sax 71, Hot Springs, TIC 29743
Affordable Comfort — Tracey Pender— 5I Holcomhe Branch Rd, Wcavervil le, TIC 28797
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27W4
Phone: [phone] I FAX 1: 919-715-0588; FAX 2; 919-715-61348 � C"rwr 5ervim-1-877-62M748
Intemet wWW,ncwa3or4uat+ice 4
Mona hCarolina
Ari Equal Opporiunity t Affirmative Azl;an Employer

RECEIVED I DENR t DWO
A[ UFFR'PROTF.nwiq SECTION
DATE:
A.
B.
NORTH CAROLINA AUG $ 3 MID
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE SQW WELLS,)
1:n Accordance With the Provisions of NCAC Title 15A 02C.0200
Prins or type the required information and mail to address on the hack page.
20 h�V I I (.o
Weft Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates tho fluid from the environment (i.e.
cipsed-taop i7
YesContinue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well in'ectin potable water into the aquifer) or a 5QM well (closed -
loop well containing additi� es such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
PROPERTY OWNER(S)IAPPLICANT(S)
List ewb Property Owner listed on property deed (if owned by a business a�_ goveTiwnt agency, state name of
entity and a representative wlauthority for signature): �� J
r
(1) Mailing Address: 1 �'7 -►'t.� -f9'� 0` ` t _
City: _ _- State:6C Zip Cade: County:
HomelOffce Tele No.: _ 46 - ' S-3; Ceii No.: _
Email Address: �!!E _,� r� � _ L_ larkr���t } �v�,Q► �.�IS
(2) Physical Address of Well Site (if different than above): 56in le
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)
Comity Name•
Contact Person: EMAIL Address:
Addrm. --
City:
State; Zip Code:
Office Tele No.: Ce 1
Website Address of Company, if arry:
County:
GPUIU[C 5QW Notification of Intent Form (Revisc;d 812008) Page 1

C. WELL DRILLER INFORMATION
Company Name: t, ' UAV_ z-)
r
Well Driller Contractor's Name:') f")Ir,mc �•?
NC Contractor Certification No.:
Contact Person4*; y�r�1'pN� �,'VO , EMAIL Address:
--
Address:
City: F t-'� , ] Zip Code: �_ County:
-
Off ce Tele No.: 1 � -�, �' jAj' Cell No.:�'--
��
E.
F.
HEAT PUMP CONTRACTOR INRMATION (il' different than driller)
Company Name: te/ed/Ut k,-
Contact Person: EMAIL Address: LMWLU r A i.Af011dx -CV►'t��f� ` •
Address:
City: Zip Code: I1{ �ioUnty?►7 L�fl
Office Tele No.: ; - O dv � Cell No.:
STATUS OF APPP ICANT
Private: I � Federal: Commercial:
State: Municipal; Native American Lands.
INJECTION PROCEDURE (brly ��he hcFw t a injection wel (s) will b Bused) t
G. WELL CONSTRUCTION DATA
I
(1) Proposed date to be constructed: , f jj �Number of borings:
Approximate depth of each boring (feet):
(2) Type of tubing to be Used (copper, PVC, etc):
(3) Well casing. Is the well(s) caged? (check either (a.) Yee or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: ____galvanized steel black steel --plastic outer (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 Sentonite Other (specify)
N Grout placement: Pumping_ Pressure Other
(c) Grout depth of tubing (reference to land surface): from 10 to �-S'b (feet)
If well has casing, indicate grout depth: from to [feet)
GPUIUIC 5QW Notification of intent Corm (Revised Saooa) Page 2

71A
1
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(4) Grout info (material surrounding well casing arid/br piping):
(a) Grout type: Neat Cement Bentonite Other (specify)
RECEIVED I DENR 101Y'D
AOUPPla PAoTFrrinV _qFCj"
AUG $ 3 2010
(b) Crrout placement: Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from 0 to '9-Z (feet)
Lf well has casing, indicate grout depth: from to (feet)
INJECTION -RELATED EQUIPMENT
Attach a diagra►n showing the engineering layout or proposed modification of the injection equipment anrl exterior
piping/tubing associated with die injection operation. The manufacturer's brochure may provide sLipp] ementary
information.
LOCATION OF WELL(S)
Attach two copies of neaps showing the following iinformation:
(l) Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater comamination and the orientation of and distances between the: proposed well(s) and
any existing well(s) or waste disposal facilities sucb as septic tanks or drain fields located within 200 feet or
the geothermal heat pump well system. Label all features clearly and indLide a north arrow.
(2) The Site Map must slow 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.
3 _W1.1M011W.11[11M]
Note: This Permit Application must be signed by e4gh 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 um this document and all attachments thereto and tiiat, based on my inquiry of those individuals
immediately responsible for obtaining said information, 1 believe that the information is true, accurate and complete.
I ant aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false infor-ration. I agree to constnict, operate maintain, repair, and if applicable, abandon time injection well and
all related appurtenances in accordance with Ihepproved spOTIcations and conditions of the Permit."
_ G�
�i_ nature 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
GPts,UIC ]QW Nod ficatiaiiof Iiiient Form (Revised 8/2008) P;Igc 4

RECEIVED � DENR i OWO
A4tltF1:R pprmr. nu SEGTM
NORTH CAROLINA AU6 S 3 Zola
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE QW WM0i
In Accordance With die Provisions ofNCAC Title 15A 02C,4240
Print or type the required irrfarmalio►r and mail to address on the back page.
DATE: �K, — I � — J0 , 24
Well Type Confir► alion: Does the proposed system circulate potable water oni_, (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop a?
Yes L--- Continue completing this form.
No __ Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well in'ectin potable water into the aquifer) or a 5QM well (closed -
loop well containing additi� es such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNERS)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business o gave ant agency, state name of
entity and a representative wlauthority for signature): _ ���_'�
t
(1) Mailing Address: 7 61to
City: Itu. y ti : L _ State: C Zip Code: County: rJLC�{
Home/Office Tele No.: r_ �� � i __dell No.:
Email Address: d'egec
(2) Physical Address of Well Site (if different than shove): �}
City: State: Zip Code: County:
Horne/Office Tele No,: Cell No.:
B. AUTHORMED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
anach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact P Il_ Address:
Address•
City. State Zip Code: County:
Office Tele No.: Cell No.:
Website Address of Company, if any:
GPUAJIC 5Qw Nolif'icadan of In lent Form (Revised 8l2008) Page i

C. VVELL DRILLER INFORMATION
Company Name:
Well Driller Contractor's Name: -� Irv)
NC Contractor Certification No.:
Contact Pcrson;r
Address:
City. Zip Code:_ County:
Dffice Tele No.; Cell No.: �-�- 7) (o — (A .')(c.-�
D. HEAT PUMP CONTRACTOR INPORMi ATION (if different than driller)
Company Name: -_ fy•i! - z:.� I.,
ContactPerson: _ y EMAIL Address: V G[1�
►s r G� �n•
Address:
City: _ Zip Code: I ! C -�� 7C OL' my
Office Tele No.: , } d� '�si ` 090 I Cell No.:
E.
F.
STATUS OF A.PYJ.ICANT
Private: L Federal:
Commercial:
State: Municipal: Native American Lands:
INJECTION PROCEDURE (brit;fly des ribe htjw the injection well(s) will be used) �
G. WELL CONSTRUCTION[ DATA
(1) Proposed date to be constructed: , � ll) Number of borings:
Approximate depth of each boring (feet): t�
7�
(2) Type of tubing to be used (copper, PVC, etc):
(3) Well casing. Is the well(s) eased? (check either (a.) Yes or (b.) No 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)
Casing extends to above ground incites
(b) No L---'
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement
Bentonite
Other (specify)
(b) Grout placement: Pumping_ Pressure Other
(e) Grout depth of tubing (reference to land surface): from C') to {feet}
If well has casing, indicate grout depth: from to (feet}
GPUIUIC 3QW Notification of intent Fonn (Revised gnOOS) Page 2

N

NECIGIVEC; / DENR I OWO
AOUIIFR 9W)TFf: ION RgrTjot1
(4) Grout Info (material surrounding well casing and/or piping): AVG $ 9 2010
(a) Grout type: Neat Cement Bentonite Other (specify)
(b) Grout placement: Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from 0 to �M (feet)
If well has casing, indicate grout depth: from to {feet)
H. INJECTION -RELATE]] EQtiIPNIENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and extertur
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 tans or drain Fields located within 200 feet of
the geothermal heat pump well system, Label ail 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 eI} person appearing on the
recorded legal property deed-.
"I hereby certify, under penalty of law, that I have personally examined and ant familiar with the inforrnatinn
submitted in this document and all attachments thereto and drat, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and complete,
I ant aware that there are significant penalties, including [he possibility of fines and imprisonment, for submitting
false information. I agree to construct, operate maintain, repair, and if applicable, abandon the injection well and
alI related appurtenances in accordance with Lhe. pproved spr.r ifications and conditions of the Pert -nit."
ti> nature of Property Owner/Applicant
Print or Type Full Nacre 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
GPU/UIC 5 Q W Notitieatioit of Intent Form (Re rised 8I20G$) page 4