WI0100151_GEO THERMAL_20110414

V
Central Files: APS SWP
04/14/11
Permit Number WIOIOO151
Permit Tracking Slip
Program Category
Status
Project Type
Ground Water
Active
New Project
Permit Type
Version
Permit Classification
Injection Water Only GSHP Well System (5QW)
1.00
Individual
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Permit Contact Affiliation
Von Plemmons
PO Box 71
Hot Springs
NC 28743
acilit
Facility Name Major/Minor Region
Frank.& Julia Bonomo SFR Minor Ashevilie
Location Address County
96 Waynewood Dr Haywood
Waynesville NC 26786 Facility Contact Affiliation
Owner
Owner Name
Owner Type
Individual
Frank Bonomo
Owner Affiliation
Frank Bonomo
96 Waynewood Dr
Waynesville NC 28786
DatesI-vent=
Scheduled
prig Issue App Received Draft Initiated Issuance
Public Notice Issue Effective Expiration
04/14/11 04/13/11
04/14/11 04/14/11
Re-7ulated Activities
Heat Pump Injection
Outfali I i wi L-
Waterbody Name Stream Index Number Current Class Subbasin

A LT
L+
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
4/ 14/2 011
Frank Bonomo
JuliaB011rrtit,
cif, W iynewood Dnv.
WaYnesvlllc, NC 28786
Sub)eci: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. Wl1)100151
96 Waynewood Drive, Waynesville, NC 28786
Dear 1b1,. & Mr:. Bonumo:
Dee Freeman
Secretary
On 4/13/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onk
geothermal injection well system for the operation of a around -source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of [his 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 construction standards specified in North
Carolina Administrative Code Tide 15A Section 2C Subchapter .0213, and
The required notification four, and associated maps have been completely and accututely submitted.
Failure to comply with ali of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Adrainistrat-ive. Code Title 15A Section 2C Subchapter .02111(u)(2). Additionally, you should contact the 1-Iaywond 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.
Pleasc contact Mike Rogers at [phone] or Michael.Rovers0ncdenr.eov ifyou have any questions.
Sincerely,
Jor Dcbra V+ airs
Supervisor
cc: Ash eviIIe Regional Office - AP
AP Central Files - Permit No. W10100151
Haywood County Health Dept.
Clearwater Well Drilling, Inc iVmi Plemmons)
Gentry I-1ea(i Ins. {Duane Gentryl
AQUIFER PROTECTION SECTION
163E Mail Service canter Raleigh. NoRh Caroliga 27699.1636
Location. 2728 Caoital Boulevard Raie)gh. North Camarna 27e64
Phone 91t,-73,-"221 } FAX ' 91�'-715-0588: FAX 2� 51G 715-60481 Coslomer Service. 1-977-623-6748
Interne". www.nuyatemualii o .
One
NorthCarolhia
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NO JU ATION OF E TI'ENT TO CONSTRUCT A CLASSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5QW WELL
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.
DATE: �"- 0` - 20J-L V ,JI 0 100 t J 1
WeU I)pe Conflrmadon: 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 UIC application forms for installing
either a 5A7 well (qM-loop well iWecting 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 ea;h Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): ►•- �- , _ 60 ,., 6 •.i �
(1) Mailing Address: I ti`-� ` ► ( ,�2
City: _ ' ' i L C State: Zip Cade: bCounty:
HomelOffice T�iele Z Gell No.:
--
Email Addressf w Vebsite•
(2) Physical Address of Well Site (if different than above):
City:
HomdOffice Tele No.:
State: Tap Code:
Cell No.:
County:
S. 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 Pusan: EMAIL Address:
Address:
City:
Office Tele No.:
State: Zip Code:
Website Address of Company, if any:
County:
Cell NQ.: RECEdWED r (�. R
r,Lr�n;-,
APR 13 20i1
GPUIUIC 5QW Notification of Intent Farm (Revised 812008) Page I

C. WELL DRILLER IN ORMATION , �1�I
Company Name: nc � 1.! v —. �'7 C,
Well Driller Contractor's Name:
NC Contractor Certification No.:
Contact Pcrson, �. ", 1 11I, r�= � °� - �� EMAIL Address. )6 �LR W*e-r 10 kUVA
Address: Tl � X 91—
City: bi 3,.)i lw 5 Zip Code: 7�3 County: M&SSM
Office Tele No.: Cell No.: U9 HC52.(o_j _1_ 7(t)_(052_[0
D. HEAT PUMP CONTRACTOR INFORMATION (ir different than driller)
Company Name: h�
Contact Person,1U a V%4 �4'i � - EMAIL Address: CL�I�c4L_ t ; f4� u' �r1�.Q�►1
Address: LLL,,k i Li e kPt5 1 ii v
City: SuayabooL - Zip Code: County: -
Office Tele No.: SZ�6 -9-14 -MO Cell No.:y S -552_ ;, ` 2A
E.
F.
STATUS OF APPLICANT
Private: V Federal:
State:
Municipal:
Commercial:
Native American bands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Hmuj Lao- Wait km &rOL "tN,
G. WELL CONSTRUCTION DATA
(1) Proposed date to be coastntated: 2A "t i Number of borings:
Approximate depth of each boring (feet): M 1
(2) Type of tubing to be used (copper, PVC, etc): HZI)E 3` 0%
(3) Well casing. Is the well(s) cased? (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 _ inches
(b) No wr
(4) Grout Info (material surrounding well casing and/or -piping):
(a) Grout type; Neat Cement Bentonite Other(specify)
(b) Grout placement: Pumping Pressure Other I
(c) Grout depth of tubing (reference to land surface): from � iw to -W13 (feet) La err►
If well has casing, indicate grout depth: from to (feet)
GPU/WC 5QW Notification of fatent Form (Revised 8C2468) Page 2

ill. INJECTION -RELATED EQUMdENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
pipingltubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
L 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 contatninaiion 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.
1I1111111111Iy :A :i!]ll LV;W11- l
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. ittaintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with Z" appWeOpec ifications andfonditions of the Permit"
yigyia ure of Property Owne i,y�plicant
Print or Type Full Name and title
Sig tore of Propexti 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
1.636 Mail Service Center
Raleigh, NC 27'6"-1.636 G'ter PT + a1r;w1S + "n
Telephone (919) 7'33�?.21! R�``"fir Pmtt�ir�r ��
APR 1 .1 ?CIS
GPt1MC SQW Notification of Went Form (Raviged W2008) Page 3

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