WI0100178_GEO THERMAL_20111102

s'r` 5rAT�y
Bullman Heating & Cooling
RESIDENTrAIL. WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- DivisiorL.of-Water Quality
WELL CONTRACTOR CERTIFICATION # 3421
--1-. WELL CONTRACTOR:
David Stratton
Well Contractor (Individual) Name
AWD Services. Inc.
Well Contractor Company Name
258 North T rkev reek Rd.
Street Address
— Leicester _ NC 28748
City or Town State Zip Code
$c 28 683-9223
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# IWI0100178
OTHER ASSOCIATED PERMFF#(if applicable)
SITE WELL ID #[dappiicable) --
3. WELL USE (Check Applicable Box): Residential Water Supply Nr
DATE DRILLED 11 /2111
TIME COMPLETED AM ❑ PM (�
4. WELL LOCATION:
CITY: Asheville COUNTY Buncombe
596 Old Toll Road
(Street Name, Numbem, Community, Subdivision, Lot No., Patel, Zip Code)
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
WSlope ❑Valley ❑Flat ❑Ridge ❑Other EleV. 2568
LATITUDE 35 37 23.0000 ° OMS OR DD
LONGITUDE 82 ° 32 22.0000 ° DMS OR DD
Latitudellongitude source: 6i3PS Dropographic map
(location of well must be shown on a USGS topo reap andattached to
this form if not using GPS)
5. WELL OWNER
Robert Buckle
Owner Name
596 Old Toll Road
Street Address
Asheville NC 28801
Cityor Town State Zip Code
8��
Area code Phone number
6. WELL DETAILS: (2) Geothermal Bores
a. TOTAL DEPTH: 2-320'
--g. WATER ZONES (depth):
Top Bottom
Top Bottom
Tap Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness!
7. CASING:
Depth
Diameter
Weight Material
Top
Bottom
Ft .
Top
Bottom
Ft
Top
Bottom
Ft
8. GROUT:
Depth
Material
Method
Top 0
Bottom 20'
Ft. Bentonite
Pour
Top 21
Bottom 320'
Ft. Pea Gravel
Pour
Top
Bottom
Ft
9. SCREEN:
Depth
Diameter Slot Size Material
Top
Bottom
Ft In.
In.
Top
Bottom
Ft in.
in.
Top
Bottom
Ft in.
in.
10. SANDIGRAVEL PACK -
Depth
Size
Material
Top
Bottom
Ft.
Top
Bottom
Ft.
Tap
Bottom
Ft
11. DRILLING LOG
Top Bottom
/
1
1
1
1
1
1
1
1
.1
12. REMARKS:
Formation Description
tr. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [� I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: NIA FT." ACCORDANCE WITH I6A NCAC 2C, WELL CONSTRUCTION
(Use "+° if Above Top of Casing) STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF cmiNf3 is NIA FT. Above Land Surface`
'Top of basing terminated atlor below land sufface may require �' ���p71 1112111
a variance in accordance with 15A NCAC 2C .0118. : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD tgpm): NIA METHOD OF TEST NIA David Stratton
f. DISINFECTION: Type NIA Amount NIA PRINTED NAME OF PERSON CONSTRUCTING THE WELL
St bmit.withllh 30:dayis'ofcotnof6tioli;ta �OiVisian of VMfatei.Quality-.•informatibnProcetasing,. Form GWAa
164'f �Vliaik: ervice Cdnter, Raleigh, NC 27699 161;Phone: t810) 807-6300 Rev. 2109

Permit Number W10100178
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW )
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit-
Facility Name
Robert Buckley SFR
Location Addrees
596 Old Toll Rd
Asheville
Owner
central Files. APS_ SWP_
10/25/11
Permit Tracking Slip
Status Project Type
Active New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Chad Surrett
driller
258 N Turkey Creak Rd
Leicester NC 28748
Major/Minor Region
Minor Asheville
County
Buncombe
Facility Contact Affiliation
Owner Name owner Type
Individual
Robert Buckley Owner Affiliation
Robert Buckley
596 Old Toll Rd
Asheville
Dates/Events
Scheduled
Orin Issue App Received Draft Initiated Issuance
10/25/11 10/17111
Regulated Activities
Heat Pump Injection
Outfall r.IUL L
Public Notice Issue
10/25111
Waterbody Name Stream Index Number Current Ciass
NC 28801
Effective Expiration
10/25/11
Subbasin

w J A,
MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
10/25/2011
Robert Buckley
596 Old Toll Road
Asheville, NC 28801
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100178
596 Old Toll Road, Asheville, NC 28801
Dear Mr. Buckley:
Dee Freeman
Secretary
On October 17, 2011, the Aquifer Protection Section (APS) received notificarion of your intent to construct a closed -loop water -only
geothermal injection well system for the operation of a ground -source heat 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 injection well system is constructed in accordance with well construction standards specified in North
Carolins 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 Subchapter .0211(u)(2). Additionally, you should contact the Buncombe County Health
Department as they may have additional requirements for this rype 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.Rouers.ar ncdennvov if you have any questions.
Sincerely,
/or Debra Watu
Supervisor
cc: Asbeville Regional Office - APS
APS Cenn-al Files- Permit Ne. W101003 78
Buncombe County Health Dept.
AWD Services, Inc. (i,mr y Wells)
Bullman Heating & Air (Joey Butlman)
AQUIFER PROTECTION SECTION
1636 Mail Service Center. Raleigh. North Carolina 27699-1636
Localion: 2728 Capbl Boulevard, Raleigh, North Gamllna 2760A
Phone: [phone] l FAX [phone]; FAX 2: 919-715-6W I Guslamer Service: 1-877-623.6746
]ntemet www,nmarernualitv.fl�
NarthCarolina
An Equal OppnmRiry k Af-irmahNe Acrna Ernpnyer

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURA L RESOURCES (NCDENR)
NOTWICATIO.N OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELLS}
In Accordance with the provisions ofNCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or TYpe information),
DATE: 10 / 20 - Q0 1 Co F)
9'ell Trpr Confirmation: Does the proposed system circulate potable water onl4 (no additives) its
continuous piping that compietely isolates the fluid front the environment (i.e.
dosed —loop)?
Yes V Continue completing this farm.
No Do Not complete this form. Complete other IJIC application forms for instatlin-g
either a 5 A 7 well (.open -loop well in'Li ng potabfe water into the aquifer) or a 5QM weal (clased-
loop NvelI conta1nIng additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors)
PROPFRTY OWNER(S)IAPPLICANT(S)
List eaeh Properly Owner fisted on property deed (if owned by a business or -government agency, state name of
entity and a representative wlauthority For signature):
A�'JGU41
(1) M.iiIinAddress: S7�r 1-o (/ Yid---
City Ile -State: /%Xf-�ip Code: '2 ( Coil nty:�nGrc'o'
I mime![?tilcl. Tole. N(r .•_ Cell Nn %O3�a 7— D 7-57$
Lmad Address:
Website_
(2) Physical Address of Well Site (if different than above):
City State: Zip Code: County:
Homy;/Office Tele No.: Cell No.:
AIJIMORIZED 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:
Add ress:
City: State
Office Tele No.:
EMAIL Address:
Zip Code: County:
Website Address of Company, if any!
Cil'llltli(' 5QW Nntilicatinn of Intent Form (Revisrti 817008) rage i

C. WELL DRILLER INFORMATION
Company Name: AWD SERVICES. INC.
Well ❑rifler Contractors Name: V � .0rfc,}+
NC Contractor Certification No.:-3-500
Contact Person: Larry Wells EMAIL Address: Wells756549w.Bellsouth.net
Address: 258 North Turke► Creek Rd.
City: Leicester Gip Code: 28748 County: Buncombe
Office Tele No.: 828-583-9223 Cell No.: 828-215-9334
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:_�Btkl frr70.r7 Q' r �_ A r _
Contact Person: +_. •, :i:,4 t� EMA I L-Address: -
Address: J12 }.J L"-
City: Zip Code: 1� county- �tn_GOAI
Office Tele No.:Cell No.:
E.
F.
G.
STATUS OF APPLICANT
Private: x Federal.:
Commercial:
State: Municipal: �— Native American Lands:
INJECrF]ON PROCFL?URE (briefly describe how the injection welI(s) will be used)
NVELL CONSTRUCTION DATA
(1) Proposed date to be constructed: Wen Pam. Number of borings. -
Approximate depth of each boring
(2) Type of tubing to be used (copper, PVC, etc): �j-i �� $ ►l��
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (h<a 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
(4) Grout Info (material surround•:ng well casino and/or piping):
(a) Grout type: Neat Cement 13entonite Pee, 6y-AV'C I
(h) Grout piacetnent: 1'umpingi Pressure ❑[tier ��P Za �� °Iv So 1 '
(c) Grout depth of tubing (reference to land surface): from to (feet)
If well has casing, indicate grout depth: train
to {feet)
Upt!/I II(,' ifs W Ni,iilitgdinn of Intent turn} (itc:vikul S1200R) Page 2

H. INJECTION -RELATED EQUFPNIENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injecting 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 ❑f
the geothermal heat pump well system. i.abel 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.
.1. CERTIFICATION
Notc. This Permit Application must be signed by each Berson 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 d)Cunent and all attachments thereto and that, basal on my inquiry of those individuals
immediately responsible for obtaining said information, 1 believe that the information is true, accurate and complete.
I am aware that there are significant penalties, ineiuding the possibility of fines and imprisonment, for submitting
false information. l agree to construct, operate, maintain, repair, and if appiicable, abandon the injection well and
all related appurtenances in accordance witli the approved specifications and conditions of the Permit."
4af� ___-. -
Signature oroperty twner/Applicant
Print or Type Full Nwiie 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-JUIC Progrant
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUA)lC-5QW Notification of Intent Form (Revised 9/2008) Page 3

440,15C
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