WI0100112_Regional Office Physical File Scan Up To 9/14/2022

-Central Files: APS SwP
08/23/10
W10100112
Permit Tracking Slip
Status
Project Type
Active
New Project
Version
Permit Classification
my GSHP Well System (5QW)
1.00
Individual
Permit Number
Program Category
Ground Water
Permit Type
Injection Water O
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility Name
David Steele SFR
Location Address
211 Cedar View
Asheville
Permit Contact Affiliation
Phyllis Steele
Co-owner
211 Cedar View
Asheville NC 28803
Major/Minor Region
Minor Asheville
County
Buncombe
NC 28803 Facility Contact Affiliation
Owner Name
Owner Type
Individual
David Steele
Owner Affiliation
David Steele
Owner
211 Cedar View
Asheville NC 28803
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance
Public Notice Issue Effective Expiration
08/23/10 08/12/10
08/23/10 08/23/10
epuiated Activities
Heat Pump Injection
Private residence, single family
Outf"all NULL
Waterbody Name Stream Index Number Current Class Subbasin

Pr
Beverly Eaves Perdue
Governor
David Steele
Phyllis Steele
211 Cedar View
Asheville, NC 28803
HCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
8/23/2010
REC IE9VEO
AUG 25 26110
A-_hr:,-v1l1C rye-gl hall Office
l�'L'�7�..SG��:v L�6'�^��s`•".-6:lE7rp
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100112
211 Cedar View
Asheville, NC 28803 .
Dear Mr. and Mrs. Steele:
Freeman
Secretary
On 08/12/2010, the Aquifer Protection Section (APS) received notification 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
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 .021l(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.Rogers()ncdenr.gov if you have any questions.
Sin rely,
for Debra Vkfts
Supervisor
_cc: -Asheville Regional_Office - APSi
APS Central Files - Permit No. WI0100112
Buncombe County Health Dept.
Duane Gentry (Gentry Heating, Inc., 100 Buckeye Access Rd., Swannanoa, NC 28778)
Steve Deweese (Geotherm Loop Services, Inc., P.O. Box 5411, Asheville, NC 28813)'
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604 One
Phone: [phone] i FAX 1: 919-715-0586; FAX 2: 919-715-60481 Customer Service: 1-877-623-6748 N0rffi Carohna
Internet: www.ncwateroualitv.om
An Equal Opportunity 1 Affirmative Action Employer

FLO loo t VD-,
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RECEIVED / DENR / DWQ
Aquifer Protection Section
NORTH CAROLINA AUG 12 2010
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 50W WELLS)
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: R/2_ , 20 M
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 r/ Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (ppen-loop well injecting 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)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): , Li) A- l 0
(1) Mailing Address: `� l / �=� 1�� IJJc t.J
City: k�t�i C .0 State: A) :'Zip Code: Z c -F-0 7 County: Y-+n/ � ►�
Home/Office Tele No.:? -� _�J Cell No.:
Email Address:`)5Tr 0` 2S7/ ct> Website:
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code: County:
Home/Office 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.: Cell No.: _
Website Address of Company, if any:
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page I

W
E.
F
G.
WELL DRILLER INFORMATION
Company Name:
f
Well Driller Contractor's Name: {�ii_a 1l,� C ,��'��<. -
NC Contractor Certification No.: 1 61--1
Contact Personsy --�� 4� c EMAIL Address
Address:c��
City:Zip Code: l s 'County:
Office Tele No.: �� . -) �7_. �7'� CellNo.: - 0i - _ - 1 !T_
BEAT PUMP CONTRACTOR INFORMATION (if different than driller)
CompanyName:_C
Contact F
Address:
City:c�C,A.r/r.:Ase/ Zip Code: % % County: 1St .,,1� — •-g!�, �r�
Office Tele No.. 2,,; Z 7te 72 a j,) Cell No.:
STATUS OF APPLICANT
Private: -!- Federal: Commercial:
State: Municipal: Native American Lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
WELL CONSTRUCTION DATA
(1) Proposed date to be constructed:,'('y r! C> Number of borings:
Approximate depth of each boring (feet): 2,0y `
(2) Type of tubing to be used (copper, PVC, etc): Iq z:>
(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 ove ground inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping): ��++
(a) Grout type: Neat Cement Bentonite Other (specify��',•T/C,Q�r��"�t
(b) Grout placement: Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from C) ` to 7 Z3 J' ' (feet)
' E-11-I :
CO
If well has casing, indicate grout depth: from to (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008)
Page 2

PV
H. INJECTION -RELATED EQUIPMENT
t!) / DENR! DWQ
,.,...,faction Seotioll.
A:J!C;.* 12 2010
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 the approved specifications and conditions of the Permit."
Signature o Property Owner/Applicant
PH y LC_cS KN SIF C4c=
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
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 3

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