WI0100116_Regional Office Physical File Scan Up To 9/14/2022

Beverly Eaves Perdue
Govemor
Derek Edwards
77 Pine Forest Drive
Weaverville. NC 28787
v�
ljA.
North Carolina Department of Environment and
Division of Water'Quality
Coleen H. Sullins
Director
9115012010
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10100116
77 Pine Forest Drive. Weaverville- NC 28787
Dear Mr. Edwards:
ABC E�Vfp_0
or-
3I JResources
k_3h()1/111() 6- 0 ,10mal Office
Secretary
On 8/23/2010, 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 Iong 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 Subbchapter .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 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 (919) 7I5-610606 orMichael.Roaers(cl,ncdenr.sov if you have any questions.
Sincerely,
fin- Debra Watts
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. W101001 1 U
Buncombe County Health Dept.
Clearwater Well Drilline —'Vote Plemmons — PO Box 71. Hot Springs, NC 28743
Affordable Comfort — Trace} Pender — 51 Holcomhe Branch Rd, Weaverville, NC 28787
AQUIFER PROTEGTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 2rn994636
Louation: 2728 Capital Boulevard, Raleigh. north Carolina 27604
Phone: 9;$_733-3229 i FAX i s 919-715 9586; FAX 2: 919-79B 6U43 i Customer Service: 1-B: i-623-5748
Ititemsi: wwwimatetaualnr.otg
An Equal Opportunity ; Atnrmativa ftrion EmpWe
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Permit Number WI0100116
V
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Permit
Central Files: APS_ SWP_
08/30/10
Tracking Slip
Program Category
l �a�a"iCa� �� ;'?�.�,'iC`,�c.� �' f;CCSta us Project
I ,� j Type
Ground Water
%� i�_�i r''s� ;; L'.+`-
Active New Project
Permit Type
Version Permit Classification
Injection Water Only GSHP Well System (5QW)
1.00 Individual
Primary Reviewer
Permit Contact Affiliation
michael.rogers
Von Plemmons
Coastal SW Rule
PO Box 71
Hot Springs NC 28743
Permitted Flow
Facility
Facility Name
Major/Minor Region
77 Pine Forest Drive
Minor Asheville
Location Address
County
77 Pine Forest Dr
Buncombe
Weaverville NC
28787
Facility Contact Affiliation
Owner
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
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin

E T� I ""q4q
A6
NCDENK
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
8/30/2010
Derek Edwards
77 Pine Forest Drive
Weaverville, NC 28787
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100116 - - -
77 Pine Forest Drive, Weaverville, NC 28787
Dear Mr. Edwards:
On 8/23/2010, 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:
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 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.Rogers(cuncdenr.gov if you have any questions.
Sincerely,
A.
for Debra Watts
Supervisor
cc:,� sheville;Regiorial=0ffice:�APS �'.
AP Central Files - Permit No. W101001 16
Buncombe County Health Dept.
Clearwater Well Drilling — Von Plemmons — PO Box 71, Hot Springs, NC 28743
Aff6rdable Comfort — Tracey Pender — 51 Holcombe Branch Rd, Weaverville, NC 28787
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604 One
Phone: [phone] FAX 1: 919-715-0588; FAX 2: 919-715-60481 Customer Service: 1-877-623-6748OI ��+arOL� itl
Internet: www.ncwateraualitV.orp � •��
An Equal Opportunity t Affirmative Action Employer P

RECEIVED / DENR / DWQ
AQUIFFR'PROTECTION SECTION
NORTH CAROLINA AUG 2 3 20.10.
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5QW 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: U - I'? - 10 , 20 \N 1 �1 �?v [A LP
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid fi-om the environment (i.e.
closed -loop)?
Yes 1-Continue completing this form.
No Do Not complete this form. Complete other UIC application_ forms for installing
either a 5A7 well (open -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 bus
iness or govet �n agency, state name of
entity and a representative w/authority for signature): _ v �'
(1) Mailing Address: AL
City:
Horne/Office Tele No.:
Email Address: d e P E
(2) Physical Address of Well Site (if different than above): 56M It
City:
State: Zip Code:
Home/Office Tele No.: Cell No.:
County:
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

C.
6b
WELL DRILLER INFORMATION
Company Name:
Well Driller Contractor's Name: V&
NC Contractor Certification No.:
Contact 1
Address:
City: IN�d—
Office Tele No.:
LiJ_
Zip Code: �� County: )/
Cell No.:
HEAT PUMP CONTRACTOR INF RMATT�ION i
Company Name:
Contact Person: -riv %1--
Address:. c ��
n
City: U" f Zip Code:
Office Tele No.: �rt`6 's�! `QX r� Cell No.:
E. STATUS OF APP ICANT
Private: Federal:
State: Municipal:
F. INJECTION PROCEDURE
G.
t than driller)
Commercial:
Native American Lands:
the injection wel (s) will be,used)
C�
0
WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: �7 f 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) 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
(4) Grout Info (material surrounding well casing and/or piping): /
(a) Grout type: Neat Cement Bentonite L_ Other (specify)
(b) Grout placement: Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from to S& (feet)
If well has casing, indicate grout depth: from to (feet)
&Id
GPUIUIC 5QW Notification of Intent Form (Revised 8/2008) Page 2

0

RECE1 & ,
AQUiFFR :oR(ITFP
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite / Other (specify)
(b) Grout placement: Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from to -�Z) (feet)
If well has casing, indicate grout depth: from to (feet)
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.vell(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 usin2T 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 infor7mation
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 with4igelpproved s olfications and conditions of the Permit."
q'gnature 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
GPU/U1C sQw Notification of Intent Form (Revised 8/2008) Pa„e 4

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Beverly Eaves Perdue
Govemor
Derek Edwards
77 Pine Forest lrive
Weavenville. NC 28787
M -DOEt i,
North Carolina Department of Environment and natural Resources
Division of Wafer Quality
Coleen H. Sullins
Director
8's012010
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
PermitNo_ VMl00116
7 i?ine Forest Drive, W eaverville- NC 28 787
Dear Mr. Edwards:
Dee Freeman
Gecretanr
RECE9VED
Asheville Regional Office
Anuiter f reLeCt1On _
On 8/23/2010; the Aquifer Protection Section (APS) received notification of your in to construct aclosed-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
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 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 Nlichael.RosersQ:nedenr_aov if you have any questions.
Sincerely,
t'
;o; Debra Watts
Supervisor
CC' Asheville Rea onal Office - APS
APS Central Files- Permit No. W101001 16
Huncenabc County Health Dept,
Clearwater Well Drilling— Von Piemmons — PO Box 71, Hot Springs, NC 28743
Affordable Comfort — Tracey Pender— 51 Holcombe Branch Rd. Weaverville, NC 28710 i
AQUIFER PR07EGTION SECTION
1635 Mail Service Center. Raleigh, North Garolina 2i$99-163e
1.oz;alion: 27 2H Capital aulwartl. Raleigh. North Carolina 27604
Phone: 919-733a221 t FAX 1: 999-71�-.1' 588; FAX 2:91847 15-o'i1981 Qstutrte; Selvics: l-K7-623-6746
IF
1118MEt: WAV,nMterquerrtq.orp
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NortbCarolina
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An Equal Opportunity, Aifirrnative Action Employer