WI0100125_Regional Office Physical File Scan Up To 9/14/2022

Stickles Services
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2603
1. WELL CONTRACTOR:
Larry Wells
Well Contractor (Individual) Name
AWD Services. Inc.
Well Contractor Company Name
258 North Turkev Creek Rd.
Street Address
Leicester NC 28748
City or Town State Zip Code
( 828 ) 683-9223
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WIO100125
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 8/2/1
TIME COMPLETED
4. WELL LOCATION:
AM El PMEV
CITY: Arden COUNTY Buncombe
52 Wood Lilv Trail
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
ZSlope ❑Valley []Flat ❑Ridge ❑Other Elev.
LATITUDE 35 " DMS OR DD
LONGITUDE 83 " DMS OR DD
Latitude/longitude source: &!�,PS Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) Lat . & Long. Unknown
5. WELL OWNER
David Resnick and Catherine Klema
Owner Name
52 Wood Lilv Trail
Street Address
Arden NC 28704
City or Town State Zip Code
8�)
Area code Phone number
6. WELL DETAILS: (3) Geothermal Bores
a. TOTAL DEPTH: 325'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING Is N/A FT. Above Land Surface'
'Top of casing terminated at/or belr.:w land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
i4
g. WATER ZONES (depth):
Top :Bottom
Top Bottom
Top 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 20' Bottom 325'
Ft.
Pea Gravel Pour
Top Bottom
Ft.
9. SCREEN: Depth
Diameter
Slot Size IViaterial
T
Top Bottom
Ft.
in. in.
Top Bottom
Ft.
IIII
in. in.
Top Bottom
Ft.
in. in. r=.:
-�
10. SAND/GRAVEL PACK:
fir--• .:
l' f ,
Depth
Size Material I
tQ
Top Bottom
Ft.
_
Top Bottom
Ft.
Top Bottom
Ft.
y
11. DRILLING LOG
'
Description
Top Bottom
Formation
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL'WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDE�THE WE ER.
"14!;;f 2-2-12
e�WNATE OF CE IED WELL ONTRACTOR DATE
Larry Wells
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1a
1611 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] Rev. 2/09

HCDEHR
North Carolina Department of Environment and Natural Resources.
Beverly Paves Perdue- `
Governor
David Resnick and Cat! *ierine Klema
300 Central Park West, Apartment 8l3
Ne`v Fork, NY 10024
Dear Mr. Resnick; and leis. Klema:
Division of l41ater
Coleen H. Suli
Director
October 29.2
Quality
ins E CC EE�VE0
Asheville Regional Office
Aquifer Protection
Subject: Issuance of Injection Well Permit
Permit No. WI0100125
Issued to David Resnick, and Catherine Klema
iiun ombe County
Dee Freeman
secretary
In accordance with your application received October 8, 2010, and additional information received
October 26, 2010,.I am forwarding Pen -nit No. W101001' 5 for the construction and operation of a vertical
closed -loop geothermal mixed -fluid heat pump injection well system to be located at 52 Wood Liiy Trail;
Arden, NC 28704. This permit shall be effective from the date of issuance until September 30, 2015, and
shall be subject to the conditions and limitations stated therein.
Please pay special attention to the following sections in Part II of the permit:
Part II.1- All geothermal wells shall be -located it minimum of 50 feet from any septic tank- system or
repair area.
Part 11.2- At least forty-eight (48) hours prior to constructing system, the Permittee shall notify the
Aquifer Protection Section's Underground Injection Control (UIC) Program Central Office staff,
telephone number [phone], and the Asheville Regional Office Aquifer Protection Section
Staff, telephone number [phone].
Part NM.2-.Submit copies of the Well Construction Completion form (GW-1) within 30 calendar
days of completion of installation of geothermal well(s).
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days prior to its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Quality. If you have any questions regarding your permit or the Underground Injection
Control Program please call me at [phone].
AQUIFER PROTECTION SECTION
i636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2,728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: wwvd.ncwatemua%,.org
G11e _
��iprffii ..-,Llrolin
An Equal Opportunity 14ffimative Amion Employe;

Sincerely,
Michael Rogers, P.G. WC & FL)
Environmental Specialist
cc: 1L iiidon Dav ds6iL -'Asheville-Regional Office—
Central Office File — WI0100125
Buncombe County Environmental Health Dept.
Brad Stickels — Stickels Service Company; Inc. (sent via e-inail)
Larry Wells - AWD Services, Inc. (sent via e-mail)
Attachment(s)

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
David Resnick and Catherine !Cema
FOR THE CONSTRUCTION AND OPERATION OF 5 TYPE 5QM INJECTION WELL(S), defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at 52 Wood Lily Trail, Arden, Buncombe -
County, NC 28704, and will be constructed and operated in accordance with the application received October 8,
201.0, and in conformity with the specifications and supporting data received October 26, 2010, all of which are
filed with the Department of Environment and Natural Resources and are considered a part of this permit.
This permit is.for Construction and Operation of an injection well and shall be in compliance with Title 15A of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until September 30, 2015, and shall
be subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 29t” day of October 2010..
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit W10100125
U IC/5QM
ver. 03/2010
Page 1 of 5

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II — WELL CONSTRUCTION SPECIAL CONDITIONS
I . All geothermal wells shall be located a minimum of 50 feet from any septic tank system or repair area.
2. At least forty-eight (48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number [phone], and the Asheville Regional Office Aquifer Protection Section Staff, telephone
number [phone].
3. The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation corners) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
4. One well identification tag per grouping or `cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g).
PART III — OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or, there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
Permit W10100125 UIC/5QM Page 2 of 5
ver. 03/2010

PART IV — PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
ground water resulting from the operation of this facility.
PART V — OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number (91.9) 71 >-6166. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
PART VI - INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Division representatives shall have reasonable access for purposes of inspection, observation, and
sampling, associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
Permit W10100125 UIC/5QM Page 3 of 5
ver. 03/2010

PART VII — MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section — UIC Program Aquifer Protection Section
DENR — Division of Water Quality Asheville Regional Office
1636 Mail Service Center and 2090 US Highway 70
Raleigh, NC 27699-1636 Swannanoa, NC 28778
Ph# 919-715-3221 [phone]
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Asheville Regional Office within 30 days of completion
of well construction. Copies of the GW-1 form(s) shall also be given to the Permittee and retained on site
to be made available for inspection.
3. A copy of the site map updated with manifold locations required in Part II.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Asheville Regional Office within 30
days of completion of well construction.
4. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface. and ground water protection will be established and an
acceptable sampling reporting schedule shall be followed.
5. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Asheville Regional Office, telephone number [phone] any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
(C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
6. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and correct
facts or information shall be promptly submitted to the Director by the Permittee.
7. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII — PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
Permit WI0100125 UIC/5QM Page 4 of 5
ver. 03/2010

PART IX — CHANGE OF WELL STATUS
1. The Permittee shall.provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(1).
Notification shall be submitted to the addresses given in Part VI1.1 of this permit.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if the
Director finds such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that failure
to do so could lead to the contamination of an underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the well
through a pipe that extends to the bottom of the well and is raised as the well is filled.
(E) In the case of gravel -packed wells in which the casing and screens have not been removed, the
casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout
injected through the perforations.
(F) In those•cases when, as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(1) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.1 of this permit.
Permit W10100125 UIC/5QM Page 5 of 5
ver. 03/2010

o�OF W A rFRQG State of North Carolina
Department of Environment and Natural Resources
r Division of Water Quality
Aquifer Protection Section
Regional Staff Report
10/27/2010
To: Aquifer Protection Section Central Office Application No.: W10100125
Attn: Michael Rogers Regional Login No.:
From: Jonathan Stepp
Choose an item. ARO
I. GENERAL SITE VISIT INFORMATION
1. Was a site visit conducted? ® Yes or ❑ No
a. Date of site visit: 10/27/2010
b. Site visit conducted by: Jonathan Stepp
c. Inspection report attached? ® Yes or ❑ No
d. Person contacted: A" Services, Inc. and their contact information: (828) 776 - 9221 ext.
e. Driving directions:
H. PROPOSED FACILITIES FOR NEW AND MODIFICATION APPLICATIONS
Facility Classification: (Please attach completed rating sheet to be attached to issued permit)
2. Are the new treatment facilities adequate for the type of waste and disposal system? ❑ Yes oi- ❑ No
if no, explain:
3. Are site conditions (soils, depth to water table, etc) consistent with the submitted reports'? ❑ Yes ❑ No ❑ N/A
If no, please explain:
4. Do the plans and site map represent the actual site (property lines, wells, etc.)? ❑ Yes ® No ❑ N/A
If no, please explain: site plan does not include utilities
5. Is the proposed residuals management plan adequate? ❑ Yes ❑ No ❑ N/A
If no; please explain:
6. Are the proposed application rates (e.g., hydraulic.nutrient) acceptable? ❑ Yes ❑ No ❑ N/A
If no, please explain:
7. Are there any setback conflicts for proposed treatment, storage and disposal sites? ❑ Yes or ❑ No
If yes; attach a ma.p showing conflict areas.
8. is the proposed or existing groundwater monitoring program adequate? ❑ Yes ❑ No ❑ N/A
If no, explain and recommend any changes to the groundwater monitoring program:
9. For residuals, will s asonal or other restrictions be required? ❑ Yes ❑ No ❑ N/A
If yes; attach list o sites with restrictions (Certification. B)
FORM: APSRSR 04-10 Pagel of 3

III. EXISTING FACILITIES FOR MODIFICATION AND RENEWAL APPLICATIONS
1.. Are there appropriately certified Operators in Charge (ORCs) for the facility? ❑ Yes ❑ No ❑ .N/A
ORC: Certificate 4: Backup ORC: Certificate 9:
2. Are the design, maintenance and operation of the treatment facilities adequate for the type of waste and disposal
system? ❑ Yes or ❑ No
;('na please s�lplain:
Are the site conditions (e.g., soils. topograpliy, depth to water table. etc) maintained appropriately and adequately
assimilating the waste'? ❑ Yes or ❑ No
If no, please explain:
4. Has the site changed in any way that may affect the permit (e.g., drainage added, new wells inside the compliance
boundary, new development, etc.)? ❑ Yes or ❑ No
If yes, please explain:
5. Is the residuals management plan adequate? ❑ Yes or ❑ No
If no, please explain:
6. Are the existing application rates (e.g., hydraulic, nutrient) still acceptable? ❑ Yes or ❑ No
If no, please explain: __
7. Is the existing grounckvaler monitoring; program adequate`? ❑ Yes ❑ No ❑ N/A.
lFrin_ ez,,l ,in and recommend an} changes to the groundwater monitoring program: _
8. Are there any setback conflicts for existing treatment, storage and disposal sites`? ❑ Yes or ❑ No
If ves, ,attach a map showing conflict areas.
9. Is the description ofthe facilities as written in the existing permit correct? ❑ Yes or ❑ No
If no, please explain:
10. Were. monitoring wells properly constructed and located? ❑ Yes ❑ No ❑ N/A
If no, please explain:
11. Are the monitoring well coordinates correct in BIMS? ❑ Yes ❑ No ❑ NIA
If no, please complete the following, (expand table if necessary):
►Monitoring Well
Latitude
Longitude
O / r/
12. Has a review of all self -monitoring data been conducted (e.g., NDMR, NDAR, GW)? ❑ Yes or ❑ No
Please summarize any findings resulting from this review:
13. Are there any permit changes needed in order to address ongoing BIMS violations`? ❑ Yes or ❑ No
'{,yes. please explain:
4. Chcck �iil t:li<it apt lv:
No Gon1phaiice Issues
❑Notice(,) of violation
❑ Current enforcement action(s) ❑ Currently under ,IOC
❑ Currently under SOC ❑ Currently under moratorium
Please explain and attach any documents that. may help clarify answer/comments (i.e., NOV, NOD, etc.)
15. Have all compliance dates/conditions in the existing permit been satisfied? ❑ Yes ❑ No ❑ N/A
If no, please explain:
16. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit`?
❑Yes ❑No❑N/A
If yes, please explain: _
FORM: APSRSR 04-10 Page 2 of 3

IV. REGIONAL OFFICE RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? ® Yes or ❑ No
If yes, please explain: Map does not include utilities that will be in close proximity to the proposed wells
2. List any items that you would like APS Central Office to obtain through an additional information request:
Item Reason
3. List specific permit conditions recommended to be removed from the permit when issued:
Condition
Reason
All wells shall be located a
minimum of 50 feet from
any septic system or repair
area.
The well field location could potentially to be closer than 50 feet from septic
system repair area.
4. List specific special conditions or compliance schedules recommended to be included in the permit when issued:
Condition Reason
5. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office
❑ Hold, pending review of draft permit by regional office
❑ Issue upon receipt of needed additional information
® Issue
❑ Deny (Please state reasons: )
6. Signature of report preparer:
Signature of APS regionalesi
Date: vl=' - V7-`1ti6 6
V. ADDITIONAL REGIONAL STAFF REVIEW ITEMS
The Operation permit for the septic system is attached.
FORM: APSRSR 04-10 Page 3 of 3

Case Number. WLS ` O�-Y05 BUNCOMBE COUNTY HEALTH CENTER PIN: Cj (rtz• (4 J 7 J
ENVIRONMENTAL HEALTH SERVICES (828-250-5016)
J n OPERATIONS PERMIT
Property Owner: Day 1 f.l l� e , r)I C I'.1 Property Location: Anlao % 1.h j r, Application Dale: J I I 1 O
Directions: Jul � 1►'�'f a rl t f - wyl-1 )t . %: . s�r� n Sln. n u n ('.%Jy on l d 6 cnd
Subdivision: — Q (�Q,—Phase/section: Lot# 2— 1 Installer:
�Vafcr S ioii ❑ Private Well ❑ Spring ❑ Shared Well OR6mmunity Min. Required Separation Distance Installed? ❑ Yes LYtKo
Conditions: 1) Pump septic tank every 3 to 5 years. 2) Divert all gutters and other surface water, away from septic system and repair areas. (3) No
cutting or filling over septic system and repair areas.
ZG'
IZepa�r /It
70 ,
5� 2
Not se '' S, •,
IU
901 9
90
CSweef� �.m )
Operations Permit For: ��B- New System ❑ Repair ❑ Revision Drawings, plans, conditions, etc. attached? ❑ Yes ❑ No
System Approved For: lil'House ❑ Mobile home (❑ single ❑ double) Bedrooms: r7 Basement: 17-1'es ❑ No Basement Plumbing: O.-Yes ❑ No
❑ Multiple Unit Dwelling: No. of Units Number of Bedrooms per unit _ ❑ Business No, Employees: No: Shifts:
Operation Description: Industrial Waste: Yes ❑ No U"'
Approved Installation Specifications: Pd ai 1)esigr}.Fiolv.'•4 600 LT k:� System C(ascifi adon: Type I_, 7I III_ , IV_, V— VI_
(GPD)
Priif}jiSus""7eni%Reyriii�Ii ❑ Yes 9impjieci dutidlt i=,.Pump Make: Model: Serial No.
Z4 a cries Length: ,31�6 it No. of Trenches �l _ Width: , � & " Spacing: It Depth: )_G in (lower sidewall) Stone Depth: n
b sfribiilioii ❑ Equal Gravity ❑ Pressure Manifold O'S'erial ❑ Dams/Step Downs NAM Septic: 750 Pump Tank:_�
(gallons) (gallons)
�rnbesErlioir ❑Prefabricated Panel Block ❑Conventional ❑ Large Diameter Pipe ❑Chamber Cl Expanded Polystyrene Aggregate ❑Other
C7nlP3'il.�:
Inspected by: (fi,tan Dale: -640—Issued To:
Dale 6
The system has been installed in accordance with state sewage rules. Approval does not guarantee the system will function satisfactory for any given time.
Operprmt.doc.rev 03/05/04

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NORTH CAROLINA
DEPARTIVIENT OF ENTVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 50M WELLS)
New Permit Application OR Renewal (check one)
DATE: Ofi► 20JD_
PERMIT NO. y (leave blank if NEW permit application)
A.
B.
C.
PROPERTY OWNERS)/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):
r TNEDNE L4e&& "12 Mite TE50(k
(1) Mailing Address:20D CQNTtAL _P4KY_ kk6r & 0
City: &lt4Det State: —4 Zip Code. ZZ County:
Home/Office Tele No.: a� oZ- �l Q(o-�n3/�/ Cell No.: Q/7- yy�j - /226
EMAIL Address: Cmk�KlQwIaf25n?�k.(OWl
(2) Physical Address of Site (if different than above): rj.a Wrm L�(Ll f / folt �-z) "C.��r
City: _ ��L State:. Zip Code: L� County: [. o un rd
Home/Office Tele,No.: Cell No.:
EMAIL Address:
'>IN 1 Q(02,K�n�(�2
AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a ietter 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:
STATUS OF APPLICANT
Private: x Federal:
State: ^ Municipal: _
GPU/UIC SQM Well Permit Application (Revised 712008)
Commercial:
Native American Lands:
R'1__ C L 1 VE_ D T E !;iDV1 l
lJ� � � ilk'(ON
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2010

E.
�"1 GIC�I 5
WELL DRILLER INFORMATION
Company Name: AWD Services, Inc.
Well Drilling Contractor's Name: Larry Wells
NC Contractor Certification No.: 2603
Contact Person: Larry Wells Email Address:[e-mail]
Address: PO Box 125
City: Leicester, NC Zip Code: 28748 County: Buncombe
Office Tele No.: 828-683-9223 Cell No.: 828-215-9334
HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Compan
Contact
Andress: \A : A �=3 ,
City: Zip Code: 2 7 in County: �3-1— L ORA (o
Office Tele No.: ?-M 4.2-1 -` "7- Cell No.: 9; t -7 7 V -1jZ21
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
SA l�Kya_
. Cow
G. WELL CONSTRUCTION DATA (Skin to Section H if this is a Permit RENEWAL) Art,
L`
(1) Proposed date to be constructed: when permitted Number of borings: P �D G r b
Approximate depth of each boring (feet): �(D I
(2) Chemical additives to be used in closed -loop system (only those chemicals indicated have been approved):
R-22 propylene glycol ethanol other (other additives will
need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc): P
(4) Welt casing. is the weii(s) cased? (check either (a.) YES or (b.) NO below)
(a) YES if yes, then provide casing information such as type (steel, PVC, plastic, etc.), diameter,
depth, and extent of casing appearing above ground:
(b) NO
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite X Other (specify)
(b) Grout depth of tubing (reference to land surface): from. to et)
If well has casing, indicate grout depth: from to (feet) _ % " p
H. INJECTION -RELATED EQUIPMENT t/-+),f�,a C
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior_
J
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplemental
information. !F
GPUIMC 5QM Well Permit Application (Revised 7/2008) page 2 i

Buncombe County Tax Lookup - Property Card
Page 1 of 1
A property with WORK IN PROGRESS is currently being reviewed by the Buncombe County tax
department. This review could include a tranfer of ownership, a split parcel, a combined parcel,
and acreage adjustment, etc.. For these properties, you will see the values which were last
approved before the review began. Be aware that these values could change once the review is
complete. If a parcel is new, you will have access to limited property data until the review is
complete and values have been approved.
w_a s COUNTY OF BUNCOMBE; NORTH CAROLINA
r s,
t
Web Property Record Card
9624-85-0762-00000
• N
Date Printed: Io/8/2olo
This parcel is currently being reviewed. Values may change.
Owner Information
DAVID L RESNICK
CATHERINE MICLEMA
goo CENTRAL PARK W APT
8B
NEW YORK NY 10024
52 WOOD LILY TRL
Taxing Districts
Buncombe County
SKYLAND FIRE
Parcel Information Total Property Value:
2,172,900
1s:
Active
cunt:
8226773
1 Date:
12/28/2007
1 Book/Page:
4505 / 1019
Book/Page:
olio / 0122
it Reference:
WARRANTY OR SPL/PARC
ition:
52 WOOD LILY TRL
s:
RESIDENTIAL VAC/LOTS
,hborhood:
WALNUT COVE
THE CLIFFS AT WALNUT COVE PH
3ivision:
7
Lot:
21
Ownership History
Transfer
Price
Legal
Deed
Qualified
Vacant
When
Account
Seller
Names
Date
Reference
Book/Page
Sold
THE CLIFFS
12/28/07
$2,325,000
ARRANTY
O S LARC
4505 / 1019
Yes
Yes
8193810
NUT
ATWALCOVE
L
Assessment History
Year
Account
Acres
Land
Bldgs
Other
Impr
Assessed
Dese
Exemptions
Deferred
Taxable
2010
8226773
1.95
2,172,9000
0
2,172,900
0
0
2,172,900
2009
8226773
1.95
2,172,9000
0
2,172,900
0
0
2,172,900
2008
8226773
1.95
2,172,900
O
0
2,172,900
O
O
2,172,900
ILand Data
Total Acres: 1.95
Acres
Land Value: Other Value: o
2,172,900 Improvements -
ption
Segment#
I Units:::]
Descri
1ji.95
Acres
ILOT
Total Building Value: o
http://www.buncoinbetax.org/PropertyCard.aspx 10/8/2010

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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 1000 feet of the
geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
J. POTABLE WATER WELL(S)
Are there any potable water well(s) on the subject property or adjacent properties? YES X NO
if Yes, than indicate location on attached map(s).
K 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 of Property Owner/Applicant
1)01\0 U, 1�_'esvltcK
Print Type Full Name
Signature of Property Owner/Applicant
Cmi,ertvte (A, 1evrlel✓
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
[TIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
r C'Ell, � 1 '
9010
GPUIUIC 5QM Well Pemrit Application (Revised 7/2008) Page 3

MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
October 21, 2010
David Resnick
Catherine Klema
300 Central Park West Apt 8B
New York, NY 10024
Subject: Acknowledgement of Application No. WI0100125
52 Wood Lily Trail
Injection Mixed Fluid GSHP Well System (5QM)
Buncombe
Dear Catherine & David:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on October 8, 2010. This application package has been assigned the number listed above and will be reviewed by
Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 - 90 days after receipt of a complete
application.
If you.have any questions, please contact Michael Rogers at 919-715-6166, or via e-mail at [e-mail]. If the
reviewer is unavailable, you may leave a message, and they will respond promptly.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
for Debra J. Watts
Supervisor
cc: Asheville Regional Office, Aquifer Protection Section
AWD Services, Inc (Larry Wells) PO Box 125, Leicester, NC 28748
Stickels Service Co., Inc. (Brad Stickels) 32 Pine Hill Road, Fairview, NC 28730
Permit Application File WI0100125
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 27 28 Capital Boulevard. Raleigh, North Carolina 27604
Phone: [phone] FAX 1: 919-715-0588: FAX 2: 919-715-60481 Customer Service:1-877-623-6748
Internet: www.nmatergualitv.orq
An Equal Opportunity \ Affirmative Action employer
NorthCarolina
Natures

Rogers, Michael
From: Rogers, Michael
Sent: Thursday, October 21; 2010 3:55 PM
To: 'larry wells'
Subject: Resnick and Kelma W 10100125
Larry -
We have received, the application and site maps for the above project. However, please clarify the grout depth on the
application. It says 20 to 25 feet of grout.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality- Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://portal ncdenr orq/web/wq/aps/qwpro/permit-applications
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties