WI0100165_Regional Office Physical File Scan Up To 9/22/2022

4 U ECTO—V
E Central Files: APS_ SWP_
08/05/11
Permit Number W10100165 0 9 26 11 Permit Tracking Slip
Program Category A-8h viljC Regional Office Status Project Type
Ground Water y y pp�y�+yp/�p� Active New Project
Permit Type w Version Permit Classification
Injection Water Only GSHP Well System (5QW) 1.00 Individual
Primary Reviewer Permit Contact Affiliation
michael.rogers Jeff Moore
Coastal SW Rule PO Box 71
Hot Springs NC 28743
Permitted Flow
Facillty
Facility Name Major/Minor Region
John & Niki Posten SFR Minor Asheville—!
Location Address County
48 Spy Pointe Ln Buncombe
Fletcher NC 28732 Facility Contact Affiliation
Owner
Owner Name Owner Type
Individual
John P Posten Owner Affiliation
John P. Posten
2000 Old Eastwood Bvid
Asheville NC 28803
Dates/Events
- Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
08/05/11 07/25/11 08/05/11 08/05/11
Recaulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin

I
Aim
HCDEHK
North Carolina Department of Environment and Natura
Division of Water Quality
Beverly Eaves Perdue
Governor
John. P. Posten
Niki T. Posten
2000 Old Eastwood Blvd Unit C-305
Asheville, NC 28803
Coleen H. Sullins
Director
8/5/201,1
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100165
48 Spy Pointe Lane, Fletcher, NC 28732
Dear Mr. & Mrs. Posten:
Resources
Dee Freeman
Secretary
On 7/25/2011, 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 Micliael.RoUers((—v.ncdenr.eov if you have any questions.
UJA '&kc V
fa• Debra Watts
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. W10100165
Buncombe County Health Dept.
Clearwater Well Drilling
Bullman Heating L Air
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 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.ncwatemualitv.ora
An equal Opportunity \ Aiormanve Action Employer
One
North Carolina
Nazl 4

I
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 50W 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: , 20 %� �l..?� © 1 00 tt..VS
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 L----C--Ontinue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well iri ectin 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 b a business or government agency, state name of
entity and a representative w/authority for signature): t� �U
t'-)tt�c
(1) Mailing Address: 2t�o cV b L-b if-.n Tzc)a (—>\ii c i-- oo tY 3eab --
City: 62�10)) L :g7 State: (il Zip Code: -Zs;z, 7, Z) —3 County:&,Jrl hA'R.
Home/Office Tele No.: 82 s ZS Cell No
Email AddresWebsite:
(2) Physical'Address of Well Site (if different than above): q s t-yi � ) o
State Zip Code: County: � O ti?C-oau.g
City: i'
Home/Office Tele No.: 9 2 1 "yam 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: RECEIVED / DENR / DWO
golfer Protenilon Section
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) ,��[ 2011 Page 1

C.
E.
WELL DRILLER INFO ��'TIO—�N�t --
Company Name:
Well Driller Contractor's Name:�n!
NC Contractor Certification No.:
Contact Person: EMAIL Address: C W#
Address: II
�fT'�-12�irrYN� p J r
City: Zip Code: ��� County: !l r�i`-�r'L�,�
Office Tele No.: O X —1����� �� Cell No.: 6f2k
BEAT PUMP CO RAC OR INFORMATION (if different than driller)
Company Name:
Contact Person h / U M � � EMAIL Address:
Address: /V �f' 1 ,
City: PJ�'% ✓)C, Zip Coder County:
Office Tele No.: g�!—(PS l � p4�Ce11 No.:
STATUS OF APPLICANT
Private: Federal: Commercial: _
State: Municipal: Native American Lands:
F. INJECTION PROCED (b ieflyf„Jdescribe how the injection well(s)will a used)
T
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: % �N7u(mber of borings:
a -
Approximate depth of each boring (feet): �//`�J
(2) Type of tubing to be used (copper, PVC, etc): J 0/` '� _3C�
(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
1 d' 11 d/ i in )•
(4) Grout Info (materta surroun tng we casing an or p p g
(a) Grout type: Neat Cement Bentonite t/ Other (specify)
(b) Grout placement: Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from to (feet)
If well has casing, indicate grout depth: from to (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 2

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.
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 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 thpaRproved specifications and conditions of the Permit."
ature of Property Owner/Applicant
-�O 0-,� I? pc,57-C �,,!
Pridrt r Type. FuI1A%Iame and title
Sign4tiure of Property Owner/Applicant
r-
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 RECEIVED / DENR / DWQ
1636 Mail Service Center Aquifer Protection Section
Raleigh, NC 27699-1636 JUL 25 2011
Telephone [phone]
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 3

ep1t
RECEWED 1 DENP,1 DING
Aquifer Proff:r6tion Section
JUL 25 2011