WI0100168_Regional Office Physical File Scan Up To 9/22/2022

Permit (dumber WI0100168
R LS C FF � iV E 0 Central Files: APS_ SWP_
08/25/11
A; i(, 10 ?Fi it Plermit Tracking Slip
Program Category
P.
�1,.�acvillo F' ooiond Office
Status
ctive
Project Type
Ground Water
New Project
I)tl;P'Yiii. n
Permit Type
` ° " " `a
Version
Permit Classification
Injection Water Only GSHP
Well System (5QW)
1.00
Individual
Primary Reviewer
Permit Contact Affiliation
michael.rogers
Bryant Smith
Driller Well
Coastal SW Rule
PO Box 204
East Flat Rock
NC 28726
Permitted Flow
Facilih,
Facility Name Major/Minor Region
Michael Goebel SFR Minor Asheville
Location Address
42 Cedar Hill Dr
Asheville NC 28803
Owner
County
Buncombe
Facility Contact Affiliation
Owner Name
Owner Type
Individual
Michael Goebel
owner Affiliation
Michael Goebel
Owner
42 Cedar Hill Dr
Asheville NC 28803
Dates/Events
Scheduled
Orig Issue App Received Draft initiated Issuance
Public Notice issue Effective Expiration
08/25/11 08/15/11
08/25/11 08/25/11
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin

NCDENR
Borth Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
08/25/2011
Michael Goebel
Martha Goebel
42 Cedar Hill Dr.
Asheville, NC 28803
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0100168
42 Cedar Hill Dr.
Asheville, NC 28803
Dear Mr. Goebel:
Dee Freeman
Secretary
On 08/15/2011, 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:
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 Michael.RogersQncderingacot��
have any questions.
cely,or Deb a atts
Supervisor
cc: ,Asheville -Regional Office = APS;
1 APS Central Files - Permit No. WI0100168
Buncombe County Health Dept.
Bryant Smith (Green River Well & Pump, P.O. Box 204, E. Flat Rock, NC 28726)
Kevin G. Guice (General Heating & A/C Inc., P.O. Box 843, Hendersonville, NC 28793)
Butch Heatherly (Heatherly Construction Inc., P.O. Box 323, Etowah, NC 28729)
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: 919-715-6048 \ Customer Service: 1-877-623-6748 1�T®11+al C�3c�
Internet; wwmr.ncwateraualitv.ora A
Ar. Equai Opportunity \ Affirmative Acorn Employer
�R

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTMCA77ON OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .A200
CLOSED -LOOP WATER -ONLY GEOTBERMAL INJECTION WELLS
These wells cinmlate'potable water only as part of a geothermal beating and cooling system.
Thew wells are'�permitied .by.nLW' and do not =quire an.fim ividuai permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Print or Type Wormation and Mail to the Address an rive Last Page,
DATE: . 20 PERMIT NO. (to be fulled in by DWty
A. S ATUS OF WELL OWNER (choose one)
Non-Governtneat Itdiyidual.Residence X, Susiness/Organi�ation
Govc=cnt: State Municipal County Federal
R WELL OWNER —For iardividual residences, list each owner on property deed. For, all others, state name of
=tity And name of person delegated authority to sign an behalf of the business or ageac j�:
P r ,2� C_C�r,,w rvt i .rc�c rA
Mailing Address. 0. 13 oY_ Z
City: -}�,A jr. Staff: Nc zip Code: Z '1 Cmu1ty: i;••_nA_ rS6 ✓+
Day Tele No.: (v 1 Zz 1 Cell No �Zi?i Zu 3 119 b
EMAIL Address: 14eta+�-_W 6 C, o� �iG l ,e� Fax No • S� ZGr (o''t 1 3 L 1, S�
C. LOCATION OF WELL SITE — Whers the injection wells are physically, located:
0)• Parcel Identi6eation Number (PIN) of well site: t;ll nty. �J
(2).-. Physical Address (if di#ferem titan mai ' addr+ess): ,� OAT't�l` _Dc
City: A / cy_1L� State: NC Zip Code:
D. WELL DRILLER INFORMATION _
Well Drilling Contiadoes Name: _ Aaihon ����, 't �tu r T (-
NC Weli Drilling Contractor Certification No.: iV C_ VLi C_
Compacy
Contact P
Address:
City: L_
Office Tole MAX-('ne) 1 7Q fi Cell No.: Fax No-:
GPU/WC 5Qw NoMgali® (Revind Y1912011) Page i
RECEIVED I DENR f DWQ
.AQUIFFR'PRnTFC;TI(1f\12ECTION
AIIG 15 2011

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
n i-
F.
Company Name: v n i
Contact Person: EMAIL Address: We-H,-.P,�-� gee
Address: PC.R&wc Slf3 .,vaT
City: h o sax/ 1b Zip Code: '8r93 State:. County: !% C
Office Tele No.: WC, 92Cell No.: Fax No.:1P,ZrG92222
WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: (P Depth of each boring (feet): 300
* If existing water supply wells will be used then provide the information in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc): ?1yG
(3) Well casing. If the well(s) will use casing then provide the tyke (steel, PVC, etc.), diameterdepth,
and extent of casing appearing above ground:
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement I Bentonite** Other (specify)
** By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(1)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from to (feet)
If well has casing, indicate grout depth: from to (feet)
G. WELL LOCATIONS — Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label,all features clearly and include a north arrow.
(1)
(2)
Attach a site -specific map showing the locations of the following:
* Proposed injection wells
* Surface water bodies
* Buildings * Property boundaries
* Water supply wells
* Septic.tanks(and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the.
facility's location and the map name.
NOTE: Inmost cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a `layer' can be selected showing topographic contours or
elevation data.
GPU/UIC 5QW Notification (Revised 3/18/2011) Page 2

JL CERTMCATION (to be sighed as required below or by that person's authorized agent)
1SA NCAC 02C .0211(b) requires tlhatall permit applications shall,be signed as follows:
1. for a corporation: by a responsible corporate. officer;
2., for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency. by either- a principal executive
. officer or -ranking publicly elected official;,
4. for all ntbers: by the well owner (which means all persons listed on the prooM deed).
If an authorized agent is signing on behalf of the applicant, then sapply a tatter signed by the
applicant that names and authorizes their ageatto sign this appUcation on their behalf.
"I hereby certify, under penalty of law, that I have personally exarnined.and am familiar with the information
submitted in this documeat and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, l believe that the info- nmation is tme, accurate and
complete; 1 am aware that there arc sigrOcarrt penalties, including the,*passibility of fines and'imprisonrnent,
for submitting false information. l agree to.consti=4 operate,, maintain, "repair, andO applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit"_
Signature of Property OwnerJAppliclipt
14- 4A4
Print or Type Full Name
Signature of Property Owner/Applicant.
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type FuL Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636.Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUMIC SQW Noti&Ktioo ([devised 3/ IMI t)
RECEIVED 1 DENR f DWQ
AQUIFPP'PROTFf;Tlm( SECTION!
AUG 15 2011
Page 3

Rug 10 2011 11:288M General Heating L R-C, In
PIr�F*6­-
8286922227 p.2
NUM-11C:AICULII4AJ)tfVAK1td1zN-1 VY k3MViVUNV1CNTANI)-NA"i•UKAL RIrSQUKUES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordince With the Provisions of 15A NCAC• 02C. .0200
CLOSED -LOOP M ATER-ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as pait'bf a gaod=mal heating dad cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction,
Prb a or Type Warmadon and Mail to the Address on the Lau Page.
DATE:' . 20PERMIT NO. (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non-Govermnertt: Individual Residence V BusineWOrgani ation
Government: State Municipal _ County Federal
B. WELL dWNER -- For individual residences, list cash own+ar on property deed. For all others, state name of
entity and name of person delegated authority to,sign on behalf of the business or agency:
1 . -t( _i. 0,.n<'a.t.— 1%,1n 1ti.i (n,rr: i 11�in� 2w• d1r`
Marking Address: f'%_0 15,ri',4 `-i r` 'S
C'1ty: -Lu, ,^ . i^ Sir.. (yc- zip cc e: county:,
Day Tele Kn.: �, ' , ���i 1 j CCU No.: ' = , i Z L4 1 f t 2 6
EMA IL Address t-� F,ri -� % s,✓ a� (t � �J i (.r Fax NO : yd Z.F
C. LOCATION OF WELL SITE - Where the injecfiou wells ate physically located:
(1) ParcalIdentficadonN=ber(P"CifwelisiW'- 9LYLyq-7617.102600 tmmty BrjAjcr•,n,na
(2) Physical Address (if different than address):. Ll 2 - i � a � ? ��� � �
City: Q-s pteVl t-. F e State: NC Zip Code:
lT. WELL DRILLER INFORMATION
Well DrMing Contractor's Name;
NC Well Drilling/�Contractor Certification No.: C- W C
CompanyName<s rem , titiJ, i t lU.v
Contact Person -Sr VA i ` -1, EMAIL Addrew:Q(�QeRit dp.Cwe-LI Q
address:—'ebk— ao l zk? C M5-F n>�T-
Ckty: �[ -P state:Caurny: �i�b�/1
Office Tole. No.0 _ � f �1� (� CalNo.. Pax No.:�i �'�`I P- j
GPU/UIC:5Qw Nodflcaticm (Revised 311V2011) Page 1

Aug 10 2011 11:28RM General Heating Q R-C, In 8286822227 p.4
IL CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .021 l(b) requires drat all permit applications shall be.signed as foliows:
1. for a corporation: by a responsible corporate. officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively,
3. for 8 municipality or a state, federal, or other public .agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the umeerry deed).
If an authorized agent is signing en behalf of the applicant, then supply a letter signed by the
applicant that games and authorizes their agent to sign this appheation on their behalf.
"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 Byer+ and that, based on lay inquiry of those individuals
immediately responsible for obtaining said infbrtnatioii, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possr'b3ity of fates and imprisonment,
for submitting false information. I Wee to construct, operate, tniaintain, repair, and if applicable, abandon1he
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Signat�u tee of Property O/vnerlApj i0gt
Pnni or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
PWQ - Aquifer- Protection Section
1636 Mail Service Center
Raleigh, NC 2769.9-1636
Telephone [phone]
GPU/[aC 5QW Notificatiao (Revised YlV201 t) Page 3

:vug Zo -11 ub:-Zya iworosott
828-697-3665 p.1
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Smith, Eric
From: Butch Heatherly [[e-mail]]
Sent: Wednesday, August 24, 2011 6:39 AM
To: Smith, Eric
Subject: Goebel signature page
Eric
I wrote on the site plan I sent you the grout being used is binanite 6 wells 300 ft deep ea.
I will foward the signature from Goebel.
Thanks Butch Heatherly

Smith, Eric
From: Butch Heatherly [[e-mail]]
Sent: Wednesday, August 24, 2011 6:40 AM
To: Smith, Eric
Subject: Fw: Geothermal notification
Attachments: Geothermal notification-Goebel.pdf
--- On Tue, 8/23/11, Michael Goebel, MD <MGoebel(&brbl.com> wrote:
From: Michael Goebel, MD <MGoebel cr brbj.com>
Subject: Geothermal notification
To: 'Butch Heatherly" <heatherlvconst(cr),vahoo.com>
Date: Tuesday, August 23, 2011, 11:08 AM
Attached is the completed document.

Godwin, Tonya
Full Name:
Mike and Martha Goebel
Last Name:
Goebel
First Name:
Mike and Martha
Company:
Biltmore Forest client
Home Address:
42 cedar Hill Drive
Biltmore forest 28803
Business: 8282362636
Mobile: [phone]
E-mail: [e-mail]
E-mail Display As: Mike and Martha Goebel ([e-mail])
E-mail 2: [e-mail]
E-mai12 Display As: Mike and Martha Goebel ([e-mail])
1'