WI0100225_Regional Office Physical File Scan Up To 9/23/2022

State of -North Carolina
Department of Environment and Natural Resources - JAN - 8 2013.
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM R E C E V E D
Permit Number: (il/
Permittee Name: d&tn6 eA1u 1-6o DES .
Address: IPO� . Lre3� Jl!'C . 2g't6q
Please check the selection,which most closely, describes the current status of your injection well system:
1) ❑.-Well(s) still used for injection activities, or may be in the future. C �"
2) ❑ Well(s) not used for.injection.but is/are used for water supply or other purposes.: Ox.
:3) ❑ Injection discontinued and: a).0-Well(s) temporarily abandoned G
b) El Well(s) permanently abandoned
.
c)-❑ Wells) not abandoned
4) >(Injection we11(s) never constructed
Current Use of Well .. .
If you checked (2), describe the well use (potable water supply, irrigation, -monitoring, etc), including pumping rate and other
relevant information.
4464=:
Well Abandonment
If you checked '(3)(a) or (3)(b), describe the method used to abandon the injection well. (Include a description of how the well -
was sealed and the e o ,material: used Co all the well i ermanentl abandoned
h'P f fi .fp Y )
Permit Rescission:
If you checked (2), (3), or (4) and will not use a well for injection on this site in the future; you should request rescission of the
permit: Do you wish to rescind the permit?
Yes ❑ .No
Certification:
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the:inforrnation submitted
in this document;. and that to the best of my knowledge the information is true, accurate, and complete." . .
Signature -. Date
Revised .5/05 GW/UIC-68 .
;,11 .0 d 2013
Asheville Regional Office.
Aguifer.PPalec`cigh

Apia
NCDENR
North Carolina -Department of Environment and Natural Resources
v [ Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor I D F C 03 27cz l/ I Director
Nov6mber 20, 2012
Adam & Erica Hodges — -
C/o Skip Brewer,
Post Office Box 638
Arden, NC 28704
Re: Issuance of Injection Well Permit
Permit No. W10100225
Issued to Adam & Erica Hodges
Buncombe County
Dear Mr. and Mrs. Hodges:
Dee Freeman
Secretary
In accordance with your application received September 20, 2012, lam forwarding Permit No. W10100225 for the construction
and operation of geothermal heating/cooling water return well located at 359 Walnut Valley Parkway in Arden, NC. This
permit shall be effective from the date of issuance until October 31, 2017, and shall be subject to the conditions and limitations
stated therein.
Please Note the Following:
• Per Permit Condition Part I.9, a copy of the Well Construction Forms (GW-1), which is completed and signed
by the well contractor, must be submitted to this office and the Asheville Regional Office within 30 days of
completion of the injection well. Copies of the GW-1 shall be retained on -site and available for inspection.
• Per Permit Condition Part 11.3, within 30 days of injection well completion, Permittee must provide an `as -built'
diagram of the injection system to the Asheville Regional Office APS Staff, and to have influent and effluent
samples collected.
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].
Best Regards,
Eric G. Smith, P.G.
Hydrogeologist
cc: : Landon Da�ii'd on *Washin o� nRegional ©ffice
Central Office File, WI0100225
Buncombe County Environmental Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St, Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone]
Internet www.ncwaterguality.org
An Equal Opportunity 1 Affirmative Action Employer
Nne
orthCarohna
Nahmally

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
Adam and. Erica Hodges
FOR THE CONSTRUCTION AND OPERATION OF A GEOTHERMAL HEATING/COOLING WATER
RETURN WELL, defined in Title 15A North Carolina Administrative Code 2C .0224, which will be used for
the injection of heat pump effluent. This injection well is located at 359 Walnut Valley Parkway, Arden,
Buncombe County, North Carolina 28704, and will be constructed and operated in accordance with the
application received September 20, 2012, and conformity with the specifications, 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 shall be in compliance with Title 15A North
Carolina Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to
well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until October 31, 2017, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the day of/UihPvtq be,-- , 2012
r ;-
�`�� Charles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #WI0100225 UIC/Return Well.- New Construction Page I of 5
ver. 07/2012

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
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 be constructed in such a manner that water from land surface cannot migrate into
the gravel pack or well screen.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well
must be sealed with a watertight cap or well seal, as defined in G.S. 87-85(16).
6. Each injection well shall be afforded reasonable protection against damage during construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.01070).
8. The Permittee shall record the number and location of the well(s) with the register of deeds in the county
in which the facility is located.
9. A copy of the completed Well Construction Record (Form GW-1) must be submitted for each injection
well to:
Aquifer Protection Section — UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section — Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 27778
828-296-4500
Copies of the GW-1 form(s) shall be retained on -site and available for inspection.
PART II — WELL CONSTRUCTION SPECIAL CONDITIONS
1. Each injection well shall be grouted from land surface to bottom of casing to reduce risk of commingling
of separate aquifers, and effluent being injected up the annulus of the well (`daylighting').
Permit #WI0100225 UIC/Return Well - New Construction Page 2 of 5
ver. 07/2012

2. At least forty-eight (48) hours prior to constructing each injection well, the Permittee shall notify the
Aquifer Protection Section -Underground Injection Control (UIC), Central Office staff, telephone number
[phone] and the Asheville Regional Office Aquifer Protection Section (APS) Staff, telephone
number 828-296-4500.'
3. Within 30 days of injection well completion, Permittee must provide an `as -built' diagram of the injection
system to the Asheville Regional Office APS Staff, and to have influent and effluent samples collected.
4. Continued operation of the injection system will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
5. The injection well system must be constructed with sampling ports so that system influent and effluent
may be sampled.
6. Each injection well must be constructed to a depth such that it is injecting water into the same aquifer that
a source well, if present, is drawing from.
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 maybe 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.
4. Continued operation of the injection system, will be contingent upon the effluent not impacting
groundwater quality. The water quality of the effluent cannot be that of a lower quality than the influent,
which results in a degrading of water quality of the aquifer.
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 which 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.
Permit #W10100225 UIC/Return Well -New Construction Page 3 of 5
ver. 07/2012

3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater 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.
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. Department 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.
PART VII — MONITORING AND REPORTING REQUIREMENTS
1. 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.
2. 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 828-296-4500, 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;
3.. 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.
4. 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.
Permit #W.I0100225 UIC/Return Well - New Construction Page 4 of 5
ver. 07/2012

PART VIH — PERMIT RENEWAL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
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 that well must be permanently abandoned according to 15A NCAC 2C .0240,
Abandonment and Change -of -Status of Wells.
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
.0240, 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 which 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 Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0224(f)(4) within 30 days of completion of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Permit #WIO 100225 UIC/Return Well - New Construction Page 5 of 5
ver. 07/2012

To: Aquifer Protection Section Central Office
Attn: Eric Smith/ Michael Rogers
From: Jonathan Stepp
Choose an item. Regional Office
I. GENERAL SITE VISIT INFORMATION
1. Was a site visit conducted? ® Yes or ❑ No
a. Date of site visit: 11/15/2012
b. Site visit conducted by: Jonathan Stepp
c. Inspection report attached? ® Yes or ❑ No
State of North'Carolina
Department of Environment and Natural Resources
Division of Water Quality
Aquifer Protection Section
Regional Staff Report
Application No.: W10100225
Regional Login No.: ARO
d. Person contacted: Skip Brewer and their contact information: [phone] ext.
e. Driving directions: Hwy 191 to Rt into The Cliffs At Walnut Cove to Rt on Walnut Valley Parkway
H. PROPOSED FACILITIES FOR NEW AND MODIFICATION APPLICATIONS
i I1le lse <at't.lc:h cornj M )lered rating, sheen. ssue4
be attached to id errrlit)
a rSt"i t11 rIL-Av t,'' l'ttll Ilt xl%tl1ii6 5 211ei1ils.Yt:' €3t` t.11 t�'plc €) bL'2% t ltl€1 ill F}(' i$1 ggyti rr1? i 7 or jr
Aro site: conditiolls i,st i1A ; depth to W lter table, etc! ConsistLnt With the Slll}rrlitted rc pollss4� Yes [_ _ No N/A
It Ili?. pleask° C'%,Plairl:
.............................
4. Do the plans and site map represent the actual site (property lines, wells, etc.)? ® Yes ❑ No ❑ N/A
If no, please explain: However, the proposed septic system on an adjacent lot is closer than 50 feet from the
proposed location the open -loop geothermal injection well.
1: Ilie 17r€. [.i€7ye.i +"E'.gi lt1:31*s t12<2.11<?,y� iY: itl}I�Iii
r� i
1'r llo. C? {'tl5e g' yTfaltll:
t. ire :'Ile I'?t'E}lt.:t t €; FIj:3()ll <I't:l€?l"l l':ltt (t .£ ., I'i3 €Sri:i€llli , €"'sll'.l'letll.t itCi 4 a fl:)le? �.__' " e'. ..11 €; }..�. K
Ii" lla;. jklb:ze e_ tt l<llr1: i
Arc Jic..-,V ,,;inv . etilack— C;ontlictc 'Is}r t:ri:i(If,'ht'.il t.iealtlient., `ts)t"cl.ge-,-l.l.l i dkil(.=: iil sil`.;:s I `Y cs or. No
lf.vcs, iltt<lch :a Intl j 1l{ S 'J'1i£ `i)ill:li.i is gal° a.< .
?t. k dic (`}I"i;p osc d or exi stilm +arotil1€;11 'e°t-b r monitoring pro -rare ft.Cli quat,:? N1' c s .1.
N "o µ_ i N`v'r�
11 no. €',wlaln and reponitl'€eMl'`1"IL' 1halwes t€7 th 'i�-,ro:ngrru
9. f.,or rosiili ah.,. i4't.11 ;yoass£?lli,d. or € ltier restl'.teL'it: w be rc-gL)irc ? N: 1j d%:'A
ff-v:4, al.r.adl list. o, i es rostl i'ctions K.ell..111"'ation B)
FORM: APSRSR 04-10 Page 1 of 4

III. EXISTING FACILITIES FOR MODIFICATION AND RENEWAL APPLICATIONS
)`Cs E No N"'
'A
............... .................. . ... . .....
Are t[ie &,,siwi. alaimciiai)cQ, �iiid operiilori zad"'�'qijau" 1,011he * y 11c, M"'a"asre tat disposal
t.-
" s,
� I.Aern?
jfsloplh"lse expl"-lill'
sirylil'stilla fli, Yt�,s or No ..... ........
I'no. pjcahe cxplain: ............................
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 Z No
If yes, please explain:
the F 1 11 111 fale , " ' �r o
e�.- )N qtllte;
L-
Ilicasee"qp1aill: ..
Are d)e exisfln�, � al-.)plicatiori rate-, -g- l.iydratific, still accejytable'� r F] �, F Yos or`
if' llo. please cxqlairs:............................
I th vn, 0 s 'e oxi�(Dlggprotltldwa t r 1y) oili L().ri ill- ro"T, i(JCqun El Yes, No N"'A
U'llo, explailland rect-')MIlle)d ally cl-lamw's 1") 1110 oroiin(]N1-ater inonitoririo prograrli:
storaiyo 1_j "!;'�,s or No
1 f'yes. atlf,,.-tch to Ti)argrata vi l-),4 coi i J] i Ut ,.i re,,ls,
9. Is the description of the facilities as written in the existing permit correct? 0 Yes orE] No
If no, please explain:
LeI N
i J i
-1 y � LJ
ft) please 1) n: .......... ...............
c'orrect M 811\18? Vo _]NNo N11"A
11, ni). oleaso f,-ovapicto the followine (oIx.vand lflleccs:;ar'0:
Monitorbig
Ik."**)9 Y— r L No
of'��"11 "ejI� 111ollito-rina C1,11a beer) Comlticte,,:l (e.g- Ni::NDAR- (.1 CS o
Ple'as-�� sill I llllarize �'-Hvv fiwfill�rs ri'stlltillg 1rorll thl'k; reviev:
......... . .................
1, Are tl)erearry pei-irtitcliailges rleeded 4) DYe-sorLjNo
It' yes, 1.flea,,e e.\p1allE
14, Ceck all
CL; ri-ent cr !'On.crnent ac i iolij �o 0.mrcw1,,r imdcr
L Moucei's) k.')f vlu'i8tioll
""Ild a:teicll ,ioy- 6ociiiiieois [hif.1't rnay liell) fi.e- NOV,
-ncc d" onJi0oll-, il.]. 1fic Q�"d"ting, Permit bee -mtisfied" F7 P! Ites Lrm�c all co!r ni 'I
tio . leaset"""."Plo ... . .......
16. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit?
[:] Yes 0 No ® N/A
If yes, please explain:
FORM: APSRSR 04-10 Page 2 of 4

IV. REGIONAL OFFICE RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes or ® No
If yes, please explain: The location of the proposed septic system on the adjacent lot is closer than 50 feet from
the proposed location of the geothermal water return well.
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
The property line on the
south-east side of the lot
should be identified by a
surveyor.
The open -loop geothermal injection well system should be a minimum of 40 feet
from the south-east property line so that the proposed septic system on the
adjacent lot will not be any closer than 50 feet from proposed injection well
system.
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 prepare
Signature of APS regional
Date: / gzz
FORM: APSRSR 04-10 Page 3 of 4

V. ADDITIONAL REGIONAL STAFF REVIEW ITEMS
Not To Scale
FORM: APSRSR 04-10 Page 4 of 4

Not To Scale

Not To Scale

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: October 1-, 2012
To: ® Landon Davidson, ARO-APS
❑ Art Barnhardt, FRO-APS
❑ Andrew Pitner, MRO=APS
❑ Jay Zimmerman, RRO-APS
From: Michael Rogers Groundwater Protection Unit
Telephone: [phone]
E Mail: [e-mail]
A. Permit Number: WI 0100225
B. Owner: Hodges
C` =FacilityXOperation''
® Proposed ❑ Existing
❑ David May, WaRO-APS
❑ Morelia Sanchez King, WiRO-APS
❑ Sherri Knight, W-SRO-APS
Fax: [phone]
❑ Facility ' ❑ Operation
D. Application:
I. Perrit;T,ype: ❑ Animal ❑ SFR Surface Irri ation Reuse
..... ..... g ❑ ❑ H-R Infiltration
❑ Recycle ❑ I/E Lagoon ❑ GW Remediation (ND)
® UIC—Geothermal:Heating%Goblin 'Water=Return A
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2. 7'rQjeetType: ® New ❑ Major Mod. ❑ Minor.Mod. ❑ Renewal ❑ Renewal w/ Mod.
E. Comments/Other Information:
NOTE: Please return a completed APSARR after completing the site inspection, and collecting water samples if
system operational. At a later date, after the laboratory results are received by your office, send us a copy of the
cover letter & laboratory analytical results, which you send to the Permittee. ALSO, please record all information on
the well tag, if present, and put on staff report. Thanks.
® Return a completed APSARR after the site inspection. At a later date, after sampling & the lab
results are received, please send u' a copy of the letter you send to the Permittee containing
laboratory analytical results.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer:
Date:
FORM: APSARR 07106 Page 1 of l

. .4
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR A PERMIT TO CONSTRUCT OR OPERATE INJECTION WELLS•
In Accordance With the Provision. of'15A N' AC 02C .0200'
OPEN -LOOP GEOTHERMAL INJECTION WELLS
:..
These wells discharge groundwater directly into the subsurface as part of a geothermal lieating and cooling syste=
,•(check one) . New. Application Renewal* 1Vlodification
.
* For renewals complete Parts A-C and the signature
rint or Type Information andMad to the Address on "the Last Page: Illegible Applications Will Be Returned& 1
DATE:
PERMIT NO. &O 1 000 Q5 (leave blank if New. Application)
A. STATUS OF APPLICANT (choose one)
Non -Government:. Individual Residence, •;. Business/Organization
Government: State.. Municipal. • County Federal
B. PERIYIIT APPLICANT -- For individual residences, list each owner 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:
Mailing Address: F013 CO -A g 0 asxio. aeajek
City: A4-401V State:N�- Zip,Code: 2570 County: �tJn�ff.AM8
Day Tole No.: $?Jl —1 *7 1 —1 q Ie R Cell No.: SAS I -
EMAIL Address: 59'1 P. 0.9*44" N%&d - W^% Fax No.: n/dnr
C. LOCATION OF WELL SITE --where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: y�Z`f �'`f 0'S� Z a V Q d6ounty:
(2) .,Physical Address (if different than mailing address):.3 S'q W,A4�vuT .VM I EY . P/ZW1 %/
City: 4" State: NC zip Code:
D:. WELL DRILLER WORMATION
Well Drilling Contractor's Name: Ley - VJ r—ER G% U36^1
NC Well Drilling Contractor Certification No.: /4G WC ZOZR "
l+VSa
Company Name • 1A) l�lEGL. t� (�C�M L� G
Contact Person: EMAIL Address: F AChUSoN wfLL t! EXc4"tC' - C*/4
Address:2731 Lett- e$�t�fik L%16jHWA i
City: Zip Code: 2V71f& State' AIC-County: tNJ000V%t r-
Office Tele No.: V9--6�9— $4'W? Cell No.: %?
(:DT TIT R!` S A 7 P.—if A nn17n-r:.aa. /AnaricoK 7.L S2 /� 1,1

;, E. AEAT PUMP CONTRACTOR INFORMATION (if different than driller)
a"v any Name:`tNC7 . �, CA eVIAAlC`q :PNC • .
EontactPerson• J�N.. Gt..;.C�urC� ENIAILAddress: gMc J�_`►fft+t^jj A► O RC(LWLr '
N
CT
dress:
;City: l%►DFJZSONVlt.t Zip Code: 2,$'? 93 State•/�C- County:' .lt�-NpEJQSoN
,`� Offiee'Tele No.: g�F!- (99a-'LZSZ" Cell No.: _f 1.$- 2J S 42.? L pax No.: -(¢4� Z22 7
F. WELL USE :Will the injection wells) also be used as -the supply,welt(4) for the following?
(1) The injection operation? YES NO l ,
(2) Personal consumption? YES NO - ` '•
G. WELL CONSTRUCTION DATA
PROPOSED Well(s) to be constructed, for use as an injection well. Provide the data in (1) through
(6) below as PROPOSED construction specifications. Submit Form GW-Tarter construction.
EXISTING Well(s) being proposed for use as an injection well. Provide the data in (1) through (6)
below to the best of your knowledge. Attach a copy of the Well Construction Record (Form
GW-1) if available.
(1) Well Construction Date: ' OGT ' U12:-' Number of borings:
Depth of eachboring (feet):
(2)Well casing type: Galvanized steel Black steel Plastic 'Other s eci t
�:tloati5 �/ t� • � �:•►
Casing thickness (in;):, Diameter (in,):
Casing depth: from: to. feet below land surface `?'D O
' Casing extends above'grotind iZ inches
' (3) Grout material sttrroundiiig well• casing:
(a) Grout type: Cement iC Beritoiiite* : -. Other (s�dcify)'
*By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C.0213(d)(1)(A), which requires a cement type grout.
(b) Depth of grout around well casing. (relative. to. land surface):. . -from. to : :..: feet Tom.
4 en B•da th' relative to land'surface to feet
(} Well Screen or O Porehole
.p ); from
State Regi- ations (Title' 15A NCAC 2C: A2'00j'require` the` Permittee to`i6ke provisions for
monitoring welihead.processes. A faucet on both Influent (groundwater entering heat pump) and Effluent
(water.:being injected back into the, well) lines is required, Is there a faucet on:,..
(a) Influent line? Yes X No '(b) Effluent line? Yes-)eNo
(6) Source Well Construction Information, If the water source well -Is. a different :well than the injection
well, attach a copy'of the,well.construction•Fecord (Form GW-1). If Form GW-1 is not available, provide
the -following data:
From what depth, formation, and type of rock/sediment;units :will the gro..undwater be withdrawn? (e.g.
granite, limestone, sand;:etc.j ...:.
Depth: Formation: Rock%se ent'unit:
Y
t NOTE: THE WELL DRILLING 0R HEAT P)UW'CONTRACTOR CAN HELP SUPPLY TBE, DATA; IF THIS
•.... '- INFORMATION ISOTHERWISE UNAVAILABLE: •:.:.: :• ' i .,
GPU/UIC SA7 Permit Application (Revised 3/18/2011) t Page 2

H. OPERATING DATA
(1)
Injection Rate:
(2)
Injection. Volume:
(3)
Injection Pressure:
(4)
"Injection'Teiriperature:
Average (daily) S . - gallons per minute (gpm).
Average (daily) 2W gallons per day (gpd). .
:Average (daily) . pounds/square inch:(psi).;_ ;..
` Average (January) (e F, Average (7uly) . ° F.
--�- ..
I. WELL LOCATIONS'' Maps must be scaled of '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) Attach a site -specific map showing the locations of the following:
Proposed injection well's *Buildings * Property boundaries
Surface water bodies * Water supplywells;
Septic tankkarid assoalated spray,irrigatiori s4es;&on fields,.or repair areas
* Existing or:potential sources of gfoundwater contamination '
(2) . Attach a topographic map -of tits: area;ex` riding 1%4 mile from the injection well site that indicates the
facility's location and the map name:
NOTE; In most cases, an aerial pliotograple• of flee property parcel showing p perty lines and structures can be
obtained and downloaded from the applicable.county. Mvebsite. TYPicielly;*tti�Pi,?,d l?_�an_ie segrclled by
owner nwne. or address The location of flee wells In relation io property boundaries, 'Houses, septic~tanks, other
wells, etc. can then ' be drawn in by Band Also, a `layer.',:.care be selected sh0,W, nig ;topographic contours or
elevation data.
nnTTrt Trn r a n n__.:. n-_r-_ai..., io....:..e.1 1211 MA11% Pao. R

I
CICRTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C..021 l(b) iequires that aUpeimit applications shall be signed 'as follows:
1. for a corporation: by a responsible cotpoiate 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 others: by the well owner (which means all persons listed on the property deed).
i an authorized • agent is `signing on behalf' of ' the 'applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application 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 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 c cc wi . proved specifications and conditions of
the Permit."
Signature of grope Applicant
Print or Type Full Name.
�ggjjef protection Signature of Properly Owner/ plicant
fir•►c.�►� does
Print or Type Full Mdle
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUMIC 5A7 Permit Application (Revised MUM 1) Page 4

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Beverly Eaves Perdue
Governor
'� 1�rr
RM
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P.E.
Director
September 21, 2012
Adam Hodges
Erica Hodges
PO Box 638
Arden, NC 28704
Dear Mr. and Mrs. Hodges:
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. WI01()0225
Adam & Erica Hodges SFR
Injection Heating/Cooling
Water Return Well System
Buncombe County _
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on September 20, 2012. Your application package has been assigned the number
listed above, and the primary reviewer is Michael Rogers.
Central and Asheville Regional Office staff will perform a detailed review of the provided
application, and may contact you with a request for additional information, To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section, requests your assistance' in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any 'questions, . please contact
Michael Rogers at [phone] or [e-mail].
S' cerely,
USA
for Debra J. Watts
Groundwater Protection Unit Supervisor
cc: Asheville Regional Office, Aquifer Protection Section
Larry Ferguson — Ferguson Well & Pump, LLC
Kevin G. Guice - General Heating & Cooling, Inc.
Permit File WI0100225 .
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] FAX [phone]
Internet: www.ncwatemuality.om
An Equal Opportunity 1 Afiinnallve Adon Employer
...One..... ..... .
NorthCarolixia

L"LiOtl I' KLJ� - GRY-- rhaQ :)-

r
Case Number: WLS `��1 FY>.Cal BUNCOMBE COUNTY HEALTH CENTER ' PIN:
ENVIRONMENTAL HEALTH SERVICES (828-250-SO t6)
OPERATIONS PERMIT
Property Owner:
Directions:
Subdivision: r Nk
j;zli v 'Bhase/section;
Water S&v: tl Private Well
❑ Spring ❑ Shared Well
ication Date: c�
I,ot# r'� Installer:
.Community Min, Required Separation Distance - Installed? ❑ Yes,,O No
O erations PermitIbr: ,§-.New System ❑ Repair ❑ Revision Drawings, plans, conditions, etc. attached? ❑ Yes ❑ No
System Approved For: House ❑ Mobile Home (❑ single ❑ double) Bedrooms: C"f _ Basemenl•�J Yes Ll No Baseruenl Plombing�l'Yes ❑ No
Multiple UnitDwelling: No. of Units ' Number ofl3edrooms per unit -- ❑ Business No. Employees: _^ _ No: Shifts:
OperationDcscription: _ ^ _ -_� _ Industrial Waste: Yes ❑ No 17
C""
Approyed Installation Sneeif cations:. 'otal'Destgn'Flow: • 7 L•!('AK: 6� systeal Class{ rcaliow Type I , II ,III% N_•J V_, VI
(GPD) •✓✓
Puriiv'S}�sterir ReilideY d: ❑ Yes ❑ No Puinn ump Make;__ ,Model:_ , _• _•.�__ Serial No,
Ti errclres Length: (—r�7I) 11 No, of Trenches Width: Spacing: _2�_ft Depth: _9,0N in (lower sidewall) Stone Depth. --- in
Disb•i r i` orii ❑ Equal Gravity ❑ Pressure Manifold 11-ecrlal ,<Dams/Step Downs N ' S'ze: Septic: Pump Tault:_••_
� (gallons) (gallons)
sf�slerrr. Desci f it u�r: ❑ Prefabricated Panel Block ❑ Conventional ❑ I.atge Diameter Pipe ❑ Chamber l xpanded Polystyrene Aggregate ❑ Other
Commnenls;
Ins wted b : / Dale: _�� ssued To: 1)—•�-�-. ��" Date
The systow has been Installed li accordancP4ftir state sewage rules. Approval does not guarantee the system will function satisfactory fur any given (into.
nperprml.doc.rev 03/05/04

A116'9 0S -Oo/S
BUNCOMBE COUNTY HEALTH CENTER
ENVIRONMENTAL HEALTH SERVICES (828-250-5016)
IMPROVEMENT PERMIT FOR WASTEWATER SUB -SURFACE SEWAGE DISPOSAL
Applicant Name: CLIFFS AT WALNUT COVE ` Application Date:
Property Owner: SAME AS ABOVE
Mailing Address: 301 BEAVERDAM ROAD, Travelers Rest, SC 29690
Property Location:Road Name:AVERY CREEK ROAD Directions:Hwy 191 - turn right - Avery Creek Road -
turn right into Cliffs At Walnut Cove
Subdivision: Cliffs At Walnut Cove Lot#: Ci �(�_PIN#: 9624-00-72-5706 (mother pin)
SECTION ONES System Design for: Residential X Commercial
Single Unit X Multiple Units No. Units No.Bedrooms/per unit 4
Basement(s): Yes X No Basement Plumbing: Yes X No
Permanent Foundation(s) X Mobile(s) Singlewide Doublewide
Available Space PS Site Classification: PS Soil Group: see below
LTAR: see below Design Flow 480 GPD
Water Supply: (1) Municipal X
(2) Well
(3) Other
***SEE ATTACHED DRAWING FOR SEPTIC SYSTEM
LOCATION AND DESIGN CRITERIA
***MAXIMUM HOUSE SIZE SHALT, BE 70' X 40'
SECTION TWO: Types Of Systems Applicable SEE ATTACHED DRAWING
(1) Prefab Permeable Block Panel (2) Large Diameter Pipe (3) Conventional,
(4) Chamber (5) Expanded Polystyrene Aggregate_ (6) Other
Comments: NO GRADING OR FILL IN THE DRAINFIELD AREA.
Is exact size and location of structure known at this time?
1. Yes - As described on application and detailed above.
2. No - This evaluation was -conducted based on a maximum of 70 feet X 40 feet wide structure
(front to.back) for permanent buildings and twenty-four foot wide structure for mobile units
unless otherwise specified by the applicant (includes porches and decks). Doublewide mobile
units -are considered permanent structures for the purpose of this evaluation. Restrictive
building setbacks were also considered.
3. This permit is valid only for a structure of this description or smaller.
4. This permit is not limited to a structure of this description, however, no part of the
structure shall extend into the designated area for the sewage treatment system.
An Authorization to construct must be obtained when final plans are completed and exact type and
location of building are established. For planning purposes, please be aware that building,
driveways, excavation, fill dirt, or other obstructions may not be placed or constructed in any part
of the area designated for the sewage treatmen� system. This permit is subject to revocation if the
site is altered or the intended use changes from those described above. Apply for the service in room
243 of the Buncombe County Health Department when an Authorization to Construct is needed or if you
wish to increase the s' a or change location of the structure. A Building Permit may not be issued
until an Authoriz IoPOLO Co ruct is obtained.
Evaluated by: Date:
Owner/Agent: , Date:' G
DCIID-£RS RCV 04-96 '

'1 SOUTHEAST SOIL SCIENCE Inc.
a f' JOHN B. ALLISON, President
Certified Soil Scientist Since 1981
�. NORTH CAROLINA LICENSED
ARCPACS and NSCSS CERTIFIED
SEPTICSYSTEMEVALUATIONS&MANAGEMENT - WETLANDDELINEATION -
ZPf
y
P"KWAY
MANAGEMENT - SOILSURVEY - TRAINING & EDUCATION
m � Itl
IKp'
1401)sE
STYE. , p ,; ��t
",.Jar qs
o
�PF
1 inch 60 feet
4i
LOT 220
THE CLIFFS AT WALNUT COVE
BUNCOMBE COUNTY, NC
PRIMARY and REPAIR:
SYSTEM KIND: 25% Reduction System
Trench Depth (in.): 18 Trench Width (in.): 36
LIAR: 0.4 - Primary and Repair 4-Bedroom Design
LINES (Down- to upsiope / 10' centers) .
LINE COLOR FEET CUMULATIVE FEET
1 orange 82 82
2 pink 102 184
3 orange 121 305
4 pink 121 406
5 orange 97 523
6 pink 78 601
7 orange 70 671
533 CRABTREE MOUNTAIN ROAD • CANTON NC 28716 a 828-648-7080

BUNCOMBE COUNTY HEALTH CENTER
ENVIRONMENTAL HEALTH SERVICES (828-250-5016)
IMPROVEMENT PERMIT FOR WASTEWATER SUB -SURFACE SEWAGE DISPOSAL
Applicant Name: CLIFFS AT WALNUT COVE Application Date: �J—" ?
Property Owner: SAME AS ABOVE
Mailing'Address: 301 BEAVERDAM ROAD, Travelers Rest, SC 29690
Property Location:Road Name:AVERY CREEK ROAD Directions:Hwy 191 - turn right - Avery Creek Road -
turn right into Cliffs At Walnut Cove
Subdivision: Cliffs At Walnut Cove Lot#: PIN#: 9624-00-72-5706 (mother pin)
SECTION ONE: System Design for: Residential X Commercial
Single Unit X Multiple Units No. Units No.Bedrooms/per unit 4
Basement(s): Yes X No Basement Plumbing: Yes X No
Permanent Foundations) X Mobile(s) Singlewide Doublewide
Available Space Ps Site Classification: PS Soil Group: see below
LTAR: see below Design Flow 480 GPD
Water Supply: (1) Municipal X
(2) Well
(3) Other
***SEE ATTACHED DRAWING FOR SEPTIC SYSTEM
LOCATION AND DESIGN CRITERIA
***MAXIMUM HOUSE SIZE SHALL BE 701 X 401
SECTION TWO: Types Of Systems Applicable SEE ATTACHED DRAWING
(1) Prefab Permeable Block Panel (2) Large Diameter Pipe (3) Conventional
(4) Chamber (5) Expanded Polystyrene Aggregate_ (6) Other
Comments: CIO GRADING OR FILL IN THE DRAINFIELD AREA.
Is exact size and location of structure known at this time?
1. Yes - As described on application and detailed above.
2. No - This evaluation was conducted based on a maximum of 70 feet X 40 feet wide structure
(front to back) for permanent buildings and twenty-four foot wide structure for mobile units
unless otherwise specified by the applicant (includes porches and decks). Doublewide mobile
units are considered permanent structures for the purpose of this evaluation, Restrictive
building setbacks were also considered.
3. This permit is valid only for a structure of this description or smaller.
4. This permit is not limited to a structure of this description, however, no part of the
structure shall extend into the designated area for the sewage treatment system.
An Authorization to construct must be obtained when final plans are completed and exact type and
location of building are established. For planning purposes, please be aware that building,
driveways, excavation, fill dirt, or other obstructions may not be placed or constructed in any part
of the area designated for the sewage treatment system. This permit is subject to revocation if the
site is altered or the intended use changes from those described above. Apply for the service in room
243 of the Buncombe County Health Department when an Authorization to Construct is needed or if you
wish to increase the si�e or change location of the structure. A Building Permit may no be issued
until an Authorizat Constr ct is obtained.
£valuated by: G� Date: ?i
Owner/Agent: - Date: v
BCHD-EHS REV 04-96

PI-5 cgwv--1;v36f
`ryli�:rj�rt":' JOHN B. ALLISON, President
Certified Soil Scientist Since 1981
NORTH CAROLINA LICENSED
.. _.. ...b, ARCPACS and NSCSS CERTIFIED
SEPTICSYSTEMEVALUAT►ONS&MANAGEMENT - V=ANDDELINEATION-BIOSOLIDSAPPLICATION MANAGEMENT - SOILSURVEY - TRAINING&EDUCATION
*- ,�
. �36
140
YAt-6f.V
PAaWWII
0
Scale:1" 50'
50'
LOT 222
THE CLIFFS AT WALNUT COVE
BUNCOMBE COUNTY, NC
PRIMARY AND REPAIR:
SYSTEM KIND: 25% Reduction System
LTAR: 0.4 4 Bedroom Design
Trench Depth (in.): 24 Trench Width (in.): 36
LINES (Down to upslope / 10' centers)
LINE
COLOR
FEET
CUMULATIVE FEET
1
orange
85
85
2
red
100
185
3
orange
110
295
4
red
130
425
5
orange
•105
530
xff
6 red 70 600 a
Note: 600' of line re ulred for recommended system 7�
A 05
q Y
533 CRABTREE MOUNTAIN ROAD o CANTON NC 28716 0 828-648-7080