Transylvania UIC Deemed Permitted 2012

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are `permitted by rule"and do not require an individualpermit when constructed in accordance with
the rules of 15A NCAC 02C.0200*. This notice must be submitted prior to construction.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in 15A NCAC 02C.0222 these wells-circulate potable water only or a mixture of potable water and
performance-enhancing additives as-part of a geothermal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS
As described in 15A NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: 12/18 20 12 PERMIT NOL I .'4 a(o� a3j� (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TO BE-CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C.0222): X Number of wells: 1
(2) Direct Expansion(as per 15A NCAC 02C .0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence X Submit this form two(2)business days prior to construction.
(2) Business/Organization Submit this form 30 days prior to construction.
(3) Government: State Municipal County Federal Submit this form 30 days
prior to construction.
C. WELL OWNER—For single family residences list the property owner(s). For all others, list name of the
business,organization,or government agency and person delegated signature authority:
Jon and Theresa Redmond
Mailing Address: 103 Gold Mine Ridge Rd
City: Pisgah Forest State: NC Zip Code:28768 County: Transylvania
Day Tele No.: 828-553-5920 Cell No.:
EMAIL Address: [e-mail] Fax No.:
D. PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site: 950847-6285-000
County: Transylvania
(2) Physical Address(if different than mailing address):
City: State:NC Zip Code:
DWQXIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Pagel

E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site-specific map showing the locations of the following:
• Proposed injection well locations • Septic systems and associated spray irrigation
• Buildings sites,drain fields,or repair areas
• Property boundaries
• Surface water bodies • Existing or potential sources of groundwater
• Water supply wells contamination
(2) Plans and specifications of the surface and subsurface construction details of the well system.
Fully grouted geothermal well, 1.25"loop,450-500' deep,steel casing,buried to 4',
over 15' from house,k=0.8-1.0 thermal grout
F. TYPES AND CONCENTRATIONS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services' Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at hqp://portal.ncdenr.org/web/wq/aps/gwpro. All other additives require approval prior to use.
Water and Ethanol
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Justice Well Drilling Inc.
NC Well Drilling Contractor Certification No.: 2150
Company Name: 3845 US Hwy 70 West Contact Person: Gga Justice
City: Marion State: NC_ Zip Code:_ County: McDowell
Day Tele No.: [phone] Cell No.:
EMAIL Address: justicewelldrillinggyahoo.com Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Asheville Geothermal Inc.
Contact Person: Rick Clemenzi EMAIL Address: [e-mail]
Address: PO Box 18757
City: Asheville Zip Code: 28814 State:NC County: Buncombe
Office Tele No.: 828-712-6786 Cell No.: Fax No.:
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 2

I. PROTECTION—Provide a brief description of how(1)water supply wells; (2)surface water bodies; and(3)
septic systems and associated spray irrigation sites, drain fields,or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
We are drilling over 75' from existing water well. There is no septic.
J. VARIANCE—Pursuant to 15A NCAC 02C.0241 the Director of the Division of Water Quality may grant a
variance from applicable well construction or operation standards provided that:
(1) use of the well(s)will not endanger human health and welfare or the groundwater;and
(2) that construction or operation in accordance with the standards is not technically feasible or the
proposed construction provides equal or better protection of the groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation of the request.
The variance request form can be accessed online at http://i)ortal.ncdenr.or web/Wg/aps/g_Tro/permit-
applications
K. SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C.0211(e)requires signatures as follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner or the proprietor,respectively;
(c) for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
(d) for all others: by the well owner;
(e) for any other person authorized to act on behalf of the applicant: documentation shall be
submitted with the notification that clearly identifies the person, grants them signature
authority,and is signed and dated by the applicant.
"I hereby cent fy, 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 offrnes 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 15A NCAC 02C 0200 Rules."
(see attached authorization form)
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent,if any
Rick Clemenzi—Asheville Geothermal Inc.
Print or Type Full Name
DWQ/LIIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 3

L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Quality Regional Office serving the area in which the injection well facility
will be located:
1RVViiI�IS O �.SAILENI_
IA .EIGH
ASH HING ON.
VILLE -
Asheville Regional Office Washington Regional Office
2090 U.S.Highway 70 943 Washington Square Mall
Swannanoa,NC 28778 Washington,NC 27889
Telephone:[phone] Telephone:[phone]
Fax:[phone] Fax:[phone]
Fayetteville Regional Office Wilmington Regional Office
225 Green Street, Suite 714 127 Cardinal Drive Extension
Fayetteville,NC 28301-5043 Wilmington,NC 28405
Telephone:[phone] Telephone:[phone]
Fax:[phone] Fax:[phone]
Mooresville Regional Office Winston-Salem Regional Office
610 East Center Avenue,Suite 301 585 Waughtown Street
Mooresville,NC 28115 Winston-Salem,NC 27107-2241
Telephone:[phone] Phone:[phone]
Fax:[phone] Fax:[phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh,NC 27699-1628
Telephone:[phone]
Fax:[phone]
(2) County Health Department in which the injection well facility will be located. A list of county health
departments can be found online at http://www.ncalhd.org/counly.litm.
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

Signature of Property Owner Printed Name Dat
Signature of Property Owner Printed Name Date
Signature of Property Owner Printed Name Date
[e-mail] 828-712-6786 www.ashevillegeothermal.com

{-..
Asheville
Geothermal,. .:
Inc.
To: NC Department of Natural Resources
Re: Geothermal Well Permit
PIN: -7 y � , ` - ~ CC, C-
Dear Department of Natural Resources:
I/We hereby authorize Asheville Geothermal Inc., a licensed NC HVAC contractor, to sign and
otherwise speak for us with regard to obtaining a permit from the NC Department of Natural
Resources (DENR) for Closed Loop Geothermal-Wells-on our praperty at the above Property
Identification Number (PIN). We ask that Asheville Geothermal Inc. be allowed to sign and
submit the Geothermal Well application, and that a representative of Asheville Geothermal Inc.
be allowed to speak with DENR can our behalf in this regard as further needed.
Sincerely,

Ti is lvama Cotfty,.NC 1'rlrrt Map lritp//arc�ls�vebgts netLnc/Trai�sylvanWorinbble.asp
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Transylvania County, N°C
Disclaimer.The tnforma" n contai.ned on this page tsNOTto be conatrued or used as a legal descipton ntormabon is tieUeved to be
accurate bmadcuracy is not guaranteed':
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Parcels
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:PIN:9508-47 6285-000 Sale Prtce 190a0": Sale Inst VI1p' ,
Owner Name REDMOND,JON S&:THERESA;H Sale Date 199409 ,Sale V.
Owner Address 103 GOLDMI NE.RDG,' COUNTY Ip T452W101,1i 01'. Land Value:45000
Cdy.'P,ISGAHFOREST: FIREDIST FR09. Assesseda'Ue 277720
State:NC Acres. 1.18521964 RutHdit Value 23Z720
p 28768 Waterfront 'Y` ACCOUNT_NO 46229100
Deed Book 00379J. Land Area :1 Legal Address GOLD MINE'DRIVE:
Deed':Page 0269" Land Units, LT
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NQRTH-CAIZOLIIA:DEEAR fMENT'O ;EI+i�(,iRf3NJVIENT AND I�IATURAL.:RESOURCESi
NOTMCA:TION OF INTENT TO CONSTRUCTOR OPERATE INJECTION WELLS
These wells.are per uando iotrutiam rp orctedin accordance`withmWedbie da
the rules of 154 NCAC 02C.0200:.*Thts notiee.riiusi-be submitted'prior.to-construction:.
GEOTHERMAL AOtfEOUS CLOSED LOOP WELLS
As described in,1 SA-NCAG02C.022 these;wells circulate potable.water only or.a-mixtu a of potable water and
performance enhanem -'addthves aspart ofa Q6ih&nial;l eat ng and coolingsyst.em..
OR
GEOTHERMAL DIRECT EXPANSION CL MEN I;OOP WELLS
A's described m 1 S A NCA :n _ 2? these w.ells circulate a refrigerant,gas as°part of.ageotbermal heating and
.
Plitit:Cletirly or fiype liefort►iattoit Illegible Sub»titfals 13!ill:-Be Returned As;Iiicditiplete
March 12 14 1
DATE: 20 PERMIT NO; Wf ODD 0 2 7 ,(to=lie completed:by
I
i
A.: If Yru-Cie GEOTYIE1 MAl.G.LOSE)-LOOT VYLLL tv m C t)N.�;1'KV(�l't U
(1). Aqueous(as per,15A NCAC 02C..0222):, Nurnber of wells:,
(2)� Direet Expansion:(as per l 5ANC'AC 02C.02231 .. Number of wells
B, STATU$Oh`V1'ELL Ql'VNER,�clioase one) ,�
(1) Single_F.amtly`Residence_✓ Submit tliis''fotm hvo(2)tiusiness.days'prlor to construction.
(2) Business/Organization .9ubmitAis nfor�m 30 days prior to:construction.
(3) 'Government,'Sfate, :Municipal_L_J� County Federal Submit this farm 30-days
prior to construction.
_ Y
C. WELL OWNER For.single_family°residences,Iist the property..owner(s) For All others, list name of ahe=
business,.organzatlon,or,govemmenti_agencyand,person del egated;signature authority.
�� �t4�i�'fOClC
lWail rig Address; Sa L
City: J421La itlr State: CQt Zip:Code3 yg C.ounty
E
Day Tele No
EMAIL Address,-. FaxNo:i '
E
PIIY.S)(CAL•LOCATION..OF'hVELL`SLTE
(1,); 'Parcel Identification',Number(PIN)of.welisite: _ QQ _.
County!RiON;Z VAN J A
2 Ph ( ,g ) 't3u�clN.4AtNts. outaur Gutty' ,( Physical 1£di Brent `ap maihn 'address
Lor If-kill
oy 11L _ _ State,NC Ztp Code
UIC/Closed I oop:Geotfierirjal Ngti,Mation;(g6ised 415129.13) Fage I
E

E. ' MAPS,P,LdNS,AND.SPECIFTCATIONS r ,
5
{l). Maps,must be-scaled or"''otlietwise accarhtely'indicate distances and orientations.of features-located
withm 256 feet of the injection wells} ,Label all features`dlearly and include a north arrow: gftach,a
site-spectScmap showing the locahons:of!the fiillowing:
• pro"osed=in'ection'u ell locations -' • S tic:`System and associated'P J ep y splay_' negation -
• Btii7dngs sites;.diain fields or repair areas.
.. Property boundanes. ,-
•. Surface,"waterbddbis -• Existing or—potential ,,sources of groundwater
• Wa`ter'-supply well"s- °contnrriinat,Qn
(2). Plans aril specifiaatrons of the.surface and°subsur#ace construction details of the well system.
F.. `TYPES AND GONCENTRAT[ONS OF ADDITNES List-any:additives.,that will be ased`:and;their.
concentrations .Only,additives.that The-Department ofNealth and°.Human Services'Division of Pub'hc Health
determines do not adversely affect human health'shall'.be used A list of approved,additives can,be,found
online"at;httn lLp'ortal.ncdenr.orglweb/wq/apslQw0fo.All other additives regwre approval.prior to,usi.
G VIWELL.DRILLER INFORNIATION::(if known}';°
`'Well Drilling Coptractor'sNames. -
NC Well Drilling Contractor Certification No.. 4
C., Dt;~/ f?�1 ;` Coritact;Eerson. f Toe)
l
- ompanr�yNa-'me:
City::tXCR�l1KL(�J, _ State: Ale_ Zip:Code:��F'f County
Day Tele No
EMAIL-Address:° f1iQd Faz No.: �
A HEAT PUMP CONTRACTOR INFORMATION _
Company Name: .` i „i Xi16 A�
Contact,Person:. 24 / WD
.
� �,`�� °- ��`
. EMAlL.flddress:
Addressi �' �.«:LA1 D4 '. 7L1t11E �.
City w1' Zig Code._ State:iii?L County .J11,4:cb►J
11
'Oftice'Tele No.i $Z8- I{4(iZ Cell No: .
UiC/Closed=Loop Geothermal Nouhca[ion(Reti ised,81520,13) Page 2
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3, G 4RI4hCE` uxsiiant to l`lA ixiCAC n2Csttw thL DirdotGrofrheDhFston f WatcrRaso uses lnEt;,graFtt
a=t arfanoe firm appSis►ble�cellscmtstruotibn orlieratit�n eta► ends prortded that
{1)•use of the weli(s}brit nab aglanger att healw and�clfare oc thgraandivater,ana
(�) that oanaira„Non nr opecabon in accordatroe with th�,etatrderds3a ttotSeArurtcal]y fne ebla,gr the _ .-,
ptspaSetaops lruCan pi 464 e4tlel of to'* Of theouidwRt�S. �'
hF;�a>'artct taque5t should nocampany aubnuttel of tuts nottficatton t4 sxpedriaeustuutto`n'cf uro raguest; - 4
!fie vs�snee zcquett€ctrrtrcunbeaoces3.ed onhneut /Wait 141cdenr•4TRlwr� CarsTt�vnFafrrrri3t :_
'• K STGY#'L' 5 Alfutldwtng secuon is to be.compieted asrequir troto�v tr by tiai;pcison a suthortzod:
rigcnt f Sc1 ACA =S} c4.1�1 fa1 r<'9uira;srgnatc tes as'*laws
{$.. ror a sg oration by a responsible corpora3�:affise ,
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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
These wells are 'permitted by rule"and do not require an individual permit when constructed in accordance with
the rerles of 15A NCAC 02C.02001'. Yhis notice ntust be submitted prior to construction.
GEOTHERMAL AQUEOUS CLOSED-LOOP WELLS
As described in 15A NCAC 02C.0222 these wells circulate potable water only or a mixture of potable water and
performance-enhancing additives as part of a geothermal heating and cooling system.
OR
GEOTHERMAL DIRECT EXPANSION CLOSED-LOOP WELLS
As described in 15A NCAC 02C.0223 these wells circulate a refrigerant gas as part of a geothermal heating and
cooling system.
- Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: - I , 20_ PERIYIIT NO.1 TQr 0 015 Q1- (to be completed by DWQ)
A. TYPE OF GEOTHERMAL CLOSED-LOOP WELL TOLE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C.0222): ( Number of wells:
(2) Direct Expansion(as per 15A NCAC 02C.0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence Submit this form two(2)business days prior to construction.
(2) Business/Organization Submit this form 30 days prior to construction.
(3) Government: State Municipal County Federal_Submit this form 30 days
prior to construction.
0 WELL OWNERl. For single family residences list the property owner(s). For all others, list name of the
~business'oiganiiarion,or government agency and person delegated signature authority:
KtMVED
Division of Water Resource9
Mailing Address: E F�� O L
City: l't State: Zip Code:%�s( County: ��` 2014
Day Tele No.: Cell No.:
EMAIL Address: Fax No.: - ionai Operaiions
Asheville Regional
(D. �r PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number(PIN)of well site:_RJ 1 j �5(q - �75 —000
County. I[,QQS'yloa 1Q
(2) Physical Address(if different than mailing address): C(A3 VE DEAINVe 2DJVt
City: LOV-9- -Tf-)YaLo V State:NC Zip Code:
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4130/2012) Page 1

E. MAPS,PLANS,AND SPECIFICATIONS
(1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
within 250 feet of the injection well(s). Label all features clearly and include a north arrow. Attach a
site-specific map showing the locations of the following:
° ° P
roposed injection well locations eptic systems and associated spray irrigation sites,
° drain fields,or repal+3-areas
uildings
° ° P
roperty boundaries xisting or potential sources of groundwater
contamination S
urface water bodies
W
ater supply wells
(2) Plans and specifications of the surface and subsurface construction details of the well system.
F. TYPES AND CONCENTRATIONTS OF ADDITIVES — List any additives that will be used and their
concentrations. Only additives that the Department of Health and Human Services' Division of Public Health
determines do not adversely affect human health shall be used. A list of approved additives can be found
online at http://portal ncdenr orahveb/wg/ai)s/Qwpro. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: /f'J�u' sue ,�//Q,epp�
NC Well Drilling Contractor Certification No.: _ !-IS—/7-
CompanyName a ! Contact Person: Ni fZ4�
City: P ' State: C_ Zip Code-,2n3 County:
Day Tele No.: . 72U—f!a��so^^ Cell No.:
EMAILAddress: /YI(_�f�LLAI�-Ct���fh}��DI t Fax No.:
H. HEAT PUMP CONTRACTOR INFORMATION
c
Company Name: e 1
Contact Person: t EMAIL AddressALyl}c2 X heAl p G a C0 09
Address:
City: G Zip Code: �_ State: County:
Office Tele No.: Cell No.: er_- `/` ©Q Fax No.:
DWQ/UIC/Closed-Loop Geothermal Notification(Revised 4/3012012) Page 2

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I. PROTECTION—Provide a brief description of how(1)water supply wells;(2)surface water bodies,and(3)
septic systems and associated spray irrigation sites,drain fields, or repair areas within 250 feet of the proposed
injection wells will be protected during construction of the wells:
ao
l /
J. VARIANCE—Pursuant to 15A NCAC 02C.0241 the Director of the Division of Water Quality may grant a
variance from applicable well construction or operation standards provided that:
(1) use of the well(s)will not endanger human health and welfare or the groundwater;and
(2) that construction or operation in accordance with the standards is not technically feasible or the
proposed construction provides equal or better protection of the groundwater.
Any variance request should accompany submittal of this notification to expedite evaluation of the request.
The variance request form can be accessed online at lim/portal.nedenr ore/web/wq/aps/gwpro/permit-
anplications
K. SIGNATURES—The following section is to be completed as required below or by that person's authorized
agent. 15A NCAC 02C.0211(e)requires signatures as follows:
(a) for a corporation: by a responsible corporate officer;
(b) for a partnership or sole proprietorship: by a general partner or the proprietor,respectively;
(c) for a municipality or a state, federal,or other public agency: by either a principal executive
officer or ranking publicly elected official;
(d) for all others: by the well owner;
(e) for any other person authorized to act on behalf of the applicant: documentation shall be
submitted with the notification that clearly identifies the person, grants them signature
authority,and is signed and dated by the applicant.
"1 hereby certify, under penalty of law, that I have personally examined and am familiar ivith 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 it jection well and all relate urten ice with the 15A NCAC 02C 0200 Rules."
`— � Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent,if any
Print or Type Full Name
DWQNIC/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 3

L. SUBMITTAL INSTRUCTIONS—Submit one copy of the completed notification package to the each of the
following:
(1) The Division of Water Quality Regional Office serving the area in which the injection well facility
will be located:
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Asheville Regional Office Washington Regional Office
2090 U.S.Highway 70 943 Washington Square Mall
Swannanoa,NC 28778 Washington,NC 27889
Telephone: [phone] Telephone: [phone]
Fax: [phone] Fax: [phone]
Fayetteville Regional Office Wilmington Regional Office
225 Green Street,Suite 714 127 Cardinal Drive Extension
Fayetteville,NC 28301-5043 Wilmington,NC 28405
Telephone:[phone] Telephone:[phone]
Fax:[phone] Fax: [phone]
Mooresville Regional Office Winston-Salem Regional Office
610 East Center Avenue,Suite 301 585 Waughtown Street
Mooresville,NC 28115 Winston-Salem,NC 27107-2241
Telephone: [phone] Phone: [phone]
Fax: [phone] Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh,NC 27699-1628
Telephone: [phone]
Fax: [phone]
(2) County Health Department in which the injection well facility will be located. A list of county health
departments can be found online at htti)://www.ncalhd.org/county.htm.
DWQ/U1C/Closed-Loop Geothermal Notification(Revised 4/30/2012) Page 4

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