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North Carolina Department of Environmental Quality—Division of T ater Rqspigrc9S7 2017
NOTIFICATION TO CONSTRUCT THERMALCONDUCTIVIT.1, TEST WELLS
Vy�ater aUty R e�a Opfone
Thermal conductivity test wells are used to determine the amount of heat thatat substOW ion Office
transmit in a given depth intervalfor the purpose ofdesigninggeohmaat ....::.=.co....i.g yserizs
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Pursuant to 15A NCAC 02C.0230, thermal cogOictivity test wells shall be subjecct to"Elie regulatory
requirements applicable to geothermal aqueous or direct expansion closed-loop wells designed to serve
single family residences.
These wells are `permitted by rule"and do not require an individual permit when constructed in
accordance with the rules of 1LA NCAC 02C.0200.
This notice must be submitted at least two.(2) business days prior to construction.
Print Clearly or.Type Information. Illegible Submittals Will Be Returned As Incomplete
DATE: 2/23/ ,20 17 PERMIT NO. Kd 0` 7 e (to be completed by DWR)
A. TYPE OF THERMAL CONDUCTIVITY TEST WELL TO BE CONSTRUCTED
(1) Aqueous(as per 15A NCAC 02C.0222): X Number of wells._ 1 @ 450`
(2) Direct Expansion(as per 15A NCAC 02C.0223) Number of wells:
B. STATUS OF WELL OWNER(choose one)
(1) Single Family Residence
(2) Business/Organization
(3) Government: State Municipal County X Federal
-WELL:OWNER —:for sin a famil residences,.liss•-al_l .rsons llsted.on:the property deed:-For all othe -
list name of Business/Governmental Agency and name of person and title with delegated authority to sign:
Yancey County Schools
Dr. Tony Tipton (Superintendent of Yancey County Schools)
Mailing Address: PO Box 190
City: Burnsville state: NC zip code:28714County: Yancey
Day Tele No.: 828-682-6101 Cell No.:
EMAIL Address: ttintnn pnra ne_npt Fax No.: 898-687-7110
D. PHYSICAL LOCATION OF WELL SITE
(1) ' Parcel Identification Number(PIN)of well site: 989000947277000 .
county: Yancey
(2) Physical Address(if different than mailing address): 952 Cane River School Road
City: Burnsville County Yancey Zip code: 28714
Thermal Conductivity Test Notification Rev.3-1-2016 Page I.

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3 E. MAPS,PLANS,AND SPECIFICATIONS
4
3 (1) Maps must be scaled or otherwise accurately indicate distances and orientations of features located
„r,ost ,� •-'-within 250 felt of the injection well(s). Label all features clearly and include a north arrow. Attach a
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.
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 hM.adN.nc.gov/about(divisions/water-resources/Water-g,uaiity-regional-operations/jzroundwater-
protection. All other additives require approval prior to use.
G. WELL DRILLER INFORMATION(if known)
Well Drilling Contractor's Name: Robert Larry Wells/David Carl Stratton
NC Well Drilling Contractor Certification No.: 2603-A 3421-A
Company Name: AWD Services Inc Contact Person: Larry Wells
City: Leicester State: _UG Zip Code:28748County: Buncombe
Day Tele No.: 828-683-9223 Cell No.: 828-215-9334
EMAIL Address: wells759549 o hPllsnu#h_net Fax No.: 828-683-9203
H. HEAT PUMP CONTRACTOR INFORMATION
Company Name: Mid State Construction Geothermal
Contact Person: Doug Craven EMAIL Address: doug af..mid-statecoristruction.com
Address: 9190 Bradford Hicks Drive
City: Livingston .Zip Code: 38570 She: TN county: Overton
Office Tele No.: 931-823-7345 Cell No.: 931-261-1373 Fax No.:
Direct No. 931-403-6406
Thermal Conductivity Test Notification Rev.3-1-2016 Page 2

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Conductivity Test Items
The test bore shall be 450'deep(if possible)and 4"-6" in diameter. Refer to the site plan included for
the suggested location of the geothermal test well.
Pertinent data to record follows:
1. Type of drilling equipment used including Make and Model(i.e. mud rotary,air rotary, air
hammer).
2. Drill rig pump size and compressor pressure and capacity.
3. List location, product and quantity required for any drilling mud orgels.
4. On drill log:
a. Each formation type encountered
b. Formation depth for each type encountered
c. Depth of any significant cracks,caverns or fractures encountered
d. Identify water bearing zones (if encountered)with zone depths and estimated
quantity(flow rate)of water.
e. Standing water level in well after drilling.
f. Drill rate:record total time required for drilling to test depth (excluding any
breakdowns).
5. Record time required for installation of u-bend and loop. Note problems encountered, if any,
and at what depths difficulty occurred.
6. Record casing requirements for test bore including material, length, placement depth(s)and
whether the casing was recovered.
7. Note the location of test well bore on the site plan provided if different than the location
indicated;.Provide GPS coordinates for final location of test well bore..
A 1-1/4" HDPE U-tube assembly should be installed in the bore and the bore backfilled and.fully grouted
with thermally enhanced bentonite grout from bottom to top. The type of grout used and%solids must
be reported (Black Hills Bentonite Thermal Grout Lite 1.07, or equivalent'is preferred)and should be a
minimum of 20%solids.
Finally,a formation thermal conductivity test should be performed for a minimum of 24 hours. The
conductivity report should include an estimate of the formation thermal diffusivity as well. The
conductivity test should not be started for a minimum of 5 days after the bore is backfilled.

L PROTECTION--Provide a brief description of how(1)water supply wells;(2).surface water bodies;and.(3) ,
sepdc`systen%and associated spray:irr%gion sites,drain ftelds,:or-repair areas withixx 250 feet of the:pro�osad
injewon wells will lie prmaed during construction of the wells;
Silt drilling,
.� VARUNCE-=Pursumt:to.15A NCAC it2C,024l:the Uwec w of the.Division of Water Qualidymaygramt a
variance from licable well coristoii�ctioii .
-applicable ogermt ioii stag lards:provided that-
(1) ase.of=tlte MKS)Will*otecidat "tuir .ltealtiiiv�retf .oi tlie:gvouttdwat ,and
(2) that msftneflon:oroperaflon in adcoulan.mwithft sUmdards is'tiiimchnically feasible:or the
praapcl.onstructian provades ettel.or.ttr proteetadii of the ground
water.,
Any variance request should accompany submittal of this mrtiflcaticin to wgxdite eMoatich of die requesL
The variance request form can-be accessed ciniine a€`hitplJportat:nc ieiir. etrr ollaps�gwpro/pEm it-
apphcaticuis .
IG SIG14ATU1RES-The folio l wing"sectiori is.to be completed as mgWt.ed 1*1ow or by'that permon's authorized
agent '15A NCAC 62C.021 I(e)repires.sig ;as follows:
{�) fora radon b*a req 'b#e:o 0. of c e
u�r:a parhners- P aorm epropreetorsh�p bya gexi #parker iot. ptopii�r,r+�y;
(cj ' far.a ic,paiity or A:state,feeral,or otFier tic:may b3'e a pnnrpal motive
oiler'ofinh'raiigpublicly°eteeted coal
(d) 1brt4l otneTs: 'by the wel!`ovirner;
(e)_ for atiy_other perm aide,&M to.art on,bo:Wf of the applicant d utiientation spat!
-. - .siabrriitted�*ft ft noMi tion the siearty 1& es" :person,.grits'.tlietii,, am de
authority,grid is signed and:daWd.by the applicant.
. `�hereby cer>�'},urader perecflty o}"i�w;#rrrt I hava psrsosz�d,7x-ex�r�dwn fanplr�=with#use=ir fnrmcitwn
submhved in this ilAmment and rill rrmwhmew arem and that,.based on my�?m`Y of tfi#�se fndfniduttls
finely rt�iisibls vbt surrdr�rtir� I #hrrt the rniuf'>r�ri is ;ups road
complete. I mn rxsv 't rE rrra azgru ptiaingi2vssib�lj'o} irres:atd raorriiro
Or 571�3P31 tt dIS Dl77SlYtT031 I . ee to Cbft97Y11L'�'•:O raw.j dh2talrt,'r .Lifld... ail 'a 0y1
f *j:f a fir,' ..
-. the iipccdon wool jmd aU°rd Md.appw mmwes ftmcordanm wfi*A.-15A NC C 02C'b200Rutes"
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L SUBMi"TY'AL.Ilti MUMONS Submit one copy of the completed notiftcation package.to be each.of tla
followitw:
(1) The-bivi5iotl:pf:Water Quality Regional Otte serving ft area in which the injection well facility
will be located:
,
2090-U S flttway 7Q 943 Wsshtngtm Mall
Swaiiwa,NC 28778. Wasirtgton,t�tC 27889
Tetep}a te. C,8 296450fl 'i'eiepbcme {2 2)94biF 81
Fair: 299-7043. Fax {252)
225`6een.Strec Suite"114 121`CbidUmd U vex:' ion
. Fayetpeyilte,NC..283Q1=5043.: . r 11�ilrixing n,N .2905,. : ..._..
Telephone: �9:16)433-330'.: Te .
�=(910)796-72,15 -
Fart:(910)4M-0707' Fax:.[phone].
610 Fast Center Avenue,Suite 301 585 waught6wft Stieet
Mooresville,NC29115 W S&m,NC.-271fl7.2241
Telephone:.(704) 6 -16". Phone:(336)-.771-5t1
Fax.(-I-q4)663 Fax:.[phone]
Offim
1629 MMI Saviee Ceatx -
Raleig%NC.27639-1ti
Telephone:(91'9)7914200
FW.[phone]
(2) County Health Deparbnent.in which the Weetian well facility will:be located. A list of county Health
deport ments can be found dWine at: ftMMKpg hdjVA�tzijg&
Dw'tyiJIC/Cto�dal Notification(Revised 413MO12) PsV 4•