WI0400100_GEO THERMAL_20081124

Permit Number
Program Category
Ground Water
Permit Type
WI0400100
Injection Water Only GSHP Well System (SOW)
Primary Reviewer
michael. rogers
Permitted Flow
Facilit
Facility Name
Wake Forest University New Admissions Bldg
Location Address
Wake Forest Rd
Winston Salem
Owner
Owner Name
Wake Forest University
Dates/Events
NC 27109
Orig Issue
10/28/08
App Received Draft Initiated
10/27/08 .
Re g ulated Activities
Heat Pump Injection
Scheduled
Issuance
Central Files: APS_ SWP_
11/24/08
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
PO Box 7286
Winston Salem
Public Notice Issue
10/28/08
NC
Effective
10/28/08
27109
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Permit Number WI0400100
Central Files: APS SWP
10/28/08
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Permitted Flow
Facility
Facility Name
Wake Forest University New Admissions Bldg
Location Address
Wake Forest Rd
Winston Salem NC 27109
Owner
Owner Name
Wake Forest University
Dates/Events
Orig Issue
App Received
10/27/08
Regulated Activities
Duffel! NULL
Draft Initiated
Status Protect Type
In review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Scheduled
Issuance
MajorlMlnor Region
Minor
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Non-Govemment
Owner Affiliation
PO Box 7286
Winston Salem
NC 27109
Public Notice Issue Effective
Expiration
Waterbody Name Stream Index Number Current Class Subbasln

Michael F. Easley, Governor
William G. Ross Jr.. Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins Director
Division of Water Quality
10/28/2008
Keith Callahan
Wake Forest University
PO Box 7286
Winston Salem, NC 27109
Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System
Permit No. W10400100
Wake Forest Road.
Winston Salem, NC 27109
Dear Mr. Callahan:
In accordance with the application submitted to the Underground Injection Control (UIC) Program that
was received on 10/27/2008, the Aquifer Protection Section (APS) acknowledges your intent to construct
a closed -loop geothermal water-on1\ injection well system for the operation of a ground -source heat
pump located at Wake Forest Road, Winston-Salem, Forsyth County, NC 27109. This system is deemed
permitted by rule (North Carolina Administrative Code Title 1 SA, Subchapter 2C, Section .0211(u)(2)).
However, it is recommended that you contact the Forsyth County Health Depat t,vent, as they may have
additional construction or permitting requirements for this type of system. If you modify your system at
any time, including the addition of antifreeze, corrosion inhibitors, or any other substances to the
circulating fluid, you must contact the APS to verify compliance with applicable rules.
Thank you for submitting this notification, If you have any questions please call me at [phone].
Sincerely,
Lk&ff&j.
Michael Rogers
Environmental Specialist
CPU -Aquifer Protection Section
cc: Winston-Salem Regional Office - APS
APS Central Files - Permit No. W10400100
Forsyth County Health Dept.
Richard Simmons (Richard Simmons Drilling Co, Inc 60 Drill Rig Drive, Buchanan, VA 24066)
N Carolina
�turljl
Aquifer Protection Section I636 Mail Service Center
Internet: wwvy.newaterqualitv.org Location 2728 Capital Boulevard
An Equal Opportunity/Affirmative Action Employer- 50% Recycled/10% Post Consumer Paper
Raleigh, NC 27699-1636 Telephone: [phone]!
Raleigh, NC 27604 Fax I • (919) 7 } 5-0588
Fax 2: [phone]
Customer Service' [phone]

Ri4mhard1 Simms u1B
ORILLINV4M
Richard Simmons
Drilling Co., Inc.
60 Drill Rig Drive
Buchanan, K,4. 24066
P. [phone]
F. [phone]
FAX TRANSMITTAL - 7 pages (including this page)
October 27, 2008
TO: Michael Rogers - Division of Water Quality
RE: Geothermal Test Wells - Wake Forest University
FROM: Stephen Brooks
Please ea if you have questions or need other information.
Thank You.
# H PA

NOM CAROLNA
DEPARTMENT OF ENVIROWENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A. SLOOP
GEOTHERMAL WATER -oNLy INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type $QW wells
is Aceosditttrs with IbAs ptavisiou of MAC Title, ISAe mr crxn
Completr spplfiodlo i red and in addrtaa en the bock Frei.
The f a . hs peopsr fbrm to be need Oar lejectian wells In an pnes-le►on,geaehs ate el system
riy not MI thfa tbrm for symtems t .itclraolatc iimaketatft:os Q.:her than watt
TO: DIRECTOR, NORM CAROLINA DIVISION OF WATER QUA M
DATE: o.•� 20 v8
A. SMARM CL ASSEFICAT ON Doan the peopo.ed system cimulete potable walar in oontionoue
pfpbss that oomplatsly+ isalsams the flold Rom the environment?
YES Ifyas, trial maix=o oamploting this form.
N[7 If not do not complete this firm Foim OW..57. „Application For
Fvmlr lb Conetrar? 4siVO Uss it We!!() Fir iniectievi iy71h4 Asru
Pump 4wie n, should be completed.
S. SYST M PLUM W111 any pddithes by iatroduntd to the sy tem's *cabinp hest transfix
Rind? This ineletles, but la not flydhsd m oouval04 iobibluirs tuldior tt�tiCrasasa.
Y5S _ um, do opt oomplsta lhia form. Form OW-57 /IP,.tppltocrlon For
Firth# To Comma' AndlOr Uro A Well(i) Fbr All rtlaas With a Beare
Amp Zinsiew, should be emplaned.
ed.
NO If no, then =tim s completing this item.
C PROPERTY' OWNER
Name: W fe,67 U jT
Addttsar ?C?�
City; WIi.J �l�f++1 sznar Zip Cods: 2149
Cote*: girrH Tel booet 2%1,-1Sf5 — Sian
13, STATUS OF PROPERTY OWNER
Privy'e: 21. Faders]: Commetdal:
State, _ Municipal: Native American Lands:
Revised MI6
C}1W12C-57 O. cage 1 of 4

E. FACILITY (SITS) DATA 111
Oral rut ONLY Mho Status of Owner its Federal, Stem Municipal or CSommareialj,
Nana atBwlneeae qr Facility: N E *) A d 3 n T S f i a Fr} 3 to I t: I•
Addtraa: Oi ; IC e (- i e r jc , a
City: I:1 '•h) t'k±.1- "Is ltw. Stal= , , C, Zip code: ]'1.1 O Coin,)), . i F� r s r 1,Teispbaao:gpat Pon:
Standard indult:Htd Coda(*), SIC, wadi dsscrlbet coa ncrcial facility:
P. HEAT PUMP CONTRACTOR DATA
Nara*:
Address:
Ctty: Spate• Zip Caode• Cobnty:
Telapbona: - L'at:t*ai Pearce;
O. CONSTRUCTION DATA (aboc arm)
STING WBLI{S) being proposed for aso as a pound-ncupi at hot pump
well(a). Provide the infbrmttdoc in (1) tbrotsb (3) below to the brat of yow
tmowimdoe. Ails k a Dopy of Porn OW-1 ail Coeastxuador Raeozdj 1!
available. aI.
PriOPc RD WILL(S) to be acraeateded the two ia s gronttd-oauplcd h.at lip
weil(a). Provide the information in (!) through (3) below ax PROPOR2D
eoamtraetion speclfaarlons. Submit )?orni 4W I altar cOosauetion.
Well Millie it Cantad i 14tma:i'g_A. StN• , .
NC o
a6O3S IOC
Ago'
to he coradruntecl: f% Number or boriuSs;x .3.
Appraxtpsafa depth of welt. bori% (fW «O0
Wall lasing is the well(*) cued?
(a) YES „ _ ,ifyes„ titan povidp the gulag Information below.
Tips: Gal noised steal Mack stall Medic Other (wapiti)
Casing depth: Prora to ft (rrfa:woo to tared radar.)
Casing sx#ada &bora ground !mhos
(b) NO
[1)
(2)
•y4
(3) Greta- (grout the vertical length or the bcrrehoto to o mixsirtran depth of ?A &et ILIA):
(a) Grout type: C+lmmL___ &manila , Other Capacity)
(b) Grouted surface god prom depth (relrararaa to arid RW DR
erouar3 olomad-tnop pipl " to
around well ck mina; born 'to ( ,
NOM Tito MA. DRILLING COMPACTOR Cid( RIPPLY ME ULTw= at= derma OK
FROPOUrta6LLi VT= INPO LITI M t.QtN/YASt E BYOrf & MAHE.
Who! 71t16 OWIt7IC #7 CL Faker 2 of 4

K, INJECTION -BELATED EQUIP rENIT
Attach a dim, Me elbowing the arj baring Iayout of the Weedon equipment and 4xterior pipieyttst inp
mandated with the Wootton °peril cu. The raanufs ar's braohure may provide supplementary
inibrroatiou.
1. LOCATION OP mum Attecb two rico.
0)
(2)
Include a she map (ono be drew) snowing: buildings, property lima gUrhinwtioee bcdters,
potential swoon of greuadwrterneertemination end the ariwtaa;um of and distances between
the prop: mod weq(e) end my existing well(s) or Nvaate dispaaal facilities such se septic ranks
or Main fiends Intet,d within 2W !feet of he grotutd-coupled hem pump well system. Labe] all
Ibadrne clearly Lod include a Death UMW.
1004110e map nhtequcins the Bier to two nearby permattant reference Mims {Lamb as mods,
atsomas and highway intemeatla ),
Hr
L PERMIT UST: Attach a Ibt of all permits es constrteticn approval, that are Wood to the site.
Emil** Isteluda:
(I) > is wdous Weft* Managerarnt progreai peonies under I CRA
(2) NC Dhiiaioa of Water Quality Noe-Diseinuit permits
(3) Siswago Trta mcnt mad ihlspe:asi Przniti
X. CSKTIF[CATION
hereby certify, under milli of law, that I have patio/ally esmmined and urn familiar with the
infirmai oe submitted to We dominant and all attedunerna thereto and !Eat: Eased on my inquiry of
those individuals iitateeediety tetapcimibie fbr ebtalniog said information. i believe that the inllarmation
true; ammo mo Arid r:t' mplcte. I am emanate then ere algid -Boaz penaidee, ltialtsdiupg the passibility
of lines and imprisonment, fbr submitting lithe €nfarmadon. i esteem onattrunt, agate, Minte%
repair, and if applicable, adadon rises ground -source boat pump eystern and all - • appttrtoamescs in
secontance With he approved apsedfieations and candilio . f the Permits'
Reviled 7/D6
(Si • of Wei a+. ` . u,• sea Agent
eteiharired agent is acting an behalf q fthe well owner,
phase suppy' a letup signed by the owner
author tying the above eegeretr,
tY1rhra54.rv,4.41t.
cm/WC-0 a 3 3 7Pgs 4 1 7

. OCT 272008
L. CONSBNTOP PllOPBR.TY OWNBR. (Owm ~ aay pnou who bo.,dl t.b, a.. orotllet prapciny
ripts la Uae wtU bebta OGISttr\1Qtod. A well ls real p-opmy ml iu conmuctloa 011 •• re1t1
c,wu.trthfp In dla ll:adOWDtr In 1be abtlnae of oontrmy qrciameni ha wrib&,) .
If the JIIOPerlf ii owned b)' IO,uoM oa.r1hln die applicant, the pn,peny OWDOr bcmby COIIIDnt. 'lO
allow the lppJiClll.tiD OCDlll'WSt CIIOh !Jdeodon nil IS otdi:o,d {u thll llpplicsdotl ud that it siall be
tu ,.,_1bBity oribo appli.t to eoaun tb1t the arolitUHOuroe heat PlPIIP. '• wcl1(1)
oo.nforml to Ibo Well ComQQGtfon Standards (Tftlo 15A NCAC 2C .OlOO
Please return two mpl• c,f the ~t• Application r-cklsa to:
UICPro ara m
AquJfll'." P,rotectfoa ~ecdou
Nolib..Carolla• DBNR-DWQ
1636 MaD s.me, Ceater . RI~-NC-2;169t-163 _6
Telephone (919) "115493!
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