WI0400105_GEO THERMAL_20090225

Permit Number
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Permitted Flow
Facilit
Facility Name
Grandmere Trail
Location Address
2798 Grandmere Tri
Burlington
Owner
Owner Name
Randy
Dates/Events
L
Orig Issue App Received
02/25/09 02/25/09
Reg ulated Activities
Heat Pump Injection
Outfall NUL L
NC 27215
Faircloth
Scheduled
Draft Initiated Issuance
Central Files: APS_ SWP_
02/25/09
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Randy Faircloth, Agent Authorized
5101 S NC 49
Burlington
Major/Minor
Minor
NC
Region
Winston-Salem
County
Alamance
27215
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Randy Faircloth, Agent Authorized
5101 S NC 49
Burlington NC 27215
Public Notice Issue Effective Expiration
02/25/09 02/25/09
Waterbody Name Stream Index Number Current Class Subbasln
NA
MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Randy L. Faircloth
5101 S. NC 49
Burlington, NC.27215
Coleen H. Sullins
Director
2/25/2009
Subject: Acknowledgement oflntent to Construct Type SQW Injection Well System
Permit No. WI0400105
2798 Grandmere Trail
Burlington, NC 27215
Dear Mr. Faircloth:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on
02/25/2009, the Aquifer Protection Section (APS) acknowledges your intent to construct a closed-loop geothermal water-
only injection well system for the operation of a ground-source heat pump located at 2798 Grandmere Trail, Burlington,·
Alamance County, NC 27215. This system is deemed permitted by rule (North Carolina Administrative Code Title 15A,
Subchapter 2C, Section .021 l(u)(2)).
However, it is recommended that you contact the Alamance County Health Department, 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].
Sir,erel.y, ' J 1 0 [ -µ
...;;JD'I--J-1<--,~l, ~ rx LtJt fy r Michael ~gers ·
Environme1ital Specialist
GPU-Aquifer Protection Section
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400105
Alamance County Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity \ Affirmative Action Employer
Ni'rth Carolina
;Natura/tu
FROM :ESC
RECEIVEO I C~Nf\ 1 yfll
Aqu\ter~Stdoft
FAX NO. :9193625783 Feb. 25 2009 05:06PM P1
i '
I
' \
I
I.
l
i
r
.F1EBti89
NORTH CAROLINA .
DEPARTMENT OF ENVIRONMENT AND NATURAL RES~URCES (NCDENR)
NOTJPICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SY~M:
TYPE 5-0 W WELL(S)
In Accordance with the provisions ofNCAC Title 15A: 0~C.0200, please
complete this notification and mail to address on the back page (please~Print or~ infbrmation).
DATE: ___ z_-~z._V-'--_ _.20~
Well Type Confumation: Docs the proposed system circulate potable water only (n.o additives) in
continuous piping tbat completely isolates t~e fluid from tbe environment (i.e.
closed•loop)? ·
Yes _x.__ Continue completing thi.s fonn.
No __ Do Not complete this form. Complete other UIC application forms for instal]ing
either a 5A 7 well (Qesm-loop well injecting potable water into the aquifer) or a 5QM well ( closed-
loop well co11taining additives such as R-22, ethanol, or oth~ antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a busine~s or government agency, state name of
entity and a tepresentative w/authority for signature):------:-------------
(1) Mailing Address:_··---------------~---------
City: _________ State: __ Zip Code:. ______ Count)':.~---~
Home/Office Tele No.: ___ ---------=C=el~I N~o-:.!..; _________ _
Email A_ddress: _________ W~eb,,,_,,s=it:.:e:'---~---~-------
(2) Physical Address of Well Site (if different than above): 'l"')9.8 G~,.,"1 O A F~e i)e,, ,~
City: i \J,tt.,.uC.'N~ State: /Jt Zip Code: ______ County: tt(#l'°""""'f
Home/Office Tele No.: Cell No.: -----------.=.=.::.:...!..!~------~---
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Pennit Applicant does not own the subject property,
aUach a letter from the property owner authorizing A§errt to instal. 1 and o_ · pe,ate UIC welJ) •
Company Name: '&t 'fu f ~t/4 ~ Ct;_ A$../: 4'1<:,...,
Coi,au;t Person;~ "f~ rdo ft_. EMAIL Address: f)j.d ~t--f'fi: & l1Af < ~,,,_,
Address: 5JtJ I 2 @
City:1 c,r--f id~+----State: il[;zip Code: k ?ZI S County: & 2?14lJ4. =
Office Tele No.1T /fa,1t,J 2-n -Z35 ;L Cell No{-Y ?:j TH-,ts ,fib
Website Address of Company, if any: __ __
~ROM :ESC
c.
D.
E.
Rt:lii:IVCLJ / UtNK I l.iV . X NO : 9193625783
Aquifer Protection Section ·
Feb. 25 2009 05:07PM P2
FEB to 2099
Company Name: iS-f\4'2; H : ,'114-Cv , WELL DRILLERWORMAT~!
Wen Driller Con1l'actor's Name: ~H--~-----1t-"-=-ll""""C,~'li'.._ .. ..JC..U-11-----~---~---~-
NC Contractor Certification No.: _]7""1"'-"~~).. __________ 1""r-----:-----=-----
Contac1 Pers011: 'R 'i AA"} ·'Bfl~ [ 1 EMAIL Addr-: 0 t, b,,.,,,,1/Qyt;k,,, l,o..ti.
Address: ~~~ () " '
City: ~~f\JiJji Zip Code: ?-? S-'t (.; County: "--A,__l,.__11'-'--mi ......... t;,d:'--=:;.....__-~---
Oftlce Tele No.: 9 / 5 _;, q.c,, '0) 'j J Cell No.: ~ :j ) :f..., 'Z)-f ':'-j On
HEAT PUMP CONTRACTOR INFORMATION (if different than dn,1er)
CompanyName: ~\JIANf'oE<.1S!" ~~.cv,te' G,.
Contact Person: g,"',._ € "~~ toE""t: 1~\. EMATL Address: Q.lJ~o•<je..J-.., @J Pe/1~~-,.lh ft ei"-
Address: I Ii ' S--;c.H-eL O$'l. t2o~
City: 'Afe:,: Zip Code: 2? $''l 3 County: __ <?_'4...,c..W1th~~il---~--'-----~---
Offi.ce Tele No.: q,o, .. '3'.2-■,8,o Cell No.: "1J') ~ e, ~-7Y t. L
STATUS OF APPLICANT
Private: L
State:
Federal:
Municipal: _· _
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the iajection wcl.l(s) will be used)
G ~~"" ... flt'\-e<..c,Se-,, lou" ~ fh., 14-C...
G. W:ELL CONSTRUCTION DATA
(I) Proposed date to be constructed: Z-'2. C,. .... oc; Number of borings: __ 1/ __ _
Approximate deptl1 of each boring (feet): $'00 1
(2) Type of tubing to be used (copper, PVC, etc): /t1ro,~ O~c,"t-+ A,.., 'I
(3) Well casing. Js the well(s) cased? (check either (a.) Yes !!I (b.) No below)
(a) Yes ___ if yes, then provide casing info.rmation below
Type: __galvanized steel _____ black steel___plastic __ other (specify)
Casing depth: From ___ to _____ feet (reference to land surface)
Casing ext.ends to above ground ___ i.nches
(b) No _')( __
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grouttype: NeatCement_/ Bentonite i/ Other(specify) ____ ~_
(b) Grout placement:·· Pwnping_l(_ Pressure__ Other __
(c) Grout depth of tubing (reference to land surface); from.12. __ to f rJJ (feet)
If well has casing, indicate grout depth: from___ to ____ (feet)
FRAM :ESC
,$/
F113 1H5 29v9
NC. :919362 An'
Feb. 25 2009 05:07PM P3
FEB 24 2U09
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
L LOCATION OP WELL(S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (can be drawn) showing, buildings. property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed wells) and
any existing wells) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system. Label all features clearly and Include a north arrow_
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections_
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed..
"I hereby certify, under penalty of law, that I have personalty 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, 1 believe that the information is true, accurate and complete.
I am aware than there are significant penalties, including the possibility of fines and imp-ism/merit, 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 approved specifications and conditions of the Permit."
ignature of Property Owner/Applicant
Print or Type Fu11 Name and title
ature of Authorized Agent, if any
Print or Type Full Name and title
Plr-ce return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section -[]IC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]

FROM :ESC
Fr X M0. :9193E257133
Feb. 25 2003 O5:08PM P4
2? 9 % Getr►„earn E 'j 1,40c.
$01Z4.11+61.1"-a. ?NIL
Environmental Health Section
Health Department
209 N. GrST-FFopedafe Road
6u►1ireg[on, NC 27217
336-570-S387 bR $31
FAX: 33&570-6362
JON FOWLKES, RS.
ENVIRONMENTAL HEALTH PROGRAM SPECIALIST
fow §a!amance-nc.com www.alarnence-rtc.CAm
FEB 2 20D9
Sibol
•-� Iive eS
fo,.. t]2.crxs4-t. Her Crom.060
C xvt cvr; e''6°"D

Re: Authorized Agent Randy Faircloth
75c-/ (c?59(/?'5.
Subject: Re:_P.utha, .ed Agent Randy Faircloth
From: Went y Nisewonder <[e-mail]
Date: Fri, 27 Feb 2009 08:49:12 -0800 (PST)
To: Michael Rogers <[e-mail]>
My current address is 4543 Freedom Drive Burlington, NC 27215
The home is being guilt at 2798 Grandemere Drive Burlington, NC 27215
--- On Fri, 2/27/09, Michael Rogers <Mrchael.Ragers@nemaiLneri wrote:
Frorn: Michael Rogers <MichaeI.RogersCa;lncmaii.net>
Subject: Re: Authorized Agent Randy Faircloth
To: [e-mail]
Date: Friday, February 27. 2009, 11:46 AM
Please give me your current mailing address w/zip and the address/zip of the location of the welts if it address is different.
Wendy Nisewonder wrote:
One further note, I just found out from Randy that the address of our property has changed to 2798 Grandemere Dr.
Thank you!
--- On Fri, 2/27/09, Michael Rogers <MichaeLRoeersca_►scmaiLnetr wrote:
From. Michael Rogers <Michael.Roeers,n ncmail.net>
Subject: Re: Authorized Agent Randy Faircloth
To: wnisewonderrarvahoo.cotn
Date: Friday, February 27, 2009, 11:42 A-M
OK, thank you.
Wendy Nisewonder wrote:
Mr. Rogers,
We would Like this email to serve as notification that Randy Faircloth is acting as our Authorized Agent. Randy has our permissit
Riley's Trail, Burlington NC.
if you have any questions, you may contact us at 336-264-8236.
Sincerely,
Jason and Wendy Nisewonder
Michael Rogers
Environmental Specialist:
NC Div of Water Quality
Aquifer Protection Section (APS)
2728 Capital Blvd., Raleigh, NC 27604
Telephone [phone]; Fax [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Publi
Michael Rogers
Environmental Specialist
1 of 2 2/27/2009 3:46 PM

Re: Authorized Agent Randy Faircloth
NC Di~ of WatFr Quality
Aquifer ?._:oti tion Section (APS}
2728 Capital Blvd., Raleigh, NC 27604
Telephone (919} 715-6166; Fax [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public F
2 of2 2/27/2009 3:46 PM
Type 5QW Injection Well System
1 of 1
Subject:-Type 5QW Injection Well System
From: "Chris Faircloth" <[e-mail]>
Date: Fri, 27 Feb 2009 12:06:31 -0500
To: [e-mail]
CC: [e-mail]
Hi, Michael. Here is the information you requested:
Homeowner: Wendy Shoffner Nisewonder
Current Address: 4543 Freedom Drive, Burlington, NC 27215
Property Address for Well System: 2798 Grandmere Trail, Burlington, NC
27215
Please contact us at 336 227-2334 or via email if you need additional
information.
Randy Faircloth
Be Yourself@ mail.com!
Choose From 200+ Email Addresses
Get a Free Account at www.mail.com
2/27/2009 1:50 PM