WI0400111_GEO THERMAL_20090630

...
Permit Number
Program Category
Ground Water
Permit Type
WI0400111
Injection Water Only GSHP Well System {5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Royal Drive
Location Address
2129 Royal Dr
Winston Salem
Owner
Owner Name ·
JB
Dates/Events
NC 27106
Mitchell
Central Files: APS_ SWP_
06/30/09
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
President Vice
1908 Hamptonville
Hamptonville NC
Major/Minor
Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
J B Mitchell
Owner
2129 Royal Dr
Winston Salem NC
27020
27106
Orig Issue App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective Expiration
06/24/09
Re g ulated Activities
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
AVA
NCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Mrs. J.B. Mitchell
2129 Royal Dr.
Winston-Salem, NC 27106
Coleen H. Sullins
Director
6/30/2009
Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System
Permit No. WI0400111
2129 Royal Dr.
Winston-Salem, NC 27106
Dear Mrs. Mitchell:
Dee Freeman
Secretary
In accordance with t~e application submitted to the Underground Injection Control (UIC) Program that was received on
06/24/2009, 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 2129 Royal Drive, Winston-Salem,
Forsyth County, NC 27106. 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 Forsyth 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 liave any questions please call me at [phone].
~.A{.~D
for Mic~ogers
Environmental Specialist
GPU-Aquifer Protection Section
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400111
Forsyth County Health Dept.
David J. Brown (Yadkin Well Co., Inc., 1908 Hamptonville Rd., Hamptonville, NC 27020)
Scott Boyles (Logan Heating & Air Conditioning, 5142 N. Causeway Dr., Winston-Salem, NC 27106)
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.ncwaterquality.org
An Equal Opportunity\ Affirmative Action Employer
NOnehC 1· art . aro 1na
;JVatutaltu
Jun. 24. 2409 9:13AM YADKIN WELL
FACSIMILE TRAMMISSION FORM
No, 3163 P. 1
DATE• C / 2 / 69 TIME: REF.NO. LOG NO
TO: Sao ' ' - (33f 4 ? 7/ - Ves
COMPANY NAME . FAX NO. PLrEAse
El
LIIEIEDa FEY
IUTEMIOIk OWE
FROM' YadiCrn Wet( C-Q . «c._ (r') 6� -
COMPANY NAME MX NO. PLEASE
Deta! d + 13r4, ❑ REPLY
INDIVIDUAL DEPt
NUMBER OF PAGES PLEASE OAIGiIMPJOR'
INCLUDING THIS SHEET REPLY BY S(GNIWRE
d„,"
MESSAGE:
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P oe re yr"'w O►bc a LL',fi`
Cita w ► £ny IRS -1-14
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"FOR ALL YOUR WATER NEEd9"
YADKIN WELL CO., INC.
1990 IiAMFTONYI -LE ROAD
HAMPTONViLLE_ NC 27020
DAV1❑
J
BROWN VICE PRES.
TOLL FAIN I000T Z414:0300
OFFICE (330) &06. 440
FAx tams 440-A0A0
RES (3661 460.4659
-arm) M[Wj 0.60941cA • 9QV 'Mess vow
PLEASE QZFCIRM US MAYFLY FYOU DO NOT RECEIVE MOILS S4 HELL.

0 ~1un.24. 2009 9:13AM YA D K I N WE L L. No.3183 1 P. 2l
NOR'IB: CAROLINA
DEPARTMENT OF ENVIRONMENT AND NAT'OKAL l<ESOUR.C:ES (NCPENlt)
NOTIFICATION OF INTENT TO CONSm.ucr A C'LQSED..LOOP GEOT.ElER'MA(,
WATER.-ONLV JNJECTIONWELL SYSTEM:
TYPE 5--0 W WELL<S}
ln,.AJ:cmdm:t: with~ pm-risioos ofN'CAC 'Iille 15.A= OlC..0200_ :p~
couiplete tlJis. norffication and mail to addrt:SS on the back page (please Print or !lZ illfottnalio~.
DATE: G-lq -oq _,,zooq
WeU T-,pt: Con,fin,urlio,,..:. Poes the proposed system circnla:te potable vta-rer omy; (Do addhiVes) in
contiuuom piping tbat eompletely isolates 1he fluid from the environment (i.e.
closed-loop)?
Yes _X_ Continue completing this fono,..
No -""'!!!'"'!'I". Po Not complete mi.s ~ Com.plete othet" UIC application forms for imtallmg
either a. SA 7 w-ell ~-loop well lnjecting potable water into the aquifer) or a SQM well (elos~-
loop well eC"lmai,:,ir,g 9-dd~ ~ch as R.-22, ~tha.noi or ot.b.q an.tif(-eeze o't con-osion ixiliibnox-s ).
A. PROPERTY OWNEll(S)IAPPLICAJIT(S)
:List each :Property Owner ~d on. pr~ peed. (if owned by a 'business or gc~ ~" stat.e mme of
entity end arepresemative w/aut:hority for signawe): _______________ _
J1r,s, .X Oz 1-,..,.:Jc L.e I f
(l) Mailing Address: 2 I 2 "'t (tG ~ Q~ ...
Chy: Wm JJ..,,_J,,Ll!.rn Sum::: JI?, Zip Code: ,;t_, 7 /a~ Co~ ffet: 9ctl
Home/Office Tele No.: ? ~#1 s(/f / rJ -5 1,Z:i@ Cell No.:
(
Email Address= Websitl::
(2) Physical Address 0fWell Site (tt"differemtban.above):. ____________ _
City: __________ Stat.e:_Zip Code: _____ County:_~--~
Home/Office 1'ele No.: ---------~,C=el=LN~o=·=---------
B. AUTBOIUZED AGENT OF OWNER, IF ANY (if the PennitApplicam: does not: o"'.Xl the subject property.
at1acb a letter from the p:ope:ty owner auth~ Ag=t to msbill and operate UIC •e;ll)
CompanyNmie: l
CIWl:IICI Pe:rson; = L EMAIL A&bress:
Address; £-CJ.~
Ciey~ • = 2 St.a.ie: _ Zip Code~ ____ -_..:Com:1-i;y: -----~-
Office Tele No.: Cell.N o.;
Website Address of Company., if any:._· ____________ _
RECEIVED / DENR / DWQ
AQUIFJ:R ·PROTFr.TION ~f:CTION
JUN 2 4 2009
'.Jun.24, 2009 9:14AM 'rYADKIN WELL No. 3183 P, 3
C. WELX. DRE LBR INFORMATION
Company Name:Yadkin �iisll_Co. Inc
Weil Driller Contractor's Name: Jody Mullis Matthew Erown Muu Cave
NC Contractor Cartifscation No.: 2572-A 3036 A 3548 _A
Contact Person! David Y. Bxowe 0 k 11-g EMAIL Address: ch drill a uksn_cez
Address: 1908 Hamprouville ltd
City: Hacartenvat N.G_ Zip Code: 27020 County: Yadkin.
Moe Tate No.: 335-468-4940 Cell No.: 336-374-8736
NEAT PTTMP CONTRACTOR INFORMATION (f different Stan driller)
Company Name: Loy n, r to\ ('4f=-i a n i' rz 1 7 1
Cori c Persoi; 5ca �n y es [4�L address: Shn Li Ie'S (oyaylhiOC. �G
AddresS:S 7 V- - i r2,ir eel.tlGi471 I
G�ity . Z p Code '7� — f'6 Cvu>/-4�
OM* Tele No.. LK3 f- *A V 4/749I Cell No_: _ ‘33 do, 4 J —4320
,STATUS OEF APPLICANT
Private: Federal: Commerdek
State • MtmioiPa1: Native A the cica lands:
F. INJECTION PBDC ?XYRZ (briefi,Y deeetibe how the injection well(s) will be used)
G. WELT.. CONSTRUCTION DATA
1 ed date too be c us1x xr 2uc7�
(? Prap�s mil.. G-la Number o€txrtiags=
Approximate depth of each. boring (feet). 3 7 "
(2) Type ambits to be 'used (copper, PVC, etc): SD lQ bi ir)4i e e f, e-P.s
(3) Well casing. Is the well(s) cased? (check either (a-) Yes at , bei
(a) Yes ifyes, then provide casing bxfoonation.below
Type: _ ,galvanized steel black steel_,plsstic other. (specify)
Cag depth: From to feet (reference to lard surface)
using extends to above ground inches
(b) Na ti
(4) Qrout Info (material surrounding well casing and/or piping): rke n&Ike , ce
(a) Grout type: Neat Cunt Bentoaite ar Other (specify)
(b) Grout placement: Pumpvag Py re Other
(c) Grout depth of tubing (reference to land surface): from , , } to =?`3b (fat)
If well has ma,�g, indicate grout depth: from w (feet)

'\l u n . 2 4. 2 0 0 9 9 : 1 4 A M1 YADKIN WELL· No. 31831 P. 44
~ JNJ'ECTION-llLA.TED .EQtr.CPMENI
Attach a di;agl:am.sbowil)g the engineaing ]ayo'Ot or pioposcd. .modification of 'the iqection equipment ud exterior
pipingltubhig usocmted -with. tb.e iDjec1ion opcmi.on: The man:of;J.~s brochare may pro'\ide supplemcntny
infac:oa:tion..
L LOCATION OF WELL(S)
Amch t-o copies of maps showing1'l.= followiPg information:
(1) Include a Site Map (~ be draWD) sh.owing: 'buildings, property' mes., sudilee 'Water bodies,-po~al
sourocs of grcnmd'WateI coll'taminati.on. att4 'the oriemaiton of qd distances bet\Veo::D. the proposeo. weD(s) :B:Qd
auy ~-w=ll(s) Ol' waste disposal mcilities such as $eptic tmks or drain ~ds located witbin 20D feet of
the g~ hem: pm:u.p well .system, Label all fe.atums c:latly ~d inclnde a n~ao:aw.
(2) The Site Map U1USt show the subjed: pxopetty in rela1ion. tc tbc smrounding area by using at least two fix:ed
re:f'ennce poinu such as toatk.1 sneams:J and/or highway ~ans. . , ~ .
J. CEI<.TIFICAT~ON
Note: This Pe:rm.:it App&catiOD. mat be sig.ued by asl person appear.ia.g oa the
a-a::orded &:pl property deed.
gI hereby certify~ un&:t penalfy of law:, tl)a,: I ])ave persomlly examined zud atn iuniliar widt tb.e izlfo:rp:ration
s'l.'lbmitted. in ti4i_ c1ocumem: and all aJm.Cbm.ems thereto and ~ based on my inquiry of 'those mdmdmus
immediately :r~onsible fOI" obtaining said informa.1ion, I believe that the iDformation is true, accurate. and complete:.
I am a.wan tiult thete are sjgniiican.t penalties;, includmg tbe possibility of fines and imprisonmem; for sabmmiag
Dlsc information. I agree: 1:0 co~ operare.. ~ tepak. and i.f applicab~ abandon. the injection well and
an·rew:ed al)pmtemnces in accordance with the approved spedtications ~d cOllflidons af b, P~ . · ~oLtt;Ji!Y~ .
':::Jo 73 . 'fYt , k h e_ \ 1
Priat or Type Fall NaD:i.e and title
Sigm.mre afPropc:r:ty Ovmer/Appliamt
Print or r::n,e Fall Name and. title
Sigua'ture of A~Agem; if auy
Print or Type Poll Name and title
Please retmn tw'O copies of the completed Application pa.cbl:ge to: . .
North Carolina DENR-DWQ
Aquifer Protection Section-me Prognm
1636 Mail Service Center
Raleigh, NC 27,9j--1'36
Telepllone (919) 715-o935
• RECEIVED I DENR I DWQ
' AOUIFJ:R'PRnTFl:TlnN ~FCTlON
JUN 2 .4 2009
Jun. 24. 2009 9:14AM YADKI N WELL No, 3183 P.
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RECEIVED / [SEW I CM
AouL RP7,11ON1
JUN 2 4 zoo9

Ro gers, Michael
From:
Sent:
To:
Subject:
Mr. Rogers,
LJLDl{OO I l I
David Brown [[e-mail]]
Tuesday, June 30, 2009 9:33 AM
Rogers, Michael
Loop field info for 2129 Royal dr.
In reference to the site plan for Mrs. Mitchell job in winston Salem, The closest hole to the building,
"home", foundation is 25 ft. The second is 40 ft and the third is 43 ft. These bores will ·be placed in a
triangle pattern with 18 ft.to 20 ft. separation.
This house is on city water and sewer systems.
I hope this information is adequate to proceed, if you need further please let me know.
David J. Brown
Yadkin Well Co. Inc.
336-468-4440
Mobile [phone]
Insert movie times and more without leaving Hotmail®. See how.
1
Rogers, Michael
From:
Sent:
To:
Subject:
David Brown [[e-mail]]
Tuesday, June 30, 2009 5:08 PM
Rogers, Michael
RE: Loop field info for 2129 Royal dr. ,:,.J f' 0 ~ Ocl I I I (~ &t..J
Mr. Rogers, l,.J~)
The grout depth is 375 ft. The hole depths were originallly planned· for 350 ft. I forget to change the grout
depth to match on appli<;ation.
Thanks,
David J. Brown
From: [e-mail]
To: [e-mail]
Date: Tue, 30 Jun 2009 10::28:21 -0400
Subject: RE: Loop field info for 2129 Royal dr.
Just one more clarification-the grout depth did not correspond to boring depth. Please confirm the grout is from
bottom of boring to 0-3 feet from surface.
Thanks
Michael Rogers
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
E-mail correspondence to and from this address may be subject to the North Carolina Public -Records Law and may be disclosed to third parties
From: David Brown [mailto:[e-mail]]
Sent: Tuesday, June 30, 2009 9:33 AM
To: Rogers, Michael
Subject: Loop field info for 2129 Royal dr.
Mr. Rogers,
In reference to the site plan for Mrs. Mitchell job in winston Salem, The closest hole to the building,
"home", foundation is 25 ft. The second is 40 ft and the third is 43 ft. These bores will be placed in a
triangle pattern with 18 ft.to 20 ft. separation.
This house is on city water and sewer systems.
I hope this information is adequate to proceed, if you need further please let me know.
David J. Brown
Yadkin Well Co. Inc.
336-468-4440
M.obile 336-374-8736
Insert movie times and more without ,leaving Hotmail®. See how.
~(;~correspondence to and from " , sender is subject to the N. Public Records ,,. and may n' disclosed to third parties
I. "\ f\il I ·-~/ l lv' ~ Lt,, S,/'>~ ~~ rt ~
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