WI0400123_GEO THERMAL_20100111

Permit Number Wl0400123 /
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule "
Permitted Flow
Facilitv
Facility Name
Sean Crane SFR
Location Address
6790 Brookbank Rd
Summerfield
Owner
Owner Name
Sean
Dates/Events
NC 27358
Crane
Central Files: APS_ SWP_
01/11/10
Permit Trac.king Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Phil Grandy
Contractor Heat Pump
PO Box 11064
Winston Salem NC
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Sean Crane
Owner
6992 Brandi Wood Cir
Summerfield NC
27116
27358
Orig Issue
01/11/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
01/11/10
Effective
01/11/10
Expiration
01/05/10
Re g ulated Activities
Heat Pump Injection
Outfall r ;u~ .:
Waterbody Name Stream Index Number Current Class Subbasin
il..~A s_;~--~-·-·~ .....
NCDENR
North Carolina Depa1iment of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Sean Crane
Nancy Crane
6992 Brandi Wood Circle
Summerfield, NC 27358
Coleen H. Sullins
Director
1/11/2010
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400123
6790 Brookbank Rd.
Summerfield, NC 27358
Dear Mr. & Mrs. Crane:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on
01/05/2010, the Aquifer Protection Section (APS) acknowledges your intent to construct a closed-loop geothennal water-
only injection well system for the operation of a ground-source heat p~mp located at 6790 Brookbank Rd., Summerfield,
Guilford County, NC 27358. This system is deemed permitted by rule (North Carolina Administrative Code Title 15A,
Subchapter 2C, Section .0211 (u)(2)).
However, it is recommended that you contact the Guilford 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].
~~· ~oo}wtQ
for Mic~ogers
Environn'rerital Specialist
GPU-Aquifer Protection Section
cc: Winston-Salem Regional Office -APS
APS Central Fiies -'Permit No. WI04001 23
Guilford County Health Dept.
David J. Brown (Yadkin Well Co., Irie., 1908 Hamptonville Rd., Hamptonville, NC 27020)
Phil Grandy (Logan HVAC, P.O. Box 11064, Winston-Salem, NC 27116)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Locat1or.: 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.ncwaterauali t1 .o r;i
An Equal Oppr,rtunili' \ Affirmative Act:on Employer
Nirth Carolina
/Vaturall!f
Jan, 5, 2010 10:59AM YADKIN WELL P,,/ 1-- i/"_1 'j J H . 4321 AP 1
- FACSIMILE TRANSMISSION FORM
DATE* / / .s' /2orl TIME:_ RAE NO. _ LOG NO.
TO: #'C 0 150" (z ( gig) oceir
ri£ ( 1 e.S Ur-J
ATTENTION DEPT
FROM' ':xik t"Jd.+eid 6. rJ' c (I. ) 5((P - Vo v.?
COMPANY NAME FAX NO. PLEASE
0a,_1ci ❑ al
INDIVIDUAL DEPL
NUMBER
INCLUDING THIS F SHEET REPLY PLEASEY SWORE •rl%LY
MESSAGE:
44,JLc„Tr , ,sr- On cis k-i,, 40 J, .1
c/1.--i-r.., . - y Seor+ <I 47iry C 0.-Lc.
COMPANY NAME . rot NO. PLT.ASE
❑ UMMEGIATELY
e-1,2J Ci► i e ciri l o,.r _ r_srb. ca,i-.
"FOR ALL YOUR WATER NEEDS"
YADKIN WELL. CO., INC.
1908 1HAMPTDNVILLE ROAD
IKAMPTONVILLE. NC 27020
DAVID J. BROWN. VICE PRES.
TOLL FREE i8001 248M355
OFFICE [phone]
FAX t336I 468-4046
RES t9361 468.4669
Y.GOC NEW4 *hl6P$CA - GPI? 1.0VC; 701,11"
PLEASE INFORM US tMHEDUWELY I'IOU DO NOT RECEIVE FAGSU.p R4 FULL

Jan. 5. 2010r 10:59AM YADKIN WELL
\AILD(-WQ-3 "No, 4321 r. P. 2
• • Noim Cfl1DLRiA
DEMETKEINT OF ENVIRONMENT AND NATURAL RSDtJRCES WCDENR)
NOTIFICAUON &INTENT TO comma A CLOSED-LOoP GEOTHERMAL
WATER -WV Drumm WELL SYSTEM:
Tra S-ow
In Morava with the prev1sions of MACVile 15A; 02C0b200. -
ctuoptete ibis not uafian auci memflia 6Cidn'tf oA the lie* (please P at or AN informaCanj.
DATE: /2 - /4Z- 200
Weil Ape Conf r matiaa: Does the proposed system circulate pa le YoUssRIX (no nddls a"aes)
continuous piping that completely isolates the fluid from tho eaavirottmeat (i,ar.
close g 7
Yes X Continue completing this forts
No _Do Not comply this form. Complete other WCWillman!' f far installing
'Atha- a 5A7 well (oza-loop vfLO injsggig potable 'maim Ito iho agnire0 u r a 50/ wcli (clasod-
loop wall captaining additives such sa R-22, ethanol, or other antifreeze or conaiinn inhibitor's),
PROPERTY OWNE*(8)IAPPLYCANI(s)
List each Wormy Owner listed on propetty deed (if owned byahiltless et goverment areGY, slats narge of
eat>ty and a re}frsentaase wlauthmaity for sigratarcr eQA 4 /42.l?G y Ctea r►_e
(2)
mailing manic 4 9f • 4 m)D) + pah 6
city-, fi-Eb_ State;Ak.7ap Codes - PI County
Hamel'UMW: c N •
Email Add[css :. - - 1Y413s(to:
Physimil Address of Well Rite Of afifFereuttkm above): 63 3O RkaQlL l dui 1
ciitr..ic.eherE 4Ln SiatwAtrap Code; V-7 3 ce cam �rrx,i
Eantia1OthcaTeleNo.: 11I1v
fl. AUTNOILIZED AGENT 0P OWNJflR. AN) Odom renal Aplrlicus win the SubjiXtpro
MAO A letter from gar pointy Om adhotizlog AgeAT m WWI ea d ammo UIC,ratill
Company Ni:ae
Coaosct Pamir EMAILAddtsv,
Address_
City; - Slele: 2Ip Cuda: Camay;
Mee Tele No.: • coil Nam:
Waite Address of may, if

Jan. 5, 2414 14:59AM YADKIN WELL "-No. 43211' P, 3
U.
DRILLER INIORMATION
Comp Loy Naga X'ad s WeJ Co, Inc.
Weil Wilier Contractor's Name:
NC Contractor Calificatioo No.4 207V- - 3036 -A 3 548 - k
Cawet rersoto: • a se.com
Addresst 1906 Hamp onailie Rd..
City: Ram3QIwi1lg + - rip ryes x70.o C000ty: YEAcink
OfBaa TeleUO.: 336-46S-4440 CellNo.:336-17i-87 6 '
BRAT PUMP CO TRACTOR 3NPOAMATYON (if dfiffciairt, Sao dr®er)
Camtpn,oyName: lO fah
Contact Person• " aav t ry EMAIL Aids p P".••4 eiziork k clan, �s i
maresif: ox UOCY -
City: flot- S ilco% Zip Cc o Fr* , X
office WOW 13C ro_- CeUNo.: S.3fr self,_4it gst
R. STATUS On APP,Lrcorr
Mat Eutaw: common
Seam: Munlcipab Nat is Anvilcao 9:
le ICUICTZON PROCEDQAX (briefly des csibebow the I cct onw dlKs)'iibe used)
Cbier.. 'Lvf _r G.
G V LL CONSTRUCTION DATA Jtr Z1-01
(f) Proposed dateto be memo tad; din& `'if' _ nusba ofborlow
itpproxiite depth *feed beat% 2 I..,e1 _16a
(2) Typo ott ttg to ba used (rapper, rye, etc}- If a Pt
(3) Weil casing• bete we ) cased? (check a tbet (,)Yens (b)No below)
(s) Yes lfyes, datalaoftdo eating kolonnition,bolooi
Tex .a�W blsslr eI ' )
�f (rofiarouco to Indsolace)
Cast* aitiosts1¢ hiliovs ground _ ias s
CO No
(4) Brood Lao (materialawrooadmg well casing andtor piping):
(a) (trod typo: Neat Cry Ewdoaite ether (cpcci) T
(b) Grout plartsaeat: rpi . t r r
(V3 GToul {tee &tuft 4rzlzmuorics s:urt~uaej: from 3 to 3 04 101)
If well has using, itulicatt gout dam: from tv )

`Jan, 5. 2010 10:59AM ' YADKIN WELL` "No, 4321 " P. 4
$. IIV7ECTION-LATE? > UIdPMV T
itrisch a diagram strafing the onglnettiag layout or proper mod4ficadoa of tbv ird colon egulpmena and wirier
pipioetubing associated with the Infection operation. The marmfactoraers book= may provide supplementary
X. OCA,UON OF'WELL(S)
Attctwo Dories ofmmps ha►vissg die Mowing Information_
Includes Site Kap (am ba draws* *Mast buildings, ptoyerty linear, sodnea avatar bodies; potrasria1
paanoer or groundwater consininetion oral the osicatatinn of sad lutes betweattthe proposed wail(} and
any exisdag was) at wash diipcaa1 facilities sb at septic Mks tar dial hods located within28G tsc4 of
fatc gentiorml beat pump vrlllsystem. 1el sil 1Pentmes *MY ailablpirlia.
Gtj Tho Siti bllalt must shave the =tootmaety In relation to tht angina * s by want to lcw two resod
reftenea potrds soma roads, msms, andlar highway interseratom.
CERTARCATWN
Not This Permit Applies rio* mast b+ good by s'l pAMU %ppm-tug an the
rrcox led legal pxapertJ dee&
'Way toffy. tinder peaty of lee, that I lava persona/Ity maimed and am familiar ► ith the information
submitted in this daft and an titteelsteents thereto and If bused on my foggily of tbotc Iodleldah
lonedistaly responsible Sr obtaining sell infc,matlou 1 believe ibatthe lalatiration Is Imo t WX4ta and CMapleto-
i sin swam -that tin are significant pspaW' bteboling der possibility of rues and ln0rbot1M, k sabmhtles
faLa ird+'o doe. t agree to coperact, ifstpplireable, Oita h rho *dim viva read
salted apptolamotriti acceolginee itao dip sad conditions trio Paola"
Axiom of Property OwnerIAppbcani
plo(orTypo Mime Oat*
P7Ca Cm•a ft e.
Not &Typo Falligarne a tie
Suture ofitudrosited Avetj Um
• iad� at Type FANama and brio
Phase )reti u tWo oaf ofthe co ogpleied APPHeatiOn Mohr to:
North Groans D]tNR-»WQ
Aquifer Protection Section -MC ProgrnM
1 6.hlin Bonito Canter
ugh, NC 211/9P-1696
TtlDO oIle 019) 7154935

fan,
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20101s-11:00,1f, YADKIN WELL" ( 1 � T jar
No.4321' P. 5'
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Ro gers, Michael
From:
Sent:
To:
David Brown [[e-mail]]
Sunday, January 10, 201 0 8:53 AM
Rogers, Michael
Subject: RE: Crane 5QW well
Michael,
Sorry I omited that info. Mr. Crane's cell # is 336-207-4841.
Thanks
David Brown
Yadkin Well Co. Inc.
From: [e-mail]
To: [e-mail]
Date: Thu, 7 Jan 2010 12:03:56 -0500
Subject: Crane SQW well
David-
Do you have a phone number for the Cranes? We need at least one phone number to enter into our
database for contact information (work, home, cell, etc.).
Thanks
Michael Rogers, P.G. (NC & FL)
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
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