WI0400124_GEO THERMAL_20120517 (2)

Beverly Eaves Perdue
Governor
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E.
Director
May 17, 2012
Shannon and Ashley Thompson
335 Cool Springs Drive
Blowing Rock, NC 28605
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0400125
Dear Thompsons:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria .and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http://portal.ncdenr.org/web/wq/aps.
If you have any questions regarding your current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely, t;_. /»d-.
Eric G. Smith, P.O.
Hydro geologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: 919-807~6496
Internet: www.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer
N°~i..c · · 1· . 01. u..1 aro ma /Vat11rnltv
6- e..19
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Nalural_Resources• Divfnion of Water Quality
WELL CONTRACTOR CERTIFICATION # 303 6 4
1. WELL CONTRACTOR:
/114-.4.4.e.t,. -I- Ian
Well ContraClor (Individual) Name
YADKIN WELL COMPANY, INC.
Watt Contractor Company Name
STREET ADDRESS 1908 HAMPTONVILLE ROAD
HAMPTONVILLE NC 27020
City or Town Stale Zip Code
f 336 }_ 46B-4440
Area code- Phone number
2. WELL INFORMATION:
SITE WELL IDS (Lf aFptrcable) /O _ 5 3
WELL CONSTRUCTION PERMIT#(ifnpptieabie)
OTHER ASSOCIATED PERMIT *Of appticable)% 7�l./.2_S
3. WELL USE (Check Applicable Box) Monitoring° MunldpallPubllcf
tndustdalfCommerclal❑ Agriculturarq Rerat(eryf InJectionC
Irrfgattoro Olher�S(list use) oo if- R ve...c.+ C tcrs 1'L, Loiy
DATE DRILLED C ` I()
TIME COMPLETED 3: AMC' P[V
4. WELL LOCATION:
C}TY: �►11�C' }� COUNTY A-)414"Cr( f1
(Street Nerne, Numbs Com Wily, Subdlvrston, Let No., Portal, Zip Cade)
TOPOGRAPHIC / LAND SETTING:
NOlopo 0 Valley 11 Flat l3 Ridge p Other
(check appropriate box) May he in degrees,
LATITUDE 1, (1. 10 . T. S 3 minutes, seconds or
in a decImal format
LONGITUDE a l 4LJ,, y,3
Latitude/longitude source: XOPS 33 Topographic map
((ocean of wait must be shown On a USGS lapo map end
altachad la [his form if not using GPS)
6. FACILITY- Is ale name of the Mir ais,tihet* the well Is located.
FACILITY ID #(if applicable)
NAME C3= TCTTY r1& OI1LIa rN TAa.rspJ6 r{‘
STREET ADDRESS .7.30 Gms,( CpA-rr1 r it-C`< City or Town Slate ZIp Code [,
CONTACT PERSON IL.7. La J •4, ,. PJIJ2'. 1I T eJ i[][h«
_ .- /4Ia+��""
MAILING AODRESS+�u,Y 14t3 5 Its
City or Town Slate Zip Code
(gar )-2C—6c2r 0-22S•c(6V,ctogr
Area node • Pho a number
a. WELL DETAILS;
a. TOTAL DEPTH: 2 - '
b. DOES WELL REPLACE EXISTING WELL? YES0 NI*
c. WATER LEVEL Below Top of Casing: .2 ‘t FT.
(use •+` if Above Top of Casing)
F
d. TOP OF CASING IS FT. Above Land Surface`
"Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118,
e. YIELD (gpm): a METHOD OF TEST AIR PUMP
1. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth):
From
From
From
e7n pta'API
. CASING: Depth
To
To
From
From.
From
To
To
To
Diameter Thickness'Weight
Fram_ To )a Ft._
From To _ FL
Front To FL
8. GROUT: Depth Material
From 0 To $ Ft 74 r _
From To Ft.i slirrrLet_
From To FL 164., l4.wi i
9. SCREEN: Depth
From
From:
F;nn;
Material
Method ,S
Diameter Slot Size Melerlal
TQ
To FL in.
10. SAND/GRAVEL PACK
Depth
From
From To
F. rI/
11.DRILL1NG LOG
Frtoin To
T1•;}}I
12, REMARKS:
in.
In.
Stze Material
F
Ft.
Ft fr Y�
Formation Description
SIZE OFF .S, `]'%' ''
BIT SERIAL Na_ (IT ► ,;
I DO HEREBY CERTIFY THAI TRES WELL WAS CONSTRUCTED it1 AGCOROANCE WITH
IMA NCAC 2C, WELL cousrnUC1'foM STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROMO O TOIh WELL OWNER,
: ' _
SIGNATURE OF CERTIFIED WELL CONTRACTOR
DATE
/ 4 / 4e k-, /u .-n
PRINTED NAME or PERSON CONSTRUCTING THE WELL
Aibg.t
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
n 1617 Mall Service Center— Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Bill : Ir16w�i-Crl►•rr ���' � -]ef is duo (r1.5
F❑(30x lror NCB, 2Esc07 it, 9 ko
r,u.- n►drC
Form GWlb
Rev.12fi)7

-7
1,

GEO-THERMAL WELL CONSTRUCTION RECORD
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Departbncnl or Environment end Natural Ream reap Division of Water Quatity
WELL CONTRACTOR CERTIFICATION H 0 3 6 A
1, W/E/�LL CONTRACTOR:
Well Contractor (lndMdval) Name
Vaaj n Writ ] flnj ny n7C.
Weft Contraelor Company Name
STREET ADDRESS 19fl1 tramph- ntri jlA 17 rd
Haireptonville i1C 27020
oily or Tat State Zip Cods
f 336 y_ 468-4440
Areacode- Phone numb er
2, WELL INFORMATION;
SITE WELL ID f(il apprIcablef
STATE WELL PERMIMI! applicable)
DWO or OTHER PERMIT ir(Ereppticaboj "i .1: C►y 0 °L2' r
WELL 135E (Check Applicable BoX) Monitoring ❑ V.unlcipat'1Publto II
In dusideflCarrunercIot D Agricullu to Rec jrvety C3 inf norr Q/I�
IrdgatIonn Otherk(l1s1 nee) b @o r4� f'f'`� C •'+ 1 4
uu
DATE DRILLED 6" reLfra
TIME COMPLETED 0.) AMb P1.
3.WELL LO TioN:
CfTYOL, aIk.C- COUHr. PAY i 514
30 C oa �y
tsrrsel Noma, Numbers., C Amenity, bdlsston, Let Foal, Zrp Coda)
TOPOGRAPHIC ILAI•1D SETTING
A310p8 L]Va'Iey ❑Fla( LRldga 0 Olhai
(check appropriate bon)
LATITUDE �(Q . y, ( Maybe'ndegrc s.
$ l • [� !7-Y Inta decfnul (or t
meads or
LONGITUDE
Latitudeitongitudc source: , (tWE DTopagraphto map
(locatlen of welrmiusf be shown one USG8 lope mop and
attached to this ram Pot using GPS)
4. PAC:Mi Y. is u.t tram clue !minus WIN& ihr trta Is 36ca nd.
FACILITY ID AV eppllolble
NAME a s et>_ F' S Qhi.Pr, I f>vs*iz+r�sr. L
STREET ADDRESS .1So rifis-. h, ft
_40It c u
City or Tom Stale )Zip Cade
CONTACT PERSON 4a1►r3c 1 i-cle/Y-14 I n e
cotha
MA�}1Nr3ADDRESS Pt. / 4/0.)�7 f
r 044 "f
City or Town Stele Zfp Coda
f YJ_k )cz- a C LJ- M pap. r( 5-
Area cede- Puma number VU i /
S. WELL DETAILS:
fa. TOTAL DEPTH: .2-(
b, DOES WELL REPLACE EXISTING WELL? YEE ❑ NOS
e. WATER LEVEL Seldk Tap of Csakig: ) 8 a. . FT.
(U34'+• If Above Top of Casing)
d. TOP OF CASINO IS FT. Above tend Surface"
'Top of casing terminated eVrr below land mince may require
a variance fri accordancaWiith 16A NCAG 20.0118.
o. YIELD tgpm): 0 METHOD OF TESTi
t. OISfNFECTION:Typa HIM Amount
a, WATER ZONES (depth):
From To From To
From To Frorn_To
From___ „To Front _To Aifar
T cs°ttzvr Thtcpxfessr
Depth t]tamale/ Weight
Fro±.,! To >j is
Frorrt___To FL _
Frmi 14 .Ft.
7. oRal3T: Depth Material
Roar 0 To puma 1lj
From_ _ To Ft. E411A-w.0
From _To _. Rr. in.+ 1 ee1
8, SGREEN:
Fr
FT
Material
Method
Depth DIamater 611181ra Maternal
�To Ft. ln. tn.
To Ft In, In.
9, sANDJGRAVEL PACK:
. Depih .... Size Matilda?
Fran_ To /t
F To_ Ft.
f� Y TT{ Fly J
10, DRUM LOG
From To Forrrmatbrf Description
f► .r ' �,.• r
ti
11. REMARKS:
.e#
tDOHrnarY mum riaratis wen Ms i �4irH
WAG 10.WELL C 11GSION TANDARDSPro aF SUSS
RECORD DEM PAM hp TOME WELL OWNER.
emu. 6-3 —IU
SIG AT ME OF' CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONBTRt3CTIN:2 THE WELL
Subrilit the original to the division of Water Duality WNW 30 days#. Attn: Infarrnotlon Mgt.,
1817 Mall Salvino Center-- Raleigh, NO 27999.1617 Phone Ala; (9i9) 733 701t3 ext 668.
Date site visited: /%` go by s'—zi Permit required: O
Fain [iW1b
Rev, 7105

NA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water ·auality
Beverly Eaves Perdue
Governor
Shannon. an.cl Ashley Thompson
335 Cool Springs Dr
Blowing Rock, NC 28605
Dear Mr. and Mrs. Thompson:
Coleen H. Sullins
Director
March 31, 2010
Subject: Issuance oflnjection Well Permit
Permit No. WI0400125
Issued to Shannon and Ashley
Thompson
Watauga County
Dee Freeman
Secretary
In accordance with your application received January 25, 2010, I am forwarding Perm.it No. WI0400125
for the construction and operation of a vertical closed-loop geothermal mixed-fluid heat pump injection
well system to be located at the above referenced address. This permit shall be effective from the date of
issuance until February 28, 2015, and shall be subject to the conditions and limitations stated therein.
Please pay special-attention to Part VII.2 of the permit and submit copies of the Well Construction
Completion form (GW-1) after construction. Please submit all data within 30 calendar days of
completion of installation of geothermal well(s) to the following address:
Aquifer Protectio~ Section (APS)
Underground Injection Control (UIC) Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
Additionally, your UIC system is subject to inspection by the APS. Per special condition Part 11.3, in the
event that there will be multiple wells with separate clusters, one well identification tag per 'cluster' of
wells shall be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location according to 2C .0213(g).
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit three months prior to its .expiration date. As indicated in the permit, this
perm.it is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Quality. If you have any questions regarding your pemiit or the Underground Injection
Control Program please call me at [phone].
Sincerely
Michael Rogers, P.G. (NC' & FL)
Environmental Specialist
cc: Sherri Knight Winston-Salem Regional Office
Central Office File — WI0400125
Appalachian District Health Dept.
David Brown - Yadkin Well Company, lac.
Attachment(s)

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
~aws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Shannon and Ashley Thompson
FOR THE CONSTRUCTION AND OPERATION OF 2 TYPE SQM INJECTION WELL(S), defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at 335 Cool Springs Dr., Blowing Rock,
Watauga County, NC 28605, and will be constructed and operated in accordance with the application received
January 25, 2010, and in conformity with the specifications and supporting data submitted; all of which are filed
with the Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation of an injection well and shall be in compliance with Title 1 SA of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other ~pplicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until February 28, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 31 st day of March 2010.
~oleen H. Sullins, Director
\ Division of Water Quality
By Authority of the Environmental Management Commission.
Permit WI0400125 UIC/SQM
ver. 03/2010
Page 1 of 5
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways. ·
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number [phone], and the Winston-Sakn1 Regional Office Aquifer Protection Section Staff,
telephone number [phone].
2. Th~ location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site ( e.g., building foundation comers) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
3. One well identification tag per grouping or 'cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g).
PART III -OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days priorto the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
Permit WI0400125 UIC/SQM
ver. 03/2010
Page 2 of 5
PART IV-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In· the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be r~quired to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
ground water resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Pennittee must notify the Division and receive prior· written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permi~.-
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the AquWer Protection Section's_ Underground Injection Control (UIC)
Program.Central Office staff, telephone number [phone]. Notification is required so that Division
staff can inspect or oth,erwise review the injection facility and determine if it is in compliance with permit
conditions. ·
PART VI: INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining',corilpliance with this pemiit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water; or injection fluids.
2. Division representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
Permit WI0400125 UIC/SQM
ver. 03/2010
Page 3 of 5
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem. NC 27107
[phone]
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Winston-Salem Regional Office within 30 days of
completion of well construction. Copies of the GW-1 fonn(s) shalt also be given to the Permittee and
retained on site to be inade available for inspection.
3. A copy of the site map updated with manifold locations required in Part II.2 of this permit shall be
submitted'tothe Aquifer :Protection:Se·ction.::CentralOffice aiiclthe-Winston..;-Salem-Regional Office within
30 days of completion of well construction.
4. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection will be established and an
acceptable sampling reporting schedule shall be followed.
5. The Pennittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Winston-Salem Regional Office, telephone number [phone] any of the
following:
(A) Any occurrence at the injection facility that results it?-any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
( C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
6. Where the Pennittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information subm.itted in said application or in any report to the Director,_ the rel~vant __ and correct
facts or information shall be promptly submitted to the Director by the Permittee. ,
7. In the event that the permitted facility fails to perform satisfactorily, the Pennittee shall take such
immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew ,the permit 120 days prior to its expiration date.
Permit WI0400125 UIC/SQM
ver . 03/2010
Page 4 of 5
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l).
Notification shall be submitted to the addresses given in Part VII.I of this permit.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 1 SA NCAC 2C
.0214, including but not limited to, the following:
(A) · All casing and materials may be removed prior to initiation of abandonment procedures if the
Director finds such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The--entire depth ·of each well shall ·be sounded before ·it ·is ··s·ealed--to insure freedom-from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director µetermines that failure
to do so could lead to the contamination of an underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the well
through a pipe that extends to the bottom of the well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been removed, the
casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout
-injected through.the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in ISA NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.1 of this permit.
Permit WI0400125 UIC/SQM
ver. 03/20+0
Page 5 of 5
ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
March 31.2010
Sharpon and Ashley Thompson
Cool Springs Dr
ne, NC 28607
6ZJ T ftzoi
,ap Subject:
n _
Dear Mr. and Mrs. Thompson:
Issuance of Injection %N eil Permit
Permit No. WI0400125
Issued to Sbannon and Ashley
Thompson
Watauga County
In accordance with your application received January 25. 2010, I am forwarding Permit No. WI0400125
for the construction and operation ofa vertical closed -loop geothermal mixed -fluid heat pump injection
well system to be located at the above referenced address. This permit shall be effective from the date of
issuance until February 28.2015, and shall be subject to the conditions and limitations stated therein.
Please pay special attention to Part VIL2 of the permit and submit copies of the Well Construction
Completion form (GW-1) after construction. Please submit all data within 30 calendar days of
completion of installation of geothermal well(s) to the following address:
Aquifer Protection Section (APS)
Underground Injection Control (UIC) Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
Additionally, your UIC system is subject to inspection by the APS. Per special condition Part 113, in the
event that there will be multiple wells with separate clusters, one well identification tag per `cluster' of
wells shall be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location according to 2C .0213(g).
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit three months prior to its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Quality. If you have any questions regarding your permit or the Underground Injection
Control Program please call me at [phone].

cc: Sherri Knight-Winston-Salem Regional Office
Central Office File -WI0400125
Appalachian District Health Dept.
David Brown -Yadkin Well Company~ Inc.
Attachment( s)
Sincerely,
-~fl-;--
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Shannon and Ashley Thompson
FOR THE CONST~UCTION AND OPERATION OF 2 TYPE SQM INJECTION WELL(S), defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at 330 Cool Springs Dr., Boone, Watauga
County, NC 28607, and will be constructed and operated in accordance with the application received January
25, 2010, and in conformity with the specifications and supporting data submitted, all of which are filed with
the Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation of an injection well and shall be in compliance with Title 15A of
the N:orth Carolina Administrative Code 2C .9100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until February 28, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 31 st day of March 2010 .
hr\ Coleen H. Sullins, Director
\ Division of Water Quality
By Authority of the Environmental Management Commission.
Permit WI0400125 UIC/SQM
ver. 03/2010
Page 1 of 5
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina -Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not ~ydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number (919) 71 5-6166, and the \,Vinston-Salem Regional Office Aquifer Protection Section Staff,
telephone number [phone].
2. The location of each of the system manifolds shall be recorded by triangulation fro~ three permanent
features on the site (e.g., building foundation comers) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
3 . One well identification tag per grouping or 'cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g).
PART III-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change oflhe Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
Permit WI0400125 UIC/SQM
ver. 03/2010
Page 2 of 5
Permit Number WI0400125
Central Files: APS SWP
03/30/10
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit•
Status Project Type
in review New Project
Version Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville
NC 27020
Facility Name
Shannon and Ashley Thompson SFR
Location Address
330 Cool Springs Dr
Boone NC 28607
Owner
Owner Name
Shannon
Dates/Events
Orlg issue
03/31/10
App Received
01/25/10
Re}ulated Activities
Thompson
Draft Initiated
Major/Minor Region
Minor Winston-Salem
County
Watauga
Facility Contact Affiliation
Scheduled
Issuance
Owner Type
Individual
Owner Affiliation
Shannon Thompson
Owner
330 Cool Springs Dr
Boone
Heat Pump Injection
❑utfali
Public Notice issue
03/31/10
NC 28607
Effective Expiration
03/31/10 02/28/15
ReDuested/Received Events
RO staff report requested 02/03/10
RO staff report received 03/17/10
Waterbody Name Stream Index Number Current Class Subbasin

Permit Number WI0400125
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
F acilit
Facility Name
Shannon and Ashley Thompson SFR
Location Address
330 Cool Springs Dr
Boone
Owner
Owner Name
Shannon
Dates/Events
NC 28607
Thompson
Scheduled
Orig Issue App Received Draft Initiated Issuance
01/25/10
Re g ulated Activities
Heat Pump Injection
Outfall r~~.Li...
Central Files: APS_ SWP_
03/26/10
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville NC
Major/Minor
Minor
Region
Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Shannon Thompson
Owner
330 Cool Springs Dr
Boone NC
Public Notice Issue Effective
·~\~, \h.)
Re o uested/Received Events
RO staff report requested
RO staff report received
27020
28607
Expiration ~13-~\,s
02/03/10
03/17/10
Waterbody Name Stream Index Number Current Class Subbasln
ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
March 31, 2010
Shannon and Ashley Thompson
330 Cool Springs Dr
Boone, NC 28607
Subject: Issuance of Injection Well Permit
Permit No. WI0400125
Issued to Shannon and Ashie�
Thompson
Watauga County
Dear Mr. and Mrs. Thompson:
In accordance with your application received January 25, 2010, I am forwarding Permit No. W10400125
for the construction and operation of a vertical closed -loop geothermal mixed -fluid heat pump injection
well system to be located at the above referenced address. This permit shall be effective from the date of
issuance until February 28. 2015, and shall be subject to the conditions and limitations stated therein.
Please pay special attention to Part VII.2 of the permit and submit copies of the Well Construction
Completion form (GW-1) after construction. Please submit all data within 30 calendar days of
completion of installation of geothermal well(s) to the following address:
Aquifer Protection Section (APS)
Underground Injection Control (UIC) Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
Additionally, your UIC system is subject to inspection by the APS. Per special condition Part IL3. in the
event that there will be multiple wells with separate clusters, one well identification tag per 'cluster' of
wells shall be permanently affixed to the heating and cooling unit or other nearby permanently fixed
location in a clearly visible location according to 2C .0213(g).
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit three months prior to its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Quality. If you have any questions regarding your permit or the Underground injection
Control Program please call me at [phone].

cc: Sherri Knight -Winston-Salem Regional Office
Central Office File-WI0400125
Appalachian District Health Dept.
David Brown -Yadkin Well Company, Inc.
Attachment( s)
Sincerely,
~ tn;~
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, a:nd Regulations
PERMISSION IS HEREBY GRANTED TO
Shannon and Ashley 7hompson
FOR THE CONSTRUCTION AND OPERATION OF Z TYPE 5QM INJECTION WELL(S), defined in Title
lSA-North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop'
geothermal mixed fluid heat pump system. This system is located at 330 Cool Springs Dr., Boone, Watauga
Co_unty, NC 28607, and will be constructed and operated in accordance with the application received January
25, 2010, and in conformity with the specifications and supporting data submitted, all of which are filed with
the Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation of an injection well and shall be in compliance with Title 15A of
the North Carolina Administrative Code 2C -.9100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until February 28, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 31st day of M.arch 2010.
hf\ Coleen H. Sullins, Director
\ Division of Wat~ Quality
By Authority of the Environmental Management Commission.
Permit WI0400125 UIC/SQM
ver. 03/2010
Page 1 of 5
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not l:iydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number (919) 715-6]66, and the vVinston-Salem Regional Office Aquifer Protection Section Staff,
telephone number [phone].
2. The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation comers) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
3. One well identification tag per grouping or 'cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g).
PART III-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
Permit WI0400125 UIC/SQM
ver. 03/2010
Page 2 of 5
PART IV-PERFORMANCE STANDARDS
' \ I
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to .surface or
ground water resulting from the operation of this facility.
PART V ~ OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior· written approval from the Director of' any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's-Underground Injection Control (UIC)
Program Central Office staff, telephone number [phone]. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions. ·
PA.RT VI -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect .or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Division representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
Permit WI0400125 UIC/SQM
ver. 03/2010
Page 3 of 5
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section -UIC Program
DENR -Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
Winston-Salem Regional Office
585 \Vaughtown Street
'Winston-Salem . NC 27107
[phone]
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Winston-Salem Regional Office within 30 days of
completion of well construction. Copies of the GW-1 form(s) shall ·also be given to the Permittee and
retained on site to be made available for inspection.
3. A copy of the site map updated with manifold locations required in Part II.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Winston-Saiem Regional Office within
30 days of completion of well construction.
4. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection will be established and an
acceptable sampling reporting schedule shall be followed.
5. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Winston-Salem Regional Office, telephone number [phone] any of the
following:
(A) Any occurrence at the injection facility that results iJ.?. any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or .electrical failures;
( C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
6. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and correct
facts or information shall be promptly submitted to the Director by the Permittee.
7. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
Permit WI0400125 UIC/SQM
ver. 03/2010
Page 4 of 5
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l).
Notification·shall be submitted to the addresses given in Part VII.1 of this permit.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to, the following:
(A) · All casing and materials may be removed prior to initiation of abandonment procedures if the
Director finds such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that failure
to do _so could lead to the contamination .of an underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the well
through a pipe that extends to the bottom of the well and is raised as the well is filled.
(E) In the case of gravel-packed wells in whi,ch the casing and screens have not been removed, the
casing shall be perforated oppostte the gravel pack, at intervals not exceeding 10 feet, and grout
injected through the perforations.•
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specifiecj
in 15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.l of this permit.
Permit WI0400125 UIC/SQM
ver. 03/2010
Page 5 of 5
Ro gers, Michael
From: Knight, Sherri
Sent:
To:
Wednesday, March 17, 2010 12:18 PM
Rogers, Michael
Subject: RE: WI0400124 WI0400125
I did find these. They had come in when I was out and I filed them in my UIC email folder. So ahead and issue. I don't
have anyone to look at right now and I won't be able to look within the next few weeks. The application indicated that
there are no on-site wells so I assume there is public water available. I can't tell from the tax web site.
Sherri l<night, PE
NC DENR Winston-Salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-maiL~&re.spondence to and from this address may be subject to the North Carolina Public Records Law a•,nay::toe
disclosed to third parties.
From: Rogers, Michael
Sent: Tuesday, March 16, 2010 1:01 PM
To: Knight, Sherri
Subject: WI0400124 WI0400125
Sherri-
What is the status of the above 5QM wells? I sent over the Applications 2/3/10. If you do not wish to conduct a pre-permitting
inspection, let me know and I will start permitting process.
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
1
Ro gers, Michael
From: Rogers,· Michael
Sent:
To:
Wednesday, February 03, 2010 4:09 PM
Knight, Sherri
Subject:
Attachments:
WI0400124 and WI0400125
Russell.pdf; Thompson.pdf
Attached are two Apps for SQM wells. Please let us know if you wish to conduct pre-permitting inspections or not. If
you elect not to inspect, we will issue permits.
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
;.;P,°~;-l · --->~: :•·
1
Beverly Eaves Perdue
Governor
Shannon Thompson
Ashley Thompson
330 Cool Springs Dr.
Boone, NC 28607 ·
AVA
'HCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
February 3, 2010
Subject: Acknowledgement of Application No. Wl0400125
Shannon Thompson SFR
Injection Mixed Fluid GSHP Well System (5QM)
Watauga
Dear Ms. Thompson :
Dee Freeman
Secretary
The Aquifer Protection Section of the Di"'.isiC>q,,qfWater Quality (Division) acknowledges receipt of your permit application and
supporting materials on January 25, 2010. This application package has been assigned the number listed above and will be reviewed
by Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests.
'
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 -90 days after receipt of a complete
application.
If you have any questions, please contact Michael Rogers at 919-715-6166, or via e-mail at [e-mail]. If the
reviewer is unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To
review our new organizational chart, go to h ttp ://h2o.enr.state.nc.us/documents/dwg orgchart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON TIDS PROJECT.
~ ~~D
for Debra ~Its
Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
David J .. Brown (Yadkin Well Company, Inc., 1908 Hamptonville Rd., Hamptonville, NC 27020)
Winston Petrey (Mountaineer Heating & Cooling, P.O. Box 1905, Boone, NC 28607)
Permit Application File WI0400125
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Ca.rolina 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 I Affirmative Action Employer
N°~i...c 1· 01u1 aro 1na
/Vaturall!I
': 1,-Jan, 25. 2.01% 10: 12AM,,,,, YADKIN WELL,h. No. 4439,JP, 2�
• NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOT3RCI;.S {NCDENR)
APPLICATION FOR PERM TO CONSTRUCT AND/OR USE A WELL(S) VOR
INJECTION WITH A GEOTUERMAL , T FUM r SYSTEM FOR:
TYPE 59M WELL(Sl
New Permit Application OR Renewal (Ole& one)
DATN:.
zo I Z
PERMIT NO. (lone blank ifNEW Permit application)
A. PROPERTY OWNER(S)/A.PPLT 4.N1($)
Lis: toLla Property C giger listed ore property deed Of awed by a business or governineed agency, state name of
entity and a reprise ative ',Authority fix signora* 45X A ASA'(7 2 Ps-1s
(1)
(2)
Mailing Address: 3 Kin (' I ."Ji
City; a-d-o- State; Zip Code: JJ467 County:
Home Office Tele No.: 8U -ems'- ja 7 6 Cell No.: 826 -773 - 37 .3
EMAILAddre3s:5.4100 ftArio �)�+teaip4,c.d"
Physical Address of Site (f difftrre nt than above):
City: Siam; Zip Code: Cortmty
Flom /Offcc Tele No.: 1iNa,:
EMAIL. Address:
B. AUTHORIZED AGENT OF OWNER, lF ANY (if the Parrott Applicant g, own the subject property,
atsat* a latter from the property owner Ong Agent to Install and optima WC we 1)
Company Name:
Contact Parse : EMAIL 4 dc1:
Ad4ra5S: - -
City: Stagy; Zip Coda: _ Loam:
❑fti a Thle No_- _ Ceu NQ:
w'ebsite Address of Co patty. ifaay:__
C. STATUS OF APPLICANT
Private: X Fes: Coaial-
State: Municipal: Native America Lands:
01-0S-2010 16:34
RECEIVED I DENR r
Aquifer Pratadion Se[ on
JAN 26 NW
PAGE2

01--Jan, 23. 2Q10.1.0:13Au"„ YADKIN WELL.,cLL
Na. 4439r.1,tP. 37
D. WELL DRILLERINFORMATION'
CompanyNeme: yADKIN ]vaL CQ4PANY. INC.
Welt Drilling Cosirecterie Nercte: .J�n! _& MAT iM IRow - IVIt VE
NC Coattractbr Certrlfce$ast No.: tMIJLLIS: 2572 A) (BROWN: 3036414CAVE: 350-A) _
Contact Parson; PAM J. BROWN (21 I Al SAIL Address: eh laias6lerttmsn.00m
Address: 1 ii.Es KaMPTOI+viLLE r qp
City: NAMPTONALE, ra.o. 24 Code: 27mo Courtly: YADM
Office Tele NG.: 333a - CCIi No.: 330374478e
E. $EAT PUMP CONTRACTOR INTO MANION (if different Hum drill')
Co )'N : /(trim*#4 .0e4-4 44-4.rl (C I.v7
ConSa=tFecvon: ;44r04wr r. L,Address w,eo{ + eso*.epie,,,e#Ors1e-Yt .cc-'"
Address. /7 & c /5'C1 Z2c / i>S q/ ,Yjm
City: &0)t PC,: Zip Cad= e4o,7 Coat11q- Seefi4'Waa; # - -
Orme Tele 140.: .9cV Ceu Not: 7* frC'f roe/
F. IMECiON PROCIDATSUI Oxley describe haw the isiectiaa walls) will be lased)
G. WELL CO STRJCTLON DATA (Skip reI ecrton M tf t $pr ow a►a]
(i) Proposed date to he constn ctcd: Feat 20 O Number of honing,: - - -
Approximate depth of each boring (et gc) -.
(2) Checni,izaI tidal -ma le be wed in closed -loop system (4rt121 these obemic&ls Indicated have been approved):
3--22 _ _-_ _ up3' e glycof ethanol dry,' from t Other (otter additives will
need prior apron( by NtDENR berms 'UV)
(3) Type of tdhingto be weed (cplr, FVC,.atc): (- P 1 S 0i
(4) Weil casing, to tbs we1E() cased? (check either (a.) YES ar (b.) xO below)
(a) Y'E8 ifyea, be Provide wing tnfhrrnetion such as ink (seed. PVC, plastic eta), filmoz.
and t rat ofcg appearing above ground:
(b)NO C
(S) drove Cmgbakti serrouranwetil-ctistag andlar,piprng): t, „ f,,,AUY 4..e% OA-
(e) C currype: Cement Btctanite XC Other (spd)
(b) trout depth of ln4bing (referetare-to ca lice):It= 2 to 2 e0 abet)
If Weilbas casing, Indic* l aapm: from to -OW
R. INIECTIONZUCIATILD EQUIPMENT
Attach a diagratn showing the engineering layout or proposed modification of the Suitwlfon equipment wad wafer
plpirgllttbing associttead with the ittjectiou won. The rneraftieturaris brochure sney provide tappieneentary
lzdtarmetino.
01-05-2010 16;35
P3

131.2Jan,25, 2010 10.13A% YADKINWELL
Na. 4439��a'F. 43 Y
1. C 4 T1ON OF WW I,(S)
Attach two copies of maps showing the following tdoxmaiion;
0)
(2)
inzlnde a site map (cvn be drawn) Showing: bulb{*cps, propestY lines, !indica water bodies, potential sources
of gran dwratatr octolmdmion end the orientation of and distances between the proposed well() acd. auy
existing walls) or waste disposal facilities such as sorties teaks Cr drain field" located within 1000 the of the
geothermal beat pump well systeta. Label all features clearly and jnell dC a _nada. arfow.
loaiude a topographic map oftbe area extending one mile from the property boundaries and
indiezte the lity's loon sad the map once.
J. PoTARilD WATU WELLS)
Are there any potable welter woke) on the subject 'vapory cc adjacent prop rdes7 Y'FS ND
If Yes, ths= indicate location on attached map(s). -
IC. CERTIFICATION
Nate: This Permit Application must be signed by each person appearing oft the recorded legal property deed.
booby cect[fy, =der pei .1ty of law. that d have personal examined and am Douala with the information
submitted in tbl,s document and all attachments thereto and that, based on toy itaritY of these tdiWchIals
immediately responsible fvr obtaining said man, I beliervc that the iafocusation is time, tom:rote and complete.
I am aware that ter are digniiicarst penalties, inducting the possibility of foss end prlgo xi t, fct subra:iitg
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well arld
all related appurtenances in accordance with the .,.prase, aihd conditions of the Permit"
Si;t•. •I t •fProperly Ownesr/A'pplicaat ca
Pribd. or Type Full Nam
•• /1
Signature of Pr • Owner/Applicant
ti Ash F-0Y -r O ,v 's
Print or Type Fh.11 Name
Siva of Azrthotixed Agmrt, if any
Prier or Type dill IsTame
Please ratasra two copies of the ao p kte ri Application pia to: -
North Carolina DENR DWQ
Aquifer Proton Section
UIC Program
1636 Mail Service Center
Rath, NC 27699-1636
Telephone [phone]
01-e5-2e1a 16:35
RECEIVED r DENR / DYQ
Aquifer Protection Sn
JAN 25 2010
PPGE4

Jan. 25. 2010 10:13AM YADKIN WELL_
324 Pwlv, atu,Payr.�
No. 4439 P. 5
gezth r -
.flot,14 QJA.•
p1
T ntios ah,• `Ow (ter
00 " ►►n,. aorte-i +0

Jan. 25, 21C10 10:12AM YADKIN WELL
FACSIMILE RN FORM
No. 4439
DATE:. (/ Po TIME: REF. NO. _ LOG NO
TO: 8:6 O E.JJ VI G frf it.) 7 (i - _ i7
COMPANY NAME
FAX ND.
c..4. o ef, I it, CV PLEASE
IMMEDILATEI�f
ATTENTION DEPt
FROM: t i Pc r ►ti c(s Q 0 Ce M�, t.33C )'4--Po e?
GOMPANY NAME FAX NO.
PLEASE
,, r , rya;,;, I". ❑ REPLY
;NOWUAI.. KEPT.
INCLUDING
IC GOPAGES REPLY PLEASBY SIGNATURE NUMBA� INCLUDING INS SHEET
MESSAGE:
] ► - ..'�- 1" at/ ■ I Cr.. 7-4Lazi
JQL �f G•t g (s CiPt t n. 4-
)
-FOR ALL YOUR WATER NEEdS-
YADKIN WELL CO., INC.
1v90 HAMrTQNYEIsE ROA❑
HAMPTONVILLE, NG Z7Q2O
DAVIO J. BROWN. VICE PRES.
TOLL FREE (GOO1 2.45435 S
OFFICE (336] 468-441140
FAX [phone]e46
RE5 (3351 4.S.46s9
•GOGO ray 1•11;R IGA • GOO LOW-3 YOt"
RECEIVED / DENx rOWQ
,vyl P ofl Sediof+
JAN 25 MB
PLEASE ENFOFIM US MMELWELY IF VoLl Do NOT RoEVE FACSMILE IN RILL