WI0400128_GEO THERMAL_20120518

Beverly Eaves Perdue
Governor
AVA
. NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E.
Director
May 18, 2012
Ronald and Gina Holste
783 Wilson Ridge Road
Boone, NC 28607
Subject: Notification of Rule Revisions Affecting
· Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0400128
Dear Mr. and Mrs. Holste:
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 ISA 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,
Eric G. Smith, P.G.
Hydro geologist
cc: UIC Pennit Fi]e
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterguality.org
An Equal Opportunity \ Affirmative Action Employer
RESIDENTIAL- WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1- WEU. CONTRACTOR:
Well Contractor (individual) Name
YADKIN WELL COMPANY. INC.
Well Contractor Company Name
1908 HAMPTONVILLE ROAD
Street Address
HAMPTONVILLE NC 27020
City or Town State Zfp Code
C 336) 468-4440
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if appiicab(o)
SITE WELL 1D #(ff appscable)
3. WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED
TIME COMPLETED AM ❑ PM CI
4. WELL LOCATION:
CITY: COUNTY
(Street Name. Numbers, Community, Subditisfon, tat No„ Parcel, Zip Code)
TOPOGRAPHIC! LAND SETTING: (check appropriate box)
Slope Dva!ley ❑Fiat 0Ridge 0Other
LATITUDE DMS CR DD
LONGITUDE • " DMS OR DD
Latitude/longitude source: L1GPS []Topographic map
(location of well must be shown on a L1SGS top° wrap andatteched to
this form if not using GPS)
5. WELL OWNER
161";i 1'46 3 ie.
anerNVame
Street Address
City or Town
Area code Phone number
State Zip Code
6. WELL DETAILS: t�
a. TOTAL DEPTH: h/a drT( f i.�9N.30
b. DOES WELL REPLACE EXISTING WELL? YES © NO fl
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT, Above Land Surface'
'Top of casing terminated at/or beiew and surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD CIF TEST
f. DISINFECTION: Type HTH Amount Cups
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
` Top Bottom Top Bottom
Thickness)
7. CASING: Depth Diameter Weight Material
Top Bottom Ft, _
Top Bottom Ft.
Top Bottom Ft.
8, GROUT: Depth
Material Method
Top Bottom Ft.
Top Bottom Ft.
Top Bottom FL
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in, _
10. SANDIGRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
1
1
1
1
1
1
1
1
1
1
1
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Date Site Visited By: Permit: Yes No
Form GW-la
Rev. 2109
What Is Height of Weil Casing? Make Sure 12" Above Ground Level! ! ! !

Permit Number WI0400128
Program Category
Ground Water
Permit Type
.Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Ronald and Gina Holste SFR
Location Address
783 Wilson Rdg Rd
Boone
Owner
Owner Name
Ronald
Dates/Events
NC 28607
Holste
Orig Issue
06/10/10
App Received Draft Initiated
03/12/10
Scheduled
Issuance
Central Files: APS_ SWP_
06/10/10
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Watauga
Facility Contact ·Affiliation
Owner Type
Individual
Owner Affiliation
Ronald Holste
783 Wilson Rdg Rd
Boone NC 28607
Public Notice issue
06/10/10
Effective
06/10/10
Expiration
04/30/15
_R_e ...... g_u_la_te_d_A_c_ti_v_it_ie_s _______________ ~R=e___.g-=ue~s~t=e~d~/R~e~c~e=iv~e~d~E~ve~n~t=s __________ _
Heat Pump Injection RO staff report requested
RO staff report received
Outfall f ~~LL
Waterbody Name Stream Index Number Current Class
04/01/10
06/01/10
Subbasin
Permit Number WI0400128
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (SQM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit ,
Facility Name
Ronald and Gina Holste SFR
Location Address
783 Wilson Rdg Rd
Boone
Owner
Owner Name
Ronald
Date sf Ev ents
NC 28607
Holste
Scheduled
Orig Issue App Received Draft Initiated Issuance
03/12/10
Re g ulated Activities
Heat Pump Injection
Outfall i•JJL:...
Central Files: APS_ SWP_
06/03/10
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Ronald Holste
783 Wilson Rdg Rd
Boone NC
Public Notice Issue Effective
Re auested /Rece ived Events
RO staff report requested
RO staff report rec~ived
28607
Expiration
04/01/10
_06/01/10
Waterbody Name Stream Index Number Current Class Subbasin
RA
NC EHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
June 10, 2010
Ronald and Gina Holste
783 Wilson Ridge Rd.
Boone, NC 28607
Dear Mr. and Mrs. Holste:
Subject: Issuance of Injection Well Permit
Permit No. WI0400128
Issued to Ronald and Gina Holste
Watauga County
Dee Freeman
Secretary
In accordance with your application received March 12, 2010, I am forwarding Permit No. WI0400128
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 April 30, 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 dat~ within 30 calendar days of
completion ofinstallation ofgeothennal well(s) to the following address:
Aquifer Protection Section (APS)
Underground Injection Control (UIC) Staff
1636 Mail Service Center ·
Raleigh, NC 27699-1-636
Additionally, your VIC ·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
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].
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
.One NorthCarolina
/Vaturaltu
cc: Sherri Knight-Winston-Salem Regional Office
Central Office File -WI0400128
Appalachian District Health Dept.
David Brown -Yadkin Well Company, Inc.
Attachment( s)
Sincerely,
~4-J~ /2;[
~ichael 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
Ronald and Gina Holste
FOR THE CONSTRUCTION AND OPERATION OF 1 TYPE 5QM 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 783 Wilson Ridge Rd., Boone, Watauga
County, NC 28607, and will be constructed and operated in accordance with the application received March 12,
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 .0100 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 May 31. 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 10th day of June 2010.
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission_
Permit W10400128
UlC/SQM
ver. 03/2010
Page 1of5

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-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 1 SA 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 pennit 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 WI0400128 UIC/SQM
ver. 03/2010
Page 2 of 5
I
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 us·e. 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 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 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. · ·
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 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 WI0400128 UIC/SQM
ver. 03/2010
Page 3 of S
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 W aughtown 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~l ·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 11.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the 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 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 in 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 RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Pennittee shall
submit an application to renew the permit 120 days prior to its expiration date.
Permit WI0400128 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 Permitt~e'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 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 som:ce 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 which the casing and screens have not been removed, the
casing ·shall be perforated opposite the gravel pack, at irttervals 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 Pennittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shaHbe
submitted to the addresses given in Part VII. I of this permit.
Permit WI0400128 UIC/SQM
ver. 03/2010
Page 5 of 5
Rogers, Michael
From: Knight, Sherri
Sent:
To:
Tuesday, June 01, 201 O 12:34 PM
Rogers, Michael
Subject: RE: W 10400128 Holste
Go ahead and permit. We tried to look at some of these, but we only able to look at one recently. These in Watauga are
a very long travel distance unless you have other things in the area, and they are difficult to coordinate. We will
continue to try to drive by these when we are in the area looking at other permits, although I really have a concern with
these older homes that have wells. This one is a 1971 home so I assume the well is also the same vintage. These is
nothing that would prohibit the installation of the system and they plan to install the well 51 feet from the existing.WS
well.
Sherri Knight, PE
NC DENR Winston-Salem Regional Office
Divisio·n of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
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: Rogers, Michael
Sent: Friday, May 28, 2010 5:13 PM
To: Knight, Sherri
Subject: Wiq400128 Holste
Sherri-
I never heard back on the attached SQM well, which was e-mailed on April 1, 2010. Do you wish for us to permit? Debra
has run a BIMS report and is asking me for updates.
Thanks
1
Beverly Eaves Perdue
Governor
Ronald Holste
Gina Holste
783 Wilson Rioge Rd
Boone, NC 28607
I •~A g,,~~
NCD ..... EH ..... R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
March 30, 2010
Subject: Acknowledgement of Application No. WI0400128
Ronald and Gina Holste SFR
Injection Mixed Fluid GSHP Well System (SQM)
Watauga
Dear Mr. and Mrs. Holste:
Dee Freeman
Secretary
The Aquifer Protection S,ect~on of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on March 12, 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 n·ivision has reorganized. To
review our new organizational chart, go to http ://h2o.enr.state.nc.us/document~/dwg -onrchart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON TIDS PROJECT.
Sincerely,
0 \J:ka._ (~. ~,u__,
for Debra J. Watts
Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
Winston Petrey (Mountaineer Heating & Cooling) PO Box 1905, Boone, NC 27607
Permit Application File WI0400128
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.ncwatemuality.org
An Equal Opportunity I Affirmative Action Employer
One . North Carolina
)Vat11ratlu
Mar, 12. 2010 12:18PM YADKIN WELL
S�JG�
:svNo.4728 F. 2
�,.��.. u'-i-uo i ag
NORTH CAROLINA
»Bwknr of EN4VIRONM NTAND NATURAL RESOURCES (NCDENR)
AP CATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WYTRA GNOTEERMALVEATFBMP SYSTEM FOR:
TYPE $0M WWLL(S)
New Permit Applirstion OR Renewal (check one)
DATE: -3 !2 zo f 0
PERMIT NO. (leave bleak tf NEW permit epplia cn)
A, PROPERTY OWNNER.((gyApPLICANT(S)
List r, a Property Owner listed on property deed (if isy a bowie= or government any, state mane of
entity and a_re dative wia be ty_signature): K Add I 54-e_-
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(1) Matting Ada6rass: � f 7 B 3 (A),.1A.
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RoadOffice Tele No.: 82- 3s-5. 1 [ Z 3—
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(2)
P1iysiaai Address of Site (if different than above): �,Y� ►8 f.) 460 Y --
C y: Suns; Zip Code: County:
Harme'OlaceTeleNa.; _ CellNQ
EMAIL Address:
AUTHO1 D AGENT ON CoWNYR, iFANY (if the Permit Applirazrt dgss slot own the Fixbject property,
attaaha Jener from the properrty owner muthoriziog Agent to install sad operate UIC welt)
Company Name:
Contact Pesos`` — - xMA iL. Address:
City: Strae: Ep Cock: County:
Office Te c Noy: NP.
Wcbeite Address of Company, claw
STATUS OF .APPLICANT
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State
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P. IN,TICTION P,HOCEIMP. (Welly &rcrib' lam the igjoctiAo wr,U(s) ► n be used)
eatLAL. cA to Syr
Q, Wrra CONSTRi3CTIONDATA kirs_sp Seentis t RTl ba ranaintiaums.0
(t) oposed dote lobe 'eenstructed?. exy /0 Number bf boriap: C
App. calcine dope of each bowing (tact): 3Q O •
(2) Chemical additives robe used in ai d loop system (only then chemicals indicated Inc been approved):
$ glycol Aol War (other additives will
mod prior [tppmalby NCD WR beater. use)
(3) pa oftnbing to be used (copper, PVC, do): at) P
(e) Weft 1 is v4eif(s) mod'? (check Otter (a.) S a(b) NO be
(a) 'MS , lye tbau provide cssiaginfccmdioo suck es tad (sma1, PVC, plaice etc), fathom
and seign of mkt appearing above gloond:
(b) NO X
(I) cat (tom sarroon.diag itiellveskg I piping): h evo,alir
(a) Qiot ty: Cement • )3euaanite Ober Weary)
(b) Ort depth of tubing (refircnco to lead striate): from 3 m 76 e[)
jfweii bas-ce :inure grow depth; from
IL INTEC,1Qk4-RZLAUD ii,Q PMZNT
Attach a &Pic showing the engineering boom or peLoposed modification of the 14caiion equipin nt and aat(ariar
piping/wisingpiping/wising aszoeinnett with the injection a a mrwufactutcre breams may provide splementary
infrrnvttton.
17E:LO 0IO2-77-£0

Mar,12. 2010 12:19PM YADKIN WELL
Leatid
No. 4728:STP 4 -gi_Lt
I. IZCATION O WELL(S)
Attach two copic of maw shouiostbe followdag ifarmatioa:
(1) Include a aite asap (cm be drove)) showlw ballaoss, prop uty Hoes, surface wsaar bodies, poundal somas
of gmnnmdweter eeteembastioa and the a iawpon of and disrwnoea between the proposal well® and any
exlat well(a) or waste disposal &aides such as septic tanks or drag fields locked within 100 bet of ibis
geothermal haat imam well system. Label all features clout, saa include aagrainor,
(2) Include a topographic map of the area candelas oar mile frma the property bo aeries and
indicate the fecilxtyra location and the map sumo.
3, POTABLE WATER W EL1.(S)
Are there any potable amen wr a) t€sv subjave property or Adiaccur properties? _LYES NO
if Yes, them indic de Lost= on meted map{a)-
CERTIFICATION
Noon. This ?xs>cit Applies tion meant be signed by l'ili person appearing on the recorded legai property deed. -
"I hereby certify, ander penalty of It" tin: I have prssoneuy tom ined sod am familiar with the itiftrmatitm
submitted m this docwnent sad sit eta thereto aai that, based on my inquiry of those indtridmaia
immeddiatel►xesponsibla for ng said intordadan, i bel5eee that the is brmalloa it tree, actuate and oa_c.
I am wen that there are sigx 1&ant realties, including the possalnlity of raps and imprisonment, for submitting
false infnnmatLon. I free to coot:met, operate, maintain, tapak, sad it; applicable, al:landr u the ireadon well and
all related appartenances in aeordeace with the approved rpecificat I,. and canditlons ofthe permit"
nr
Property ■ wrae /Applies=
Too( iG E - q a (S i-e
Prim or Type Pull Name
APPlicani
Qc e, \D\5)
Pen or Type nxii Name
Signature of Authorized Agent, rem
- Print or Type kit Name
Phase return two copies of the completed Application psckage to:
North Carolina DENk DWQ
Aquifer Protection Section
UIC Program
i
1636 Man Service Center
Raleigh, NC 27699-1636
Telephone [phone]
bad
wirn.r rf1A7 •AI .,Am
tM'c:L0 0IO2-2T-at

Mar. 12, 2010 12,19PM YADKIN WELL
4 21 1V3v, 1 Z. j i0A- b e+ e e M. v"
3bL AZ ", e. Oh Z4 •
Is\‘/
y�,,11 e1 �•- No.4728 P. 5
�7
[34'���0 !Ztl r nn IJf tl % ta @.
Rona` 1414'
ii
y i W J s a&A I 3 k

Mar, 12, 2010 12:18PM YADKIN WELL No. 4728 P.
•
DATE:
11
FACSIMILE TRANSNliSSION FORM
REF. NO
TO: QV/viz D Q
COMPANY NAM!
I41 C hae I go ems)
MENTION
FROM' c-
COM NAME
NOMMUA1.
MIER PLEASE
DINGFMIS SHEET REPLY BY
MESSAGE: '
e i 4,4 ( 77/ ! Cf • 10 rr
OP E
LOG NO,
Acii/)
FAX NO. MAU
❑SIX
(sr)rt(g 7oa
WHO. ROSE
5:04/vit012 PIUSPLY
DEPE
1',
won
NAME
-FOR ALL TOUR WATER NEEDS'
YADKIN WELL CO., INC.
1905 NAMPTONVILL£ ROAD
HAMFTONV1LLE. NC 27020
t AVI❑ J BROWN, VICE PRES.
TOLL FREE MOO) Z48.035S
Oilier (3363 4E44440
FAX [phone]
RES (3361 458.4659
•6000 1.I! AmokicA i COD uyaa you -
PLEASE 1NFOCim Pi£LY1FVDUDON rRECENERAOSP LENRJLL

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