WI0400132_GEO THERMAL_20100506

..
-Beverly Eaves Perdue
Governor
FA
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
5/6/2010
Davidson County Community College_
Rusty Hunt -VP, Financial & Administrative Services
PO Box 1287
Lexington, NC 27293
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400132
1205 Salisbury Road, Mocksville, NC 27028
Dear Mr. Hunt:
Dee Freeman
Secretary
On 4/26/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-
only geothermal injection well system for the operation of a ground-source heat pump located at the address referenced
above. An individual permit is not required for the construction and operation of this type of geothermal injection well
system as long as the following conditions are met:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction.standards specified
in North Carolina Administrative·Code Title 15A Section 2C Subchapter :0213, and
3. The required notification form and associated maps have been completely and accurately
submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and
North Carolina Administrative Code-Title 15A Section 2C Subchapter .021 l(u)(2). Additionally, you should contact the
Davie County Health Department as they may have additional requirements for this type of system. Noncompliance with
applicable state, county, or mun1cip·a1 rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Ro2:ers (@,ncdenr.gov if you have any questions.
Sincerely,
-O~A-~
for Debra Watts
cc: Winston .. Salem Regional Office -APS
APS Central Files -Permit No. WI0400132
Davie County Health Dept.
Supervisor ·
Midsouth Geothennal (Jan.ice Scott) 8275 Tournament Drive, Ste 185, Memphis, TN 381"25
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh,.North Carolina 27604
Phone: [phone] \ FAX 1: 919-715~0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www .ncwaterguality.org
An Equal Opportunity \ Affirmative Action Employer
_ J)ne
North Carolina /vatitrallg
Permit Number WI0400132
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael .rogers
Coastal SW Rule
. Permitted Flow
Facilit
Facility Name
Davidson County Community College
Location Address
1205 Salisbury Rd
Mocksville
Owner
Owner Name
NC .27028
Davidson · County Community College
Dates/Events
Central Files: APS_ SWP_
05/06/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Janice Scott
8275 Tournament Dr
Memphis TN
Major/Minor
Minor
Region
Winston-Salem
County
Davie
Facility Contact Affiliation
Owner Type .
Government -County
Owner Affiliation
Rusty Hunt
381250851
& Administrative Dean Financial Services
PO Box 1287
Lexington NC 27293
Orig Issue
05/06/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
05/06/10
Effective
05/06/10
Expiration
04/26/10
Re g ulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasln
wz(yi 0013a.)
NOWTIVAROLINA
PEPAENT'OPEimomottr AND NATURAL RESOURCES
ES.
1401111CATION OP MEW TOc STRV AcL'[l GZOTHSRMAL
INATICA1VILY iNJECTION WELL
TYPE Sow.'FLIAS
In Acourdande WWI the: Provi9iona of NCAC 11 a 15A'O2C O2OO
Print or ippe the required Peutougion-aridetaititi dams eat thelogitheaget
DATE: }Lgril , 2010
Well Type C +taq! ihion:.Dae&the proposed system circulate ale want only (noadditives)in
continuo' us piping that corpktety isolates the fluid from the aaviromtd04
ctased+i�vg��2 i�ECENp r t Oa
APR 28 ZU�
ND ,^. Do trot complete �t its Ron. Complete other U C application forms #fir- #> iag
Abet e S7 well (open loop watt itileAging potable water Into the aquifer)•ar a.5QMwell Owed -
bop well lcorttaining additives: such as R-22, ethanol, or other antifreeze of won inhibitors).
aR _ Continue completing this form.
lloPil i!TIP - ffiVAPP'LIC:'.AIMS)
List ''e Y OwnOr listairoo prape;Cty deed (ironed 5 by a business dr government agency, state -name of
en* end.e rives for signnwrc)
(t) M#i1it Andre > 0
city; L ivi -f-oki shot Codes. ?72: : 0414
Horne/Office Tee No.: 4` 4' t7 2 'C
Eraa:'l.Hd We.#site_
(2) Physirai Address of Weft; Site (if:different than above): 1245 Salisbo.iY'R a I
City, Kagalville Staoe; NC Zip Coder.27I328y9302 Comty: Davie
Horne/Office Teie No.: Cell Noss
AUTHORIZVD AGENT OF OWNER IF ANY (lithe Permit Applicant does trot even -the subject prop;
attache letter tem the property owner authOrizing ;Agentta.install and operate`JAC well)
Compony:Nemo: Pavissoei n y ezionenani c v/ca
c t -pa t
Mess: PD . y Z
city .1-4744 IJ Btu; N. " r Zip Code: 7.72-q 3' $ 7Couni r D rddavl
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1Q4►ebsite Mdreos of pan freely:
SMALL Address
oputure 5GW Nrflifiration of Watt Form (Revised 81Z008)

C, WELL DRXLLER XPORMATION
Company. Name:& I1))4 M e t r. r i& (Of 11 1)J .1
We3Driller Contractor's Name . n 1:62D G _h p
NC Contractor Certification No.: A) 0_,P L).e, :37 3-1 Contact Person; Janice Scott OM Mgr Ems. Adr1Te5s: iscuttamidsPuthgeotberm .com
Address: 8275. Tom smerit Drive, Site. 185
City: M rnpbis hip Code: 38125
County: Shelby
Office Tele No.: 901.- 748-9095 Fax Nil: 901 748-9097
A ILAT PUMP CONTRACTOR INFORMATION (if different then driller)
Company Name: MidSotith rte thermai LLC
Contact Perso t Janice Scott, Offf, Mgr Addr rnsdsnuth stream .
Add. : 8275 To nAme nt Drive, Ste 1.85
City: Memplus :ZipCode: 38125 County: Shelby
Mee Tele No.: 90I-748- Fax Na. 901 748-9097
STATIC Or A'PLICANT
Private:. Federal: Commercial:
State: t Ivlunicipal: Native American Lands: —
F. INJECTION PROCEDURE Melly .desc x. how the -injection vie(a) will he used)
C ed-Lop marnal water some host eum_O
G. EL COD FRUC'I1O N.D LTA
(1) P oposed:date to be c onstructed:Idler April:22 2Q10 .NuMber .of booms:
Approximate depth of each boring (feet): 600'
(2) Type of tubingto be used (copper, PVC, etc): / 1 ; 1)P'L I
(3) WW1 casing. Is the wmell(s) cased? (Check either (a.) Yea st:(b.). No below)
,(a) Yea if :yes, and tea probe casing information below
Type: galvanized steel bLaok steel plastic other (specify)
Casing depth: From to feet (reference to: land surf)
Casing extends to aboveground inches
(b) No X
(4) Grout Info (material surrounding -well razing and/er piping):
(a) Grout type: Neat Cern nt Bentonite X Other (specify)
(b) Grout placement:. Pumping Pressure Other
(e)'Grout depth of tubing (reference Inland surface): from 0 to 600 (feet)
If well hasiensing, .indicate grout depthfrom to {feet.)
GPVID10,5fellislapcinien of linen Perin tgevlsed 812008) Page 2

H'. INJGTION*1 LATED EQUIPMENT
Att a diagram showing:the. engineering layout or proposed modification .of:the. infectionequipmant and exterior
piph!gitubing associate with ..the injentinn operation,. The masnufarr uter-'s:brochure mg pron+ide:supplemantaey.
information.
L LOCATION OF WELL(S)
Attach two copies ofmaps showing the following information:
{1) Include a Site Map (can be drawn). showing: buildings, property lines, surface. water bodies, potential
sources of gnnzndwater contamination and the orientation of and distances between the proposed.well(s) and
any existing well(s) or waste disposal: facilities such as sepfic tanks or drain fields located within 200 -Beet of
the geothermal heat pump wail system, Label all features clearly and -bank; a rtoa ow.
(2) The Site Map must show the subject property in relation to dm surrounding area by using at least two fixed
reference points such aS roads, streams, tsar highway inteMectiotia.
� CERTIFICATION
Note: This F.rmkt Application moat be signed. by at personappearing on the recorded legal.
Propei ty d6ett
"i hey undo PcteltY of law, that t have parsonal[y ex hied and ant familiar with the ltifotanation
submitted in this doeumesit -ant all attaehrments thereto and that, based on- ray ineuiiy of these individuals
immediately responsible far obtaining ad inforrna ± on,.I bellevethat theinformation is:tGue,, accurmeand:cnmplete.
t am aware that there are significant penalties, including the possibility of fines and imprisonment, for sum
'base Information t agree to construct, operate, maintain, repair, and if - licaible, abandon the
applicable, iraje¢ton well and
all related appurtenances in accordance oft the.approved sped cations and c editions of the Permit."
sign„Rwsfituret6,014vnY texdApgiicaat
f Printer T 'Pall Name and -tie
Signature of eray Owner/Applicant
Print r type Ftdl:iatame Rod 't e.
Signature of Authorized Agent, if anyy
Print of Type- Full Native and lige
Please reznrri two copies of the completed Application package to:
North £,rolinn'DtriERQ.
Aquifer Protection Section;VIC Program
1636 Mail Service Center
Raleigh,.NCC 27699-1636
Telephone(1)133:3121
GitY1c 5QW Woeifizeuon of item term Olgvietc,41 812008) liana

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'PAINTED BLACK
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2 Lo ` Run DaA4$1,1 401 G" .� P -R E
SHALL BE AS RECOMMENDEO ON THE SOIL REPORT,
11. THE CONTRACTOR SHALL NOTE THAT THE DRAWING:
NOT SHOW EVERY OFFSET, TRANSITION, FITTING, ETC
COMPLETE AND WORKING SYSTEM
12. ALL PERMITS RELATIVE TO PROJECT MUST BE OBTA
CONSTRUCTION TO HE IN ACCORDANCE WITH PERMIT
COUNTY AND LOCAL CODES.
13_ THE CONTRACTOR SHALL VERIFY LOCATION AND ELEe
THE LOCATION OF ALL EXISTING UTILITIES ARE NOT
W1iERE SHOWN ARE ONLY APPROXIMATE. THE COMM
NO EXTRA COST HAVE LOCATED ALL UNDERGROUND
NO CLAIMS FOR DAMAGES OR EXTRA COMPENSATION
FROM THE PRESENCE OF SUCH PIPE OTHER OBSTRU
REMOVAL OR REARRANGEMENT OF THE SAME. THE C
ANY DAMAGE TO UNDERGROUND STRUCTURES, CONT
CONTACTING ALL NCINSUBSCRIBING UTILJT1ES. THE CC
CAROLINA "ONE CALL" AT 1-8GO-632-4949 FOR A'
UTILITIES. CALL AT LEAST 48 HOURS PRIOR TO ANY
14. FOR BUILDING DIMENSIONS. SEE ARCHITECTURAL DRA
15. LANDSCAPE PLANTINGS AND SIGN LOCATIONS AT ENT
MAINTAINER SO AS NOT TO INTERFERE WITH SIGHT
PARKING AREA AND AT ENTRANCE/EXIT LOCATIONS,
16. SEEDING TO BE INSTALLED TO LOCAL REQUIREMENT
17, PRIOR TO STARTING CONSTRUCTION, THE CONTRACT
THAT ALL REQUIRED PERMITS AND APPROVALS HAVE
FABRICATION OF ANY ITEM SHALL BEGIN UNTIL THE
AND ANY OTHER DOCUMENTATION FROM ALL OF THE
REGULATORY AUTHORITIES, FAILURE OF THE CONTRA,
SHALL CAUSE THE CONTRACTOR TO ASSUME FULL R
MODIFICATION OF THE WDRK MANDATED BY ANY REG
18. ANY AND ALL QUANTITIES SHOWN DR IMPLIED ON Tl
PURPOSES ONLY.
CONTRACTOR NOTES:
NOTE: ALL DIMENSIONS AND RADII ARE 1
BUILDING OR TO FACE CF CURB, OR TO
STRUCTURES SUCH AS INLETS, SIGN PD5
O FHERWISE NOTED.
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Ro gers, Michael
From:
Sent:
Janice Scott Uscott@m idsouthgeothermal .com]
Monday, April 26, 2010 1 :10 PM
To: Rogers, Michael
Cc: Janice Scott
Subject:
Attachments:
re: new 5QW application 4/26-Davidson Co. Comm. College
Document(21 )'.pdf
Mr. Rodgers,
Attached is a new 5QW application. Please process and let me know if you need anything else.
Thank you,
Janice E. Scott
Office Manager
MidSouth Geothermal, LLC
8275 Tournament Dr. Ste. 185
Memphis, TN 38125-0851
Office [phone]
Fax [phone]
j scott@midsouth geothermal.com
www.midsouth geothermal.com
1