WI0400138_GEO THERMAL_20100602

Beverly Eaves Perdue
Governor
Mark Overby
Debra Overby
6203 Windcrest Drive
Summerfield, NC 27358
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
6/2/2010
Subj _ect: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400138
6203 Windcrest Drive, Summerfield, NC 27358
Dear Mr. & Mrs. Overby:
Dee Freeman
Secretary
On 5/12/10, 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 Guilford County Health
Department as they may have additional requirements for this type· of system. Noncompliance . with applicable state, county, or
municipal rules -and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Ro gers@ncdenr.!WV if you have any questions.
Sincerely,
O~A.~
forDebraWatts ·~
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400138
Guilford County Health Dept.
Supervisor
Yadkin Well Co (David Brown -1908 Hamptonville Rd, Hamptonville, NC 27020)
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 I Affirmative Action Employer
N°~i...c 1· 01 u1 aro 1na
Jvaturat/11
Permit Number WI0400138
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
Mark & Debra Overby SFR
Location Address
6203 Windcrest Dr
· Summerfield
Owner
Owner Name
Mark
Dates/Events
NC 27358
Overby
Orig Issue
06/02/10
App Received Draft Initiated
05/12/10
Re g ulated Activities
Heat Pump Injection
Outfall NULL
Scheduled
Issuance
Central Files: APS_ SWP_
06/02/10
Permit Tracking Slip
·status
Active
Project Type
New Project
Version
-1.00
Permit Classification
Individual
.Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville NC
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Mark Overby.
6203 Windcrest Dr
Summerfield NC
Public Notice Issue
06/02/10
Effective
06/02/10
27020
27358
Expiration
Waterbody Name Stream Index Number: Current Class Subbasin
May. 12., 2010 8:33AM YADKIN WELL No, 5118 P. i
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"FOR ALL YOUR WATER r-4907
YADKIN WELL CO., INC.
1909 KAMFTONIIILLE RVAD
HAMSPTONVILLE. NC Z70W
DAVI❑ J. BROWN, VICE PRES.
TOLL FREE (OW) 2485399
OFFICE 1336) 468.4440
FAX 1336i 448-AC"
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.May. 12, 2010 8:33AM YADKIN WELL No. 5118 P.
2
NORTH CAROMNA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIMCATION OF nVaNT TO CONSTRUCT A CLOSED -LOOP OEOTBERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5—OW WELLN
La Accordance xr-ith the provisions of NCAC Title 15A: 02C.0200. please
complete this not ication and mail to addrem oa the back page (please Print or Tvp-e information),
DATE: -T-- 6 20-L-0-
Pell Type Confirnmadon: Does the proposed system circulate potable water otlly (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-loo 7
Yes —X . Continue completing this form.
No I)o Not complete this farm. Complete other LJIC application farms for inst;&Uing
either a 5A7 well (open -loop well inj potable water into tba aquifer) or a 5QM well (closed-
Ioop well containing additives such as R-22, etl7.atnol, or other antifreeze or corrosion inhibitors).
A. - PROPERTY OWNER(S)IAPPLICANT'(S)
List eLeb Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): Ravk Qvov4L,-a0, "
(l) MaBing Address: _ G C73 f, i lam, J v ofy' 49P.
City' + rri�r r Stabs ,[fL ,dip Code: ? � 33'�' Cau�ty:
Rome/Office Tate No.: CeUio—:/2 7 51
Email Address: Website:
(2) Physical Address of Well Site (if different than alcove): 9aA-,P,
City: State: Zip Code: County:
HomeVOf ce Tele No. -- Cell No._ -Y� 3 - 31�.
B. AUTHORIZED A (;FN'T OF OWNER, V ANY (if the Permit Applicant does not owe the subject property,
attach a letter from the property owner wathorizing Agent to install attd operaze LTIC well)
Company Name:
Contact Person: PMAIL Address:
Address:
City: State: Zip Code: County:
Office Tele No.: r Cell No.: _
Website Address of Company, if any:
RECEIVED i UENR 1 OVVO
► qudw Pt014:tion Section
MAY 12 2010

Ma1y, 12 .• 2010 8:34AM YADKIN WELL No.5118 P. 3
s~Q~
C. WELL DRILLER INFORMATION
CompanyName:Yadkin Wen Co. lnc..
D.
E.
F.
Well Driller Coo.traol'Or 1 s Nam.e~ ~Jo~d~y~M~u~Uis~_.....1Ma=tthe=w~B=r=o=-w~n.----=M=ilt=on~C=a=y.;;...e _
NC Contractor Certification No.: 2Sn:....::-A~---~3=03~6~-A,._._ __ ~35=4~8-..!....A~~~-----
Contact Pers on : David J_ Brown 2195 -A BMAJL Address: cbi,efdr.iUer@msn .c om
Address: 1908 HainptonviUe Rd .. ___ ~-----~~-------------
Ci1y: Hamptonyjlle N.C-Zip Code: 27020 _______ Co1.111ty: Yadkin'-------
Offlc.e Tele No.: _336-468-4440 _________ Cell No.; _336-374-87'36 ______ _
HEAT PUMP CONTRACTOR INFORMAnON (if differen1 thilll armer)
CompanyName: EJ:-.erjk· Le,;at..1i:L'J,~.:y
Contact Per.son: Ha rry B,f> d y EMAIL Address;
Addtess=-----~---~------------r---------
City: -::)t;t1'1(!Jfq,vj/\ ZipCode: 2./Z8!:J. Connty: r~:l fl ,.,.J
OfficeTeleNo.: ---~---CellNo.:_.13 ,., (gg _ 2 '9~
STATUS OF APPLlCANT
Private: X Federal:_ Commercial:
State:_ Municipal:_ Native American Lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
doJeJ l,., 9p J lo:6!..,.,,k ..-M I y g eo f /.. e ,,, ,.._,,/ t' y.J. -/--41.., 1h
G. WELLCONSTRUCTIONDA'fA
~\0
(1) Proposed date to be constructed: .S-(( ls:-(5' Number ofborings~ 2. , ----
Approximate depth of each boring (feet): 3 0 ~
(2) Type of tubing to be -used (copper, PVC, etc): /IA lfDP£ [. [>IG -ll
(3) Well casing. Is the well(s) eased? (ohe~k either (a.) Yes !I (b.) No below)
{a} Yes ___ if Y6S:t then provide casing information below
Type: _galvanized steel _black steel_plastic_other (specify)
Casing depth: From ___ to ____ .feet (reference to land surface)
Casing e,a.ends to above ground ______ inches
(b) No X
( 4) Omlli Info (material SUJJ:Dllllding well casing and/or piping): -rJ,z..-1'-'/ ly ..,J,,..-, t.t.J
{a) Grout tYPe: Neat Cement__ Bentonlte ~ Other (specify) _____ _
(b) Grout placement: Pumpin~ Pressure__ Other __
(c) Grout depth of tubing (n,ference to land surface): from 3 to .I 6() (feet)
If wen has casillg, indicate grout depth: from ___ to ____ (.feet)
.May. 12, 2010 814AM YADKFN WELL
No, 5118 P. 4
H. INJE CTFON-RELATED '1r Q UIPMEN'F
3 ^dzVJ
Attach a diagram shaving the engineering layaur or proposed modification of the injection egwpment and exterior
pipi4tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
informtion.
L LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) include a Site Map (can be drawn) shoving: buildings, property lines, surface water bodies; potential
saurces of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within. 200 feet of
the geothermal heat pump well system. Label all features clearly and ' c ude a earth arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIICATION
Note: Tbi:a Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, undar penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said in£oxmadoA 1 believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the possibility of finis and imprisonment, for submitting
false i.nfonnation- I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications d aamditi of the Permit"
S1gAatur roprrty OwnerlApplicant
4 P _ atize
Prom or Type Full Name and title
(;- :)J 'U V, a 0�qA'
Si jhature of property OwnmlApph t
�e�, ou6r, fir
Print or Type Full Name and title
Signature of Authorised Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Swdon-T IC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone] RECE)VEO I DENR 1 DWq
Aquifer Pmter*00 5aVon
MAY 12 2010

YADKIN WELL NO.5118 P. 5
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.M�y, 12. 2010 8:34AM
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