WI0400141_GEO THERMAL_20100616

Permit Number WI0400141
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
Barry F. Darnell SFR
Location Address
567 CB Eller School Rd
Elkin
Owner
Owner Name
Barry
Dates/Events
NC 28621
F Darnell
Orig Issue
06/16/10
App Received Draft Initiated
05/26/10
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall hl'.JL~.
Scheduled
Issuance
Central Files: APS_ SWP_ 1
06/16/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville
Major/Minor
Minor
NC
Region
Winston-Salem
County
Wilkes
Facility Contact Affiliation
Owner Type
Individual
Owner Afflllatlon
Barry F. Darnell
Owner
567 CB Eller School Rd
Elkin
Public Notice Issue
06/16/10
NC
Effective
06/16/10
27020
28621
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
AWA
MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Barry F. Darnell
567 C.B. Eller School Rd.
Elkin, NC 28621
Coleen H. Sullins
Director
6/16/2010
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400141
567 C.B. Eller School Rd.
Elkin, NC 28621
Dear Mr. Darnell:
Dee Freeman
Secretary
On 05/26/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl
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 .021l(u)(2). Additionally, you should contact the Wilkes 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 [e-mail] if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400141
Wilkes County Health Dept.
s~~ ~~
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Supervisor
Barry Darnell (Dorsett H & A/C, 248 Service Rd., Yadkinville, NC 27055)
David J. Brown (Yadkin Well Co., Inc., 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.orq
An Equal Opportunity I Affirmative Action Employer
No~l,..c 1· 01. u1: aro 1na
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DATE: 1 JA 1 (0 . , -nME: -REF. NO.
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NUMBER OF PAGES PLEASE ORIG UMOR"S
INCLUMNS THIS SHEET REFIY 8Y UNATURE
MESSAGE:
In
le
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-FOR ALL YOUR WATgR NEKEW
YADKIN WELL CO., INC.
iWa HAMFrrONVILLE ROAD
HAMPTONVILLE NC 27020
❑AVID J . BROWN, VICE PRE$.
TOLL FREE (500) 2AS-V355
OFFICE (334) 4664440
FAX I9351 45B.4045
RES 53361 4604559
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?LEASE TIFORM VS GIMMMUnLY IF)W W HOT F EC9VE FACBVALE IN PUU
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTMCATION OF INTENT TO CONSTRUCT A CLOSID-LOOV QVOTHEMV AL
WATER -ONLY INJECTION WELL SYSTEM. -
TYPE 5-QW WELL
in Accordanne r itli ft prorisions of NCAC Title 15A: 02C O240, please
complete this noti doation and wail to address on the back parr (please Pxi tt oz 11M iuformtica),
DATE: T" ik 20 1 c7
Well Type Confirmation: Does the proposed system circulate potable wata flab Ono additives) in
continuous piping that completely isolates the fluid from the envirorxment (i.e.
clos -400 �
Yes Continue completing tWs form -
No Do Not complete this form Complete other LIC application forms for installing
either a 5A7 well 4onen-loop well jj�jeetin potable water into the aquifer) or a SQM well (closed -
loop well containing additives such as R-22, a^flaanol, or other antifreeze or corrosion inMbitors)-
A . PROPERTY OWNERS)/"PLYCANT(S)
U
List each Property Ownez listed on property deed (if owned by a btsiuness or government agency, state name of
entity and a representative wlsuthcTity for Signature).
(1) Mailing Address: ,�tz l� . 8 . i: t I etv JC-A t I
City: } t ; i 7 State: L. Zip Code: 2-9 C t Cony: k� : I .k� t .
HornalOfftce Tele No.: ?z3 3s= C. �t2- Ceti No.:-3C 5<6C 2 �
Email Address: Website:
(2) Physical Address of Well Site (if di%rezt than above):
City:
Home/office Tale No.-
.
State: Zip Code.
County:
AUTHORIZED AGENT OF OWNE%t, IF' ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agezt to install And operate UIC well)
Company Name --
Contact Person: EMAIL Address:
Adclms:
City:
Office Tale No. '
State: Zip Code:
Website Address of Company, if any:
Catmtr
- M No...
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C. WELL DRILLER INFORMATION
Con p&nyNamc:Yadlan_ Xell C4 Ine.'
Well Driller Contractor's Nsme: dads+ gUit Maithµw •rown N t n Cave
NC Contractor Cerlficatlan No,: 2572-A
Comet Persoza_,_.Dav1d I_ Broom �,��5.�. �� IL Adt : cf�iefdrif3ert�msn.cam
Address-, 1908 Hamptonville Rd. —
aty; Ham 1Q `.C. Zip Cade: 27020 County: Yadkin
O€Fiae Tele NQ.: 336-468-4440_ — Ceg No.:—336-374-37S6
0
IU,;A-T PUMP CONTRACTOR MORMATSON (f dif ereal tbast drMer)
Campany Nam D r " -< ---
contact >?errs7an• X eA enGt*i EMAi%
Address.
City: rg k feel [ a .. tip Code: 2 7a s: •.i County.•
Dfitce Tile No.: ,- -' 0L ,ZIAC,� Cell No_:
E. STATUS OF APPLICANT
Private: t Federal: Co=eraiai:
State: Municipal: Native American lends:
V. INJECTION PROCEDURE (briefly describe how the hVecdon well(s)
will be used)
G.
WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: 4' — to Number of borings:
Appraxir % depth of each boring tfeei): --
(2) Type oftubing to bo tied (copper, PVC, etc): _JA Q iQ a4D A- {
(3) Well rasing. Is the well(s) cased? (cheek either (a) Yes or (b.) No below)
(a) Ices if yes, then provide cosine, information below
Type; aivanized steal blade steel plastic other (specify)
Casing depth: From to feet (reference to land surface)
Casing extends to above ground inches
(b) No A �—
(4) Grout Info (material surrounding wat] casing andlor pip,ng):
(a) Grout type: Neat Cetttent Sezrtouate !C ogler (specify)
(b) Grout placement: P=j>ing L Pressure (alter
(c) Grout depth oftubiug (re7:errenee to land surface): from 3 tv 2192 (feet)
If well has casing, indicate grout depth: from to (feat)
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iN,UCTION-1SEATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injections equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure array provide supplementary
information.
L LOCATION OF WELL(S)
Attach two copies of =ps showing the following information:
(1) Include a Site Map (can be drawn) showing: b,"iugs, property H=, surfiace water bodies; potential
sources of groundwater oontaminatlon and the orieatatiou of and distances between the proposed wells) and
any existing wel(s) or waste disposal facWfies such as septic tanks or drain figlds located within 200 feet of
the geothermal heat purap well system. Label ail feawres clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at feast two fixed
reference points such as roads, streams, and/or highway intersections.
I CJERTMCATION
Nate: This Permit Application must be sigued by each, person appearing an the
recorded legal property deed.
"I hweby certify, undeT penalty of law, that I have personalty examined and am fauuliar with the information
submitted in this document and all attacbments thexeto and that, based on my inqutry of those individuals
immediately responsible for obtaining sand izxfozmation, I Wieve that the lufou atioa is true, accurate and complete.
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for subrnitdDa
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
4 related appurtenances in accordance with the ed secifi 'ons and conditions ofthe Permit:"
Signature Property Owner/Applicant
DA�i
Print or Typ4 Full Name and title
Signature of Property Owner/Applicant
Print or Type Full dame and title
Signature of Aut monad Agent, if any
Pant or Type Full Name and titi,e
oVE j VF_, jR . Please return two copies of the completed Applications package to.
�ujfer Pro 4* _ North Carolina DENR-DWQ
MAY 28 1tj Aquifer Protectin Section-UIC Program
1636 Mail Service Center
Raleigh, NC 276.99-1636
Telephone [phone]
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