WI0400149_GEO THERMAL_20100830

Permit Number Wl0400149 /
Program Category
Ground Water
Permit Type
Injection Water Only GSHP WeU System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
169 Locust Lane
Location Address
169 Locust Ln
Blowing Rock
Owner
Owner Name
Dennis
Dates/Events
NC 28605
Norris
Central Files: APS_ SWP_
08/30/10
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Afflllatlon
David J. Brown
1908 Hamptonville
Hamptonville
Major/Minor
Minor
NC
Region
Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Type
Individual
Owner Afflllation
Dennis Norris
169 Locust Ln
Blowing Rock NC
27020
28605
Orig Issue App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective Expiration
08/20/10
Re gulated Activities
Outfall MUt •.,
Waterbody Name Stream Index Number Current Class Subbasin
NCDENFZ
North Carolina Department of Environment and NatUrai Resources
Division ofWater Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
8/30/2010
Dennis Norris
1.69 Locust Lane
Blowing Rock, NC 28605
Subject: Acknowledgement of Intent to Construct Type 5QW iniection Well System
Permit No. W-10400149
169 Locust Lane. Blowing Rock, NC 28605
Dear Mr, Norris:
Dee Freeman
Secretary
On 8120/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onh
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
individual peruvt 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 .0211(u)(2}. Additionally, you should contact the Watauga 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 Micbael.Ro«ersr)ncdenr.�-ov if you have any questions.
Sincerely,
�..1uit,"/,A .�
for Debra Watt
Supervisor
cc: Winston-Salem Regional Office - APS
APS Central Files - Permit No. W10400141.1
Watauga County health Dept.
Yadkin Well Co, Inc. (David Brvwr - 1909 Hanrptnmille Rd, Hamptot3vilIe. NC 27020)
Scott Brothers Healing & Air (Mike Carter - 1970 l .iberty C;rovc Church Rd, Fleetwood, NC 28626)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capltal Boulevard, Raleigh, North Carolina 27604
Phone: [phone] I FAX 1; 919.715-0588: FAX Z 919.715.0048 I Customer Service: 1-877-623.6745
Internet. WWW'MCWateMualitY.qM
An Equal Opportunity) Affirmam Action Emp*et
ne
OrthCalrolzna
Natua'ally

Aug.20. 2010 3:05PM
YADKIN WELL
FAMNLF TRAHSh UMON FORM
No, 5803 P. 1
DATE: TIME: REE NO. l.OG �0.
COMPANY NAWIE FAX N0. nEASE
Q G i ea 7� nyr�_ .. ❑ DEUVEur�Etx
AnEnON DEPT
FROM: "a aAox Ca
COMP 1�NAME
INDMOUAL
NUMIJER OF PAGES KIASE
tN LADING THIS SHEET REPLY BY —
MESSAGE: '
"FOR ALL YOUR WAFER NREQS"
YAOKINE WELL cO., INC.
19QO HAMPTONVILLE ROAD
HAMPTONVILLE. NC 27020
DAVIb J BROWN. VICE PRE5.
TOLL FRE5 (0001 T_a6-'!s<3SS
OFFICEFAX
(336) d69^44U48
�.ti
FAX i836y 468�U48
R£5 f3361 A68-A659
Y.QQV NGWS AMCRjCA - GG9 Ldvin YOU'
T
FAX CIO.
DEBT
OR1GWAiDR'S
- SIG"TURE
MUIF;R
1
PLEASE
❑ REPLY
PLE0k$ E iNFO P#A US MWEMArMY F'tW Cb "OT RECEIVE FACS0A .E m FL LL

nU��l //Aug. 20. 2010: 3:05PM �IcOcyADKIN WELL' eAl Na. jj� b r r '4jn ,No, 5843 ,)P. 2
• �7 y � i f`-r
NORTH CaCT INA
DEPARTMENT aF EKVMONNXNT AND NArLMAL I OURCES aT ENR)
NOTMCATION Old YNx NT TO CONSTRUCT, CLO..SED,LQQP GLO IWAAkL
WA LM—ONLY X J-EC7l:ON WM ,5YST
TYPE 5-QR YELL{5
Yu Accarda= ivkth the provastcms of NCAC Tifle 15A: 02C 0200: please
carugleta Ids uotiivatloa W =11 to ad&M on #ba barb pus (Tease � or Iya inbrmaa=).
DATE z0 'i
W#11 Type Cogffrr&ae,P)%: DM the prapwed system cirmlaze pctahie water cmly [no adwnvas) is
[outluuow piping the t=pletely isolates the fluid from the environ eat (i.e.
yes X� Cantume completing this form_
No Do Not complete this f&w- Comploto other tZC applicmdoa foims% for imtOiing
either a 5A7 well (2p n-loop wall jW-gc Ax potable water irdv tlxe 2gater) or a 5QM weU (closed.
loop well comimi $dditives su;h as R-22, etltaml, or other antifreeze or =osion inhibitors).
Pp,pFERTY 0WN8Pt(S)/AFPLICANT(S)
Lasr a h PropaV Oww 3istzd on Pnperty dced (if owned by a business or government agency, st da na= of
entity and a repsescntative •vlaulharity for sipautre): D t l�larr�'
(1) Mailing Addz*ss • J- 4' _ k,, aA,
City: ptoao 11.6; &1_ Stets_ �V,C. zip
Nona office Tel,e No.: 32
Email Address;
(2) Fhyslaal AddvnS pi' VVeli Me (if diifereat'tl= abov,&):
City:
Homel01mce Tele No.:
State: Zip Code:
2
l3. kU AORX D ACEi T OFOWNER, iF AN-Y ir.£the Permit Applicant does not dwa the subj=proparf,
ads aletterfrom the property owaes awhmizing Agent to install aad opera#a UIC w
ell)
Company l4sm,a: _ Yq d ko t,
Contact Pctso:c` io `+ at-d FVAIT Ade;;: ' N M *.r ►ra A,
Address: 00 L Corr,
City: On yj jtt State: 1,J47zip code: 2"2--q count t
office Tate No.. ��0'-,eL--5� 5,yo Cell No.: -7 T �' �'�' $'7 -T6
Webs'teAdcress of Company, if
n
RECEIVED I DENR 10WQ
)jFFR'PR 1Tr r..TtnN SECTION
AVG 2 0 2010

''Aug, 20. 201 a'' 3:05PM O°`YADKIN WELL's PAA lYD, 3M o r r M.
Mo.•58Q3 rP. 3;
C.
D.
E.
F.
VV LL ))ML:R YNFoRMATION ;
Compmay Name'.$ rd t71� I;o C.
wall EkliiarCaarr cbn?sWM& Jodyul� Mst��aeaHra:m MitSo�_
NC CQ=ctor Q.100at€co No.,
C5, Q ld
Cmft& Pessan: Dayld .T,Srot►�n_ �, c �^� sn►�t, a�_�����
Gtty: Efan2 torrv•IIa .G 2.!tp Cody: 27420 CauMI�yt Yadkin
Q-Mce Tele Na.: 336-468-4440 CeI Xv.: M-3Td473b
SLATIiVXF CONTRACTOR WFORMATION (if amxent eau drMer)
Caznpsny N�mc:,..� c
Contact Par;on:
Addmss: 19 7G
r
City,g _ Zip Code• jBCdMAr. s �;
STATISTS OF APPLICAM
pdvete. x FO&Ml- Ca�iet
Stale: Muuivipai: NativeAme6caatands:
TNJ..EC I0NFR0CXDVR7- (briefly descilbe iaaw she lgjectioa weli(s) -%ill be used)
Gn� a 9
Q. VMLL CaN TIWCn6NDATA
(1) Proposed damb h4 aombmaed: Num7mv of borings:
Apgra%i=ft depth of each, boring (aet):-
(2) Type cft�bbgtc bemsccl (copper,PVC, etc). 31
Weu using. Is the tvel7(s) cased? (aerJ� either (a.) Yes or (b) No below)
(a) ".des uyes, then provide casing kufhrt 66n Mow
Type; !—.MLVInWd Sta01 black 5tee1wDl�adc � athCr (spec*)
Casing depth: Rom __ tty feet (r4ference to land sui;'ace)
calag extends to Almve ground isirhes
(h) Nn X, +1
t4) Grout Bib ( ma'trial su=undl;DS well casnag =Ntv piping): -
(a) Croat type: Nest G.ment Bentouilte ; ❑Flier (spate
(b) Grout pw-Went. pumpitr Pressure other
(C) groat depth of tubing (Tc:fc oce to land sur$ce): fr= �M to �Jbco-
If wollb s cdsfn& iadtcale gxo'at depth: tom to (*co
c- .COAL

A1111 Aug, 20. 2010' 3:06PM x`YAOKIN WELL-5 r x nto, jJ0 0I r 100M I,No. 5$03 Y. 4=
I:N3 CnON-ABATED EQMMEN7 j [U
Attach a dia9= shluuft the eugiue&1t-9 layout or proposed =&0096u of the iT4ictlon e#pmmnt and CgWiOr .
piping bxrg astociated Wit'b the Wection operation. The manufacturer's bror3aW my pznvide suppletnenwy ;
information- .
L LOCATION 4F'WXU(S)
Atmch two copies of maps showing the follower iafomlatim
(1) bwjude a Site 1U,p [csa be arawnj slowing: buildings,, property lbxs, a ea wwbat r bodies; pot8VtW
sources of gTotu4w-hfcr contamcuafion and the orientation of and dlg=cw betP+'eeu t1le proposed wells} and
any eiQstiag wc]1(s)or waste disposal facilrtiw shale as septic tanks or dr4m iocaxecl withir 200 Ant of
the geothermal heat pump wo]l rystezn. Label ali features clearly and include ac� narrow.
(2) The Site Map sanst show dam subject pvpeaty is xelatioZ to the sttrz=diag 2�1& by t$zug at I623t two fted
refcrcnca pozuts such as roads, stsea=, and/or highway intersectiola,
IT. C TMCATX0rr
NoW- This Permit Apptiution m st be persot appearin on
recorded iegal property deed.
"T hereby =iffy, =dsr penalty of law, that i liave personally ex miaad and am �6i} with the information
submitred in This docu=iat and ag atrachments thereto and that, based on my. inquiry of those iadiy c&M s
immediatcV ,respotsible for vbta.i7itag Said itfoctaaat1M i behove that the information' txt� aecww and complete -
I am aware that there are significant penalties, including t o possibility of des and ln�o=m% for submittlag
false information. I agree to oansmict, operate, mainta" xcpair, =d if applicable, abandoa she 1400 san well and
all related apptatenaxces in accordance vAth dk approved ifi d dill af'th P
please rer= two cola
Nor�tl
Aquifer Pri
163
Ra
Te-1
e spec cattobg an can a
e errra7tt.
Sip.atUre of Propexty QwnedApplicaUt.
Fri= or Type Fall Name and title
Signature of Propaty OwuerlApp]irant
print (x Type Full Name and title
3i8aarzara of Authri adJ/Aj�gyes� if any
0 ^`'!y .6ro
Print or Typo FQ Name and title
[as of the completed Applicatiok package i
x Carolina DIENR If WQ
Aettron Section-UIC Program
6 Mail Sew 00 Center
loath, NC 2.7699-1636
RECEIVEDIpENR
aphoue (919) 715-6,935
uiFFgpp0TFMfr)1
AUG 2 0 20
I DWQ
"ECTICA
to

Aug,24, 2010 3:06PM YADKIN WELL
No.5803 F. 5
bedtj/vfJ p 0 rv� s`
t c I G. ca jkt �
131�(rf,q "
p/�
�Ct
h o w a6r ivdt )
Oh Comrwdy4y well
iO4p
44-t.
It
r
0
REC&
A�U1F�O�Iltrr�! IDWO
AUG 2 0 Z�� �crroN

A u g. 2 0. 2 0 1 Ovt 3 : 0 6 P Mil Pri YA D K I N W E L L
Authorization
Dennis Norris II
To [e-mail]
Hi David:
N o. 5 8 0 3 f P. 6 I of I
11:56 AM
Per our telephone conversation, I authorize you to act as my agent in the signing of he geothermal
permit.
Please let me know if you need anything else.
Dennis
REL:1:IVEO l DENR / owa
AQUIFFR'PROTECTION SECTION
AUG ·2 0 2010
http://byl48w.bay148.mail.live.com/mail/PrintMessages.aspx?cpids~9fe2c29-aa-1 ldf-... 8/19/2010
NCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
8/30/2010
Dennis Norris
169 Locust Lane
Blowing Rock, NC 28605
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400149
169 Locust Lane, Blowing Rock, NC 28605
Dear Mr. Nonfis:
Dee Freeman
Secretary
On 8/20/2010, 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 irtiection well system as long as the
following conditions are met:
The injection well system contains only potable water,
The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Titic 15A Section 2C Subchapter .0213, and
The required notification form and associated reaps have been completely and accurately subnutted.
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 .0211(u)(2). Additionally, you should contact the Watauga 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_,ersscr)ncdenrxov if you have any questions.
Sincerely,
o�.�.�
jor Debra Watts
Supervisor
cc: Winston-Salem Regional Office - APS
APS Central Files - Permit No. W10400149
Watauga County Health Dept.
Yadkin Well Co, Inc. (David Brown — 1908 Hamptonville Rd, Harnptonville, NC 27020)
Scott Brothers Heating & Air (Mike Carter — 1974 Libertv Grove Church Rd, Fleetwood, NC 28626}
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699.1536
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27504
Phone: [phone] FAX 1: 919.715-0588; FAX 2: 919.715 60481 Customer service; 1.877-623-6748
Internet: www=wateroualitv.oro
An Equal OpporluMly I Afrirmatlwe Action Fmployerr
NonrthCarolina
Naturally

North Carolina Department of
Environment and Natural Resources
Division of Water [duality
—V3.4W Mail Service Center
Raleigh, North Carolina 27699-1617
lLe3ze
i
� r
�■a ►
+'
• - s • f �x
1
riT1Cv«:'i'+3i7
O'7oH26523172
$ 00.357
43 i 09/01/2010
!iolrw ftwn 2 76i i
US POSTAGE
NIXIE 274 OE k 00 09/08/10
RETURN TO SENDER
ATTEMPTED - NOT KNOWN
#Jig ADUE TO FORWARD
MCI: 227699452799 ``{{ {II*11{48--0913{1-01-41
F]l�i11]]1{i7�1i�]3iil!!!l]!Jlli{I!1]1lk�F]!]{�i�lifillil]11lF