WI0400156_GEO THERMAL_20101022

Permit Number
Program Category
Ground Water
Permit Type
Wl0400156 /
Injection-Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Edward L. Edgerton SFR
Location Address
432 Shady Ln
Wilkesboro
Owner
Owner Name
Edward
Dates/Events
NC 28697
L Edgerton
Orig Issue
10/22/10
App Received Draft Initiated
10/20/10
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall 1·.jiJl... ..
Scheduled
Issuance
Central Files: APS_ SWP_
10/22/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual·
Permit Contact Affiliation
Edward L. Edgerton
Owner
432 Shady Ln
Wilkesboro NC
Major/Minor
Minor
Region
Winston-Salem
County
Wilkes
Facility Contact Affiliation
Owner Type
. Individual
Owner Affiliation
Edward L. Edgerton
Owner
432 Shady Ln
Wilkesboro NC
Public Notice Issue
10/22/10
Effective
10/22/10
28697
28697
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Edward L. Edgerton
Melissa Meyer •
432 Shady Ln.
Wilkesboro, NC 28697
A~A ·•1'-~ NCD~EN ....... R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
10/22/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0400156
432 Shady Ln.
Wilkesboro, NC 28697
Dear Mr. Edgerton:
Dee Freeman
Secretary
On 10/20/2010, 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 constructjon 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 Ac(and North.Carolina
Administrative Code Title 15A Section 2C Subchapter .021 l(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 Michael.Ro [e-mail] if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files. -Permit No. WI0400156
Wilkes County Health Dept.
Si}i erely, . n /\ ·
-;?n!lta~D
Supervisor
David.J; Brown (Yadkin Well Co., Inc., 1908 Harr_iptonville Rd., Hamptonville, NC 27020)
David Burchette (Associated Heating & Air Conditioning, Inc., P.O. Box 249., N. Wilkesboro, NC 28659)
AQUIFER PROiECTION 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
N~rthCarolina
J\}aturattu
Oct, 20. 2010 10:14AM YADKIN WELL WINa)I So No. 6153 P. 2
NORTH CAROLINA
DEPARTYMNT OF MMONMENT AND NATURAL RMOURCES CNCDSKR)
NOTlUCATlON OF WMT TO CONSTRUCT A CLUB-WQ GEOTMMAL
wi CrI4N WmL SYM M:
TYPE S-OW WELUS)
In Asaow4we lrith the p Mistoas OMCAC title I5A f1 0200. please
oosuplm dais wtj&aWn and inail to address on the back' page (please BW or M= be0rMS9(M).
DATE: ?A —to
Well T)Vv Confirmation: )Does the pmaposed ayatem circulate potable water vn�i (no additives) in
continuous piping that completely isolates t'he fluid from the epvironment (i.e.
closet -Ida ?
Yes X6-Continue ociVleflrigthisform.
No Do Not complete this form Complete other MC application fonns for inftflbS
either a SA? well (gn-loop welleps' potable water into the aquifer) or a SQM. well (closed -
loop well corxta4i2 additives such as R-A ethanoL or other sntifftt or corrosion in]li kon).
A. FROMRTY OWNER(S)IAPPLICANT(S)
List peNh property Owner listed on property deed (if awned by a bu&h= or govemmern agency, stare name of
aiztity and a t�epra®r�tatzve sslszrthaority €ar signature}: 1, -E 06 T-P JA - 4
(1) MaibingAddress: *2- U
City: I state: W-Zip Code:
HomafOffrce Tale No.:. �'�o _�.'. ,' 3 � ceii xe -
Email Address: website:
(2) pluck Ad&ess of Well site (if d&rax than above): $,4IM 115
COY• Staor _ Zip Code- C=ATI
HamelOffsoe Tete No.: Cell No.:
B. AUTHORISED ACI NT OF OWNER, IF ANY (tfthe permit Applicant does awn the sabjent PVexty,
attach a letter from the pre" owner avttmrixing AMM to install end operemt Ux %vall)
Campauy rTem -
Comaet Peraon: EMAM Address:
Address -
City: Stain _ Zip Code: County:
0 fioa Tele No.: Cal] o.:
Website AAddrest of Company, if sny

4ct,,24. 2010 10:15AM YADKIN WELL
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Ho. 6153
wea ITrijller casaftwOnr1s MMw rgbMullts_ - l+ ff-&w i liven ca"
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D�aiacfTe�nrie �x iciv �.��'p�L�lfi�a�r.. ..�. -.,FII►+fAl'i�Qddre.,����e53dile n.cosn
Add=-,M FtraaptanviNs Rd.
City. 13anrebDdY! ie M. _ _.- Zp Cads 27020 Om y, YtdkkL
Office TeloNo.: 33646ti 40 Cell Na.: _336-374.973d
YJEAT FUJO CONMACTOR 1NXt0RMATd+dN (i£diffiWent tbRn drflW)
CarapaO' Name 4
Caottct pesswr. l VlID AvAeme ff- _ _RWAU.�ddre*s; G
Address- i'-- Z-v.7 - —
cgty, W. zip Code: V6-401 Coru:ty:
Ot39oe Tue No.: '7 tsly Can No...
STATUS OF AITMCANP
e.k-05
private: -& Fsdermh, C.mmmesc st
state: Wahi*.' __r___ 'Native American'.ands,
INJEt rION MOM= ,(brkgy d=r&e how tic injwdua ►ya(s),?M be tmd)
G. i967,X. COMTRUCTION DAU
(1) PMwed data to be c❑wected; Number otborinst;
Aww)mate depth oieach baring
(2) T]r of tubing tp be tiled (svppa, PVC, eto):-
0) Well cog. is tip. Won($) cascd? (cheek either (e.) Yes gr (b.) No below)
(a) Yes if yes, fbea pradde Ming inrormatfoa bolow
Type: �gaivar�ta�d ste4i^bl�eck stew' _,_ p[astse other tSA3
Casing dep4r, loam to fact (r6Mvftoe to Sand a 4km)
C aStg adds to above grauad. loo .
(b) No X
(4) C3rowt 3nfb (aua►eria! s�otmdtng we3f a Iugamdltu pipinp�: .` p ,
(a) Crevt Type: Nest Cement 8eatarte. O l aPoQify)
(b) Qmuti7b=vmn9: Pum*&,je_ N++ssvra ether
(c) Grantda oft,obzrag{7eftrceaae to isndsvrfkue}: 5nns _ to. .,X
if'trnli bss � isdica�o grout depilicc frown b
F. 3
.dam
SM

Oc t. 24. 2010 10:15AM YADK I N WELL No, 6153 P. 4
S. MrrMN-MaAUD XQUiPMENI.'
Atla h a diegram sh%ving the eugJmmkg *out or )unposed ntodiftptxon of ft injectim ag,►t4vaat and exterior
pi*Sbhizg ass a ated whit the Wcotion operation. The n=dketvres'a larochm my provide supplemftt ry
infarrntttian.
1. LUCATI M DP WELT M
Attach two aagies of =aps sbaWft tba following i3Ara a.tion:
(l) ladudo a Site Map (can be drawn) showing: bu9l nga. property lines, surface water bodies; potential
sonron oltgrauadwater coraninatiaa end the wicntation of and distances bdwaeo'tbe proposed well(s) and
any a dWzg wcU(s) or waste disposal facilities such as septic mnh ox- drain finds located YVIUn 200 fact of
the geothern al beat pump rmll sy*m. Label ail features oleardyr and include a ixWA ar[_
(2) The Site Map mast sbom ft subject property is relation to the swmndiog aces by usimg st hmst two fixed
refcreaaa paints such as roadsy streams, aadlor lugh"y lutermeciions.
J. CRtTMCATION
Nota. This ftmidt Applteation must be signed by eadk person appearing nn the
recorded legal prop" deed.
`q .hereby certify, under penalty of law, ih I have pwsm* tumLaad sod am familiar with the ifx% matron
submitted in this domwd and all attachments tmeretn and that, bued on my inquiry of those individuals
immediately rospous ibie for obtaiLWg said i hnnation, I behave that the information is true, accmabe vad comple-M
I am await that there are sigclBOW pb aUies, mQuding the possilsilitp of Sties and. =priso=en4 for subs
Mn information. I airee to coact, open, maintain, repair, and if apgcable, abandon the injection well and
ail rW*d appm*auoea in aocordame with the approved specificadow and conxlst cm of tho Permit."
4"gIt �h
Signatuue of prcpe* Owv Appl w xt
66(",4 C . cqgcr4-�,
Print or Type mil Nam and title
Signature of l3Caprriy thvnadA rxt
Md or Typo Fol Mama anti title
Signature of'AuthmbzdAgin, if any
Privt w Type Fall )Name and We
Please return two copies of the completed Application pacimp to:
North Carolina DINR-DWQ
Aquifer ProteWoa Suction -MC Program
1636 Mail Savke Cexxter
Raleigh, NC 27699-1636
Telephone [phone]

Oct, 24. 2010 14:1-5AM YADKIN WELL
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Oct.20, 2010 10,12AM YADKIN WELL
FAMAM1 E TRN MISSION FORM
No. 6152 F. 1
DATE: �r7 Lc7 TIME: __REF NO. LOG NO.
TO: /le,;Uw
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CAMPANY NAME
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FAX NO.
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PLEASE
ATFENMON
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COMPANY RAMIE _
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FRX NO.
PLE11-%
❑ RUSH
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INDMOUAL
DEn
NUMBER CF PAGES S
INCLUDING THIS SHEET
PLEASE
REPLY BY
ORnMATM
SIGNATIJRP
MESSAGE:
- - - . -'f-Y f -
-FOR ALL YGUR WATER NEEDS-
YADKIN WELL CO., INC.
19ge HAMPTONVVLLE ROAD
HAMFTONVILLE. NC 27020
DAME j. SROWN, VICE PRIES,
TOLL FREE (SOOT 2AS:9355
OFFICE (336) 46$•4"0
FAX M36) 4$$-4049
RES (5361 40.4659
.0=0 M9w4 A'4011CA • 60C L.CVE9 YOU -
PLEASE INFOrM US MWEDUMY F YOU 00 NOT RECEYE FAQ F rH FULL

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Oct.20. 2010 10:14AM YADKIN WELL Na.6153 P. 1
- FACSINULF TRAMMON FORM
DATE. �'� / 9-z l tD I -nme REF NO. LOG NO.
COMPANY NAME FAX NIT.
�n ls m DEWBR
► LJ IMMEDMLY
ATFENTiON OEn
FROM: 4 � V �= � . j - 6 fzp
CGMAAHY NAME �— FAX NO. PLEASE
are �' J f Y n _ � FF*ir
INDMDUAL DEFt
NUMBER OF PAGES PLEASE 09101NATUn
INCLUDING THISSHf REPLY 8Y SrGNAT1JR�
MESSAGE:
-FOR ALL YOUR WATER P COS'
YADKIN WELD CO., INC.
19M HAMPTCNViLLE ROAD
HAMPTONVILI-E. NC 27020
❑AVICI J. BROWN, VICE PRE5.
TOLL FRCC L9001 24a4355
OFFICE [phone]
FAX [phone]
RE3 {3"j 4G8-4¢59
,6600 NEWS AMSHMA . GGO LOvES YOV
PLEASE INFORM US IltUMM Y iF)IDU DO wr �UVE FAGWJU IN RIl.1.