WI0400157_GEO THERMAL_20101118

Permit Number
Program Category
Ground Water
WI0400157 /
Permit Type .
Injection Water Only GSHP Well System (5QW)
-Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Donald W Goodhart, Jr. SFR
Location Address
914 Parker Eller Rd
Lansing
Owner
Owner Name
Donald
Dates/Events
NC
w
28643
Goodhart
Orig Issue
11/18/10
App Received Draft Initiated
10/25/10
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall N1JLL
Scheduled
Issuance
Central Files: APS_ SWP_
11/18/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1 ~06
Permit Classification
Individual
Permit Contact Affiliation
Donald W. Goodhart Jr.
Owner
914. Parker Eller Rd
Lansing NC
Major/Minor
Minor
Region
Winston-Salem
County
Ashe
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Donald W. Goodhart Jr.
Owner
914 Parker Eller Rd
·Lansing NC
Public Notice Issue
11/18/10
Effective
11/18/10
28643
28643
Expiration
Waterbody _Name Stream Index Number Current Class Subbasin
A7A
INCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
11/18/2010
Donald W . Goodhart.-Jr.
Frances C. Goodhart
914 Parker Eller R.d,
Lansing, NC 28643
Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System
Permit No. WI0400157
914 Parker Eller Rd,
Lansing, NC 28643
Dear Mr. and Mrs. Goodhart:
Dee Freeman
Secretary
On 10/25/2010, the Aquifer Protection Section (APS) received notification of vour intent to construct a closed-Ioop 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:
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 Title 15A Section 2C Subchapter .0213, and
The required notification forth 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 Ashe 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.Roeersra ncderingov if you have any questions.
Sin rely,
for Debra,)p atts
Supervisor
cc: Winston-Salem Regional Office - APS
APS Central Files - Permit No. W1040015 7
Ashe County Health Dept.
David J. Brown (Yadkin Well Co., Inc., 1908 HarnptonviIle Rd„ Hamptonvilie, NC 217020)
Mike Carter (Scott Brothers Heating & Air, 1870 Liberty Grove Church Rd., Fleetwood, NC 28626)
AQUIFFIR PROTECTION SECTION
1636 Mail Service Center, Raleigh, {North Carolina 27599.1636
Location: 2728 Capital Boulevard. Raleigh, North Carolina 27504 One
Rhone: 919-733-3221 IFAX 1:919-715-05K FAX 2:919.715-6W4 CustomerService 1-877-623.674$ NorthCarolina
Enternek: www.ncwaten7ualit+r-ors ���llrL�l��
An Equal Oppcnunay � Aff+rmativeAcl�on Employer i

Oct.25, 2010 9:09AM YADKIN WELL
FMNOLE TRANWWON FORM
No, 6174 P. 1
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DATE: d � D TIME: _ _SEE NO. LOG NO.
COMPANY NAME%
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FAX NO, Plug
❑DELIVER
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COMPANY NAME FAX NO PLEASE
❑ REPLY
1NDIRDUAL Din
NUM DER OF PAGES _ PLE 9Y ORIGINAT f
INCLUDINGTHL5 SHEET
MESSAGE:
An "FDR ALL YOUR WATEIi N"bS'
YADKIN WELL CC., INC.
199E HAMPTONVILLE ROAD
HAMPTONVILLE, NC 27620
D :viO J. GROWN. VICE PRES.
TOLL Fw££ 12001 241/4355
OFFICE t336) 468.4440
I� FAx MS&? 46&-4CA8
RES i33M 4"-4659
•Gco4 mr," A$46RSCA • 050 &4VfS YW
PLEASE INFORM US IFdAAMOMY IF YOU 00 NM F F+CSSM ZO4 FULL

"JU1/6`Oct. 25. 2010' 9:09AM -"O'YADKIN WELLS
rA.k lvo. in rrp r i �n� No, 6174 rF. 2'
�_ _!LD,C0v;�1
NORTH C.AP OLWA
DEPARTIvONT OP EN' MONMENT AND NATURAL RESOURCES 0XDENR)
r(OTMCATiON OF MT.NI' TO CONMUC"T A CLOSED LODP GEOTERMA,L
W IMUMON WELL SYSTEM
E 5_0 W !nLL(S)
In Accordance zviZ Ctrs provi4o= ofNCAC Title 15A. 02C.0200, plegSd
cowplete i13is aotWcatioa"matt to *d4mm on the hack gage g4aasr Pfmr or Type iPftnmr1oQ.
DATE: L -a 24-LQ
A.
Well Type Confirmailom Does the proposed system circulate potable waver on.1y (no addidV%) in
continuous piping tbw eaaapletely isolatas the fluid fYom the environmwt (i.c.
alased-loon]?
Yet X _ Continue completing this fors
No Do Not eompim this form. Complete othecr T.3IC application forms for kistalling
either s SA,7 wall tar -loop well potable water into %a aquifer) or a 5QM well (closed -
loop well containing addi '❑ such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
PRO.MTY O WNER(S)/AFp)LXC,A.NT(S)
L'lst lDAgI Property Owner listed on Property dead Cif awned by a business or government agency, state scams of
cutity and a ropre. tnta.tive wlauthority fur signature): �0AiA t-1 ls7 . ,- TW_ ..
(1) Mailer Address. 't L 4 f K 11teV- JZZ -
City: _ L_ k ! Sl N(r- - - - - Srare; _AZ_r- ZiP Cod,- 4 Lf County: "
Hame/Of raTelcNo,. 33L.- 35?`t- iD3� CeltNo.: 3G-•-�"1'# `S
Zruail Address: �_ftfted ek s•416 rt- Websitc;
halo, 1. 4.,%
(2) Physir4 Address of Well Site (if differeat than above):
City: score, —*Zip Code:
HaMO/Oface Tela Na
Cauury_
B. AUTHORIZED AGENT W OWNER, MANY (ff the F0ftt A.ppli= d_ !Pgs_uct owa the subject property,
attach 8 [curt' from ItD propeFC ow-mw auti oriziug Agent to install and opersna UIC Well)
Company Name:
contact Person, FV.�-� L - Ad.aress�
Address;
City: State: lap Code: Cormiy:
Office Tele No.: Call No.:
WebsiteAddress of Compaq. ifany. --

uuLiz'Oct, 25, 20101' 9:1DAM �cCYOKIN WELL�s rA3 �"0 $dO d�< «�y No. 6174 'P, 3 '
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WELL DRU'I'z t INFORI%aT=
CompanyName:`�ain Wei Ca.Oe
WO J3rllier Contmotor'sNanac: 10UMNIUN Natbaw-BraziCave
XC Ccntr&cW Np4jr.ativnl+ia.: 2572 A 3 QIL-L 3548-A
Goatacl PetsonTl7a�1d P Btotvre 249�-A _ _ AIL Addrass' rhiafdrlller ce
Add',= 1908 HamptonviWe Rd.
City: Ha ^ vljIe i2.C. Zip Code: 27020 DowAr.. Yadkin -
Office Tels No.: 33646& 4440 Cell No.: 336-3744736
HUT PUbe C4NTRACTURYNFORMATiDN (ifljdiff"mi than dcfliiar)
Company•Name: At
Contactk'aSBnVn, t •1 f+ rt,� �} 1riMA 4 •v' r v rer
�i.cMdrass: f n ! ia, nP e 7j SyS fnL !ID. �r. irr. R A I
Ci4+: _E ! �I W ^^ �� _ Zap Code: -481&k— Conaty. Sk f,
CMae 7'eteNa: 3b 77- 17b^ CeilNa:6) I77- 4r{�.
STATUS OF "PUCA,NT
Private: Federal:
Stata:
S]NxECTYQN
�?IrCi.til�
ki
mt uic9pal:
Commercial;
Native American Lands:
(briefly dascriba haw thn 4codon well(s) will be uacd)
WELL CONS RUMM DATA
(I) Proposed dere to Be constructed: N%imber of 6arim:
Approxirrrate depth of each boring {feet}; 330,
{{v
(2) Typt oftubing to ho Vaed (copper, PVC, eta):
(3) Wrll Casimg. is the weals) rased? (cbevk a ther (a) Yes or (b.) Xo bsIovv)
(a) Yes if yes, then provide casing fatbrm duftbelow
Type: galvanized steel 6iack stecl pick other (spsc*)
Cesing depth: From to feat (reference to land surface)
Casing axtarlds to above ground fnChl-A
M No . 2C_
(4) [3rcut Info (material suuaunding well aastogand/or pipistg): rr� , �''n
(a) Grout type: 'Neat C== Bcntauite„ Dther (spec$y)
{6) CrOert plaoemenfi PtnApilJg,�_ Pr+DsBF]x8 Olher
(c) Qraxrt doptlY of tebmtg' ¢4S�e:�lan to land surfaice}; F,raAn�� tti .� (feetj
IfNvelI hAs rasing, indicate graddepth: from to (feat)
AC, C-0—

V�'ircOct. 25. 2014' 9: 1aAM "`YADKIN WELL75
rAA 170. JJa •u r r Md No. 6174 }P. 41
-Jr^ ekV..3
Attach a disgmm showiAg the ensWefiug h your or proposed =mNesi= of the injection eguipmmat and eacWiO r
pipi4taing associated With the injection operation. no manufacturces broebwe =y provide supplmentary
lnforarotiozr_ .
1. LOCAIXON OF WELL(S)
Attach two copies of maps sbawing the following infxmnlio.w
(l) Include a She Map (ran be drawn) shoving: - buiiding% property lines. surfte water bodies; patenilal
sources of W=dwatcr conwination and the orieatWoa of and distances between tlu proposed well(s) and
any existing well(s)or waste disposal facilities such as sapt[c =ks or drain 8;4ds located within 200 feet of
the geotherru l beat pump well system. Label all features clearly and jn 1pft a norm' arrow.
(2) The Site Map must slow the subject property in rek6on toThe surrounding area by -sing at least two fixed
reference points such, as roads, stream, &C&or highway intersections.
J- CERTIFICATION
Note: This Permit A.ppAcation must be edgpted by Rath person appesriag am the
recorded Iegsl properly deed.
"I hereby outify, under penalty of law, 'that I have personally examined and. am &miiiar with the inforuaaifon-
subtnitted la this doaumeat and all attach== fbA reto aAd that, based on my inquuy of those in&viduals
it diarcly xuponsiblt for obtaining said infanuatlon, I believe That the informsdon is true, accurate and complem
I am awart that &ere are. significant penalties, iulading the possxblity+ of f = and imprisonment, for seibmiding
else information. X agree to constauc� oparare, wftiwkiv, x1epair, and if applicabia, abudoa the Woff for W eD and
all raved apptrrteaa wee in accordp ce with the approved spaoi6car3oas anal conditions of the Pwmit,7
Signatnae of Property Owm/Applicarrt
_ f.4t A A)tVS GWW6tA,
Print or Type Pall Nome and t#tle
84ntmro o prOp'Ay OwDCrlAppuomd
Print or Typo Full Nam and title
Signature of AuthorizedA,geM if any
Print or Type Flrli Nanat aud Title
Please return two copies of the completed Application paclage to:
North CaroUa DM DWQ
Agufferkrotceifon Secf[on-UxC Program -
1636 Mail Service Center
Raleigh, NC 27699-1636
Telepbone (91.9) 71.5-6935

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