WI0400158_GEO THERMAL_20101119

Permit Number
Program Category
Ground Water
Permit Type
WI0400158 /
Central Files: APS_ SWP_
11/19/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (5QW)
Version
1.00
Permit Classification
Individual
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Gary & Beverly Poole SFR
Location Address
1114 Independence Rd
Sparta NC
Owner
Owner Name
Gary D
Dates/Events
28675
Poole
Orig Issue
11/19/10
App Received Draft Initiated
10/29/10
Re gulated Activities
Heat Pump Injection
Outfall NUL~.
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville
Major/Minor
Minor
NC
Region
Winston-Salem
County
Alleghany
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Gary D. Poole
11 1.4 Independence Rd
Sparta
Public Notice Issue
11/19/10
NC
Effective
11/19/10
27020
28675
Expiration
Stream Index Number Current Class Subbasin
NCDEN R
North Carolina department of Environment and
Division of Water Quality
Beverly Eaves Pardue Coleen H. Sullins
Governor Director
11/19/2010
Gary D, Poole
Beverly F. Poole
1 114 Independence Road
Sparta. NC 28675
Natural Resources
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400158
1114 Independence Road, Sparta. NC 28675
Dear Mr. & Mrs. Poole:
Dee Frearnar..
Secretary
On 10/29/2010, 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:
I. 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 1(u)(2). Additionally, you should contact the Alleghany 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 Micltael.Rosersr ncdeitr.9av if you have any questions.
{Si Sincerely,
( ` :n'
jar Debra W atl.%
Supervisor
cc: Wingto n-Salem Regional Office - APS
APS Central Files . Permit No, W10400158
Alleghany County health Dept.
� adkin 14-cli Co. (David brown) 1908 Hi,mpton0le, NC 37U20
Evans Hearing & Coolinc, Inc [.Mark Evans) 22(47 Rich Bill Row. Gtacl.e Valley, NC 2$627
AOUFE+R PROTECTION SECTION
1636 Mali Service Center. Ralftr, North Carolina 27699.1636
LwzWn: 2728 Capital Boulevard, Raleigh. Nortlt Carolina 276iA
Phone: [phone] I FAX [phone]: FAX 2, 919-715.6W) Costomsr Service. 1477-623.6748
Internet www,ncwatanzua1ttv,or4
An �p�ialF]pnarrunity A�irmatwe Hcpo�i Empioye�
On
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Nh Carolhia
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Oct, 29, 2010 $:50AM YADKIN WELL No. 6-2.24 P. 2
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NORTH CAROLINA
DEPARTM SM OFENVIROENIaIIINT AND NATURAL RESOURCES (MC DBNR) ,
NOTMCAT1011 of 1N'rM TO CONSTRUCT A CLOSAD-LO 02 GEOTMR A
IN3I MON WELL SYSTM
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TYPE 5-0W WELD ;.
In Aooardwot Will the provlsiom of NCAC Title 13A: 02C OD, pl"se
cam&to rwr notmeetion sud wail t+o address an am back page (Please =a orMz l diana&Q. 1
20 5j = p
Weit hype Carrffrmirt ion: Does the p woscd ayatem *cidate patablo yater (no additives) in �
coollnuous piping that coMleiely isolates the fluid fknm the environment 1^.-
Yes X Contima completing fftls form. _
No Do Not complete this form. Ccanplets other UIC application dorms far installing
either a 5A? wall (oyrrloop well Jpj6W1 potable water into the aquifer) or a SQMwefi (closed..'
loop wall containing �e aurh as A 2.2, ethanol, or other antiErme or comloe ln1t!bitor#, ,' .
A.
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PROPERTY 0 W1gXR(S)1A*FMCAN'liM -r -
Llst eao Prope* Owner listed an proparir dead f awned by a busineaa or gaYarntn4nt aigency, statb am# o[ .;
entity and a represamtel" w/eutla4y for firm ra): i�nrLOT) rt e, d --'6P-g M1
(l) Mailing Address:
Clty:. �Znn�� Efate,. .1( zip Coda: `Z& —County;-
; =
Homd office Tel Nw Sat-
Fktail Address: l�'etasile: J
(2) Physical Address of Well Site (tf di$aterd than above):
City: slate: — Zip ewe: CoWtt,�r. • '
HolnelDffte Tels No.: Coil Na.:
Ai1TH0R=D AGMT OF OViNM 17 ANY (if the Permit AppE=t does own the subject prapetfY,
attach n Iott= from the pro" owner enlhariAPS Agent to sr► Wl and opm to UiC well)
Compffi y Name:
Cantaot Ponan; � }�ddrass• _ -_
- � - _ .
Address:
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City, Stata: Zip Coda; County:
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D.iiice Tale ido.: _ _ - Q&No.:
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Webahe Address ofCorprkyT, lfaw
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Od- 29,
2010 8:51AM YADKIN WELL No. 6224 P.
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Well Driller Coaftolor's NwUV. ,1Q.dY M- wBrayn 1pLt L�tro-_
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NC Comr2Ctof Ctrtlfro WAN4,: 157z
Caalao! 1'ersBMATi4,Adds,rhF�rdrliler&3
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Address: 1908 flaoaplonv#11e
Cityl _ Saimmoylag N G _ Zip Cade: 21420Ommy: Yadkin
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Of ceT*Na; 3S6-d68-qd�8 Cai1Na•: 33637�-873d
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HFATTUM1' CO RACTOAWFO"Uxl ditymsint tUP3 driller]
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t. ompany Name: 4- C, J
Contact perso • t- V d ► Aru.� Qav l '! -
City: V G 7.1p Code'. afi County: �►tii K
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STATUS OV AMICANT
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PAvate: '{ p'e gmL.•, Coannrerclak
- IF .
$talc; i:dun *4h.• — Dative Amenlca Urids: _ -
Tr,
W,MC lod4 PROCEDtM (brlei#y deacrkbohow the Wtetlon vmll(s) vdg be used)
a.
WEL% CONMUCTION DATA
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[IJ Piopmed dart to be coui rusted: N Number of bwhtps;
_
Appreshnato depth Of mch bwing (%at}: ( U
(2) Type of tubing to ba used (copper, PVC, etc); wn RE Sf) a - u
.ti
(9) Well coslug, is the ►vall(s) cased? (abeclr olther (a) Va or (b,) ft bt akv)
(a) Yes if yu, hers pravlda casing 10mmatiou below . _
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Typo; _• _$aivar�Fiad sIeel��jsc� s#tclti_�rltts{!c olHer(spccl+}
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CSSIngdeptle to kild Blare*$)
Casing viands to abm ground, Juckcs
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(b) No
(4) Ctroat�i>}.b �netarIat atsrrotaadEng ►veil oaslag gndlar plying}; ,�,�r�(�� �nh� � � 1
:-1 � 'r ,
(a) Gmnt type. NaatCpmeat Beatostlit: a[ • 011w opegiw
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(b) Orout p]aoamaat: Pumplag Pressu7 Wier
(a) Grant 4cp W of tobing (reft awe to land surlhoe): £seta to�-
[fwalf has casing, ladiame grmAdepthi f jn to

Oct, 29. 2010 $; 51AM YADKIN WELL No, 62241-4,14
1 [. INJECTION-M-LA M EQVdPMUi'y
Amlt A diagram sbowiog the engineering layout or proposed moditicAou orthe I1ec>J on aoprimlt saidUW45
Pi ngllubing associated w16 the f4eatlon operation. The mar►4eturien brochure may provide sup�Iem�e�
lnformailan• �,y;:
1, 7.0CATEON OFw$LL(S)
A tactn two ropdee ofmaps showing the following informaliau:
1 itrctude p Sito Un can be drawn AowiP ' buildings, rd !!
(] p � } B• mS , F �y ues, surface water bodies;
sources of groundwater coWroInWon and iho oxxeattat€on of end dlamvices between the proposed-well(s) sol " -
any axlstlag wall(s) or waste disposal hellities such as septic tanks or drain fzpids located witlaln,200 het of.; : _ -
dw gsot1mr M but pump wall system. L,tbei' all featames clenly and ineludc a march aa0p1. .
(2) The Site Map must show the subject pzasperty In reiatlan to tine surrounding area by using at least two ��cd -
ref xwei polnts such as roads, sltewts, anNor bighway fntersectians. _ - -
' r'
J, CnTMOATION
Notet MI'lcrmlt ApplWilon must bs shW by Se person a>ppeaxlq an the -� • `
recnrded Iegal property du& �
"i hereby cwllVy mft petmalty of law, that 1 have puzsoully examined ad aw fltmUlat with the inforitte dw,":
submitted in this dooum ut. And ali nttas h ments thmto and that,, based an nV *city of those lnd�xd�- ;• '
immediately responsible for obtaWna said irXeL mtion, I belive that"lpfvicoatIait is too, wourate aw ebiglets. •�
I am rime that there we aignitleant penalties, ioclpoing the poaslbltify of Nixes and ImptIsonment, lbr si6rAlttiag''.
fhlse. informatiom I Was to consbv4 operates mdrua'ln, rV*, and if applloabla, abendon tba lrtjeadon, wall %d'
all related appuTknances In aocaordnaca with ticv approved specifcra:60m And ccwditcans of cite perm%-7 : --
'
ftl ature of Property Owner/Applicant
Pilot or n►p Ni Name and title
Sigrratu fProp�ty tivt�dhpplta�t
Print or Type FbaxaeazA clad��-
S*Wure of Authnslxad Agent, if any.
Print or Type ftl Name and title
Please return twa copies of the completed Application yackAgc to:
North C aroUns DI&NR DWQ
Agul�x Protectlatz S�ci�� 1riIC P�rogxam
1636 Mali $a'vice Center
Ralclgb, ACC 37699-1636
Telephone [phone]S

Oct,29. 2010 8:51AM YADKIN WELL
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Ort.29. 2010 8.50AM
YADKIN WELL
DATE: 10.11-fl,t'6 TIME: - -REE NO.
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COM ANY NNAAME, �
FAX NO_
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NUMBER OF PAGES
PLEASE �IdlNrf`IDFFS.
INCLUDING THIS NEST
REPLY BY SI9FIAiLIAE
MESSAGE:
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,FOR ALL YOUR WA7[R N6rrOS'
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WELL CO.,'INC.1908
HAMP'TONVfLLE ROAD
HAir PTONVILLE. NC 170M
AVID J. BROWN. VICE PRfES.
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TOLL FRIEZE (a0O) 2A"3s5
;• .:. , _
OFFICE S336) 466-4440
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FAX r3W) 498-4Cd6
ASS 026] 4564559
xve0 P14WO AMEPKA • 400 LOv= room
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PLEARINF'OPIM UB IAM EMA YT1M DO NOT H6ORM R1O3 UIN M-