WI0400161_GEO THERMAL_20101201

Permit Number WI04001·61
Program Category
Ground Water
Perniit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Pete Roberts SFR
Location Address
829 Circle Dr
High Point
Owner
Owner Name
Pete
Dates/Events
NC 27262
Roberts
Central Flies: APS_ SWP_
12/01/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Billy Clayton
4137 Moores Mill Rd
Spencer VA
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Pete Roberts
829 Circle Dr
_High Point NC
24165
27262
Orig Issue
12/01/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
12/01/10
Effective
12/01/10
Expiration
11/18/10
Re g ulated Activities
Heat Pump Injection
Outfall : 1 h .: .
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Pete Roberts
829 Circle Drive
High Point, NC 27262
NA
.MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
12/1/2010 ·,...._,
Subject: Acknowledgement oflntent to Construct Type SQW Injection Well System
Permit No. WI0400161
829 Circle Drive, High Point, NC 27262
DearMr. Roberts:
Dee Freeman
Secretary
On 11/18/10, the Aquifer Protection Sectiol} (APS) received notification of your intent to construct a closed-loop water-onl y
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
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 ·1sA Section 2C Subchapter .021 l(u)(2). Additionally, you should contact the Guilford 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 gers(@ncdenr.l!ov if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. W.10400161
Guilford County Health Dept.
Aqua Drill (Billy Clayton)
Duggins Heating & Air (Sassie Logan)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard , Raleigh, North Carolina 27604
Sincerely,
to,~~~A-i~
Supervisor
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
Nirth Carolina
/vaturall!f
Nov 18 10 01:05p Lothridge Plumbing 3363572951
NORTH CAROLINA
DEPARTMENT OF ENViRONMSNT AaVD NATURAL RESOURCES
TWliFllCA'TION OF PrMW TO CONSTRUCT A n- ❑-f GEDTFILERMAL
WA -QM INJECTION WELL SYSTEM
w s
In Accordance With the Pmviskiis OrNCAC Title 15A 02C.02W
!Vint or type Me regtdred Warmatkm and moll to addresr on At back page-
P
DATE' _NQKamber 145, 2010 . �� [ � LA L) l tX 1
Wei! T" Cory low Does the proposed system ei►mlate poUble 2tu only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
clase�J�? -
Yea _X— Continue completing this form.
No T)o Not complete this forth. CoTp]ete other W application forms for installing
either a 5A7 well (qM-Iovp well ;1}jc-SAeg potable water into the aquifer) ora 5QM welt (elosed-
loop well containing ddittivel such as R-22, ethanol, or other anti&eexe or conrasion inhibitors).
A. PROPERTY OWNER(S)lAll?MICANT(S)
t.ist Arb rAgxrty ❑vaier listed on property deed (if owned by a businesx or govermlrent agency. state name of
entity and a representative wlatnhority for signature): rate Ruby
(1) Mailing Address: 822 Ci Z 've
City: _Nigel EPf n? Swe: _NC_ Zip Code: 27262 Cowly0txiM d
Horne/Office Tele No.: I844 5 a 1 q cell No.: 9 5 Ct -
Cmail Address: Web9'te:-�,
(2) Physical Address of Well Site (if different than above);
Cit1: State: Zip Code: County:
Home/Office Tale No-: - Cc]I No.:
0. AUTHORIZE, D AGENT OF OWNER, IF ANY (if the Permit Applicant d, gam- own the subject property,
anwh a letter from the property owner authorizing Agent to install and operate UI;C well) .
Co+npany Larne:
Contact Person:
Addrm;
City: Stale• Zip Codes County:
Office Teie No.: C4 No.:
Webaite Address of Comptuiy, if any:
CiPUMIC 5Dw Nodficedt)n oflntcm Fo m (Rcvbcd 812CM) hp i

Nov 18 10 01:05p Lothridge Plumbing. 3363572951 p.3
C. WELL DRILLER JNFORMAT1;ON
Company Name: Aquxrill
Well Driller Contrnctor'� Na+ne: Bi112C1$yWnn�, _ Bryan L ICY
NC Contractor Cetftfication No.: 2241 A 2839 A v -Jr_
Cont=t PerusnL Blur Glayto F-MA ddr�e a�nadr�IlCdthmhnnat
Adtlre8 s: 4337 MqM M#il Road
City: ccVA Zip Code: T County: _-4erirV Office Tole Tole No.: 336 767 0747 Cell No.: 336 8719747
A- HEAT FIUM [' CONTRACTOR INMRMATiON (if dWerent thmn driller)
Company Nun: - l�u$t�i i Air
Contact Nrson 9ossie Lagan _ - FA161L A dre hvac i
Address: 4761 Walke"ovvm Plaza Blvd
City: Wzd C Zip Code: __ 27051 County: .
Office Tcle No.. 336-.595-9520 Cell No.:
E. STATUS OF APMICAN]r f
Private: X Federal: Commercial:
State- — — Morici pal, Nabvc Ameritan Lads:
F. TAT,TEMON PROCEDURE (briefly describe stow the infection welts) will be used)
ClgLs, ioop_w-areranly for heal.pMy
G. WXLL CONSTRUCTION DATA,
(1) Proposed date to be constructed: Number of borings: 1
Approximate depot of each boring (feet):
(2) Type of tubing to be used (copper, PVC etc): _HDPE
(3) Well caging. IS the well(s) cased? (check either (a.) Yes of (b.) No below)
(a) Yea if yes, then provide casing information below
Type: __galvanic steel black stccl--plastic other (specify)
Cawing depth; From () - to !J� Feet (raferxnce to land surface)
Casing extends to above gmund inches
(b) No X ll
(4) CrMut 1n Po (material surroundifrg well casing wxYor pipirtg):
(a) Grom tylx: Neat oment Bernonite _X_ Other (specify)
(b) Grout placement: PumpigL _ Pressure Other
(e) Grout depth of ruts ng (refarer►ee to land surfitce): from _450 to 0_ (feet)
If well has rasing, indicate grout depth: from to (feet)
G-PU/LrtC 5QW NoHlida ion of Int;nt TWM (Reviacb Srt{l4it)
F,W 2

Nov 18 10 01:0Sp · Lothridge Plumbing • 3363572951 .• P . ..:. .. • 4 --vw, w,
H. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modifi*lon of the injection equlpmetit and md.crim.-: .i ._
plpingltllbing aROci.a.12d wnh the injection operation. The manufacturer-'$ brochure may provide suppleinentary··
Information.
L l.OCATIONOFWELL(S)
Attach two copies of mops showina the following informat1011:
(1) Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contantinatiOJ) and the orie.ntation of and distances between the proJ)OSed weU(s)_ ~~.
any existing weJl(s) or waste disposal facilities s.uch as septic ta11ks or drah, fie.Ids looated within 200 feet bf .
the geot.hennal heat pump weil ,;yste,n. Lnbet an features clearly and jncludt. a north arrow. . ..
(2) The Site Map must s:how the subject propeny in rcladon to the SUff01.111ding aru by usins at least two .fixed
reference points so~h as road&,.streams, and/or highway interscctiot,s. · ·
.1.. CF.&T11'1CAT10N
.Note: This Permit ·Application m••t b~ signed by eaeb 99rsen appeariilg on the
recorded lcp~ propctty d~. ·
"I hereby certify, under penalty or law, that I have personally examined and am familiar with tbe intbrmation
submitted ;n th is document and · all attachment$ thereto and that. bBHd on my inquiry of those individuals ~:
immediately ,asponsible for obtaining sa;d informadon, I believe tba1 the infotmatiol'i is ttuc, accurate and compJete~ ,~
r .am aware that there are significant penalties,. including the possibility of tines aod Imprisonment, for sub.m,Jtnng
false infonnation. I agreo to construe~ operate, maintain, repair, and if appUcablc, abandon the injection well and
al f related appurtenances In accordance wi~. the "°""d s~fications. and~~?= PenTI~ M • • :_
~7 ·~~Jd .. -~ -
Sjgnaua,eofPropc.11310wner/~li~. ·t . _ ., :
.. ~~ ber·I G KtJ b~r ~. ·. •
Print or ·rype Full Name and title
Signature of'Property Owner/Applicant
Print or Type full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
.Please retum .twb copies ot't'he complel£d Application package to:
. Norffl Carolina DENR-DWQ
Aquifer Protectio11 Seetion-UIC Program
1636 .Mail Service Center
Ralelp, NC 2769,-1636
Telephon.e [phone]
O'PWUJC .5QW NotiflePtfon c'lfhll.'ent .Pei"" (Revised 8/2f)08) rqe3
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Nov is 10 01:04p Lothridge Plumbing 3363572951
IL
25 Years of NOW Service
Lothridge Plumbing, 1nz.
To
Company: _NCDENR .
Sent By: _Tina Yates
Date: _November 18, 2010
Time Y
# of pages including cover : _5 pages
919 715 0588
Cover sheet only
Dear Sir or Madam,
Following is a Type 5QW Well application for processing. Thank you for your
attention to this matter.
Sincerely,
Tina Ya s
Comptroller
Phone: [phone]
PO Box 249 Fax: [phone]
Linwood, NC 27299 Email; [e-mail]