WI0400166_GEO THERMAL_20110103

Permit Number WI0400166
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (SOW)
Primary Reviewer
rnichael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
David Brown SFR
Location Address
3232 Sharlen Dr
Hamptonville
Owner
Owner Name
David
Dates/Events
NC 27020
J Brown
Central Files: APS_ SWP_
01/03/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David J . Brown
1908 Hamptonville
Hamptonville NC
Major/Minor
Minor
Region
Winston-Salem
County
Yadkin
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
David J. Brown
President Vice
3232 Sharlen Dr
Hamptonville NC
27020
27020
Orig Issue
01/03/11
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
01/03/11
Effective
01/03/11
Expiration
12/28/10
Re g ulated Activities
Heat Pump Injection
Outfall f\:UL'
Waterbody Name Stream Index Number Current Class Subbasln
Beverly Eaves Perdue
Governor
D av id .T . Brown
3232 Sharle n Drive
H amptonv ill e, N C 27 020
A.WA
NCDEH R
North Carolina Department of Environmen t and Natural Resources
Division of Water Qual ity
Coleen H. Sullins
Director
1/3/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0400166
3232 Sharle n Drive, H am p to nv ill e, N C 27020
Dear Mr. Brown:
Dee Freema n
Secretary
On 12 /28/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
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 construction standl!-rds 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 Yadki n 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.Rogersrai.ncdenr .1wv if you have any questions .
Sin cerely,
fo,.Q;~A-k~
cc : Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI04001 66
Ya dki n County Health Dept.
Supervisor
Timothy Jame s White-1501 Morgan Road , Boonville. NC 27011
AQUIFER PROTECTION SECTIOI~
1636 Mail Service Center, Raleigh. North Carolina 27699-1636
Location: 2728 Capital Boulevard , Raleigh. North Carolina 27604
Phone: [phone] I FA X 1: 919-715-058 8; FAX 2: 91 9-715-6048 I Customer Service : 1-877-623-6748
Internet: www .ncwatera ualitv.om
An Equal Opporb ni iy I Affi rmat1v fr Aciion Em plover
NOnehC 1· ort aroma
;Naturall!f
Dec. 27. 7010 3:52PNf VADKIN WELL No, 6561 � �: '�•- .
NORTH CAROLINA
DEPARTMENT OF ENVIRONvMNTANT) NATURAL RESOURCES (NCDENR)
NOTMCATION OF =NT TO CONSTRUCT A CLOSED -LOOP +GEOTHERII�L�
WATER-0 INJECTION WELL SYSTEM:
TYPE 5—QW WFILL(S)
Ih Accordance with the provisions ofNCAC Title ISA: 02C 0200. please
coruplete this notTication and mail to address oa the back page (please Prim or Iva: iufaraxatiou)•
DATE: 2-- 2 Z0j_0 00 t CC QP
Well Type Confarmation' Does the proposed system olrcuIate potable water onl• (no additives) -in.. A
continuous piping that completely isolates the fluid from the envirmitnes. f
closed -loop, ;r t
Yes _ ,�� Continue completing this form.
IN Do Rrot Complete this form- Complete other MC applic4o:n f❑rins for izL�in`
either a SA7 well a en -loop well Lziectin potable water into the aquifer) or a 5Q%L l well (closed.—,' '
loop well coritaining additives such as R-23, ethanol, or other antifreeze or corrosion inhibitors). r
A. PROPERTY gWNER(S)lAYFLICA.NT(S)
List each Property Owner listed on properly deed (if owe ed by a business or government agency; state name of
entity and a representative wlauthority for signature): ;,i �+ T� io W e'er r _� 4
(1) Mailing Address: •.rz -rZ -C11 OP --
city:
_4om,/r flPi 1to- State:Vt"—'zip Code_ 2—'2 �3 2-0 County: ��
IiomelOfce Tele No.: S " [ , 15 Cell No.: 3 - 3 7 SG -.- 7_?'
Email Address
(2) physical Address of Nell Site (if different /than above): _
City: _ State: Zip Code County:
EcraelOffzee Tele NO.: Cell No.:.
M
E. A UTHO:E MED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subjectproperty,
attach a letter from the property owner authorizing- Agent to install and operate UIC well)
Company Name:
Contact Person: EMALL Address: -
Address:
City: State: Zip Cede: Gou
Office Tele No.: Cell No.:
W ebslte Address of Company, if any.

bec.27, 2010 3:52PM YADKIN WELL
C. WELL DR.I<LLZR INFORZVIA'TYON
Company'Name:Yadkm Well Co. c
1Vo.6567 3 Tir�
x
r
WcU Driller Contractor's Na=: T d Mv116 Matthew Brown 'Hon Cave
NC Contractor CmiflcatiouNo.: 2572;A 3548-A .
Coutact,Person: David 7. Prown P195-A _. EMAIL Address: chieidr_ jQmsn.com
.Address: 1908 namptonville Rd. ;•
City: Hare t�nville N.C. Zip Code, 27020 County: Yadkin
Office Tele No.: 33&468-4440, _--- Cell No.: _336-374-8736
I). RRAT iPTJi g CONTRALCTOIZ INFORMATION (if different than drJinr) 4
Company Name' j 1 M07 �¢astCvl�
Contact person: T 4- G. EMAiT Address- _ •
Address: �;1} c ►k T'`� _
City: 60n at'j t l _ _ Zip Carle: Com►ty: Tyr 4)-rs,
OfficeTeieNo.:.s Y62(; Cel[No.:
E. STATUS OF APPICA.NT
Private: Federal: Commercial:
State: Municipal. Native American Lands-
F. INJECTION FROCEDUJU Oriefly describe how the injection wells) will be used)
G. WELL CiA' MUCTIONDATA
(1) Proposed date to be eanstrvcfed: �tr: � /" Number of borings: 2— ,
Approximnate depth of each boring (feat): (1 36 0 / j 6 0 a f
(2) Type of tubing to be used (copper, PVC, eto). SD X - � r' ff h QJE- 4CD
(3) Well casing. Is the well(s) cased? (check either (a) Yes!jr (b.) No below)
(a) 'Yes if yes, them pzoride casing l ormation below
Type: ___83lvanixed steel black steel plastic other (specify) s
r
Casing depth, From to feet (reference to land surface)
Casing extends to above ground inches CD 2 .
(b) No
(4) Grout Info (material surrounding well casing And/or piping)-
(a) Grout type: Neat Cememt Bentoaite >< Other (s cify)
(b) Grout placetncTat: patapin A pressure Ofiler
(c) Gront depth oftubing (reference to land surface): from --z f to 116 _ tfe
if well has casing, indicate ,grout depth: from _ _ to {feet)

Dec.27. 2010 3:52PM YADKIN WELL No. 6567 P, 4
H. INJECTION -RELATED EQ'LTIPMENT
Attach a diagram shuwivag the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELL(S) ,. A
Attach two copies of maps showing the following information
(1) Include a Site Ma (can be drawn) showing: bull
P � property Junes, �Gurface
sources of groundwater mntamr nation and the orieutatielpf and distances betv=4 the prod
any existing well(s) or waste disposal facilities such as sep:,c tinks or drain fip;ds located witiun:2p4: `'k
the geotheroaal heat pump well system. Label at features cleai'Y an include a ziorth
(2) The Site Map must show the subject property in relation to the su::4,undipg axea by Using at;leasitwo
reference points such as roads, streams, and/or highway intersections. v.
3. CERTIFICATION 1k
Note: Thi.; Permit Application must be signed by each person appearing an the
recorded legal property deed. -.
"I hereby cer� y, under penalty of law, that I have personally examined and am farniRar with the iaal*'611 „
submitted in t1is document and all attachments thereto and that, based oa my. i;tgz `f-;,'ose ;tas�ividuals
immediately re:,pons'ble for obtainitg said information. I believe that the infcrmatian is true, Vrttirate and cGrnplete.
I am aware that there are significant penalties, including the possibility of trues azad. impr�ut'x�r t;; lbr�subirntting
false inforrnativu. I Agree to construct operate, waittain, repair, and if applicable, abandon U.`4.5'. ki�ktt"well and
all related appurettances in accordance with the approye�} spacificatiozLs anzd conditivms of Lbe Qetu'�
-..� .
Signature of Property C erlApplicaryt
w'l T 13rowki
Print or T'ype 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 t1
Please return two copies of the completed Application package to -
North Carolina DENR DWQ
Aquifer Protection Section-TAC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
CD
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Dec, 27. 2010 3:52PM YADKIN WELL
No. 6561"1
FAMMILE TRANSMOM FUFN
5�
18
�t
DATE- Q TIME: REF NO
LOG NO.
TO: 1A)
COMPANY NAME PAX No. PLEASE
UNIEDIATELY
ATTENTION DEP'C
FROM:
COMPANY NAME
INDIVIDUAL
FAX NO, R EAE
USH
REPLY
DEPT
NUMBER OF PAGE$
INCLUDING THIS SFIEEF
PLEASE
REPLY 6Y -
ORIGINATORS
SIGNFCIIJRE
MESSAGE:
zL 41
�1 c- a �
a-4
-FOR ALL YOUR WATER NEEDS'
YADKIN WELL CO., ING,
1908 HAMPTONViLLE ROAD
HAMPTONVILLE. NC 27020
DAVID J. BROWN, VICE PRIES.
TOLL FREE (800) 2.043S5
OFF1CZ i3361 469.4440
FAX f3361 468.4048
RES f3361 46&4659
appn mmc Amf!RIGw - 000 wvlrs rnv-
7-71
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PLEASE INFOAM Lis tIAMMM E3Y IF VW Dp NOT f;ECE3vE FAc-gkcx IN m_U