WI0400173_GEO THERMAL_20110215

Permit Number
Program Category
Ground Water
Permit Type
WI0400173 /
Injection Water Only GSHP Well System {5QW)
Primary R~viewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
William and Courtney Curtiss SFR
Location Address
1704 Regents Park Ln
Greensboro
Owner
Owner Name
William
Dates/Events
NC 27455
Curtiss
Scheduled
Orig Issue
02/15/11
App Received Draft Initiated Issuance
02/09/11
Re a ulated Activities
Heat Pump Injection
Outfall 1: J' .
Central Files: APS_ SWP_
02/15/11
-Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Joshua Niles Robertson
8228 Kerr Chapel Rd
Elon NC
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
William Curtiss
1704 Regents Park Ln
Greensboro
Public Notice Issue
02/15/11
NC
Effective
02/15/11
27244
27455
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
William Curtiss
Courtney Curtiss
1704 Regents Park Lane
Greensboroi NC 27455
A."f'!5JIA
B.1".~--~-HCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
2/15/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0400173
1704 Regents Park Lane, Greensboro, NC 27455
Dear Mr.& M.rs. Curtiss :
Dee Freeman
Secretary
On 2/9/201.1, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop 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:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards spe~ified 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 sub!llitted.
Failure to 9omply 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 l(u)(2). Additionally, you should contact the Guilford County Health
Department-as they may have additional requirements for t~is type of system. NoncollJ.pliance 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 !.!ers@ncdenr.1rnv if you have any questions.
tserely,
forDebra~~
cc: Winston Sak111 Regional Office -APS
APS Central Files -Permit No. Wl040017 3
Guildford County Health Dept.
Supervisor
Triad Drillers (Josh Robertson -8'.!28 Kerrs Chapel Rd. Elon, NC 27244
Crabbe Service Compan y (Ray Evan s -3410 Maple Ave. Burlington, NC 27215)
AQUIFER PROTECTION SECTION
163G Mail Service Center, Raleigh , North Ca rolina 27699 -1636
Location : 2728 Capital Boulevard . Raleig h, 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 Acticn Employe;
NOnehC _11 , _ ort arouna
J\Jaturallu
140=4 CAWLINA
OaAttIMENT OF ENVMCNMENT AND NA.TUM RESOURCES
MTMCATION WMEW TO CMgMUU .A CLOSED -LOOP GXOM AL
NAM&CM INJECTION WELL s"UM
0.4
In ACCo rdenoc Wf h Me Provisions of N[:GAC Title ISA 02C.0200
Pr u or rye the requowd aeon cmdPud to ad*au an the past.
DAM r-%, 20f u VV oL�cut3
WeA Tjpa Coofwmadore; Dots the propowd systan oitmutlibe potable n atetr (no additives) its
coutinuow pipit that com idely isolates the fluid from the mviro t (Le.
Yes woo"-Camimw compk[ing [iris Farm.
NO Do Not cunplete this form, Comcplete other UW application fofm for Wol alling
eitber a. 5A7 weal (2eM-Iovp well inieaoiit potable waw T into the aquifer) or a 5QM well (alowd-
loop wall c0awking such as R ?s, eth ml, or outer antifreeze or cctr mion inhibitors).
A- PROPERTY 0VV?i MSYAPPLICANT(6)
List gVA Prop" Owner Listed = property deed (if awned by a buss or Fm ranew any, fit" a,a a of
ernity, and a reptesentathm wlaaftwity fbr si rre)- c]�► r
' , --�
(1) Mailing Addm 6:
Stew. [! zi;, Coda: 7yS� _ Cv=v, OF gwcm
Horne/Mce Tele No.. 6-12 a7
Entail Address: C P � ' � . s
(2) Pbrical Addrm of W&ll Sits (if dilfnvut ►km above); �+7
City: $tote• fflC 74p Cads: County:
Nom6VMce Tele No
& A.UTSOXMD AGENT OF OWNER, YY ANY Gf du Permit A,pplic m dggs txOt, own the sub}e d pmWty,
attach a lei ftM 4w propetty owner u6m izing A va k=dl avid opera 101C welly
Comgarty Nam: �14 e t� �w �ae.4� /d.,4
Contact Pearson,. , .F..r _ MAIL Address: d � ��f� • �"'
Stese/f/, 6 zip co": �2-7 7--I 15 Cowsty.. 1{ S X
dfat ndC Na.: f-�e Cell No.:
Webzize Address of Company, if any.
O PWC SQW Notifi"tiou of Damns Pam (ge+is� i
RECUVED ► CENR I UWCI
Aqusfer prO boss Sactcm
FM 0 9 2011
TT101 3Jbd Sci3 ING QdI I GBDSTZV966
gt?:91 TT0Z1691Z0

uomp=y Name,- r�
Well IMlla Contractor's Nauta: _ "1
NC Contra w r Certifscariop No.: � -
Cont= pawn A
Address_ Z2.R xarrs r,4a raa1
I - City: OLip Code: IM Z�No
Oftc T'cle No.: Cell No.:
D. I1FAT PUMP CUNT' MACTOR 3NFalEtMTllaN (if dlMomt then drMe r)
Comic[ Persona;. lrNlAii 9ddress: r
Address:
City: t Zip Codez �,� Catmty:
Office Tale No„ -
E. STATUS OF A MCANT
Private: ! Fe&M1. Comnaerrlal:
state: Municipal: NSWe American Lands:
F. 1NJECTIO14 FSOCEDURE (briefly describe how the injection wells) will be used}
G.
WELL CONSTRUCTION DATA
(1) proposed date to be eotl eWted. Z ~ Number of boriugs:
Appwxaruate depth of each boring (feet):
(22) Type of iub4 to be used (capper, PVC, etc).
(3) Well casing. Is the well(r) cased? (dwd (a.) Yea trs (b.) v below)
(a) Yea if yes, then provide caft i derma6en below
T"An: ___gwlvanzed steel bl�lc s�eel�lss a otinar (ulpeci r7
Cminx depth: Drum _to feet (reference to laud surface)
Casing eucte3lds to above Swurid , j uche5
(b) No �
(4) Orout Info (material swmumft wall casing arid/or piping).
I 4rsj@��
(e) Grout type: Ne'd Cement 8monite Other (specify)
(b) Orout placemesat: PurrspiaE�+r Presstua_,_____ Other
(e) Grout depth of tubing (reference to lmd =r1hm)_ front to met}
If wcll hu c ham, irdicate g+'m dcp& hum to (feet)
43PUAAC SQW Nvarnmum ortdax iaan (ltevrsva VMS)
Page 2
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AVAWA r-V L% PC5 91 rasps su0w3ug IM rollowtmg mroTtl mon:
(1) lnelude a Site Map (cm be drawm) shwxiug- . bvildungs, pmp M laces, smuf ace watef bodies, potential
sour a of gmtmdwaW eonbamimation amd the wqauwn 4f imd dj#lces between the proposed well(s) and
try udsting well(s) or wale diaposel thciliaes such as septic aerates or drain M& bested within 2M feet of
the geo*tmAl heat pump well system. label all facvres clowly ma -A include anorth arrow,
(2) The Site Map must show the subject property in ralation to the surrounding arcs by using at least two fixed
reffetenee polnu such as muds, smeanrs, aztdlor bx&way = t mops.
Note: Thb Prmit AppAmdott most be aigalld by �cb puts app mriag on the
recorded $pl Fop" deed.
"I hey =tify, under pa,r»lty of law, that I have pexspoAy examlr3ad'aad am fmmiliar with the inibrtnation
submitted in this doaammtt and all aetachmejaft the rw aped that, based on my Wguiry of ftm Individuals
immedixtely tmspMmble for abtalr Ing said mf mmoA 1 btlwye that the informsdon is uw, aQ"Me and complete.
I am imu thm *me ere significant penalty, bxhdit the possibility of flees 2W Imprisonam; for submieriztg
false won. 1 " t4 oongrvc� operate, areal, repair, and if applilcable, rbwAvn the trajection well ad
all m1mW appurmamwes in acmdance with the apppmved specificw m u ad canditions of'tbe PaxmiV
urea of ft"T'ty Ov mW/Applieant
Pribt or Type Full Name and title
i
SigFratum of /Applicant
wry �
' t OAType pull N seal title
uttilortzed Atw% if soy
Print or Type full lame grid tine
Please ratan n mo epics of'the coWletad Application VW2V to:
North Cttrttllna DENR IWO
Aquife r FrotscFiO $CetiPu-UjC Pra%r'=
1636 MAU Service CoWer
Rald* NC 27699-1636
Telephone [phone]
RECEIVED � oENR / DwO
Aquifer Priidec.taon SeVion
GPUAK 5Qw r4OOGWm vf)bW Fwm (Re -ml arzr3")
,0218412811 16tg8 3364215085
TRIAD DRILLERS
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C. wrj'L DRILLER R F()OT1!() , rI_

H. INJECTlON-ULATED EQUIPMliNT
Attach a diagram sbowmg tbe engineering ~µt or proposed modification of tho injection equipment and exrerior
piping/tubing a.,sc,ciated. · with the injection operation. Toe manufacturer's brochure may provide suppltmentmy
iDfarmati~
L LOCAnONO~WELL(S)
.. •• • .... • --- - I a ,.. •· ... .,,.
02/09/2011 15:45 3364215085 TRIAD DRILLERS FACE 11/11
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