WI0400177_GEO THERMAL_20110325

Permit Number
Program Category
Ground Water
Permit Type
...
WI0400177
Injection Water Only GSHP Well System (SQW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Phil Bolton SFR
Location Address
5234 Hwy 16 N
Grassy Creek
Owner
Owner Name
Phil
Dates/Events
NC 28631
Bolton
Orig Issue
03/25/11
App Received Draft Initiated
03/02/11
Re a ulated Activities
Heat Pump Injection
Scheduled
Issuance
Central Files : APS_ SWP_
03/25/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville
Major/Minor
Minor
NC
Region
Winston-Salem
County
Ashe
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Phil Bolton
180 Greystone Dr
West Jefferson
Public Notice Issue
03/25/11
NC
Effective
03/25/11
27020
28694
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
North Carolina
Beverly Eaves Perdue
Governor
Phil Bolton
180 G reystone Drive
West Jefferson, NC 28694
NCDFAR
Department of Environment and Natura
Division of Water Quality
Coleen H. Sullins
Director
3/25/2011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10400177
5234 Hwy 16 N, Grassy Creek, NC 28631
Dear Mr. Balton:
Resources
Dee Freeman
Secretary
On 3/2/2011, the.Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-
2ply 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. Thd 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 .0211(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 riles and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Rovers :i acdennuor if you have any questions,
Sincerely,
OUJA
,for- Debra Watts
Supervi %or
cc: Winston-Salem Regional Office - APS
APS Central Files - Permit No. W10400177
Ashe County Health Dept.
Yadkii7 Well Co., Inc. (D7 i+yid $romi)
Scott Brothers (Mike Carrot)
AQUIFER PROTECTION SECTION
1636 Mail 5ervice Center, Raiagh, N" Carolina 27699-1636
Location: 2726 Capitai 8aulevard, Raleigh. North Carolina 27604
Phogal 919-733-3221 1 FAX 1: 819-71,5-M-. FAX [phone] A. Customer Service: 1-877.623-6748
Internet www.n waternuplity.o_nn
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PBB12912011/d4N 09:25 AM Scott; Brothers . FAX XS H 877 2359 P. 002
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NORTH CARflIINA
DEPARTMENT OF Mi*MONbMgT AND XA,TURAL MOURCES (NCDENR)
NOTMCA TION Or E=NT To CONSTRUCT A CLOSER -LOOP GEOTIMMAL
WATER -ONLY IMEMON WELL SYSTEM(:
DTR j-Q—W F-ELLU
In Aroma= Ifith tht proeiSMW of NCAC Tblk lik- 01C.0200, please
C=pleie tUs notificatiortand mil to sddrKa on thcba-page (p� 9fM arse km ok=tiot=.).
2011
WeV Type Confi9- wdon. Does to proposed system circulaza potable water only (no additives) is
contimon p�pung that ccMplestely isolates the fluid from tho en riranmerat (i.e.
],osed-lootr ?
Yes X - Canine completing this f0m
Me Do Not =nplete this farm. Complete other U1C applicolioa f"= f�r!a-talling
either a 5A7 rrte]1(-Icrop well g potable wa`mr into the aquifer) or a 5QM wdl (clasecl-
loop well cmMinirig 9ditiveA savh as R 22, etbanol, or other antifreeze or conw on inMbitcrs).
A.- • , 2ROXER x' O'WY,NXR(S)lAPlr�'JCA1+NT(S)
List e&0 Property Owner listed oa property creed (if owned by & buses orrgover=W aa4mY, state asxae of
mffty emd a Xc7csentab va tlwiautharirg ft SI?+ Rej: �ts t-o rti
(lj bA ingAddrtss: _ 1M�o G� ���ent Drk_.
City; 1 rSa+S , SSd'L1:; 1J,C`Zip Code: PL (9 CiQTlx:ty:
EomelQffca Tt1e No__ 336 Coll No.:
B122 l .A.ddress: Websitt:
(2) flw 4 f A IJ, f
City: G rus 4 rat Stutz: •C,Zip Cede:317 County: A5 h
Hozwoffice 'Tale No'! Cell No.:
g. AuIMO=RD AGENT OF O WWM17 ANY (if >he Permit Applitar:.t does not awls for stz7*zt property,
Amckh aIetter **= the property u-mct' authodziug Agent to install and cpetata UIC Weil}
Company Name -
Contact a?�rta : EMAII. Ad -sss:
tlddxWs:
City: Seats: dip Cone; Co=tT"
Office ale N4,: _-- Cell No.:
Wcbah Address afCamp=y, ifeur.
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FEB/28/2011/M09 09:26 AM Scott Brothers PAX No-336 877 2369 P.003
C. WUJj D=j-MR ]NJFORXATXON
C=pmy14=e:19-Um W,, L4;_g
WeTd30rilles Contracinr`s2+iam�: gd3Lm1IZL- Mst-�ewBrown I�ii t z
ABC Contractor Certi�aa�ar] Na.: :�57 -A 3 3G. 3Sl, -A -
Caats Persons=Ds dr. Bm1VV1t 21 p5-A �� LIM A Tr A 1 ' c dtil er cy rr+ cn�
Address i8 Aa�pta�apSile Rd,
tity:
VAX ntorn'lfia _G Z%Code: 2700 Couxx Yadkin
fl .,Ce T* rt xo , j8fP469444k Cell No.: 336374-873d
V. BTwa PUMT CONTRACTOR MORMATZON (if d4&rant thR n drMer)
C,QmRanyN : C.: 9ta�] es [�
Address'
Cif+: -,--Luj_ - Z-r Cady:G C6Wky:
Q S"tee Tek tNm- 33 t. -17 o O&MI .c 33 6 77 - (, y2 2.
E. SIA TUS OF A►.FZIaCANT
PrIme. >� Fgderai; C-0=erclai:
state: bdunieipai: Wative Ammon Laad-.
S. XhJXCTT0XFR0VnE (toriefb, describe IwW tbo sajettioa (s7 *dU be used)
- a c•+c 1 �.0�7
G. W>c"C0m, mUC%70x])ATA
(1) Psaposes3 data to be cawtmefe4: Nrt�bwr of hair, e:
ppirtiste depi� of each baring (fit); 3 5E�
(2) Type of tubing to i)e msed (Copper, FvC, ale); IDIRK
(3) W ell casing. 7s tls r %wP(a) aastd? (d=k either (a) ices or (b)'ia Wow)
"c) YC5 if q s then xl ido CBsins Strom don below
Typo: ___.,RtlivanI2ed steel bias$ LspeZ4)
Casing 44fla. hem to feet (rrFeronce t4 lsudsurkm)
Gaging w"tma!5 to Abem around, inchas
(4) G outlyd'a (ina'tcrial stmauudlrg well castag audkv piping).
(it) C-.mut et Naafi Cement 8emmilte. I `
tYF �. Cuter (ePad*,)
(b) GroA piace n1w; i'u*M-Zl Fressura Clher
(o) Grom depot o£taing (rfermov to Land surface); fmm
If%v l bsa casing, indicate gxantdepth, &am _ _
—ta -7 (feat)
td _ (Ret
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FEB/2812011/MON 09:26 AM Scott Brothers FAX N0. 338 877 2359
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TJ. T1DC37EM0N-"LATED EQWVMNT
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Attach a cUagram sbavving the layout or proposed modslzcatzoa of the Wwbou oop=ant aEA e4cnor
pip �bss Woc%ated with the injacuon opemtior. The mamifa, L is broch=6 maY provide svpple=WL Y
infvrmaiion.
L L 0 C ATION of W7114S)
Attach two aopias of=ps show;ag the foUwmirg idorwxd=
(1) Include a Site Map (=a be drawn) showing: build, propeny ll ms, surface water bodies, potential
sources of gound-wAt r wmzminadan and the vriourmtioa Of and distances between ibee pr oposed wdl(s) Ud
any e�dstlM well(s) or waste disposal faciaes =h w septic tanks or dram tisjds tecaled within 200 feet of
tlxe gcotlaernml heat purap w dl system. X. 81 a3I fast= clearly ad include a nor$ arrow.
(2) The Site Map cast show the s6ject property in ickdon to The sirrmmdiag a= by usian at l $No &ed
referema points such as roads, streams, and/or hi&wzy irriiswt ous.
I CRXTMCATION
i�''at'a: 1'liis Pexmir.Applica�ian: fu�at he si�ueci. by e�el� person appearing an the
cetorded ieg2l property deed.
"I hereby verify, under gemalty of law, that I bavo prrsawVy eumiued and am Fnmitiar Wirh exec Wormation
subu ;d in this d e�tt and all atmcbmears thmato and t % bas tied ou my inquiry of 'those indivndnals
imm-ediately re spowxble for obt&dng said imfoxmart m I 'behove tbAt the hfvrna7aoa is true, acaLua s and earnplexe.
I am aware dart there Sze significant penalties, kcludiag the possibilily of l a4 imprisonmemt, fox Eubmittzng
ELI--* iuf=u'don. I zz= to cowtttIM operate, maintain, repair; and if applicablc, abandon the 4*ction W4 and
aU rid appuntensnces in =ordanca with the approved specifaatiws and cooditiox. of the Permit"
Signa=eofPropesty Owar/Applimm
,PN /Z i --> IV.r�L7aA_1
pslut or Type L Mama gad tide
Signatu ra of Property owneslAppli=
Prim or Type Atli Name and title
MAR 4 2 7011 SiPatwa of'Au mizedA.geat, if auy
Punt or Type Full Name and title
Fleaw remm two coplos ofthe oorsplate d A gcz.Cwu package to:
North CwroDna DENR-)[)WQ
Aquifer Protecdca 5eetiou-UIC Program
1634 Mail Service Cemfex
Raleigh, NC 77699-1.636
Telephanv [phone]
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FACSIMILE TRANSMISSION FORM
GAFF: -nME: REF. NO, LOG NO.
COMPANY NAME FAX f4 PLUM
a nDELNER�L� � �� .L � - ❑ I�l1rlE�iAiELY
►IT FENTIO DEPL
FROM: d ki I c (.T,3E) fig -
COMPANY NAME FAX Na PLEASE
INDIVIDUAL DEPT.
NUMBER OF PAGES �^ PLEASE ORGINAT09S
1HCLUi7fN�, THIS SHEET REPLY BY - SIGNMRE
MESSAGE:
-FOR ALL YOUR WATER NEEDS'
YAr)KIN WrELL_ CO., AMC.
1908 HAMYTQNVILLE ROAD
HAM.PTONVILLE, NG 27Q20
DAV[D J. BROWN. VICE PRE—S.
TOLL FREE (WO) 245=9385
❑FF[OE (336) 468-4A-44
FAX M61 468-4048
RE$'206, 468-46!9
-daOO NEW$ AMERICA - cop LOVES Vesr
MAR 4 2 2011
e
PLEASE INFORM US M8AEAL W IPIOU CO NOi AMU4 K4V4=WmM&lH FMI �
1 13A N DCVA 4� Z' : b — OZ 'Z •apt