WI0400179_GEO THERMAL_20110328

Permit Number _WI0400179
Program Category
Ground Water
Permit Type
/
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facili N
Facility Name
Glenda Evans SFR
Location Address
6718 Hwy 421 N
Vilas
Owner Name
Glenda-
NC 28692
Evans
Scheduled
Central Files: APS_ SWP_
03/28/11
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
Watauga
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Glenda Evans
Owner
PO Box 338 .
Vilas NC
27020
28692
Orig Issue
03/28/11
App Received Draft Initiated lssu·ance Public Notice Issue Effective
03/28/11
Expiration
03/11/11 03/28/11
Re a ulated Activities
Heat Pump Injection
Private residence , single famUy
Waterbody Name Stream Index Number Current Class Subbasin
94 "
w-A
NCDEN R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Severfy Eaves Perdue Coleen H. Sulfjns
Governor Director
03 /28/2011
G}ends Evans
P.G. Box 338
Viias, NC 28692
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W104OO179
6718 Hwy 421 N.
Vilas, NC 28692
Dear Ms. Evans:
Dee Freeman
Secretary
On 03/11/2O11, 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 geotbenwl injection well system as long as the
following conditions ate met:
1. The injection well system contains only potable water,
?. 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 i5A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Watauga 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,
PIease contact Mike Rogers at [phone] or N1icbael.RoLers a),ncdenr.yav if y6u have any questions.
� � r C
for Debtor 1R watts
Supervisor
cc: Winston-Salem Regional Office - APS
APS Central Files - Permit No. W1O40O179
Watauga County Health Dept.
David J. Brown (Yadkin Well Co„ Inc.. 1908 Hamptonville Rd„ Hamptonville, NC 27020)
Winston Petrey (Mountaineer Heating and Cooling, P.O. Box 1905, Boone, NC 28607)
AQUIFER PROTECTION EKTION
1636 Mallasrvlc4 G enser. Ralew NoMh Caroling 27$N 1626
Locat{ori: 2728 Lapital 9oulevaw�, Ralagh. Nortil C,arolur. 27604 {3nr
Pnorle: 948.733.322' I FAX,` fr - 9'.5 ".058E. FA,' 2: 916-71M0481 CustomerSprvice: 1-877-623-6748 � t
Interne,: www:nmataruualr` .oro N orT L�]'j�-iili'U1,i�na

Mar. 11. 2011 3,16PM YADKIN WELL No, 7176 P. 1
5
DATE I �I TIME: KF NO. LOG NO.
COMPANY NAME FAX NO. KUM
pn V, 0.': ❑ SLY
A7TE MDH DEPI;
FROM. 'Z as We[ CA Lzo - 'Q xp
COMPANY NAME Fax No. PLM
REPLY
INOWUAL DEPE
NUMBER OF PAGES ' PLEASE OF ISR0NOiI'S
INCLUDING TM SHEtT REPLY BY Sai1tAE -'
MES$AQE:
1),19
"FOR ALL. YOUR WATER NEEDS`
YADKIN WELL CO., INC.
19W HAMPTONYIL4E ROAD
HAMPTONVILLE. NC 29020
oAYIo J. GROWN, VICE PRE&
` o" FACE (WO) 2A@4255
QFFICR 13N) A¢$-440
FAX ("61 469.40M
Rd$ i3161 4ga-A650
-acme F4&vm Flmditlei% . 000 Wrn MU"
Aquifer Protection Section
PLUM P[PDRM US IAiNYlElWQ &Y F YOU DG N N R easw FPCes E 3N RJU

Mar. 11. 2011 3. 16PM YADKIN WELL LJD No. ���V�r P• Lrar�.r
NOxTA CAROLINA
DEPAMOMT OF MWMOMMNT AND NATURAL RLSOURCM (NCDFNR)
NOTIWICAITON OF MM TO CONSTRUCT A OP OEOTYMRiL AL
WATER-QNLV, IiJZC nON VML 5"rM:
la A=Kda= with floe prnftoW afNCAC Title 15A' MC 02DO, please
dons** t1us nat&cawA and mad to address on tl+a back pap (plaase Egg or Tyme wnrmati=).
DA'1.Tle: p 3 1 ! 26 1
llya l"ype Cox ltun: Do% the propped synm oircubo pe able m= agly (= adftives) w
covtinuous piping d= completeIy isolates the fluid ftm the envi_ro=ent (i.e.
2joed-j2g7
Yes X_ Continua oompletiag tbk fon m
No Do Not complete this fo= ['.arTlete other MC application firms for imp g
ehber a. 5A7 well s -loop well in mb potable waw zulo the aquifer) or a 5QM weil (closed -
loop wcll cozrraulirzg xdi` 'v s ouch as V,22, ethawl, or other ar;bftam or corrosion inhibitors).
A. PROPERTV OW'NER(S)[AFMICANT(S)
List each Property Owaer listed om prop" deed (if owned by a bu&inm or gove y, sae roe of
endty and a represt=6ve w1mahop ity for side): &I r-A ACC. Sy O A15
(1) Mailiag Address: `� 334
GixY: �1 i ( - S Stag !■ � dip Cade• County W okt-,A��
Homnel0fSceTe3eNe._ g$—�9'] - �.�i Iq
R=Ril Ad&ws; W ebsite-
(2) Physical Address of WrU Site (if dii of tban above): _ �o ? l $ MW 4 �{ 1
City. t/. �it� Stale ►�C 7ip Corte: , � "Cau uty_ 4,�4 slatla
Home/OfftcaWeNo.: $2$-a9-)- Cell No.:
B. AU TaO MED AGENT OF O'WNU., IF ANY (ift't;e Permit Applicwt does not own the strbject property,
atmd a letter from the property ow= =hwiz4 Ageiat io instep and opemto TJ1C waW
Comact.Person: RM ATvd ess;
,Address:
City: State_ Zip Code: C❑uaCy:
Ofbce Tole No.-, Cell Na.:
'W'ebsite Addms of Company, if any: "►ECEIVEO 1
DENR 1 ❑V>�
Aquifer Pr�tirr S�tion
r"rcr nu»u �lrvnul u11�n:C MAR�1 ;1241de,

Idar. 11, 2011 3,16FV1 YADKIN WELL No. 7176.sT P. 1,0z_,T
C. WEU pMLER MORMATION
Compaay Name•YadYda 'WrO Co, I=.
Well Driller Cauftmor's I+ um- 3Ay Mitt Mcftw groat �, bl bm.cye
NC Gannac= C dfWAtaott No.: 2572—-
ContadPersona Dayid_L Brcaw� Z!4 r4_ EI►t�rlx ,Address: [e-mail]
Addrew;1908 Hampttsvllle Rd.
Ciy: nrMyWe N.C. Zip Code: 27020 Co=ty: Y
Office Teie No.: _.)3� 4b9-mid Call NQ.; 336-374-8736
D. BRAT Pump CONTRACTOR moRmATIQN (ff different thn draverr)
Co=party N&=: ^a&*,rcf 4 ,Fay, ,44 '04-
CQatw Parson:
Address:
Crty: r Tip a: o& Comty: W,#6,-f,4 _. .
Office Tale No_. Ue ," < - � +: J� C� No.: � - � `f _ �!
E. STATUS OF APPLICANT
Private: V Fedeal• Commercial:
$wale: MunicipaL Native Amaic= Lands.
F, INJECTION PROCEDURE (bneEy describe bDw ttye bge weil(s) wM be o4ed)
G. WEU CON'ST VCV0N DATA ` 5 0 �O N
(t) Proposed daft to be �awra=4: ,� { __ Number of b* iAgs-. 2
•
Approximate depth of each boring (feet): 2 1ja
(2) Type of tubing to be nsad (copper, PVC, em): na to OE SAZ " ! t
(3) Well casing. Is t1te well(s) cad? (chvak rithft (a.) ides ar (b) No below)
(a) Yes if yes, then provide c aW g iakcmation below
type: Aebrash steal —plastic vthw ( fy) Aq ferVp 1j
o
vW4
Casing dejra- From to feet (reference to ]and surface} �dqy
Casing wnads to above grouad ; RAR 12 2011 °n
(b) No X
(d) Crrom Info (ms$teriol sounding well caste and/or piping): r f�i� Brti�pnc e+�
(a) Grout type: Neet Cement Banttox4te ,�Otha (speoify)
(b) &ottr place =V Pwrm& Prtsmre other
(a) Groat depth oftubiug (recce to I&W =fiwe): f m. 2(j) � to Z [feet]
if well has casing. indicate $Font depth: from to (feet)
r ;err •nN, 11114 rMArlui WHA'r 4AA7 Al &ON,

Mar, 11, 2011 3:16PM YADKIN WELL Nq. 7176 4
3
g. rinCTION-U)L ATED EQMMENT
Amwh a diagram showtng the engWba , Iry= of proposed modificadon of the injection equipment mW maerior
gip�g�bubi�g associated with the injoction operation. The. ma=&ct" °."='*'s brocUre mdy provide supplementary
iafvxtaaec�.gm.
L LOCAITON OF'W)EX�LM
Attach two copies of maps shawing the following u& rmatm:
(1) Iadude a Stke Map (0= be drawn) showing: btriidiggs, property trues, soda= water bodies., potertial
sources of gra=dwater conwmkwdon sad the odo=d= of and disumces between the proposed well(s) and
&ny e4sfmg well(a) w wasta disposal faG9lifm such as septic tam or drain fields located within 2OU feet of
tlae gecrthamad heat pump well system Label all famm clearly and include a. north arrow.
(2) The SAM Map must slow lie Subject property in relation to the swmmdiaxg axea by nWag at least rwo $red
referme pouter such as roads, sITaaws, andlor hwmmy iixsecuous•
X CERTMCATXON
Nate; Tb s Permit Applicstioxt must be signed by ac person appearkng on tka
recorded legal property deed-
-1 herby 0mafy, under penalty of law, that I have personalty examined and am fasaMar with tbz u forinadon
submrtted in this document sand 111 s:ttachmau% zbmo and ithn based on my mq yy of those Individamls
i=odiately msponsiblo far ob airing said roatigoa, l behwft ibat tbo information is true, a,cctsrste and complete.
I am aware that flz= arc sit pwakties, mdu&uig the possibility of fa and m4wiso=ew, far submitting
Use infoxmsriosi_ I agree to cowtruct, oger�te, wn3ntafn repair, and ifappUcable, abandon the Injection we11 W
all related appummmnm m accordwam with the approved speonf catiow and conditions of the Pew"
' Signature of NOMV Owner/Applicsat
Pant of Type loll Name acid title
Sigaatute ofPropextyOWAe6App]$CW
Prmt mr Type FUU Naas and tulle
REGEIVED r QENR 1 M
Aquifer Protection Sec ion Sipe= oi:AuftwOedA a% if=y
MAR 112011
Prim or Type FUR Name md title
Plan retiam two copies ofthe completed Application package to,
North Carolina DM-DWQ
Aquifer 1° rotdcOan SeWotr MC Pmgmm
1636 Mal Service Center
1.iAIdgh,JiC 27699-1636
Telephone [phone]
.. , , 0 -r.1 -49"W k!}%IA,1, po inn, r 4'4A7 •A1 14nls

Mar,11, 2011 3:17PM YADKIN WELL
No, 7176 P, 5
Gte-v4a E uem) 3 P, 'r I^ if
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Mar,11, 2011 3,17PM YADKIN WELL
Na 7176 P. 6
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�3aera Name: ,�orrL, ►�[lc w�
ems:
P'gbr3aer: - 2 4 *- C2
j"
�2�
-?r 7
RECEIVED I DENR I uvvu
Aquifer Protection Section
MAR 112011
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