WI0400180_GEO THERMAL_20110328

.Perm it Number
Program Category
Ground Water
Permit Type
WI0400180 /
Injection Water Only GSHP Well System (50W)
Primary · Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Steve Bissette S FR
Location Address
7020 Maylake Rd
Clemmons
Owner
Owner Name
Steve
.NC 27012
Bissette
Scheduled
Central· Files : APS_· SWP_
03/28/11
Permit Tracking Slip
Status
Active
Project Type
New Proje·ct
Version
·1.00
Permit Classification
Individual
Permit Contact Affiliation
Steve· Bissette
Owner
7020 Maylake Rd
Clemmons NC
Major/Minor
Minor
Region
Winston-Salem
County·
Forsyth
Facility Contact Affiliation
Owner Type
• Individual
Owner Affiliation
Steve Bissette ·
Owner ·
7020 Maylake Rd
Clemmons NC
27012
27012
Orig Issue
03/28/11
App Received Draft Initiated Issuance Public Notice Issue Effective
03/28/11
Expiration
03/18/11 03/28/11
Re o ulated Activities
Heat Pump Injection
Private residence, single family
Waterbody Name Stream Index Number Current Class Subbasin
AWA ..... , .. ___ _
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Steve Bissette
7020 Maylake Rd.
Clemmons, NC 27012
Coleen H. Suliins
Director
03/28/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0400180
7020 Maylake Rd.
Clemmons, NC 27012
Dear Mr. Bissette:
Dee F reernan
Secretary
On 03/18/2011, 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 beat 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 stanqards spec_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 submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Ac~ and North earolina
Administrative Code Title 15A Section 2C Subchapter .021l(u)(2). Additionally, you should ·contact the ·Forsyth 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 (9'19) 715-6166 or Michael.Ro ger.s fW ncdenr.'lQY iftr ha. ve any questions.
_Jcerely, ~
for~ atts
Sup~:~
cc: Winston-Salem Regional Office -APS
APS Cenn;-al Files -Pennit No . WI0400180
Forsyth County Health Dept.
David J. Brown (Yadkin Well Co., Inc., 1908 Hamptonville Rd., Hamptonville, NC 27020)
Brad Falk (Logan Heating & Cooling, 5142 North Causeway Dr., Winston-Salem, NC 27106)
AQUIFER PROTECTION SECTION
.1636 Mail Service Center, Raleiqh, North Carolina 27699-163~\
Lo:=ation: 2728 Capital Boulevard. Raleiqh, North Cerolina 27604
Phone: [phone] \ FAX 1: 919-715~0588· FAX 2.: 91H -7 15--6048 Custome; Ser1ice : 1-877-623-6748
Internet: www.ncwaterauali rv.oro ,
An Equal Opport1mit\1 \ .t,,fiirrnat1ve Action Ernoloye r
-,...~Onehr 1· 1.~lort. ~aro ma
,7\7t1tural!g
Mar, l$ 2011 11:15AM YADKIN WELL No, 7235 P. 1
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DATE: TIME: EF NO. LOG No.
COMPANY NAMI: FAX NO, P ZAM
L. A DELIVER
❑ IMMEDWELY
ATTFN7lD DEPL
FROM: Jk o CIA ] W- �-- ?'
COW W NAME FAX NO. PLEASE
PLO
FIEFLY
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wDMDUAL DER,
NUMBER OF PAGES PLEASE 0FRGINATOR75
INCLUCING T1418 SHEET--(,-- AEPtY BY SIGNA'NRE
MESSAGE:
/ � a
-FDR ALL YOUR WATER NEEDS'
YA©KIN WELL CO., INC.
ism KmArrorgvILL£ ROAD
HAMPTONVILLE. NC $7=
DAVI❑ J. BROWN, VICE PRES.
TOLL FREE (900) 249-935S
y ❑FF1GE i3.3$j 46a-4'4
"i FAx (336) 46a.4048
RE5 [3861 46a-4559
Y.aao xEwS n�1SR�Gn 4W 4p+Tis YPV'
♦�
182011
PLEASE U 8 ipF[fyl US R E== IF M DO Wr RMSVE FACSMMLE IN FF.I1J.

�`�• "Mat, 18, 2611 11:16AM YADKIN WELL ,}� k 7235) P. 2'
NORTH CAROLINA
DEPARTMENT OF ENWIR4NM5NT AND NA73RAL RESOURCES (NCDENR)
NOTMCA-nON OF INTFNT TO CONSTRUCT A S LOOP GEOTB RMAL
'WATRA.-ONLY INJECrION WELL SYSTEW,
TYPE 5-QW WEIR
Ia Ao=da= -,Vith the vmviuo s of NCAC Title 15A: 02 CO200. pleats
complete this nod&catian and mail to address on W beck PaP (Please Print or T informat W.
DATE-. Z - & 20-IL
FP'e!i J'p,ve CorrfL mafiars: Does the proposed system: circulate potable water only (no additives) in
continuous piping that,-.omplately isolates the fluid from the environment (i.e..
c wed -Ica '�
ices ^�Continue cotnpletiaS this form.
No T)o Not coraplece this foam- Caraplete other UIC appuoatioa forots for installing
aitber a 5A7 wa11 o en -loop well in�ng potable water into the aquifer) or a 5QM well (closed -
loop well oontainirtg additives such as R-22, ethanol, or other anti uze or coanslon ilaWbitors).
A . pROPE1tTY O WNLR(5)IAPn1CANT(S)
List gigh Propm,y Owner listed on property dyed (if awned by a b sinew or government agency, state name of
entity and a rcpreseumtive w/authority for signature): Q•v e � r.r�
Mailing Address -
j�' C ty' UP Stowe:-AZLZip Code: 2- _ County: .
�- Home/offiae Tele No.: Cell No.:
Email Address: Welssite:
(2) Nvsicw Address of 11eIl Site (if different than above): cam*. n.
City:
Srie: Lp Code Cowmty:
Home10Q&ce Te10 No : -Cell No.:
S. AUTH:Q=ED AGENT OF 0WNF'L,1T ANY (if tba Pmnit Applicant d-m-n own tote sub jest property,
attat,b a Ietter frow the property owner autbonzing Agent to install and operate UIC well)
Company Name: _ - -
Contact Person_ RY—AU, Address:
Address:
City: State' Zip Code: County:
Q&ce Tole No- Ce1lNo.:
Website Address of Company, if any:
RECEIVED I DEW I DWU
A0U1iFFP'pPnV-f' ON RECTION
MAR 18 2011

hfNar. 18. 2011 11:16AM YADKIN WELL No.7235' P. 3`
u-)
C. W*ZLL DMLER WORMATION
company Nam: }„�ad1�'Siir� Co. Ina
WaII>3rill� Cdntcactoz'sNaaze: � d e ro�f1 'Iran e
NC Cootractax Cet1i�iratioisNo.: 2572-A _M96-A - 3546-A .
CoataciPersoaa: D��'d 3. Sro'►vn 71 G�-A �i1�L.Addre�a: c�7iefdrijI�x�a rrnn,e�g
Address: 1909 Aampfonvflle Rd. y
City: _ I3aWtonvtILL _g. Zip CQd� 27020County: Yad nn
OffteTelsNo.: 336-462-4440 _ C.oilNo,= 336-37d-9135
D. SEAT PUM' CONTRACTOR 1"ORblAnON Cf diffsreat thin driller)
C=PanyName:_ _ o n G „
Coo�aaPerson: mac. ddn�s:
Ca u el r,�, d cr _0s►
City: W r�•s ��• t�ALs—. , Grp Cede: '7 tQC, Comift : rzs
v icaTeleNo.: �3� q 4� �1 WNo.:_�3G 6-01L G
E. STATUS OF APkLICANT
Private: s Fedarai: I Counnue W:
States Municipal: Native Amerioaa Sands:
F_ INJECTION PR.00MIME'i (briefly drscsibe how the it}itedon well(s) -,A[ be used)
rbu A� C /oJ
G. WELL COIrtMTRUC'TXON DATA
(I} Prepared date tQ be eamwctrd:. Z1 Number of borings:
Appmxiamte depth of esa Wring (fee=);_ 2.2--r _ 1 �rl (46,PC I ]2- 0
(2) Type of tubing to be used (capper, PVC, etc): /71Ii 9 i
(3) WeU casing. Is the vrell(s) cased? {check either (a.) Yes gr (b) Nv below)
(a) Yes if yes, then provide casing iufcrmatiou Wow
Type: _ - - pIvuiaed steal black steel plastic of6r (specify)
Casing depth., -Rom to feet (reference to land sultoe)
Casing extends to above ground iacL-*
(b) No
(4) Grout Info {material sucrourtdng well using aadlor pipir* j _ ►+ /� a n e-e.�
(a) Grout type: Neat Cci_ _ 8earoaite f rather (specify)
(b) Grout placement: PumpingPrew= Other
Cz) Grout depth of tubing (►t:fu=o to hmd azafiare): fom ZZ t- j
If well bw casing, indicate grout depttit from m F
REGENEDrDENR -
(e
A41�� atxOTFt Tfl7fl5E C
BAR IS2011

"Nla r. i $, 2011 ' 11, 16AM
. ^ Q u�)
]NjBCTION-RELATED EQUMMIENT
Ata.eh a diu ra.ffi showing the engwttrixtg layatg or proposed =tuncadon of tho iojecdou cgWpm= and cxterior
pigi4tubin& associated wit4 the injection operation. The man&cturg's broeh= may provide supplementary
information.
YADKIN WELL
X. LOCATION OF VE DR
Attach two copies of maps showing the following iaft=1doa_
(1) I=Luda a Site Map (can be drawn) showiW buUdb3A proper
sot» of goilndwatcr cons lUliort and the orlon of and d!
any existing woIl(s) or wasto disposal Acilities such as septic tools
the geoth=n; l bW pump well oste= Label aII features clrarly U
(;) The Sit~ Map must'show the subject property in relation to the sur
refereaae points such as roads, $tream$, aadlor bsglraray itctemccdos
I CERATION
Note: This Permit A.pplieatiou must be signed by each person
recorded lege property deed.
No, 7235 P. 4
lines, surface water bodies; potential
W= between, the proposed well{a) and
r drain fipids located -within 200 fret of
include a north arrow.
area by using at Zrest two fixed
0o the
"I hereby certify, under penalty of law, that I bave person Wy examined and am ihmm" with the information
snbnn m d in this doctm3eat and all att$chments thereto and that, based on my inquiry of those individuals
Immediately responsible for obtaining said b farmation, I believe thatthe i' ==a.tion Is true, accurate and complete.
I am aware that there use sigzzi$cartt gaalties, iholudittg the pa5sibi�itY I ftes sad imprxomosa4 for subznitftg
false informariort. I agree to construct, operate, a n, repair, sad if applicable, abiml= the iujecdon well and
I related apptutenanew in acoaorclaaot -with the a ro ed sp j28c n pnd conditiorA of the Permit '
rant ar �,�
��?�l,� cf+r Signature
R 18 �011
Friar or Type FuU Nun zad title
Signature of AuthotlUd Agent, ' f any
] 401 or Type Full Name and title -_
Please rat= two espies of the completed Application package to:
North CaroUna DM-DWQ
Aquifer Protection Section-UIC frog m
1636 Mail Seance Center
Raleigh, NC.27699-1636
Telephone (M) 715-6935 ,

N1ar, 1$. 2011 11:17AM YADKIN WELL
No.7235 P. 5
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Mar,18, 2011 11:17AM YADKIN WELL
RECEIVED I VEN' `DW
MAR 18 iF'�TfON
No.7235 P. b