WI0400181_GEO THERMAL_20110331

Permit Number
Program Category
Ground Water
Permit Type
WI0400181 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
m ichael. rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Mark Ford SFR
Location Address
389 Pine Branch Rd
Boone
Owner
Owner Name
Mark
Dates/r=ve nts
NC 28607
Ford
Scheduled
Orig,lssue
03/31/11
App Received Draft Initiated Issuance
03/24/11
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall rwu
Central Files: APS_ SWP_
03/31/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Mark Ford
Owner
389 Pine Branch Rd
Boone NC
Major/Minor
Minor
Region
Winston-Salem
County .
Watauga
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Mark Ford
Owner
389 Pine Branch Rd
Boone
Public Notice Issue
03/31/11
NC
Effective
03/31/11
28607
28607
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Mark Ford
389 Pine Hranch Rd.
Boone, NC 28607
Coleen H. Sullins
Director
03/31/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0400181
389 Pine Branch Rd.
Boone, NC 28607
Dear Mr. Ford :
Dee Freeman
Secretary
On 03/24/2011 , the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onlv
geothermal injection well system for the operation of a ground-source heat pump located at the address referenced above. An
individual permit is not requir~d for the construction and operation of this type of geothermal injection well system a~ long as the
following conditions are met: ·
1. The injectio.n 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 ~ubmitted~
Failure to comply with all of these conditions constitutes a violation of the North Carolina We11 Construction Act and North Carolina
Administrative Code Title 15A 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.
Please contact Mike Rogers at [phone] or Michael.Rogers(a),ncdenr.gov if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Pemli.11 · o. W l0400 ls-I
Watauga County Health Dept.
Sjcerely, . Q ) .:---..,
00iJt5'1;}x1h.Jt~
for Deb W tts
Supervis
David J. Brown (Yadkin Well Co., Inc., 1908 Hamptonville Rd., Hamptonville, NC 27020)
Winston Petrey (Mountaineer Heating & Cooling, 220 Postal St., Boone, NC 28607)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard , Raleigh, North Carolina 2760i;
Phone : [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715 -6048 Customer Service: 1-877--623~6748
Internet: www.ncwaterquality.org
An Equal Oppo:-tunity Affirmative Action Ernploye•
l J)nel r-. ,.. .. \J ort 1. ~arouna
,l(atural~l/
Mar.24. 2011 1;24RM YADKIN WELL
No, 7214 R. 1
9
FA FMLE TRANSMISSION FORM
GATE: 3 TIME: AEE. NO.
D- _ Leta) nI - Tytr
COMPANY NAME � 11 rAx ISO. PLC
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COMPANY NAME FAX NO. PVASE
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wG�UAL DEK
NUMBER OF PARES
INCLUOMNGr THS SHEET
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PLEASE r � a',,,'
MESSAGE: ' j n A
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�,uter P�atectio� �
MAR
-FOR ALL YOUR WATER NEE05'
YAAKIN WELL CO., INC.
IBM MAMPTOWILLE ROAD
HAMPTONVILLE. NC $7M
OAVID J. DROWN. VICE PRKS.
TOLL FRE@ (OM 14IF93 s
OFFICE 13U? 406.4`14
FAX 4N) 49&A*"
RE9 S#") 466.4669
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Mar, 24. 201111 1, 20%v{ YADKIN WELL-�L wloqnol� I Na. 72744F. 2r J
FORTH CAIROUNA
AEPARTK+ NT OZRRVIRONI r!A= NATURALMSOURC,11s (NCDENR)
NOTMCATION OF XNTEW TO CONSTRUCT A QQME LOOP (ATA$RMAL c.
eo
Ira A0=48we Wfth Me FV;W= of NCAC TIU UA- MOW, Dte�.re" r•�
aomplec tbLs antk&=t = abd mAd to erd&m as the back pap mac BW or 12M ivft=ffba3)_ a �
DATE:. 3 — _ _ 20 (1
Weu hype Cv�au: l= the prgpou d MUM chmdaft potable W"M (ma addit#v'es) i ft
cwt lr a pipiug that eomplately i solem the E dd from, the eovir*=em (i.s.
a ecl- ?
Yea coutirm oompledus this form
No DdNot mmpbete this'1v. Complete olhor LUC agplimtiou for= for ius'talli S
ehbw a 5A7 well (Me 1QW well W potable water into *oo aquifer) ar a 5QM weal, (alosm-
loop well c❑n%ini.ag such ss P.•22, ethanol, or other anfftv= or como lion Wnbitors).
.t PxaPERTY OW"R(WA"MCANTM
List Propm-ty Owntr listb. ca MperW dead tiff by a busimen cc govamogmt alpacy, pDaw of
aac zy and a repre"Ufttiv'e vlauthosiiy err si n): A14-4 i CA, 1 r-, - --
(z) Malting Adams; w S /' �P - - - 44" - A -LA W - - — —
Q -- r. Scam: All. Tap .? K4 � CouUty.IrLALIJTIt
HomelOffice Tele Ift: -2441. 7E/3
Email Address:
(2) YD'4ca1 Address of W all Sitc (if dsff:e wa tb m above):
City; - Sbm Zlp Gods Cotmgr. --
Home/Office Tole No.:
H. AUMORUED AGEW Ole' OWNXJR, Uy ANY (if the Prnit Applicezt � owd the subject pmpany,
gdwh a latter from the gfa ovrnar IWIWdZiW, -U--cat to ill Aid vlrtxaya TZC wdl)
Company Name:
Contact PersoaT�, _..,�_ EMAIL �A cidrass: -
City: _ SWe. Zap Cody: Count r
Qfce Tale No.. _ "
wcbsite Addram of company. if say-
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Mar.24. 2411 1:24PM YADKIN WEl! No.7274 P. 3
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C. WELL D,it,YI LER TN ORM TION
Caulauy xa=-)C " `4V
W&E Daer Cac►tr Wr's Name: 'Nve
NC Cottractr CerUcatioa No._ 25724-543 - A
CoutactPersoz�- Ds cl 31�t- ...._-�.�chiefdrillerfci?msn_cey
Address: 1908 Hmp'bodvilie Rd
City: viik Zp Code: 27020 Cvuuv: Yadkin
❑Mee Telo Irv.: 33"8-4440 Coil Na: _33"744736
1?. EMAT PUMP CONTRACTOR EW072"UOV (it Merest tMa drftr)
Coxatact Pexso. w e g
Ad*tss: 2 Zo
eYry: zip caaa: 2XA 7 Cov=e - . bu a �,p Cs _
Gffoe Tola No.: g2frr GGZs- Cell No.;
E. STATUS OF APPLXCAM
Privava: � �adea-s� Commercial:
Sues Muaiczual: Na&a Ammician Lan&
k�. w3rCr om PR1)CMURZ (bitty dame kow *0 Weetitm well(s) will be used)
G. W LL CONSTRTICTION DATA � 20 W
()] I''tcrposed date to be vomsbvctpd: T -2? Nro*ber of bpri�W. .2-
Appr be depth of esob bodog =Raz):_ (e7 r ,
(2) Type oftobing to be imed (aoppea, PVC, etc); Q PA �'��-- i 1
(3) WoU oasing. Is the weti(s) sased7 (obsok tither (a.) Yee or (b.) No below)
(a) Yas if yes, tlo piravidag atl� below
Typo; _plyamlzeid steel black stcel_�p]$stic o*w (app6 fy)
Casing depth: From to feet (reface to lead surfam)
Cas4 extends to above gm and itches
(h) no , A--
(4) Groff Info {dial svraotmding well casing endlor 71p4 - , , �+ ►`+�
(a) Grater type: Nial Camenr Aemwnite�,_•w, Dtltaza ("Cify)
(b) Gar= pl=amanzc +tmp :g PrtB Me 0&ff
(c) Gru,2 depth oftaiag (M&Mpt to land mr&c ).- from :110 - to 2 Chat)
If wall b" MM8, ivAcate great ckpth: ir= to
01-05-2010 is:35
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Ma r. 24. 20111 1:24PMn YADKIN WELL.t
No.7274 P. 4
Iv. 7140 [
4 INnCTION-UILAT vD IQUMMUNT
AUVA a &as[= SbowiW dw a uiueafns 14yoig or propwad m odiiGadou of the iz emdon equipmem ae t, &.69:'
pipingltabing associata(l wit the injee4on opera*= The maw*Mxw's brach%n may pnvi& suFPlevient"
informtiau.
X. LOCATION OF wX3G]uS)
Anmoz swo copses of sags xhawitg the: £0llnWIM ivfXs=ien
(1) lnc vL& a site leap (cm be drawl showing: bwwh$i. pope"y linen, Surface war bodies; pot nbzl
sources of WovndwaW corI CR sud the otie4aea- of and diftno% between t$e groppbed wej .) and
my MxigtMg wel(s) or Was'la disposal UQUICS suab as sapdo Unh or charm fields located wfrl�ra 200 feet of
rbe geadft=3 hoat puV well aysW= label all fiaturm clearly and
(2) The Site map Mxwt ohm tt w4eat paorpeaty in sewoc. to tko sutr&and"igg area by WiUg at 1eW two tmtd
raterauce poiEft such as rank sttaams, sWoa h4tway intmwctiow.
J. C3iRTVXCAIIt]Iy
Fate: 'I'�is x'+Ar�rt AprpEsrsrtioa mast ba �rted b� e�e� }�x641e appr�ring o n chic
recorded toplorapvrty dae@..
"1 %cby octif', under pdmlly of law, tlzt I havo persatily a=dmd and am ftdHar with tbo ig mw%im
submittod in this doe= mat a4 all AUwhw*=00 and tb4 bue d on my h gvaxy of tWe iudividxmis
immadiateiy re3pow1bla far obtaining said infa=t =4 I b*Uw" thaE'lba iaformatcn is true, act and eamuplete.
I am a%we that #bore are sit peaaldes, hWUdJnS the possibMW of fines Ud ixprisonn=t, For submitting
fabe ikm i up= to oc%nwt, opam* Mol =h4 reI'Y,iC', end if a pliablo, abud= ttka irjacOoon well awd
ail rued apmUm= ea in aoaad = wkh the epp w-md speeMonums and con ti of ffia Permit."
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please return two copies of five completed AppRoatiort pa'up to:
North C arogns DM DWQ
Agn*r ProUdion Secpan-MC Program
7,+�34 Axai4 $axvks Cevtbsr
Ittivii;b, XC 27699-16%
Tel phtokt+e t919j 715-6-35
�1- r'-0-2210 16 E 35
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Mar.24. 2411 1;25PM YADKIN WELL
No, 7274 P. 5
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