WI0400185_GEO THERMAL_20110525

Permit Number WI0400185
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System ( 5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facili t ,
Facility Name
David & Nicola Hulse SFR
Location Address
7204 Townsend Forest Ct
Browns Summit NC
Ow ner
Owner Name
David R
Dates/Eve nts
27214
Hulse
Scheduled
Orig Issue
05/25/11
App Received Draft Initiated Issuance
05/17/11
Re g ulated Activities
Heat Pump Injection
Outfall r·HJU ..
Central Files: APS_ SWP_
05/25/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Ruban W. Clayton Ill
5307 NC 704 Hwy E
Sandy Ridge NC
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
David R. Hulse
7204 Townsend Forest Ct
Browns Summit NC
Public Notice Issue
05/25/11
Effective
05/25/11
27046
27214
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
A.VA
NCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
David R. Hulse
Nicola J. Hulse
7204 Townsend. Forest Court
Brown Summit, NC 27214
Coleen H. Sullins
Director
5/25/2011
Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System
Permit No. WI0400185 ·
7204 Townsend Forest Court, Brown Summit, NC 27214
Dear Dr. & Mrs. Hulse:
Dee Freeman
Secretary
On 5/17/2011, 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 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 specified in North
Carolina Administrative Code Title ISA 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 ISA Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Guildford 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 Micbael.Rogers(@.nc<lenr.1mv if you have any questions.
cc: Winston-Salem Regional Office-APS
APS Central Files -Pennit No. WI04001 , 5
Guilford County Health Dept.
Aqua Drill, Inc (Ruban W. Clayton)
Sincerely,
D~Af<r--' .... -~V4 for Debra Watts
Supervisor
Williams Plumbing, Heating, and Air Condition (Daniel Mara)
AQUIFER PROTECTIOM SECTION
1636 Mail Service Center, RaleiQh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27804
Phone: 919-733-•3221 \ FAX 1: 919-715-0588: FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwateraualitv.o ro
.An Equa! Opp0rtuniiy \ Affirmative Action ErnpiO'.'er
N°~i..c 1· 01 u1 aro 1na
/vatural~lf
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT A14D NATURAL RESOURCES
NOTMCATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5O W WELU S)
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Print or type the required information and mail to address on the back page.
DATE. May. 10 _ 20.11
A.
wr-oq-ccl'�5
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
coutinuous piping that completely isolates the fluid from the environment (i.e.
cios -12207
Yes x— Continue completing this form.
No Do Not complete this form. Complete other LIC application forms for installing
either a 5A7 well (open -loop well �g potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
PROPERTY OWNER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): David R. Hulse Nicola J. Hulse
(1)
(2)
Mailing Address: 7204 Townsend Forest Ct.
City: Brown Summit State: _N-C_Zip Code: 27214 County: Guilford
Home/Office Tele No.: 336-5lM215 Cell No.. 336-337-3770
Email Address: nlhulsea)triadxr.wm Website:
Physical Address of Well Site (if different than above):
City:
Home/Office Tole No.:
State: Zip Code:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City:
State: Zip Code:
County:
Office Tele No.: Cell No_:

C. WELL DRILLER INFORMATION
Company Name: __ ___;;::A=q=u=a=--=Drill=-=·=-=In=cc...:..... ______________________ _
Well Driller Contractor's Name: -=R=u=b=an=-W....:.....;...;·-=C=la"""'ytc...;;..o=n=ill=----------------
NC Contractor Certification No.: 2241A ___________________ _
Contact Person: Ruban Clayton EMAIL Address: a guadrill@hu ghes.net
Address: 5307 Nc704 Hwy E
City: Sandy Ridge Zip Code: 27046 County: Stokes
Office Tele No.: _3_3_6_-8_7_1-_9_7_47 ______ Cell No.: 336-399-0747
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Williams Plumbing, Heating, and Air Cond
Contact Person: Daniel Mara EMAIL Address:[e-mail]
Address: 1051 Grecade St ________________________ _
City: Greensboro NC Zip Code: 27408 Co\Illty: Guilfoi-d __________ _
Office Tele No.: ___;;3;;..;;;3'"""'6-=-2=-=-7..:;;...5--=l=-32=-8;;;...,__ _____ Cell No.: 336-215-8561
E. STATUS OF APPLICANT
Private: X Federal: Commercial:
State: Municipal: __ Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed loop water only sy stem for Geothermal heat pump
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _May 16,201 l ____ Number ofborings: _3 ___ _
Approximate depth of each boring (feet):_300 ______ _
(2) Type of tubing to be used ( copper, PVC, etc): ___;;;HD;.=;;....;;Pc....:cE=---=S-=D-=R=l -=-1 _____________ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes Q!'. (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: __galvanized steel __ black steel__plastic __ other (specify)
Casing depth: From ___ to ___ feet (reference to land surface)
Casing extends to above ground inches
(b) No _x __
( 4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite X Other (specify) ______ _
(b) Grout placement: Pumping_X _ Pressure -Other __
( c) Grout depth of tubing (reference to land surface): from __ one __ to _three __ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page2
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELLS)
Attach two copies of maps showing the following information.
(1) Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. I agree to construct, operate, mains n. repair, and if applicable, abandon the injection well and
all related appurtenances m accordance with the appro�i�i 4)gcifications and conditions of the Permit."
RECEIVED 1 DENR i D*Q
AgWfer Prolaoion Section
MAY 17 2011
Signature of\Property Owner/Applicant
34 3BAVI0 HvLsf—
Print or Type Full Name and title
Signature of Property Owner/Applicant
141 G]a� "L--.E .
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Nance and title
Please return two copies of the completed Application package tom:
North Carolina DENR-DWQ
Aquifer Protection Section-U 1C Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUIUIC 5QW Notification of intent Form. (Revised 8/2008) Page 3

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NORTH CAROii1INA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A·CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM
TYPE 50 W WELUS}
In Accordance With the Provisions of NCAC Title 15A 02C.0200
3: ~ ....
Print or type the required information and mail to address on the back page. -..'.I
I-...:>
c:::) -DATE: May, 10 . 20_11_ -
Well Type Confirmation: Does the proposed system ·circulate potable water only (no additives) in
continuous pipi:ng that completely isolates the fluid from the environment (i.e.
closed-loop)?
Yes _X_ Continue completing this form.
No __ Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (Qmm-loop well injecting potable water into the aquifer) or a SQM well (closed-
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPUCANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): David R Hulse Nicola J. Hulse
(1) Mailing Address: ------'7-=2-"--04.c....~~o""-'-wns-=-e=n=d-=-F-=oi,=es=::;t_;;:C"-=t.'------------
City: Brown Summit State: _NC_Zip Code: 27214 County: Guilford
Home/Office Tele No.: 336-510-6215 Cell No.: 336-337-3770 ~---........... ...c.=-a-'-"------------===-=--'-'"-'-'-----=-=-aa.......a...-............. """'--"'--'-----
Email Address: Jihulse @triad.rr.com Website:
(2) Physical Address of Well Site (if different than above): _____________ _
City: ________ State: _Zip Code: _____ County: ____ _
Home/Office Tele No.: -------------=Ce'-=ll=-N~o•a.a...: _________ _
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: ___________________________ _
ContactPer~n~: ____________ -=E=MAIL-=-==·~A=d=&~~=s~: _________ _
Address: _____________________________ _
City: ________ State: __ ·Zip Code: _____ County: ______ _
Office Tele No.: Cell No.:
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C. WELL DRILLER INFORMATION
Company Name: __ ---=A=q=u=a:;..::Drill=·=-=In=c:.:.... ______________________ _
Well Driller Contractor's Name: -=-R=u=b=an=-W....:...:....:.•...;::C=la=yt'-"-o=n=-=ill=----------------
NC Contractor Certification No.: 2241A. ___________________ _
Contact Person: Ruban Clayton
Address: 5307 Nc704 Hwy E
EMAIL Address: aguadrill@hu ghes.net
City: Sandy Ridge Zip Code: 27046 County: Stokes
Office Tele No.: _;.3::..=3-=-6-=-8:..:..7-=-1--=-9-=-74-=-=7'------------Cell No.: 336-399-0747
D. BEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Williams Plumbing, Heating, and Air Cond
Contact Person"--: -=D...;:;am=· e=-1-=-M=ar=a:;:__ ______ --=E=MAIL=-==-=A=d=dr=-=e=ss=-:dan==®=w'-'-'il=· l=iam=s=p=ha=·=co=m=--------
Address: 1051 Grecade St;__ ______________________ _
City: Greensboro NC Zip Co<ie-. 27408 County: Guilford __________ _
Office Tele No.: _;.3;;;.;;;3...::.6-=-2::..;;..7=-5--=1;:;..:32:;a.;;8'--------Cell No.: 336-215-8561
E. STATUS OF APPLICANT
Private: X Federal: Commercial:
State: Municipal: __ Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed loop water only system for Geothermal heat pump
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _May 16,201 l ____ Number ofborings: _3 ___ _
Approximate depth of each boring (feet):_300 ______ _
(2) Type of tubing to be used ( copper, PVC, etc): __,;;.HD=-=P=--=E=--...:;::S;.:::;;;Dc=R=l-=-l _____________ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes Q! (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: __galvanized steel __ black steel__plastic __ other (specify)
Casing depth: From ___ to ___ feet (reference to land surface)
Casing extends to above ground __ __:inches
(b) No X ---
( 4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite X Other (specify) ______ _
(b) Groutplacement: Pumping_X_ Pressure__ Other __
( c) Grout depth of tubing (reference to land surface): from __ one __ to _three __ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page2
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping;/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
1. LOCATION OF WELL(S)
Attach two copies of maps showing the following information.
(1) include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that 1 have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, l believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information I agree to construct, operate, main n, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the appro cifications and conditions of the Permit.,,
KWEDIV~0 i �iENFi 10 60
Acluitar Pfa�[1 � Sag re or roperty 6;WerlApplicant
MAY 17 200 DV. JrAv�D H irk
Prm t or Type Full Name and title
Signature of Property Owner/Applioaut
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Fill] Name and title
Please return two copies of the completed Application package to:
North Carolina DENR DWQ
Aquifer Protection Section-iJIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notifi lion of IrL= Farm (R wised 8/2008) Page 3

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