WI0400187_GEO THERMAL_20110526

Permit Number
Program Category
Ground Water
Permit Type
VV104001 aJ /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Mark & Debra Overby SFR
Location Address
5810 Willow Way Ct
Oak Ridge
Owner
Owner Name
Mark
Dates/Events
NC 27310
Overby
Orig Issue
05/26/11
App Received Draft Initiated
05/17/11
Re a ulated Activities
Heat Pump Injection
Outfall f'_,,_,. ........
Scheduled
Issuance
Central Files: APS_ SWP_
05/26/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville NC
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Mark Overby
5810 Willow Way Ct
Oak Ridge NC
Public Notice Issue
05/26/11
Effective
05/26/11
27020
27310
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
Beverly Eaves Perdue
Governor
Mark E. Overby
Debra A. Overby
5810 Willow Way Court
Oak Ridge, NC 27310
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
.Division of Water Quality
Coleen H. Sullins
Director
5/26/2011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400187
5810 Willow Way Court, Oak Ridge, NC 27310
Dear Mr. & Mrs. Overby:
Dee Freeman
Secretary
On 5/17/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl
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 onlypotable 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 .021l(u)(2).-Additionally, you should contact the Guilford 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.Ro2:ersrcv.ncd.enr. Qov if you have any questions.
cc: Winston-Salem Regiona1 Office -APS
APS Central Files -Permit No. Wl0400187
Guilford County Health Dept.
Energy Innovations (Harry Booty)
Yadkin Well Company (David Brown)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-163€
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Sincerely,
forD~~
Supervisor
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Sernice: 1-877-623-6748
internet: www.ncwaterauality.org
An Equal Opportuni\y \ Affirmative Action Employer
None, C 1. ortn aro 1na
JVatural~I/
May, 18, 2811 8:09AM
k 0221 P. 1
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INCLuaI>�!G THIS SKEET REPpr BY SI6NAi1JAE
MESSAGE,
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L"ADK",FOR A" Youpt WATM NEEOW
WELL CO., INC.
190e HAMprmNVILLE ROAD
HAMISTONVILLt NC 27M
AV;D J. BROWN. VICE PRES,
TOLL F!!EB (w) X"!9355
1�4OfFlC! [336) 4664ddC
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y la May. 1S. 2011 1 8:09AM 336-643-0806U. 0221 p. 2
NORTH CARCLIINA
DEPARTMENT OF BNVIRONbWNT An NATLIF.AL RESOURCES (NCDENR)
NfJ'it`MCATIW OF INTENT TO CONSTRUCT A Cl , 01907W t KAL
WATR401gly INMC ION WML SYSTR lr't:
TYPE S, w WEYILSI
In Accordance pith rhepror'iiskm of-NCA-C Talc 1.5A: 02C4200, please =-
convieie this notizcatim and mW to address oa the back page {please Prbt cr T ]�brtnaklwl).
Well 2ype Conj?rmaYivH: Does the proposal -system eirautate potable water one (no additives) its
comimous piping that completely Mlem the fluid frost the environment (Le.
closed -lam)?
Fes x— CortdnUe complesinthis fbm
No Do Not mrapletet#ns ImM. CnrTIdv other MC applioalion Pwma Fpr installing
either a 5A7 well (Me_rl-loop well iWeelin potablf symer into the aquifer) or a 5QM well (clasad-
Mop well containing adda=* suck as R-22, ethanol, or ether antifrom or corrosion inhibitors),
A. PROPTs TY OWNERMAPPLICA.NT(S)
List each Property 0%vue: listed on property deed [if owned by a business or govemutent agency, state rame of
entity and a representative wlattthority fvr sigaafmre): —.m! a e- k 5- 0 �A
Ij
(3) MaiLag Ate: . v - �� ��� ",r Lvk
City: Oa stata:rt C zip Gods: Q 2=j
Home OfUea Tole No.: ^ _.21 G - L- -�- '- r C2;zo rX>-U No.:
Email Address: h t eo Wq0,C:Z T
�Yebaite•
C2) PhysicalAddress ofWell Site (if ditkre:nt thanabove):
Ctiy. . —._ _ Slate: Zip Code; Conoco;
Homerbf'firm T£ do No.: __ _ Ce.0 1"4a. ;:
R. *'UTHORIZED AAORNT OF OWNER, IF ANY (if the Peauit Applicant d Per � own the svEjwz property,
attach a letter from th,e property ow= a1mlb0C&ing Agent to i nstail and operate UIC weft)
Company Flame: _ _
Contae Person: IrMATL Address;
Address:
Cry: State: zip Code~ Catmty:
OfTce TeIc No.= o.:
Wehsite Address of Gmnpaay, if Lay:

May 18May, 18, 2011 8:09AM
336-SQ-0806No.0221 P, T
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WaU Drilier CaPftotot''s NRn3t: M 2s tv n ..Mj1fonCkyq
NC Cordmctor Cerdfiaeii.miX*a 25T2_A 3 3-6�_ ,- 3s4s-A . _
Cal Ittof Fessa • msn cam
Add 1908Htunpxmv1l1C Rd.
City, Ramoftyl1le W.Q Tag Code: 27020 = Yadkin
Offtce TeleRoz 336-468-4440 Call Noy: —J36-374-
JD. VrAT PUMP
Coamct
�=�" X
Omoo Two No.;
L STATUS OF APPLT —4M
Zip Cod
thnn
Countr
t eliNas,� - CPFZ =
mmtm ►/ Ft&ml: Co=asrlal:
slater b1midpal: Native Americet Lands:
F. JY(JBCTfON YAOCRtl = (hrlelly duerlba how tbei*ct1ou%vQ(e) YAF1 he used) I
G. VVSLL GON6fRIJC1IOX ]DATA
(1) Pjroposed date to be a* st meted: _lUft L 1► umW of bmiaSk
Approximate depth of each barieg ffnetj �r__.
(2) Ty_m of tubing to be mad (topper,,
(3) WO mOng. Is the %vOXs) case& (aheak alihcr (s.) Yss or (tc) No balaw)
(a) fires ify es, then piovldt casing itd'armatiaa below
Type. ---afvaa'szed steal Meek gtcwi pJast2c�anc�r (spec*)
using &p& From to feet (reAam* to laudaasface)
Cmsb)g mama& to above, groWid mGhes
(b) we L ,
(4j GtnutInfc (saaterial �utromadlrrg tiveFf cash:gaQd%r 1��'�i= %�,..,..�.�/'�. �n�.c s.�
(P) Croat lype: NestCement Bmtoaile V Oiha: (sp$")
(b) Grap1 plmcamcr* Pumpigs —IL/ Pressure Otter
(a) Groat depth ofabieg (refersttce to laud mv+480e)! Groin ' 10 -- -- (hot)
Uwalf has asing, indlrategroutftth,. From to (fbat)
t7T)S) {,

May 18 May. 18. 2011 r 8: HAM 33s-6a3-0806NIo, 0221 P. 4
W INJEC nONZM ATW XQUIPMwT
Amch a dWpmshavriar, the engineering Iayavt or praposed modification of the injtation equipment arW odw1w
pipinWtubiag associated wtdt the injw ou operation. The manuOLotuxsr's brochure may pmvide supplemesnttuy
irAmation.
Y. LOCATfON OF VVELL(5)
Atkwb two copies of maps shPF-vnag*e following infw=Eow
(1) Include a Site Map (cau be drawn) showing: buildings, Iroicxly surtho water bodies; powantiai
sources of gxanndwzWr ocrxtwW=tian and the orlertation of mnd distauces betxntenthe proposed waia(s) and
any eadsang twdi(s) ar wLsie disposal facxJrt' ►es swh as septic mmlm or drain -bolds located within 200 feet of
the geotbarrual liter pump weia syxtwn. Label all feaW es clearly aid in l!* a narthI
(2) The Site Map moot slaw ,the subject property in relation to the surro=&nS area by -Ucwg at law two fixed
refute pohds such as roads, stream, and/or bl&vay inteme+cdoes.
Note% This Nrmit Appfiastiow Host be sited by each person nppex ring on the
reearded legal property deed.
'i he7nby comity, under peualry of Iaw, that I have persotrmaily examined and am fi,rOar with The information
snb=Wtd in dds do==nt and at attack,ments tamtto and lksd, bawd on my latuiry of tisase indiv ob
itamedbWy rtspoixsible for abtaWog said Information, T Wien that the infbrAntlon is trua, accurate and cornOetc.
I am aware that these are skpn jlcant POU&MC4 indufts the puoubily of Eves and imprWoa ent, for submitting
&Ise iafornation. x a&= to coastmr,t operate, mainta4 zepair, and ieappticabie, Mond= the trajection well and
aii reWed appurtemnres in *Dec' cos. �4"Odeondaftjaawz W IPerw e
igna, fFropertyOwraerlApplka�t
Prink or Type Full Va= cad turtle �
Si w"M o"ropertyt3wm Agpii
Phut or Type Full Name and SUO
ftsattrre ofAUdLodkod Agent i£auy —
PrW ar Type rutl Name and title
Plcase MUM two ccpics ofthe completed ApphoatUn pwJmp to,,
North Csreliwt Des DWQ
Aquifer Protection Section-U.W ftograxn
1636 Mail Service Center
>R.akkb, NC 27699"I636
Telephone [phone]

May. 18, 2011 8; 14AM
No.0221 F. 5
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