WI0400188_GEO THERMAL_20110526

Pe.rmit Number
Program Category
Ground Water
Permit Type
WI0400188 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers ·
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Richard & Cathy Guidetti SFR
Location Address
800 Merry Acres Ct
Winston Salem
Owner
Owner-Name
Richard
Dates/Events
NC 27106
Guidetti
Orig Issue
05/26/11
App Received Draft Initiated
05/18/11
Regulated Activities
Heat Pump Injection
Outfall
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
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Richard Guidetti
800 Merry Acres Ct
Winston Salem NC
Public Notice Issue
05/26/11
Effective
05/26/11
27020
27106
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
•~A ·a;,~~
NCD~EN~R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Richard Guidetti
Cathy Guidetti
800 Me1Ty Acres Court
Winston-Salem, NC 27106
Coleen H. Sullins
Director
5/26/2011
Subject: Acknowledgement oflntent to Construct Type SQW Injection Well System
PennitNo. WI0400188
800 Merry Acres Court, Winston-Salem. NC 27106
Dear Mr. & Mrs. Guidetti:
Dee Freeman
Secretary
On 3/18/2011, 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 pennit 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 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 .021 l(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 [phone] or Michael.Rm!ers@.ncdenr. !!OV if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400188
Guilford County Health Dept.
Yadkin Well Co (David Brown)
Energy Im10vations (Harry Boody)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Sincerely,
rv. ,-...La_ ti ,A""""" .
forD~ •~
Supervisor
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportuniiy \ Affirmative Actior, Employer
One NorthCarolma
,Natural!!/
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May. 18. 2011 2:46PM
RMLE TAANSMNN FORM
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DATE; � �� t 11ME; _ _ REF NO.
FROM:
LAG NO.
COMPANY NAME fAX N0. PLEASE
O^ Li �Fl�EgRKM
ATTENTION wt
COMP/A�NNY��NAME FAX 40. PLEASE M RUSH
INDIVIDUAL Din
NUMBER OF PAGES PLEASE ORIGlTi ms
INCLUDING THIS SHEET >i>� BY S AMFIE
MESSAGE; �j I /7 ,��
s- Ow IL8 +sca 1�13� r �* ! `.-t GAR r f ir�lld a +r T7r -
'FOR ALL VQQR WATER NZ905'
YADKIN WELL CO., INC.
19" 14AMPTONVILLE RQAQ
HAMPTONVILLL NC 27020
nAVID J. BROWN, VICI£ PR9S.
TOLL FR$S (4*m j4"=$
QFfIG6 (a3S) 468.4 .0
PAX 4SSI S
RIES [phone]
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PLEAJX NFOW U81WME=&YIFl7J GON7T PROVE R C0MLE IN FULL

SON May. 18, 2011 2 , 46 FM
0M KLLnhtw WVILeI I
FAX NO. t 336-579-88% May, 17Z cLvl x 1 i : +arc H m P1
A.
NORTH CAMWA
DEPARTIWT OF BOMONMSNTAND NATURAL RESOURCES (NCD]37;R)
NOTMCATION OF INTENT To CONSTRUCT -i QO&E-D-LOOR GEOTHERMAL
WATEW-O M INJECTION WELL SYSTEM:
TYPE 5-Qw MELDS
In Aoaafd=c a tiTi'ffi the proTidow ofNCAC T►iie 15A: 03CVDCq please
CoMplete this atolifseatlon asld nsail to address og the ba& pap (please Zdgwl= iufm madca).
Well rygc Cwf mcl3an: ,Dap the propvW sym m ciroulato potable mW a (no additivm) in
*=ftuous gjpj lg tht comylat4 Isolelas the Wid from tlia environment (Le.
closed-laap)P
Yea XCarrUnue oompleffiv Ujs form -
No Da �Iox ros�p3etc tFus fortur Cotinpleta otiter'�C appJyoatiaa. forms for fc�stalling
Dither a 5,0 wdl (Man -loop wo!! iz LMEug potable crater it [ the aquifcr) or a 5QM wc;l (closed -
loop wee eontaiftrag addlitiv suohae R.22, uthauoS 0.0 othcr ateew or comsion iLtibftors}
PROPERTY OVM(S)IAPPLICANT(S)
List each property Ovmar listed on prOPtAY dced Of owurd by a bass or gnvoTument
wity and a representative w/imc rorityfor signature}:
(2)
('-x Acczs- c�
a
■
r
C
y
Maiiitlg Addrpm: 40 '!% rc��� _ "-r-7"
city: &e4=uff9 ezP Cam A 7r6'G cn�snty:
Homm/OISCCTeloNo.:.33,= 2,2.? -, QUX2-! 3 2 4- -J1P-1 fs
Email Address: � f` � Ve sQt�`?' 3 3 G - I� 7a 3 - t',a f/ y
Physicil Address of Well Sate (if &&$dent than above): �'ft•L�
C4gr: Sire: _Zip Coda: County;
kf om woffice Tele No. o '
D. AUTROAMD AGENT OF OWNER, IF ANY (sfft PermhApgXi+t=4= 0 own dwsubj� property,
attarb a letter from the ptopwW owner assthaixiag Agertt to W" aid opm to VAC well)
Company Name:
Cotlwct Perso Ali. Addrm-
Address:
City:
_ State; Tap Code.
affice Tale No.:
Wobsite Address OfCorapany, ffany:
Comty:._ _..

Nay.1$. 2011 2:46PM
No, 0236 P. 3
C. WELL DRU. ER PM1t?"nOx
Company Nance:
Wall Driller ContMelor's NaM& ❑ sz .�.i"i___�._._ . - •..a
xc Contractor CortiCat NB,:� 4 s.d _ _ `�'� -+ p+
— JWILAddma-. 3-9—
_ a
Address:. cam$' ,tit U. i � � - -
City; _ { _Zdp Code; .-AV C Z 7e2c Cottr►ty : '
4fl3ccTeleNv.: Na.._ YX-
D. IMAT PUMT CONTRACTOR MCMM TION (if different fhAn driller)]4
Company Name:
Loniact Fe on �riQia-
Addrass;
City: J-e we r /-,A, +L Sip Coda: 2 7-z county:
Office TelerNo.: Cc#IN o.: 776- G ? 9 - 2k q 2-
E. STATUS OF AP PUCAi+ T
private: V Federal: _ Commercial:
slalar Municipal. NadvmAmcrken- ands:
F. INJECTION pROCEDIM (brlaflydaseribe 11ow the hiltctlan woll(s) will be used)
C, WELL CONSTRUCTION AATA
(1) Proposed daft to be constructed, 7 ('I Nusubet of busiYV;
Approxi=to dcpth of tech baring (fan(}:_ 14 G "
(2) 'ijTe ofrpliiag to lee vs '(coppCr,.PVC, eto); 1 6' -5'09- t( I4 () P C
(3) Wall easing; isIha wells) COW? (check either (e.) Yes or (h) No blow)
(a) Yea if yes, theta prWide casing irdcusuatiatt below
Type: ­galvanIzed steel black steel �Isiast3a ot5er(speal�}
Casing depth; From to feet (ralemnee to landmnfiLca)
Casing oxtends to above ground i=hes
(b) No V
(4) Grout In# (tnatsrlal surrounding Krell casing and/or pipir;g3: , 8
6) Grovt aypw 'Matt Cc=nt Senlovite f 01her (s!
0) Grout placeineat: PPamping-L/L Fame Olher
(o) Grout:dapth aftabing (mfbrenw:to load m rCaca): fmm ta(feet)
If well bag Gn -Ing, indicate groa4pth; from to (lbefl

FROM . May, i 1 820 11 I � r 0 4 P ii� F'W{ NO. -- 335-579-6e% May. 'L o' 0236 ' 11 � r�r���{"R f 2
11. W=TYON =- A TED EQVI ME,NT
Atmcb a dlagrarn sh&wEng the eAgl layout or proposed modMceoxs of tho injection equipment aw exterior
piping/tubing associated with tlts itae4on opeaatior+, The =nufLdxuVrsa brochstre may prWAdc supplementary
wwmatiom.
'L LOCATrON OF WLLL(S)
Attach twvo copies of maps showvmg the fotloyving informatiaa
(1) Inoludo a Site Map (can be dra%r* showing: WIdings, property linos, sw*ce water bodges; potential
sources of grouadwvasec corAminatim and the of 6ntatim of and distances betiyeen the proposed wvell(s) and
way wdsting weiI(s) or waste disposal fbdBties suck as septic tanks or drain folds lasted within 200 feet of
the geothermal heatp=p well system. Label all &atures clearly and include a nq th artnwy.
(2) The She M$p must show tho subjeW prdpwo in ralation to tho Surrounding area by using at lost ttvo fted
rye weace points suds as roads, sUvamt, sndlor highway intersections.
a: CFATMCATION
Note; Taxis Permit ApplitWlioa must he sigued by & eh person appearing on. the
retarded legal property dead.
"I hereby ccrdfy, under peradty of may, that x havo pasonally cvmi=d and am familiar with ilia inibmailon
submitted iu this domn=t and an attaclmxnts ihmeto and that, based on my Inquiry of those individuals
immediax mxpondibk for ob4daing said irAbr=dAx , I beHeoe Olaf the Information is true, accurate and oomplets,
I am awars that there are ssi&AYmaut penal[im kclud4 the possFbMl y of fim and impdsonmcnt, far suimzi#9q
fAlso Wo,rmatiou. I agree to comtrvice oper0% xoszntaK xcpak a*& if alspilcable, abandon the injection %yell and
all related appsrrtmances In accvrdaace with** approved epee catraas and canditioos o£ths Permit;'
Signature aMopeaty OwvnerlApplicent
Print or Type ijlttl Maw andtide
1:8� 4f � aedA�lioemt
[. # I 4
Print or Tgpe lull l+k= sad title - -
Sop lum of Aniharixed Ago ; if urw
Print or Type Full Naive and title
Please setm, two copies of the c;=plated Appllcatlon package to:
Nurtb Carolina DDNR AWQ
AqulforProtectloo Seetfab-MC Program
1636 Mail Service Center
Raleigh, NC 27699 1636
Telephone [phone]

May.18, 2011 2:46PM
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