WI0400191_GEO THERMAL_20110620

Permit Number
Program Category
Ground Water
Permit Type
WI0400191 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Martha Rice SFR
Location Address
Lot 16 Foxtrot
Boone
Owner
Owner Name
Martha
D ates/Eve ms
NC 28607
Rice
Scheduled
Orig Issue
06/20/11
App Received Draft Initiated Issuance
06/19/11
Re a ulated Activities
Heat Pump Injection
Outfall ",'.U!..:..
Central Files: APS_ SWP_
06/20/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonvflle
Hamptohville
Major/Minor
Minor
NC
Region
Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Martha Rice
2408 Hwy 105
Boone
Public Notice Issue
06/20/11
NC
Effective
06/20/11
27020
28607
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
Beverly Eaves Perdue
Governor
Martha Rice
2408 Hwy 105
Boone, NC 28607
NA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
6/20/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0400191
Lot 16 Foxtrot, Boone. NC 27607
Dear Ms. Rice:
Dee Freeman
Secretary
On 6/9/2011, 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 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 15A Section 2C Subchapter .021l(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 Micbael.Ro2:ers@ncdenr.2ov if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI04001.91
Watauga County Health Dept.
Yadkin Well Co (David Brown)
Mountaineer Heating & Cooling (Winston Petrey)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Sincerely,
forQr~A. Boov_
Supervisor
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 Customer Service: 1-877-623-6748
Internet: www.ncwaterauali .O ro
An Equal Opportunity\ Affim1ative Action Employe;
One . N orthCarohna
l\lfltuta/111
V
Jun, 9. 2011 3:14PM
No.4392 P. 1
JL'J1IiIJJ,
DATE: _.TIME: REF. NO. LOG NO.
Too 4,
COMPANY NAME FAX NO. PLEASE
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ATTENTION DEPE
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COMPANY NAME /] FAX Nm
Pl.E►1SE
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INDPADLIAL DOT
NUMSER OF mis PLEASE 0mag qR'S
INCW DING THIS SHEET REPLY BY SONATLIN
MESSAGE:
D
RE IV_..,rrnnu is011Q4
'FOR ALL YOUR WAMR NEEDS'
YADKIN WELL CO,. INC.
1999 HAMMOWILL£ ROAR
HAMPTONVILLE. NC 27020
DAYID Jr $ROWN, YICIE PRMS.
TOLL FREE COW) 2A9345
OFFICE 4336) A69-4640
FAX 433M 404-OQa8
RE5 t3wl 466-"S9
SOW MEWS AMERGA • 000 r.CM ~
P LIBM `INI'V" US IIYYMO[A W lFVW WNW R&:M &ZM= IN FULL

-ecjVrig 9. 2011 3,14PM No. 0392 iP. 21
J SF It, 1• cV Iv It JvIM I(WAL r IM 4)4U
NORT#i CAR01INA
DEPARTMENT OP ENVIRONNUNT AND NATURAL RESOURCES CNCDENR)
NOTMCATtaN OF WTENT TO CONSTRUCT.A MOMT p GI�4TS��th��
INJEC ON WnL SY3UW;
IS AOQUtaw+e WI& die pmvW= cf NCAC Tfde I5A. 02C.0200, please
oampute ibis Wti IM11M and mad to aftew ea ft bask pie (pkede l= (w IMM W=ixtm)-
DATE: C- q - . 26 /A \I_= 04 0 01al t
iioU Typo Conflr►rea,dox. Dow me proposed systou+ ctvaiada parable water on] (no aditVas) in
aonti=ous piping that complately isolates tho fluid from the anviro== (i,,�L
gjQed-jgqp 7
Yes x__ concinue complating this form.
No Dd Not complete thb Zarin. Complete other UIC application Emma for [n�
either a 5A7 we11( a -troop well ia12ajD potablo grater into tho aquifer) or a SQ24 well (closed -
loop well co=alaing ' 'ves such as R-22= ethanol, or other antj&om or corrosion inhibitors)_
A. PROPERTY OWNER(S)IARPLLICANT(S)
List cac Property OW= Amd 01 property deed (if owrod by a bugmss or a0vammm a$ra 0y, state =ffw of
antiry and a reprmeptKvs w/awhority for signature): N) 1,� L Rlcp
[l} Ma 109 Addms: 2'M � Iyw 4 I` s
City: 'sa a - ey 9mer - h e Zip Cedar .T I C+ - 7 CouMw'(41- re
Homo/4@ica Tale No.: f-7F; J",, ] C Cell No.:
Email Addtcse:
(2) PhysicalAddsm of Well Sits (if differentth. above): z �- f C r ��f •
City: a c a State• ,r , ? & G -- " Caumty:
Hom /office Tale No.: 1 Na.:
S. ,kUTRORIZED AGENT Cat OWNE Rt, = ANY' (Mbo F=mlt Applicam 4M avela rlac s►>b�e�[ psapexty,
aline a letter Frew the propaM owner anti adxW9 Agont to iaftu and 0ftm UIC wcif}
CowApW Name
Contact Perso vM A rr. AxAftss'
Address: .�--
City: State• • 74p Code: Catsad�:
QT Bce Tele
Wcbsite Address of Company, if any:
Z80°1 I p j t L olz-4 P I N
91-0!L _2elo 16:35 PACES

06-e~Jun. 9. 2011 3:14PM RECEIVED / DENR / DWQ
AQUIFF=R·PRnTFr.TION SECTtON
NO. 0 3 9 2 Ip. 3=
,'dll , "J, 1.\J IV It; :,vrm Tl'Wl\11~ t•C.L.L l'HI, 'tJ.!0 r. 0
JUN 9 9 ·2011
c~ WELLJ>RILLERINFORMA.l'ION
Company Namt:Yadl;itt Well Cd , In c.
Well Drillcsr Coo.ncto.r's Na:m.e: ...,Jod_,._y,AI.Mlll,ll;lu1a;;,,:1is=--_....,M.a.il~ttbl,;l,l;•.,.w-=Jk.a.::8.;..:.:wn;.::....._......a-1Mla,;,alt,;,;;.oc.n ,;::Ca~y,~e-
NC Contractor Certific.tion No.: 2s12_-.;...A'---______ _3e.z:om.361S-.. -'-A""'---_. _ _....3~Sii.:.8_, '-■1A ........ ____ _
Confltct Person: .I21;rid. l, BtO.WJl ~tqr"-A Blvf.A;lI, Aciskeu.: c'hiefdtilw:@m111,com
Addross: 1908 Hamptonville Rd., ______________________ _
City; Hammopyille H,C, Zip Code: 27020____ County: Yadkin _____ _
Offiec Tele No.: _336-468-4440~-~---Cell No..: _336..374.-81,6_~------
D. :a:EA l :PUMP CONTIUCTOlt. nG'ODIA IION (if differnt tllan driDer)
Company Name: /fol/ !>h c,,, 'el-/h-a.l:b_J d-6· o / i hJ
Contact Perso n;,,,~) /,..J +DA. /Je..Jv~ Y ... SMAIL Addres s:
Address: -:f-6 & 1 I qoS"
C\ty= & ~A£ ;l Zip Code: 2,Bt;o, Co~~ _9lJ_~ ..... -..,..V1: ......... -J~,-....::U)=..-------
Offiee Tele No,: 5"f_~ .. 26fl,. ((2_.s" CellNo.~-~~~----
E. STATUS OF APPLICANT
P?i'Ys.te: L
St.ate;
}1adaral:_
Mwncipal:_
Comm.cre~l: _
Natl-v~ Atl\erlcpn.Lands: _
JNJECTION P.ROCEDU.U.: (briefly deocrlbe how the ~ecdon wall(s) will be used)
:-i e::cu I ":!:... w o ±e ,,.. fu v.,.. o/ & a, d II l--ed / a 21:, g :e,, /&vi,,,.,..A
;,1. ys:+e,...._ . • I
WELL CONSTllUCTIONDATA
(l)h0p0sedda.'tctobeG~ctod:S!t(y -k1 l1 .,.. 1:'1'umberofborillp: _2._· __ _
Approximate depth of .aob boring (feet):. __ ..... _·· ....:....'f_o ___ _
,~) Type o!tubi.ns to be used (coppei:~ PVC, etc): I ~ '/.:1
' raR-..i I ( ti!J f£
(3) Well casmg. Is tbe well(s) oaMd? (chedt oi'tMI' {a.) Yes m: (b.) No below)
(a) Yas __ if yes, 'then prtwide casbl& Sn!ormalion below
Type: ,,_galvm=ed ;ta-1 _black steel__plastic_oth..\" (spedfy)
Ca.em& depth~ From ___ to -~f•°' (rof'~r.m:e ta land s\rilee)
C•in& exteuds to ,i,ova ground ______ inches
(b) No _)(' __
(4) Oroutln8) (Qll.1mial sumnmding well casin,s aud/or pipiDS): ~~ti'/ ~Q.,,u,,J.
(a) Grou:t type: Neat Cement_ Bmto~ ~ Other (speeif:Y) _____ _
(b) Groutplacem=t: ~ Pre:ssute __ . Other_
(c) Grout deptb of't\lbing (~e~ t(, land surface)~ fro:m ~ ro 1
to s. ,. (feet)
If well has casing~ .indicate grout depth~ fi:'om ___ 'CO ____ (feet)
01-05-2010 16:35
es-wJun, 9, 2011 3:15PM
van. 7. 1VIV 'i:3Vtrn YAVNIA nr.L_
No, 0392 'P. 4�
lays �r;J .. i
a Iiti.TEC' ON RELATED EQU2MENT
At %Oh a diagx= &hQW1X)1 tha eq[!Mw ng layout or proposed modification of the bW Ocd= equi?zap and exterkar.
pipingltu'biag associated, With the injection operation. The mannfacMpr's WChWo mey pro►ldm supplementary
infor=d=
I_ LOCATION of .li•(;,)
Aztc�] rwo copiev ofmaps ShMiDg dsa fal1uWio8 kdbMabon:
(1) Include a Site Map (ican be drawn) sh&wiag: bulldinga, propany 14nal, sarfam waver bodies; pozomw
sources of grouadw= contLminivion and t'ho orientation of and dtVMzcaa berwean the proposed well($) and
uy existing well(s) or waste disposal Uc ities suet as aagio tanks to drab telds located within 200 foes of
the gsothe mad heat pump well systa n. LAW dA f t = cleuly and hw1als a nvrtb-azxrn�.
(a) Tim Site Map =tot ab.ow the subject prapmV in rekdon m tha ftrr=ding area by using at lest two yeti
isfetauca points such as rozds, streams, and/or highway iutrrsectiow,
CEXTMCATION
Noce., TW Permit Appl$-.2tion must he ifiga6d, by tub pe rsoa appearnag on the
rccurdad lbgxi,,psvpexty dvttL
'`I brrnby cextify, =der penalty of law, tha2 x Lave patwmn y axam:=d and am lax AUar with the informmorn
311hmitted M thu doctMxaAt mad alI at is thereto and that, based oz my inquiry of those individuals
immediately raspowlbla for obta� said infarmatio% I believe that the b*rmation is mue, arcuate and complete
I am aware that there are s4pificaat printers, includlAg the pos.,&Wty of data$ and imprisonment, fax submitting
taae informxd= 12SM to =S'Wft, operata, mokmin, rep Jz, aud if applioable, Rbandou the iWectioa wall aLad
ail related appurtenances it e.ccordance with the approved spocificadams and conditions ofthe Fit'
rC .
SignatMe of praperry OwIrlARPIicant
RECEWD 1 DENR 0 Q ,
A4t11FPRpRnTFrrtnN Si=(:IION Print or'SYP-- rQ NL= an$ title
Sjpnaa ofPrepwr) Oww/Appbcam
prink ar Type Full Nark and title
S4nz= of Authorized AgeZt, if any
rrcnt or Type Pau Nazar •and title
Please ra= two eopiu of the wmglet7ed kpplirarion pa*aga 0:
North Carolina DENR DWQ
Aquffer Protection 3eevtion-UIC Program
1636 Mail S"ce Canter
Raleigh, NC 27699-1636
T'clephone [phone]
ra. ,ate ^+n. n r - -•r R;GE !

Jun, 9, 2011 3: j5PN!
No.0392 P. 5
pa,r-fL JZ6
RECEIVED 1 DEAR i OWq
AWFF:R'aPyTFrrtnnr sFcTION
JUN 0 9 2011
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