WI0400192_GEO THERMAL_20110620

Permit Number WI0400192 /
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System {5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Eddie Alejandro SFR
Location Address
145 Eastridge Acres
Boone
Owner
Owner Name
Eddie
Dat es/Eve nts
NC 28607
Alejandro
Scheduled
Orig Issue
06/20/11
App Received Draft Initiated Issuance
06/14/11
ReCJ ulated Activities
Heat Pump Injection
Private residence , single family
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 Hamptonville
Hamptonville
Major/Minor
Minor
NC
Region
Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Eddie Alejandro
Owner
145 Eastridge Acres
Boone
Public Notice Issue
06/20/11
NC
Effective
06/20/11
27020
28607
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Eddie Alejandro
Dona Alejandro
145 Eastridge Acres
Boone, NC 28607
Coleen H. Sullins
Director
06/20/2011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400192
145 Eastridge Acres
Boone, NC 28607
Dear Mr. Alejandro:
Dee Freeman
Secretary
On 06/14/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-only
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 15A Section 2C Subchapter .0213, and
3. The required notification form and a~sociated 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 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.Rogersra:mcdenr.QOV if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400192 .
Watauga County Health Dept.
::;;Y· . M(i~
forDeb~ ~
Supervi:~~
David J. Brown (Yadkin Well Co., Inc., 1908 Hamptonville Rd., Hamptonville, NC 27020)
Winston Petrey (Mountaineer Heating & Cooling, P.O. Box 1905, Boone, NC 28607)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Rale igh, North Carolina 27699-1636
Location : 2728 Capital Boulevard , Raleigh. North Carolina 27604
Phone : [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customor Service: 1-877-623-6748
Internet www.ncwaterquality.org
An Equal Opportunity\ Affirmative Action Employer
None~ r 1· oru,~aro .ma
,Natural/£!
Jun.14, 2011 12:39PM
FACONULE TRANSMISSION FORM
No.0445 P. 1
DATE: _ 6 11 / '� 11 ZLTIME:
EF NO.
LOG NO.
To: 1Lfe-
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(91�)
71, 6'0 �49
COMPANY NAME
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PLEASE
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FROM: �la I k«_
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FAX NO.
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ORIGINATU»'S
INCLUDING THIS SHEET
_ REPLY BY
SIOWURE
MESSAGE: ' _
4-c]_�''
"FOR ALL, YOUR WATER NEE05-
YADKIN WELL CO., INC.
1990 HAMFTQNVll LP_ ROAD
HAMPTONVILLE. NC 27020
DAVLD J BROWN, VSCE PRES.
TOLL FREE f4W) 2AS-9255
OKFIC£ (3361 AGBA4"O
FAX 0361 4GO404-0
RES 13361 46D-4559
-00CLS MEWS AMERIC■ • G07 ►AVES TC4r
RECEIVED f DENR I L]VYU
4 2I` 3 SECTION
sure 14 2011
PlEP1SE IHFQRkI US IARMEQU4fEiY 1ON DO WT ASD VEFACaULE FN FULL

Ou"66-L,Jun, 14, 2011 12:39PM No. 0445 MP, 21
• +su,} J. [Ve1V 'Y•JV+m TIALM!" VELL IYiI. `ia10 P.
NORTHCAl�f];:,Il�TA WEDC/009;k
_
A131'A TMWT al: MIMONMENT AND NATURAL RESOURCES (NCDMI
NOTMCATION 03' VENT TO CONSTPtu r A CL GEOTHERMAL
WATER -ON LY INYEMON WELIL Sit'S :
In AoDord=m -wish du- pmvislaw &NCAC Tide ISA: 02C,0200. pleam
Complete this notMcatim and MMI to addreas an dm bads pW (phut Epg exr lype udD=zdaa)_
Well Type Cor)Rrmq#i.an: Does the proposed syxt= cir=lge pe uUz waur uW)v (no ad4xiives) in
ccmtimous piping that corllpletely isolatm the fliAd from 03e au*o=ent (i.e.
cIgied- 00n)?
Yeta CorWnue oozpletiuug this foam.
No I)d Nqt ramplete WA farm. CaUple to other UIC application forms for iW�
either a 5AT well (open -Iota well fly poMble Water iota the aquifer) or a 5QM well (oltAed•
loop well containing additives such a$ P,-22, a ol, or other av ,*eeu or corrosion inMbiiars).
A, PROPERTY OWi► R(S)lAP?UCANTM
List =Q Propwty owner listed on papa ty doed (if owuod by a bwiw= or govammaw W acy, claw name of
andzy and a represe Ufma wlauthority for signaUa): A(Z ► 4g A.f�pt . ---3o AJ4 /4, 0-4b a
(1] Meiling Address: dr
Home!Offca Tele No.:
Email Address' We k sits: _- —
(2) physical Mdtass of'Well Skt (if different th-34above):
City: Stara Zip Coda: County: -.
HOMS)Offiae Talc ]PTO.: gell 110,!
]3. AUTEORIZED AGENT OF OWNER, IF ANY (iftba Permit ApptlrSt IM owathe subjacc pN>P",
anarh it latter from the proper'>3w owner atnhadzrgg AS=t to inftli and Opera UIC wally
Company Dame:
Coat wt Perso,:.' EMA , Add-Lesa'
Adds: - —
City: State: Zap Code: cQua y:
Office I`olo No.: ' ' Ce -
Website.Address OfCoMpany, if MY.
01 05 -2010 16 ::x; RECEIVEi] 1 MNR I QwU
AC]LF R PPnTFrT" Si`rTo
JUN 14 2011

06-i-J u A. 14. 2011 12 : 39 PM
1dfl. 10IU 4.)Vrivi tMVh111 RLLL
No.0445 P, 32
rqu. YaLD f. U
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4
WELL nXIC LBR MORMATION
Cvmp3ny Name.
Well DrMar C wraaorrs Nam: I& Myllis arowa Nlilwa Cave
NC Comtractor core &Atxon No.: 2572-A 3036 .R 35ag - E1 __--
Contac-x Ferson: DavidJ. Brown 1145 A � . --- 'ef msn�raru
AddSr=- 1908 Hamg:onvllle Rd. - -- _
City: a r Y Le I.C. _ Zip Cods: 27020 Co=ty: YadkiuL_.
Office Tale No.- �336-468+"40 Ce31 Nn..—336-374-ms -
NEAT M MOP
INFQRMA MN (if dMarent tb*s drMtr)
Campany Name: ei
C4Gt Pe;Saa-1R_1 1 Tt •/ �� r� �c e L• '~MA1T r1 ■ tcti ,
Address_ o 6o Ql-
City. �n ^q- Zip Cade.. i 06 6 7 Covutr.
OfoaTetoNo,; ?Z$ 2-6fC-V-4- CenNo.:l929''
E, STATC 6 OF A PPLICAt► T
Prima*.a: Fedata -. Cam azcSal:
State: M=i iPA1-- %Native American Lands;
lr. INJECTION PROCEDUAE (briefly daScribe how tha injection waU(s) vlrM be us CA)
G. WLLL CONSTRUCTION DATA I
(1 } I'r�rpa.Scd date to he cotzstrucDtd: man � t4 - � { � lN�ataber of i�o><in&8: 2
Approxiw= depth, of each boring (fw*t -3
(2) Type oftabing to be a0d (copper. PVC, eto). -1/1 H
C3) Well casius. Is the wel4s) erred? (check anther (a-) Yes 41(b) No below)
(a) Yen i£yes, tlwcm provide miAs informadoa below
Type:--plyanized Steel black sT�olipla c btlier (spocify)
Casing depth: PTvm to fret (rvfcrmrm to laud sw&ce}
Casing ex ands to 60w gtomd ohrS
(b) No _ 4
(a) (3, a= TJ* (material =M=ding -Weil casiag and/or pipl J: P �'� �n�y •, cc
(a) Omut type: Neat Cement Hc=,ujty �% 7wCther (special
(b) Grout plaeameat-. P=pm& ✓• Praaaurc Other-
(o) C3ma dep:h of tmb ft (rafors=' to Isaad swf m*): from �K f�a to -3 � (w)
if wail hu cutag, indicate grout dcptb: froze to
e1-0LS •• P010 16: 35 PPGZ6

06-1-J u n, 14. 2411 12: 39PM
. van. r. LOU-r.}ursrt tnuhil atLL
No. 0445 IP. 43
IVU. Y3La f . 1
TL INJ ECTION-12LATED f1QtTn91 XNT
AttAch a dim showing tip anximprims Iuyoat yr proposed modffimdon of'the iajact3on a i:Apmrm and cxmrior
pipingltubiDg also sated v tla. the 'hljsc don, oparafies, The uaslaufactu pe$ brochwe may provide supplementary
inform don
I. LOCATION OF U7.1 )
A13=h "M Cgdt5 Of XMpa sbVWJAg the fOU W=C A DfW=,xdvm
(I) ins:lode a Site Map (era be drawp) showing: buildings, prop" tics, swfkm wax bodirs, poumW
sources of ground►vator comh=dnzdoa and tbp- odeuta4ol of 2ad dLmaces bazween the pmposed wows) Arid
say a dnb4 WeWs3 or wage disposel facjUties such as septie mWa or d;an iiieids located within 200 feet of
the geod==23 hem pump Wall system Labe[ aft features clearly and include a north ate,
(2) The Sift Map =wt sSbow tbo *ubjaot properly is rdation to to swrouaditg area 1;Y wing at lean rwo fixed
referwloe poiab such as ruads, streams, audla highway interse dons.
J. CWTUMATIOX
Dote: TV* Parry t Applks0ow must be *4 by t4 penoa appearing on the
recordad logaLpmparty deed,.
"I busby C tit, under penalty of law, that I b ive pmozally =a�- wivad Lad = famitias vM the fixtirsrasi U=
submitted !a this doa==% en.d 4 aft4mu ms thurw and tba% based on my imgv y of tho,:se individuate
immediately responsible for obtaiWng said b*rwariatt. I b6avp that the iaioraaation is tea, accruate and coarplete.
I am awarc that dma arc sigaifloant p=aldes, includog 2c poaAfty of $teas and imprisotZ ft; for x ftildag
Was hdbmx2i= i sgroo to co=trvA opume, main rep k, and if 4pllcsb* abandon trip injection well aud
aU xclud appxtnances in aerordaacc with
fthe appnovad spuificld= =d7"91
ofts Pmult."
� A1w._ -41 n 0 1 . I— ,n."oA
ig== of"rQpstey 0\6W/Applicsnt
�o AL a AL f.,j kN PL-t2 _
t or -Type t4N = and tide
x
%pat e I
f hopaV 0w=1App1i0ttnt
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Print or Type Fa NA= oust Utk
Signmro of Authorized Agent, If av
Priam or Type Fall Natter and lit] e
Please reitun two copies of the compleiad AppUB404 packaga tti:
Noah Cardin DZNR DWQ
As;Wbr Promotion Season -MC Program
1636 Mail Service Center
Raleiih, NC 27690-1636
Tele bona 919 715-69
F j 5FCTn4N
JUN 14 2011
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Wi-�.'7-�'� F IU lC=»

Jun.14, 2011 12:39PM
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No, 0445 P. 5
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