WI0400193_GEO THERMAL_20110620

Permit Number
Program Category
Ground Water
Permit Type
WI0400193 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Perm itted Flow
Facilit
Facility Name
Double M Ranch
Location Address
1585 Jones Ranch Rd
West Jefferson
Owner
Owner Name
Double M Ranch LLC
Dates/Events
NC 28694
Orig Issue
06/20/11
App Received Draft Initiated
06/15/11
Re a ulated Activities
Heat Pump Injection
Outfall ~.IUI.~
Scheduled
Issuance
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
Dewey Wright
PO Box 308
Boone
Major/Minor
Minor
NC
Region
Winston-Salem
County
Ashe
Facility Contact Affiliation
Owner Type
Unknown
Owner Affiliation
Mike Jones
65 Leucadendra
Coral Gables
Public Notice Issue
06/20/11
FL
Effective
06/20/11
28607
33156
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
Beverly Eaves Perdue
Governor
Double M Ranch LLC
Mike Jones
Laura Jones
65 Leucadendra
Coral Gables, FL 33156
&,rA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
6/20/2011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400193
1585 Jones Ranch Road, West Jefferson, NC 28694
Dear Mr. & Mrs. Jones:
Dee Freeman
Secretary
On 6/15/2011, 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 associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a vi_olation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Ashe County Health
Dep'artment as they may have additional requi~ements 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.Ro2erst@ncdenr.2ov if you have any questions.
Sincerely,
forD9~~
cc: Winston-Salem Regiona1 Office -APS
APS Central Files -Permit No. Wl0400193
Ashe County Hea1th Dept. .
Dewey Wright Well & Pump Company (Dewey Wright, Jr)
Evans Heating & Cooling, Inc (Mark Evans)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard , Raleigh , North Carolina 27604
Supervisor
Phone: 919 ~733-3221 \ FAX t 919-715-0588 ; FAX 2: 919-715-6048 \ Customer Service : 1-877-623-6748
Internet: www.ncwaterguality.org
An Equ ?.I Opportunii y \ Affirmativ e Action Employer
Nirth Carolina
JVaturallg
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE IN,]ECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Print or 7j,pe Information and Marl to the Address on the Last Page.
DATE: _R , 20 1 i PERMIT N0. Si3i OC A J 3 (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence Business/Organization _&_
Goverment: State Municipal County Federal
B. WELL OWNER - For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
Cn . kr
Mailing Address:
City: Q P_k C� _e �k State:`�-_7L Zip Code: _ i 5 ]�-
County:
Day Tele No.: � _ [iQS� - �O Cell No.: 7jQS- - A 4S 8 - aCi 4 D
EMAIL Address:_17 Fax No.: -_�?oV - (6IQF - 64 Y,-1
C. LOCATION OF WELL SITE - Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: a 3_t - y County: A%,
(2) Physical Address (if different than mailing address); ISMS _��-, ��-,c� 201
City: , -1 State: NC Zip Code: -q!r— - -
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: i34Mr
NC Well Drilling Contractor Certification No.: -(AV
Company h-k �o_11 Q ��t _ i��. r� p CQpe. n
Contact Person:- -J-, ENTAIL Address: _
Address: I!j5Lhie. %D5 3�h.. cj%s
City: �k e Zip Code: 2 SWC I State: tc County: �cc_Aa n c%
Office Tele No.: 1:� -ZAgr l Cell No.: Fax No.: 3Z2 —Up!1- (at Z-_
GPl11UIC 5QW Notification (Revised 3/18/201 l) JUN 15 2011 Page 3

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: bADl W.~ o.,""', oo Dr-<:i ) Cs,o\ ~ "~ i :I:~
Contact Person: N\o,c ~ £yo.. N EMAIL Address: fbo,-.\.:-~e van,. beo.tv~a.o:iCoOla...a..CP l . ~
Address: c;)c}..g '7 :X ,ch bl, l \ 1< d
City: CA\o..d~ \Jo..\\e.¼ ZipCode:2,2Ga2/1 State:J\/C. County: A.\ le'4loA~
Office Tele No.: :>~ct: 'v'74 .. ~ooo Cell No.: 33t0 -lS'7-~~ 21.. Fax No.: '33lo· '1S'2· )Pl9
F. WELL CONSTRUCTION DATA
(1) Number ofborings to be constructed*: 9 Depth of each boring (feet):_-_,.~-=:;_c.,-=--.....D--------
* If existing water supply wells will be used then provide the information in item ( 4) below.
(2) Type of tubing to be used (steel, PVC, etc):t?a\~~, .. w.':e n:c *u;;'°~ ~\dtii p ,pj ("\<\ ~t)R-C\
(3) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground: N / 4 _._.'-#-, _____.. ______________ _
(4) Grout (material surrounding well casing and/or piping):
(a) Grouttype: Cement__ Bentonite•• L Other(specify) _______ _
•• By selecting bentonite grout, a variance is hereby requested to ISA NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from D to 300 (feet)
If well has casing, indicate grout depth: from N/li to ____ (feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
• Proposed injection wells * Buildings * Property boundaries
• Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
GPU/UIC 5QW Notification (Revised 3/18/2011)
RECEIVED/ DENR / DWQ
AQUIFJ:R·PROTFr.TION SECTION
JUN 16 2011
Page2
06209/2011 15; 12 FAX [phone] BARTER NORRI,S CONSTRUCTN ,ZOQ;
H. CERTMCATiON (to be signed as required below or by that person's authorized agent)
I SA NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer,
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively,
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking Nblicly elected official;
R, for ail others: by the well owner (which means all persons listed on the womrldecd).
if an auttlsorized agetat is signing on itehali of the appUa mt, then supply a letter signed by the
applicant that names and artbor7lses their agent to sign tkis nppliiatation on their behalf.
"I hereby certify, under penalty of law, that t have personally examir+ed and am familiar with the information
submitted in this document and all attachments ther+ew and that, based on my inquiry of those individuals
immediately romp nsihle far obtaining said information, I believe that the imfwmadon is trite, accurate and
complete. I am aware that thane are significant penalties, including the possibility of fitter and imprisonrnemr,
for suhmitting false information. I agree to construct, operate, maintain, repair, and if apilirable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit"
Signature of Pr Owner/Applicant
Print or 'Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature ufAuthorized Agent, if any
Pi or Type Fvll Name
Submit the complete application package to
DWQ - Aquifer Protection Section
1636 Mail Semice Center
Raleigh, NC 27699-1635
Telephone [phone]
RECOVER ► MNR 1 DWQ
A.Ikjl1'erp P;MTF1''TI'AI "TUTM
,jury 15 2011
GPUAnC SQW Notification (Revised 3/181201 i)
Pape 3
d
dto:Zo l l 60 UfIr

Ashe County North Carolina--
Buildings
Results
City Limits
VI Farm Preservation
Fare Zones
Flood Way
FLEEfWOOD FD&RD
Flood Zone
A/ 'Parcels
Parcels
I1 Roads
Owner: DOUBLE M RANCH, LLC Address: 65 LEUCADENDRA DRIVE CRY; CORAL GABLES
IV Water
State: FL Zip: 33156 Parcel ID: 15231-043 Size: 140.00000 acres Bldg Value:
County
2763700.00000 Total Value: 3739200.00000 Deed Book: 263 Deed Page: 1912 Plat
Rook: <blank> Plat Page: <blank> Gpin: 296535819803 Xfer Date: 2001
Townships
PINE SWAMP
VDistriMA
PINE SWAMP
RECENEQ I DENR I DWO
A0 UlFFR-1PP0T (',T1r)K RFCTl()N
JUN 15 2011
1 of 1 6/13/2011 11:40 AM

To Whom It May Concern,
The company in charge of the work being done at the Double M Ranch is
Baxter Norris Construction, Inc.
Their Contact information is:
Phone Number: 828-297-3657
Fax: [phone]
Address: P.O.Box 159 Zionville, NC 28698
Contact Names: Baxter Norris
Mike Andrews
Please call with any questions or scheduling of site visits. Thanks.
RECEIVED / DENR / DWQ
AQUIFJ:R·PROTFr.Tlnl\1 ~~CT!ON
JUN 16 2011
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Map provided 4MyTopo.cam