WI0400196_GEO THERMAL_20110627

Permit Number
Program Category
Ground Water
Permit Type
WI0400196 /'
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Mikhail Balaev SFR
Location Address
1112 Hammel Rd
Greensboro
Owner
Owner Name
Mikhail
Dates/Events
NC 27408
Balaev
Orig Issue
08/27/11
App Received Draft Initiated
06/24/11
Re a ulated Activities
Heat Pump Injection
Scheduled
Issuance
Central Files: APS_ SWP_
06/27/11
Permit Tracking Slip
Status
Active
Project Type
New Project
)
Version
1.00
Permit Classification
Individual
Permit Contact Afflllatlon
David J. Brown
1908 Hamptonville
Hamptonville
Major/Minor
Minor
NC
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Mikhail Balaev
1112 Hammel Rd
Greensboro
Public Notice Issue
06/27/11
NC
Effective
06/27/11
27020
27408
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
ALT4
HiCDERR
North Carolina Department of Environment and Natura
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Govemor Director
612712011
Mikhail Balaev
112 Hammel Road
Greensboro, NC 27408
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10400196
1112 Hammel Road. Greensboro. NC 27408
Dear Ms. Balaev:
Resou roes
Dee Freeman
Secretary
On 6/24/2011, the Aquifer Protection Section (ALAS) received notification of your intent to construct a closed -loop water-on1L
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:
The injection well system contains only potable water,
The injection well system is constructed in accordance with well construction standards specified in North
Carolina Admitlistuative Code Title 15A Section 2C Subchapter .0213, and
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 .0211(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 Micliael.Ro�,.ersra?ncdenr.,-,oy if you have any questions.
Sincerely,
�
,for Debra W oj_)w
Supervisor
cc: Winston-Salem Regional Office - APS
APS Central Files - Permit No, WIN00196
Guilford County Health Dept.
Yadkin Well Company (David Brown)
Green Horizon (Bobby Ferrell
AQUIFER PROTECTION SECTION
1636 Maii Service Center, Raleph. North Carnllna 27699-1636
Location: 2728 Capital Boulevard, Rs"n, North Carolina 276V
Phone: [phone] t FAX i 919-715.0588, FAX 2; 919-715-6048 l C ustomer Service: 1.877-623.6748
Internet: www.ncwa1eroua1ity,orG
ne
oAh Carolina
An Egaa: Oppnrtunrry % Alhrmative Potion Employer

Jun.24, 2011 11:020
No, 0514 K 1
FACSIMILE TRNSMION FORM
DATE: TIME: -- REE NO. LOG NO.
TO: (?/c -7Zj-'-m,0)K9—
COMPANY NAMI FAX NO.
o
A'RENTION
FROM: C .
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mx K0.
INDPADUAL GEPx
NUMBER OF PAGES PLEASE aRIGI�ImNs
INCLUDMO THIS SHEET _ REPLY BY SiGFIRTiJRE
MESSAGE: '
.. &
,,FOR ALL YOUR WAT1cR N19IM9'
YADKIN WELL CO., INC.
1908 IIAMPTanVILLE ROAD
HAMPTONVILLE. NC 27020
CAVID J. BROWN, VICE PRE3.
T01-L FREE IWO) ZI&IM5
OFFICE (336) 468AA40,
u FAX (336) &a111-9148
RES JBMI A66-afig9
`GOOD N6Wi AMERICA - "* VC$ V*U'
E....I iAdA�E�aIFAIE�]'
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PLEASE XFOW US IMMEOMW IF tau 00 NOT FOOMY11 FACSM= N FULL

J u n. 24, 2411 11 43AM
No. 0114 P. 2
NORTH CAROLINA
DEPARTKMgT OF ENVIRONNPNT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRICT A CLOSMLGOP GEOTHERMAL
WATER ONaLY INJECTION WELL SYSTEM
TYPE Sow WELL(S)
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Prim or type the required information and maid to address on the back page.
DAB: G-'7's , 24—jiUTLC� 001gU
WeII Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes / Continue completing, this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well Co -loop wen injecting potable water into the agta fer) or a SQM well (closed -
loop well containing ad " '�e such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned bye a business or gove�lant agency, state name of
entity and a representative wlauthority for signature }: A• 1'i l d & la e V
{ 1 } Mailing Address: 0�
City; C_- Stater —Zip Code: County: )
Home/Office Tele No.: _53 o —59Y 3 37 4 Cell No.:
Email Address:A4 & i &RU W bsite: ..
r -cou,
(2) Physical Address of Well Site (if different than above):
City:
Home/Office Tele No.:
State: Zip Code:
No.;
County:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not ow•n the subject property,
attach a letter from the property owner authorizing Agent to install and operate LTIC well)
Company Name:
Contact Pets E Address:
Address:
City:
Office Tele No.:
State: Zip Code:
Website Address of Company, if any.
County.
GP'U/MC SQW Natiftcatfan of Intent r9nn (Rrviscd 8/2008) Page 1

Jun, 24, 2011 III A3AV
Vo, 0514 P, 3
C. WELL DMLER m•FORHATION
Company Name: YADKIN WELL COMPANY, INC. �} ;h
Well Driller Contractoes Name: I� ,�. 1, rzL-.rL' ^'
NC Contractor Certification No.: _
Contact Person: DAVII) J. BROWN EMAIL Address: [e-mail]
Address: 1908 HAV TONVILLE ROAD
City: HA1vMONVILLE State: NOR'TH_CAROLLN_,� Zip Code: 27424 County.
Office Telo No.: 336-468-4440 Cell No.: 336-374-8736
D. HEAT PUMP CONTRACTOR INFORMATION (if different than drWex)
Company Name: _Ayr et+ i" 4a -
Contact Person:_. ! n � E. M Address:
Address: i+ sol q
City zip Code: 2—'� -& i _ County:
Office Tole No.: `l( 4 - .I I i - '7 q .YS Cell No.:
E. STATUS OF�AFPLICANT
Private: Federal. Commercial:
State: Municipah Native A nerican Lands,
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
-L[.�-f. v ears lk q 4 -'-t c_-(�.�c, zi.
G. WELL CONSTRUCTION DATA e' _7Ut
(1) Proposed date to be constructed:`- - L 2 Number of borings: 2
Approximate depth of each boring (feet):_'
(2) Type of tubing to be used (copper, PVC, etc):
(3) Well casing. Is the well(s) cased? (check either (a.) Yes o_,,r (b.) No below)
(a) Yes if yes, then provide casing informatioa below
Type:alvanixed steel black steel___plastic other (specify)
Casing depth: From _to feet (reference to land surface)
Casing Extends to above ground inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Sentonite Leos"' Other (specify)
(b) Grout placement: Pumping r/ Pressure Other
(c) Grout depth of tubing (reference to land surface): from 2XO to —7 (feet)
If we4 has casing, indicate grout depth: from .r _ to (£eet)
GPUIMC SQW Notificadon of Intene Form (RLmAmd 812008) Page 2

J un. 24. 2011 11: 03AM
No, 0514 P. 4
H. LgJII'rCTION-RELATED EQUIPWNT
Attach a diagram showing the enginea * layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
infomation.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (can ba drawn) showing. buildings, property lines, surface water bodies, poreutial
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tames or drain fields located within 200 feet of
the geothemal heat pump well system. Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTMCATION
Note. This Permit Application must be signed by eac person appearing on the
recorded legal property deed.
" T hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based oa my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and complete.
I wn aware that there are significant penalties, including the possibility of fines and imprisomnent, for submitting
false information. 1 agree to constrttct, operate, maintain, repair, an applicable, abandon the injection well and
all related appurtenances in accordance with the approved specific s and - anions of the Permit"
AQtli� Profet� SeMDn -_-r�
J UN 2 4 20 i 1 S, ature of Property Owaer/Applieaat
Lltkail at-ev
Print or Type Full Name and title
Signatvxe of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Nance and title
Please return two copies of the completed Application package to:
North Carolina. DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUIUIC SQW Notifioatiou of Intent Fonn(RoAsed V2008) Page 3

J u n; 24, 2"' 11: 03AM No, 0514 P. 5
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