WI0400199_GEO THERMAL_20110714

Permit Number
· Program Category
Ground Water
Permit Type
WI0400199/
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
m ichael. rogers
Coastal SW Rule
Permitted ·Flow
Facilitv
Facility Name
Edward Ball SFR
Location Address
899 Buena Vista Dr
West Jefferson
Ow ne r
Owner Name
Edward
D ates/Even+s
NC 28694
Ball
Scheduled
Orig Issue
07/14/11
App Received Draft Initiated Issuance
06/30/11
Re a ulated Activities
Heat Pump Injection
Outfall N:J! .. L
Central Files: APS_ SWP_
07/14/11
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
Ashe
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Edward Ball
606 E Lane St
Raleigh
Public Notice Issue
07/14/11
NC
Effective
07/14/11
27020
27601
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Edward Ball
606 East Lane Street
Raleigh, NC 27601
"NA
MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
7/14/2011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400199
899 Buena Vista Drive, West Jefferson, NC 28694
Dear Mr. Ball:
Dee Freeman
Secretary
On 6/30/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-only
geothennal 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 constru.ction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification fonn 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 Ashe 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.Ro!![e-mail] if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400199
Ashe County Health Dept.
Yadkin Well Company (David Brown)
Scott Brothers Heating & Air, Inc. (Mike Carter)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh . North Carolina 27604
Sincerely,
for~~A-~
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 Opportunity\ Affirmative Action Employer
One North Carolina
;Natura/tu
JUn, 30. 2011 0:27AM
No.0540 P• 2
NORTfi CARCLDZA
_?EPARTNTW OF ENVMON3ENT AND NA.7'iJRAt RWOURM MC DEW
N{3TT 'i"f o:'i OF INTMTQ CONSTRUCT A 51'UM 1ti GEOTBERMAL
WATER-dINJECTION VIML SY5'nM-
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iu A=z► V_c—. WM tea prNieiWs of NCAC'Me ISAt OTC 020 , pleW
rampirte this Aotdl atioa sand =41 to *6tvw on ft bamk pW {pleas 2i OrTTz 'Lldsaa], �
Walt Typc Canj rrrratian: D=1heprop osed Cyst= cxxcui a potable v a (no &Iditsves) is
nortimtopa piping that complctaIy isolates t1w fUd ftOM the envizo=B U (i.a.
oI - oo P
ices NC_ Coatinne completing this fbrM.
No _ Do Nat a=plcte this foam. Complete utbAr MC appEc atioaa forms fcr
oither a 5A7 wolf (n-Imp w4 i4im;iu potahla water into the 'cr) or a 5QM weii (closed,
loo-p well coatai:L8 addi :❑es such Es R-22, ethanol, or other anti£re= or corm= i'3110ors).
a PRO TY OWNM(WAITLICANT(S)
Liss g5�_h Pro pertly awnex kisted oaproperV de e4 (if wred by a bosiAw or pvtr=eAt a$azy, state mane of
are ty aad a rq"esettati+ra wlaulize:ity fr r sic= u'c):
cam: ; c GlGr sue! A/C- Zip codo: i a cou�r. dates
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{2a P ics3Address oz i ell Site (f d:ffereut t; = rbove):.
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P, AUTE1411MD AGENT 01 OWN 7ZP, LF ANY (if :be Permit Appl.iczatt dM Ucrwa tre sulajat: p: aperty,
aftoa a lee kom the Propam OWILar =10-W-Lug Agent to i as4?i sad apea-ft UIC W4
Campsq� Isere:.
COn=?asoa: v - A
Address:
City: _ State: Zip Lodz: Cav:s*;
Ofaau Tel$ I'o.:
Websf^r Address of Ccmp=y; if azy:
RECSVED 1 DEN R I tJM
Aquifer Pmlwr16n Sei boil

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G. CON=Vlr ,mON DATA � 2,o [ r
(Q Proposed damta be�,,u au ofbudnv
App: aYimatc d�;.1a D� tzch car1�, ;Fae�r 5�
{2) Type of NubiWo tw.mW (aopW, WC, etc); �2
C) Well usin?, Is the waryA) Cased? (r4eok either ta, Yes a (o.) T9a b"y)
(A) Yes ifyc;, then ptovid4 casttrg iaf�taatian I~e)cw
Type: gavxuiz�dsteel_,bleokstec� �fasSla �rhe: tsPa�+�Y)
Casing deFtz: JFXvM to trAl'mnce to Itud smfhce)
Casing sus to abova�rouGd inckas
(4) C c�: Iufa a�cr$1 s zsvimdis� III Ong axlatar gip; o ff ; T ,y,,� �,, �,1 t O k e td
(a) Grou; wx Nest �t srnfaufte +� Other (speei f}')
t'n) C coos p1acE�r,L- >�y�g�r� Fres Dih� -
;Q) Grp d e; tIZ of tubing {te�r� m �3 sariacej: tio� 2� �+ 3 (fit}
ff ImIa -SAS =irg,1061ow pa'at &ptic from
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iiLC,Z-XVEO I DENR ! D'Nq
Aquifer Pral&-Xon Section
JOIN 3 0 2911

Jun.30, 2011 10:27AM No.0540 P. 4
Attrch a &q= shcwiug the eggiamiag lcyotc or pxoposed modfE'tsatiou of the 4ccl;m tOpment ad cftiar
oipkwttioing asudeaed via the lajedien opwatiap. 110 maaubctzt •s brocb= =y Feu#de sopplemvuy
irdb=A iot.
L LinCATION 0IMMU(s)
Attach two oapim of=aps skowlig tha follov6ug zcfb=--d=
(I) Include a $Zvia�p (run be drawn) 3howb,� b4dh;A pwvm ry Lum, $vu u, ter badus, pmntW
sources of F=dwater ==bm6an'aad iiz mrieutoion of aqd tUstanow bcMeu tit gopmed wCU(a) Me
aw 02ti ff W41(s) or was* &SgaBal faralitioa amh is septic 1 or dry lids larabad evitbiin 200 fed of
the gwthcrmalal heat pump wcg sxsWm. Li4cl &U feetttm ckey and ! clude a u ow
(2) Mw Site Map rsys! %bmv the subject proytry im t4ados to t1is s=ouumng arse by usi2S at teast two fixed
teierence poia!s rueb as roads, shams, a --dfcr bighmy s'twwkons.
7. CMT2IC-4,Tlt]N
Note: This Pe, App14t7an must be si„goned.bj a,5Aperson sppezr�og e on th
ret5xded le;21property deed.
"I hereby ratify, undo: oa=ltj of Im, that i tasve peraa*Wy egad and am &mWu with Ibc idwir dm
subrlir€d in zblr d==mat and all admfteats tbereao acid thg, bad on my is IW of these i*tdivid'A18
in =ca atrly respvmibU ft a'a� $aid Wwmtion, I btlim that the i tiaa is true, Acewatie and Wruplefie,
i era awuc the t4ae are szgadfl t pe®a dqi iUclux= the pods yd* of fig Teed impriso=mt' fat sub=tdas
fal&e infer MdOn. I WM to C=trMt oP=IBA► =icb� TgniT, Bad if IppECablei ah=dw the injeodwx WOW Ard
all rslated apputcnr m in =ordancc eft fe Approved specMcWEOns apd corOQX uftbe P=02V
Sara ofProp&* Ow kIAppU=
Ftird or Type FrliXame and lids
SiPatura afPropers , Ownez/Anplima
PrIat 0., Type Fua Nast and dde
Sigcoxt ofA ffimiud Aaw4 if any
Pant al Type FuU Name nud txtie
Please return tu'a tapie< afthe completed Applicatica pukage to:
Surth CIrtalihtu D ))WQ
Aquifer Prttettion Sectog-MC grogram
1016 Mtzill. SOrd cc Center
Raleigh, NC 270916:56 REEC=_IVEO i OENR + PC
Telephone [phone] Aquilet Pr0ler"n Sarl+or?
JUN 3 0 2011

Jun. 30. 2011 10:28AM
No.0540 P. 5
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Aquifer ProtFdnn SOC tOn
JUN 3 0 2011

Jun, 30. 2011 10:27AM
No, 0540 P, 1
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DATE: a (nME: REF NO. LOG NO.
COMR4WY NAME L FAx No.
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ATTENTION jr DAP'[
FROM:. LOL. tVS L2 e (3x) �
COMPANY NAME FAX NO. PLEASE
LJ FIERY
INDIVIDUAL Olin
RUMBIR OF PAGES PLEASE dIYGINAiGV{'S
INCLUDING THM SFIEEr REPLY ay_
Y SUWURE
MESSAGE:
ED ! DENR i ❑WQ
4DrnFn-i-n Ce. 4ii
., JUN 3 0 2011
-FOR ALL YOUR WATCR NCEDS'
YADKIN WELL CO., INC.
1904 NAMPTONVILLE ROAD
HAMPTONVILLF- NC 17010
OAVII7 J. BROWN, VICE PRES•
YOLI, "rC 1600) 24"355 gEioWCE S3361 4684440
FAX (336) 4eb4049
R85 13301 446&46"
'DWO.+Rws AwauaA • 600 L.aves VW
PLr-AMRCFC M U$ IKGM!D WtPYCLI DD NCF FACSI AKIN FULL