WI0400200_GEO THERMAL_20110715

\
Permit Number
Program Category
Ground Water
Permit Type
W10400200 /
Injection Water Only GSHP Well System {5QW)
Primary Reviewer
m ichael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Rex Riley SFR
Location Address
4719 Groomtown Rd
Greensboro
Owner
Owner Name
Rex
Dates/Ev ents
NC 27407
Riley
Scheduled
Orig Issue
07/15/11
App Received Draft Initiated Issuance
06/23/11
Re gulated Activities
Heat Pump Injection
Private residence, single family
Outfall NlLL
Central Files: APS_ SWP_
07/15/11
Permit Tracking Slip.
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Rex Riley
Owner
4 719 Groomtown Rd
Greensboro. NC
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Rex Riley
Owner
4 719 Groomtown Rd
Greensboro
Public Notice Issue
07/15/11
NC
Effective
07/15/11
27407
27407
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
Rex Riley
4719 Groomtown Rd.
Greensboro, NC 27407
Coleen H. Sullins
Director
07/15/2011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400200
4 719 Groomtown Rd.
Greensboro, NC 27407
Dear Mr. Riley:
Dee Freeman
Secretary
Op 06/23/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl '
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 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 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 Michael.Rogers1Wncdenr. !!OV if yD have any questions.
3iLY, \ ~(Al~
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400200
Guilford County Health Dept.
for De~att.s
Supe~~
Scott Lohn (Duggins Heating & Cooling, 4761 Walkertown Plaza Blvd., Walkertown, NC 27051)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Caroiina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customei Service: 1-877-623-6748
Internet: www.ncwaterauality.org
An Equal Opportunity Affirmative Action Employer
Nirth Carolina /Vaturally
IUD I WR D-D
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP
GEOTHERMAL WATER —ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
In Accordance with the provisions ofNCAC Title 15A: 02C.0200
Complete application and mail to address on the hack page.
This is not the proper form to be used for'injection wells in an open-120 geothermal system.
I?o nnot use this form for systems that circulate any substances other than water.
TO: DIRECTOR, N( TH CAROLINA DIVISION OF WATER QUALITY
DATE: 20 !�
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isoiates the fluid from the environment?
YES _,Ll If yes, then continue completing this form.
NO If no, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Ilse A We11(s) For Injection With A Meat
Pump System, should be completed.
B. SYSTEM FLUID Will any additives be introduced to the system's circulating heat transfer
fluid? This includes, but is not ihnited to corrosion inhibitors and/or antifreezes,
YES If yes, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Use A Well(s) For Injection With A Heat
Pump System, should be completed.
NO6'If no, then continue completing this form.
C. PROPERTY OWNER
Name: ee-- -%
Address: 4t71 r �j�:;r�'%9ldwrlJr�;;
City: State:
County: r/A Telepbone, ,
D. STATUS OF PROPERTY OWNER
Private: —ke�- Federal:
State: Municipal:
Revised 7106 GWIMC-57 CL
Tip Code: Z 7 YO {
Commercial:
Native American Lands:
f1i ., i'jEa r dEWR r DV4Q
AUJ Fir, Gn'i-Cr7r^-,r IL-71N4
JUN 2 3 2011
Page 1 of 4

E. FACILITY (SITE) DAT A
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: ____________________ _
Address: __________________________ _
City: ________ State: _._ Zip Code: ____ County: ____ _
Te:ep:.~ne: _________ Contact Person: ___________ _
SmnJard Industrial Code(s), SIC, which describes commercial facility: _______ _
f HEATPl""}lPCONTRACTORDATA
G.
.-.: ~-lf t. r Wf' /lf!i /l/1/( { u;dt,INb
:\~: -1 7V /Ji/u<6(L,?v w# /JIA:Z ~ _lj l-1/ 42 .;
C~7 · ·, ,1~6 1-Tdlv~ State: ,A/l.-Zip Code: Z-710 County: E 1P'L {Y'·v1-
Teiepro-ne; J)[-6 £7-7 5 '() 7 Contact Person: i CA.77 LtJ/1'-A,,
CQ"SSTRUCTION DATA (check one)
(1)
/ EXISTING WELL{S) being proposed for use as a ground-coupled heat pump
well(s). Provide the information in (1) through (3) below to the best of your
knowledge. Attach a copy of Fonn GW-1 (Well Construction Record) if
available.
PROPOSED WELL(S) to be constructed for use as a ground-coupled heat pump
well(s). Provide the information in (1) through (3) below as PROPOSED
construction specifications. Submit Fonn GW-1 after construction.
WellDrillingContractor'sName: __ B~'A.~~~/.-~~/J~~L~/_L_L.~--E-"~1 _______ _
NC Contractor Certification n~ber: __ 2-_<l_J~9~/l~-· -----..--------
Date to be constructed: '/ « / / Number of borings: ___ / _____ _
Approximate depth of each boring (feet): __ c::; __ u __ --_() ____________ _
(2) Well casing: Is the well(s) cased?
(a) YES # If yes, then provide the casing information below.
Type: Galvanized steel_·_ Black steel __ Plastic __ Other (specify) ____ _
Casing depth: From _· __ to ___ ft. (reference to land surface)
Casing extends above ground inches
(b) NO _L_
(3) Grout (grout the vertical length of the borehole to a minimum depth of20 feet b.l.s.):
(a) Grout type: Cement__ Bentonite __ ~ (specify) 7 #(fA..,/7,t#L,lft ~.AJMAI~
(b) Grouted surface and grout depth (reference to land surface): 1~~..V/,lc/ ~
__ around closed loop piping; from __ to __ (feet).
__ around well casing; from __ to __ (feet).
NOTE: THE WELL DRILLlNG CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
Revised 7 /06 GW/UIC-57 CL Page 2 of 4
R INJECTION -RELATED EQUIPMENT
Arach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
LOCATION OF WELLS) Attach two maps.
(1) Include a site map (can be drav`n) showing: buildings, property fines surface water bodies,
potential 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 tanks
or drain fields located within 200 feet of the ground -coupled heat pump well system. Label all
features clearly and include a north arrow.
(2) location map referencing the site to two nearby permanent reference points (such as roads,
streams and highway intersections)_
PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Disebarge permits
(3) Sewage Treatment and Disposal Permits
K. CERTIFICATION
"I 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 on my inquiry of
those individuals immediately responsible for obtaining said information, I believe that the information
is true, accurate and complete. I am aware that there are significant penalties, including the possibility
of fines and imprisonment, for submitting false information. I agiree to construct, operate, maintain,
repair, and if applicable, abandon the ground -source heat pump system and all related appurtenances in
accordance with the approved specifications and conditions of) lie Perna' ."
.r
,
(Signature of Well Owner or Authorized Agent)
Ifauthorized agent is acting on behalf o_ f'the well owner,
please supply a letter signed by the owner
authorizing the above agent.
L"i
Revised 7106 GWILTIC-57 CL Page 3 of 4

L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If 'the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the ground-source heat pump system's well( s)
conforms to the Well Construction Standards (Title 15A NCAC 2C .0200)
Revised 7 /06.
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UICProgram
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh_, NC 27699-1636
Telephone [phone]
GW/UIC-57 CL Page 4 of 4
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NORTH CAROLINA
JEP.kRT%,1EN-T OF ENVIRONMENT AND NATURAL RESOURCES
-NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP
GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
r.
This is not the proper farm to be used for injection wells in as opea-laop geothermal system..
Do not use this form for systems that circulate an■• substances other than water.
TO: DIRECTOR, Nt TH CAROLINA DIVISION OF WATER QUALITY
DATE: 20
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES If yes, then continue completing this form.
NO If no, do not complete this form. FoTM GW-57 HP, Application For
Permit To Construct And/Or Use A Well(s) For injection With A Heat
Pump System, should be completed.
B. SYSTEM FLUID Will any additives be introduced to the system's circulating heat transfer
fluid? This includes, but is not limited to corrosion inhibitors and/or antifreezes.
YES If yes, do not complete this form. Farm GW-57 HP, Application For
Permit To Construct And1Or Use A Wells) For Injection With A Heat
Pump System, should be completed.
NO If no, then continue completing this form.
C. PROPERTY OWNER
Name: '
Address: •- - , - ---- --
ih State: - ? dip Code:
County, -- Telephone,
D. STATUS OF PROPERTY OWNER
Private: _IZ' Federal:
State:
Municipal:
Commercial:
Native American Lands:
Revised 7106 GWIUIC-57 CL JU N 23 L li i i Paget of 4

E.
,i
FACIL`.T`. k SITE) DATA
tfi'si o ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
N.z:-: -: 3u-ziress or Facility:
State: Zip Code:
Ya':r h�ane: Contact Person:
S' rdwd Industrial Code(s), SIC, which describes commercial facility:
County:
HEAT PUMP CONTRACTOR DATA
Name: T 0 C� � v
Address: __ ✓''
City: . r. State: _ /:.. dip Code: County:
Telephone: 3 - Contact Person:
G_ CONSTRUCTION DATA (check one) r
E)ISTING WELL(S) being proposed for use as a ground -coupled heat pump
weil(s). Provide the information in (1) through (3) below to the best of your
knowledge. Attach a copy of Form GW-1 (Well Construction Record) if
available.
PROPOSED WELL(S) to be constructed for use as a ground -coupled heat pump
well(s). Provide the information in (1) through (3) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
(1) WelI Drilling Contractor's Name: �; /z.
NC Contractor Certification number: -
Date to be constructed: Number of borings:
Approximate depth of each boring (feet): _ 0
(2) Well casing: Is the well(s) cased?
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel Black steel Plastic Other (specify) T
Casing depth: From --to ft. (reference to land surface)
Casing extends above ground inches
(b) NO
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b,l.s.):
(a) Grout type: Cement Bentonite Other {specify}
(b) Grouted surface and grout depth {reference to land surface}: .
around closed loop piping, from to (feet).
around well casing; from to {feet).
NOTE:
THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS rNFORMATION IS UNAVAILABLE BY OTHER MEANS.
Revised 7/06 GVIW/MC-57 CL Page 2 of 4

a Li3ECTION-RELATED EQUIPMENT
AtLwh a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
LOCATION OF WELL(S) Attach two maps.
(1) Include a site map (can be drawn) showing: buildings, property lines surface water bodies,
potential 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 tanks
or drain fields located within 200 feet of the ground -coupled heat pump well system. Label all
features clearly and include a north arrow.
(2) location map referencing the site to two nearby permanent reference points (such as roads,
streams and highway intersections).
PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include-
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
K. CERTIFICATION
"I 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 on my inquiry of
those individuals immediately responsible for obtaining said information, I believe that the information
is true, accurate and complete. I am aware that there are significant penalties, including the possibility
of fines and imprisonment, for submitting false information. I agree to construct, operate, maintain,
repair, and if applicable, abandon the ground -source heat pump system and all related appurtenances in
accordance with the approved specifications and conditions of lie P rmi :"
/J f
(Signal,ire of Well Owner or Authorized Agent)
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
RECEIVED i DEw i DW'O
AouirriR apmrrrai vcmN
JUN 2 3 2011
Revised 7106 GWILIC-57 CL Page 3 of 4

L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the ground-source heat pump system's well( s)
conforms to the Well Construction Standards (Title 15A NCAC 2C .0200)
Revised 7 /06
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UICProgram
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW/UIC-57 CL Page4 of4