WI0400205_GEO THERMAL_20110809

Permit Number
Program Category
Ground Water
Permit Type
WI0400205 /
Injection Wate.r Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Laura Goings SFR
Location Address
628 Woltz Atkins Rd
Mount Airy
Owner
Owner Name
Laura
Dates/Events
NC 27030
Goings
Orig Issue
08/09/11
App Received Draft Initiated
08/03/11
Re q ulated Activities
Heat Pump Injection
Outfall t\i ~h .
Scheduled
Issuance
Central Files: APS_ SWP_
08/09/11
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
Surry
Facility Contact Affiliation
OwnerType
Individual
Owner Affiliation
Laura Goings
256 Mills Rd
Mount Airy
Public Notice Issue
08/09/11
NC
Effective
08/09/11
27020
27030
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
Beverly Eaves Perdue
Governor
Laura Goings
256 Mills Road
Mt. Airy, NC 27030
AVA
NCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
8/9/2011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400205
628 Wottz Atkins Road, Mt. Airy, NC 27030
Dear Ms. Goings:
Dee Freeman
Secretary
On 8/3/2011, th_e 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 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
Surry 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.Ro!.:!:ers (a),ncdenr.f!ov if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400205
Surry County Health Dept.
Yadkin Well Co, Inc. (David Brown & Tim White)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Sincerely,
fo/'2~~-~
Supervisor
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Custcmer Service: 1-877-623-6748
Internet: www.ncwaterauality.org
An Equa! Opportuniii' Affirmative Aciion Employer
N~rth Carolina /,7aturaltu
Aug. 3. 2011 10:17AM No. 0786 P. 2
\ l
NORTII CAROLINA
DEPARTMENT OP BNVIllONMBNT AND NATURAL RESOURCES (NCDBNR)
NO'l1FICATION OF INTENT TO CONSTRUCT A CLOS'A)-LQOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM:
TYPE 5-0 W WELL (S}
In Accordance "!1th the l)to,1.Wons ofNCAC nrie 1SA: 02c.0200: please
complete tllis notification aiicl mail to address on the back page (please J![b![ or Im.t info.tmation).
DATE: S-!1.. 20.JL u.,..lL04-0 000:,
Well Type Co1,jirn1atio,z: Does the proposed system circulate potable water omx (no additives) in
continuous piping that completely isola.te.g the .fluid from the envil·oiunent (i.e.
closed ... loo p}?
Yes _X~ Continue completing this form.
No ___ Do Not complete this form. Complete other UIC application forms for installmg
either a SA7 well (smn-loop well iJlieetipg potable water jnto the aquifer) or a SQM well (closed-
loop well containing· additives such as R-22, ethano~ Ol" other antifreeze or coltosion inhibitors),
A~ PROPERTY OWNER{S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency~ state name of
entity and a representative w/aufh:ority for signature): b g:y v a (,r o i fl ~ r
(l) Mailing Address: 2 S6 H, If r R.J
City! 11 f • A , ,,. 7 Siate: LL. Zip Code: 2 1 D g O Coun~ S ClV' v k
Ho:me/0ftic~ Tele No.: Cell No.:3,U-7/o .. ,2 ::ii
Email Address:, ______ ~ .... W __ e=bs__.ite==:..-...----------
(2) Physi~lAddress ofWellSite(ifdifferentthanabove): ( 2. 8 l!Jolf&A-fh,";.,1 h..J
City: f14:,. 4iv:y Staie: '1£:,_ Zip Code: 2. 7 o J: o CoUllty: Jh v ~ y
Home/Office Tele No.: Cell No.: ~
B. AUTHORIZED AGENT O:B' OWNER, DF ANY (if'thePe.nllitApplicantdoes not own thesubjectpropertyJ
attach a letter ftom the property owner authodzing Agent to install and operate UIC wtll)
CompanyName:~---~--------------------
ContactPerson~: -------~--~~-.... B;;:.:.,M_..A..,;;IL;:.;;..;;.;;A=ddres=--... s: ________ _
Address: ________ ~----------........ -~~----
City: ------------.....----Stati,: _Zip Code: ~-~~-County: ______ _
Office Tele No.: --------~~----C=e=ll:....::..N=o.!!,..: _______ ~-
\V ebsite Address of Co~pany, f!any: ____________ ,E,CEIVEO / DENR / OWQ
AQUIFf:R·PROTFr.r,oN SECTION
AUG'O 3 20U
Au g, 3. 2011 10 :17AM No. 0766 P. 3
C, VML DIZILL'ZR INFDIMAnON
Company Namc--V-r a Ca. hn�.
We(I DAller Cbrttraator's Name Jody Mul13s 'I4iEAM Brown 14�iifott {:eve
NC Contractor Ccrtifoxtim1No : Z72-A 3036--A — 354-8'►A ,
Cnataci]Persotl: i?stiid J. Brown 21. A„ MJQAddress ;mitiaffdrii[er msn.oatn
Address: 1949 Hamptcnville
City; }3anretoMd;1e X C. -- � Zip Code: 27020
O ffice T ak Na.: 336-4 68-4440 Cell NW
Cnutit)Yadkin►
W-374-8736
D. Hr, AT I'UbX CONTMCTOR URTa tYMAUDN (if dif[ wani than drift)
Company Name: `.�� ;' ' i u if [ a — L., i —.
C4atACt Per$ot1' M f;J a rac1 + Q
City: ZJD Coda_ conty:
OflSot rekNo.: C41N0.9
E. STATUS OF A ICAI"i 1'
Private: zI/ Federal: Cammucinl;
State: _ lvlwcipal; Native American Lands:
F. iN3mcnoN`rnoC.i3I3v= (May desGribfe fhow the 4 c6on weU(s) will b e ascd)
G. WELL CONSTRUCTION DATA yo lit
(I)Proposed date to beeonsbmcted: �gr�� Number ofbuinga: 2
App=huate depth of oachborlrg (f$ct): S 85-0 r
(a) 'Type ofttabingto be used (copper,l?VC, etc): -5-6,9 -14 Z� n 1_
(3) Well casing. is the well(s) eased? (check either (R) Y$s pr (b,) No below)
(1) Yes if yes, then ptbvidc casing information below
Type;[lvauixad steel Mack steal plastic ollrer (specify}
Casing daptli; From to Feet (reference to land svrfRce)
Casing cAonds to above ground inches
(b) No '-'
(4)GrcutInfo (tnatarialsurroundingwell casWgauditpipiqs): %� 'AG red
�,��r� !�)
(a) Grout type; Neat Cernant 1Bcntoalt$ Oilier(spe e'
(b) RTRPt placament: f umping 1L- pressure Other
(c) Q rout depth oftutb nsg (mAf enaa to laid svtfate}, frtam 3 6 to (feet)
If Sven }ems cussing, jnd(c$ts grout ciepfl7: from to —(fed)
�tkovtY u' Z+[ lYr _
ACXV.r�, r-nr►+�, ,F. 1u
AUG D 3 2011

·Aug. 3. 2011-10:17AM _ __,_---1;..._-=-------------No. 0786-P. 4
ll:, ll'iJECT.ION-ImLATED EQtJI?MEt'tt
Attath a diapain sho\viog the cmglmaring layout '1t ,PrOposcd modification of the ,uuection equipment end ~lor
ptp1ngftubiJlg associated wtth tho iqectlon opma.1ion. The mamdllctarffs brodwr~ may provide sui,pleinentary
infbrmaliou.
I. LOC.4.TIONO:FWELL(S)
Attach two coples afmapsshowiDgthe m11owlng ~~
(I) lnol'ade a Sito Map (cm be dtawta) show;ing: 'bulldJngs, pw_perf)' lincs.11 surfflce water bodie.s; J)Otential
sources of groundwater contamination and the orientation of end distlncea behveeJJ 1be p?oposed we1l(s) and
;11'1,y exiatfog weU(s) at ,vasto disposal :lamlitle.s. snob. as septic 1anb or dmin fi~ds loc,ied ,vithi,Q 200 feet of
the gaother-1 heat pump well a)'mn. Label all hMa cteat'(yudjylpdea norfharrq,
(2) The Site Map m11sf show thJ subject p.ropeny in ieJatlon to the surrouu.ding a.tea by 1lSi.ug at least two fixed
retere.uce poin!S such as.roads, streams, and/or highway inteneotlons.
J, CERT.m.CATION
Noto: ThisPermitA.ppllcadon u111st1Je sr,pe.a by!U!9!lpe.l'aon sppearlng on. tbe
recorded legal property deea.
c'l htreb)r ~erlify. undor ~ of law, fhat 1 have. psrsonally examined and am familisr wlth the in.fotmfttion
sob:mitttd in tftls doeunwit and all aUachmcnts thtreto 811d thatl' based on. my inquiry of those indtviduals
J.muu,diately responsible. tbr obUlinldg said information, I bellm tbat the mtormafl~ is tnie, &CCUQ\te and complete.
I ain awato that tficro are s!gnfru:ant peu=thies, btclud"mg tho poSS11illlty of fines and impr!sonmont, :for aubmitfing
ftlse infonnlldon. I agree to codStrl!Ct o~ meinhibt~ xcpak, and if ap_plica~ abandon tho J~<>D 'WCI] aJld
all related apputtemnces Jn acoordance with tilt ap_proved specifications and (I01Jdnio11s of tho Permit.>'
~~~()~
LaY.-ra B-&oh1:t5 owt,cr
Prlnt tit Typiliiitt'Naa agd 1itl
SiJnature of Prope.tly Owl1tf/Applioent
Ptint or Type .'.FnD Name aod title
SJpa'11m of AutbodzedAgent, if any
~tor Ty_pe Pull Name aod title
Pleue return two copies otthe completed Apptlcatiou. paqo to:
North Catolina D'.mNR-DWQ
.A.gulfra• Protection Bection .. mc :Program
1636 Mail Serric:a Center
hleigh, NC 2769.9-.. 1636
Telephone (919) 715 .. 6935
RECEIVED/ DENR, owa
AQUlFJ:R·PROTFr.TtON SECTtON
AUG ·OS 2011
., ""' "' ·-·-··"·-•-"----··--·.' --··-..... __, ...... ""' '"" ' __ ...... ···-·-·-....... ,,,,,,,. __ _.___,,
Aug. 3. 2011 14:18AM
laakk 0; f �YPL
Oev
6ayOfA-
NOCAS e-
tLO r n
1
RtL;tIVEij I VENh � uvvtj
AQU FFR'PRO TF( TION SEC-P()N
AUG 0 3 2011

Aug. ?, 2 011 10 : 17 AU
FMINULE TRMMWON FORM
No.0786 P, 1
E
96
w
d
DATE, !? TIME: -------REF. NO. LOG NO..
T0. r �l -7 Cc 9?
COMPANY NAME FAX NI
d aF��
ATTIAMON f - DEPL
FROM: J- (2iX ) Ali - �Za�
COMPANY NAME FAX NO. PLEASE
o� - - __ ❑
RUSH
FIEFLY
INDIVIDUAL OEPT.
RMSER OF PAGES
INCLUDING THIS SHEET
Kim
REPLY KIASEY
ORIGINATOR'S
SIGNATURE
MESSAGE; /
fry I� ni'r C'g�1 Dn� r h-��D liL4,� T,L�
FOR ALL YOUR WATER NEEDS'
LDYADKIN
WELL S CO., IN.
igg6 HAMP70MVILLE ROAD
FiAivll�TpNVILLE. NC 27020 RECEIVED I DENR I DWQ
,4V10 J. BROWN, VICE PRIES. r
TOLL FREE I$00I 2dE-'9.355
OFFii"E (336) .2 -6440
FAX t3351 468.404E
RES i336 d6B afi35
•6eQp NGw'i AMNAICA • 609 LOYCS VOtr
PLEASE [NFORM US IMMEDMILY IF YOU 00 NOT RECEIVE FA{STMU W FULL