WI0400207_GEO THERMAL_20110812

Permit Number
Program Category
Ground Water
Permit Type
WI0400207 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
m ichael. rogers
Coastal SW Rule
Permitted Flow
Fa cilit,
Facility Name
Barbara Larsen SFR
Location Address
541 Woodlands Rdg
Lansing
Owner
Owner Name
-Barbara
D a tes/Events
NC 28643
J Larsen
Scheduled
Orig Issue
07/27/11
App Received Draft Initiated Issuance
07/27/11
Rea ulated Activities
Heat Pump Injection
Outfall r..:u;__;_
Central Files: APS_ SWP_
08/12/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville NC
Major/Minor
Minor
Region
Winston-Salem
County
Ashe
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Barbara J. Larsen
541 Woodlands Rdg
Lansing NC
Public Notice Issue
07/27/11
Effective
07/27/11
27020
28643
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Barbara J. Larsen
541 W ood1ands R idge
Lansing, NC 28 64 3
JF?'A ----."-~---~~-
MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Q~ality
Coleen H. Sull ins
Director
8/12 /2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0400207
541 Woodlands·Ri dge, Lansi ng, N.C. 28643
Dear Ms. Larsen:
Dee Freeman
Secretary
On 7/27/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-.onl y
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:
I. 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 ISA 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 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 Michael.Ro gers(a).ncdenr . ..!OV if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400207
Ashe County Health Dept.
Yadkin W ell Co. (David. B rown)
·Scott Brothers Heating & Air, lnc. (Mike Cutter)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-16:~6
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Sincerely,
forQ~A-~
Supervisor
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919 -715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterauality.org ·
An Eqm1I Opportunit:1 \ Affirmative Action Employer
NifthCaroli.na
J\?atural!lf
Ju1.'27, 2011 11:17AM
No.0730 P, 1
4
FMIMLE TRROMON FOW
DATE: Z 7 1 TIME: REF: NO. __
LOG NO.
COMPANY NAME FAX HO PLEASE
DELIVER
IMMEDVaELY
ATTENTION DEP1
COMPANY NAME^ FAX NO.
PLEASE
tr] a 53 6 ❑ Y
INDMDUAL DEFT.
NUM DER OF PAGES PLEASE ORIGTNAMRS
INCLUDING THIS $MEET REPLY 8Y $i MATURE
MESSAGE: ((11 �'�Jyw.t¢
.'j r �Cpe l 4 Al rt0 Ifi cry -\ dry A ' d 7
-FOR ALL YOUR WA -PER N=S'
YADKIN WELL CO., INC.
190e HAMPTONVILLe ROAD
HAMpToNVlLLE. NC 270$0
DAVID .i. BROWN, VICE FRE5.
TOLL FRFE (WO) 240m9353
OFFICE I3363 468.4440
FAX i336Y 466.4048
RES (33G) A66,AO89
-f.Gdo Nroos AMEBIC► • GOD {„OVCS VoLP
RECEIVED 1 DENR I DWO
Agus��mtrtrpri 2rr ,vis-----
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PLEAM INPOM US WMMVff= Uw WU Dp NT;=MVE FACMAII.E rN FULL

Jul', 27, N11 11:17AM No. 0730 P. 2
NORTn C,A,ROLINA
I EPARTMENT OF ENVIRONMENT AND NATURAL RBSOURCES (NCDENR)
NOTIFICATION t FXNTKKT TO CONMUCT A CLIDS01) L00P GEOTURMAL
WATER ONLY INJECTION WEI►L SYSTEM:
TYPE 5—OW WEILU5`}
ru AcC�da�>rre tiSitl�theproSisiams of NCAC T�Ette LSA; U2C,i}2DC: pleas
c=pid a this m8ftation suet ,mail to add.-= oa the bs& page (pL:ose PIbA oc T�ye i,Arnledau).
Well Type Confirmarian: Does the proposed system cirouhta putabl& roaster o (nc additives) in
continuous psphig that completely isolates tlj�,,~laid from the en*oIIment (Le.
dosed -too 1?
Yes X . Conthxue completing this form.
No DO Not compIft Us &rm Complete other UIC applioation foams for installing
either a 5A7 well Cga=40op well i;j1 'n potable water into the aquifer) ox a SQM well (olmsd-
loop well contairaitg add sash as X-22, etbanol, or oilier aztitt= or corrosion inWbitors).
A. PROPERTY OWINM(S)IAPPLICANT(6)
List oath Property Owner 11s#ad on proFuty deed (if owned by a !95ams or govar ent agate, state name of
entity and a rVresantative w/autbority far signatum): PJL� -- - _ �_O_Q o r'
(]) MaiYmZAddress! S itl tjo ad 1 c'nd s_? 14
City: L .• .. State: Zip Code- V9..y3 aunty. s � r _ .
I3ermElOffice Teie No,: r334)-Celt No.:
EraftU Ad ess: Websita:
(2) Physleal Add= of Nall Site (if different than above):
City. State: Tip Code: - County:
Homelolnica'fee No.; Cali T&:
B. AUTHORIZED A.G'LNT OF OWNER, IF ANY (if the Paenit Applic*ot loss n owu tha sabsectpropurty;
atmcr a teftPa cram the pzoPerty owner authorizing Agent to install and uperate UTC welt)
Company Name;
Goratact Persob_ EM,kU_ Ad Ims:
Addrrss-
City:
S`Gzte Zip Cede: Catmty:
4f oe TeleNo.: CCU No.:
Website Addzess of Conipmy, ifaw..
RECEIVED I jDENR I Oft
Aquifer Pra[prtioq Se,%On
JUL 27 201t

Jul', 27, 2'011 11;17AM No, 0730 P. 3
CcmpaayNarue:'Y�adtun)K4 CCa, Ian
Wol! X3riller Ctyntrxct�t's Naate, .may mil_ L Y-Y-ghew Emwg Milton Cave
NC Cormulor Candficsiva Q.: 2S72-A -gLA _�548-A . _
Confocf $?e=6 . David J. 1y : Q
Addms,19d8 HamptoaplJla Rd.
City: 1N.Q ZIP Cade; 27020 Catttsty: Ya
flf rcTeleNo,. 336A68.4440 CeVNo.: 336-374-Md
D. MAT PUMP COM&L'TCiRIT�+'QF+NAMON (If difffer"# than drillo r)
Compel yName' Lxa
n e I Co-K—
,x�dres C �---
City: - r1r rJ t-, bU j zip wo. 2AC-24 Comply:
DficaTcfeNo.: 63��$77-171� 2— CcNo, :�3,36} $77-9112�
R. STATUS OY APPUCART
Private: V Fedcral: — Coa�mera?a?I;
State,, maAgipat:-vafiveA=xf=a1Auds,
Tl, Il<F7,t."d`iON PROORDU= (brieCly ducribetowtae Iq cdc awpX(s) will be used)
G. Wtq&L Ccl'NSTRUMON DATA � qua 7, 2-Pr,
0)?topmed dlftto beconstrooted:�'' ' NumberofbW111gr:
Appmximaty doth of oath Wing (font): a'
{2) Tl pa of tgbluglo be used (coper, PVC, eio): S Dl�_ 1 __ f IMP �' f • • __ _
(3) Ve t -miog. Ts The wedl(s) cased? (check aifier (a.) Yos rC (b.) Wo belmy)
(1) YCS 1$yos, ll m provide nos)ng Wormdou below
Type; „gaivasilm eleel _blaok tither (gSCIfy)
Casing dopiln Prom to (relamoe to TBad stir&c
Caging axwds toAbOV6 grolimd _ taches
(b) NQ _�W-____
(4) Groutlufe (metdt'fal s=ovnd[ lg well c slntg ndloxt►iF+i�gj: y-� rA14 r ►r—A •,m
(r,) Qrmt typo: Alaat Comsat Betifouitc � `C thur (spacfy)
(8) Grwt plaacemmt: Pump Preseum C� filer
(o) Gmnt clmpth of tubing Crvf'ereueo tD land surfhm): from Z.:M to .3 Uect)
if woil b; s rWj;g, Wio* grM depth; froul to (feetj

Jul;2T 2011 11:',1AM
No.0730 P. 4
a RQECUON-inn XQUIPM10ff
Attecb s diagram showing the eadneavIng layout os proposed modillcadw of tba injection equipment and exterior
plpingltubing associated with the injectim opmatlon, The =nufectmVr°s bmahLTa may pravi,de stlpplametwy
informatl=
I. L OCATTON OF WELL(S)
Attach two copies of maps showing tiro following i;Armatiou:
(3) Include a Site Map (can be drawn) showing: b0dinp, pmpefty fl=s, surf§cc loafer bodies; potentie3
sources of groin dWater eantaminatiaa cad the orlontation of and distseaea between the proposed well($) and
agy Existing well(R) w waste disposal facliitics sash as sepdo taus or drain ids located within nO fW of
the geatbermal heat pinup well systern. Label all tkatRres clearly and ins7liAc a narlh artow.
(2) 77e Site Map crust show the subject property in xeladen to the surrounding area by using at lead two fated
mfteuce pckgs such as roads, sheaves, taftr highway tnterseadons.
S, C)MTMI C.A 770AN
r"orded lapl. pxvperty deed,
"I hereby cartU%/, wader pendzr of haw, that I have personally examlaed and am famlilar with the in 0=8tion
submitted in this document and all attad=enls th=ta and that, rased on my fugtdry of those Individuals
Immediately responsible for obi.izdmg said informatioe, I believe that the inf'ornxti= is MA accurate and aomplote,
I am aware that theta are significant penalties, including the possihilhy of fines and Imprsomnent, for submitting
false information. I agree to construct ope�'ate, ranintain, repair, and. if appileabie, absudon the Injection wolf and
siI related arrpurtcrrances in accardaace tFa tGe epproved apeoi caqoas and conditions ofthe Permit."
11xint or Type MI Name and title
Signature ofPsoperty Owner/Applicant
Print or Type hint Name and title
slgnakis of Aulbudzed Agent, if any
P4d or Type loll Name and title
Pieria ]-atom t Yo copies of the completed Application package to:
North CaralWa DDNE -DWO
,Aquifer Protection Section-UIC Frogram.
1636 Mail Service Center
RaWgb, NC 27699-1636
Telephone (9I9) 715-6935
RECEIVED r DEN, r
Agw(er prole( G0
0If

Ju 1·. 2 7, 2'0 l i i i : i7 AM
JM te. iL,.. Io, . ~
p V"',I P (;v-!y l, "o
No. 0730 P. 5
RECEIVED/ DENR / DWQ
Aquifer Protection Section
JUL 2 7 2011
Ashe County, NC GIS - print
Page 1 of 1
Asbe Colrnty, North Carolina
"'"
p ` Cs
18290-014-012
>V 1 1820-014404 1 6-0��1-0OG r
* 563,
B1 P9B-014-02D� � ` a�
r r► 0 O.Y3i.01 ni
Buildings
j Results J
• City Limits
• ®Farm Preservation
Buildings
• Flood Way
Address: 541 WOODLAND RIDGE
. Flood Zone
Fire ZonCs
a !' Parcels
JEFFERSON FD
■ A/ Roads
i
* Water
®
er: LARSEN, 8 7 } Address: 541 WOODLAND RIDGE City: LANSING State: NC Zip,
• County
28 3 Parcel 9 4.005 Size: 1.99500 acres Bldg Value: 277200.00000 Total Value:
3222 0 k: 395 Deed Page: 0255 Plat Book: 6 Plat Pape: 283 Gpin: 298967586060
Xfer pate: 2009
To�i3s
WALNUT HILL
Vg_i1g-D-I�ir-us
NEW RIVER
http:llashegis.ashecountygov.comlwebgislprint.php?txtExtentwl285443.51071 %2C997279... 8/12/2011