WI0400211_GEO THERMAL_20110823

Permit Number WI0400211
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
·coastal SW Rule
Permitted Flow
Facilitv
Facility Name
John Brame SFR
Location Address
90 Legra Rd
Grassy Creek
Owner
Owner Name
John
Dates/Events
NC 28631
Brame
Central Files: APS_ SWP_
08/23/11
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
Alleghany
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
John Brame
216 Ashley Dr
Dobson NC
27020
27017
Orig Issue
08/23/11
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
08/23/11
Expiration
08/18/11 08/23/11
Re g ulated Activities
Heat Pump Injection
Outfall i-~uu
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
John.Brame
216 Ashley Drive
Dobs_on. NC 2701.7
A.VA
MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
8/23/2011
Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System
Permit No. WI0400211
90 Legra Road, Grassey Creek, NC 28631
Dear Mr. Brame:
Dee Freeman
Secretary
On 8/18/2011, 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 fc;,r 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 .0211(u)(2). Additionally, you should contact the Alleghany 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@ncdenr.!mv if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400211
Alleghany County Health Dept.
Yadkin Well Co., Inc (David Brown)
Evans Heating & Cooling, Inc. (Mark Evans)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Sincerely,
for2~A-~
Supervisor
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwateraual itv .oro
An Equal Opportuniiy \ Affirmative Action Employer
NOne 1 ~ 1. art 1 '-aro. .ma
,Natura/It/
8Aug.17. 2011 5:15PM
Y
tvans Ilea[ i ns & t ao l l ng
No, 0877; P. 2"
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-NOR''H CAA4lr, NA
DSPARTMB T OF-ONYORQNM HT ANTS NAx URAL'EMIURCES (NCA13t'11z]
Nf]TY ICATION OF 7NUNT TO CONSTRUCT A " (;MMRK4L
p,T - Y rWCTItON W XLL SYSTEM,
PtAwardmico NT111%dtAImy1sload afNCA& TIO1SA.' o2ge2oo, gkose
comglett ddenotOlCadan glut ma11 [a add= on SO hark pogo (Wass M arm i htlue4cl .
iy�► rya CantIri�a�(ore: bass the propo9ed3yatom eiroi late poloblo Miu q*(no additives) in
continuous piping that calnpleteiy lsalstcs tie Mild from tha enviromnent OX
ILWO426]?
Yes X . - Colitinue aompletl lag this form.
Ku ,��)]allotoomplete this farm, Cwttptato otter MC appboationfQrms ft lrntalling
either a sm wall (MM-1cop well fuk§L1nA potabl4wato into the aqulf ) or a SQMweli (0,109 d-
loop►vela otvltairkg addltivea such as R 22, tthanol, or outer andfrooxe or corrosion inhibkors).
List as l�rope�y t)Wsrer tistad art proBetiq d eed (1r'owtled by a 6ustgd58 argwercwent agency, stafa i�e�na oY
cntlty and a represenfativo w/authority for elgrsa4►us);
(i} Wi[ng Addreas: 1 ­') ( t
City: �i b i!�+� r - slate; LiL zip cod�ea 2t3 CoLmty��—
gonlelof000Tejo Na.'
Small Address, _ _�Y�6sy
(2) PhysL^ Pl Address of Well 61te (If dfftrent timn ilbo%).
Cistate. •r L zip code: Caurlty: n
HntnelC}fftee Tells No.. "r
ATJ't UBIMI) AGENT OF GWNZ t 17ANY (if 140 PermitApplicanl does r�otown theaubject propm-ty,
attasia e.letter from tht ptopcM oWn&f authaxkatng Agent W lns;ail and opetAta uZG well)
CompsrLyNalnat
Comsat Pam'. aL Ad&;M,, _.
Addreus:
C*., Stste: —ZIP Cade. 00ttnty
0, icaTels No.:
weklta A,ddfut dcomov. If any.,
RECEIVED 1 DENR 1 aVM
Aqu'der Protartion 5edon
AUG 18 2011

Aug• 17• 2011 5,15PM
tv1ns h e a i i n g & �ooling
No.08771 P, 3111
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C. WM , DI MM MIORMATAN
WeADtlller CarrTraalol�s 1�a�et �Y t�A'rrllls �+iritiha�vBt4w _ �1{oit �t�a -
gC Cb$ireetor Cad RaftiaNaw,-
. Cania�persa � i
Mdmu 1908 kiamptoilvlllo V,
City, i Grp Coda 2742a Oahe Ytdkln-- _._.
O#fkeTeIGNo,� 336-468.d440 Coll Noz 336-3744736 __
D, BrATMIMP CON30ACTOR FOAMAMON (lf dIAVOt MRA dxllly)
Coo PetAddi",&awk
Clbr, gi {&' 2t Code, aig7_ cmt)n
P. STATOR OF iL3'1IxM#l+iT
Prlvale, t Federar:— Caia+rnaralnII _.,,,
WTet �- bbwolpt>la,...._, Native AmerloarrUndet�,
17, MJ TK*N MOWDM (brS01(y NAR b 0 used)
s r�
Q !'flIZU CONSTADMION DATA,
(1) Propascd dare to be oanstrnaI;d-. �� » m if Of baAnpl ..
ApproxImir, 41h crotch borthg (fi 60
Q) TyPe of wwwo be -Oa ad (oapp r, PVC, 919)1 "T
(1) NVOR aslog, Ts The %WJI(a) cased? (check alltser (@ j YU& (w No haioj�
(4 Yoe ifyes, the grorldecerll,g 1niOrma11vn6eloVi+
�,rpa� ,.,"gaL►riittltedaltel blaolcrtao�._,._piasua 4x1,ar(�pa��
Ceslr� dtptiti lain to feel (TOAMIft to1111d sarbaa)
Cteln,g oxtenA to above gronnd� luift
(h) Na
(4) Chout Inib (+naiarial eusrounfiis wall casing mdforpipiing); aa4
in9 Qenut [ypot NeKtG�emen+,� ' Bei�lauT[e ✓ Ogsor taE�aci$►j '
{b) QrouL p1AC4iitenl; Pumplvg� Pt�ssure puree
(6? Clroakdvplta oS`tel5ingreassta tart d atYrl;tca)SL; m, (feet}
[ftivGlilzas 9ing,lndlaal4groutdeph., fhin�
r
►4AuHffr Prd.�,^.
AUG 18 1DI1
IL

A'Aug, 17. 2011 5:15PNE t:van s Heaz i ng & Loa i i ng No. 0877 P, 41J
�, ��,TJCTYQN sir A�� F�v7Fn�TIT
Attach a d[ag showlag tho onginculag lteyout or propodad modltleallo"D orthe Injecuon equtPTmmt artd exterior
ptpingltubing assaclated wltll the 1n ecllft optratlorz TEO manufttwrlea 6rocltuta may provide :trppiem0nMY
fArmadlae,
L LOCiL'7 xon 0,F WALL(S)
Attach two OPW of tnspa Showing Ra MADWIng Wbamallmn
(i) Inoltida a Slto Nip (can be drawn) sliowie$: tl iMigs, pm RV dries, aural" "Let $014W; ,poteallaI
sources of gra�ndwatar catltsttrlae4ara and Z� orle>�[atlaza of ar�d 3lstaacw bstwLan rho prapflaed wc11(a} atad
r q �g Lei!{�} or Wgsle dlspasal fZc1JUW ouoh as segilz tanks or drain fa$#ds localed ivithlti 200 feat of
the geothermal hsutpump well system. Label ailft Duos otcarly and j
4Z3 The site Map mttst show the suwwt propow In relatiaA to tho surrourading sres W using at least rwo fixed
rejuanee polnls such as roads, etreams, and/or bl&kway lrrterscciio�►s.
4 CBIt=ICATION
motsi Thts rcrmtt A"lizAtlota must ho slgaad by pacts parson appaaring nrs Tice
recorded tegalprepdr(y deed,
"I iterdby cn i(�, v adef pertxlly of few, that i )Mva ker%oneW eurn(ned and a-M Ibmillar with 1ho infarartailon
sftlttad lit this dncwnent and all atiacfaments tf=vto and that, based on my triquky of dines ladlviduala
Immedistaly responsibla ibr obtaining Bald InCormallon, I behave that (he ith nul(ca Is Ira, acct retie and complete.
1 am mvatia flint than pro avg doant pdnaltiesr fuoiardtag d►o posslbOlty of fines end Imprtgomnont, ibr sobmitsfng
Ma intbematlon, I agwa to aonshaai, operate, nWntaW, rapsls, and It applicable, abandon to hd otian Welland
aU related apgorlanancoa In eccordeme i ththo approved apecifteel(ons tad oondl$)rrs ottke permit."
11ELfUto ofPropelty OwacTfApplloont
M _r
RrIM o; Typo FURNama na$ t1d6
go -nature ofl?rapOrty CWM Appliearit
PAM or Typo Fall Aine and tide
SWaturaofAutlw*cdAgrnt, ifaR
Pruct orTgPft W Warw anti title
Please return twn caplaa of tlto completed 4plivallou pac&age to:
Wortli Carolina IIXNRtDwQ
A quifl)r Protection S ectivz;l•DIC rl,ogrxm
1636 iV M) Sawko Center
RaWgh, NC 27699-1656
Telephone [phone]
RECEIVED I DENR 1 D4Vp
Aquifer Protfrtion 5erWf,
AUG 18 2011

Aug, 17, 2011 5:15PM k 0877 P. 5
li-C)Ail )s r-Olne-
�kth [iC ti G. 17m
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RECEIVED I DENR f D'VQ
Aqu4f$r Protertion Section
AUG 18 2011

Aug.17, 2011 5:15PM
No.0877 P. I
FAMLE TRANSMISSION FORM
DATE: -- 'L1 TIME: RIEE NO. LOG NO.
TO: A) ell. 7.1X -P.6 0�
COMM4 Y NAME FAX Ha mtfrA9E
► on ,j car- Fl r it TC9
ATTENTI
FROM:. I/g �/; q k t-a Ga
COWRY NAME -
�J
INDMI?UAL
NUMBER OF PAGES
INCLUDING TKS SHEET
157
MESSAGE: 4
e
1
-F'OR ALL YOUR WATER NEEl7E
YADKIN WELL CO., INC.
i" HAMPTONViLLE ROAp
kAMATONVILLE. NC 87090
OAVI❑ Jr BROWN, VICE ME&
TOLL FREE (*=I 24"255
pFFicf (3n) 4$4.4"0
FAX i336) 4"-40"
RES iam AW-4659
-0001; NO* Al1CRICA . roW 16OV93 YOU'
{ MEQu1TEi1r
DEP.
FAX K PLEASE
❑ FEW
ORIGINRwel
RECEIVED i DENR r 0WQ
Pro actian Section
AUG 18 2011
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