WI0400216_GEO THERMAL_20110915

Permit Number
Program Category
Ground Water
Permit Type
WI0400216
I
lnjeq~ion Water Only GSHP Well System (5QW)
Primary Reviewer
m ichael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Paul Hudson Gulley SFR
Location Address
332 W Main St
Elkin
Owner
Owner Name
Paul
Dates/Ev ents
NC 28621
Hudso Gulley
n
Scheduled
Orig Issue App Received Draft Initiated Issuance
09/15/11 09/15/11
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall MU LL
Central Files: APS_ SWP_
09/15/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Paul Hudson Gulley
Owner
332 W Main St
Elkin NC
Major/Minor
Minor
Region
Winston-Salem
County
Surry
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Paul Hudson Gulley
Owner
332 W Main St
Elkin NC
Public Notice Issue
09/15/11
Effective
09/15/11
28621
28621
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
A IF
NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Govemor Director
09/15/2011
Paul Hudson Gulley
Anne Connelly Gulley
332 W. Main St.
Elkin, NC 28621
Subject: Acknowledgement of Intent to Construct Type 5QW injection Well System
Permit No. W10400216
332 W. Main St,
Elkin, NC 28621
Dear Mr. Gulley:
Dee Freeman
Secretary
On 09/15/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -on),,
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:
The injection well system contains only potable water,
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 -
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 Co:astruction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(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.Rouers a ncdenr.Lov if youve any questions.
5inc � �el�; i
for Debra art
Superviso
cc: Winston-Salem Regional Office ­APS
APS Central Files - Permit No. M11040C216
Surry County Health Dept.
David J. Brown (Yadkin Well Co., Inc., 1908 Hamptonville Rd,, Hamptonville, NC 27020)
Mark Evans (Evans Heating g Cooling, 2297 Rich Hill Rd., Glade Valley, NC 28627)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina. 27695-1636
LDcawn: 2728 Capital Boulevard, Raleigh, North Carol Ina 27604 One
Phone'. 919-733-3221 1 FAX 1:919-715-0588. FAX 2: 945.715.6048 I Customer Service: "77-623.6748 �
Internet. www.ncwaterauallr;.or- O �.0��a
An EQual uppgrTuno r AHimram, wion Empinver - " fin( tC ` rally

Sep, 15, 2011 10,47AM
No, 1005 P. 1
F,y
t.
F=IMiLE TRANSMISSION FORM
DATE: _2 I C 3" 1 r R .. 7nME; - REF NO. LOG NO.
TO:
loc
coMPANY WE FAX M PLEW
TVA r COP- In 61LIQ ❑ IMMNEOIIAM
AiTEM1oH QEP[
FROM: _ u. n CAm 9b
COMPANY NAME FAX NO.
�u • �fi+ }+ ❑ REPLY
INON M]UAL DEPE
NUMSER OF PAGES S, M'LM?A3E R°S
INGLUDING THI$ SHEET RkPIY M3Y SIG}HpIQRt6tNAi0NAE
MESSAGE: C
!L- �` •P-1 -r eA Tla
'FOR ALL YOUR WATCR NIM139-
YADKIN WELL CO„ INC.
190E NAMrMNVILLE ROAD
FIAMPTOI~NVILLE, NG t7o2O
❑AVID J. BROWN. VICE 12Ctg3,
M.6 FREE (6W) 249335
OFFICE 1336P 466.4"0
FAX 1330? df&%60La
Res (3361 +68•a65!
-09" NCW$ AMERICA • 1555 LIAKS'05Lr
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PLEASE wFoRm US cmmcxffmy lF vvj oo wi FiEcaw FiACS A E w PULL

09.S a p, 15• 201 1- 1 0:47AM368356038
YVAII
No.1005 P. 7E 01/03
NORTH CAI OLDTA
DEP RTMWT of ENVIRONMENT AND NATURAL RMOURCS8 MCDEM
NOT)MCA,TION OEDrrXNT TO CONSTRUCT A CLOMfiDLOOP GEOTMM ►►MAL
�1`LTER_UNIr J NT,]RCTION WELL isym N.I:
•
11tAccordwce HaltriteProiWousofXCACTitle 15A:02C:A200, please
complete this azoftsdon ad mail to odd= ou W Uatb Page (Please IIrW or Tng.id'oznui P),
DAB: � ��..� � _� 20-k-
A,
B.
Wall Typa Corfimiallom, Does the Proposed system circukty potable vmtw crjv (no additives) In
• o0�iriuoas pipsrtg tkia,4 coxnp],c�aly lsolatrs t]�c fluid ixom l3sc cra,►,iz•atunet�t (i.c
c osed�lao F
' ms . Cor6nue completing this fmm,
No Do Not complete this fo= Complete otherU,lC appflcatl=farrns for installiaag
either a 5A7 wall Cogc.J."-loop well inicaft potable water into the aquifer) or at 5QM wall (alosed.
loop wall aomaluiag edditivas such as R.-4 mOunal, or otber aWjfi =e or co•roslon ioMbitors),
rROURTY OWNER(S)iAMICANT(S)
List eftcOropartY ftw listed on props* deed Of o►vnd by a beuiam or gonmment agenoy, state Dame of
entity wad a represeututive wlaud=lty for sigaatare): Puri L H c3 D 50 n1 G V i-L C-,- ,
AArAE CGrI P1ELL-? drOLLE e
(1) Mailing Address: _ .33 2- W. MrA l rl .S 1
Cif+:. F-LV-) r,,A Ram N C zip Code: 2 S<Z 1-
HaMcffiF,lco Tell No.:_ 3 3 to . 636. 14 40 jjjL-
Bmail Addross: c-• a w-&e. , cc-Vebtliga
(2) Physical Address of W4 Site of dt amt than abDve):
Ciky:
State- Tap Code.
FiomclOffloc Tc]e No.; 4 xY
County:
AUT HORTZED AGENT dF OWNER, W ANY [if the P=att Applieaat 4,gAtn awn the subject pzope y,
attach a letter from tba property oNvAer sutboriz* A p* to instnll And operate uM wojn
C=par►yNama: _
11ddIB9S�
City: ` stfttm zip code: Guitaty; -- _
Off ce Tela No.: CCU No.:
WcbSitA Address of Company, ifany.
RECEIVE01 DENRr ❑VQ
Moffirpr ecljon Serbian
SEP 15 -)Off

09 Sep. 15. 2011= 10 :47AM 368S56038 Y'v'AM No. 1005 P. 3iE 82103
I ,. •
C. WILL DltlLLER lNFORMAl'lON
CompN\1:Namc:Yadkln'WeU Cg.Ilic
Well Driller Conttaoror~.s Nam.ct ... Jod~vMJ__,Jllym~-.M~dJ~b!~~~li-PW~n~_M=iU~on~Cim~~· _
NC Contractor CartUicatlon No.: 2S72.~•A:;,:,..._ __ ~--=3~03~G:.:.c .. A::i....----=B:c-.~~a-il..s.'"6.:. ·:..------
C001&cf Peaoi1• J1Ayld J, Brpw.n 21 QS~A BM,AIL Address; chicfdrlller@msn,cpp1
Address: l908Hamptonvllle Rd,·---------------~-----
Clty: Th1m)tor1vHJe N.Q. Zip Codo: 21020. ____ Coimi.r■ YRdtdn. ____ _
Ofilco Teto No.: _336-461·4440. ______ Cell No.; _336--314-8736. _____ _
D. HEAT PUMP' CONTRACTOlt tm?OKMA'?ION (it different fhsn drnicr)
CotnpanyName: IEv'f 111 HeJ~ f G.a U."4,
G.
Cootact Person: f1. q l:h.. E=. va: n r BMAILAddress;
Address: 2 2 't, R, s-b H-, ·111 t?. c.
City~ ' \ch.~Yc,rJftJ.i! Zip Cod~: .2 ~( :J.; Can11ty. .... .Lfi&~,e,11J9'.e.,L-..,; 01'..1,.;ir"'4E--~.__..--
Oftlca TeteNo.: 3~;.6-i)-1..)/t. 2.1 CellNtt-= _______ _
STATUS OF APPLICANT
Prlvm: ~ Federal:_
S11ts:_ . Mmtlclpa1,_
Co,rn.o:u~rc;lrd~ ___
'Nstivtamcatt Lindi!_
INJECTION PROormnm (brloDy dB$Crlhei :how tbe iQiectiou ,velY(a) ,vm be. QScd)
Gt,,.~ ~4c ~rr"<ph-~ ctfltl~A. G:oo/2
~ ~ ;> H..e t'??,., ,,J r•~y ,rfy2, ....
WELL CONSTAUCTIO'NDA.T• u £a.fl ~ z,.,.
(1) l'roposed date to be comtructed: q._ I q,.. ~, -Number of borlnga: --=.3;....._ __
Ap,Pto,cin2ate de,Pth of eacli borlns C~QI d ~O ' .
(2) Ty_peoft~blogtob•'ascd(coppw~,VC,elo): &~ ;,[:J2.&"it. -.IX~ 1
(S} Welt caf;ing. I& tbe \teil(s) cased? (ahcc.k oithcr (&)Ya~ (b.) No bC]l)w) .
(a) Yes __ ifye,, tlltn pt0'Vltlc coins 1n.r«.malia11 bolow
Type: ___ga11n1liud stcd _blAck stcc1 ___ pla~do ___ mher (ap~)
Casing dep1h: Fxom ___ to ___ feet (ro~~~nce 10 lt\od S\1dhce)
Casblg o1dtrios to abo'Ve rround._---:lDchGs.
Cb) .No -""'
(4) Grout.Info (material sun:oundlngwelJ catlogandfotpiplng): -r/..,t,~f.,, e,"'1,. "'"-c~ J.
{R) Gmut ·Cyp1>: Neat Comcat_ Btntonltc L Olher (spooli)) _____ _
(b) Grout pl&Gerncnt= fump.to~ Prtssure_ Olhu-_
(c) Gt~ d~i,lh af tahing (ref'~cnco to ISQid. sur.ftaco): &am 364" io 3 (lcot:)
If well bas c=asJng, mdlcate grO\lt depth: Jtom -eo ___ (teot)
0'3Stp,15. 2411=14,47AMSSP�55038 `VAM No.1005 P. 4E a"
WkCrOW-RUATED EQUU MM
AtUch a diagram shotivittg the enginee:rint lrFout or proposed modidiaatiota of the injection equipment and exterior
p1ping1tubing associated with the injection operatlom The manulkewmes bra hL rc may provide supplementary
irafbrtaatt,an.
T. LOCATION OF WALL(A)
Attach two copies of maps showing the fbllowing iniarroation'
(1) boltide a Site Map (can be drum) showing: bisildinga, propmv liras, su faro water bodies; potnfml
soi rca of groundwater contaminAnn and the orientafm of and distaoees betwu a the proposed well($) aa(I
any existing Well(s) or waste disposal facilities arch as septia tart er drain holds located .vhl3 n 200 feat of
tbo geothermal heatpump well systwn. LRW ail fbatum clearly and include a arrow.
P) The Sits, Map most al]ow the sabjee property in relation to the surrounding area by udng at least two fixad
ra&remco pouts svoh as reads, stsea t; andlor bxg way inw6ections.
X, CLRTMCATION
Note: pine Permit Appbeation mast be eignad by each person appaarbg amtthe•
recorded Legai property dmd,
"Y haeby certify, under pansy+ of law, that I havo persoualiy e"mined and am familiar with iba iafCrm on
nll=lttsa in tads document ,and ali aMchments rJ uvto and that, based oxx zriy i,ngtdry of those indIvIdtals
.immediately responsible for obtaixftssid infor=tim l isel3eva that the iniQrmad3aa true, aecurflte aad complete.
I am aware that there are sl&ffcant pansWes, including the pos3'bilfty of lines and imprlaommeut, for wbmh mg
Wse inf'armatioa. I agree to caastruc% operate, otait repair, and if ap iioabl% abiwdon the Neodon cwell sad
ail related appurtersanaas In aocardaacc with the a raved specs tat ana conditions of thD permit."
kQ L- Mun i aOLL.E.Y
or Type pWl Naas aad title
r�
Sigaature of pre ti ApppliFT
Arr i N G Con1 (�,9CLLY 6ULLE-4
Print or Type n?) Nme and He
Sigtxature of Authorized Agezt if any
?tint nr Type -Pull Name and title --
phase return two ooples of the comgleW AppllGation psokage to:
North Carorma AENR AWQ
Arjmife r Plrotation Section-UIC Program �kpr 1636 Mail Service Center
Meigh, NC 27699-1636 SEP 15 2011
Telephone [phone]

Sep, 15, 2011 10:47AM
No.1005 P, 5
]fit a[ R
A
q�i er rQtectig
ne
on
SEP 16 2011
4