WI0400218_GEO THERMAL_20111018

Permit Number
Program Category
Ground Water
Permit Type
WI0400218 /
Injection Water Only GSHP Well System (SQW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Charles & Lesley Lewis SFR
Location Address
355 Beaver Creek Estates Dr
West Jefferson NC
Owner
Owner Name
Charles
Dates/Events
28694
Lewis
Scheduled
Orig Issue
10/18/11
App Received Draft Initiated Issuance
09/28/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
10/18/11
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
Ashe
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Charles Lewis
355 Beaver Creek Estates Dr
West Jefferson NC
Public Notice Issue
10/18/11
Effective
10/18/11
27020
28694
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
A.VA
HCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Charles Lewis
Lesley Lewis
355 Beaver Creek Estates Drive
West Jefferson., NC 28694
Coleen H. Sullins
Director
10/19/2011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400218
355 Beaver Creek Estates Drive, West Jefferson, N.C. 28694
Dear Mr. & Mrs. Lewis:
Dee Freeman
Secretary
On September 28, 2011, the 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:
l. 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 .021 l(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 [e-mail] if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. Wl0400218
Ashe County Health Dept.
Yadkin Well Co. Inc. (David Brown)
Scott Brothers Heating & Air, Inc. (Mike Carter)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Sincerely,
0 U~A taw
for Debra Watts
Supervisor
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity I Affirmative Action Employer
NOneh·ri .'" ort L-arouna
,Naturall!I
-Sep.28. 2011 10:31AM +nun+�r �_'_ °lNo.lab$ ' -P, 2
'r C+2
NORM CAROLINA
DEFA)'iNMNT OF EN VUtONMENT AND NATURAL RBSOURM (NCDM)
NOTMCATION OF iM1► T TO CONSTRUCT A CLMD10OP GEOTFTERMAL
WATER -My INJECTION WELL SYSTEM. -
TYPE 5—OW WELL(S)
In Accordance Ivitiz ttLe provisions ofNCAC Title 15,Ar 02C.0200, please
complete this notification mid =29 to address on the hart; page (please Prhaf or in izfotaxatian).
DATE. 7".49 � 201j..- V_S� 0 4 0 0 D'V�
WeI! Type ConfrrmatiM: Does the proposed syst= circulate potable water only (n❑ additives) in
continuous piping that completely isolates the fluid ftom the environment (i.e.
as h
Yes _X . Continue completing this form.
No _ Do Nat complete this form. Complete other UZC applimtlomforrzs for metal( ng
either a SA7 well {deg -loop well jecti& potable water into the aquifer) or a 5QM w611(ciosed-
loop well containing add' vas such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A, - PROPERTY OWN-ER(S)IAPPLI<CANT(S)
List each Property Owner listed oxx property deed (if owu.�d by a business ox government ageAcy, sects name of
entity and a represeutative wlauthority for signature): C P. eS
(1) Meiug Address: 355 9ec+. V e r Greek , s 1�c� �S f
Cit}r: 5tm. h1 L Zip CodeAr
Hoe eOffiee Tel. - No.: Cell No.., -
Bmail Address Website:
(2) Physical Address of Well Site (if different than above):
city�
State: Zip Code;
K=el0 Moe Felt No,: r'.11 N .:
County:
B. A,U' 50=RD ACZNT OF OWNR, IF ANY (if the Permit Applicant doe$ a own the subject property,
aMzh a letter from, the property owner anthorizing A.g t to install and aperate UIC well)
Company N&=.
Contact Parsons - EMAIL Address: �.
Address:
Cfty:
State: Zip Code:
❑ffloe Tele No.: Ce11
6Webske Address of Company, if any:
County:
RECEIVED 1 DENR 1 [)vvQ
Aquifer ProterW i SecUon
,%P28Mt

'Seo.2$, 2011 10:31AM YAugN wt-_
Nk 1068 ",P, 3
L5, Q Lx)
C. 'VELL DRMLER L' FO-AXATIOX
C.cmpnuy 3�'aiae:Yadkin FJ9tI Ca c.
WeIIDsI(l� Caaaactar`s itiame: Ia Muiiis Msttl:ow _rown, Milto�z �,.�
NC Contractor Ctttiftr.stion No.: 2572-A 3-WA 3548-R .
Cozaact person: Dxvic3 J. Bro�vts a F�UTAIL A : c$ie dei o� ss.cn�
Address: 1903 R=ptaaville Rdti
City: , 4nvitla _ N-C. zi2 Code: 27020 County: Yadki
0fn" Tel&Nc-- 336-463.4444 CellNo.:_�36-3744736
D. HEAT ]PUbM CONTR6,CT01? IMF OSKA' ION(if differoat tixa &Mer)
company Name:�5=o p ' &-nj L-� j d J' my
- � r J
' At2G4l?er3� r�1LT L�Carre r AiL A ddres : @ *bro
Address: _I.8 �o���ve• �. -_ G�a u � Gi14, -� _� _
City: Zip Code: gfI6.2t. County: Ask s
Df ice Te1eWo.: 36 ,P77 IT0.9 Coll No.: ,Ls _8 7 i-- 4,V 2 z
1r, STATGS 4F AFFIJ"NT
Private: a,1 Federal: Car�mertial:
State: Municipal: NativcA=erimLands.
F. DMCTrC:F PROCX.DU W- (bri8y desczlbe how the lajectiva wv11(s) will be, used)
G.
WELL. CONMUCTIO DkTA,
(1) PrOpaeed date to be cant aed-. 04 - • ? tat' { Xumbtr of borings: off.
Apgmxitrxte depth of etch, boring (feet): .2 54
(2) Type of tubLcg to be -used (eoppa, PVC, eta): r — ( %
(3) Well using. IS the wall(s) cased? (aeck either (a.) 'des ar (b.) Z! io b"v)
(a) Yes if yez, then proide casing inf7rmat1on below
Type: --gat,faniaed steaI blao?r steel piasEio other (specLW
Casino, depth: FFcqua to fsst (-N^encc to Said Suttee)
Casing axterdt+o above ground inrhss
(b) -ya .!
(4) Gr vut Info (material suzrotmding ►rtli wring amVor piping):
(a) Grout, IyTa: Neat Cezueat�Scritarsite tf other (spacirv)
Co) Ctraut placement: PumpiBL—Z Fresatne other
(C) Grant depth o£tuting (reference to land surfaoe): from ZLJ7o to D (feat)
I`will has easing, 3,a iwt grout depth, tom to (feet)
RECEIVED i DENR I DM
Aquifer Protetion SOCJon

"Sep, 28, 2011 10: 32AM T'd%1" .'r_ _,
" No. 1068 P.
g. Va, CTiON-RELATU EQ'UTMENT
(VLu
A.tt=h a diagram showing tize cugineerina layout or proposed modiBcau00 of the iajwdort equipment and esx-Cior
pipingltubirg associated witli the iajeMoa operation. Tic manufacturer's broehi'e may provide sapplamelltary
in£ozmatia,u. .
I.. LOCATION OF WELL(S)
.attach two copies of maps showing the follow-iAg ilaforiti=
(1) iticlude a Site Map (can he drawn) showing: buildings, property lines, surface water bodies; gvteatia2
sourc;.s of groundwater cou= azation and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such ag seprtit tanks ❑r dra h $eIds located witbiz 200 feet of
tl�a geothermal hest pump well system. Label nit features clearly and include a n ow,
(2) The Site Map rnut show the subject property in relation to the surmun&g area by tisixig ai xeast mo fixed
reference po.mts such as roads, streams, and/or highway intersections.
;- CERTIFICATION
Note: This PcrmitAPPUestion must be signed by Leon Berson Appearing on the
recorded lega3, property deed.
"I hereby certify, under peuatty of law, that I have personify examined anal am familiar with tine Wormaiioa
submined in this dccumeat and all attQchmeuts thereto and that, based on my inquiry of those individuals
immediately responsih!a for obtaining said informatim I believe that the informmation, is true, accurate and complete.
I am aware that there are saga ficant penalties, t�aludiug the possibility of. fines and imprisonment, for submitting
false information,. I agree to construct, opmte, maiatain,, repair, and if applicabie, abazdon the injection well and
all related appurteaamcw in accord—ance %Ykh the a proved specifcarions artd cala l = ofthe Permit."
t
Siga"e or Property Orvvner/Appllcart
'PI/- Cl rlej /61 Jher �—FwI�
Prim or Type Full, Xame aid title
Sigasture of erty ow�rlApplicant
Frizt or Type Full Yame and title
SIVRture of AGlnorixed Agent; if any
Print or Type Full Name =d title
Please ze= two copies of the completed Apphcation package to.
North Carolina DENR-DWQ
Aquifer Prnteetion Seetiou-UIC Program.
1636 Mail Service Center
Raleigh, KC 276W1636
Telephone [phone] RFCEIVED i al<MR I Ltd
koter prde iio;t S50011
SEP I8 IN

Sep. 28. 2011 10,32AM
No, 1068 P. 5
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RECEiVEO I OENR I DvvQ
AquPr°Seal,
a r�
SEP 28 ?ntt

Sep. 28, 2011 10:35AM
NG.1069 P. 1
�J
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Y
FACSIMILE TRANSMISSION FORM
DATE: { TIME: -, REF NO. LAG NO,
TO: e' p Na 7[r - 6 a f g
COMPANY NAME FAX NO, PI,m
0 [] DuEUVEU�LY
ATTENTION DEn
COMPANY NAME mX NO.
nrAj a, — - - p
� T3$RLY
INOMDVAL DEPC
NUMBER OF PAGES � PL EA8E ORIGIHATOMS OG i
INCLUMUG THIS SHEEP REPLY BY =NATI IRE -
MESSAGE:
r
"FOR ALL YOUR WATER NEE1363
YADKIN WELL CO., INC.
}ypa HAMPTONVILLE ROAD
HAMlPTONVILLE. NO 27020
owo J. BROWN, VICE PRES.
TOLL FPl66 4464i 24043"
OFFICE 13M) 468.4440
FAx r336) 46840AS
pas swel AG&4459
°EF' 28 2011
FLSAW I M LTG SDACDIRTMY IF'VOU DO HOT RWUA $ FACWLS TN FULL

-'Sep,29. 2011 10:35AM rnunt+r rrt'-
r Flo. 1069 P.
Z ~QV.."
NORTH C.AROLINA
DEPA.RTMMa OF FNVMONUENT AND NATURAL nSOURCES (NCDENR)
NOTTa9'ICATIOI4 OF INTENT TO CONSTRUCT A CLOSE OOP GEOTIM M kL
WATX -QNLY INJECTION WELL SYSTEM:
TYPE 5- W LL
Tit Accorda= lvith the provis = of NCAC Title 15A: 02 C,4204. please
cowplete this not&cadou aid =1 to address on the barb, page (please !! or Lv2—c i vfbr=iou).
DATE: �� _ 20_
bill Type Conflrmat4ore, Does the proposed system circulate potable water oral (no adMvet) in
continuow pip4ig chat catoplc;ely isolates the fluid from the eavkuwnad (i.e.
c sed-loo 0
Yes X; Continue oompleting this fornt.
No I)o Tot complete this form. Complete otber UIO appitcatozz foru:s for iostaU xx47
either a 5A'7 wall o en -loop wall ini� potable water into the aqulfer) or a 5QU wall (closed -
loop well codaining ad 'ves such as R-22, et#aanoL or othm antiixeeze or corrosion inhibitors).
A. PROPERTY 0WNXP.(5)IAM1CANT(S)
Lot each Property Ow= listed on property deed (if ovvaed by a business or governxaentr agency, state Wme of
entity and a repros eatadve wlauthority for signature): cti f ) e-g
(1) Mailing Address: -f5 Creek Fr La Is Z)r,
City: We + � a� �..ro .1 State_ A/ G Zip Code:^.8 6 9 � — County: rd s
Home/o fflce Tele No 3334� 2 7 7,- -" 6 _ Cell No. -
Email Address = Websita:
(2) Physical Address of Well Site (if different th34 zbovs):
City-: State: ?lip Code, Ccna dye
Hame'Of "Tale No., Cell ltia.:
13. AUT]E 0XZED AGENT OF OWi1ER, IF ANY (if the Permit Applicant does not own the subject property,
atnch 3 letter tram the property owner w7thorizing A.gera to iosw and operate UIC well)
Company 11 amz:
Contact Parson: = a Address:
Address:
City: State; Zip Code: County:
OfEce Telo No.: Cell No.
Websim ,Address of Company; hazy: _ oGCEiVED ► GENR i OM
j qultei Prott~dion Ee,10 I
SEP 28 Hii

Sep. 28. 2011 10:35AM YA! KtN 4!'k
C. V►ELL DR]LLLER L�7R,IVIATION
iori7my Neute:Yadldn W$]I o. c.
1069 P, 3
S' Q ('�-)
wall Drift Ccrtttmctor'a Na=. JodLMullis Ngrbo—y grown _ _ 1MiIt-04 aWa
NC Cgntractar Certi&ra aahio.: 2S7Z-A 3 36 -A. 3548-A .
Contact ftsos, jDavid 3- $roF�n�19.9-A EMAIL All , chiefd ' �,00
Address: 1909 Hamptanville Rd.
City; i3smpt nVille hi.C. _^ Zjp Coda; 27020 County: Yadkim,, ..-.
Off4o Tele No,, A336-46S-4440 Ceii N'v.:�336-374-873b
A. HEAT[` PUMP CONTR.. CTf>~R .Le1II�,Fb OPMATIO1 (if different j�tbRz arMer)
CaraljEcsj+?�latne' SCc7 C+ �7 ��r� a i rtts L�- l'F f i
c'oatact 1
Address:
City: ,L
DfMce Te1sN1o.: Call No,:. 36) 8 7 i— 6 yZ 2—
E. Sz'ATCS OR gFPlaCAn
Friv..te. t!, Federal: Cnrnmerni�.l:
Statc; Ivltmicipal. Native American Unds.
F )N,%ECMN' FRQCED1=- (briefly dtscrlbe }taw the Weeiou we?F(s) will be used) I
00
G. A7ELT. C01%nVCT10 1) ATA
(1) Proposed dateta be constl'=ed T=0c' 20 t Number of bcling& v2—
AppTa:drwc depth of etch boring (.feet): r2 5a
(2) '[ape of t�gto be us#d (capper, PVC, vto): F' {
(3) Well easing. Is the weil(s) cased? (turtle either (a.) Yes or (b.) No below)
(a) Yes _ if yes, then provide casing infor=don belaw
Type: galvarkedstec1 blao% steel plastic other (spectzy)
Casiag depth.- From
to �iret (reference to Itod sur_fece)
Cssing extents to aba'vs ground iuchss
(b) 24a
(4) Grott Info (rrAttrW stz ;mdirg well casing and/or piping): T�r.w,••�1� �,.� �
(a) orau< we., Nest Cement &entonite other (a pacify)
mac.. Cow
(b) GTCUt p,l=Zlent: Pumping FtCSIMe— othar
(c} Groat depth of tvbirg (mferenee to ]and surPaco): ftm 2 ro to O (sty
Tf wall hna casing, i,odicxte grout daptb: frotrz,`= to 14. (fees
�TrGE1VED 117EfVR
Aquifer Prctectean Section
SEP 28 2011

Seo.28. 2011 10:35AM "`No.1069 P. 4
Ii. INJECTiON ULATED EQiTJVZv ENS'
Attach a diagram shvwia g the engineeriaz layout or proposed modifica�oa of the injection egnipment and exterior
pipia;ttl ing associated with the iajacRon aperetim The rmmSzcturpr's brochure may provide suppleroas wy
information.
L LOCATION O7F YaLL(S)
Attach two o❑pies of traps showing the follow]mg zufar=tion;
(1) Includs a Site lylap (coat be drawn) showing: bttildiags, property lines, surface water bodies; potential
sources of groundwattr wntamination and the orientation of and dices bet veera tbit proposed wells) =d
any existing welI(s) or waste disposal facilities such as septic tanks or drama fields located within 200 feet of
the gtotbermal hcat pump wilt system. Libel all features clearly and iris udY I north
(2) The Site Map must show the Subject property in relation to the surrounding area by using At Iesst two faxed
reference points such as reads. streams, and/or highway intersections.
J- CtRTTFICATION
Nate. This Permit Application crust be signed by eaeb parson appearixg on the
recorded ietrpI property deed.
"I heraby certify, uu&— ponalty of law, that i have peasonaty examined and am familiar wit The iuformetian
submitted in #iis document and aU attachments thereto and that, based on nV lrquiry of those individuals
immediately irespomible for abtainsi said i fozrnatiorl, I believe that the information is true, acawate and aomplety.
I am aware that there are significant penalties, iaaludiug the possibility of fiaos and imprisonmexa; foz submffing
false idormadon. I agree to eowtm4 operate, maintain, repair, and if applicable, abandon the injection well and
all related gptuteaanccs in accordance with the a roved s�pecafications and conditions of the permit„
r
Sigraattire of PropeAV Owner/Applicant
)VL-C4r%F$ /14l �r -Fwi2
Ffiat or Type Full Name :.ud ti de
r�
Sigaa�tvroofP�erryovvaar/Applirut
Print ar Type F 11 Yz=e aztd title
siguxttzra of Authorized Agent if 24Y
Print or Type Full Naive znd tide
Flease rez= two copies of the completed Applicatian package to:
Korth Carolina D ENR DWQ
Aquifer Protection Section-QIC ?roaram
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]a RECEIVED / DENR 1 MQ
muftr Pmte-dirm Sec6orr
SEP 28 2011

5ev, 28. 2011 10:36AM
No.1069 P. 5
54:�4 ov &--; #;13 4'dw'w
wyO
D�F�4
RECEIVED ► [ENR 1 MU
Aquifer Pmterftn so,-