WI0400220_GEO THERMAL_20111024

Permit Number WI0400220
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Betty Winslow SFR
Location Address
176 Bomont Ln
Moravian Fis
Owner
Owner Name
Betty
Dates/Events
NC 28654
Winslow
Scheduled
Central Files: APS_ SWP_
10/24/11
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
Wilkes
Facility Contact Affiliation
Owner Type
Individual
Owner Afflllatlon
Betty Winslow
176 Bomont Ln
Moravian Fis NC
27020
28654
Orig Issue
10/24/11
App Received Draft Initiated Issuance Public Notice Issue Effective
10/24/11
Expiration
10/11/11 10/24/11
Regulated Activities
Heat'Pump Injection
Outfail N:.JL:..
Waterbody Name Stream Index Number Current Class Subbasln
AVA NCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Betty Winslow
17 6 Bomon.t Lane
Moravian Falls, NC 28654
Coleen H. Sullins
Director
10/25/2011
Subject: Acknowledgement oflntent to Construct Type SQW Injection Well System
Permit No. WI0400220
176 Bomont Lane. Moravian Falls, NC 28654
Dear Ms. Winslow:
Dee Freeman
Secretary
On October 11, 2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onlv
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 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 violatfon of the North Carolina Well Construction Act and North Carolina
Administrative Code Title ISA Section 2C Subchapter .021 l(u)(2). Additionally,_ you should contact the Wilkes 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. Wl0400220
Wilkes County Health Dept.
Yadkin Well Co., Inc. (David Brown)
Associated Heating & Air Conditioning (David Burchette)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Sincerely,
forQ~~ft~
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-\ Affim1ative Action Employer
Ninrth Carolina
!Vaturall!I
Oct.1a, 2011 5:16PM No.1152 P. 2
NORTH CAROLJNA
DEPARTMENT OF ENVIRONMENT ANY) NATURAL RESOURCES (NCX)ENR)
NOTMCA17ON OF WENT TO CONSTRUCT A CLOSED -LOOP GEOTMRUAL
WATER ONLY INJECTION WILL SYSTEM:
TYPE 5—():w WELL0
In Accardauca 117th the protdsions ofNCAC Title 15A: 02CD20% please
complete this uotWcatian and mast to address on tare back page (please p�fi or TWe Wfarnwtion).
DATE: Zo — -5` _ Ztf_LL \,�04 00aq,0
Weir 7" pe Coqr1rinafron: Does tho proposed system circulate potable ;rater Oulu (no additives) iu
oon&uous piping that completely isolates the fluid tom the ertvlro=ent (i.e.
Yes �� Continue completing this form.
No Do Not coruplcto this form. Complete other UIC application forms for installing
either a 5A7 well (2=--loop well in' n pnta-Wo water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antif'rme or corrosions inhibitors),
A. 1ROPERTY OWNRA(S)/"FLTCA.NT(S)
LisqLq4 Property Owner listed ors property deed (if ow�n7ea ed by a busizm or gov=errt agency, stato name of
tntity and a representative�s wlauthority for sigasture): uj""" r�I 11
(1) Malling Address: l *2 (a 1�6~e-V L P%—
City: o Stage: JC.7ap Cade:�2 K,.rP Cou0rr.-kd'2'k e -.r
HomrJDfficeTole 3+Ea.: _Zrc, W)- .27 _celiNv.:79,V. 7o3o
Email Address: WeMLA
(2) Fbyalcal Address of well Site (if dilibreat than above): _ _.S 4 rr a
City; Stair: Zip Code: County.,
Homel05ce Tale No.. Cell No.:
R. AUTHORIZED AGENT OF OWNER,17 ANY (if the Permit Applicant does not owls the "bjectproperty,
attach a letter from the property owner auihorizf Agent to install and operate InC .veil)
Company Name:
Contact Persons: _EMAM Address:
Address:
City: state: Zip Coda: County:
OfficeTelawo.: Cell No.:
Websita Address of Company, oaf any:
RECEIVED 1 ❑ENR + {}fir; j
Aquifer Protacdori SeMon
OCT 1 1 2011

Oct, 10. 2011 5:16PM
No. 1152 0.
C. WELL DRiLU R XNFOTMITION
Company Name;YBdkin'Wall Co.I=
Wall Drlllar Caatrector's Nsn�: Jodymull Martbaw Brown Milton CM
NC Contractor Certif[cationNe,: 2572-A _ 303G A 3348 A . -�- -__---
CcatacfPersojt- Davidl. aw 219,rt-.A .._ �MAiLAddress;,glg&lfer{ W=,,Mm
Addtess:1909 F=ptonQ311e Rd._
City. Hamatonvi11• N.C. Zip Cade: 2ID20 CounV, Yadkin— --
OjMce TeleNo.. 336.468-4440 CcH14o.: _,336-374-E73,5: --
b. Rr,.krI'UMP CONT"CTOR ITUORMATEON (if diffexent than dril er)
CompanyNaiw: IaG.a.
Coataof Feau: el l7y'ld 6 uv-c k5j 4-r.-, MATiR. address: --
Address: FG 1141V a 451 _ -
City: ,U• 4?• Zip Code: - 1 County:
Qffice Tele Na.: _ — � �_ 2Vf-2 CCH Na:
P, STATUS OF APPLICANT
-p-rivate: f Federal' ComnterGiA1:"
F.
Stele: Ylanicipal: 'Native American Lands:
1NJECTiQN PROC]ti MM (briefly describahaw the be usad)
C. iYM CONSMUCTIONDATA
(1) Proposed date to he constructed, &,ki -(S� —Number of borings:
4prv4vaute depth of each borIng (feet):
(x) Type of (,:bla be -ased (pp, PVC, Eta}: p� �D��e
(3) 'Wei[ casing. Is the vvell(s) cased? (cheek eifiser (a) Yes or (b)No below)
(a) Yes ifyes, then providacasingiafQf=6oabclmv
TYPc: sfeel btaak sier piasHc_ct]ter(sPOrft)
Casing depth: From to Feet (reference to land srr$ce)
Casing extends to above grouad inches
(4) Grout Info (material surrovikdtng well caslagand/erpiping): �r�.=6I� En�gFtr.�J,
(a) Grout typal Neat Cement Bealeuite 01har (specify)
(b) Grout placement: Pumping__ iz Pressvra other
(e) from -TZ O to (feet)
If ivO Las rasing, Indicate grout dapfir from �to - (tto
RECEIVED 1 DENR f OW Q
Aquifer Protattion Section
OC I 112011

Oct.10. 2011 5:16PM No.1152 P. 4
' .
:f;l, XNJECTION-RELATED'EQUIPMENl'
Attach a diagram showing the engu,eering layout or proposed modification of the injection equiplllent and exterior
piping/robing associated with the i~ectio.11 operation. The manufactur~r~s btoehUte may provide supplementary
infor1nation,
I. LOCATION O:F WELL(S}
. Attach two copies of maps showiDg the following information:
(l) Include a Site Map (cau be drawn) showing: buildings, property lines, surfaC'e water bodie.s; potential
s01lI'<ia af groundwater contamination and the orientation of and distances betweeti the pl'oposed well(s) and
any existing well(s) or waste ctisposal facilities such as septic tanks or drain fJ~!ds located within 200 feet of
the geothermal heat pwnp well system. Label aU features clearly and include a north arrow.
(2) The Site Map mus~ show the subject property .in relation ~ the surroundhlg a,ea by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
j_ CEllTlFICATION
Note: This Permit A.pplicstion must be signed 'J;ly each person appearing on the
recorded legal property deed,
HI hereby certify~ under penalty of lawJ that I have personally examined and aui iainiliar with the information
subnutted in tl1is document anc1 all attachments thereto and that., based on my inquiry of tl1ose individuals
immediately responsible fer obtaining said information, I believe that the information is true_. accurate and complete.
I ain aware that there are significant penalties, including the possibility of fines and imprfaonmentJ for submitting
false inform1.ti0n. I agree to cons1ruets operate, maintain., repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with tht approved specificatiom and conditions of the Per.mit/1
~~ d l/4:-,.,~
Signa'turf Property Owner/Applicant
LJ .C ff-) 5 ✓, ~ ;1 / 6 W
Print or Type Full Name aud title
Signature of Property Owner/Applicant
Print or Type Full Nanie aud title
Signature of Authorized A.geJ2t, if any
Print or Typr; Full Name and title
Please return two copies of'tl1e COJnpleted Application. package to:
North Carolina DENR-DWQ
Aquifor Prottction Sectfon-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
TelepboJi'e (919) 715-.6935
RE~EIVEO I DENR ID
Aquifer Protection Se t~Q · CIOh
OCT 1 I 2011
Oet, 10. 2011 5:17PM
No.1152 P. 5
ad'
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IN60-4&id^ PtVJ kC - 2 $C s 0
RECEIVED r ❑ENR / DM
Aquifer pro,Af;tsan Se dan

Page 1 of I
Your search found the following database informatlan. Map wlll display in a few moments.
PRUPOZIY CAfW ,+fe w f Foft A,
SEARCH RESULTS.
PARCEL —ID
2203341
ACCOUNT
26506
OWNERI
WINSLOW. BETTY
S
OWNER2
MAIL_ADDRi
1176 BOMONT LANE
MAIL_ADDR2
CITY
MORAVIAN FALLS
STATE
NC
ZIP —CODE
28654
GLASS
F1
FIRE_DIST
F21
FIRE —NAME
I BRUSHY MTN
TOWNSHIP
WILKESBORO
PROP ADDR
176 BOMONT LANE
ORTHO_NUM
3865.02
PIN
3865-7"914
TOTAL —ACRE
2.74
LAND_VAL
174200
AGLAND_VAL
0
BLDG_VAL
184470
TOTAL_VAL
258670
COSTTOT_VA
258670
SK_PG
518/236
BOOK
518
PAGE
236
DEED DATE
00100/0000
OLD —NEIGH
427
NEIGHBORHD
21100
SALEDATE
SALE PRICE
10
http:llwww2.undersys.comiscriptsltestadvlusiwehsfix.dlllusl?formis=selectnam&MouseX... 10/24/2011

Oct, 10, 2011 5,16PM
NQ.1152 P, 1
F=IWLE TRAMSSION FORM
we 14 TIME: REF, NO. LOG NO,
To: (g1 -mr 6c?W
COMPANY NAME rr FAX AA PLEASE
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1uupI1umv
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FROM: -_4-kr t% w•Q(( (.3,t )
COMPANY HATE FAX NO.
NNOMDUAL
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PLEA,,E
PAM
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NUMBER OF PAGES PLEASE ORIMNAYOR'S
INCLUDING THIS SHEET REPLY gY SIGNATURE
MESSAGE.
_ 'c- w X1, g ej f:�' to "4J
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-FOR ALL YOUR WATRR Nxms*
YADKIN WELL CO., INC.
tsoe HAMPYONVILL> ROAD
HAMPTONVILLE. NC 27020
DAVID J. DROWN, VICE PRlE5,
TOLL FACC JGQOy 265;4365
a17FlcE (s36) 468+444
Fax I3s6I 45&40"
RES (ZS61 46&4669
'GOW NEWJJ AL.$RIr.A • GCD (,WO Vft'
REL"EIVED i DE -Ng i nte►r►
Aquifer Protection S". on ...._
PLEAASE INPDW LI8 R4MMIF4 W IF VW no Nor R20or r FACSlr= IN FULL