WI0400221_GEO THERMAL_20111025

Permit Number
Program Category
Ground Water
Permit Type
WI0400221 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Christopher L. Gifford SFR
Location Address
4568 Frye Bridge Rd
Clemmons
Owner
Owner Name
Christopher
Dates/Events
NC
L
27012
Gifford
Scheduled
Orig Issue
10/25/11
App Received Draft. Initiated Issuance
10/18/11
Re gulated Activities
Heat Pump Injection
Private residence, single family
Outfall NU~L
Central Files: APS_ SWP_
10/25/11
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
Davidson
Faclllty Contact Affiliation
Owner Type
Individual
Owner Affiliation
Christopher L. Gifford
Owner
4568 Frye Bridge Rd
Clemmons
Publlc Notice Issue
10/25/11
.,
NC
Effective
10/25/11
27020
27012
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
A�A
NCDENR
North Carolina Depadment of Environment and
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Covemor Director
10/25/2011
Christopher L, Gifford
Shang E. Gifford
4568 Frye Bridge Rd.
Clemmons, NC 27012
Natural Resources
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10400221
4568 Frye Bridge Rd,
Clemmons, NC 27012
Dear Mr. Gifford:
Dee Freeman
Secretary
On 10118/2011, 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:
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 I SA 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 Davidson 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;R-ncdenr.«ov if you have any questions.
S aerety,
for D1'�
watts
Supe
cc: Winston-Salem Regional Office - APS
APS Central Files - Permit No. W10400221
Davidson County Health Dept.
David J. Brown (Yadkin Well Co., Inc.. 1908 Hamptonville Rd., Hamptonville, NC 27020)
Mark Keaton (K & V Heating & Air, P.O. Box 547, East Bend, NC 27019)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, Norm Carolina 27699-1636
Locaflon- 2728 Capital Boulevard, Raleigh, Worth Cmi n8 27604
Phone [phone] FAX [phone]; FAX 2:919.715-60481 CustomerService, 1-877-623-6748
Internet: rrww.iticwaterovality-om ""'-"""` '
tura!!m
An Equal Opmnunity % Affirm ative Action FmotoyeF

Oct. -1 2gAi1 2:37PM
NO, 1199 P. i
EMNALE TRANSMON FORM
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NUMBER OF FAKES � OAIGIHAMS
INCLUDING THIS SHEET BY 51GNATLIHE
MESSAGE:
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-FOR ALL YOUR WATER NeE09'
YADKiN WELL CO., INC.
1998 HANIFTONVILLE ROAD
14AMPTONVILLL NC 87=
DAVID .1. BROWN, VICr6 PRIES.
TOLL FREE 10001 ""3"
OFFICE [phone]
PAX 1340a0
RES ii341 841 AS&458.4654
-avow mews .,*nslmC■ • ado ti ovw Tdw
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PLLW D FORM L!S TMME DW&Y IP VOV CO WT FNK VE I%OSMW IN PLA,L

OCTII10c t,• 18, 20111: 2: 37PM FAX No, No. 1199 ;P, 22
NORTH CAItOLIKA
t)EpAR T OF MTMON MT AND NATURAL MOURCES (NCDMM
N07MCATION OF -IN )MT TO CONSTRUCT A 0MtD-L00? GEOTHRUOAL
MTER--ML_X VJJECIION WELL SYSTE&fs
"TYPE S— w YELL
Ill Apoor4mce tvitLdtepzmUkm dNCAC Titte 15A: 4ICO200. pkase
complete dla aaOCAtdon and wail to address on the bars, page (pimp, Ed! t Ur MW fi&= tlota).
DA.IE' a- 20-Zi,
Nerd Type Confirmolon: Dm the proposed systam oWulata potablematcr (no additives) is
oontimuo,as pxpingthat campietely,isolatw tha:id from the tAvIronmerst Clx-
cios - o 7
Yat X - Coriinve complet'sngtHs foss.
No _ _ Do trot complete this ftm. Compl de outer MC application; Toms for installing
either a 5A7 weal (q r=-loop well i 'e potable water into the aquifv) or a 5QM well (ciused-
loop Naell containing add— itivas such as R 22, ethanol, or otthtr antifreeze or eorroalon inbibitora),
A. MOPERTY OWNER(S)WPLICA,NT(S)
LIsTALt Property owner t{stsd on Prarrerty deed (if owned by it bosinesa or gover=tntagency, sWe came of
errtity and s representative cvfauthvriiy Por �> � J: ,��'�' � `�'+�,��� 1-• - � : ����
y� (1) Meiling Address: b *ram -4-- z
4' City: 4A Smre: .tp Colt:
HomelOf$oa TeJe No.: -_� -2(Az. Celaia
Br*WAddress _ WehsiSe __
(2) Plyfw�l Address a€W4 Sirs (if difkrmt tbaa above): SA)wwe
City: stds; Zip "a: Cauaiy:
.Ho=lO>Q&ce Tale Noy CCll xla:
B. AlCrHORIZit"!7 AO"ENT OF OWNt<R, ]F AKY (Ltthe PuiurtAppticant data net own the mAjeetproperzy,
nRk�Ch g Xetter �� the pr�exty nwrter $titha�zng Agent to insFt9ll altd opai�t9'(�.'�VC]Ij
compsuyxamo.
Codactpersort: ! !.VA • Address;
--
City: Suet Zip Cods; Cvtmty;
Qco Tale No.:
wabaite Andress a�c8mpaayt lf�y:

0CT11 Pc t.• 18. 28111 2.38PM FAX No. No. 1199 P. 33
C. VELL I)Td. ,R MOMWAXIM
Carnpuw Ce. In� — -
1Vstlriritler C�antractar'Sriib: v9
X,C co:itraetor Gart oatimNo.: .2 921A 106 A 354V _
contact.person,, I]avid r. Br A 21 ,�}s_ — ligzam n,com
A,ddtem:190 RamptoavIlle PA,
City. to Ha Zsp Wc- 2/020, CCZRCW, )rS
oface xeleNo,: 336-468-4444 Cep Nn.:. 336-374-Md
01 HI ATP11DO CCNT"C1l33INFMMATs0N (r£difPordnf (han4fJ1 car)
Comptury xnrr>A; _. 4, V-
Contact Person:
Address: '7
cl�+: zj� Cage; --Lta .... Coaut"
E, $TATUS OF ANIE' i
Private: 1 F4deral: Covsroisl,
Stale: A'iaaialpel. NetlYt.�mariCaaLst
V. dN'JEMON PRO ML.U' URZ (hrIaB 1 dL aloe how to Ne4(w YyAs)14It be used)
a Vac CONSTRUCTION DATA 1614
(1) Proposed dattta be coustructed: — � Number ofborinss:-..�.--.
Appra4matb depth of each boring (fi4*-j kL: —
(2) Type of tubing to be -wed (coppar, f1VC, eto): =C4E , L
(3) Wea oasbg. B t�6 vietlok) aasad? (Ghtolt eifher Co.) Xrasz (b.) No Wow)
{a} 'Yes if yes, then praY1de casing iafor dojo below
7l�Po;: ,, . gRlvantzcd steei blealce�eci� spIastio other (swlili )
Casing dopfb: Pram Mtn idCt (rafarenm to Iaud sarfaim)
Ce6to$ e?cmarrds toabavo gromd iache►
(b) No L<
(4) Grout-Wo (wAterla l auaomuting well mina and/or pipaw):
(A)Groat typo; Neat Gemeat REMO ite Qfbsr (apicuryy)
(b) Oxoutplaosmeat; Fumpb& _,,- Pressure otha,r
(a) asout: dqui o£talring (inference to lendsvri#ot): from to f�„ ! (het)
If%Y4 Lms casing, lndEcatrgroat depth. from to (ffto

OCT/!:Oct, 18. 26111 2: 38PM FAX No, No, 1199 P. 44
U. VJtC ON VW-,ATRD•r3QUrPM ', T
Attach a di&gram showing the e4oncrbg layout or proposed modi8ratiou of the Injection equipment and extador
pipingAubing assocfited with tlin injection operelon. The mnuftoturpr'a broa=ei mey pro*da supplementary
intbrsrzation.
T. LOCATION OF WELL(S)
Attach two copies of maps showing the following txftmatiou:
(l) inetudc a Site Map (pan be drawn) showing; WIdings, pmp=y hues, surf o water bofflw; potential
sources of gmupdwater cordaminagon sad the caienWi,nn ofind distances batwsaa The proposed wall(s) and
any pdz&g tvaDW or wists ftMailicWties such, as soptle t wih or drain flplds located wltbin 20Q feet of
she geothermal host pump wel] systnsrs. label all features clearly and iru;tWe gJwt1t&ag1v,
C2j The Site leap must show the subject property sa relation to the suaoonding area by u4AS at least two &a
reference points such as roads, streams, and/or highway iW=ectiow,
;, C,ER=ICAMON
Note; TBfs Per'atit AgpL�caL44ri nitasf tse sigugd r raeli person mt►pearing as tLr
recorded legs 1property deed -
"I lady cart*, under penalty of 1MV, that I have parsonaiip ftwniued and am Ammar whh The information
s6mitted in this docuanent and all artachments thereto and that, based on.. nw ingairy of those indirriduats
immediato(y responsible for obulaingadd trdbfmation, I bdiffm that the informeon is trne, accurate and oDurplete.
I = wware that tWo are 409car►t penalties, including the passibility of fnea and iusgrisoament, fot r6=1tting
false information I agree to construct; opexata, n-Wata4 repair eud if applicabfe, abandon the injection wet and
all relaw appuat=new iu Wordance vakh tfia p d specitieatiam and candhbw of the Pernik"
Signature of'Property 0vkwJAppHoW
Mnt or Type'FW1Nam and Erie
�Itws Uflllo�rwty V,er1A �laicj
r
Print ar Typo AM Nana and bile
Sigtaatwo of Authorized Agent, V say
Frlot eT T Ps Pall blame and tine
'Please retnm two oopiaa of the coMleltd Applica.don pacirsgn to:
North Carollwk Dl�t-DWQ
Aqukfer ProteodoA Bectlow-MC Program
1636 Mail Service Center RECOVEII I UYlri
RAleigh, SIC 27699 1636 A0UWPP'PPn1-r.
Telephone [phone] t?[ t I 8 �QI1

Oct 17 Oct. 18. 2W : 2:38PM
336-249-6774 N c. 1 19 9 P. 5
File Number:+r
Systm-Type: -74 xv.
Davidson County -Health lie en
eratians Permit
�Cl,,;s 61;4 . J. _ --
Applicamt's Name
F. �S ra�rr
rar &Qu- 22 W
s
wastmuff System &sWicr
AutbaftW Sty Agmt
Pftm it Canditiom
cry— 401
• Sep& Tank ghwLjga2gcv, $ 6760
Pmmp Tmk -S)wa .. PT3�3
F'd=1"W PQ1410K
-Loa4-'70SR
C-�. S�r�
f LirK,n5
0 re&
\I
`vi coo 5
Subdivkkm/5e cdowI&t #
Nitrification Field (Sq. Ft.) = 4, ) qq °f
Nitd&adonLine 4LinearFt.) 340 "
0r'n fAw Icao IL ���7�ro
or -a AaaFl000y-dl. PT 34
.PT LT
ki
1,a 9-15

4
Oct, 18, M11 2:38PM No. 1199 P. b
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