WI0400222_GEO THERMAL_20111025

Permit Number WI0400222
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
Mitchell Isaac SFR
Location Address
1121 Claverton Ct
Winston Salem
Owner
Owner Name
Mitchell
Dates/Events
NC 27104
Isaac
Scheduled
Orig Issue
10/25/11
App Received Draft Initiated Issuance
10/20/11
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall r-!U~L
Central Flies: 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
Major/Minor
Minor
NC
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Mitchell Isaac
Owner
1121 Claverton Ct
Winston Salem
Public Notice Issue
10/25/11
NC
Effective
10/25/11
27020
27104
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
��..r`"u.. A—
WDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly ;saves Perdue Coleen H. Sullins
Govemor Director
10/2 5I2011
Mitchell Isaac
1121 Claverton Ct.
Winston-Salem, NC 27104
Subject: Acknowledgement of Intent to Construct Type 5QW Infection Weil System
Permit No. W10400222
1121 Clavcnon Ct.
Winston-Salem, NC 27104
Dear Mr. Isaac:
Dee Freeman
Secretary
On 10/20/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onl.
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
-
I . The injection well system contains only potable water,
7.. 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 Forsyth 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.Roversr&ncdenr.sov if you have any questions.
Si erely,
[ .
for D' atts
Supervisor
cc: Winston-Salem Regional Office - APS
APS Central Files - Permit No- )Ag04OO222
Forsyth County Health Dept.
David J. Brown (Yadkin Well Co., Inc., 1908 Hamptonville Rd., Hamptonville, NC 27020)
Mark Hollingsworth (Logan Heating & Air Conditioning, Inc., 5142 N. Causeway Dr., Winston-Salem, NC 27106)
AQUIFER PROTECTION BECTON
1636 Mail Service Center, Raleigh, North Carolina 27699-16H
Loeafion: 2728 Capital Boulevard, Raleigh, North Carolina 276N ORe
Phone: [phone] FAY 1:919-715-0588; FAX 2: 919-715-6i048 I Customer 5ervicer 1.977-623-6748 NorthCarolina
Internet www.ncwateroualih+.o►u �{�+/�
An Equal 4Dporruii41 AMrmative AMn Employer u � s1�

20, 2011 8:'59AM -, :^ *A o - 122a P, b',
o
NORTH CAROLINA
DEPARTMWT OP 13N M0NTVMM AND NAMLAL MOURCBS (MCD t)
No=A.Tim of INTO' To Colsnt]cT A cLosmLna GEoTmR mAL
WATYMONLY IN1EMON WELL SYSTM
TYPE 5- W MXLL
ID Accordance with tfie proriaions of NCAC Title 15A: 02C.02 Q, plwse
c=pkte this uotMcation sud =xU to ad&rw on Ilia back pale (please Pjai or Z= ice).
IDAM— _:0 ^1 — 201L
Well Type Conn' ma ian- Does the proposed System circalatepotable tivsber only (no amtives) it
continuous piping that completely isolates the fWid from the mviroameut (i.e,
c e - 7
Yes X . Continue completing this form.
Nn Do Nat completet9ais form. Complete other MC application%rms for iwtalfg
either a 5A7 well (ooeA-loop well injecting potabla water into the agoifer) or a SQM well (closed -
loop Vreu costa 4nff 4MLIVO such as X42, ethanol, or other And eaa oc corrosion i&bftrs).
A. PROPERTY OWNER(S)IAPMCANf(S)
Llsr each Property Oxvocr ltvmd on property deco (if awDAd by b of gavernmern agency, state name of
entity and a rWesenfative w/authority for sign me). _M jL oc .
(1) Ms3IiiigAddress: I1.k f C 1C
City: — Stec: Ltzlp cod1P:.X21Q�L .-c*uw--
Idomel0fficaTale Cell NO-: r
FtualAddress:/1Y.i SC���.�4 � t �'� �ye�si[e:
(2) Physical Address of Wen�Site of dif%sant than above).
aw. j �._' _ �G wcta'+, G4 ,Ste z., JLL zip code^ 27/0 y County: L"
Home/Qffim Tate No.: Cell .
B. AVXVOR=D Ate DP OWNI.R, 37 AIRY Of the BacmitAppli=t own the subject property,
atthth a letter from to property owner authorirsag Agent to 3asWI and operate UIC w4
Cozape.ad Naze:
Contact Pmon:
Address:
City: I-,"- State rip Code: County:
Office Tale No.:
Websim Add= of Company, if nay

O.Oct. 20. 2011 8-'59AM
No.12201 K 17
C. Vm1j riSilma LOOPIWION
Cornpanyxame: Yadkin ��t
s SSCL-C,
yJeIl Driller CQtztrsctoor's Nsn1e: y 1milrtts - - Matthew Broom ]vliliorl [fie
NC Contractor Cert4iicnti=Xw =-per _ --,3036-A 3$48-A .
Contad.?ersnn: T?avid7. ld�ra�vrt its §:A _ RMAI� A�dress: cbi i'iJ�ert�aLsn,e�m
Address: J9081iansptaaV11la Rd.
City: „Rmpn OMlile Ai.C. — Zip Coder 27020 Ommty: YAdkla
Ofiicc T&No,: _, 36.468.4440 Cs[i No.: 336m374-V3
D. BMAT Me CONIVACTOR.Il O-iRMTLDN (if diffeXant than. ardor)
Camp�yNsma� c `t y
Caumdpe1m"! 1`}' r►[ k �- ; nss� �r - 59" Adam, -
Ad&w.. Nit 4 _
Clfy: L&e t Tip Coder ,-�2iaca _ Co=t . ` u�
Cell Na:
r4 STATUS 07 A IXCAM
pxivste: V ComosrJel.
sum 1+4t vipal: Nativa A=WcanLaa3s
F. xl MCTIO14 PRO CEDUR'I; (brleZy dmnbe ba►v & hDjeetionwef(s) -*Ube used)
�. W= CONMUCTrax DALTA
(I) ptopvsad dattto bcomtracfcd. LO j„_1,%mber of buiags:
Approximate depth 6f moh borlrag
(2) Type 4rtubiag so be *3ssd (copper, PYCF ate);
(3) Neil sasia& Ts &a ►dell($) CUM? (check Ober ,) 3tes a ) No bsdo\
W Yea — if yes, then provide Codas f ftmaticn ow
Types _,plymil it steel black moo plMaC Other (sp8clfh
Casing dspttL Flom to ��at (rafarortca tv T�attd anrtbce]
Casing o *a& to abavis ground inohes
tb) No f
(4) Grout man )material sm=unding well casing andfor piping): 7 4o'��V � •.cam
(A) grout typo! Neat Cemsot_ / $entonita ►� C" (Sp ry)
(p) Orcut deptL oftubins (ieii iwoa to Iand stake): from -2J—O to 0 McO
If wdl Tins a 6n& indicate gro'vt d4pti►: from to ( ter)

'Oct. 20. 2611 8�659AM
No. 1220 / P. 8 J
x xNaCTION AM EQUIPBUM
Attach a diagram sbMag the engh*erhlg layout or pMosed madMcatioa of the i fj action equipment and WxXior
pipnWtolung associated with the lWoctica operation. The maaufacturgt's broevura rMy provide supplementary
brf on.
L LOCATION OF WELLS)
Attacb iwo copies of mapx showing the col OWIng irtOrmadw-
(1) Include a Sits Map (can be dmvn) sho 4zg-, buildlnm pteperty IftLe4 surAce water bodies, potential
sources of gronudwater Wr4i A atioon *ad the Wa motion of and distances bahvem the proposed well(s) and
ow existing wog(s) or waste disposal fhdJAes Mach as septic t mkz or drain f3ei�ds located Vhbin !200 £act of
the geothermal heat ptmmp well system. ow
(2) 771e Site Map must show the subje4 pmpeM ih reftE oa to the Sturounding area by ikking at least two farad
reftwe points such as roads, streams, andlor W&h%V b tersections..
x CEST3IF Q TiON
Note: Tbis Fern* A,ppHeatidia must he signed by ea ch pa,3on atppeaft oox the
recorded legal property deed.
'I hereby certify, tinder paw4 of law, that I have personally axamiaed and am &WMar with the infom-atxon
submitted is this document and all atmobioent lb otto and tbat based on my Ezgd7 of noose individuals
im:nediarely resp=tble for ob'tsuaa g said Wormatiory I believe tbatths laaformationit true,:Accurate and complete.
I ara avvara that there we ai n t peaaaleies, including the posmbility of &ms and i mprisoazae 4 for submUftS
fayse bdbrmation. I agree to cownct, optrate, maintafi, repai and if appUcab* aba3odon the isjcd3on well and
all related apptatemnaea in aecwrdxi=v itla#he approved spcaifadoo and amdHiOr s of the Perza t."
5ignattxe ofFtopaxly 4WW/Applicaat
Pot or Type Pull Wam arid. title
Sipe= ouropesty OwasdAppllcant
m,�Pz c l —t-s civ e,
Pziat or Type Fall Nome and title
Signature of AadLaAzad Agsat, If any
Pzmt or Typs Poll Na= sad title
Plansc raftn two copies ofthe completed AppUcatiom, package to:
North Caroffna DMM nwQ
AquMrProteotiou Section-UIC Frognm
1636 Ma;H Service Center
e%b, lC 27699-1636
Telephoic [phone]

Oct. X 2011 8:59AM
No.1220 P. 9
TS-Sa cs
j-4
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