WI0400223_GEO THERMAL_20111027

Permit Number·
Program Category
Ground Water
Permit Type
W10400223 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilitv
Faclllty Name
Kent Zotter S FR
Location Address
210 Maple Tree Ln
West Jefferson
Owner
Owner Name
Kent
Dates/Events
NC 28694
Zotter
Scheduled
Central Files: APS_ SWP_
10/27/11
Permit Tracking Slip .
.Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Kent Zotter
Owner
PO Box 1224
West Jefferson NC
Major/Minor
Minor
Region
Winston-Salem
County
Ashe
Facility Contact Afflllatlon
Owner Type
Individual
Owner Affiliation
Kent Zotter
Owner
PO Box 1224
West Jefferson NC
28694
28694
Orig Issue
10/27/11
App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
10/18/11 10/27/11 10/27/11
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall r,1ULL
Waterbody Name Stream Index Number Current Class Subbasin
l;'A
-HCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Kent Zotter
P.O. Box 1224
West Jefferson, NC 28694
Coleen H. Sullins
Director
10/27/2011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Pennit No. WI0400223
210 Maple Tree Ln.
West Jefferson, NC 28694
Dear Mr. Zotter:
Dee Freeman
Secretary
On 10/18/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-only
geothennal 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 geothennal 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 15A Section 2C Subchapter .0213, and
3. The required notification fonn 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 .021l(u)(2). Additio~ly, 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 assessme~t of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Rogers@.ncdenr.gov if you have any questions.
cc: Winston-Salem ~egional Office -APS
APS Central Files -Permit No. WI0400223
Ashe County Health Dept.
31t·~r0
forD~'atts
Supe~
David J. Brown (Yadkin Well Co., Inc., 1908 Hamptonville Rd., Hamptonville, NC 27020)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh , North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588 ; FAX 2: 919-715-6048 \ Customer Service: 1-877-6 23-6748
Internet www .ncwaterauality .org
An Equal Opportunity \ Affirma ti ve Action Employer
N°~i...c 1· 01w aroma
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0: 1$. 011 12:42PM
No. 1195 P. 1
FACS M1LF TRANSMON FORM
DATE: / TIME: REF, NO. LOG NO.
TO
FROM:
COMPANY NAME FAX NO, PLEASE
o r �. ❑ DELIVERNOWRLY
ATTENTION dL<-LL-
TEFL
Va
COMPANY NAME W NCL PLEASE
RUSH
�{' U l l REPLY
NUMBER Of PAGES PLEASE
INC LUOIN G ThiS SHEET I REPLY By
MESSAGE:
F�
-FOR ALL YOUR WATXR NEECS"
YADKIN WELL CC., INC.
1908 NANIPTDNVILLE ROAD
HAM"ONVILLE. Nd 27020
DAuto J. aFtOWN. VICE PRES,
TOLL FREE IS= 24$-'2355
OFFICE (336) 46$-4440
FAX (3361 d6 4040
RCS 13364 460-4659
wO00 NEWS AM"i CA • GOO L0V43 VOW
HEFT.
4jj3�jNATpfi$
SIGNATURE
Aquifer Protection Section
OCT 18 2011
PLEASE INFORM US MAMEi}W&Y IF YOU DO MT RECENE FAC$WLZ SN FULL

Qc;.. 18. •2011 12:42PM i 1195 P. 2
NORTR CAROLINA
DEPARTMENT OF SNVM0NMENT AND NATURAL RESOURCES (NCDE ** R)
NOTIFICATION OF EMVT TO CONSTRUCT A a_OS"U-L00 OEOTHERKAL
WATER Q»Y INJECNON WELL SYSTEM.,
TYPE 5-OW WEL
Iu Accardauce With tk provisiouss of NCAC Title 15A: 02C.0200; please
complete tWs uotifcation and mail to addrrss on the back pago (please Print or die h foaa atim).
DATE: o ^ G zt]
Well Type Confirmation- Does the proposed system circulate potable water only No additives) in
oWinuous piping that completely isolates the avid from the environment (i.e.
closed-loon)Z
Yea `Xi Continue completing this form.
No Do Not complete this form Compile other MC application forms for ulstailing
either a 5A7 well en -loop well ffilecling potable water into the aquifer) or a 5QM tivell (closed -
loop well aontakins additives such as R 22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)IAMICANIti'(S)
List each Property ON wer listed on properly deed (if ownedbya business or gvvenunent agency, state name of
entity and a represeutativo ►vleutbority for siguature): C: �. _ e_J-A-_ )—
Fa
(1)
4y (2)
Couut -
Home/0 Moe Tale No.: Cell No.: 6 l d "" 7'0'- — Y4 I-J
Email Address: Kr AA ��N ' v'Ad'� Welssite �'Z$ - Y� l• - `�g2�
Q�T�I�tII��D�{h4lr�• (� ���
Physical Address of Well Site (if differentthem above): tD ~
- -City: �¢� tea'" State zip Code: A County:
Romdoffice Tole No.: Cell No..
Mailing Address: �0
City: 'hi ntvk,
"'--� state• Zip
AUTHORIZED AGENT OF OWNER, IF ANY tiff the Permit Applicant draw, not awn the subject pxoperty,
attach, a letter from the property owner authoriziug Ag=t to instai3 and cpeFate-UIC wail)
C=paay Nano'
Contact Person: g&AIL Address:
.A,ddress:
City:
State: Zip Cade:
Office Tele No.- Cs
Website Address of Company, u`auy,
z 1 o Mo.Ot Tr,.t t-ii.n
County:
RECEIVED 1 DENR 1 ❑WO
AgUifef PrOted'On Section
(off OCT 18 2011

Oc,.t.18. ;2011 12:43PM
C. WELLDRILLEROOORMA.TION
ComplliyName~Y11 dfdn Well co. In c.
No.1195 P. 3
\Vell Ddllet Contractor's Name: .&:JD~d~y M=ta.,.::JlBA=-_ __.}A~aw.iUh.e!~\v~i~tQr.1,1wni.=:...._ ... Mwl:.!.!llf~~n~Caw~_
NC Contractor Cer:tification.No,: 2572-:....::-A:....:.-___ ___.:3~0~36,.__-L.JA.....__ __ -='.35:=...,4~~---A:..!:. ___ ~~-
Contact .Pei:son: David J. BrowJ\ 2195-A BMA1L Address; cbic;fdriJ!cr@rn&com
Addreu: 1:908 HamptonvJlle Rd._ __ ~----~-~----~-----
City: HamptonvJ lle N.C, Zip Code: 27020. ____ Count,y: Yadkin _____ _
Office Tele.No.: _336-46'8·4440~-----Cell No.: _336-374.&736 _______ _
D, m.AT .P'tlMP CON'l"lUCTOli OO'ORMA.'.DO:N llf aift'mnt 111111 drfflW~ . .•
CompanyNamc; ,a:> kl ll 5J
V Contact Perso n: B'MA,]L A4dret§;
r, Address:
City: _______ Zip Cede: ____ Comity: -------~----
OffieoTeteNo.: _______ CellNo.t ~----------
STATUS OF APPLICANT
Prl\'ate= .,/ Federal:_ Commerc1al: _
State:_ Municipal:_ 'Native American Lands:_
E', INJEC'.l'ION J?n.OClmU8.li (bric!ly describe how the injectlon wcll(s) "ill be med)
·a,...-c,•.c.~ ~4:f.e; .. +A."'r.u,L ,a c fu J.e~ ?,;p
&<:,!! ~~ rytk ~
G. WELL CONS1".R.UCTIO'NDA'rA
(1) Proposed date to be constructed: lo -C-H Number ofbcdngs: __ { __ _
Approxhnate depth of eacl1 botJng (feet)~ 3 d'
(2) Type of tubing to be 'tlsed (copper) .PVC~ etc): llp,8!: .f'l)g.. ~{11 I L' •
(3) Well casing. J.s t'he ,velJ(s) cased? (eheck oitlu,.r (a,) Y'-5 ~ (b.) No below)
(a) Yu . v"' itymJ then provide ceslng blf'or.maticn balow
Type: ~e.1vauized steel _black steel_plasffc_other (spec~)
Casing depih: Fto.m ./k to V. .2.. f"t (rerorence to land $\1rince)
Castng o,c.tend, to above !fCu.ad O inches
{b) No
(4) Groutl:ofo(material sucroundlngwell cashlga:o.d/otpiping): 7i,e.1r,et/}' ~Iv-. .... ,,.l
(a) Grout type: Neat Cement_ Bentonite ~ · Other (speoify) __ ~-----~-
(b) Grout placement Pumping__.tL' Prossure_ Othe.r __
(c) Grout de_pth of tubing (refereace to land.slJl'ntee): iotu Jrr_ to Q (feet)
lfwell lms tfflsing, indicate grout depth~ from 2~ to G (feet)
2011 12:43PM No, 1195 P. 4
13- INJECTION-RELATED'EQUIPMENT
Attach a diagram showing the cogineering layout or proposed modification of the injection equipment and exwior
pipingthibizg associated with the inje ua operetion, The manufactur;r's brochure may provide supplementary
information,
T. LOCATION OF WELL(S)
Attach two copies of maps shawl& the following information:
(1) Includa a Site Map (can be dra=) showing, buildings, property fines, surface water bodies; potential
sources of groundwater contamination and the orientation of and distances between the proposed Well(s) and
any existing wezl(s) or waste disposal 1�cilities such as septic tanks or drain $clds located tivifhin 200 Feet of
the geothermal heakpump tivell system. Label ail features clearly and 4n 1+ e a ngrthT arro v.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, And/or higInny intersections.
S. CERTWICA TION
Note. Tills Permit Appiiostiion Must he signed by Jack p¢tsou appearing au the
recorded legal property died.
"I bomb), certify, order penalty of law, that I have personally vxamiaed and am famiUar with the information
subraitted in this document and all attachments thereto and that, based on nay inquiry of those individuals
imm4ately responsible for obtaining said information, I believe that tbc information is true, accurate and Complete.
I am aware that there are significant penalties, including the posdbility of fines and imprisonment, for submitting
false information- I agree to coastraet, operate, maintain, repair, and if'applicable, ebandon the injection ►yell and
ail related appurtenances in accordance with tte ap roved d conditions of the permit'
gigninfre of Jopaty 0wrierfAppliCant
Frkt or T) pe Pull Name and d� fiac
Signature of Property Owm/Applleatxt
Print or'IWO Full N=a sad title
5iguahue of Autlwrized Agent, if any
Print or Type.' ull Name and title
Flease return two Copies oftim completed Application package to:
North Carolina DL1TR-UWQ
Agiifex Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636 RECEIVED 1 pENR 1 OM
(919) 7I5- 35 Aquifer Protection SWIM
OCT 18 201t

4: ,, 18. 2011 12:43PM
No. 1195 P. S
�erj- Za JL� r