WI0400225_GEO THERMAL_20120523

Beverly · Eaves -Perdue
Governor
a~4-. •· •.....-. -·-;;;----'¼. . ••··-----~-
MCD EMR--=--:·· -
North-e~arolin~a-Bepartment-of Envirorfrrieht and Natural-Resoarces
Division of Water Quality -
Charles Wak1kf P~E-;--
Director
May 23, 2012
Edward· and Leslie Smith
1999 Georgia A venue
Winston-Salem, NC 27104
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0400225
Dear Mr. and Mrs. Smith:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title ISA Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefmitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http ://portal.ncdenr.org/web/wq/ap s.
If you have any ·questfoiis ·reilardirig your currerirjieririif or the fule revisions; please -feel free-to
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydro geologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer
One North Carolina
/Vat11ralt11
Central Files. APS SWP
11/01/11
Permit Number W10400225
Permit Tracking Slip
Program Category
Status Project Type
Ground Water
Active New Project
Permit Type
Version Permit Classification
injection Mixed Fluid GSHP Well System (50M)
1.00 Individual
Primary Reviewer
Permit Contact Affiliation
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit,
Facility Name
Edward & Leslie Smith SFR
Location Address
1999 Georgia Ave
Winston Salem NC 27104
Owner
Owner Name
Edward
DateslEvents
S Smith
Major/Minor Region
Minor Winston-Salem
Cou my
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Edward S. Smith
1999 Georgia Ave
Winston Salem NC 27104
Scheduled
prig Issue App Received Draft Initiated Issuance Public Notice Issue Effective
10/31 / 11 10/21 /11 10/31 /11 10/31 / 11
Regulated Activities Re,-guested/Received Events
Heat Pump injection RO staff report requested
RO staff report received
Outfall ,I L-L
Waterbody Name
Expiration
10/31/16
10/31 /11
10/31/11
Stream index Number Current Class Subbasin

Permit Number WI0400225
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Edward & Leslie Smith SFR
Location Address
1999 Georgia Ave
Winston Salem
Owner
Owner Name
Edward
Dates/Events
NC
s
Orig Issue App Received
10/21/11
Re g ulated Activities
Heat Pump Injection
Outfall l\;tL~,
27104
Smith
Draft Initiated
Scheduled
Issuance
Central Flies: APS_ SWP_
10/31/11
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
'Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Edward S. Smith
1999 Georgia Ave
Winston Salem NC
Public Notice Issue Effective
\Ol~1\ ll
Re a uested/Received Events
RO staff report requested
RO staff report received
27104
Expiration
10(3, J 1<1
10/31/11
10/31/11
Waterbody Nam, Stream Index Number Current Class Subbasin
' )
AVA RcDEMR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Division of Water Quality
Coleen H. Sullins
Director
October 31, 2011
Edward and Leslie Smith
1999 Georgia Avenue
Winston-Salem, NC 27104
Ref: Issuance of Injection Well Permits WI0400225
Issued to Edward and Leslie Smith
Winston-Salem, Forsyth County, North Carolina
Dear Mr. and Mrs. Smith:
Dee Freeman
Secretary
In accordance with the application received on October 21, 20_11, I am forwarding permit number WI0400225 for
the construction and operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well system to
be located at the above referenced address_. This permit shall be effective from the date of issuance until October
31, 2016, and shall be subject to the conditions and limitations stated therein, including the requirement to install
well identification tags as specified in Part Il.3 and to submit well construction records as specified in Part
Vll.2. Be sure to read the entire permit to ensure that you are aware of all compliance requirements of the pennit.
You will need to notify this office at least 48 hours prior to beginning construction and operation of the injection
~ell system. In order to continue uninterrupted legal use of the injection facility for the stated purpos.e, you must
submit an application to renew the permit 120 days prior to its expiration date. This permit is not transferable to
any person without prior notice to and approval by the Director of the Division of Water Quality.
Please contact at [phone] or michael.ro gers (a),ncdenr.gov if you have any questions about your permit.
cc: Sherri Knight, Winston-Salem Regional Office
WI0400225 Permit File
Forsyth County Environmental Health Department
Best Regards,
~~
Michael Rogers, P.G. (NC & FL)
Billy Clayton, Aqua Drill, Inc., 4137 Moore's Mill Rd., Spencer, NC 24165
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: 1-877-623-6748
iniernet: www.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer
No1!.S. i... C 1 · -O:.u .. u aro.1.na )\7aturn!lv
"' {..I
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Edward and Leslie Smith
FOR THE CONSTRUCTION AND OPERATION OF 2 TYPE 5QM INJECTION WELL(S), defined in Title
15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at 1999 Georgia Ave., Winston-Salem,
Forsyth County, NC 27104, constructed and operated in accordance with the application received October 21,
2011, and in conformity with the specifications and supporting data submitted, all of which are filed with the
Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation of an injection well and shall be in compliance with Title 15A of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and. use,
This permit shall be effective, unless revoked, from the date of its issuance until September 30, 2016, and shall
be subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 31st day of October, 2011.
Coleen H. Sullins, Director
u Division of Water Quality
By Authority of the Environmental Management Commission.
Permit #W10400725 UIC/5QM Page 1 of 5
ver. 03/2010

PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II-WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number 919 715-6166 and the Winston-Salem Regional Office Aquifer Protection Section Staff, telephone
number 336-771-5000.
2. The location of each of the · system manifolds shall ·be recorded by triangulation from three permanent
features on the site (e.g., building foundation comers) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
3. One well identification tag per grouping or 'cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with ISA NCAC 2C .0213(g).
PART III-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to , and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
Permit #WI0400225 · UIC/SQM
ver. 03/2010
Page 2 of 5
PART IV-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with . the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this· permit shall not relieve the Permittee of the responsibility for damages to surface or
ground water resulting from the operation of this facility.
PART V ~ OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit.
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number 919 715-6166. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions. ·
PART VI -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Division representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
Permit #WI0400225 UIC/SQM
ver. 03/2010
Page 3 of 5
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
Winston-Salem Regional · Office
585 Waughtown Street
Winston-Salem, NC 27107
336-771-5000
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Winston-Salem Regional Office within 30 days of
completion of well construction. Copies of the GW-1 fonn(s) shall also be given to the Permittee and
retained on site to be made available for inspection.
3. A copy of the site map updated with manifold locations required in Part 11.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Winston-Salem Regional Office within
30 days of completion of well construction.
4. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection will be established and an
acceptable sampling reporting schedule shall be followed.
5. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Winston-Salem Regional Office, telephone number 336-771-5000, any of the
following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
(C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
6. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
7. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII-PERMIT RENEW AL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
Permit #WI0400225 · UIC/SQM
ver. 03/2010
P_age 4 of 5
PART IX -CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. · If a well is not to be used
for any purpose, then that well must be_permanently abandoned according to 15A NCAC 2C .0213(b)(l).
Notification shall be submitted to the addresses given in Part VIl.1 of this permit.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to, the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if the
Director finds such removal will not be responsible for, or contribute to, the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that failure
to do so could lead to the contamination of an underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which· shall be introduced into the well
through a pipe that extends to the bottom of the wen· and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been removed, the
casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout
injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.1 of this permit.
Permit #WI0400225 UIC/SQM
ver. 03/2010
Page 5 .of 5
Ro gers , Michael
From: Mitchell, Patrick
Sent:
To:
Monday, October 31, 2011 2:07 PM
Rogers, Michael
Cc: Knight, Sherri ·
· Subject: RE: WI0400225 Smith SQM application
Michael,
I have reviewed the parcel on the GIS using 2010 aerial photos. Given that the system will serve an existing house and it
has been reported that no wells or septic systems are located in the area, I feel that a_ site visit is not necessary for
issuing Permit WI0400225. However, caution should be used by the driller to avoid sanitary sewer lines in the area
during installation.
After review of the application, it is my recommendation to proceed with issuing the permit for WI0400225.
Please let me know if you need anything further.
Patrick
Patrick L. Mitchell, LSS
NC DENR-DWQ
Aquifer Protection Section
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
Phone: [phone]
FAX: [phone]
E-mail c~rrespondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Rogers, Michael
Sent: Monday, October 31,. 20111:08 PM
To: Knight, Sherri; Mit<;:hell, Patrick
Subject: WI040022S Smith SQM application
Please find attached a SQM application for Smith. Please expedite your recommendation to permit or not. According to
the driller the site is on city water, and there is no septic tanks on site.
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://portal.ncdenr.org/web/wq/aps/gwpro/permit-applications#geothermApps
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
1
HCDEHR
North Caroiina Department of Environment and
Division of Water Quality
Bever#y Eaves Perdue Coleen H. Sullins
Governor Director
October 31, 2411
Edward S. Smith
Leslie H. Smith
1999 Georgia Avenue
Winston-Salem, NC 27104
Dear Mr. and Mrs. Smith:
Natural Resources
Dee Freeman
Secretary
Subject: Acknowledgement of
Application No. WI0400225
Edward & Leslie Smith SFR
Injection Mixed Fluid GSHP
Well (5QM) System
Forsyth County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on 10/21/2011. Your application package has been assigned the number listed
above, and the primary reviewer is Michael Rogers,
Central and Winston-Salem Regional Office staff will perform a detailed review of the pro'% ided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail].
Sincerely,
O�,A . �c�
far Debra J. Watts
Groundwater Protection Unit Supervisor
cc; Winston-Salem Regional Office, Aquifer Protection Section
Billy Clayton - Aqua Drill, Inc.
Richard Harrington - Gwyn Electrical Plumbing, Heating, & Cooling
Permit File WI0400225
AQUIFER PROTECTION SECTION
1636 Mail Service Center, FWegh, North Garolina 27699-1636
Locattor- 2728 Capital Boulevard, Raleigh, North Carolina 27604
Rhone: 919-733-3221 l FAX [phone]; FAX 2; 919.71MG481 Customer Service: 1-877-623-5742
Internet: www-newt&nual�om
An Equal Oppmtumly ti Affirmative Action Employer
Nortb Carolina
f ` !'4aiLd��

Pr,
NORTH CA ROLINA DEPARTMENT OF ENVIRONWE-NT Ah77 N:ATUR. AL RESOURCES
APPUCATION FOR A PERMIT TO CUNSTHUCT OR OPERATE RikWCTION WELLS
In AomrdEncte With the Provisttms of 1 M NCAC 03C -02W
CLOSED -LOOP MMD-FLUID GEOTHERMAL MECTION WELLS
3iie-sr wets crit alate fluids other than potable water as part of a geothermal heating and coo"g system
(chink one) New Application Renewal*- Modification
t For renewals complete Parts A-C and the signature page.
re Worrnalfon and Mail in the Address on the Last Pate. Illezible Applications Will Be Returned As Incomi
DATE: _ CT. j , 20-LL
PERMJT NO. 00". _ (leave blank if New Application)
A. STATUS OF APPLICANT (choose one)
Non-Govemment: Individual Residence Business/Organization
Government. State Municipal County Federal
Ctq
C.
D.
PERMIT APPLICANT -- For individual residences, list each owner on property deed. For all other
state name of entity and name of person delegated authority to sign on behalf of the business or agency:
Mailing Address: 1_o! qq �' EQ�t GLA ► ?y,-
City: -W-L&173N- 546641 State: ^-Zip Cade: 2'7104- County:
Day Tele No.:_Z3-3 ` f4 Cell No.; 16-3-
EMAIL Address: Fax Nam: (3.3ee)
LOCATION OF WELL SITE - Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site:Ck2;�5 - 3-1- -183S-on County: _.!�jfsy7W __
(2) Physical Address of different than mailing address):
City:
WELL DRILLER INFORMATION
State: NC Zip Code:
Well Drilling Contractor's Name: ► L1� � � "� 1
NC Well Drilling Contractor Certification No.:Z`I _
Company Name: ^ �C _ � � >- ` "A ► �
Contact Person: J�)�. EMAIL Address: G=�►- ► �� ��"
Address: y�3 c-�rtior a�.r
City: -_ Zip Code: State: County:
Office TeleNo.-31Jl a1 Cell Na. 'J`� "� 1t2�� a No.: -1Li2-1' 9, (aj

L BUT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: G w yrJ &,eq--p.1/1/fL PUl{MHt ~ lt&Tl# /k i C dot/.A)G
Contact Person: le.II AR!) Hrtll lbNG-to r.l EMAIL Address: RtuM,tl>. l/t}ltteNlil-1'H e
Address: 31ft (,1/Gez-rPuNr-73LIJ P 6-wYH S£RC/' cli.'i . ca,,.,.,
City: W/lfls'11N-~/JI&»\ ZipCode: :i.11,3 State:Alc County: ::....~~=-~+..::-,7H'--'------
Office Tele No.: _l_~t; -~I-C36'-7 Ce11 No.: ';1~ ·3#1/S · .P.)'S3 Fax No.: 7/1,-n.p. ·ldlo
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed•: ~ Depth of each boring (feet): Y S-0
* If existing water supply wells will be used then prcwide the information In item (47
(2) Chemical additives to be used: R-22 ___ Propylene glycol___ Ethanol ·
Other ________ ( other additives will need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc): _H-=-~ ___,_µ__,_f___,f-.__ ________ _
(4) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, plastic, etc.), diameter, depth,
and extent of casing appearing above ground: _n_Or'\ __ '2-____________ _
(5) Grout (material surrounding well casing and/or piping): ~ ~ ~• '0
(a) Grout type: Cement__ Bentonite** __ Other (specify) t\:e("' ~\ ~
•• By seJccting bentonite grout,, a variance is hereby rcqucsred to I SA NCAC 2C .02 l 3(d)( I )(A}, which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from O to 4s:Q (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
G. WELL LOCATIONS-Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
( 1) Attach a site-specific map s~owing the locations of the following:
* Proposed injecti"on wells • Buildings * Property boundaries
* Surface water bodies • Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
• Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area ex.tending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial plwlograp/1 of tl1e property parcel s/1owlng property lines and .,tructures can bi
obtained and downloaded from tl1e applicable co1111ty GJS website. Typically, tl1e property can be searclted by
ow11er name or address. Tl1e location of t/1e wells 111 relation to property boundaries, houses, septic ta11ks, other
wells, etc. can tl,en be drawn In by haml. Alto, a 'layer' can be selected sl,owing topographic contours 01
elevatitm data.
H. CERTI I<CAT ION (to be signed as required below or by that person's authorized agent)
' -4A'tiCAC 42C .tit l l(b) squires that all permit applications shall be signed as follows:
- for a corporation: by a responsible corporate officer;
for a partnership or soft proprietorship: by a general partner or the proprietor, respectively;
s. for art municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the properl4_deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalE
" l hereby certify, under penalty of law, that l have personally examined and am familiar with the inforinativr
submitted in this document and all attachments thereto and that, based on my inquiry of those individual
immediately responsible for obtaining said information, l believe that the information is true, accurate anc
Complete. 3 am aware that there are significant penalties, including the possibility of tines and imprisonment,
for submitting Use information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit.,,
Signature of Noperty,fhv:agrlApp c ant -
.Ja s
Pri nt or Type Full Name W -
Signature of Property Owne#Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit two copies of the completed application package to:
llWQ - Aquifer Protection Section O C T 21 2011
1636 Mail Service Center
Raleigh, NC 27699-1636
Telenhone [phone]

Al

?rint Preview Page 1 of 1
L
j
•
�,
Forsyth
a _
County,
i
1
NC
'titetc
�
g75
- -
y `
:'
Scale
•�
ropi7�
1 inch =
'h
152 feet
,tea
,o0
•I[ 3
3416
4o
1
i3Rn 7
N ti
i
PIN
6825-37-7835.00
Current Deed Stamps
Property Address
f 1999 Georgia AVE
_
Map Number
L
' B 18854
Block Lot
1313 008W
Assessment Method
Cost
Additional Lots
—1 —
+WlP
l No
�••$398,000
Disclaimer.,
Tax Jurisdiction
Winston-Salem
1 Land Value
Forsyth
_;$281,805
County
Anx
N
{dwelling Value
cannot
Taxable Owner Name
; Hedrick, Richard E
s Commercial Value
guarantee
he accuracy
Taxable Owner Name2
,Industrial Value
of this
Taxable Owner Address —
i 351 Holly Lake DR
} Misc Imp Value
information,
and the
Taxable Owner City St Zip
'Manakin Sabot, VA 23103
'Total Value
S677,800
County
Taxable Deed Bk-Pg
681-48
i Acreage - -
10.99
hereby
disclaims all
Taxable Deed Date
� 1212211953
! Sq Ft Living Area (Res)
14593
warranties,
Taxable Deed Stamps
- -
4-1
Gross Sq Ft (Com)
including
warranties
Current Owner Name
i Hedrick, Richard E
Year Built (Res)
�—
1927
as to the
} -
- --
accuracy of
Current Owner Name2
Year Built (Com)
this
Current Owner Address
351 Holly Lake ❑R
Census Tract
.12
information.
Currant Owner City 5t Zip
Manakin Sabot, VA 23103
Zoning
RS12
Current Geed Bk-Pg
68148
Last Qualified Sale Price
—
Current Deed Date
12/2211953
http:llmaps2.co.forsyth.nc.uslgeodata_081printPreview.aspx?PrintOptData=Forsyth Coun... 10/18/2011