WI0400236_GEO THERMAL_20120130

Permit Number
Program Category
Ground Water
Permit Type
WI0400236 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Timothy J Braun SFR
Location Address
906 Marguerite Dr
Winston Salem
Owner
Owner Name
Timothy
Dates/Events
NC 27106
J Braun
Scheduled
Orig Issue
01/30/12
App Received Draft Initiated Issuance
12/06/11
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files: APS_ SWP_
01/30/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Timothy J. Braun
Owner
906 Marguerite Dr
Winston Salem
Major/Minor
Minor
NC
Region
Winston-Salem
County
Forsyth
Faclllty Contact Affiliation
Owner Type
Individual
Owner Affiliation
Timothy J. Braun
Owner
906 Marg~erite Dr
Winston Salem
Public Notice Issue
01/30/12
NC
Effective
01/30/12
27106
27106
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
��;
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakiid, P.E.
Governor Director
01/30/2012
Timothy Braun
Elizabeth Braun
906 Marguerite Dr.
Winston-Salem, NC 27106
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10400236
906 Marguerite Dr.
Winston-Salem, NC 27106
Dear Mr. Braun:
Dee Freeman
Secretary
On 1.2/0612011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop wafter -only
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 15A Section 2C Subehapter .0213, and
3. The required notification forrn 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 time 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.Rogersoncdenr.gov if y have any questions.
4or
rely,eb a W tts
Supervi
cc. Winston-Salem ]regional. [office - APS
APS Central Files - Permit No. W10400236
Forsyth County Health Dept.
David d Brown (Yadkin Well Co., inc., 1909 Hamptonville Rd., Hamptonville, NC 27020)
Mark Hollingsworth (Logan Heating & Air, 5142 N. Causeway Dr., Winston-Salem, NC 27106)
AQUIFER PROTE"ON SECTION
IM Mail Service Center, Raleigh, North Carolina 27699-1536
1.oeatian; 612 N. Salisbury St, R"ll;h, North Carolina 27M C
Phone: 919M7-64M %FAX: [phone]% No' �a+ralina
Intemel: www.nr.►vatamuslltv.ara ���i ArLyf■
An Equal Dpportunity i AlhrmaHva AcUon Employer i� +JY

.DeC, 6. 2011 8.26AM
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NUMBER OF PAGES � PLEASE ORMAIOR'S
INCLUDING THIS SHEET REPLY SY 5%NATUFtE
MESSAGE:
-Fo7R ALL YOUR WATER NEEDS'
YADKIN WELL CO., INC.
190E MAMPTONVIL.LE ROAD
HAMPTONVILLE. NC l"20
DAVID J. SFtOWN. VICE PRES.
TOLL PRICE We00I 2AW9355
OFFICE I3361 468+dddO
FAX Ili 4694045
RES 13nk 46&4559
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No.1423 P, 31
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e engbxomag isyovt or proposed =oMcaflon offhe f jecti(m equtptmcat and Wedor
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lidn must be signed by eaLeh person agpas bZ on the
Wty deed_
ty of law, That I bavt persc Ay mmiod aid = famMu the motion
it and an emahm=u thm%to nd th4 based on my ingtary of those mdivld=B
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Mo r Fxoteesola Sec4exa►Mc Progmm
1636W Serdee Cmtear
uAwg,h, -iC 27699-1636
T'eIephoue [phone]

Dec. 6. 2011 8:27AM
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No. 1423 P. 5
RECEIVED 1 DENR i c7VVQ
Aquifer Prdection SecOn
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