WI0400238_GEO THERMAL_20120202

Permit Number
Program Category
Ground Water
Permit Type
WI0400238 /
-Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility .
Facility Name
Brenda Carter SFR
Location Address
2172 Shore Rd
Rural Hall
Owner
Owner Name
Brenda·
Dates/Events
NC 27045
Carter
Scheduled
Orig Issue
02/02/12
App Received Draft Initiated Issuance
01/05/12
R~g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files: APS_ SWP_
02/02/12
Permit Tracking Slip ·
Status
Active
Project Type
New Project
Version
1.00
Permit Classlflcatlon
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville Rd
Hamptonviile_ NC
Major/Minor
Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
0Wl'!er Type
Individual
Owner Afflllatlon
Brenda Carter
Owner
·2172 Shore Rd
Rural Hall
Public Notice Issue
02/02/12
NC
Effective
02/02/12
27020
27045
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Brenda Carter
2172 Shore Rd.
Rural Hall, NC 27045
Charles Wakild, P.E.
Director
02/02/2012
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400238
2172 .Shore Rd.
Rural Hall, NC 27045
Dear Ms. Carter.:
Dee Freeman
Secretary
On 01/05/2012, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onlv
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 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 .021 l(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 [e-mail] if yfjhave any questions.
s&cerely,. -~ f ), ~
cc: Winston-Salem Regional Office -APS
APS Central Files :-_RermitNo. WI.04002~
Forsyth County Health Dept.
.._;;JJi1 -1fXJ L 'J7JJ
-for De~natts
Superv1l'w
·navid J Browri (Yadkin Well Co:, lnc., 1908 Hamptoriville Rd., Hamptonville, NC 27020)
Mark Hollingsworth (Logan & Heating Air Conditioning, 5142 N. Causeway Dr., Winston-Salem, NC 27106)
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\ Affinnative Action Employer
. One c · .....
.N.~Jth . arobna. :;yattatilltl
Jai„ 5, ' 2012 3, 22PM
FAMULE TRAHSMMON FORM
No, 1588 R. 1
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INDIVIDUAL DEPT
NUMBER OF PAGES
INCLUDING THIS SHEET
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SIGNATUAE'
MESSAGE:
-5- & w n a 77 A, Coi to ►i -gD I'^
e
'FoR ALL YOUR WATER HEEDS"
YADKIN WELL CO., INC.
194E HAMPTONVILLE ROAR
HAM"ONVILLE, NC 27020
pAVI❑ J. WtOWN, VICE PRES.
TOOL FREE (5W) 2A-04355
CFFtCS 1336) 4684La40
FAX 1336) 44e-4048
AEG t3361 458-4B69
'GOQO NZWJ. ►WtNleA • e*0 LOVER VOW'
PLED& IN :0W US IMMECWIRY IF Yr'�.0 CO NOT RECEIVE FAC MLE iN FULL

Jan. 5. 2812 3:23PM No, 1588 _" P. 2
NORTH CAROLINA
DEPARTMENT OF ENfviftvNi�rr,�] I�A'I'CRF4% 1�saU�tC�S (NCDENR)
NOTIFICATION OF LWENT TO CONSTRUCT A CLOD -LOOP GROTEM?34AL
WATM-ONLY INJEMON WIZLL SYST.Ke
TYPE LQW WELDS)
In Accords= s4tli d e piovisians afNCAC Tide 13A; 02C,0200, please
- can4dde this nutificaftan and mail to address ova the bark, p2e (plem Bdk or TME i a).
DAM / l j 20 I.L-
We111ype ConfYrmatfon: Dom the proposed system c4rcalate potable water o (no addWve s) is
continuous piping that eomplcioly isolates the Avid from tho oaviro=nt (La.
closed ioao)?
Yes X_ Continue completing tNs farm.
No Do Not campletc this fam Complete other UIC applzcatiou foffrA for aftl ng
either a SA7 well (qm-loop well injecting potabia water into the aquifer) or a 5QM W4 (ciosed-
loop weZ containing additives such as R-22, ethanol, or other anffr=e or corrosion inbiMors).
A. PROPERTY OWNE,R(VAPPLICANT(S)
List, Property Owner listed on property deed (if owned by a business or govammeut Wavy, stagy name of
entity and a re xmUtati,ve wlauthority for signafam): a 7 _ C_0_"4�
Cfty� 'ra [ i t SWIM.
: L.4p code: buutr
Home/Office Tole 0 4 0 3
Rmasll Address: Website-
(2) Physical Address ofWall Site (if differml t1= above):
City: Ste: lip Coder Coe AT.
HomeJOfce Tale No.: C'eil Rio_:
R. A=ORMD Afr= OF OWNER, IF ANY (f the Permit Applicant does not own the sebiwt property,
&Uwl a latter from the property owner auffiorizing Agent to i ustail and operate MC well)
Company Name:
Contact Pcrson; EM6L Addressa:
Address:
City- State: Zip Coda: County:
o ice T'e1e Nat: 9eA -Na-_
Wah&ite Address ofCamnmi y, if �;r

Jan. 5, 2012 3:23PM
No, 15 $ 8" -P. 3—
c. WELL DR=M MMA7=
e.�mparxyz+Farae:Yad�We3i Co. zQ,c. � ,
Wrl1 Driitar �s Name, syMu 'ild$tChew 33rowa lldilion eve
NCContmtWCertiditRfLMXO.: 1572-A 3Q36.A 354$-A-
CoB[aefPersow David? Hwwn 1aLL— AO ' Ie .n
Addca m 1909 HampbmwIlls Rd.
Cii ,' Ham,ptam HO N-C, Tap Code: 27020 Coamty: Yadkim
Office TekXd.: __,3364684440 Cell No.; __�36.374-8736
D. ADAx XILW C41►TUCTU$ ant own drm")
Compere M me- ka ► �^ �� �dY� i �?+�1 1
Cantaot Parse+ Y t ` dy
Cif: wrYLS � aiar -- �- Camnty,
OwQc ralvx6 1 con x*:
E. STATUS OF APFMCANT'
Private_ f Pedmh c4mmmvm:
Suit: la IMWPO.. Native Amer3m Leads:
�. INTEC 10lq PTLOCYDIME (b I*JIY dessce"be baw the Wec�on m X(s) Td9 ba used)
O. WELL CONSTRUCTTONDATA.
(i) Proposed dateto beoonstrnctcd: -- Q — k�ium�rr afbarlagsr .
Apprw ruate depth of each baring (ttj:
(2) Type of tubing to ba msad {aopper too. PE S O —1 l i 1&0 oS
{3) Weii casing. is tLg we}I('a) cased? {check either (a.) Yes a {b) No baicm)
(a) Yes if yes, then provide casing iA d. below
Type;--plvanizerl steel bleak steel�plesAc otHe� {spdclfYj
Casing daptlu From. to Beet (refemrft to land surface)
CMIag =:ads to above ground inches
(�) No
(4)Crotiilatbtmatexlal suaatmding wi sngandlarPIPitzgi: �j�.ar,rwGYn^t
(a) Orout ty�.Nw Cement 8entonibe _z- Otitar (specify)
(b) Caw Placarnertt: PurnpiAK Presets Otter
(a) Ormt depth of tubing (rd=we to UM& swikce): fits `1- e 10 (F )
Lftve3l Isaa casing. -Indicate grad depth: ftm ,r— to � [feet]
)�r �Ld(-Cv'>%

iL DrnCTION-;6iEL TM XQUMPM=
Attach a dl g= showing the enemee eing 3Wnd or prcrpesed modiuficadon of the 4ecdon equipment and atelior
pipiagbbiug associated with the iLj�ou operation. The manuthcb er's brochure tray provide supplementary
kforma,tims,
I
1. LOCA.TJION OF WELL(S)
Attacb ter copl= of maps abovving the following fi farma#oa:
(1) Include a Site Map (can be d RVM) sbo►ving: btuldin property lines, =&cc water bodies; potential
sootm of grouadwaW cow mftr ion ead the or?entw oa of and &taaees behwen the proposed welds) and
ARY axxistrng wells) or waste disposal fa.eili4ies such as septic tags or drain Bolds located within-200 feet of
the gwtba ai heat pump NveU system, Label Al #t atutes clearly mid jaRl_ude a worth Wr_,
(2) The Site MILp must $bow the atMect property in relWan to tho surrosmfts area by using at least two fted
MXMWoe points Such as roads, etra=, =Nor h4&vay intorscx u=,
J. CER'l VICATION
Note: TbU Permit AppifopEtift mud be signed by eacA person appearbl; on the
recorded legal property deed.
"I b=cby certify, trader panalty of Saw, that I have personally examined shed, am fare isr with the information
submitted ixL this document and all attachments thereto find that, based on my inquiry of those individuals
I=wdfatcly responsihle fbr obtaining said inf emetion, I believe that the information is trtis, accsuate and coaaplete.
I am aware that these ere sigaifimt pamIdes, including the possrbility of $tlea and irnpnsome4 fro• m*mittmg
false izlformatzon. I agree to construct, opwrW, maintain, repair, aad if eppllcable� abmtdon the 'injection well and
all related appurtenances' in accordance with the approved specmcaticms and ndtfi the Permit."
Signature ofFxoperty OsvnerlA
or TyPa Pull Nagm and
S&anue of Fropmty OmezlApplicant
Print or Typo M Nam and title
8i�attue of Authmr wd Agent. if say
Pit or Type Pt;il Natae sad txtie
Please rct m two copies of the c=mldted A.ppEcs?'04 paeUge to:
North Cararm DMR-DWQ.
Aquikr Proton Scadon-MC Program
1636 Mag Service Center
1ta.ieigb, NC 27699-1636
Telephone [phone]

. Jan. 5. 2012 3:23PM No. 1588 P. 5
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