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Home My WebLink AboutWI0400240_GEO THERMAL_20120222.,. -,-j{~·-·• '""1 •,•.··.~.,-... Permit Number Program Category Ground Water Permit Type Wl·0400240 ... -· Injection Water Only GSHP Well System (5QW) Primary Reviewer eric.g.smith Coastal SW Rule Permitted Flow Facilitv Facility Name Thomas Efford SFR Location Address 422 Mountain Air Ln West Jefferson Owner OwnerName Thomas NC 28694 Efford Scheduled Orig Issue 02/21/12· App Received Draft Initiated Issuance 02/03/12 Re g ulated Activities Heat Pump Injection Outfall NULL Central Files: .'APs_· _ SWP_. _ 02/22/12 Permit Tracking Slip Status Active Version 1.00 Project Type New Project Permit Classification Individual Permit Contact Affillation David J. Brown 1908 Hamptonville Rd Hamptonville NC 27020 Major/Minor Minor Region Winston-Salem County Ashe Facility Contact Affiliation Owner Type Individual Owner Affiliation Thomas Efford 422 Mountain Air Ln Public Notice Issue 02/21/12 Effective 02/21/12 Expiration Waterbody Name Stream Index Number Current Class Subbasin Permit Number WI0400240 Program Category Ground Water Permit Type Injection Water Only GSHP Well System (5QW) Primary Reviewer eric.g.smith Coastal SW Rule Permitted Flow Facility Facility Name Thomas Efford SFR Location Address 422 Mountain Air Ln West Jefferson ·Owner Owner Name Thomas Dates/Events NC 28694 Efford Scheduled ...... J Central Files: APS_ SWP_ :02120112 Permit Tracking Slip Status In review Project Type • New ~roject Version Permit Classification Individual Permit Contact Affiliation David J. Brown 1908 Hamptonville Rd Hamptonville NC Major/Min·or Minor Region Winston-Salem County Ashe Facility. Contact Affiliation. Owner Type Individual Owner Affiliation Thomas Efford 422 Mountain Air Ln West Jefferson NC 27020 28694 Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration 02/03/12 Regulated Activities Outfalf NUU_ Waterbody Name Stream Index Number -Current Class Subbasin �rl P Not1h Val[7illia U'epal Iniellt of C:i1Vl!{,tnmen t al16 Natutai iiebource5 Division of Water Quality Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman Gevemor Director Secretary February 2I. 2012 Thomas Efford 422 Mountain Air Lane West Jefferson, NC 28694 Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System Permit No. W10400240 422 Mountain Air Lane, West Jefferson, NC 28694 On February 3, 2012, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-Anly 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 uijection well system as long as the following conditions are met: 1. The injection well gstem contains only potable water, 2. The injection well system is constructed in accordance with well construction standards specified in North Carolina Administrative Code Title 1SA 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 Norio Carolina Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, 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 assessment of civil penalties, Please contact Mike Rogers at (919) 807.6406 or Michael.Aos,,ersfgnOenr.goy if you have any questions. Sincerely, or Debra .� ' l Supervisor cc: Winston-Salem Regional Office - APS APS Central Files - Permit No. Wi.0400240 Ashe County Health Dept, Yadkin Well Company, Inc. (David Brown) Scott Brothers Heating & Air, Inc. (Mike Carter) ACUFER PROTECTION SECTION An Equal Oppott i try L AiikfMa" AMh EmV4yar iti zt tt1:.:cia'U i14 ��turall�t� Fob. 1 2012 3:02PM 01 I. 4VI� 2,VIO l TIiU O fftLL IVU, I18VI P. 4U, hUrJJiJ NORTH CAROLVA DEPA,RTME1?NT OF EN VMONMENT AND NATURAL USOURCES (NCDENR) NOTITION OF INTENT TO CONSTRUCT A . O GEDTMMAL WATER- O Y WRCI'ION WELL SYSTEM: TV?E 5-0W WMLL(S) lu AccordarLoa I3ltb theprovin= of NCAC Tlrla 15A: 02C.4204, please cotnpkte tuts gaiantioa aw =oil to e44M cu aria tads page (plegee $z or DT—e iui�7amat3aaj• DATI : .4 20 %Ty__ c400 a,`_ 0 2• WW Type CouPmoka: Does tea proposed system siraulate potable w o (no autiives) In contimows piping that =pldtcly isolates the fluid ftom the euvirowmeat (i.a. oa - 9 Yes Xw Continue comp feting this form. No Do Not comp►ete this form. Complcto other UIC applicWoo, forrns for iustaljing either a 5A7 well Co= -letup wau npotable water into the aquifer) or a 5qM well (oksed- loop well oontain4 dam' 'M sah as R 22, othassol, or other aatMseze or rarrosion inhftors), PROPERTY O"M(S)IAP?UCANT($) List = Property Owner listed 0 pr*rM deed (if owlaod by a busmi ess or joyemnleat agency, sure Im me of entity aad aropreaentative wlauthorityfor sigaalwa); (1) (2) Mailing Address: Li-29 t' i 'r ck,/: laeA TrAzs46t.. Srsta: A,Zip coda: zpg 9 County How,eO ca Tele No,: Broad Addr,"s: +&0 fty&ic� A.ddrm 0f Wet Site (ifdiff8rctt= above): r city: State Zip Code' County: -Iomelaf m role Na,• _ ._ rajl VA AUT]aOrR.L XD AGENT OF OW;TEX, I1!' ANY (if to Permit Applicw does yt owiltlua subject property, ettaoh a latter tom the pragerty owner wing Agent to iasnll and aperste UTC welt) CompanyNaaw C=tact Few — EMAIL a w_- Address: City: St ta' — .Zip Code: a6fice T81a No.: Websim ,Address of Company, if nay: County, RECEIVED 02-03-`12 14:40 FROM- TO- NC DENIM P&S P002/005 Feb, 1 2012 3:02PM Jul. I. 1010 Yl1AM YAUKIN WELL No. 571,J18br, J P. C. WELL D== WLILLMATION CompanyNme:3Laftin Well CQ, is WoU Drlilcr Coatraator's Naate; Jody 1,►Ar .MStthm 3rom NC Contractor Certification No.: 2572-A 94 G• 354 -A . Cortaol Palo ' d 7 vn a - HMAZI. : rbief c Address: 19081�asnptozr�iZTe iLd. City: 9am t i lIa Zip Code: 27tSZt] Cpttttty Yedklr�_�_ OIECe Tela No.: 336-468.4440 Ceg No.: ,_�36-374►9736 K J D. WL T FUMY CONTUCTOR 1"ORMATION (if dUhrant time 3riUer) CoateGtPet5ntly �>ti,�:� r x:IylratLs�ddr,5Sy 1al c,� c 1r,r1 _- :� �:fl3RG.� &go Ad&mir:._1 Cily! - i x� .1 Zap Code: ,49,r, 2.4, Cowkv E. STAT138 OF AFFUCANT Private: V Federal: Camraarci�l: 51ble, _,,._, Municipal: Nvtive A=tdcm Le:zds: ,_.-_, F. 1XYECT r0N FR4CXDU&> [briefly deacrlb+ Ixaw the �ecttaa �vcii(t} ; li 6e osed) j LrQ6 r Cr. YVELL C 04NnAu c 17 ON D A TA 41 (1) Proposed date to ba constzveted: Number of borings: Apgrawi=m depth of each boring (NQ, o' (2) 'type of tubingto be vmd (copper,FVC, ate): ►� - t (S) Well Casing. I5 the wall(s) eased? (check either (a.) Yar,4r (b.) No balmy) Cej Yes ifyw, then provide aaslog infaWdoabelow Type: �plver:ized steel! _.black steeiplasflC v#her (spec*) Casing depth; hom to -_feet (refaren ce to land suc*ce) Casing extends to Above ground inches (b) No �G_ (4) Crout info (insroerial suxro=dln$ ►roll castvZ and/or piping): ,r ►ts n O j q.�es' (a) Grout typo Neat Com at 8etita11110 s/ offer [apaettq (b) Grout pfaoement: P'=*&-L/ prw"re Other {a) i=ratzc eeptlz aft'sb�ri� (reference to Ia�d aurf x); lkom .7- i ,0 m (fcatj Ta wall has Casing, lodl ftte gxaut dOPtb. i= _ io (fees RECEIVED 02-03-' 1P 14:40 FROM- TO- NC DENIM P&5 P003/005 Feb. 1 2012 3:02PM �u I. r. LU �V �: u +nm 1i1UAi1I nc�� lov, 1N°. 1801. T P. 4 WJECTION-RELAUD EQU]7X= Attach a diagram showing the engiz otw layout or proposed raodifas ioa of ft injection equip=re, ad Mtwor pipinghubing associated with the iajeGtorr operatin. The rMufactales br%14n racy provide supplernentarY informez;.au• L LIICATYON OP' WELL(S) Attach two copies of maps showiag the followiz.g #fbrmation; (l) Include a Site Map (an be draws:) showing: bidl tags, property Brien, surfsoe w$mr bodies; pvt3W&1 8ouram of grouadwafar cordamitfetian and tine orierdatiou of and cilstaaems between the proposed wells) and any exisfuig waIksj or waste &&pawl facilities rails n septic ranks or drain �pjds located witbiu 200 feet of the gect crnW.hestpurap wall system. label all lhatums clearly and 1nGlu& a ne n� (2) The Sit! Mip tuust shmv the subject p7operty in reWoau to the s>zrroundsng area by using at leabt rwo Ixed retieTnrice pWnts sib+ as roads, str'euas, ind/or h9ghway imwk om- IT. C-MMCATZON Note: This FerndtAppycadou must to sipad try each person appeari q on the recorded leg�lproperty deed. "I hereby certify, under peaatty of law, Hutt I have prsoasVy axUaimd and M familiar wit the irt£armatfon submitad in this .dm neat and all anteciments thareto and that, based on my wiry of those individnal8 irnmediately rapozslble for obtaining said information, I haBove that the infarmatlom is true, accurate and aompleta. I am aware that then are sigxomt panaltiea, inomdig rho pmiblry of finee and imprisaataeat< for submittiNe, false infvrmAtiaa. I agree to carsstctsct, np tc, mast iri, repair, and i#'appIi la, al=don the i4ec ion well and all related appur5.-=r 3 is swordance with the approved specie 'onuw aps of the Perxift" Sipawre of Propart5 waer/Appl o= Pr%rFt or'�7a ]Ft�it �iamE and �kttl� Sipan ro afProperty Ownerh4plime Phut or Type Feel] Siza and field SlgaeM of AulhWi2ed Ag=a if Any Print or Type Full Name and title Please return rwo copies ofrhe aompletod Application packago to. - North Caarolua DEN-R DWQ Aquifer Protection See ioia-IIIC Program 1636 M -01 Sex ice Center. Raleigh, NC 27699•-1636 Telepkoae (9I9) 715-6935 RECEIVED 02-03-` 12 M AO FROM- TO- NC DENR P&5 P004/005 Feb. 1 2012 3:02PM N a. 1801 P. 5 T406%aj aft�41FW a N { { p RECEIVED 02-03—'12 14:40 FRC11— TO— NC DENR P&5 r/t P005/005 Feb. 1 2012 3: 41 PM NO. 1801 P. i FAmLE TRANSIMON FORM DATE: /2 TIME: REE NO. LOG NO. CON" NAME ffix No. no.iv_a Q1 w A17i<MitO>r aEP'F. FROM; add.- c•R C s�� - COMPANY NAME FAX NIX PLEA&f _ 100,,j of wow.• ❑ ��nr WOMOUAL OEP3 NUMBER OF PARES PtEA$E ORIOIMAIQR8 - IMMMIgG THIS $MEET SI6HI1Y1K MESSAGE: "FOR ALL YOUR WATCR NIEEOr. YADKIN WELL CO.. INC. 1008 HAMPTONVILLE ROAD HAMPTONVILLE, NC 97020 ❑AVID J. BROWN. VICE PRES. TOLL FRE@ 48001 24134355 OFFICE t3361 AB&A"O FAX 13361 4e8-4648 RES t3361 4 8.4659 -**Oct News .µems■ - coo wave row , PLEASE INFOM Ut WEOUMV IF 1OU 00 NW RBCQVE FRIAR i w RU TO- NO DELVE P&5 F0011005 ECEIVED 02-03-'12 14:40 FROM-