WI0400249_GEO THERMAL_20120423

Permit Number WI0400249 /
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
Michael & Tanya Wilson SFR
Location Address
40 Shady Ln
Roaring Gap
Owner
Owner Name
Michael
Dates/Events
NC
L
28668
Wilson
Scheduled
Orig Issue
04/23/12
App Received Draft Initiated Issuance
04/20/12
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Flies: APS_ SWP_
04/23/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville Rd
Hamptonville NC
Major/Minor
Minor
Region
Winston-Salem
County
Alleghany
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Michael L. Wilson
PO Box 10
Roaring Gap
Public Notice Issue
04/23/12
NC
Effective
04/23/12
27020
28668
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Michael L. Wilson
Tanya Wilson
PO Box 10
Roaring Gap, NC 28668
AVA·
NCDENR .t}kt,,,.. .
North Carolina Department of Environment and Natu.raP~0~<JUrces
· · Division of Water Quality '\
Charles Wakild, P.E.
Director
April 25, 2012
Subject: Acknowledgement ofintentto Construct Type 5QW Injection Well System
Permit No; WI0400249
40 Shady Lane, Roaring Gap, NC 28668
Dear Mr. & Mrs. Wilson:
Dee Freeman
Secretary
On April 20, 2012, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-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 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 Alleghany Health
Department as they rn·ay have additio~~l. 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 you have any questions.
cc: Winston-Salem Regional Office -APS .
APS CentralFiles :-·PennitNo. WI0400249
A11eghany CountyHe~th Dept.
David J. Brown--Yadkin Well Co., Inc.
Mack Evans -Evans 1:Ieating & Cooling, Inc.
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.ncwatemualitv.org
An Equal Opportunity\ Affirmative Action Employer
Sincerely, 01 ,-it\ A. 8oovu
forD~tts
Supervisor
N~hcarolin.a ··~.· .. t,· .· ... ·~~ ... . . 'tl U~'tl ·. . . .· . . ' . . . :.:: ... : .... .-..... 1/
Ap r. 24, 2012 1, 03PM No. 2239 P. 2
RECEWTA)ENRMWO
APR +, .
NORTH CAROUNA
imPARTMRNT OF SNymow8w AND NATULAx, P-MOVAM MCDEW
NOTMCATION OF INTENT TO CONSTRWr A _LL4. SED-101 G90TWtNAL
WECUOK WELL SYSTEM:
TYPE 5-0w wML(S)
In A=rdaucr-Aii1%tkcPwVlslnas GOCA Mda k3k 02!*MOOL gZeede
catnpteta Ws nolloceaw and M%U to Qftm oo Me bade pose (Pkaw Ew arm latbsmetta4 r
CC
DATE:_ �I_I �7. . 3004
Wall 7ypa Conjbmctiais: Does the proposed aya m circislatepotable a* tan additives) in �
cotttimtow piping tbat c=plettly lsolates the fluid from the enviros+ment (i.c
Yu —xi_, Continue eoatpleting this form.
l'fo Do Not eamplero this ftn Complsle other MC appaiaetio tfbno for irsatatling
either a W wall („ M-laop ►v W1 inimill"I potable water into the nquifa) Ora 5W well (elesed-
toop well cw t 4bg additives such sa R 22, ethano), or other Wiltioeao or corrosion inhibiturs].
A.- FR0p=TY QWNEAWA1TUCANT(b)
List,gbProp" owwr listed ass propucy deed (ifewned bye bualnws or govunmentaVmcy, stave rAm of
entity and A repramft0a wAudwity for sigas -C G. 1150�1
City: f+ State: vp c0d62
BoaCovspty
HomelD[fiee xelGNo.: ��' ,��p ^� �� Ce11 No.� Sys • �7n +-�DSZ
Email Address W
3 Mike. W n Pu.[GM
(a) physioi3 ofwelt sire (if di�ecetsc than soave): S �ALv
C1tr r ' 8tatal xtp cede: Covtrty:
Rome210f6ceTa►allo.: -1s i'CNa �CwlNa.:-371J-}�P
B. AUTHOMW AGENT OF OWNER, IF ANY (f t e Petrnit Appttsotst does npl awa tha subjecr propeaq►y,
attaea a letter ftm the properly owner authanrins Agent to instal! and opmtc UIC Weil)
CwcpsnyNaine:
Contact pmcn- 1 it"-dceas: —
Address:
ciog State: — Zip Code: County:
00wTeleNa- CAIRO.., _
WaWtc Address of Company, if arty,
RECEIVED 04-20—'12 11:38 PROM— ITO— NC DENR P$5 F002/005

Aa r. 20. 2012 1.03PM
No.2239 P. 3
���E�VEDID��RIDWQ
APR
Aquifer protection Seft,
5, Q P
C. WnL DRMXTdR I NFORKATION
CGIWYNIMO,. W
Well Dr11+I Conlm*tar,s Name; ,104-t-mulus tbenbe�r�vn 14tlttnn Cme
NC CcnvaemrrArt fwr&omWO.: 'Z -A
COatsat per.o>a _ D.ey ►vn 4 � BI►dA� AAdry s�eIil�driller�tmtn eom
{lddress:190814amptonvIlla Rd,
City: Hem*taitv111e _ Ila Elp Coda.' 27020 44mly: Yedich
OSPtcoTeleNaa 356-468.4440 CallNar M74.8736
D, EUT1O
Coatw patmil-
Addrm. ;�;Iq
Car Aide
Ol11ec Tele No.:
lb -Al d Wa)
zlp Cods: p7� 423 COUM . jjllP�J&Q
1. STATUS OF A=OANP
Prf11410d Z Fedml:— COriail chl:,
Siata' NUWCIPti; — Nodya AmadeaaLands: `-
X M=C1 Q" Ypop tL (brldly deaerru ow the Wacdon wolf(s) will be uscc)
m
W1I'LY.CQ1"TACICTTDNDATA �-� Z21
(1) Pnposad date to be commuctedAwkj �'� - 1`lnmbu oLt:oringa �
Appra dinato depth *Peach b* ing (Aelle 2..So
(2) T&oitublegtode med (oopper.lYGala�; e I
Z=-( ! I� •
(3) W61i oealas. Is the rre *) oesrd? (Chwk ellher (a) Yea or (b ) We be"
(a) Yes ifyes,lbanprovidecasing ]thrmo6oabalm
Type; �alvudaed else! 61so1c steal glasll� othertsper�Cy}
Ceaf a$ deem; From to filet (raltranae to land varf$oE)
Cuing oxtonds to above gromd,�nches
(b) No r!
(4) OsmdInfo (malertatxwomdldg wall osstegaodlorplplW- 74r,.%4ftty O^A .944ir-i
{a) Graw lypa: Nast Ceraeat eeititouite A!�odzr (,peem
(tr} Oroul pbeearnml; Pcmpin&_V Pmeure Oomr
(c) Grant depth MOMS Ovfteace, to lead whca). 6om Z1-V to 0 (Nq
ti woll lws cnslrsg, iedleategptn deplb: ti�a 4C�- to _z j6j
tau k. Coo&-t
RECEIVED 04-20-'12 11,38 FROM- TO-- NC DENS P&S
P003/005

AR r. 24, 2012 1, 03FM
k 2239 P. 4
RECE VFDJDENRIDWQ
APR 2 4 2o12
Aquifer Probecbo l Se*r,
�. S�W$GTION-I�LAT� �QV�NT
Attach a dlsi ram dWWIOg the err mering layout ar proposed. modif moon of the iujectlon egtrdpmW and waios
piploghubbt ancoieted With the Wactica operation. The ma► kdvnes brorhtus may "We anppiomentary
WOMUO. '
L LO CATiOrf OSr vaL(S)
Astaolt Ovo copses of maps showing 09 followlag WorrasR u
(i) Include a Sito Map (cart be dravm) :ttowiat: buildinga, propoy lima, surface water bodtoe; p tenflsl
sources of granndwaier coomimticn and Ills orientation of and distances botwsmn the proposed wails} ■nd
aw exiafing wells) as waste d4w87 f1do ies such as sepiie.UvJ l or drain 5ylds located wifhta 200 Rot of
fltn geodwroal heat pt mp.well system. Label all features clearly and include j�%(h erraw,
(2) The Site Mnp mvat dww the sweet propeaty in relatlan tote sumo trove area by wWz; at lout two fixed
rcieteace psdnta anch as MIA, si MRS, a NOT hiWWWW IntersedloM
J. C2ATMCATION
Note: This Permit Appficattoo must bestgood by e, oc paxaonrppe�rrug on the
recorded legalpmparty deed.
"I heseby woo, under perolty of law, tlral I ltave panon■I)y mmmfoed and un familiar w14% the infarjollon
submitted in Ws damumt and a11.attaeltwts tt►acto srtd that, based on Ty iaquity of those Individuals
Immd]aWy responak tw obtafalag Bald Wormatiorh I believe brat the inf4rsaatloa is true, aeanratc and complete,
I am aware that there are *dficam penaltlea, lacludiug *a passibility of Burs end impriommot, for submitting
;hire i0mutton. I agree to sort act, operate, maintaln, sepaL4 ad lfapplimbte, abandon tho igjeotloA Well, and
all related Munemces In accordmae with the ap� , ;eon a� frhe permit."
ftt twee pfProgerty Owmr/Appboant
/1�/rCJ1C� L.1�i I aI — �r4 �rNhe�
Print or Type FulMMM sad fate .
Signature f Property v►v WAppricsnt
Ptltu or 1j a Pu{1 Name and title !'
Sigaatura otAuttwrized Agent, if any
FrW ar Type Full Name and title
Plem rcWM ewe copse&efthe Completed Applicatioa package to;
wpm Cttrohusk DPM bWQ
Aquifer Protection SeWou-UfC Promm
1636 NO Service Center
Ralclgh, MC 27699-im
Telephone [phone]
RECEIVED 04-20-'12 11:38 FROM- TO- NC DENP P&S P004/005

Apr, 24. 2012 1: 03PM kt -1 , —
f
l.lwcj" jMHllJWQ0, 2239 P,
p Ammer pfatcuM SWW
° SkL
.406
le-arco'll - Afc.
�N
flL
RECEIVED 04-20-'12 11:38 FROM- TO- NC DENP P&5
P005/005

Apr, 20. 2012 1; 03PM
Na, 2239 P. 1
FACOMH TRAMMON FORM
DATE: 1 TIME: REF NO. RAG NO.
COMPANY NAMIe PAX NO. PLDWM�
40 �►f a ._� ❑ p�VIMFbIATfIY
AMnDN DEn
FROM: . CA 0 Po fe?
OOMMY r AME _ FAX NO.
INDIVIDUAL
NUMBER OF PAGES PLEASE
INCLU0ING THIS SHEET REEPPLY $Y
OFF[
MESSAGE: _
lei
AQUA% Proteclion
r
r
-FOR ALL YOUR WATER NE609'
YADKIN WELL CO„ INC.
1990 HAMPTONVILLE ROAO
HAMPTONVILLE. NC 27020
DAVID J. BROWN, VICE PRES.
7066 FREC W41 2489353
OFFICE 1336i 4456-440
PAX 43361 4,59-40a8
RES 4 $411 A6a4659
roOOo Mcw: •Keefe■ , am LOVse " r
❑mv
IVED 04-20-'12 12;38 FPOP1-
PLEASE n1iF M US MAIL ffELY IF WU DO NOT Mi*JVE RA MMU 1N I"
TO- NC DENP P&5 F001I00