WI0500298_GEO THERMAL_20101020

Permit Number
Program Category
Ground Water
Permit Type
WI0500298 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
David Cooper SFR
Location Address
1231 Nc87 N Hwy
Pittsboro
Owner
Owner Name
David
Dates/Events
NC 27312
Samue Cooper
I
Orig Issue
10/20/10
App Received Draft Initiated
10/08/10
Re qulated Activities
Heat Pump Inj ecti on
Outfall NULL
Scheduled
Issuance
Central Files : APS_ SWP_
10/20/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville NC
Major/Minor
Minor
Region
Raleigh
County
Chatham
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
David Samuel Cooper
PO Box 1824
Pittsboro NC
Public Notice Issue
10/20/10
Effective
10/20/10
27020
27312
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
SI%
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
10120/ 2010
David Samuel Cooper
PO Sox 1824
Pittsboro, NC 273122
Subject: Acknowledgement of Intent to Construct Type 5QW injection Well System
Permit No. W10500298
1231 NC 87 N Hwy. Pittsboro. NC 27312
Dear Mr. Cooper
On 10/812010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onl\
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 weIl 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 .0211(0(2). Additionally, you should contact the Pins 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.Roeersrthricdenr.sov if you have any questions.
Sincerely,
for Debra Watts
Supervisor
cc: Raleigh Regional Office - APS
AI'S Central Files - Permit No, W1051X 20 -I
Chatham County Health Dept.
adlcin Well Co. (David Brown) 1908 HamptouvilIc Road. Haisptonvilie_ NC 27020
Louis Heating & Cooling Svc. Inc (Louis Aenulutro) 5213 !.ease Lan_ Raleigh. NC 27617
AQUIFER PROTECTION SECTION
1636 Mali Service Center. Raleigh. North Carolina 27699-1835
Location: 2725 Capital Boulevard, Raleigh, North Carolina 27604
Phone'. 919- 7 33-3221 \ FAX 1: 919-715-U58E: FAX 2: 919-?15-6048 I Customer Service. 1-87r-623-57A5
Internet, www.rcwaterquality.orq
An Equal Cpponunay', afirrnativs.Action Employe-
NorthCarolina
Naturally

rOct. S.,
io/u4i4viu
■
Y
2010; 2.31PM YADKIN WELL,' LUULJN ,
vo 1 r vnn i iin.. C�cR OF COURT
•
NG. 6082
NORTH CAROUNA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
2/3:/vuu
NOTIFICATION OF IN t l T TO CONSTRUCT A CL ED-LOOQ GEOTHERMAL
WATTR.ONLy INJECTION WELL SYSTEM
TYPE 50 W WELLS)
Accordance With tha Provisions of1NiCAC Title 15A 02C.01100
Print or type he required lxrformarrdn and ma is Gdthress on he back page.
DATE. OcrQber 3 20 10 NSIT C75n0 C� r
Well Type Confirmation: Does the proposed system circulate potable -later onllx (no additives) in
continuous piping that completely isolates the fluid from the environment (Le.
Closed-lQobr
Yes Continue completing this form.
Na Do Not complete this form. Complete other VIC application forms for installing
either a 5A7 well (ppenrloop well injecting potable Water into the aquifer} or a 5QM well (closed -
loop well containing pdcliives such a& R-22, .sthanoi, or other EITitirrtteZe or corrosion inhibitors),
A, PROPERTY UWNER(S)IAPPLTCANT(S)
List each Prope;ry Owner listed on property deed (if owned by a busintss or government agent; stirname of
entity and a representative v{lattthority far signaitst re):
.9 umo ,Sr4tr7a�l�¢'J�
(1) Mailing Address: 1231 NC SINHw_tr /eO 1T=_e- .2p'
City: Pittsbare State- NC_ hip Code: 27312 County: Chatham
Horne/Office Tele No.: 60.) 5dI 320_O Cell No.: q_1q z57
Email Address! Wabsite:
yezio-citt, aver,
(2) Physical Address of Well Site (if different than above):
City: _ State: Zip Code: County
Home/Office TeleNo.'. Cell No.:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not van the property,
attach a letter from the property owner authorizing Agent to install and operate UiC well)
Company Name: goensplconatrvcAipn SsviCC 1ne. -
Contact Pe or..' Icihrk Cumn' g _ Emti Address iohnScos<nSpl-com
—A res:;- —
City; PittSboTo Stare: NC Zip Code: 27312 County;
Mae TeleNo,: _ (919) 8Q5-34g2 Ce1t'vo_!(914) 524-/479_
Wehsite Address of` Company. if any:
GPURTYC SQw Wptificatiw; cf LiDtvra Form (Revised tta468)

1°'Oct. 6. 2010 2:31PM YADKIN WELL
ynnlfinal 1UL,rtl
No. 6082
�l;SI�UC
C. WELL ARII.LER XNFORNL TION
Company Name:_ Yadkin WJ Co.mpanv. lne.
Well Miner Contractors s Name'. David Brown
NC Contractor Certification No:: 2 aid A
Contact Person: David Brown , EMAIL Address:
Address: 1908 Harxsptorsuille Road
City: Hernotonvifle
Zip Code:
1C County:
27020
Office Tele No.: 336-468.4440 Cell No.:
D. HEAT PUMP CONTRACTOR EIFORMATION (ifcliffcrent than driller)
Company Name; Lc' .is Hain and Coolinc Servicalne.
Con Person: Louts Agnolm#o _ ElvLAdi., Address:louisairlebe11south.net
Address: 5813 Las Lena
City: Raleigh. NC Zip Code_ 17617 County: Wake
Office Tele No.: (919) 7& i.8435 Cell No.:
E. STATUS O O r rLXXCANT
Private: V Federal: Commercial:
State: Municipal! Native American Lands:
�. INJECTION PROCETUR.E (briefly describe how the injection wc11(s) will be used)
G. WELL CONSTRUCTIOIst DATA
(1) Proposed date m be constructed: OC ?ten l a Nurn bty. of bork : 2
Approximate depth of each baring Cfent): 320 r
(2) Type of tubing to be used (copper, PVC, etc): �� PI
(3) We1l casing. is the well(s) cued? (check either (a.) Yes 21(b.) No below)
(a) Yes if yes, then provide casg information below
Type: _galvanized steel black steel plastic other (specify)
Caging depth! From to feet (reference to land surface)
Casing extends to above ground T inches
(b) No R
(4) Grout Info (material surrounding well casing and/or piping): eri"ewd( it rIC
tea) -type: Neat- n ent Benton to {' her (specify)
(b) Grout placement: Pumping )C Pressure Other
land . f ): ra !a (feet)
Cc) irtit5[J� d�t�l C►i'�it'�1Lg (reference to �m7� 5u� f• ••{�� [..,-_,
if well leas casing. indicate grout depth: fom rb (feet)
GPi1/rf1C 5QW Na¢Ssarion of Iza at Fams (Revised. Sr204$) page 2

1°Oct, 20101 2:32PM YADKIN WELL u, LAL.thR ur LI+UK' 44, 6082
LOUJ
H. IN. ECnON R!LATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment end exterior
piping/tubing associated witb :be injection operation_. The manufacturer's brochure may provide supplementary
irefarrnnrion.
L LOCATION OF Vef..LL(S)
Attach two copies of maps shawlztg the following information:
(1) Include a Site, Mop (can be drawn) showing: buildings. property lines, surface water bodies, poter>fial
sources of groundwater con amfnaxion and the orientation of and distances between the proposed wail() 3ipd
any existing we11(s) or waste disposal facilities such as septic tar+bs or drain fields tocared within 200 feet of
the good -lama] heat pump well system, Label all features clearly and include a north arrow_
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads. Streams. andfor highway intersections.
3. CZRTIFICATION
Note: This Permit Application mist be signed by each person appearing on the
recorded Iegal property deed.
"I hereby certify, under penalty of Jaw. that 1 have personalty examined cad sm familiar with the information
submitted in this document and all arachtnents thereto azFd that, based on nay inquiry of those individuals
immediately responsible for obtaining said ipfbrtxlation, l believe that the irtformarion is true,accurate and complete.
1 am aware that there are significant pene1tios, iriclvding the possibility of fines end imprisonment, for submitting
e informations I agree to construct operate, maintain, repair, and if applicable. abandon the injection well and
all related appurtenances in accordance ►,4,ith rho approved specifications and conditions of the Permit,"
Signature of?: perry Owner/Appli
Print or Typal Full Name and title
Signature of Property Owns/Applicant
Print or'1ype Full Name and title
Signature of Authorized Agent, fluty
Print or Type Full Name and title
Please return rw❑ copies of the completed Application package to,:
Nord/ Carolina DEN1:t-tiWQ
Aquifer Protection Section-VIC Program
1636 Mail Service Center
pAteigizi NC 27699-1636
Telephone [phone]
Gl?UI[IIC 5 pw Wailfir of him nt Form (ReVisad g2008) Page 3

Oct. 6: 2010. 2:32PM VADKIN WELL No.6082 P. 5
/23( Qc 77 Ai-
P b- 4fr-e, /t' G: 27 3 (2

Oct. 6. 201c 2:31 PM YADKIN WELL No. 6082 P. 1
FACSIMILE TRANSMISSION FORM
DATE. �;'' G kitI1ME'
TO:
d1Q
COMPANY NAME
ATTENTION
_REF. NO. WG NO.
(Lt) /r- 'l
FAX K0.
DEPI
PLEASE
❑DELIVER
IMMEDIATELY
FROM: ✓4 icin e a (33c) 544i - re?
FAX NO. PLEASE
CO MPANAAME r�
�/ 1 VO W 1'` u fiRUSH
EPLY
DWI
PLEASE ORIGINA
REPLY BY SIGNATURES
INDIVIDUAL
NUMBER OF PAGES
INCLUDING THIS SHEET
MESSAGE:
7-4 tt,Zi
"FOR ALL 'YOUR WATER NEEDS
YADKIN WELL CO., INC.
1908 PIAMPTQHVILLE RC AO
14AMPT0NVILLE, NC 27020
DAVI❑ J. BROWN, VICE FRES.
TOLL FREE [89O) 2484355
OFFICE 11336) 4G&A.4dO
FAX 1336) d66-4 4
RES A3361 468-4659
-GOQC KCWS AMERICA - GOO L V you'
PLEASE INFCFWI US IMMFD/KELT IF YOU DQ Nar RECEIVE FA MA•E IN FULL