WI0500423_GEO THERMAL_20110831

Permit Number
Program Category
Ground Water
Permit Type
WI0500423 I
Injection Water On_ly GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Frank & Elizabeth Arnold SFR
Location Address
16108 Morehead Dr
Chapel Hill
Owner
Owner Name
Frank
Dates/Events
NC 27517
Arnold
Orig Issue
08/31/11
App Received Draft Initiated
08/30/11
Re a ulated Activities
Heat Pump Injection
Outfall NULL
Scheduled
Issuance
Central Files: APS_ SWP_
08/31/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Glen A. Darch
13109 Bold Run Hill Rd
Wake Forest NC
Major/Minor
Minor
Region
Raleigh
County
Chatham
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Frank Arnold
1319 Beulah Rd
Vienna
Public Notice Issue
08/31/11
VA
Effective
08/31/11
27587
22182
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
A i71
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Col -Gen H. Sullins Dee Freeman
Governor Director Secretary
9/11201 i
Frank A. Arnold
Elizabeth M. Arnold
1319 Beulah Road
Vienna. VA 22182
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0500423
16105 Morehead Drive, Chapel Hill, NC 27517
Dear Mr. & Mrs. Arnold:
On August 30, 2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-oni
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,
'. 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 .0211(u}(2). Additionally, you should contact the Chatham 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.Roeers•t ..ncdenr..cmv if you have any questions.
Sincerely,
LJ (Lik &)ofti
for Debra Watts
SL1pervisor
cc: Raleigh Regional Office - APS
APS Central Files - Permit No. W I0500423
Chatham County Health Dept.
Clan A. Darch Well Drilling, LLC (Glen Darclti
8nw1nati Mechanical Services, Inc. [Steve Bowman)
AOUIF?`.R PROTECTION SECTION
i63G Mai! Service Center, Raleigh. North Carolina 2769g-1536
L o;:ation: 2725 Caoital Boulevard. Raleigh, North Carolina 27804
Phone' 919-733-. 221 +FA.Y ; 9i9-71.5-O598: FAX 2:91g-715-3O4E\Custorner Servlce.1-B 7-S2 2. 745
laternet www,newateroualil .om
N ob Carolina
AI `y-2! Afi rme ye is7:70 _fllery"

NORTH CAROLINA DEPARTMENT OF ENV!RO!' MENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION -WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "permitted by rule' and do not require an individual permit when they ore c-onstructed in
accordance with the rules of 1 ?A NCAC 02C _0?00 and this Notice is submitted prior to construction.
Print or Type Ir?for marinn and Mail 10 the Address on the Last Page.
DATE: 7' a • - -. 20 i t NO. (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence ' Business/Organization _
Government State Municipal County Federal
R. WELL OWNER - For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf ofthe business or agency:
Yr� IL 4. Av-r a id
Mailing, Address: t3irt Be.uta,k (A_city: U l g State: 1IfA Zip Code:_ j2,j ' Z County:
+�
Day Tele No.: L0�] "7SC "65'�II. T Celi No.: '3-05 18 3Z
EMAIL, Address: Je 1f t r"toH I4►7Sc9r ' at No.:
cJ CtlYyt.
C. LOCATION OF WELL SITE - Where the injection wells are physically located:
(1) Parcel identification Number (PIN) of well site: Lt q County: _ 0, dykliti
(2) Physical Address (if different than mailing address):
City: �.
14i II
State: NC Zip Code: e2 1 l7
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: (,-le.l A t'VQ /, Or11/i 2.4C
NC Well Drilliiw Contractor Certification No.. 00 4
Company Name` C le -A A !fcI N�e/�rrl� �� C
Contact Person;_ Glee, 11 i2elf EMAIL Address: 9064, 41-;: • ' Ro%'tvi
Address: I3 /09 &r9 iy4 y./ Ad
City: 6•4ii4e Fes]- Zip Code: .7-9 Stare: AteCou ntv: '-#'
Office Tele No.: 96-5-6-38 39 Cell No.: Si) YZZ- 993i Fax No.: [phone]
r)I'C" t:IC SO,,,, "NolItieatiuu 4Revi ed 3' 1&:201 l?. ":Ice

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: ___ B_· _owm __ a_n_M_e_c_h_a_n_i_c_a_l_S_e_r_v_i_· c_e _s _,_I _n_c_. _______________ _
Contact Person: Sfefle &wma,, EMAIL Address: [e-mail]
Address: 145 Technical Ct.
City: Garner Zip Code: 27529 State: _NC_County : _w_ak_e ---,----,,.~-
[phone] [phone] Office Tele No.: -Cell No.: __________ =-F=axc=--:..N=occ.,.:c_ ______ _
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: Z.... Depth of each boring (feet): '"30 tJ
* lf existing water supply wells will be used then provide the information in item (4) below .
(2) Type of tubing to be used (steel, PVC, etc): //OPE -~~~--------------
( 3) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground: __________________ _
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite** X Other (specify) _______ _
** By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(l )(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from ~re to 3 'b (feet)
If well has casing, indicate grout depth: from ____ to _____ (feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north anow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of tile property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of tile wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showi11:g topographic contours or
elevation data.
GPU/UIC 5QW Notification (Revised 3/18/2011) Page 2
t?. CERTIFICATION TION (to be signed as required below or by that persons authorized regent)
15A NCAC 02C _O211(b) requires that all permit applications shall be signed as follows:
For a corporation: by a responsible corporate officer,
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected of icia[:
1. for all driers: by the well owner (which means all nersort$ listed on the property deed).
If an authorized age at is signing on behalf of the applicant, then supply a letter signed by the
applicant that names nail anthotizes their agent to sign this application on their behalf.
"l hereby certify_ under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. 1 am aware that there are significant penalties, including the possibility of fines and imprisonment.
for submitting false information. I agree to construct. operate, maintain, repair, and if applicable, abandon the
injection well and all rclated appurtenances in accordance with the approved specifications and conditions of
the Permit.'
Suture of Proper-t_ Tier ppficarai
Print or Type Full Name
i t-! ire .4i "Sr- rj
Signature f "rcperty Owner/Applicant
'E3fir ia.k.ttk fliLASIvio Jd
Print or Type e Full Name
Signature of Authorized Agent. if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
fla eigh, NC 27699-1636
a eiephone [phone]..
�,Pt►;I'i 3itti1' Ito Ned3,IS 01I) Puge.

SETBACKS:
FRONT= 40'
SIDE= 15'
REAR= 50'
MAP REFERENCE
PLAT SLIDE 94-320
DEED BOOK 736-2
PROPERTY ADDRESS
16106 LOREHEAa
CHAPEL I-iLL N.C.
)O3 105165
DWC1 '05165FL
f3ARSCALE FOR REDUCTION 3-
�r I
Uwe 04_
FOUNDATION LOCATION
{ }PIPE FOR
� �41
p�� FRANK & ELIZABETH ARNOLD
❑4C., ¢ LOT 930 PHASE SIXTEEN
GOVERNORS CLUB
'. h� /� N. LOT WILLIAMS TWP. CHATHAM CO. N.C.
O4 �A�'1" / / N 931 DATE: MAY 20, 2011 SCALE: 1' 5O'
/ N
/ N
/ \ �s,
`112-,11L
t _ N
2°E y GENERAL NOTES
N.gyp 1, AREA OF LOT 930 IS 1.10 AC.+/- (MID).
zY SEE
BOOK
NOTES OF RECORD.
7362 FORO1e•s
3. THIS I5 AN EXISTING PARCEL OF LAND.
LOT t
929
CONTROL
CORNER
45.
PREPARED BY:
THOMAS L. RAMSEY PLS L-2871
FO4 YORKTOWN DRIVE

16108
L 15108 M REHEAD
930
t2 16106
CHATHAM COUNTY, NC
Property Map
Disrlefiner:
The data prwidad on Itao r„op are prepared for the Inven4XY d reel puperty found wrIhn
Chatham County. MC and era oomphod from retarded plate, deeds, and other public records
and data. Thls data Is for Inlama oido prsposes only and Should not be suhsthuled
bra hue fda ,OINEtM1 drepedyapproisof survey, prior toning yerincaion.
32
GotAtO
One Inch = 59 Feet

CHATHAM COUNTY, NC
Property Map
Olsclalm9r
The dela pmvIed en this map aro !modeled for the invonmry of real property found Mthln
Chatham County, NC and aro =copied from recorded plalc, deeds. and other potter records
and data. This data as far informational purposes only end should not be eJhs;ilutea
fpr a eon Sae Soifer. pfdperhy epp+aisal_ SOOSY, or for ?eni g VariRcet n.
One Inch = 1536 Feet

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CHATHAM COUNTY, NC
CpG;T
Property Map
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Clsda'mer
The data provided or. this map aro prepared for the Novo Mary of real property found Rohn
Cha9oam County, NC and are compiled from retarded plats. doede, and other pidlic records
end data. This dera is roe inlernalioml purposes only end ShdJd not be sudsfteled
fee a eve Oa search. property apprafoal. survey. or for zoning+nerificalkn.
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One Inch = 3458 Feet

tl~?~
!iervice&,, Inc
: I t-i 11\il fi .¥;j I :I i•i~•I •l I 11 1 1,11 f~I d ij, J;,11 :'-ii ■ I• J;LW
145 Technical Court • Garner, NC 27529 • [phone] • Fax [phone]
Aquifer Protection Section \ NCDENR
1636 Mail Service Center
Raleigh, NC 27699-1636
Subject: Frank A. Arnold\ Elizabeth M. Arnold
1319 Beulah Road
Vienna, Va. 22182
To Whom it may concern,
10-27-2011
Permit# W10500423 for a 5QW geothermal injection well has Glen A Darch Well Drilling listed as the drilling contractor to
perform the requested work. Please change the records by removing Mr. Darch from the permit and adding;
N. W. Poole Well & Pump Company
3500 Rolesville Road
Wendell, NC 27591
919-266-9223
Wake County
Contact Person-Harry Lechworth
NC Well Drilling Contractor Certification#-2833A or 2514A
[e-mail]
Please let me know if any further paperwork is required. Thank you for your assistance.
Sine~ ~
~~~~-
Robert Marshall z_
Bowman Mechanical Services, Inc.
RECEIVED/ OENR / owa
AQU\F!=RPROTFt.TION SECTION
NOV & 1 2011