WI0300170_GEO THERMAL_20110328

Permit Number
Program Category
Ground Water
Permit Type
WI0300170 I
Injection Water Only ·GSHP Well System (5QW)
Primary Reviewer
m ichael. rogers
-Coastal SW Rule
Permitted. Flow
Facilitv
Facility Name
Jason Shade Burgess SFR
Location Address
723 Mt Vernon Ave
Charlotte
Owner
OwrierName
Jason
NC 28203
Shade Burgess
Scheduled
Orig Issue
03/28/11
App Received Draft Initiated Issuance
03/11/11
Re · ulated Activities
Heat Pump Injection
Private residence , sing le family
Central Files: APS_ SWP_
03/28/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit-Contact Affiliation
Jason Sh~de Burgess
Owner
717 Mt Vernon Ave
Charlotte NC
Major/Minor
Minor
Region
Mooresville
County
Me~klenburg
Facility Contact Affiliation
Owner Type
· lndivid~al
Owner Affiliation
Jason Shade Burgess
Owner
717 Mt Vernon Ave
Charlotte
Public Notice Issue
03(28/11
NC
Effective
03/28/11
28203
28203
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
LW-
vw;A
NCDENR
Forth C"arolina Department of cnvironmerli and natural Resource,
Division of Water Quality
Beverly Eaves Pe -due coleen a_ Sullins
Govemor Drrecto:
03/28/2011
Jason Shade Burgess
Elizabeth Donaghy Burgess
717 Mt. Vernon Ave.
Charlotte, NC 28203
Subject: Acknowiedgement of intent to Construct Type 5QW Injection Well System
Permit No. W10300170
723 Mt. Vernon Ave.
Charlotte, NC 28203
Dear Mr. and Mrs. Burgess:
Gee-=reemap
Secretary
On 03/11/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-ordl
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 Mecklenburg 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.Roueml nedenr.20v if you hot any questions.
Sin el J
J
It —
for Debra 61'aM
Supervisor
cc: Mooresville Regional Office - APS
APS Central Files - Permit No. W10300170
Mecklenburg County Health Dept.
David J. Brown (Yadkin Well Co.. Inc., 1908 Hamptonville Rd., Hamptonville, NC 27020)
Geoff Floge (Ross & Witmer, Inc.. 4620 Rozzelles Ferry Rd., Charlotte, NC 28216)
AWTER PROTELTIpN SECT[014
1636 Mail Service Cenrer, Ralegh, North Cam] nit 27699 16 3.
Location: 272„ Genital Boulevard, Ralaiar, Nor0i Cardina 276M
Phone: [phone] FAX 1- 3?9 715.G586, FAX 2' 919•; 5-6040W Customs; Serv�:1.877-623-6745 One C
Irnernet www.na+catemua�i om �r�tryh ar�Ii9r.
�qua� r�pW:rNn{�y p?nrrnalive Acur�ti �aAmv=: iI►dG����L`i:�

E
N
0
z
a
ur
a
Q
Q
w
Q
ti
Ma`r, I I. 2011 8: 06AM
YADKIN WELL
- FAMNLE TRAMPMON FORM
DATE: -3 l'' SME: F, NO.
COMPANY NAME
T¢A i.
�.
AMNnON
DEPL
No. 7170
LOG NO.
4!) ZYZ
FOXM.
-- 9 f/l?
n
LJ IMMEDIATELY
COMPANY NAME — FAX NO. PLfA,SE
C-IAM
REPLY
1NDIMUAL DEPIL
NUMBER OF PAGES � PLEASE ORIGINATOR'S
INCLUMNG TliZ SHEET. REPLY 9Y SIGNANRE
MESSAGE:
..T
-FOR ALL YOUR WAFER NEE05'
roe. -pc' Eat-,, c !'r T6 6_ r
;o
Gh� i 6C.i
YADKIN WELL CO., INC.
190$ HAMPTONVILLEs ROAD
HAMPTQNVILLfi. Nr- 27020
❑AVSD J. BROWN, VICE PRES,
TOIL FREE WOO) 24"365
OFFiC,E t$35J 458=win
FAX[3361 44 RES 659
RE5 S336r a68ea-a859
- QQV NEWro ,AMCRICA • GOO LQv%G VGU-
PLFAW DMPM US MOMOMY IFYW DO NCR' FEC" FACSMEIN F=
:�
21
CI
<r
c
sn
1=l

Mar.. I . 2011 8:07AM
YADKIN WELL "� � � �] No. 7170 P, 2
DrITS;
DWARBffNT OF MTMG 'AM NAT't%" ACM OKUMIP
OrRaENT To CaD1Vmucr A 919904 P QROTMOOIAL
'WATT-0NLY TNJMMON WSUI. SYS :
' M 5-Ow wELUSJ
to Accardaurc w�� �wrer �e .i�A: DZOO� p�
mm�6e+�m�s��maeroae�ca.m�t+�:[��#bmta '�h
.5 %'
20-L
wea Tipe Conflr tl vw D= ibC pramd 4}wm pObOff wabxGdlIYB�Y (w odffi6 m) in
MtEm m ��'I piping *d Cctdy boll m the flII1d fi= tb4 C�Q. kOn.mem(i
�x,
Yea_-+, C Or6nue cam kft f31:S'ibm
NO - Do NotComp% riles V m- Comp)*w dffiw OIC ,ppHwfiw%rm fbr inst &MV
either a SA7 vrdl �boP � potai�fe s�atet #n6p 13� aq�£er} cx' a 5�l� 3veII {c]oaed-
VMH conkinina snehas R 27, 4bami, or offia aka or =rosim inh W=�
L FROFMTY (bNAPPWVA,MT(S)
rist each �cperiy �,� listed aa, Prrr�ctry dccd �tFo4rnod isg a � gamma agency, a�tc gym! a vF
�ry � are�ussl�t�e zyla�ioty irn si�tma� roksvn��. '�r+�,r• � crvr/�
$.
(�} Ads vl '-y
Ra Address p[Sar asi •Goy' iosite:
(2)' PWC' i Addrw of WeIl Site (lftb=aba"): T t rAM AVe,
amv�,; Teie Na.:
AMMOaM-ED A U� �, �A IY cif se Pemrt A nk aura tine pcayat9,
ana& aIWU f = the PMPMty Qvmw s ffiPrb t Agedta and Wc" iSBC w4
Coact E �sa71
.ate:
g�9= Sir _T�p QodC Cc+�r• - - -
WeImb Ad&tw of Campm i#`mr

Mar. 11. 2011 8:07AM YADKIN WELL No, 7170 P, 3
1
v�e�f Dyer oars ]+itme� ,R,Fa��s_ �MrT[tharr�ir� �-,.-Moan a�
�iC C.�IIZ<act�' �1d"Tc�firmrCo:: 2572-A 3436-� 3541�- , _
Oonmi Lisrid X_.BrOrBn 24 � +4 ,_� r3>a6dri� ormi
A&kvw 1902 S%loIIv�C iQd, _ _
C� M. _ Zbp 27M Cody; 'Yaftk- _
Ofm7:aUff*4 Cc4Nca: M-374-4734
{rL'. es" ` I
IL STATU$ OF APIMICANT
Private 1r Fedes> C�
F. Oft�R� daar5�e�pyaci4oa?i(s] wr�i 5e
-
t 1 15r�e ortTstitng m ae bsea [tom $to): AC- 11
f3�i1Ve[f a�g. 7s the weQ(a} easca7(ahe�k cHhrr (s]3!'�Qr(bj�o ba1aN}
(a) Yes Bryas, then pmV, cwiQs kfbrmafi bakw
TypM __Idymftd smed b[ac7C air [Spb 9}
Casingdq4k Pma to dad (Mtmw to kad swam)
cadwa kaedatoabovsgroatrul ,m
(b) NO r�C
C�3CBoas.Inib(z�rlaisuu'oamdhrgvta�i�s�gea�rpipiu�: �,,���y eh ��'.� •�.
(a) [dr#ataep o£t(}�r�a �[od aiaRcaey. flDM 3 Rd_to (fed
Ii n�s�f laes,ctsaiag, fn4icate � depth: £ram to (�eq
i
i
.....M7J�,. a. ,ram-y:M:{�;:.:•.:iw�ls...�:.•� � f.._y��.;:,r,;.e�::^�^ei..-.«� ` • .i�+....5w•..,' ir' � Y.• iJ . - � - _•

Mar, 11, 2011 817AM YADKIN WELL
No, 7170 P. 4
a MMMON-$ELAM )*vR%CUrr
Attach a d slaaw�g the or �. mo3ifir�ia� ai'the �tject�va ° and exb�r,R
PP d W[m tt iwmen "MWM Tho usmu&c�$ "Ohm icy provide swemmurY
L LOCAIIMW OF WMIAM
Attack two copsra of wqs sktreiug ae fdilol ft iufarzoa =—
(1) ih U& a Sine MOP (WA be dtawm) shM&v brriidatg fa� i;nw, aarbm wearer bows, l
sour= of tsrian=on afand d sautava bdwomthe "wed wW3) sud
any egg WeWs) or 3wwte disposes & il� suchas expft UP13 ar dram U& located whbhk2OO led of
t$a geatht mi hestpomp wail syskm Ubd aii 62UM cks*mud ltwAude a ase& zKo%
(2) The Site Abp z=t doer the subject pnTcrty is teie to the sarramtding aura by adog st)nat s ffimd
m&�l amb saohas roads, stzu=6 w&or hiotwary am
Notr: Thk Pwzs& Ap#fimVoA cant be sued[ by msh pe mn apper♦xiag on the
recar4ed MW pr.puiy deed.
"Z heasby rertii}, under penalty of ]aw, V* I have: paraonity anria 54 and am Amffiu wA sse ; 6 "on
s4mvUed m dus dam and Q ebcbmats thereto and that bood on aw mgwy of S se m&vxTmb
iitmm &iwy ramie 24r obt uan said &b=& oi6 I herww true, == tte $ad complete.
I am arum mar lb= sae 44dauffla penalties, inrludlag &�C pvssgbmy of fines w MvftOMC4 for
zobmbtmx
W e utrmabm I ;gm to caakwt ' mein, PT;*. sod if M&c.W A ndan ft !*Wm ►ten, and
ail related qpwftabwesbs.awo[d-t#�ceti s.amditians oftlae Pam!"
ftm f ` r?
D f' 2 jj
FfiMwT ne1%UWs=w&
a�� Az� ifaay
P&t er TncF 1ft= zud tale
Picase rattan tea aopdea of �c oomQIeard Alspgc�tt� pexka� to:
Norlb Cam ina DEMBL-DWQ
Aquftr Pn ftcden Seal A -MC Program
106 Mel SMTM C'esiw
R&)O h, NC 27091IS36
Telepbona (91.9) 71s-Ms
t�
w
F.+
v

Mar, 1 f,' 24f 1 s; 08AM YADKIN WELL
No.717a P. 5
&W�c'r/ U-61
N
T
LC M4 rn

Mar, 11' 2011 8:O$AM YADKIN WE! L No. 7170 P. b
Address: e s
Lfs
. AEC --
Phcne ter:
{
�m
�Q
z
Ov