WI0400108_GEO THERMAL_20120517

A'f'N'A-=------------. ,~~--------------~, . -, ' -~ -. ·-.. NC DEN R~~~-~-
North Carolina Dep·a~rtmentof..Envitonmentand~Natural Resources
· Division of Water Quality--_: ____ _
Beverly Eaves Perdue--·-----
Govemor
David Anderson
Sharon Fortner
2160 Royall Drive
Winston-Salem, NC 27106
Charles Wakild, P~E -
Director
May 17, 2012
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0400108
Dear Mr. Anderson and Ms. Fortner:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title I SA Section 2C .0200 entitled ".Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for inj~ction wells including geothe~al wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http ://portaLncdenr.or g/web/wq/ap s.
If you have any questions regarding your current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely, c~-
Eric G. Smith, P.G.
Hydro geologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
PMne: 919-807-6464 \ FAX: [phone]
Internet: www .ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer
Ni~carolina
JVaturallg
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIPICATXON # 5 a.
1. WELL CONTRACTOR:
Wail Contractor (InIlvtdUaI) Name
Yadkin Well Company, Inc
Welt Contractor Company NaTt0B Hamptonvtlle Road
STREET ADDRESS HamptonviliC, NC 27020
City or Town State Zip Coda
Area code- Phone number
2. WELL INFORMATION:
SITE WELL 1D #{k applicable) i SI x 1
• WELL CONSTRUCTION PERNIFI O applicable}Jry//,j Cie r
OTHER ASSOCIATED PERMIT Cif applicable)
3. WELL USE (Check Applicable Sox) Monitoringp Munldpat!Pubilol]
tndustrlal/CommerclalD Agrlcytltutsl7 iiacovpryD lnjecliorf
1rrig allorU Othe7 ' (fiat use) Lead;-�eF ,1
DATE DRILLED el-;; 7• 0
C 1n5CG6o}ff
TIME COMPLETED S` b0 AMID P '
4. WELL LOCATION: WY:Y Jfi"�
}\417S•-ki, -3a4 •r^ COUNTY Fib' f
a 1C'°yy ( Pi~
{slreat Name, Num rra, Ccmmurt}ty, 8ubdlAston, Let No., Pascal, h p Code)
0POGRAPH10l LAND SETTING:
Slope 0 Valley 13 Flat 13 Ridge 0 Other
(check appropriate box)
LATITUDE . L (VW?
LONGITUDE, Q
Latitude/Iongitudo source:. -GPS 0 Topographic map
(tocatlon of wee must boihr wn an a USGS topo map end
attached to this form If nor using GPS)
Maybe 3n degrees,
misnrtea, seconds or
in a decimal form at
6. FACILITY -Is the nano ar the W1lnes. when the vein Is located.
FACILITY ID #(If applicable)
NAME tr•I1LTfY ['al' 4,A e
STREET ADDRESS ', 4Oi i
City or Town Mate �y Zip Code
CONTACT PERSON S¢.orri't &,j/ c?J L 9 A III
MAILINGADDRESS Pa ,&- f Oc `Ir
Po th.J- A \L it !'.- .0 C a 7l i t
City or Town Stale Zip Code
W (33G )- ii4G' tI(67 Jt Vtc-- ie8Ec3
Area cads - Phone number
e. WELL DETAILS;
B. TOTAL DEPTH:-
b, DOES WELL REPLACE EXISTING WELL? YES11 NOD
c. WATER LEVEL aglow Tap of Casing: FT.
(Use'+' If Above Top or Owing)
d. TOP OF CASING 1S PT. Above Land Surface'
'Top at caatng terminated after below land aurtaca may require
a variance In accordance with 16A NCAC 2C .0118,
e, YIELD wpm): METHOD OF TEST`
r. DISINFECTION: Typo_ — Amount
p. WATER ZONES (depth):
From To From To
From _ To From To
From To From To
7, CASING: Depth Diameter ThIckneseMeighl Material
From To Ft.
From To FL
From To Ft.
1
Mehod
From 6T o 3� s Ft ik( . - rSr
Material p C+'itia r
From To Ft.
From To Ft.
B. GROUT: Depth
9, SCREEN: Depth
Diameter Slot Size Materiel
From To Ft_ In, in.
From To Ft. 1n. In.
From - To _ Ft. 1n. In.
10. SAND/GRAVEL PACK:
Depth Size Material
Fmrrt_ To Ft.
From To FI.
From To Ft.
11.DRILLING LOG
From • To fprrriation Description
/73 eel
12. REMARKS:
I CO HEREBY CERTIFY THAT IRIS WELL WAS CONST1tUCTEO IN ACCORDANCE WITH
16A BOAC 2C. WELL CC NM RUCTION STANDARDS, ANO THAT ACOPY OF THIS
RECOR. EE1:4 PROVIDED TO 7H • °'DER,
f. li J Gt r •
.St 1 UR F CERTIFIED WELL CONTRACTOR DATE
U.) l(i) 113
PRINTED N ME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water quality within 30 days. Attn: information Mgt.1
oo '-
1617 Mall Service Center— Raleigh, NC 27899-1817 Phone No, [phone] oxt 668.
f k r/I cr v g 4•t i •I' €,ufieti I
Form GW-lb
Rev,121O7
L-a u.p , -kJ. Il .4
563 IA -Pe 4 / - 6; j ,TX y.

go It kr (7.
erg
eikt

NON L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1. WELL CONTRACTOR:
ei CAN- fJ \.V\c,\
WeII Contractor tndtvfdual) Name
Yadkin Wall COrtJanV, Inc„
Well Contractor Company hl91 0B Rariiplonviile Read
STREET ADDRESS ,,ELITtptonVil`C, 'NC 2,7020
City or Town State
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 11drsprit ice bte) 6
WELL CONSTRUCTION PERMlT#tlr appi abte),W elo Od %p Y
OTHER ASSOCIATED PERMIT #(1f applicable)
3, WELL USE (Check Applicable Box) Monitoring MunIc$pulfPubllcD
industrial/Commercial° Agricultural RecoveryO tnjeddoria
lrrigatlorfr °rher plat use) C-er. • e
4rn, •a l
DATE DRILLED -)8. [ 9 c '4-el
TIME COMPLETED ci i OO AMC>
4. WELL LOCATION:
CITY: (v /+.0p' url-.�JeA(evt, COUNTY F4..iy�li
1-((i 1[.dj.Cr I DP,
(Street Name, Num ers. community. Subdivision, Lot No. Parcel, Zip Code)
TOPOGRAPHIC f LAND SETTING:
Slope D Valley D Fiat 4 R1dge a Other
{sheik appropriate box) May b indegee.%
LATITUDE 3 6 O 1 r `7r' minutes, seconds or
€n a dceimal format
LONGITUDE 8" O (C • 731'
Latitudellongitude Source: FOPS El Topographic map
(location of wort must be shown on USC9 typo map and
attached ro this form lfnot using GPS)
6. FACILITY- Is the name of the NIdrioss where the we!J t :mated,
FACILITY ID Cif applicable]
NAME BF-444M- ' Fop ' Az - - f►e%>P��'� r�
STREETAOORESS 2 r_4C !toy r ( 0
(' AIC.
city or Town State Zip Code
CONTACT PERSON --1( 0 44
11 ayF(S -
MAILING ADDR L' SS /%o ' o k ' (to y�
Grain.,' 4on -S61IS/ L c 2 7r j 4,
City or Tower State 2}p Coda
w ( 33‘ )- ti2'L1 y' 1 3rG 5'r6 s eo
Area coda - Phone number
8. WELL DETAILS:
e. TOTAL DEPTH,
b. DOES WELL REPLACE EXISTING WELL? YESE) NOX
c. WATER LEVEL Below Top of Caeing: .FT.
(Use '4* if Above Top of Casing)
d. TOP CF CASING IS FT. Above Land Surface
'Top of casing terminated atfarbelow land surface may require
a variance in accordance with 15A NCAC 2C .0118.
a. YIELD (gpm): 0 METHOD OF TEST,
f. DISINFECTION: Tyra Amount
g, WATER ZONES (depth):
From To From To
From To From _ To
From To From To
7. CASING: Depth Diameter ThtcknwuNfefght Material
From To Ft.
From To Ft. _
From To Fi.
8. GROUT: Depth Material Method From CD To- 3rc1�5- I,c • 6',..-k J u" .Oc ry
From To F1_ 4 Scta4 t I f
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From, To Ft. in, in.
From To FL in. in.
From To Ft. €n. In.
to. SAND/GRAVEL PACK:
Depth Size Material
From. To FL
From To FL
From To Ft.
11.DR1LLING LOG
From ;1
14 F,pionnDescription '
LLB, 774-e'#-
72. REMARKS:
00 HER ear CERTIFY THAT TUC WELL WA8 O7NS7RtJCTEA TN ACCOROANCE WITH
1 r,A HCAC 2C, WELL CONSTRUCT1 ON STANDARDS. AND THAT A COr Y DF 7 Hl
RC0RDtV.5BE jPROVDEDTOTHE 1. nn
..351 TURES]F CERTIFIED WELL CONTRACTOR DATE
tea' �U
PRINTED N E Oi= PERSON CONSTRUCTING THE WELL
u
Submit the original to the Division of Water quality within 30 dsys, Attn: tnformatlon Mgt., /Ft 3 OO FormGW-1b
1617 Mall Service Center — Raleigh, NC 27699.1617 Phone No. [phone] ext 566. Rev.12/07

I
I
L
Permit Number W10400108
Central Fifes: APS SWP
04/24/09
Permit Tracking Slip
Program Category
Ground Water
Status Project Type
In review New Project
Permit Type Version Permit Classification
Injection Mixed Fluid GSI- P Welk System (5QM) Individual
Primary Reviewer Permit Contact Affiliation
michaei_rogers
Permitted Flow
Facility
Facility Name
David Anderson and Sharon Fortner SFR
Majnr!Mlnor Region
Minor Winston-Salem
Location Address County
2160 Royal Dr Forsyth
Winston Salem NC 27106
Owner
Owner Name
David
Dates/Events
Facility Contact Affiliation
Owner Type
Individual
Anderson Owner Affiliation
David Anderson
Orig Issue App Received Draft Initiated
04/28/09 04/17/09
Scheduled
Issuance
2160 Royal Dr
Winston Salem
NC 27106
Public Notice Issue Effective Expiration
04/28/09 04/28/09 03/31/14
Regulated Activities Requested/Received Events
Heat Pump Injection RO staff report requested 04/21/09
RO staff report received 04/23/09
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasln

Permit Number WI0400108
Central Files: APS SWP
04/23/09
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael,rogers
Permitted Flow
FaCIIIt
Status Project Type
In review New Project
Version
Permit Classification
Individual
Permit Contact Affiliation
Facility Name
David Anderson and Sharon Fortner SFR
Location Address
2160 Royal Dr
Winston Salem NC 27106
[ lwnQr
Owner Name
David
Dates/Events
Major/Minor Region
Minor Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Anderson Owner Affiliation
David Anderson
2160 Royal Dr
Winston Salem
NC 27106
Orlg issue
App Received
04/17/09
Rertulated Activities
Heat Pump Injection
Out -fall NULL
Draft Initiated
Scheduled
Issuance Public Notice 54E169 Effective
gigiratri
B'eauesledlR�reIyeri Events
RO staff report requested 04/21/09
RO staff report received 04/23/09
Waterbody Name
Stream Index Number
Current Class Subbasln

Ef'A ----.1"--~-~ MC DEH
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
David Anderson and Sharon Fortner
2160 Royal Drive
Winston-Salem., NC 27106
Re: Issuance of Injection Well Permit
Permit No. WI0400108
Coleen H. Sullins
Director
April 28, 2009
Issued to David Anderson and Sharon Fortner
Forsyth County
Dear Mr. An.derso11 and Ms. Fottner:
Dee Freeman
Secretary
In accordance with your application received April 17, 2009, I am forwarding Permit No. WI0400108 for the
operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well system to be located at
2160 Royal Drive, Winston-Salem, Forsyth County, NC 27106. This permit shall be effective from the date of
issuance until March 31, 2014, and shall be subject to the conditions and limitations stated therein.
Please pay special attention to the bolded language in the permit. In addition, please submit copies of the
Well Construction Completion form (GW-1) and site map within 30 days after construction as required
in Part I paragraphs 8 and 9 ..
Please submit the data within 30 calendar days of receipt of this letter to the following address:
.,
Aquifer Protection Section (APS)
Underground Injection Control (UIC) Staff
163 6 Mail S·ervice Center
Raleigh, NC 27699-1636
Additionally, your UIC system is subject to inspection by the APS and at the time of the inspection must display
a permanently affixed identification plate in accordance with requirements of 2C .0213(g). Please insure this is
completed in accordance with permit condition Part I, paragraph 7 of this permit issued April 28, 2009.
AQUiFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: 9,19-733-3221 \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer
NOnel C 1· ort 1 · aro .1na
/vatnrallg
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an application
to renew the permit three months prior to its expiration date. As indicated in the permit, this permit is not
transferable to any person without prior notice to, and approval by, the Director of the Division of Water
Quality. If you have any questions regarding your permit or the Underground Injection Control Program please
call me at [phone].
Best Regards,
✓~~4--' -
Michael Rogers, Environmental Specialist
cc: Sherri Knight -Winston-Salem Regional Office
Central Office File-W10400108
Forsyth County Environmental Health Dept.
David Brown -Yadkin Well Co., Inc. (emailed and sent.fist class mail)
Attachment( s)
2
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
David Anderson and Sharon Fortner
FOR THE CONSTRUCTION AND OPERATION OF 2 TYPE SQM INJECTION WELLS, defined.in Title
lSA North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed-loop
geothermal-mixed-fluid heat pump system. This system is located at 2160 Royal Drive, Winston-Salem,
Forsyth County, NC 27106, and will be constructed and operated in accordance with the application dated April
17, 2009, and in conformity with the specifications and supporting data submitted, all of which are filed with
the Department of Environment and Natural Resources and are considered a part of this perm.it.
This perm.it is for Co:g.struction and Operation only, and does not waive any provisions of the Water Use Act or
any other applicable Laws, Rules, or Regulations. Operation and use of an injection well shall be in compliance
with Title ISA North Carolina Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until March 31, 2014, and shall be
subject to the specified conditions and limitations set forth in Parts I through X hereof.
t/J
020' Permit issued this the =-1,s day of __ ~----1-'T----' 2009.
~ ~ uJJtr
M Coleen H. Sullins, Director
~v Division of Water Quality
By Authority of the-Environmental Management Commission.
3
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Perm.ittee must comply with all conditions of this perm.it and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this perm.it constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This perm.it shall become voidable unless the facility is constructed in accordance with the conditions of
this perm.it, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well
shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well
must be secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during construction and use.
7. Each geothermal injection well shall have permanently affixed an identification plate according to 2C
.0213(g).
8. A completed Well Construction Record (Form GW-1) must be submitted for each injection well to:
Aquifer Protection Section -UIC Staff
1636 Mail Service Center
Raleigh, NC 27699-1636
and
Aquifer Protection Section -Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
GW'.""ls must be submitted within 30 days of completion of well construction. Copies of the GW-1
form.(s) shall be retained on-site and available for inspection.
9. Well construction records must also be submitted for the existing water supply wells on-site as well as a
site map showing any water supply wells on adjacent properties as specified in NCAC .021 l(d)(l)(D).
PART II-WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing system, the Perm.ittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number [phone] and the Winston-Salem Regional Office Aquifer Protection Section Staff,
telephone number (336) 77'1-5000.
4
2. Boreholes shall not connect separate aquifers (i.e., shallow surficial aquifer and fractured bedrock aquifer)
and shall be filled with bentonite grout from the lowermost water bearing zone to land surface, as
specified in 1 SA NCAC 2C .0213(d)(8).
PART III-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume · of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days .prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
PART IV -PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Pennittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Pennittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART V -OPERATIONS AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Pennittee must notify the Division and receive prior written · approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit. ·
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number [phone]. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
5
PART VI-INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART VII-MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence ~r first knowledge of the
occurrence, to the ·winston-Salem Regional Office, telephone number [phone], any of the
following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and
correct facts or information shall be promptly submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well
Construction Standards.
6
l
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding 10 feet, and grout injected·through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
(G) The Pennittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment.
3. The written documentation required in Part IX(l) and (2) (G) shall be submitted to:
Aquifer Protection Section-DIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X-OPERATION AND USE SPECIAL CONDITIONS
None.
7
Ro gers, Michael
From: Berry, Stephen
Sent:
To:
Wednesday, April 22, 2009 4:17 PM
Rogers, Michael
Cc: Knight, Sherri
Subject: WI0400108
Follow Up Flag: Follow up
Flag Status: Flagged
Categories: Red Category
Mike,
I left a voice mail regarding the said SQM permit. To reiterate: I spoke with Sherri and we are in agreement that an
inspection will be conducted at the time Yadkin Well drills and also when Logan Heating charges the system.
Please issue the permit as soon as possible.
Thanks for your efforts,
Stephen Berry
NC DENR
Winston-Salem Regional Off.ice
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: {336) 771-5288
FAX: {336) 771-4631
***************
E-mail correspondence to and from this address may be subject to the
North Carolina Public Records Law and may be disclosed to third parties.
***************
1
State of North Carolina OF WAT►4
Department of Environment PG
and Natural Resources �,, . I It'1 r
Div'sion of Water Quality
Beverly Eaves Perdue, Governor
Dee Freeman, Secretary
Coleen Sullins, Director
-1
Division of Water Quality
Aquifer Protection Section
Location: 2728 Capital Blvd.
Raleigh, NC 27604
Mailing Address: 1636 Mail Service Center
Raleigh, N.C. 27699-1636
FAX: [phone]
[phone]
Date: ii/zi Vet
FAX TO: S Lvt` fC
FAX NUMBER:
FROM:
PHONE: /0' 6-ea
NO. OF PAGES INCLUDING THIS SHEET: j
1 . 4 5 -�. 2
G`'� 1
If you receive this fax by mistake call: Aquifer Protection Section © 919-733-3221

DATE, TIME
FAX NO./NAME
DURATION
PAGE(S)
RESULT
MODE
TRANSMISSION VERIFICATION REPORT
04/21 16:08
91336 7714631
00:02:56
09
OK
STANDARD
TIME 04/21/2009 16:11
NAME NCDE&NR/WATER QUAL
FAX [phone]
TEL [phone]
ArA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
To: Sherri Knight
W-SRO - APS
From: Michael Rogers AA
I- =
DWQ — APS
co
Date: 4/21 /09
Subj: Anderson and Fortner 5QM Permit
WI 0400108
.6),)2-spie0 �,/°2
Attached is permit application for a 5QM permit for your review. Per our 5QM permitting process, we are
allowing the RO to decide whether to conduct a pre -permitting inspection for Single -Family closed -loop
geothermal well systems and submit a Staff Report. Please decide within 5 days of receipt to decide if you want
to conduct a pre -permitting field inspection or not (the inspection does not have to be done in 5 days - just the
decision whether to schedule a pre -permitting inspection or not).
If you elect not to conduct a pre -permitting inspection, let us know and we will go ahead and issue permit.
Thanks
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Customer Service: 1-877-623-6748
Internet: www.ncwatemual.org
An Equal OpporIunfty I Affirmative Action Employer
or NthCarolina
aturally

NA
MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
April 21, 2009
David Anderson
Sharon Fortner
2160 Royal Drive
Winston-Salem, NC 27106
Subject: Acknowledgement of Application No. WI0400108
David Anderson & Sharon Fortner SFR
Injection Mixed Fluid GSHP Well System (SQM)
Forsyth
Dear David & Sharon:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on April 17, 2009. This application package has been assigned the number listed above and will be reviewed by
Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Pleas~ also note at this time, processing permit applications can take as long as 60 -90 days after receipt of a complete
application.
Ifyou have any questions, please contact Michael Rogers at 919-715-6166, or via e-mail at [e-mail]. Ifthe
reviewer is unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To
review our new organizational chart, go to http://h2o.enr.state.nc.us/documents/dwg orgchart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincerely,
/o,Qb~A -~
Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
Scott Boyles {Logan Heating & Air Conditioning -5142 N. Causeway Drive, Winston-Salem, NC 27106)
Permit Application File WI0400 I 08
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604 .
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity\ Affinnative Action Employer
Ni~carolina
;Natural!!/
DATE.
FACSIMILE TRANSMISSION FORM
/ 17 /09 TiM>r• REF NO. LOG NO.
TO: AId, ew
COM
FROM:
COMPANY NAME
•
Ca vs
WO ea.
LIEF%
(cm )7fLT -OYu
MIND. PLEASE
1.� EDiATELY
(J ) Stir - Os
FAX NO. PLC
!NOMINAL
'NUMBER OF PAGES
INCLUDING THIS SHEET
©AEi"Y
DEP[
PLEASE ORIGINATOFCS REPLY BY SIGNATURE
gatl,�
MESSAGE:
O. 32S c - giro £aya l Dr,
. r
Ah4 freeze 44•14ele Foe, AOCa Rear%4 Ell LeVieoha f
"FOR ALL YOUR WATER N8E45
YADKIN WELL CO., INC.
i$QS MAMPTONVILLE ROAO
HAMPTONvILLC. NC #T82,0
DAVID J. I#ROWN, VICE PRES.
TOLL FREE Iwo 2s&e355
OFFICE MSS) 4
FAX !SSW 468.4048
RE^S I33$I £G$,459
-0000 mews AWAIC* - earl LOV I vow
'd-008Z '°N
PLEASE INPQFN US IMMEDIATELY E iW CO NOT FiECEIVE MAME W Ft n I
113M N I VIVA—NVL L : 6 -600Z 'Li V-

Apr. 16. HO. 3:74P1 No. 1177 P. 2
REONED I OENR +1~livR
AoU FFRPC7+1TFr'+H SFCTr41
NORTB CAROUNA. �D r
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR) 7009
APPLICA 1ON FOR ITMTT TO CONSTRUCT AND/Ok USE A WELL(S) FOR
DEFECTION WX17 A GEOTHERMAL HEAT PUMP SYSTEM FOR
TYPE 59M WELLS),
permit AppUe th n OR Renew (c1?er,k one)
nA 4-15 2009
PERMIT NO. (leave blank if NEW tgrmit app )
A. PRovutry OWx s)/APPUCA] T(S)
List f=rlaroperty Owner listed on property deed (if owned by a business or government agency, state name of
ermty and a esentstive wlauthority for sig:aane): -Sti A ►- 0 h /11
otV+', I-nelr 1,545
(l)
(2)
Mailing Address: -1 i.� Q—R0 LAa t r _
city: \f\'J ales-s-, _` ,WC -Zip Coax �1 /v
HotneJCfdae Tele N a.: 473 / 416 3 5IS' -3m3 jls c u No.:
EMAIL Adder: Cfa G W T1t • C w
Conrey:
pirysiaal Add of Site Cif different than. above):
City: State: Zp Code: Cotutty: -
Home/Office Tele No.:
EMAIL Address:
& AT.ITHORTZD AGED' OF OWNL:R, EFT ANY (if the Permit Applicant dves_not own the subject property,
Ala a letter from the property owner antbonzing Avg to nstaii and operate WC well)
Cony Name:
Comet Person 1 EMAIL Address_
Address:
Cr
4ilxce Tele Noy
Size: _ Tin Code: County:
Cali No.:
Wabsi'te Address of Company, if any:
C STATQS OF AFFLICANT
Primate- X Federal:
Commercial:
Stare; Municipal: Native American. Lauds:
� H 'd 40086 '°N
.113M N I avA WVC l 6 6006 1 'AV

Apr. 16. 2009 3: 24PM
Nti.1177 P. 3
A•
WELL DRILLER rNFORMATION
mttettvcu tzk+, w+u
A4tr>wg'Pctntr.rrn0n, c:FriyAN
APR l7rol
Company Name:Yadkin Well Co. Inc -
Well Drilling Cone actca's Name: Jody Mullis Matthew Brown lkifilton Cave
NC Contra= ConNo.: 2572 3036 3548
Contact Pew: Darts J. Brown
Address:, 1908 litamplonvOIe Rd.
S VEAIL. Address: c�zie dri�1 er�]yn s sacom
[sty. Ramprap:Mlle Zip Code: 27020 County: Yadki�y
Office Tele No.: 336-46S-4440 Cell No.- 336r374--8736
F . FEAT PUNT CONTRACTOR INFORMATION (iViifferei than dialler)
Company Nam L4D qaV I- -ece rear a pr o r-r4. • 4-i o v-► i
Contact Persow •x� (f S'-/ lEMAlL Address: 5O40(4 hg'.S5 �Arth Lib .0044-
Address 41 - a.:r�`� gsre r vau a 3� - - City: I IriS #Sr`a IE' Code: n /7/ : d
Office TeleNo.:C �-4/Ati'Y161 CellPyo.: L�-��v- r�v-$et1
F. INJECTION PROCEDURE (briefly describe bow the infection well(s) will be used)
completely dosed loop stern circulat 12 water and foe heatrrausfer
L
O. 'WELL CONSTRUCTION DATA. (Slap to Sect an trills is a Permit RENEWAL)
(1) Proposed date to be constructed: ASAP after 4-1$-2009 Number of borings: 2
Approximate depth of each boxing (feet): 325
(2) Chemical additives to be used xn closed -Loop system (only those chemicals sndlcared have been approved):
R 22 glycol ✓ e - athea ttsther a.daiives wall
need prior approval by NCDENR before use)
(3) 'fie of Curbing to be used (copper, PVC, etc): HOPE (polyetheIene
(4) Well g. Is the WeagO cased? (check a (a) YES or (b.) NO below)
(a) YES if yes, then provide casing information stela as ttte, (steel, PVC, plastic, etc.), diameter.
dew and extent of rases appearing above groin:
(b) NO X
(5) Grout (=ate rial sonotmding well casir and/or piping):
(a) Grout type Cenexu Bentonite X Other (speafy) _Thermally Enhanced
(b) Gout depth of etching (reference to land surface): gym 3 to 325 (feet)
If well has casing, Militate grout depth: from to (feet)
a INJECTION -RELATED EQUIPMENT
008 '4N
013611 N I ICIVA ,WVL H 6 ,600Z L l 'nay

i rr_a 6, 200 , 3.24PM3357586008
FFv_sxaav
h. 1177 P. 4 02/e2
Attach a c gram shoanag the engb eoring layout or proposed "acidification of ma injecion equipment and ex zi r
pEphigintug associated wrlth the far won operation. The manuditdm'ar:s brochure may provide slurs
LOCATION Or WELL(S)
Attach two copies of maps$lioseia8fbriawing Wa ;
(1)
(2)
1ndudo a site map n be dfawn) showier huilffmgs, property Um, surface water bodies, potential sotxrccs
of grate contsminatioa sod the boa of sad d smaces between the proposed well(s) and any
racket n (s) or wasto disposal Skates such as seg3le tsar or drain 5s6s lncabadwi#tin 1000 be o€tta
geothermal b atptunp wei1 system. Label all was clearly estianomsgarrow.
Ikeda a topog apluc map 011ie area Wending CM a $elan The property bouadariLes nisei
iad'irm fie fealty's location and the map camp.
POTABLE WATER WELL(S)
Atet eta any potable Weft well(s) onfao subjectprapelrty or adJaeshtpopttes7 YES NO
IfYax, then indicate location ou attached lasp(s).
. ClaTTF CATXON
Nebo: The Zealots Apptiaarlou Unit be Bip ed by mai person appearing on >tbe recoiled ded legal property dead.
"I hereby cettif , tinder penalty of ia:a►, dart X lave p3rsomaly examined and ant familiar the iefoxazatiaa,
submitted lat this dac►mde t mad as att c i ats thereto and that based oa my inquiry of those lndividusia
immediately responsible fix obtaining said nfosmation, 'believe that tho information is troo, accurate and complete.
I ern aware that there arm signi6csat p itte% iru4mg she posallatly of Van and imprisonment, far submitting
thin 1 agree to etinsiruct, operate, inn nta a(apait. aad 1f applicable. abaden. the injection weft attd
xelatta maces in aecordoneewiththe aQpmrcspaciftce5ans and conaraions of tits: Pam"
Sigoatnrc ofProperty 0 IAppTicant
'DeWitt, Mnde,rv,
Print of TypoFalLName
Sigatore ofProperty oWnedApplitsult
i e
Pert or Tlfpo FUL Newt
Signature ofAndiated Agent, if shy
Print or Typo Poll Name
Please return two copies attic, cesaapleretl Application package nos
North Carolina DE R DWQ
Aquifer Protection Section
kKogrmat
1636 Moil Service Cantor
�V 7 .�N ll Saiwlf pl 11 r .r /�w7 .rl �a��'
4 v it 113M NIirVA' WVL! 6 6441 'L R 'a V

A r. 17. 24 091 9 ; 0 ANrrinston-Salem, NC 27106`, Googic Maps
Goog1e�
Maps
Address 2180 Royal[ Dr
Winston --Salem, NC 2710G
61,u;AQ W7-9
pse-ctoY
aark-k-/Xse--y, ¢✓.�iy
No 1182 11".�1 1 ofl
IGet Goo* Maps on your phone
Text Or word "GMAPS" to 466451
hffp;//maps.google,com/mapen—q&-sourcs_q&hl—en&geocode=8N=2160+Rayat+Ddve, . 4/17/2009
5 'd 008Z '°N 11361 NDIObd YIV :6 60E 'Ll IV

RECEIVED 1 DEW i DWU
AQU RPRnwr'nfw,*criO`r
APR 17 2005
-----7q-164-67—'-
no eV I
tbo
N.--
0k
Pio
lic
n�
i
V
9 'd 009Z '°N
113M1h NIXUVA WV81 : 6 600Z •any