WI0400119_GEO THERMAL_20091118

Permit Number
Program Category
Ground Water
Permit Type
WI0400119 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Robert & Janis Roten SFR
Location Address
2860 Lexington Dr
Fleetwood.
Owner
Owner Name
Robert
Dates/Events
NC 28626
Roten
Orig Issue
11/18/09
App Received Draft Initiated
11/17/09
Re gulated Activities
Heat Pump Injection
Outfall . AJLL
Scheduled
Issuance
Central Files: APS_ SWP_
11/18/09
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affillatlon
Winston Petrey
PO Box 1905
Boone
Major/Minor
Minor
NC
Region
Winston-Salem
County
Ashe.
Facility Contact Affiliation
Owner Type
Individual
Owner Afflllatlon
Robert Roten
240 Ridge Rd
Boone
Public Notice Issue
11/18/09
NC
Effective
11/18/09
28607
28607
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
AI a
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
11 / 18/2009
Robert Roten
Janis Roten
240 Ridge Road
Boone, NC 28607
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WT0400119
2860 Lexington Drive
Fleetwood. NC 28626
Dear Rev. & Mrs. Roten:
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on
11/17/2009, the Aquifer Protection Section (APS) acknowledges your intent to construct a closed -loop geothermal water -
only injection well system for the operation of a ground -source heat pump located at 2860 Lexington Drive, Fleetwood.
Ashe County, NC 28626. This system is deemed permitted by rule (North Carolina Administrative Code Title 15A,
Subchapter 2C, Section .0211(u)(2)),
However, it is recommended that you contact the Ashe County Health Department, as they may have additional
construction or permitting requirements for this type of system. If you modify your system at any time, including the
addition of antifreeze, corrosion inhibitors, or any other substances to the circulating fluid, you must contact the APS to
verify compliance with applicable rules.
Thank you for submitting this notification. If you have any questions please call me at [phone].
Sincerely,
Michael Rogers
Environmental Specialist
GPU-Aquifer Protection Section
cc: Winston-Salem Regional Office - APS
APS Central Files - Permit No. WI0400119
Ashe County Health Dept.
David. Brown (Yadkin Well Co - 1908 Hamptonville Rd, Hamptanville, NC 27020)
Winston Petrey (Mountaineer Heating & Cooling - PO Box 1905, Boone NC 28607)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital boulevard, Raleigh, North Carolina 27604
Phone: [phone] FAX [phone]; FAX 2: 919-715-66481 Customer Service: 1-877-623-6748
Internet: www.ncwatatouallty.ort
An Equal Opporluniiy i ATirmariwe Action Employer
North Caroli na
Naturally

FACSIMILE TRANSIVIISSION FORM
DATE' 88 i /7 / Oc3_ 11ME: _REF NO. LOG NO.
TO; a 6 n r ,1Z.. 0 Pi - (?/?) 'CIS ,� as- &Z
COMPANY NAME FAX NO. PLEASE
f" r' c . i R o t e rF� ❑ WIMEI: E1Y
ATTENTION 0EP'[
FROM• Yctakit" _ ii k..L Co L'►-tc (1Z6) </C, - cep'
COMPANY NAME FAX NO. PLEASE
0 t 11 ,,a ir` a w n _ ❑ REPLY
INDIVIDUAL DEPT
NUMBER OF PAGES PLEASE ORIGINATOR'S (F3--
INCLUDING THIS SHEET REPLY BY SIGNATURE
MESSAGE: J
na7a' �1"cc! 47a,61 -Poe
isi4e igootte,
lea e Q#(,
T.
-FOR ALL YOUR WATER NEEDS-
YAvr[IN WELL Co., INC.
t9O5 14AMPTOIlvILLE ROAD
LIAMPTONVILLE. NC 27020
AVIO J. DROWN, VICE PRE$.
TOLL FREE 18091 z43- 355
OFFICE 13351 45e.4446
FAX (S35) 4 -4O48
y7g9 {336i 468.4659
•0009 NLwB AMERKIA - GOO LOVES. VOL'
SZOti (IN
PLEASE rN FORM US IMMEDIKIZ Y W'OU DO NOT 1+DGerVE PACS:mill IN FIAT.
113M N171GVA 1dEE:ti —6006 .Lt '^°N--

` G=VC 1T .rT erj'az , r7
G�Jt.+
Noma CARO1J
D PARTM NT OF ENVIELONYLENT AND NATURAL RESOURCES (NCDENR)
NOT1CA11ON OF INTENT TO CONSTRUCT GEOTRERMAL
EATER -ONLY INTECITON WELL SYSTEM:
TYPE -OW WELLS
In Ju arda= with lbe provisions of NCAC TT le Z5A 02C.0200, please
ooi pt a this notification atvi mail to address an the back page (please $jig or Zan information),
DATE: if-- 1 / — 20 f
Win Type CoglbwraikP: Dom the proposed system circulate potable w (no additives) n
cpkot. w,us piping that completely isolates the fluid 3 m the en vis'anmeuv (i.c.
vlased-loop)?
Yes X_ Continue completing this form.
No Do Noe complete this fovea Complete tamer UM application fOrtlis for inst Bing
either a 5A7 veil o[ E4 loop well W.oggyig potable water into the agxifer) or a 5Q1.1 wail (eloecd-
loop well containing Iddatives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNE.R(S)fAPP'LICANT(S)
List ail; Property Owner listed on property deed (if owned by a business or government agency, skate name of
melt? and a repr. Mr tative wla»tharity for Agawam): Rev. As 6.zr / ogu..4j A {CAI iv 15 Oa,/
B.
(1)
(2)
Mang Address:' RZ crj
City: &&ado' State: f-C 4p Code: 2 $407 Cooney: 14/0
Hoke Tsle pia.: er5.1 3 Coe. Cc1i No.: 8-7d 7 73 C .T9
Email Address_ Wcbsix:
Physical Address of Well she Of different than +above): c7e413 Lev- + Jt tarp -Pr oil
ty; F�elu►vad • slate: NC zip Code_ -5G c County: S /IF
Home/ . ale 740.: 6".78-'3. Ofs c;Q.: �.78-77�- der
M TRORFLED AGENT OF owrintii, At ANY (if the Permit Applicant does not own the subject proper tY1
attach a letter from the property owner authoriiing Agent ro i ll and operate UIC well)
Company Name:
Comte Fuse E. Address:
Address:
Catty_ fie: Zip Cods: County_
Office TeleNQ.; Ceti No.:
Wcbsito Address of Company, if any:
'del *S1617'6N cb556 SLR 'naN:

G WELL DER INFORKATION
Cow+ Haren:1 n WcU Co, - - - - —
Wc l Dram Conudcr's Name Jody Mullis Mattew Dtowsi mgon Cgec
NC 03:41: aCCar Cenificafioa Na_: 2572^- f t 3 D36 - ' 3 4
Contact Fuson; pink} ). Browq_ BAAL. AdclicsESlikfdrill a msn.com
Address: 1908 HBmpteervil eRd.
City: i ourilie N.C. Zip Code. 27020 _ Courtly: Yadkin
Office Tole No.: _336-463-4440 Ceti Na.: _33.6-374-S736
b. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Courpin y Name' c or%bb:nt ��►� Iy.,p4�E/A�r ry �� /yr,� A 7� L - �p f
Contact Pocson: Yy I.VeT � " - ` I Ewa, eez: i i*W �l sorAev!=epitet :of ,
Address: Rd. go ie I rb T
p ; Zip co&; 7eg"7 Counr f4,oA pe
Mee TeleNo.:dgle-. - Cc CellNo.: -ems/_ /
E. STATUS OF APPLICANT
POrate: Federal' Ca�oo�o�rczal:
Sum: Municipal: Nam American i anda•
I NIECTION PROC U RS (briefly describe leer the injection waits) wif be used)
G. WELL CONSTRUCTION DA TA
CI) Proposedl date to be cad: - a 9 _ Nu aba: of %sms:
Approximate depth of each being (feet); 3 (C)
(2) Type of rulafng to be need (capper, PVC, etc): HO R S•'n
(3) Well casingg, is the well(s) cased? (check eitbker (e) Yes Pt (b.) No below)
() Yes if yes, tip ode casing won below
Type: _galvanized steel black steel plastic other (specify)
Cttsi depth: Fronx to fact (r aferance to tend surface)
Cuing extsnde to above graliad inches
0* No _X
(4) gout Info (rastesial luminding well casing endlor pipiag): 11 e�►"a 7 �° �� v4 nit
(a) Grout type: Not Cement Bentonite Qt#ea (specify)
(b) Grout placement: Purmpin Pressure Other
(a) Grout depth of tubing (reference to Iabd surface): from j to .30o (feet)
If wtsslllas easing, indite grout depth: from to (set)
1 13M U)QVA 'NEE 'P "600Z 'CI 'nnN:T-IT

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