WI0400120_GEO THERMAL_20091119

Permit Number
Program Category
Ground Water
Permit Type
WI0400120
Central Files: APS_ SWP_
11/19/09
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (SQW)
Version
1.00
Permit Classification
Individual
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Jerry Rowland SFR
Location Address
833 Glen Echo Tri
Winston Salem
Owner
Owner Name
Jerry
Dates/Events
NC 27106
Rowland
Orig Issue
11/19/09
App Received Draft Initiated
11/09/09
Re gulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
Brad Fulk
5142 N Causeway Dr
Winston Salem NC
Major/Minor
Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Afflllatlon
Jerry Rowland
833 Glen Echo Tri
Winston Salem
Public Notice Issue
11/19/09
NC
Effective
11/19/09
27106
27106
Expiration
Stream Index Number Current Class Subbasln
4.e;,,A B.,i;~~
MCD ..... EN ..... R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Jerry Rowland
83 8 Glen Echo Trail
Winston-Salem, NC 27106
Coleen H. Sullins
Director
11/19/2009
Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System
Permit No. WI0400120 ,
83 8 Glen Echo Trail
Winston-Salem, NC 27106
Dear Mr. & Mrs. Rowland:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on
11/9/2009, 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 838 Glen Echo Trail, Winston-
Salem, Forsyth.County, NC 27106. This system is deemed permitted by rule (North Carolina Administrative Code Title
15A, Subchapter 2C, Section .021 l(u)(2)).
However, it is recommended that you contact the Forsyth 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 nie at [phone].
Sincerely,
C)~~
l n ·""-Michael Rogers
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400120
Forsyth County Health Dept.
~ -Enviro1m1ental Specialist
GPU-Aquifer Protection Section
David Brown (Yadkin Well Co. -1908 Hamptonville Rd, Hamptonville, NC 27020)
Brad Fulk (Logan Heating and Air -5142 N. Causeway Drive, Winston-Salem, NC 27106)
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.ncwaterquallty.org
An Equal Opportunity\ Affirmative Action Employer
Ni1fuicarolina /vaturaltu
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'Joy, 12. 2009 3: 07PM YADKIN WEL[, No, 3990 P, 1
FACSIMILE TRANSMISSION FORM
DATE•
TO:
FROM:
ge:DEse-.b 14J Q
COMPANY NAME
ATITtkoii4 ,rz5eDEPT
rs
/ad/elnL1a[l C4
COM€ArNNAME
1 aut d 1*3i/ow"
REF. NO. LOG NO
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FAX M0. PLEASE
❑n° tY
FAX NO ._-....
❑r
INDIVIDUAL DEPT
WI NER OF PAGES PLEASE ORIGINATOR'S 21)-
MIMING THIS SHEET REPLY BY SIGNATURE
MESSAGE: y±
AA,i^1_2+ 110 440 % Jr -.(1,6A Wf//,
Jhtiw. d .J e drib erC r1. co ►r►
e l� #.?3C-a?€-> 7,��
-FOR ALL YOUR WATER NEEDS-
YADKIN WELL CO., INC.
1990 hAMPTONYII.LE ROAD
HAMPTONVILLE, NC 27020
0AVIO J. 'BROWN, VICE PRES.
TOLL FREE (800) 24843Si
OFFICE (336) 4'^
FAX [phone]B
RES I3361 46$-4659
-p1747u Hews P.y[141(.R • 4C7 LOVC9 1.E11`
PLEASE INFORM LIS SAIMEI !FWD GO NOT Pt1c31fE FACSIMILE IN FULL

Nov. 12. 20091 3:07PM YADKIN WELL,
'No.3990 P. 2
rraRTLt cAatoLnzA
DEPARTMENT OE:NVIRONIONT.AND NATURAL RESOURCES (NCDENR)
NOTITICA,TI CN ❑ )TENT TO CONSTRUCT A CLOSED LUUP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5- W WELLjS)
la Accordance with the proyisfoRs of NCAC Tile 15Az 02CAlaK please
complete this notification. and triallto asdress CM ate back peg (please Print at k, t:nfatasl#ioa},
1
fYt3I ,Tnfn na ors: Does the px p ed srysteea circulate potable water only (no additives) a
ccntinrzous piping that completely isolates the fluid from the anvil anment (Le.
closed -Icon)?
DATE: , 29 O 9
Yes X Cantina completiag this forts.
No Do Net complete th4s form. Complete other UIC appE a ol. fcs for i w.iling
either a 5A7 well (opsn-loop well ink potable water into The aquifer) oz a 5 ! well (closed -
loop well containing additives sii.cb as R 2.2., ethsfol, or other antifreeze or corrosion inhibitors)_
PROPERTY OW"NER(SYA ICA MS)
List each Property Owner listed on property cud (if owned by a busing= or government any, state name of
eaaty and a xes tarive wlauthoizty for signature): /G tr'Yy ( w 1 Gn
Mailing Address: 2 3 Cl [en E ckb tY
City: ,t n .-ris a.. State: Zip Cade:
Home/Office Tele No.: {o J 6150 Ce1T o.:
Email Address- 1 Website:
(2) Physical Address of Weii Site (if
City:
Rome/Office Tele Na,:
different than above):
State:. Zip Code:
Sri►:I ,,4A
Cell
B. AIITHORIZED AGENT or OWNER, ANY (fthe Perttat Applica= do not own the sabjeet property,
attach a letter from the ptopesey owner anshori'zing Arm to irises and era MC well)
Company Name:
Couta t eison:
Address:
City: Slate: I ttp Code:
Office TeleNo.:
W ebsite Address of Cotapaay, if arty:
EMAII. Addtess:
County:
CA,1 No.:
"d E96E 'oN 1 111M NA(1YA Wd9L�I. 6OOZ 'noN

p`C�av, 17. 2009' 3:O7PM YADKIN WELL. No 3990
C. WELL AR.TL UR INFORMATION
Company Nanze:.Yadloo Well Co- Ins _
Well Driller Contractes Name: Tody_arillis MatthewBro'vin
NC Contractor Certification No.: 25724 ►) 3036 -A
?431ton Cave
3548-A
Court Porson David d reas_cixiefd Yler� ss�com
Address: 1908 Hampton. a Rd. 1 - - -
Cry: Haropzoneralc td.G Zip Code: 27020 Connizr Yadk o
Office TeleNo.: _336-468-4440 Cell No.: 3316.374-8736
D. IIEA.T k'tJMP CONTRACTOR LiFORMATION (if different ems driller)
Company Nam. !—d &T 1 i Dir i - CONNCli
Contact Person: V- CA-4 -1 EMAIL Address: ah n ; v� . Q elyl h tl t . C or''
��
:-74(a-- s � z — —
city: (AA) 5 1 o zip Colder' a 1 /d eP County: %-J-r ,
7
Office TeltNo(331.i)COLI—s416/ E Cell No.: ,�, G)%d1v/63 .
1
E. STATUS OF APPLICANT
Private: Federal: Commercial:
State: Mticipal: Native A.meFiana ]Lands:
I
F. ) 3EC I /QNPROCEDURE(briefly descrTe h►� ow the injection (s) rr ill be
C.2J-C Gv li Ai 4 r 1
t - ord ! /Ir ° J [.dwc -1 e'
G. 'WELL CONSTRUCTION DATA,
(1) Proposed date to be constructed: Ad? 20 Number of baring
Approximate depth of each b (feez): 3 73—'
(2) 'type oftubing to be used (copper, PvC, etc): I#r P _Ja.6,644e,4, Sn J1
(3) Wen casing. Ss the well(s) cased? (check either (a.) Yes or (b. , Blow)
(a) Yes _ if yes then provFde casing information below
Type: _galvanized steed blackk1szeei plastic other (spescify)
Casing depth.. From to .1 feet (reference to land smart)
Casing exxeads Zo above ground 1 inches
(b) No
(4) Grouz raft) (material swnrounding well lcasing andlar piping):
(a) Gx'aurrype: Neat Cement J Bentonite Other (specify) 7) -,..
(b) Grout plume -at Pampb } ___ Pressure Ott' i . ".x
Grout depth of t :bid (j efai euee to land stelaoc): from to .TO— (feet)
If well bas rasing; inliicate gad depth: from n to (feet)
(c)
CeA
'd E96E .°N 113M N j)(0YA INd9L 600 'fi 'h'N

.. 'Nov. 12. 2009 ` 3108PM YADKIN WELL 'No. 3990
31NUG'TION—A,TEb EQIIVI N"t
Ate a chug ratri sowing the eagmeetial layout or proposed inoclificatoLe of the kijection equipment and exterior
piping/tabiog assoeiazed with the injection operating, The unszufacturcrs brvcbure may provide supple: ae:mxy
irrforMad ort.
1,. LO CATXON OF W) LLr (S3
Attach two copies of maps showing rho folovriarg won:
(1) Inolude a Sire Map (can be drawn) showing: buildius, property lines, surface water bodies} potential
sources of g roundwuer coon and the orientation of end &stances benweeaa >le proposed well(s) and
any existing well(s) or waste disposal faeilitisuch as septic t s Ot drain fsglds located within 200 feet of
e geothermal heat pump well system, Label all festres clearly aitd inehlde a north arrc
Tie Site Map must show the suojw prOPesry in relation to The s+tiro maix% area by usi?ag at least two fixed
refsrenoe points such as roads, streams, and/or highway intersections.
(2)
J. CERTIFICATION
Note: This Ferruit App.li csdoe mvst b4 sued by eke'h person appealrbng on the
recorded legaLproperty deed
"I hereby certify, under penalty of law, that I have personally examined and am familiar wktb. t e. intumatioa
submitted in this dorm and all amticbmez 'thereto and that, based on my inquiry of those individuals
immediately teaponsibie for obtainlog sa.itl information, I believe thaz the information is true, accurate and complete.
I am aware that (here are significant parses, including the possrbiiity of fines and imprisonment, floe abmintix'$
false mob I Agee to construct, operate, gym, repair, cud if applicab abandon the injection well and
all related appurtenances ha accordance with 't pproved ors aed ofthe c Pt "
Sigoat ce of Property Owner/Applicant
rot or Type Fall Name and title
signature ofAuthorized Ageatt if any
tEtint or Type Irbil Name andte
Please return two copies ofthe completed Applicalidn package to:
No4 Cambria DE1'.R D"WQ
A.guffer Froteciioa Section -WC Program
1a6.� Service Center
R �ieigh, NC 27699-1636
'1t e1laphoae (919) 715-493S j
I
MA O]OWk WA41:7. Afn7 'F nod

•Nov, 12. 2009 3:08PM YADKIN WELL,
No, 3990 P, 5
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