WI0400127_GEO THERMAL_20100310

--~W~I0400127
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers .'
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
River Mill Village Test Well
Location Address
1715 Saxapahaw Bethlehem Church Rd
Graham
Owner
Owner Name
Rivermill Village LLC
Dates/Events
NC 27253
Orig Issue
03/10/10
App Received Draft Initiated
03/01/10
Re o ulated Activities
· · Heat Pui:np Injection
Outfall ,,:uLL
Scheduled
Issuance
Central Files: APS_ SWP_
03/10/10
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County . ·
Alamance
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
John M. Jordan Jr.
PO Box 128
Saxapahaw NC 27340
Public Notice Issue
03/10/10
Effective
03/10/10
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
3/10/2010
John M.Jordan. Jr.
Rivermill Village, LLC
P.O. Box 128
Saxapahaw, NC 27340
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400127
1715 Saxapahaw Bethlehem Church Rd.
Graham, NC 27253
Dear Mr. Jordan:
In accordance with the application submitted to the Underground injection Control (UIC) Program that was received on 03/01/2010.
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 1715 Saxapahaw Bethlehem Church Rd., Graham, Alamance
County, NC 27253. This system is deemed permitted by rule (North Carolina Administrative Code Title 15A. Subchapter 2C, Section
.0211(u)(2)). However, please note boreboles shall not connect separate aquifers, which have differences in water quality (e.g..
shallow surficial aquifers, saprolite, fractured bedrock, etc,) as specified in 15A NCAC 2C .0213(d)(8)(C),
Please notify the Winston-Salem Regional Office at [phone] at least 48 hours prior to well installation. Additionally, it is
recommended that you contact the Alamance 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],
for Michae'l-1 ogers
Environmental Specialist
GPU-Aquifer Protection Section
cc: Winston-Salem Regional Office - APS
.APS Central Files - Permit No. W10400127
Alamance County Health Dept.
Janice Scott (Midsouth Geothermal. LLC, 8275 Tournament Dr., Ste. 185, Memphis, TN 38125)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh. Nam Carolina 27699.1636
Location! 2728 Capital Boulevard, Raleigh, North Carolina 27664
Phone [phone] I FAX [phone]; FAX 2: 919-715-60481 Customer Service: 1.877-623.6748
Internet www,newaterruafttv•orq
An Equal Opportunity 1 Aftrrnative Action Employer
One
NarthCarolina
Naturally

03/01/2010 10:15 '9017489097
MID -SOUTH GEOTHERMAL PAGE 01
MidSouth
GEOTHERMAL k
Specialty Geothermal Well Field Services
FAX LEAD SHEE T
-10
To: Mr. Michael Rogers
Company: NC Dept of Environment & Natural Resources
Fax Number: 919-715-0588
Pages (include, cover):
Date: March 1, 2010
From: Janice Scott
RE: River Mill Village Test Well - NC DENR 5QW
Permit No. (pending)
Mr. Rogers,
As per our conversation earlier, this is to inform you that we are doing the
Test Well on the River Mall Village project., We are only doing one test
well at the moment, but the project could pc$sihly he up to 59 wells.
Please do not hesitate to call if you have any questions or require additional
information. My number is [phone].
Sincerely,
Janice E. Scott
8275 Tournament Drive Ste. 185 *Memphis, TN 38125-0851
Office [phone] • Fax .901) 7'48-9097
RECEIVED r DENR i DWQ
AOUIFFR PR(TR TION SECTION
MAR 6.12010

03/01/2010 10:15 9017489097 MID-SOUTH GEOTHERMAL PAGE 02
vJI.01oo la 7
NORTH CAROLINA
DBF ARTMBNT OF BNVIR.ONMENT AND NA TIJRAL RBSOURCES
NOTD1GATION OF INTENT TO CONSTRUCT A CLOSED.LOOP GEOTHERMAL
. WATER-ONLY INJECTION WELL SYSTEM
TYPE SOW WELL (S)
In .Accordance With the Provisions ofNCAC Title ISA 02C.0200
Prl"t or type the req11fr1d lnfl>miarion and mail to addrsss on th~· back pap.
DATE: --~-... -~_S-~__, 20 f (!)
Yfell Type Cotiflrmation: Doee the pl"Oposed 9ystein circulate potable water only (no additives) in
continuous piping that completely isolates the fluid frotn the e•iviroJuno,it (i.e.
~losed-loou)?
Yes ~ C0:~tinue completing this _fonn.
No __________ Do Not complete thi:S fonn. Comp!• ather UIC application fonns for installing
either a 5A7 well (Q.(Hm-loop well ·~ potable water lirto th~ aquifer) 01 a SQM well (closed ..
loop well eontaining additi\'es such es R .. 22, ethanol, or other antifreeze or.conosion inhibitors). ·
PROPERTY 0\VNER(S)/AP:PLlCANT(S)
List a Ptoperly Owner listed on property deed (if O\vned by a businos:, or government aacncy. state name of
entity and a representative w/a,dtority for sJgnanu-e): -~-----------,-----
.:f't,vcav// VtL/45 e L-« C. -I
Mailing Address: tt?a C3ta< I Zi'
City: ~>:4-/lfi'A4NtJ Sta~:&ZipCode: 6l73Vo Courrty: A/mrwzc.e
Home/Office Tele No.: 3.3/a -3 Z@ · 1i.Z-2... Cell No:: 336 ~il/y._ Kl-3 ,(
Email Address: lnlt?/FLJocdhA .l)ftt,Webslte: .
. -;:J V . _f r'l!°~1'lc»S', ('}(Jh,.w
(2) Pn~icalAddressofWeJI Site (if different than above): ,/~ £--s.>?"y,¥~ JJ-ttf6/4/e.,r" f'A
City: &/'i?&rn State: /p/{zip Code: ~ 7~.(::2 Cotmty; J:J/41114-d, c. /2t:I
Home/OtnoeTeleNo.:_~~--,,.""14~4(,lt!,.~F--------=Ce~l:,.:lN~o=::!!.~-..L.~..S,...L~=----~~""'----
B. AUTHORIZED AGENT OF OWNER, IF .A.NV (lfthe Pennlt Applicant dog Ml own the 51:1bject property,
attach a letrer from the property owner authorizing Agei1i to l11sta11 and operate UIC weJl)
Company Name:_ .......... _____________ ~----~~--_....... __ _
Contact Person~:---------~ .. :---· -=E=-=-=MA=IL:..::A-=-=dd=res=se.;...,· ----~~-----
AddrC$s: -------=-------~"""";------------=-------
City: -........ ------State:_ Zip Cod~~ _______ C.ounty: _______ _
Office Tele No.: __________ , CeJI 3:-12,:
·websltt►, Address of Company~ If any: ________ _,......-.-,-___ _
OPUJUIC SQW ~atiftcatlo1t l)flnt~-'t Fo:nn (Revised 8/.l008) RECEIVED/ DENR / DWQ
AQUIFFR·PROTFCTION SECllON
MAR -~12010
03/01/2010 10:35 9017489097
MID -SOUTH
pr
GEOTHERMAL PAGE 01
C. WELL DRILLER INFORMATION
Company Name:I Z`u ca-E \1 U -e-CA \ it r ill la t \ L. L
Well Driller Contractor's Name:7
NC Contractor Certification a.: 46 L. - � },18 5
Contact Perscro Y1t0'Address: v i7 c iri[ l
Address: C .1 S 1 C Q. \- \v • 'e , t$S o r-►
City: 1N1.\Q kAA h\S - ,Lip Code: S County: \"1'€. t. C'J
Office Tele No.: CILIA -14 -0t0c3i5 €No.: 9N `i 1
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller) (50 VtA,Q
Foise
Company Name:
Contact Person: EMAIL Address:
Address:
City: f tip Code: County:
Office Tel No.: Cell No.:
STATUS OF APPLICANT
Private: Federal:
Commercial X
State: Municipal: Native American Lands:
F. pTJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
\QC l a VA\
G.
WELL CONSTRUCTION DATA
(1) Proposed date to be constructed:
Approximate depth of each boring (feet):
(2) Type of tubing to be used (copper, PVC, etc):
(3) Well casing. Is the well(s) cased? (check either (a,) Yes or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: __galvanized steel black steel plastic other (specify)
Casing depth: From to
Casing extends to above ground
(b) No Nf
feet (reference to land surface) •
inches
(4) Grout Info (material surrounding well casing and/or piping):
(a)Grout type: Neat Cement Bentonlite
(b) Grout placement: Pumping Pressure
Number of borings:
IN" H pkpolat
If(NA'
()‘r-•
Other (specify)
Other
(c) Grout depth of tubing (reference to land surface): from to 9 s_ (feet)
If wc11 has °Aging, indicate grout depth- from to (feet)
Paget

03/01/2010 10:15 9017489097
MID -SOUTH GEOTHERMAL. PAGE 04
I. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the Injection operation. The manufacturer's brochure may provide supplementary
information.
L LOCATION OP WELL(S)
Attach two copies of [naps showing the fallowing Information:
(1) Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contreninatfon and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal beat pump well system. Label all features dearly and $u&lude a north 902.
The Site Map must show the subji t property in relation to the surrounding area by using at Least two fused
reference points such as roads, streams, and/or highway irate ectinns.
C2)
J. CIRTlF ICATlON
Note: Thla Permit Appliention must be signed by each person appearing an the
recorded legal property deed,
"t hereby certify, under penalty of law, that I have personally examined and am familiar with the infurntation
submitted in this document and all attachments thereto and that, based on my inquiry of these individuals
imsmedintely responsible for obtaining said information, I believe that the information Is true, accurate and complete,
I am aware that there are signiZaant 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 watt and
all related appurtenances its accordance with the approved specifications no conditions of the Ptrmit."
Print or Type Full Name end title
Signature of Property Owner/Applicant
Print or Typo Dull Ne.ne and title
Signature of Authorized Agent, ifany
Print ar Type Full Name and title
Please return two copies af the completed Application package to:
Ndrtb Carolina DENR DWQ
Aquifer Protection Section.iliC Program
1636 Mail Service Centex -
Raleigh, NC 27699-1636
Telephone [phone]
Cil?U/UIC SQW Notification of Inteur Pork (Revised 812008)
REC1~AD!DE,NR/Oft
MAR 012010
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