WI0400135_GEO THERMAL_20100506

Beverly Eaves Perdue
Governor
Vince Hamrick
81: 90 Whipporwill Lane
Rural Hall, NC 27045
£.~A a,.;,~~
MCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
5/6/2010
Subject: Ac~owledgement of Intent to Construct Type SQW Injection Well System
Permit No. WI0400135
8190 \v11ipporwill Lane, Rural Halt NC 27045
Dear Mr. Hamrick:
Dee Freeman
Secretary
On 4/27/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-
only geo~ermal . 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 Titlfr 15A Section 20-Subchapter .0213, ~d
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
Forsyth 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.Ro ger s@ncdenr.2:ov if you have any questions.
Sincerely,
O~A-~
for Debra Watts
cc: Winston Salem Regional Office -APS
APS Central Files -Permit No. WI040013~
Forsyth County Health Dept.
Supervisor
Energy Solutions, Inc (Danny Goff-5723 Country Club Rd, Winston-Salem, NC 27104)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699~ 1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX t 919-715-0588; FAX 2: 919-715-6048 \ Customer Servi~: 1-BTT-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity I Affirmative Action Employer
N~rthcarolina X/aturnt/11 ·
Permit Number WI0400135
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
Vince Hamrick SFR
Location Address
8190 Wipporwill Ln
Rural Hall
Owner
Owner Name
Vince
Dates/Events
NC 27045
Hamrick
Orig Issue
05/06/10
App Received Draft Initiated
04/27/10
Re g ulated Activities
Heat Pump Injection
Outfall NU ' I .
Scheduled
Issuance
Central Files; APS_ SWP_
05/06/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Afflllatlon
Danny Goff
57?3 Country Club Rd
Winston Salem NC
Major/Minor
Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Vince Hamrick
8190 Whipporwill Ln
Rural Hall. NC
_Public Notice Issue
05/06/10
Effective
05/06/10
27104
27045
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
TO:
A.
C.
Mool Y,
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP
GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
In Accordance with the provisions of NCAC Title 15A: 02C,0204
Complete application and mail to address on the back page.
This is not the proper form to be used for injection wells in an open -loop geothermal system.
Do not use this form for systems that circulate any substances other than water.
DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: '-\ r \- ':�— , 20 1 0
SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES - If yes, then continue completing this form,
NO If no, do not complete this form. Form GW-57 HP, Application For
Permit To Construct AndlOr Use A Well(s) For Injection With A Heat
Pump System, should be completed.
SYSTEM FLUID Will any additives be introduced to the system's circulating heat transfer
fluid? This includes, but is not limited to corrosion inhibitors and/or antifreezes.
YES if yes, do not complete this form, Form GW-57 HP, Application For
Permit To Construct AndlOr Use A Wells) For Injection With A Heat
Pump System, should be completed.
NO V If no, then continue completing this form.
PROPERTY OWNER
Name:
Address:
C ity:
County,
STATUS OF PROPERTY OWNER
Private: i� Federal:
State:
Revised 7/06
:��ip Code:
- C1 LOCI a 1
Commercial:
Municipal: Native American Lands:
RECENEO 1 DENR I INQ
GWIUTC-57 CL p�fer Prtn 8 Page I of
APR 21 2010

E. FACILITY(SITE)DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: _____________________ _
Address: ____________________________ _
City: ________ State: __ Zip Code: ____ County: ____ _
Telephone: _________ Contact Person: ____________ _
Standard Industrial Code(s), SIC, which describes commercial facility: ________ _
F. HEAT PUMP CONTRACTOR DATA
Name: 6--e ~~\ '=°d,,-:b~ ~115 . Address: :S-·, -i; Ca..t,~~~~=~ S r ,he ~-,cou
City: \./2.-2-':~ State: nC...Zip Code: ~ 7ta-\ Coutl_!Y : -Goes.· ~-i.c-.....,
Telephone: 334?· 35 9 -·7. 3> ~ Contact Person: 2:h o D.7 G:?o-£.£--
G. CONSTRUCTION DATA (check one)
EXISTING WELL(S) being proposed for use as a ground-coupled heat pump
well(s). Provide the· information in (1) through (3) below to the best of your
/;
1owledge. Attach a copy of Form GW-1 (Well Construction Record) if
vailable.
' PROPOSED WELL(S) to be constructed for use as a ground-coupled heat pump
well(s). Provide the information in (1) through (3) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
(1) Well Drilling Contractor's Name: .{\ ~J...C>\... :0 -.r-, \,\ .., ~ ,,
NC Contractor Certification number: ~oL.\ \ -~ _______ _..,__ _________ _
Date to be constructed: L\ -;;\. \-\\) Number of borings: --~-------
Approximate depth of each boring (feet): __ ~-'----=5'--0-=---~-·-.. _______ _
(2) Well casing: Is the well(s) cased?
(3)
NOTE:
Revised 7 /06
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel_'_ Black steel __ Plastic __ Other (specify) ____ _
Casing depth: From ___ to ___ ft. (reference to land surface)
Casing extends above ground ____ inches
(b) NO ~
Grout (grout the vertical length of the borehole to a minimum depth of20 feet b.l.s.):
' ..1____L _,... -t \.. I! """\.c((9-(a) Grout type: Cement__ Bentonite Other (specify) ~{"4'Q..'»::1
(b) Grouted surface and grout depth (reference to land surface): ~<\ti \e.,. \ s.q~c\,
__ around closed loop piping; from <-.\ to.;).SD (feet).
('\\~around well casing; from __ to __ (feet).
THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
GW/UIC-57 CL Page 2 of4
f
ies,
,l • 1
r�rC�4 cvc�LL

H. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELL(S) Attach two maps.
(1) Include a site map (can be drawn) showing: buildings, property lines surface water bodies,
potential sources of groundwater contamination 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 ground-coupled heat pump well system. Label all
features clearly and include a north arrow.
(2) location map referencing the site to two nearby permanent reference points (such as roads,
streams and highway intersections).
J. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(l) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits
K. CERTIFICATION
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the
information submitted in this document and all attachments thereto and that, based on my inquiry of
those individuals immediately responsible for obtaining said information, l believe that the information
is true, accurate and complete. I am aware that there are significant penalties, including the possibility
of fines and imprisonment, for submitting false information. I agree to construct, operate, maintain,
repair, and if applicable, abandon the ground~source heat pump system and all related appurtenances in
accordance with the approved specifications and conditions of the Permit."
Revised 7 /06
(Signature of Wel ~ wner or Autho
(/
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
GW/UIC~57 CL
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OMO / ~N30 / 03Al3~3~
Page 3 of 4
L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the ground -source heat pump system's well(s)
conforms to the Well Construction Standards (Title 15A NCAC 2C .0200)
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
1JIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
10? l 9 8dy
Uql�
4+Ni(7 IS U0W0,,VJd
Revised 7/06 GWIUIC-57 CL Page 4 of 4

April 21, 2010
To Whom It May Concern:
This letter is to provide verification that Aqua Drill, Inc. has been given permission to act as an
authorized agent in the construction of a closed loop geothermal water well system located on my
property at the address stated below. If you have any questions regarding this matter, please feel free to
contact me at your convenience.
Sincerely,
S �gnature
Home Owner's Name
Address 12
L� L _L
Phone Number Z fir, - ci Lc c G� '
RECEIVED 1 DENR I DVVQ
Aquifer protection Section
APR 27 2010

' '
NORTH CAROLINA·
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP
GEOTHERMAL WATER-ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type SQW Wells
In·Accordance with the provisions ofNCAC Title ISA: 02C.0200
Complete application and mail to address on the back page.
This is !!91.the proper form to be used for injection wells in an open-loop geothermal system.
Do not use this form for systems that circulate any substances other than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: i..\ ---\. ~ 20 t 0 ,
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely i~tes the fluid from the environment?
YES _✓_ Tf If y ves, then continue completing this fonn.
NO Ifno, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Use A Well(s) For Injection With A Heat
Pump System, should be completed.
B. SYSTEM FLUID Will any additives be introduced to the system's circulating heat transfer
fluid? This includes, but is not limited to corrosion inhibitors and/or antifreezes.
YES
NO
__ If yes, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Use A Wel/(s) For Injection With A Heat
Pump System, should be completed.
~ no, then continue completing this form.
C. PROPERTY OWNER
Name: V\-c\.L'2.-~v-,G~
Address: ~ \ C\ 0 '-"-?\i, ~ r"--U\ \\ \ Cc-"\ e__. .
City: ;2.~'-"'"c \.. ~\ State: Y:\C_,Zip Code: ___ ,._:;r_ra.=:,--"-..-o_'-\~S=-------
County: ~G:::\\~ Telephone: 3 ~lo -ct \..0 °I -la S ~ \
D. STATUS OF PROPERTY OWNER
Private: ~ Federal: Commercial:
State: Municipal: __ Native American Lands:
Revised 7 /06 RECEIVED/ DENR / D~
GW/UIC-57 CL Aquifer Protection Secti6,tce 1 of 4
APR 17 2010
f I
E. FACILITY (SITE) DATA
(Fill out ONLY ifthe Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: ____________________ _
Address: ___________________________ _
City: ________ State: __ Zip Code: ____ County: ____ _
Telephone: ------~--Contact Person: ___________ _
Standard Industrial Code(s), SIC, which describes commercial facility: _______ _
F. HEAT PUMP CONTRACTOR DATA
c_ -C " ·
Name: ~'ef 'SI 2Cj\ v <--:b j't 1fi5' ·
Addres~: 5"w1 * \ C~~'---C: =i,; ~ 5 u .\--;i 1C>l=-~,1
City: \ A?--::, _ State: nc_zip Code: ~ 710--\ Coun~: -+q:->r:5),, ~
Telephone: 334?--3':J 9 .. • ?-, ~ Contact Person: ~ o f>'---4 bo :f..£---
G. CONSTRUCTION DATA (check one)
EXISTING WELL(S) being proposed for use as a ground-coupled heat pump
well(s). Provide the infonnation in (1) through (3) below to the best of your
/:
owledge. Attach a copy of Form GW-1 (Well Construction Record) if
ailable.
' PROPOSED WELL(S) to be constructed for use as a ground-coupled heat pump
well(s). Provide the information in (1) through (3) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
(1) Well Drilling Contractor's Name: .f\ ~-J...C 3:) ~-" \,\. , ~(__ ..
NC Contractor Certification number: ~o~ \ -~ ------___;;_~----------
Date to be constructed:-I-\ -do.\-\"\) Number of borings: __ cA _____ _
Approximate depth of each boring (feet): __ ~_---=5_0 __ ~ __ • _______ _
(2) Well casing: Is the well(s) cased?
(a) YES If yes, then provide the casing infonnation below.
Type: Galvanized steel~ Black steel __ Plastic __ Other (specify) ____ _
Casing depth: From ___ to ___ ft. (reference to land smface)
Casing extends above ground inches
(b) NO ~
(3) Grout (grout the vertical length of the borehole to a minimum depth of20 feet b.I.s.):
(a) Grout type: Cement__ Bentonite Other (specify) ~_.-N'Q..\.\.y ~~
(b) Grouted surface and grout depth (reference to land surface): ~ \e,. \ Sc:l.i'\.c\
__ around closed loop piping; from '-\ to~SQ (feet).
0 \~around well casing; from __ to __ (feet).
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE.BY OTHER MEANS.
Revised 7 /06 GW/UIC-57 CL Page 2 of 4
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H. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELL(S) Attach two maps.
(1) Include a site map (can be drawn) showing: buildings, property lines surface water bodies,
potential sources of groundwater contamination 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 ground-coupled heat pump well system. Label all
features clearly and include a north arrow.
(2) location map referencing the site to two nearby permanent reference points (such as roads,
streams and highway intersections).
J. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
( 1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits
K. CERTIFICATION
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the
information submitted in this document and all attachments thereto and that, based on my inquiry of
those individuals immediately responsible for obtaining said information, I believe that the information
is true, accurate and complete. I am aware that there are significant penalties, including the possibility
of fines and imprisonment, for submitting false information. I agree to construct, operate, maintain,
repair, and if applicable, abandon the ground-source heat pump system and all related appurtenances in
accordance with the appr,oved specifications and conditions of the Permit.''
Revised 7 /06
(Signature ofW/
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
OW /UIC-57 CL
RECEIVED/ DENR / D~
Aquifer Protection Section
APR 27 2010
Page 3 of 4
L_ CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the ground -source heat pump system's well(s)
conforms to the Well Construction Standards (Title 15A NCAC 2C .0200)
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED I DENR 1 DM
Aquifer Prcftdion 5edon
APR 27 2010
Revised 7/06 GWlUTC-57 CI. Nee 4 of

W
April 21, 2010
To Whom It May Concern:
This letter is to provide verification that Aqua Drill, Inc. has been given permission to act as an
authorized agent in the construction of a closed loop geothermal water well system located on my
property at the address stated below. If you have any questions regarding this matter, please feel free to
contact me at your convenience.
Sincerely,
r �
gnature
Home Owner's Name
Address �q L• i.t ���-L
Phone Number--
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