WI0400139_GEO THERMAL_20120518

Beverly Eaves Perdue
Governor
A.TA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P. E.
Director
May 18, 2012
Michael Ryden
29 Cascade A venue
Winston-Salem, NC 27127
Subject: Notification of Rule Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
PermitNumber: WI04001 39
Dear Mr. Ryden:
Dee Freeman
Secretary
Our records indicate that you curren.tly 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 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection w~lls including geothermal wells.
This letter is also to inform you that your closed-lo.op 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://portal.ncdenr.org/web/wq/aps.
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,
~bu-tt-
Eric G. Smith, P.G.
Hydro geologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Seivice Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterquality.org
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Permit Number WI0400139
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Michael Ryden SFR
Location Address
29 Cascade Ave
Winston Salem
Owner
Owner Name
Michael
Dates/Events
NC 27127
Ryden
Orig Issue
07/22/10
App Received Draft Initiated
05/18/10
-Schedul,d
Issuance
Central Files: APS_ SWP_
07/26/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Billy Clayton
4137 Moores Mill Rd
Spencer VA
Major/Minor
.Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Michael Ryden
29 Cascade Ave
Winston Salem
Public Notice Issue
07/22/10
NC
Effective
07/22/10
24165
27127
Expiration
06/30/15
_R_e...._g_u_la_te_d_A_c_ti_v_iti_e_s _______________ Re quested/Received Events
Heat Pump Injection Additional information received
Additional information requested 06/18/10
Outfall i\l~JU ..
Waterbody Name Stream Index Number Current Class Subbasin
~A ' ~1
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Brian Ryden
29 Cascade Ave.
Winston-Salem, NC 27127
Dear Mr. Ryden:
Coleen H. Sullins
Director
July 22, 2010
Dee F reemar,
Secretary
Subject: Issuance of Injection Well Perm.it
Permit No. WI0400139
Issued to Michael Ryden
Orange County
In accordance with your application received May '9, 2010 and additional information received July 22,
2010, I am forwarding Permit No. WI0400139 for the construction and operation of a vertical closed-loop
geothermal mixed-fluid heat pump injection well system located at 29 Cascade Ave., Winston-Salem,
Forsyth County, NC 27127. This permit shall be effective from the date of issuance until June 30, 2015,
and shall be subject to the conditions and limitations· stated therein.
Please pay special attention to Part I. 7 of the permit and submit copies of the Well Construction,
Completion fonn (GW-1) after construction. Please submit all data within 30 calendar days of receipt of
this letter to the address below:
Aquifer Protection Section (APS)
Underground Injection Control (UIC) Staff
1636 Mail Service 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 1.6 ofthis permit issued July 22, 2010.
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 pennit or the Underground Injection
Control Program please call me at [phone].
Sincerely,
/2-tUC?/
JohnMcCrat,'
Environmental Specialist
cc: Sherri Knight -Winston-Salem Regional Office
Central Office File-WI0400139
Forsyth County Environmental Health Dept.
Lothridge Plumbing
Billy Clayton, Aqua Drill
Enc: Permit WI0400139
...
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
Michael Ryden
FOR THE CONSTRUCTION AND OPERATION OF 1 TYPE SQM INJECTION WELL, defined in Title 15A
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 29 Cascade Ave, Winston-Salem, Forsyth
County, NC 27127, and will be constructed and operated in accordance with the application received May 18,
2010 and additional information received July 22, 2010, 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 permit.
This permit is for Construction 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 15A 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 June 30, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
~
Permit issued this the J3 -day of _ __,.►---~--~"---'---'le--' 2010. er
~_)-~
j(\ Coleen H. Sullins, Director
\" Division ofWaterQuality
By Authority of the Environmental Management Commission.
r
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicableto Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions of this permit 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 permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect s~parate 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 afforded reasonable protection against damage during construction and use.
6. Each geothermal injection well system shall have permanently affixed an identification plate on a nearby
building or other permanently fixed structure indicating the location and presence of underground UIC
wells according to 2C .0213(g).
7. 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 27107-2241
[phone]
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.
8. 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 Permittee 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 [phone].
WI0400139 2
2. Boreholes shall not connect separate ~uifers. 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) and
shall be filled with bentonite grout from the lowermost water bearing zone to land surface as specified in
the permit application.
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 Pennittee, 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 11?-at will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance COJ.?.ditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee 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 Permittee 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. Th~ 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 Permittee 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
Pennittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number (9l9) 715-6168. 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.
WI0400139 3
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 or 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.
WI0400139 4
2. When operations have ceased at the facility ~d a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 1 SA 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 Permittee 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 Paii IX (1) and (2) (G) shall be submitted to:
WI0400139
Aquifer Protection-Section-DIC Program
.DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
5
Permit Number WI0400139
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
john.mccray
Coastal SW Rule
Pe.rmitted Flow
Facilitv
Facility Name
Michael Ryden SFR
Location Address
29 Cascade Ave
Winston Salem
Owne
Owner Name
Michael
Dates/Events
NC 27127
Ryden
Scheduled
Orig Issue App Received Draft Initiated Issuance
05/18/10
Re gulated Activities
Outfall (.'Ui..L
Central Files: APS__ _ SWP_
07/23/10
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Perm it Contact Affiliation
Billy Clayton
4137 Moores MHI Rd
Spencer VA
Major/Minor
Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Michael Ryden
29 Cascade Ave
Winston Salem NC
Public Notice Issue Effective
Re auested /Received E v ent s
Additional information received
Add itional information requested
24165
27127
Expiration
06/18/10
Waterbody Name Stream Index Number Current Class Subbasln
Permit Number WI0400139
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Michael Ryden SFR
Location Address
29 Cascade Ave
Winston Salem
Owner
Owner Name
Michael
Dates/Events
NC 27127
Ryden
Central Files: · APS_ SWP_
06/03/10
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit ContacfAfflllatlon
Billy Clayton
4137 Moores Mill Rd
Spencer VA
Major/Minor
Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Michael Ryden
29 Cascade Ave
Winston Salem NC
24165
27127
Orig Issue App Received ·Draft Initiated
05/18/10
Scheduled
Issuance Public Notice Issue Effective Expiration
Reg ulated Activities
Outfall l\!ULL
Waterbody Name Stream Index Number Current Class Subbasin
Mccray, John
From: Mccray, John
Sent: Friday, June 18, 2410 11:10 AM
To: Knight, Sherri
Subject, 50M permit application W 10400139 for review
Attachments: wi0400139app lication. pcif
Ms Knight,
Please let me know if you have any concerns with the 'issuance of the permit for this application of a geothermal system
in Forsyth County.
Best Regards,
Jahn Mccray
DISCLAIMER: Per Executive Order No. 150, all a -mails sent to and from this account are subject to the North Carolina
Public Records Law and may be disclosed to third parties.

Prirrt Preview
http://maps2.co.forsydLne.ustgeodata'/o5FO8/printPreview.aspx?Print...
Forsyth County, NC
PIN
6834-38-2162,00
Current Deed Stamps
Property Address
29 W Cascade AVE
Map Number
630M
Block Let
0672 013
Assessment Method
Cost
Additional Lots
107, 108
WIP
NO
Tax Jurisdiction
Winston-Salem
Land Value
$87,360
Anx
N
Dwelling Value
$172,602
Taxable Owner Name f
Ryden, Michael S.
Commercial Value
Taxable Owner Name2
Easter, Arthur C
Industrial Value
Taxable Owner Address
29 W Cascade AVE
Misc Imp Value
Taxable Owner City St Zip
Winston-Salem, NC 27127
Total Value
$260,000
Taxable Deed Bk-Pg
2197-247
Acreage
0.43
Taxable Deed Date
8/30/2001
Sq Ft Living Area (Res)
3079
Taxable Deed Stamps
Gross Sq Ft (Com)
Current Owner Name?
Ryden, Michael S
Year Built (Res)
11916
Current Owner Name2
Easter, Arthur C
Year Built (Com)
Current Owner Address
29 W Cascade AVE
Census Tract
19.02
Current Owner City St Zip
Winston-Salem, NC 27127
Zoning
R59
1 of 2 6/22/2010 2:16 PM

Print Preview http://maps2.co.forsyth.nc.us/geodata%5F08/printPreview .aspx?Print. ..
2 of2
Current Deed Bk-Pg 2197-247 Last Qualified Sale Price $170,000
Current Deed Date 8/30/2001
Disclaimer: Forsyth County cannot guarantee the accuracy of this information, and the
County hereby disclaims all warranties, including warranties as to the accuracy of this
information.
Map Scale
1 inch = 56 feet
6/22/2010 2:16 PM
Mccray , John
From:
Sent:
To:
Subject:
Attachments:
Mr. McCray,
lothridge@m indspring .com
Thursday, July 22, 2010 1 :46 PM
Mccray, John
Michael Ryden
Michael Ryden.pdf
Mr. Lothridge searched the Forsyth County website for almost an hour and couldn't find
anything satisfactory to him so He wanted me to send you the att~ched drawing.
Thank you,
Tina
1
kTO'i
NCDENR
North Carolina Department of Environment and
Division of water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
June 3, 2010
Michael Ryden
29 Cascade Ave
Winston-Salem, NC 27127
Subject: Acknowledgement of Application No. W10400139
Michael Ryden SFR
Injection Mixed Fluid GSHP Well System (5QM)
Forsyth
Dear Mr. Ryden:
Natural Resources
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on May 18, 2010. This application package has been assigned the number listed above and will be reviewed by
John McCray.
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. Please also note at this time, processing permit applications can take as long as 60 - 90 days after receipt of a complete
application.
If you have any questions, please contact John McCray at 919-715-6168, or via e-mail at John.mccrayCancdenr.gov. If the 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:11h2o.enr.state.nc.us/dc)cumcntsldwu on -,champ
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT
Sincerely,
jor Debra J. Watts
Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
Aqua Drill (Billy Clayton - 4137 Moores Mill Rd, Spencer, VA 24165)
Lothridge Plumbing Inc (Eddie Lothridge - 394 Bill Medlin Rd, Lexington, NC 27292)
Permit Application File WI0400139
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 276(0
Phone: [phone] FAX [phone]; FAY 2- 919-715-6048 l Customer Service; 1-877.623-8748 o° ��.a a
InlemeC www.nc�yateroualit�,oro ,JVat�r��!!t�
An Equal Upwrtunhy t AMrmative Acton Employe

RECEIVED!
Aquifer Prote~~NR I DWQ
., ion Section,
DEPARTMENT OF ENVIRO~ ~~~~ RESOURCES (NCO~ JS 20/0
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE 50M WELL{S}
X New Permit Application OR ____ Renewal (check one)
DATE: 5 -ll , 20Jfl_
PERMIT NO. ________ (leave blank if NEW permit application)
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a· business or government agency, state name of
entity and a representative w/authority for signature): _/Y/~1=..:d-=1/l'-'--'e,=-/L-..L-~4-+I r/.____,,.,,m~---------1
(I) Mailing Address: ;/t,J Ul.x:a.J~ We
City:·/J,ri.sJm,-:saJe.m State:~ZipCode: c:27/;;J.7 County: ~fh._,
Home/Office Tele No.: 334.,--2?~-q,;J, ~S Cell No.: 33~ -5 Z2:-s>l/?8'
EMAIL Address: m r(Me)@, lrbrt4.l-es~ Com
(2) Physical Address of Site (if different than above): ______________ _
City: ________ State: __ Zip Code: _____ County: ____ _
Home/Office Tele No.: ___________ C_el_l N_o~-~= _________ _
EMAIL Address: ______________ _
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC weH)
Company Name: __________________________ _
Contact Person"-: _____________ E_MAIL __ A-'-ddr=----es ___ s: ___________ _
Address: _____________________________ _
City: ________ State: __ Zip Code: _____ County: ______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: _____________ _
C. STATUS OF APPLICANT
Private: X
State:
Federal:
Municipal: __
Commercial:
N"a:tive American Lands:
s
D. WELL DRILLER INFORMATION
Company Name: 1/{}_1( a__7Jr; / / .
WellDrillingCon~t:r:sName: f3_i//y ('_,/6.,(,~ _,: &yan l!/~
NC Contractor Cert1ficat1on No.: c:?24/ A-dc;f 3J,4-_
Contact Person: 6,/ ff {//1.1.,~ EMAIL Address: ti.itjt--W Jr,j/@Jw.f ~.5. /Jd
Address: i./; 3 7 /YJtJ~res fYI,'/ I £c}_
City: 6pettcer I V ff Zip Code: c:/ Lf ltS County:. _M-=------..;.en_r---1-/'---------
Office Tele No.: 33&?-8? /-97t/7 Cell No.: 3 3lR-?I, 7-~7'./ 7
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Na~:JJ,'f11nJ&. /J/~ n3 k _ . . .
Contact Person: £c:f~1e, ltrtkr~ EMAIL Address: /o!(y,dC)l@ m,ndsp'1fj-C'(}/Y/
Address: 311 /!!JJI md!tn ;td
City: (JN10L-skvt I ;VC-Zip.Code: ;;L7;1..9eJ. County: _72 ........ ---'-~-"--1&_· · __ ~'/J"-' ______ _
Office J'ele No.: 33&-357-:22~.;i_ Cell No.: 33(p-;J,=t?--i$t?~
F. INJECTIQN PROCEDURE (briefly describe how the injection well(s) will be used)
I! Lt&.d Imp m .Ye d -fl wd fnc fu.rJ pw,cfJ
G. WELL CONSTRUCTION DATA (Skip to Section H if this is a Permit RENEWAL)
(1) Proposed date to be constructed: ______ Number ofborings: __ !.__ __ _
:'=A/ Approximate depth of each boring (feet): _ __,:t,.c....:::,:~:::;._v=--------
(2) Chemical additives to be used in closed-loop system ( only those chemicals indicated have been approved}:
___ R-22 __ __,propylene glycol X ethanol _______ other (other additives will
need prior approval by NCDENR before use)
(3) Type of tubing to be used (copper, PVC, etc): __._H.....:.......:D;__·P_'/3-_-_________ _
(4) Well casing. Is the well(s) cased? (check either(a.) YES m: (b.) NO below)
(a) YES·___ if yes, then provide casing information such as~ (steel, PVC, plastic, etc.), diameter,
~ and extent of c~ing appearing above ground: _______________ _
(b) NO X
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite ){__ Other (specify) ---~ _~ __ _
(b) Grout depth of tubing (reference to land surface): from 'f'50 to 0 (feet)
If well has casing,-.indicate grout depth: from ___ to ____ (feet)
\'
H. INJECTION-RELATED EQlJlP~ENT
Attach a diagra.iii. showing the·e_n~neering layout . .o:f'proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information. \ 1
May. 13. 2010 3: 4$ M LtONAHU HYOLN BURN KCAL WAIL Na. J4U9 r 1
i
L LOCATION OF WELL(S)
Attaoh two copies of amps showing the followiug infomtataon:
(1) Include a site map (can be dtawaa) showing: buildings, property lira, surface water bodies, potential sources
of groundwater contamination and tba orientation of and distances between the proposed we11(s) and any
ex'isttng weil(s) of waste disposal facilities suchas aeptic taaalm or drain gelds located within 1000 feet of the
geotbermai heat pump well system. Label all featum clearly and Wjude a north arrow•
(2) Include a topographic map offt arra extending out mile from the property boundaries and
indicate the facility's location and the map name
I. POTABLE WATER WELL(S)
Are there any potable water well(s) an the s abject property or adjacent properties? YES NO
If Yes, tbu indicate location on attached map(s).
K� CERTMCATION
Note: 'plats Per nk Appllcxtlan mast be dLrxtad by et ch person appearing ou the rccordtd kg&1 property dead.
"I hereby certify, under penalty of law, that I have personally examined and am knAliar with the information
submitted in this document and all attachments thereto and that, based on lay inquiry of those individuals
immediately responsible for obtainin¢ said information, I believe that the information is time, accurate and complete.
I am aawiaara that tbera are siolkant pmai#ies, including the possibility of fines and imprisonment, for submitting
false infmnatioa. l agree to cantt-aet, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurGenmices in accordance with the approved speciflmti s and conditions of the Permit."
1 tetra o operty Applicant
RECEIVED I ❑ENR 1 GV4 D1, A t r, - -
Aquift!_'i Praletgion Sedbn Prim or Type Bill Name
MAY 18
Sigtatore of Propexty pw=/Applicant.
Print or Type N11 Name
SiVatmV of Authorized Agent, if ally
Print or type l�ail Name
Pleaso return two capiea of the complatr:d Applicatina psdmge to -
Worth Carolina DENA DWQ
Aquifer Protection Section
UIC Program
1636 Maid SeMce Center
— Raleigiy NN 27699-1636
Wephabe [phone]

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68 — Section Four
Earth Coil Type: Vertical - Single U-Bend
Water Flow: Parallel
Pipe Sizes: 314- or 1-inch loops, 1 1/2--
or 2-inch headers
Bore Lengths: 176 to 225 feet/ton
Pipe Lengths: 350 to 450 feet/ton
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