WI0400147_GEO THERMAL_20100716

Permit Number WI0400147
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
207 Barvarian Way
Location Address
207 Barvarian Way
Todd
Owner
Owner Name
Kelly
Dates/Events
NC 28684
Allison
Central Files: APS_ SWP_
07/16/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville NC
Major/Minor
Minor
Region
Winston-Salem
County
Ashe
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Kelly Allison
207 Barvarian Way
Todd NC
27020
28684
Orig Issue
07/16/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
07/16/10
Expiration
07/14/10 07/16/10
Re gulated Activities
Heat Pump Injection
Outfall t-:~ _,: 1•
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Ke11 y Allison
207 Barvarian Way
Todd, NC 28684
AVA
MCi>ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
7/16/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0400147
207 Barvarian Way, Todd. NC 28684
Dear Ms. Allison:
Dee Freeman
Secretary
On 7/14/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-on Iv
geothermal 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 Title 15A Section 2C Subchapter .02i3,.and
3. The required notification form and associated maps have been completely and accurat~ly 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 ISA Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Ashe 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 t.ersramcdenr.~ov if you have any questions.
Sincerely,
~ A. p____ ~
for Debra Watts ~
cc: Winston-Salem Regional Office-APS
APS Central Files -Permit No. WI0400147
Ashe County Health Dept.
Supervisor
Yadkin Well Company-David Brown -1908 Hamptonville Rd. Hamptonville, NC 27020
Scott Bros. Heating and Air --Mike Carter -1 870 Liberty Grov~ Church Rd, Fleetwood, NC 28626
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.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Employer
Ni~hCarolina
l{Jaturatlu
Ju1. 14. 2010 8:33PM YADKIN WELL V No. 555~~ P. 2
~ -~11',J
NORTII CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM:
TYPE 5-Q W WELL{S)
In Accordance ,litb the pro'1is~ons of NCAC Title 15A: 02C.0200; please
complete this notification and mail to address on the back page (please Print or~ information).
DATE: Jr-' I~ , 20.& 'N \ oqoo14\
Well Typfl Conflrmanon: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid frolll the environment (i.e.
closed .. Jo op)?
Yes _X....:.... Continue completing this form.
No __ Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open-loop welJ injecting potable water into the aquifer} or a SQM well (closed-
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)_
List e&&h Property Owne,:-listed on property deed (if owned by a business or government agencyt state name of
entity and a representative w/authority for signature): ___.k,.....,.e_tt_7_., _,4=-..::/;c...L..½....L.....,L..D-=M~-------~
(l) Mailing Address: 20 7 /.fqe ll12 1r/c,A V~y_
City: lo j J State:JLL Zip Code: Z-:n(li ,Y County: At1./v~
Home/Office Tele No.: Cell No.: ZDl7(--Cf9-C!>.2(;__2...
E:i:nail Address: ____________ W.._e=b.:::.,sl=te.:...: ___________ _
(2) Physical Address of Well Site (if different than above): -....,...,z;;,..'-,.._-"6'2,""""'"~-"---"----=---------
City: ~-------State:_ Zip Code: _____ County: ____ _
Home/Office Tele No.: __________ ___,Ca....a.e-=-11 -=--Na...-=..o.""'"": ________ _
B. AUTHORIZED AGENT OF OWNER, lF 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 well)
CompanyName; __________________________ _
Contact Perso n..._: _____ ~----~~---'B=MA~=IL_A __ d ___ 4':_es_s_: _________ __
Address: ____________________________ _
City: --~----~ State:_ Zip Code: _____ County: ______ _
Office Tele No.: _______________ C=-cell=-=N..;..;:o~-=-------~--
Website Address of Companyl if any:. ______________ ""it~'nl~ari:,v$;;;/,!~R / DWQ
ion Section
JUL 14 2010
,, ' ' ,,,, ___ , ___________ _
Jul. 14. 2010 8:33PM YADKIN WELL I No. 5556 P. 3
s~ Qe,J
C. WELL DRILLER INFORM.A.TION
CompanyName:Yadkin Well Co. Inc.
Well Driller Contractor 1 s Name~ ~rod~y ,.6,!.M_u_Uis __ ~M=att=he:..W:.:....:!:!:.B=ro!..!.!w=n-----'M=nto!=..n ~C-1r..:::v~e -
NC Contractor Ce1tification No.: 2S72~-A--=--------=3-=-=03=--=6:.......1-A:....a........ __ --=35~4'--"'8--=--A..:...:•::....__ ________ _
Contact .Person: David J. Brown 2195-A BMAIL Address: <::hiefdrinec@l1lSll ,coro.
Address: 1908 Hamptonville Rd·-~---------~----~--~--
City: J:famptonvjlle N.C. ZipCode; 27020. ____ County: Yadkin·---~-
Offlce Tele No.: _336-468-4440 _______ CeH No.: _3:36-:374-8736 _____ _
D, HEAT PU.MP CONTRACTOR INFORMA'I'ION (if different than driller)
Compa11yName: £ o l -1-(3.A f • /-kdAy sf--&,t~
Cotrtact Person: M, 'b 1 ~ ft.Jc BMAIL Address:
Address: L,1kec.&_Gtpµf c" ~~
City: Ffra /r.J(J o ;;i Jrf.~p Code: /t Conney-: --£,-4~rh;....u&.~-------
Office Tete No.: :J:J(-?7-z,,(7 .a2 CellNo.: _______ _
E. STATUS OF APPLICANT
frittte: ;{__ Fede1'8l: Commercial:
State: Municipal: _____. Native American Lands:
F. INJECTION PROCEDURE (brjefly describe how the iqjection w-eU(s) will be used)
cf.,reJ Ls..~~ o:,,fy 1 9eJ/4,._,_(
G. WELL CONSTRUCTION DATA
(1) P,oposed date to be consiructed: f -(,Io Numbel' of boringS: _.2. _____ _
Appl'oxiroate depth of each boring (feet):__;;2.~C.....:2.oiii.-..' -~-
(2) Type of tubing to be -used (copper,. PVC~ etc): --t::/J+-<Q_.......l>. ..... ir ___ S':.......,,Q..._.....£: ...... --...... u ___ ~---
(3) Well casing. I5 the well(s} cased? (check either (a.) Yes or (b.) No below)
(a) Yes ___ if y~ then piovide easing information below
Type: _galvani~d steel _black steel __ plasfic_otber (specify)
Casing depth: From ___ to ___ feet (reference to land surface)
Casing extends to above ground ___ inches
(b) No <{
( 4) Grout Info (material sutTounding wen casing and/or piping): i,-J1t1.'f II C!,l'lh~
(a) Grouttype: NeatCement__;,_ Bent0nite~ Oth:Zecify) _____ _
(b) Orout placement: Pumpin~ Pressurs__ Other_..._
{c) Grout depth of tubing (reference ta land surface): from 3 to 2..C.. 2. (feet)
If well has casing, indicate grout depth: from ----~ to ____ (feet)
Jul. 14. 2010 8:34PM YADKIN WELL No. 5556 P. 4
~ INJECTION-RELATED EQUIPMENT
r-~.cv
Attach a diagrain. showing the engineedng layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The inanufa.~r' s brochute may provide supplementary
information.
I. LOCATlON OF WELL{S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (can be drawn) showing: buildings1 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 :fi~lds located within 200 feet of
the geothennal heat pump well system. Label all feawes clearly and include a north arrow.
(2) The Site Ma:p must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFIC.AnON
Note: This Permit Application m.nst be signed by ea.ch person appearing on the
reeo.■ded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined an.d am &miliar 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 a.re significant penalties, including the possibility of fines and imprisonmeni for submitting
false information. I agree to cons1ruct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the apf ~~~d specifications and conditions of the Pennit."
UWtzsr--~
Si&natuie of Property Owner/ Applicant
i.'l:-1 l~ 6-.. A'L,L,)SQN
Print or Type Full Name and title
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application paekaae ·to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone] RECEIVED ID
Aquifer Protec~NnRSI D~ ect,on
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Jul,14. 2010 8:33PM YADKIN WELL
FAMP&LE TRANSMISSION FORMA
NO.5556 P, 1
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MESSAGE:
-FOR ALL YOUR WATER N£CCOS"
YADKIN WELL CO., INC.
1090 HAMPTGNVt"E ROAD
F(AMPTONVILLE, NC.27020
OAV✓D J. BROWN. VICE PRIES.
TOLL FRIES 1190111�X
2a 9955
OFFICE 1336) 46p,...,-4-�-..w �^
FAX (336) 46&4659
RES 53351 d6S�6639
`GOCP NCW A.rCRIGA - 090 t0V69 YOIT
RECEIVED / DENR 1 aWQ
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