WI0400151_GEO THERMAL_20100910

Permit Number WI0400151
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
mich_ael. rogers
Coastal SW Rule
Permitted Flow
Facilitv ·
Facility Name
388 Beverly Heights Avenue
Location Address
388 Beverly Heights Ave
Boone NC
Owner
Owner Name
Scott
Dates/Events
28607
Warren
Orig Issue
09/10/10
App Received Draft Initiated
09/08/10
Re g ulated Activities
Heat Pump Injection
Outfall Ml H -~
Scheduled
Issuance
Central Files: APS_ SWP_
09/10/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville
Major/Minor
Minor
NC
Region
Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Scott Warren
4 77 Mountain Springs
Sugar Grove
Public Notice Issue
09/10/10
NC
Effective
09/10/10
27020
28679
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NCDENR
North Carolina department of Environment and Natural Resources
Division of Water Duality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
9 10/2010
Scott Warren
477 Mountain. Springs
Sugar Grove, NC 28679
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400151
388 Beverly Heights Avenue, Boone, NC 28607
Dear Mr. Warren:
Dee Freeman
Secretary
On 91812010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
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,
The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code 'Title 15A Section 2C Subchapter .0213, and
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 ❑hell Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Watauga County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations tray result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Micbael,Rouerslsancdenr.gov if you have any questions.
Sincerely,
0,
for Debra Watt,
Supervisor
cc-. Winston-Salem Regional Office - APS
APS Central Files - Permit No. W 104i10151
Watauga County Health Dept.
Yadkin Well Co -- David Brown
Mounrairieer Heating & Cooling — Winston Petrey
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Raley h. North Carolina 27699.1636
Location: 2728 Capital Boulevard, Raiegb. North Carcilna 276N
Phone: [phone] I FAX 1: 919.715-0588, FAX 2: 919-715.6D48 I Customer Service: 1-877-623-6748
Internet: www.nmateroualitv.ora
rs'
One
NorthCarohna
An Equal ❑ppWunity 1 Affirmative Aerlan Employer

sea, $. 2010" 2; 34P► "' YADKIN WELL•L
No.5902" P. 2
NORTH CAS OLWA
DEPARTbUVT QP BI+MONV1 AND NATURAL RESOURCES (L+iCT31r a)
NOTMCAnON OF DMM TO CQNSMUC r A CLg§&U= GE0MRMAL
WATERONLX INJEMON WELL SYST'M
YP`E 5 4� ran
M
In Accordance Nvith the pro%isfow OfNCAC Tit7,e 16A; 02C.024D, pleaw �
complete thas uotiffcadan sad mml to address on to beat~ page (pkasa btg or T"'P-e �)A�
W4d14p* Coajirmatiola: Dori the pt; osed sys tam circ We potable 3w&% %al (ao additives)-k
=ndnuous piping that completely isolates the fluid fi= the wvkonn=1 (1.0-
dosed-1 7
Yes cantin= completins Itill fot' L
NO Dd Not oomplete thb fnM CoMpiet■ other THC applicadtut forms fee UWM IUS
either a 5A7 well (o,-loop well luting potable vrater iarcea the aquifer) or a 5QM well (dosed -
loop well eow istisag additiva, such as R-2.2, at amol, at other artifreeze or corrosion inhibitors).
A PROPERTY QWNZR(SjIAPP'LXCA-NT(l)
List tlgh Property Ow= liswd on pmperty deed (if awned by a bwiu>=s ar govraumeni agency, stare of
entity and a regrew trtiwrr wlavtlxn for signature): MO fir'" P) w - — --
(I] 94ing Address; , -g!77 Ad0►4,JJ .?f"-T s,-
City.. '�
llama! JECO Tela'1o.: &a •70 Ie3 3 £ Cell No.: P] 7 fit' I F ,
Email A.d&z3a61-'-9-A-"i V7'0•trk W
(Z] physical ,Add s of Well Site (1f dsfffMi 1b&U aN rM)a 3.56 / -A
City: ►d ca..+� S=: Art dip Coda; 7SCG'7 —county: GAB}�i•Y�
Howivo Qcd Tale No.: -01-t 9 3 S.
B. .A'[Tfi'HUi MI) AGENT Of OWNZU,» ANT (if the PerrmitApphoW ¢.M ow,a the AZject property,
attgtb a iatw fr= the property ownar wWwdt5* Agoset to kutzU and opm to UIC waW
Company Name:
Contact Parsaa� 4dkP-s -'
Address:
city; __ State: Zip Coda: Catttltyy:
QlEce Tele No-: o
Website A,ddarms of Coatpany, if d3tasy;
01-05-2010 16:35
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Sep. 8. 20I0' 2:35PM"' YADKIN WELL"
No.5902" P. 3
C. WF L ))RIS,LZR I190RXAT10N
Congmny Namc_Y46j V� C
Welt p1mar CsanmWmr's Nam, , My Hub, Ngthaw Onwa Milmn Cate
NC Ccmtraccor Cartifiration No.: 2572� 9^ _ 354 -
Coutact pmon� Srowa *Z[qS'-A R.. 15M 1�Address� (1Le-Qril1ao, mmcoza
CZ) -
Address: I908 H&mPWQ M8 Rd- r
City: "e2mja�+ lc NZ Zip Codas 27NO Cvr AV; Yadl£' -O
sae Tele No.: �336-46U 4140 Call No _336-374-8736 '5
s
-. 1ZA,T I' W CONTRACTOR WORMAVON (j (differegt t)ma dr ier) r
Contact demon; t,/& SLPN - '�! Y _ -. MAJJ Address;t� y od•,iG..�eri �'h
City: _ Zip Code: 'e-o' City: e.iy10-x'o --
Office Tale No- eV�4 lG ,4 Cell No,: 22S I'CY s' 0
L STATUS OF APPLICANT
privm -k Fsdell• Conr=cial-
state munwpal: Native ,American Lmdg:
F. MSECPIiON PROCEDURE/j{#ui� deunbe how the Mac -torn well(s) w1U be used)1.11
C. WELL CONSTRUCTION DATA
(l) Pxuposed dare to tze con�:�e�� .� r o Nvanber of boxiz<gs: �
Approximate deptb- of e=h horlag (feet): eZ ��,(�•n �j �y
(21 � Type of tub'mj to be itsed (coppn, I'VC, etc):
(3) Well Casing- b the well(s) mud? (chWt ether (a.) XvG 2E (b ) No below)
(a) Yes ifym then Pmvide miens Worm3trcm below
Type: ___plyanized steel black stoe3__plan iv oar (specify)
owing depth From to fW (rekrouve to land svQfaea)
Casing vxtetrd8 to above g:=4 incT s
(a) orcvt iao (mamta s=ormftg wan =&s =&or piping), ,1 � ,.���
(s) Qro A type: Nest Cemeut Scntaurte A Zr (spec fy)
(b) Crent phrcmeat: Fumg _ pie Other
(c) Grout depth of t44 (refamnes to land =face): f m UO to � � Owo
If WOU hay rising indicate grout depth: fmm m 0m)
01-05-2017 16:35 PAGES
2BV�d 2T :21 0102-80-60

— 'Sep, $, 201011 2,35PPI'll' YADKIN WELL'Ll No. 5942"a P. 4
L LOCATION 4P WELL($)
AUa0b two c*es of MMP showiAg tho IbHow=S %formation:
(1) rnclade a give map (cm be dravaO mowing: buildings, property lines, gw&ce water bodies, poleatial sources
of gro=dwrw conuadvetion and tlty aricaardon of aW disfamm ba woon the proposed w0s) anA any
mcisdog weUQ;) or waster dispersal ftWex sum as septic wuh or draiz ids lowed within 1004 foes of the
Ste" l heat pump well system Label aall fames cl=ly and
(2) belade a t%jogsaphfc map ofthe am Weaft OM mile ftm the property W=dwiw and
bidicm the f Hity's locsAon and the map .
J. POTAELS WAX'KW=M)
Ara there MY Ppaebla wau r weXA) an the eUb, jeor p aperty err a =92 properties? Yhf9 No
IfXoe, than indicate locetiam on atlRafY--d map(s).
K. CEPJMCATION
Note. Thfa NrmJt Appllestrae mast be signed by aaeh person appearing on the rbcarded legal propoM deed.
"I hereby certify. =der penalty of law, that I have parsano®l3y camIned Md am &mMar w[th tba infarmal"
ssftm ed is' this docurmtut gad ell warb+aaents thane and tb2r, based on my inquiry of ftm individuals
irnm dmmly rosp=nble for Qbftftihag said infmzadon, I believe that the infx=tiona is sae, acmift and complete.
I am aware that gene are sigd6cmt peas des, facluft the poWbiifty of $nas aad i M=m, fnr nbmltd%
false fnfaxmmon. I agm to cauxwactC operate, maintaim repair, and if applicable, abaudon the irtjocdon well gad
all. slated agpmtenmaoes in wor&we with the approved;pegff inti ms and conditions of the Permit"
53�attae of Pro QwaaalAppliCmt
W' ��►h Cd � 4 rr
Print or Trpa Fua l,Ieoue
a Signature ofPrcrp8* awWiAppilcant
-t Phut or Type Full Namr3
- c�a
`~ Sigw"a of A►sf dzad AgaA if my
. Prim or Type Full Namt
Pjez5e xn un two copies of the cotaplotod AppUcmdaa paclMe to:
Now Carolina DVM DWQ
Aquifer Protecdon Section
U1C Program
1W Nail service Center
Rakish, NC 7,76"-1636
Telephone (919� 713-6935
01-05-afte 16=35
PAGE4
t,39bd 2T I£T OT02-80-60

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Sep. 8. 2010 2:34PM YADKIN WELL
FACSIMILE TRN MMON FORM
No.5902 P. I
GATE: TIME: _ REF NO. LOG NO.
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FROM:
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COMPANYlNAME FAX Nil PLEASE
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NUMBER OF PAGES + PLEASE DWGINATaR S
INCLUDING TH15 SHEET _ RFRY 3Y $1GHAiE1RE
MESSAGE:
._ _�:�� _._�x�--? � �- ems, a�--� GC7�r►r�'e�►
-FOR ALL YOUR WATER NEEDS-
YADKIN WELL CO., INC.
19M HAMPTQNVILLE ROAD
HAM070NVILLE- NC Z7020
❑AV IO j BROWr1, VICE PRES.
TOLL FREE MCC) 245:935S
OFFICE [phone]
FAX [33C 468.4048
RE5 e3391 468.4659
-prep µFWS AUJCA . GOD LCWU YOV-
PLEASE WFORH US MWEDATnY IF )DU DO NOTRERPME FAQ%tlLE IN RJLL