WI0400152_GEO THERMAL_20100922

Permit Number
Program Category
Ground Water
Permit Type
WI0400152 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
5010 Queen sway Road
Location Address
5010 Queensway Rd
Winston Salem
/
/
Owner
Owner Name
Glenn
Dates/Events
NC 27127
Winfree
Orig Issue App Received Draft Initiated
09/13/10
Re c::i ulated Activities
Outfall r ~1· 1
Scheduled
Issuance
Central Files: APS_ SWP_
09/22/10
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Cont.act Affiliation
Greg Carpenter
2218 Cragmore Rd
Winston Salem NC
Major/Minor
Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
·Individual
Owner Affiliation
Glenn Winfree
5010 Queensway Rd
Winston Salem NC
Public Notice Issue Effective
27107
27127
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
'AVA
MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Glenn Win.free
501.0 Queensway Road
Winston Salem, NC 27127
Coleen· H. Sullins
Director
9/22/2010
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Perm.it No. WI0400152
5010 Queensway Rd, Winston Salem, NC 27127
DearGJenn:
Dee Freeman
Secretary
On 9/13/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
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 .0213, ano
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 .021l(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.Ro2'ers(@ncdenr.£!ov if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400152
Forsyth County Health Dept. .
Sincerely,
for~l~~
Supervisor
Knight Top line Services, lnc -23 .18 Cragmore Road. Winston-Salt'ln, NC 2 7 J 07
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 I Affirmative Action Employer
NOnetl C li or 1 aro na
/Vaturaltu
Aug. 31. 2010 12:~8PM No. 7761 P. 1
2010-08-3114:29
TO:
A.
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 1 SA: 02C.0200
Complete application and mail to address on the back page.
Dis is JU!!.tbe proper form to be used for Injection wells in an open-loop geothermal system.
Pt not use this form for systems that cjrculate any s ubstances other than water,
DIRECTOR, N01TH CAROLINA DIVISION OF WATER QUALITY
DATE: '{i' 3() . 20 It)
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 Jfno, do not complete this fonn. Fonn 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 circuJating heat transfer
flujd? This incJudes, but is not limited to corrosion inhibitors and/or antifreezes.
C.
YES
NO
_ If yes, do not complete this form. Form GW~57 HP, Application For
Permit To Construct And/Or Use A We//(s) For Injection With A Heat
/.."""' System, should be completed.
_ If no, then continue completing this form.
PROPERTY OWNER
Name: G l.e n4:-lAl__l_nf;e.
Address: n« o {Qu~;;;; • 'J£R
City: Wt' 0 si1y1.-S:-a. J../'Atn State~C:.... Zip Code: --=~-2--l-2-2""------
County: I f,,cs1f" Tet~phone: $~ I, -6 q;l -¢"o ¢0
D. STATUS OF JROPERTY OWNER
Private: _£_ Federal: _ Commercial:
State: Municipal: __ Native American Lands=
Revised 1106 GW/UIC-57 CL Page 1 of 4
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Aug.31. 2610 12:58PM No.7761 P, 2
E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: Al /A
Address: I
_
City: State: Zip Code:
Telephone: Contact Person:
Standard Industrial Code(s), SIC, which describes commercial facility:
F. HEAT PU
Name:
Address:
City:
Telephone:
G. CONSTRUCTION DATA (check one)
(2 )
(3)
NOTE:
Revised 7/06
VU Zip Code:
Contact Person:
County:
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
knowledge. Attach a copy of Form GW-I (Weil Construction Record) if
/ available.
1J PROPOSED WELL(S) to be constructed for use as a ground -coupled heat pump
well(s). Provide the information in (I) through (3) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
Well Drilling Contractor's Name: GL G
NC Contractor Certification n mber:
Date to be constructed: Q 119 Number of borings:
Approximate depths of each boring (feet):__10 C) x
Well casing: Is the wells) cased?
(a) YFS - If yes, then provide the easing information below.
Type. Galvanized steel Black steel Plastic :/ Other (specify)__
Casing depth: Fromto ft- (reference to land surface)
Casing extends abov ground inches
(b) NO
Grout (grout the vertical length of the borehole to afminimum depth of 20 feet W.s.):
(a) Grout type: Cement Bentonite ✓ Other (specify)
(b) Grou ed surface and grout depth (reference to land surface):
7around closed loop piping; from to P (feet).
around well casing; from to (feet).
THE? WELL DRILi.iNG CONTitACTOR CAN SUPPLY THE DATA FOR EITHFR EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVA;LABI_E BY OTHER MEANS-
GWILIIC-57 CL
Page 2 of 4
2010-0E-31 ia:z9
Pane 2

Aug 31 2010 12:59PM No. 7761 P. 3
H. >i JECTION-RELATED EQUIPMENT
Attach s 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.
LOCATION OF WELL(5) 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 and any existing well(s) or waste disposal facilities such as septic ranks
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 interwtions).
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 Man -Discharge permits
(3) Sewage Treatment and Disposal Permits
K. CERTIFICATION
"I hereby certify, under penalty of law, that 1 have personally examined and am familiar with the
informattion 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 approved specifications and conditions of the Permit,"
Revised 7/06
(S ture of W Owner or Authorized Agent)
V
f f authorLeed agent is acting on behalf ofthe the ,veil owner,
please Supply a letter signed by the owner
authorizing the above agent.
GWIUIC-57 CL
Page 3 of 4
ZOID-08.31 14:30 Page 314

Aug. 31. 2010 12:59PM No. 776"1 P. 4
2010-08-3114:30
L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the wett 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 welJ(s)
conforms to the Well Construction Standards (Title 15A NCAC 2C .0200)
Revised 7/06
~ignature Of Property Owner If Different Prom Applicant)
Please return two copi~s 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]
GW/UJC-S7 CL Page4 of4
Page4/4
Wiu-FcEE�
6616

1010 12:58PM
No, 7761 P, 1
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 i 5A: 42C.0200
Complete application and mail to address on the back page.
This is not the proper form to be used for injection wells in an at1en-love geotber nai system.
Do not use this form for systems that circulate any substances other than water.
TO. DIRECTOR, NORTH C.aROLINA DIVISION OF WATER QUALITY
.BATE. — � 20�f�
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid From the environment?
YES t If yes, then continue completing this form.
NO If no, do not complete this fora. Form GW-57 HP, Application For
Permit To C'onsrruct AndlOr Use A &i✓'eld(s) For Injection With A Heat
Pump System, shouid be completed.
8, 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, ,AppRculion For
Permit To Construct fi ndlpr Use A Fl ell(s) For Injection With: Meat
ump System, should be completed.
NO _ If no, then continue completing this form.
C. PROPERTY OWNER r
Name: _
Address: "911 c j �
City: _i,� n i f 5tatc: �fpCode: _ o� 7 G} fir -
County: f' Cs Telephorie: ' "
D. STATUS OFF ROPERTY OWNER
Private' v Federal:
State: Municipal:
Revised 7I06 GW/UIC-57 CL
Commercial:
Native American Lands:
Page 1 of 4

Auk 31 2010 12:58PM
ND.7761 P. 2
F-
F,
G
FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federsl, State, Municipal or Commercial),
Name of Business or Facility::d --
Address:
City: _ State: Zip Code: -- County.
Telephone: Contact Person:
Standard Industrial Code(s), SIC, which describes commercial facility: �r�
HEAT PUMP CONTRACTOR DATA L � t � I I Yv—
Name:
Address:
City:
Telephone: -
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
knowledge. Attach a copy of Foram GWA (Well Construction Record) if
f available.
V PROPOSED WELVS) to be constructed for use as a ground -coupled heat pump
weli(s), Provide the information in (I) through (3) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
(1) Well Drilling Contractor's Name: n to -
NC Contractor Certification number,
Date to be constructed: 5�3� r� Number of borings: _ f
Approximate depth of each boring (feet),_ �- -- _-
(2) Well casing. Is the well(s) cased?
(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 abov, : ground _ inches
(b) NO
(3) Grout (grout the vertical length of the borehole to a rninimurn depth of 20 feet b.i.s.):
(a) Grout type: Cement 8entonite k/ Other (specify)
(b) ;.Grou ed surface and grout depth (reference to land surface):
around closed loop piping; from _ to rii� (feet).
around well casing; from t0 (feet).
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS Ii THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
Revised 7/06
GWILUIC-57 CL
,Page 2 of 4
ZOiG-00-31 14:29
Reno 7

2010 12:59PM No.1761 P. 3
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 suppiememary
information.
LOCATION OF WELLS) Attach two maps-
(1) Include a site map (can be drawn) showing: buildings, propeM 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 ]mated 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 ail 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, r 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."
* X!7)"1_2'�� -
(S ,n hwm'of WO Owner or Authorized Agent)
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
Revised 7144 GWIUIC-57 CI. page 3 of 4

,010-nA-".11 tA•~n
1010 12:59PM No. 7761 P. 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 I SA NCAC 2C .0200)
Revised 7 /06
~ignature Of Property Ownor If Different From Applicant)
Please return two copies of the completed Application package to:
UICProgram
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW /UJC-57 CL Page4of4
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