WI0400155_GEO THERMAL_20101022

Permit Number
Program Category
Ground Water
Permit Type
WI0400155 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
2625 Belwick Drive
Location Address
2625 Belwick Dr
Winston Salem
Owner
Owner Name
Alan
Dates/Events
NC 27106
Cronk
Orig Issue
10/22/10
App Received Draft Initiated
10/18/10
Reg ulated Activities
Heat Pump Injection
Outfall '\:Ut -~.
Scheduled
Issuance
Central Files: APS_ SWP_
10/22/10
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
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Afflllatlon
Alan Cronk
2625 Belwick Dr
Winston Salem
Public Notice Issue
10/22/10
NC
Effective
10/22/10
27020
27106
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
4.VA
MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Alan Cronk
Jotinden Sekhon
2625 Belwick Drive
Winston-Salem, NC 27106
Coleen H. Sullins
Director
10/22/2010
Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System
Pennit No. WI0400155
2625 Belwick Drive, Winston-Saleni, NC 27106
Dear Alan & Jotinden:
Dee Freeman
Secretary
On 10/18/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onlv
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 ge9thermal 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, and
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 oftl:i.e North Carolina Well Construction Act and North Carolina
Administrative Code Title ISA Section 2C Subchapter .0211(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 Micbael.Ro gers(a.mcdenr.QOV if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400155
Forsyth County HeaJth Dept.
Sincerely,
()~ A.~
·.tor Debra Watts ~
Supervisor
Yadkin Well Co (David Brown) 1908 Hamptonville Rd, Hamptonville, NC 27020
Blaze Air (Johnny Armstrong) 2406 Farrington Point Drive, Winston-Salem, NC 27107
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
None C 1. of.th aroma
;Naturallu
Oti5. 2010 5.,52PM VADKIN WELL --- ----- t, No. b132
P. 3 r -�
C. WELL jj1!)F,T,li3t INll+4MAI" ON
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Weil Drllier Goatraerm's Name: r4adv Mjillfr Mattha�r Eravrn 11Rlft4tt Cava
XC Co►Ytractor [:cr0cattonNo.: 2.4T7^A
Contacl Pisan: _D& di L Bmwa 4995-A _ EMAIL Addm!.-.:_.
Address: 19o8 Hatnptanvllle Rd. _ _ ._ _ _ -
City: 11amptonville Tip Coda 27020Cmmty: Yg&bk- ._
Mets TeleNoz 336-4694440 Cell No.: 336-3744M6
D. 7=Tpumr
Clampeny Nam
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(if dif%reat than doll)
ConiacC Persa : rs . ' rd+K _�d�`.
Address-
City: ,`�+ �►� - ►�+ Zip Ccde: �—) Co[ul r.
officeTeieNo,: 33 � -n3 L CeilND.(
M. STATUS of APPIJCANp
PAvat Federal: Ca► rciaE;
state: Mnait pnl: Native Amadcon bads:
F.
Me
INJECTION PROCI 31ME (hdclly &mribo hmv the injection wel)(s) will be used)
WML C*rRMWCT10WD.&TX
(1) Pfopased date to 5e cpnstructed, 20/0 Bummer of tmr;W
Approximaia depth of each borlug (fiw)' ' f
(�) Type aftuUang to $a t�scd (coppor, p�C, ttaj: I� � � 't�
(3) Well casing. Is the wells) mst& {check Q1mr (a) lies jr- (6.)15o below)
ta) Yes i£yes, then provide caAag h0brmstion below
Type. _,_ _Zalvwr =d steel bleak atael piasda outer (speol£y)
C`a ng dsplh: Prom to Feat (reforonoD to land swfim)
Casing extends to above ground Inches
(b) No, _k
(4) Gmut lofo (muatedai su munding wall casfmgenWo r plping3- r � e'ti � �•, ca.
(a) Cmat type: New ammo- Hentonite --L—T other (pzoify)
(b) Grcnt p}ammnt: PnmP*,k— Pressure Other
(c) Gsoutdepth oftuWpg (wfemnce too Ind surthoe): fmm _&Q to 3 Umo
1twcli has casing indicate grout depth. Srm to Cam)
t }^.GBH

Oct.15. 2010 5.53PM r YADKIN WELL .
R.
Attach a diagram sbmying fhe engY c=ing layout or proposed moMcauon of the injection aquilv=t sad c aerior "
piping/tubing i mclaW with 11ua injection opwation. The m nu&cttr;es br-ochm may pmida supplemontari r•1._
iz�au-�n�slFan. x .
X LOCATION OF W)ML(S)
Attad two copies ofmaps showing the following informatiow.
(1) behule a Site M2p (can be darn) shoving: b►uldings, property hues, surihce water bodies; putendq •: `...•;
sources of prouadmW coramenation and the orieyrtatlon of amd distances bet►s►m1he proposed tveii(s) rpi {r ,
any cdst!Ag well(s) or waste disposal facilities such as septic mWm or drain #bids located within 200 bw 4f
Doe geothermal heat pump well systom. Label an ftiures clearly and iaclu a aharro,Z
(2) The Site Map most show the subject propmfty in relation to the surrouadwi g area by rising at least.
rc Sena points such as ems, streams, andlor b% ivay inten wdovs.
X C. &ATMCATION fi
Note: This Permit Application must ht signed by eI!Sk person appearing outhe -
record ed legal pk opeity deed,
"I hereby certify, under penalltiy of law, drat I have personally examined and am Ame ar with So in*wmfign
subrmaitted in this docurneat and all etfaafmments thereto and that, based on nW inquiry- of those individnali
h=cdiately responsible for ohtaiamg said iart'oxrnation. I belleve that the Waruation is tee e, acovrate and oomploi;.
I am aware that Owe are significant pe=Wes, including the possibility of fleas. and imprisommnt, for aubmitlfng. , - ! • s.
false inf oration. I Woe to corLSbm4 oporztae, maintain, repair, ind if applicable, abandon the injection ►Yell aj� `y r '
all related appwoana ices in aocordanas witht%r: a d spy esF yqm and condikiow of the Permit-.. }'=
e- ❑tL _.
RdA or Type Pull Name and title
Sig tore Wroperty OwnedApplicaat -
Print or Type PVll Name and title
Sipature ofAuthmizedAgent,, ifany
Print or Typo Foli Nam and title
Please return two copies ofthe completed Applksli=package to:
North Carolina IDM JDWQ
AgvNer Pretectfon Secttian-U,IC Program
1636 Mail Service Center
R21dzb, NC 27699-1636
Telephone [phone]

Oct, 15, 2010 5:53RM YADKIN WELL No. 6132 F, 5
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Oct,15, 2010 5:52PM YADKIN WELL
No. b 132 P. i
FACWLE TRNWWON FORM
DATE: �� �� TnME: U NO.
TO:
LOG NO.
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COMPANY NEE
FAX NO,
PLEASE
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❑ F9u�lME TELY
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FROM: � kr eW C .
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COMPA RAME
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FAX NO.
PLEASE
❑ REPy
INDMDUAL
DEPt
NUMBER 4F PAGES ,�
INCLUDING THIS SHEET
pI me
REPLY BY
ORlGINATUR'S
Si AMRE
MESSAGE:
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VgAL
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-POR ALL YowA WATCR NEEO5-
YADKIN WELL CO.. INC.
1908 NAMP'TONVILL,E RGAA
HAMPTONVILLIZ. NC 27020
DAVID J. BROWN. VICE PRES.
TALL FREE IWO, x-W8:155
OFPiCS 1338, 4 4Ea.444
- FAX 1338) 4a&4046
RIZ$ (3361 Aoa-A55B
-GOOD NEWS AnlRrCA - aoo 1.0 s% roar
PLEASE INFORM LIS IMMEDV= IPN0V D0 NW RECBIE FAC9iAIUL91N FULL

4'0---0015, 2010' 5:52PM ­YADKIN WELL `4 `'• No. 6132 P. 2 `� A
14ORTH CAROUNA
DBPARIMENT OF 04VMGNMENT AND NAMR.AL RESOURCES (MCD3WR)
NOTII,'ICATION OFINTENT TO CONSTRUCT A f"SED-J-00P GFO7EWItMAL
WATER -ONLY INJECHOW WELL SYSTEM:
;TYPE 5—!2W WELLfS)
1n Acoordauce w" dre pmisig= of NCAC rtlr� 15A: 02C.0700. pkL-;e
compkw this aphfic tloa aid ux3A to address on Lbt back page (pkam kid or Pwe idormadw).
DAM LQ- Is J 20JQ- V�T 0Lf M 155
Wdi Type C'a►{firm�ti�r2: Does the proposed systcrn r.'srculata patabla ?watcz asxly (ao addeH es) in
oondnuous piping that completely isolates the fluid from the enVhWM t (f.e.
closed -loon]?
Yes X_ Continoe aorapleri )g this form.
No Do Not complete this farm CwWlete other UIC application farms fbr iw alling
either a 5A7 well totsen loop wall Ong potable water into the aquifer) or a SQM well (closed -
loop well containing Additives such as R-22, ethanol, or other antifreeze or corrosion lnhlbitors).
�. PROPERTY OWNER(S)IAFPLICANT(S)
List Mcb Prop" 0woer fisted on pMmty deed (if owned by a buusia= or govermnent agues , ramo of
entity and a representative %Ylsut'barity for sigpature): A1A N- L YU Mk 2L r ._rt .ti , dui J-C-IOA
(1) MailiugAddsress: &-1L1UPC ve
City; � r.;30er-li LkA-% State: N 67Sp Code r County: w's
HornelOf ce TelleNo.;
^;;��
Email Address:��f,-) W3'?LZYMAJWahsfte:
(2) 1PbYsical Address of Well Site (if different than above);
City: - — State: Zip Coder county:
Home; Qfficc Tele No.: Cell No.:
S� AUTNORIZED AGENT OF OVMR, IF ANY (i€ the l'erwltApplican t does # own the subject property,
aMch a letter from the property owner andhorlaiug AgeTA to install and operate UIC ,ytil)
Compemy Na=: _ - —
Coutact Parson- I�MAJL Address!
Address_
State: Zip coda; County; —
Office Tile No.: Cali No.:
Website Address of Company, if any: