WI0400169_GEO THERMAL_20110106

Permit Number
Program Category
Ground Water
Permit Type
WI0400169
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Little Creek Recreation Center
Location Address
610 Foxcroft Dr
Winston Salem
Owner
Owner Name
City of Winston-Salem
Dates/Events
NC 27103
Orig Issue
01/06/11
App Received Draft Initiated
12/08/10
Regulated Activities
Heat Pump Injection
Outfall 1\1!.IL! .
Scheduled
Issuance
Central Files: APS_ SWP_
01/06/11
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
·Forsyth
Facility Contact Affiliation
Owner Type
Government -Municipal
Owner Affiliation
Lindsey Smith .
Dept Facility Mgmt
101 N Main St
Winston Salem NC 27101
Public Notice Issue
01/06/11
Effective
01/06/11
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
,4;;l\
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Lindsey Smith
City of Winston-Salem
101 North Main St.
Winston-Salem, NC 27101
Coleen H. Sullins
Director
01/07/2010
Subject: Acknowledgement oflntent to Construct Type SQW Injection Well System
Permit No. WI0400169
Little Creek Recreation Center
610 Foxcroft Dr.
Winston-Salem, NC 27103
Dear Ms. Smith:
Dee Freeman
Secretary
On 12/08/2010, the Aquifer Protection• Section (APS) received notification of your intent to construct a-closed-loop water-onl y
geothermal injection well system for the operation of a ground-source heat pump lo.cated 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 accqrdance 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 aU of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title ISA Section 2C Subchapter .02ll(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.Ro 2:ers Ca1ncdenr.!!ov if r,have any questions.
si J())tt-i.>&-1 0_Q
'-{,}Debn©tts
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400169
Forsyth County Health Dept.
Supervisor
Bruce Whitney (EMCOR Group, Inc., 11521 Reames Rd., Ste. 103, Charlotte, NC 28269)
AQUIFER PROT~CTION 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 Equ2! Opportunity Affirmative Action Employer
NCZ:rth Carolina
J\7aturall!f
. 11
dDqwl�oq
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 5¢W Wells
1n Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and maul to address on the back page.
This is not the proper form to he used for injection wells in an open -loop geothermal system.
Do not use this form for systems that circulate anN- substances other than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: 1 i -� -_, 20_L�->
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely ' ates the fluid from the environment?
YES If yes, then continue completing this form.
NO If no, do not complete this form. Form GW-57 HP, Application For
Permit To Construct AndlOr Use A Well(s) For Injection With A Heat
Pump System, should be completed.
H. 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, Application For
Permit To Construct AndlOr Use A Well(s) For Injection With A Hear
Pump System, should be completed.
NO �If no, then continue completing this form.
C. PROPERTY OWNER
Name: �` . ti "- ►Q.� 1.�� i >nr� M
Address: L 0 k f1Qr-A-k�, CY �►n� rt �t—
City: State: QZip Code•
County:Telephone:
D. STATUS OF PROPERTY OWNER
Private: Federal: Commercial:
State: Municipal: Native American Lands:
Revised 7/06 GW/UiC-57 CL Page l of4

E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility:
Address: k n % -� _e—
City: state: rn 'LZip Code: ,--b p -j County:
Telephone: ? lan -- lrc7,lo41' Contact Person: L..� n e-4
Standard Industrial Code(s), SIC, which describes commercial facility: I ``
F.
G.
HEAT PUMP CONTRACTOR DATA
Name:
Address:
city: _C,�
Telephone:
I
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 Form GW-1 (Well Construction Record) if
available.
PROPOSED WELL(S) to be constructed for use as a ground -coupled heat pump
well(s). Provide the information in (1) through (3) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
(1) Well Drilling Contractor's Name: AXi,10 ;-•'� - ' a r1 j y
NC Contractor Certification number:
Date to be constructed: llw'� �r ► l� Number of borings:
(2)
(3)
NOTE:
Approximate depth of each boring (feet):
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 lane} surface)
Casing extende ground inches
(b) NO
Grout (grout the vertical length of the borehole to a minimum depth of 2 feet b.l.s. :
(a) Grout type: Cement Bentonite Other pacify)
(b) Grouted surface and grout depth (reference to land surface); is
1I around closed loop piping; from to' aO (feet).
around well casing; from to (feet),
THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR ErrVER )E)USnNG OR
PROPOSED WELLS IF THIS INFORMATION I5 UNAVALLA13LE BY OTHER MEANS.
Revised 7106 GWIi11C-57 CL Page 2 of

K INJ EC-FIO N-RELATED EQUI PIVIf:NT
Attach a diagram showing the engineering layout of the injection equipment and exterior pipingftubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
LOCATION OF WELL.(S) Attach t" maps.
(1) Include a site map (can be dmwn) showing: buildings, property lines surface water bodies,
poternial sources of groundwater contamination And the orientation of and distances between
the proposed wells) and any existing weli(s) or waste disposal facilities such as septic tanks
or drain fields boated within 200 feet of the ground-couplod hqt 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).
PM- MIT LIST: Attach a list of all permits or construction approvals that arse related to the site.
Examples include:
(1) Ha7ardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non -Discharge permits
(3) Sewage Treatment and Disposal Permits
K. URTIFICA'T'ION
"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 resporisible 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. absndan the ground -source heat pump system and all related appurtenances in
accordance with the approved specifications and conditions of the Permit."
(Signature of 1ltrell Ovme a Autizarizze?d Agent)
If authorized agent is acting on beha y-af the well owner,
please supply a letter signed by the owner
authorizing the above agent.
Revised 7106 GW-VIC-57 CL Page 3 of 4

L CONSENT OF PROPERTY OWNER (O►tinur means any person who holds the fee or other Property
rights in the well being constructed. A wctl is real psaperty and its construction on lard rests
ca►►nership in the landowner in the Absence of contrary agreement in writing.)
If the property is owned by somcorie otherthan the applicant, the prop"oAmer hereiny consents to
ally■+ 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 purnp system's.vell(s)
conforms to the Well Constniction Standards (Title i SA NCAC 2C .0200)
r `.. (Signature OQV rry Owner If Differern From Applicant)
~� Please return two copies of the completed Application package to:
UIC Program
Aquifer Protection Section
North Carolina DENR-UWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Rc isrd TiG6 G%V UC-57 C1. Pao of.4:

UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Dear Sir:
tfu
\\mstonlillem
P.O. Box 2511
Winston-Salem, NC 27102
December 1, 2010
This letter is attached to the permit for the well to be installed on the City of Winston-Salem's
property at 610 Foxcroft Drive, Winston-Salem, NC 27103 in Forsyth County. The City owns and
operates the "Little Creek Recreation Center;' which is constructed on this approximately 15 acre
property. This well is being dug as a test well for the future installation of a ground source heat pump
to be installed in the recreation center.
I am an engineer in the City of Winston-Salem's Facility Management Department and authorize this
well to be installed on this property.
Sincerely, ,
,-x~· I /':} {' .,-/
1----,.A/J--~;1) l,X-,,fj?J-a;-, ._/
Lindsey A. Smith
Facility Management Department.
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Taxable Owners - M: 6994-65.2405 00
Lost Nance or Company Feat Middle Suffix Suffix 2 Dead Dab Dead Book Deed Pays
Crty Of Mnstw 52 a- 11)2Qri9B0 .` '7Tv"
Cep -rear Owners - PIN. 6804-65-2405.f10
L.aat None or Company First Middb Suffix Suffix 2 Deed Date Dead Book Dead Pays
City DF Winston Salem 1i12€ INS 1615 1776
_ ® 6804-65-2405.00 - City Of Winston Salem
61,0 Foxcroft DR
68"-2405.00
Zoom Tq Parcel
iviir*�2
Tax 8111inin -form-atbn
lPropert]' images
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IProperty Address-
a6 FoxcrolE DR
181ock Lot
.3904 303E
lAddkional Lots
--
r
�Tax Jurisdiction
Vinston-Salem
, axabie Owner Names
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City Of Winston Salem
;Taxable awner Name2
PTaxablle Owner List
_
View All Owners
•Tsxabie Owner Address
PP6 Box 251i
Taxable Owner City St Zip [Winston-Salem, NC 27142
Taxable Deed Bit-ag
11615r1776 v� --
,Taxable Deed Date
;71120f1� W
'Taxable Deed Stamps
;Current Owner Namel
IC4 Of Winston Salem
T
'-Cwent Corner Name2
Cvrrerrt Owner Address
PO $ax 2511
lCurrent Owner City 5t lip Wm onSalem, NC 271D2�
I1a16-1778
Current Deed Bic P9
icurrent Deed Date
1112WIM

- - Drill Well
- Here ti !1
t
' 1
North Little Creek Recreation Center
610 Foxcroft Drive
Winston-Salem, NC 27103
(awned by: City of Winston-Salem)
SM-
�0

Cry- ction.nl view of Th7e Thermacouple' Earth ]Energy System
Input flow of
Aqueous -Based
r
T-1. into inner Flow
Channel
HeaderMistributor
111r h Swivel Flange
er Tube
Flange Fitting
1hermally
Enhanced
Grout
Thorn -milt'
Cenduc ivc a
Outer Tube
Turbulent. Flow af -_
Aqueous -Based
Fluid along the
Outer Flew
Channel Breaks up_ �
Boundary Layers
Along the inside
Surface of the
0104+ r 1111 -
Earth Surface -
h
■ inches
Output Flow of
,Aqueeuii�Based
Fluid at
Tempel attire T2
Flange Belt
Flange Gasket
Helically Extending
_ Turbulence
Generating Fin
309 Feet
Inner Tube
'Transition from
Laminar flew
occurs at the
Outer Tube
End #-' JI)