WI0400186_GEO THERMAL_20110526

Permit Number
Program Category
Ground Water
Permit Type
WI0400186 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Olian & Freda Holladay SFR
Location Address
1057 Blue Ridge Church Rd
West Jefferson NC
Owner
Owner Name
Olian D
Dates/Events
Orig Issue App Received
05/25/11 05/17/11
Re q ulated Activities
Heat Pump Injection
Outfall br.1; __ :
28694
Holladay
Scheduled
Draft Initiated Issuance
Central Files: APS_ SWP_
05/26/11
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
Wilkes
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Olian D. Holladay
2473 Acadia Ct
Kannapolis NC
Public Notice Issue Effective
05/25/11 05/25/11
27020
28083
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Olian D. Holladay
Freeda A. Holladay
24 73 Acadia Court
Kam1apolis. NC 28083
Al.rA
MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
5/26/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Pennit No. WI0400186
1057 Blue Ridge Church Road, West Jefferson, NC 28694
Dear Mr. & Mn,. Holladay:
Dee Freeman
Secretary
On 5/17/2011, 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 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
C~olirta Ac:iministrative 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 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 Wilkes County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regula6ons may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Ro!:!ers@.ncdenr.l!ov if you have any questions.
Sincerely,
forDQ~A-~
cc: Winston-Salem Regional Office -APS
APS Central Files-Pennit No. WI0400186
Wilkes County Health Dept.
Yadkin Well Co., Inc. (David Hampton)
Scott Brothers Heating &Air (Mike Carter)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh , North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Caroiina 27604·
Supervi.sor
Phone:·919-733-3221 \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-523-6748
Internet: www.ncwaterguality.org
An Equal Opportunit;' \ Affirmalive Action Employ~1r
Nonel C 1· ort 1 · aro 1.na
/Vat11rallg
May. 17, 2011 5; 20PM
No, 0213 P. 1
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DATE: -� �1 if TIME: REF, NO. LOG NO.
COMPANY NAME } TAX NO. PLEASE
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MESSAGE:
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-FOR ALL YOUR WATER NI:EDV
YADKIN WELL CO., INC.
19p9 MAMMN1IL.L11 ROAD
i-IAMPTONVILLE NC 370M
0"10 J. 6ROWlN. VICE PRGS,
TOLL FREE (OW) 2A"-155
QI7ICE (936) d 0
FAX I3961 A68+4044
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MAYI1WaY. 17. 2011:: 5:20PM Scott Brothers
Jul. V:u1nm 11MIn Vr LL
FAY No. 336 877 2359 No- 0213 Y. 27
NORM CAROLINA
aDMx ARTMRn OF lrhT MONMEXT AND NATURAL RESOURCES VCDEM
NOTMCATION Olt RUENT TO c0�T91'$X T A, CT -1LQ P GEoTMRMAx
INJEC 1ON WELL SYSTEM:
DIE L
w A Witlitlicpr4y�tdons ofN'CACTkle ].SA-. oaC-0200_ pleas-,
complete this notification and 9211 to etddress 09k [are lack Me (please = or Ze iu�d0u).
DATE: .20-210—v I[NJY� o 4 00 rg CI
We7i 2y7,r Confam i6on: Does the proposed system circlaw potAblag@ger only (no additives) i7a
continuous pTigg that completely isolates the fluid fr= tht environment Ci-e.
closed loop]?
yes CaZinue compleeng This form.
No I)o Not c=plete this fo m. Complete other MC applic. t oa f'or= for bsWing
eithet a 5A7 wall (=a -loop welt =erecting potable water inn the agnifar) or a SQtd well (closed -
loop well ooaYuiing adds suCla as R2, e��hanol, or other axrtr.eze or corrosion iubitriiors).
A. PROPERTY 4W V.R(S)IAKPLl4CAn(6)
ust eva Properly OWW lasted on. proporty deed of owned by a buszxess or gavm=u =a2ency, state name of
enftTy and a ieXesmttai ive wfauthor ty for gpaL zre): _
(1) Mani► SAddmss: ;2 y 7
cam: ANO- L stM: 1LL-MP Code: 260A R
HaazeJQ f&ca Te : Nv__-.S� Cell No_: 70_q
L� yy
(2) Pbysic;1 Address of *all site (if & fc=af tL u shove): 0 27
City, 8tetc• -AJGip Cads• _� 5L'2/ unxy:
Ho=/Ofrice Tale ?►io.: Ccll No.=
R, A-II=4=E1) AGENT OF 4WffM EF ANY (iflhe Nezn3it Applioaut does hoi qWn the sect property,
eUMb s letter from the property ow= =hmixing Agent to iasd and opemle UTC well)
Company Name: ---
Comma Person: Addrb
AMMS:
C*" Stata^ Zip CocL:;
tifiace Vale No.- Ca11 Tin.
Wobske Address of Company, ix am - -

MAY/1'Way, 17, 24111. 5.241"Nf Scott Brothers PAX No. 336 877 2359 No. a213 IP. 3
JP 1, 1, . 2010 9.101 AM YAJU N Wt �L N o. �� i j r, �
1 S� Q P
C, WELL DMM DMORMATIOx
Cornpa w Name :-YAdaA_ 04
W llUrxliSs C# tectar'� esaa: lady ulHs t tt�e�v$rowt- M_ ftp i:ay's _
NC Contraeiar C=- floatiMW0.: Z7 -A ID36-A _ 3$A . a
Genteel Pelso D 3 1 : �E r er rhea. Ir
Address: 194$ ptat�apta�+r�"!lc � � �'
City: i 7bp Code: 27020 Coursty: Yadkin — n
O-facaTele.No:: 336-468-4440 Cali'No.;, 36-374 735
D, VK&T PUMP COMUCTOR Ewe ORK4,276N (if I?iln drltiier)
C+rnajpe�yNar tt,, el. &`x % n
eoAhLt P8L9 i 6C i �y Cat ► e r� e e b yr e n C C7 -
Addl us: 1876 C-*+au C
Chy: lerr 23p Code: 6 Camp; s �— ---
Office Te1Na.: 6F � $77"L 7! � CO'UNO.: 3G ?7-e /Z Z-
9. STATUS OP AYMCA►NT
Privartc -% Fens 41. commeroi& :
Sia±e M=iaipel: NativeA=alcamLandm
�. SI�T�CTrvx FRDC�37 ( [l'ri6�Iy dee�ik� how the !Wectioa veli(s) will be eased') _[
Q W3z7i.T.00NMrJCT10xD1kT1k
W 13roposed date to be cau=dad; _ � � � ` j I Number of b cu it ss; �
Approximate depth of each bor1ng (l=t): a 50 _
(2) Type of tubingto b;. vo-d (copper, PVC, eta); + 1y, . E S1 �, 41- an. -
(5) WeU erg. is the w90) rased? (check either (a.) Yes g: (b) No bel*
(1) 1"as ?Dyes, Neil provide fi#4i�g �}'ormat3�alye]Gw
Type:—PivanIzad steed black steet,_p.�, io Mhar {Opool*)
Casing depib: Pxoz;a to ibtt (raf`atEr+Oe tv farad s�8)
CHIOS extends to Shove groLmd #Gbes
Cb) No V
(4) 0root in fo Cmatrial =roanding well cni�g and/or piping); r4
(a) Grouttype: Feat Camwe $entanite;�_ _ 01ber 4@w
{b) 4rant Meat P=P Fressa— 04t►O� - - -
{e) #°oat 7r tv - _ (tat)
If wets has rising, i.adlwa groat depth: from to m")

MAC'/lVay, 17. 2011: 9:20PM Scott Brothers FAX k 336 877 2359 No. 0213 FP. 4
dui. 1. LUIU 7.HInir1 1PIV(►1iY nul.L rrv, JJiJ T
�. I�iT�ECTiON ItIE�A'TEri EQ�1V��i'p � ~ � {.0
Attach a dzagtm sha wing the m4zeolDa ayoac or propmod moaaficzioa of the i4ection equipment and exterior
pipingftbkg associated with the inj ectf oa opaxat?oai.. 'Ile manufacturer's brorhwe may provide supplementary
I. WCATION Ok WELL(S)
Attach two copies of maps Showing the foumvirg inf-bi at[os:
(1) Iacl-ad: a Site Map (can be drawn) showing: buildings, propM Dimes, swftce watea boches; pab n*1
sources ofgr=dwater canumWrtim and the orismtatim oaf and dimftres betwum &e proposed we1l(e) and
any exiAiAg wel(s) or waste disposal fa,cl-lities svch as septic tanks or draiA Uds Iooated within 200 feet of
the geougrzal heat rum well sysi m. Label all features clearly and iw-hide a north arrow.
(2) 'i'be Site Map nl= shove the Subject pseperty in rcMoa to die surrovndiag area by Using at least two ft=d
reference poiz z stuh as roads, screams, andlor Egh ay bdersecdons.
S. CZRTMCAkTION
Note: ViIs Permit A-PpUcatlan mast be Vipea by t2qh pisrmon appearing em the
recorded lepl property deed.
"I bxeby certify, =der pn4ty o.f law, that I have panoaaliy exam aed and am familiar with, tho informatou
submitted is Us -documeat and all atrachztianu thereto tom. thA based ou my iuq*y of those iadividmIs
ir=efttcly respowble for ohtabiiag said inforsnatim I bdicvo that tic iIIfm =tion is try ao=ate and complete,
I am aware that there are sixi8aant penalties, iuolu&ug the passibility of fines and imprisoamezt. for mtmitsng
SIsa Iolbr-ruBon. I agme to construct; operate, nmiaWn, xepaL, oAd if appUmble, abandazLTbe�injectiazl well and
all xetaW apptuta =A* is acaordenae with the approved speoi fio tions and oond_itions of the permit.'
sign�ruce ofptopsxtyownea'IAppli t
Primd or Type FuU Name and title
mature of Pr O ``llorlApp 'cant
pant or Type Fill Nome azdtitls
SLWtuze of Authorized Ageat, ff any
Pit or Tie pull Name and title
Please xa=two copies of the completed Apple catim package to:
Nor tls CaxoUa DFNR DWQ
Aquifer Protection Secular-UIC Progrmn
16361%UJI Se vice Center
eta, NC 27699-1636
Telephone [phone]
P;Q
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May, 13, 2011 5 ; 21?M
No, 0213 P, 5
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