WI0400194_GEO THERMAL_20110622

Permit Number
Program Category
Ground Water
Permit Type
WI0400194 I Central Files: APS_ SWP_
06/22/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (5QW)
Version
1.00
Permit Classification
Individual
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Jim Berry SFR
Location Address
2548 Woodberry Dr
Winston Salem
Owner
Owner Name
Jim
Dates/Events
NC 27106
Miller
Orig Issue
06/22/11
App Received Draft Initiated
06/20/11
Re g ulated Activities
Heat Pump Injection
Outfall r.i
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Jim Miller
2548 Woodberry Dr
Winston Salem
Public Notice Issue
06/22/11
NC
Effective
06/22/11
27106
Expiration
Stream Index Number Current Class Subbasin
P A
CD E
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governo r
Jim Berry
~548 Woodberry Drive
Winston-Salem, NC 27106
Coleen H. Sullins
Directo r
6/22/2011
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400194
2548 Woodberry Drive, Winston-Salem, NC 271. 06
Dear Mr. Berry:
Dee Freeman
Secretary
On 6/20/2011, 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,
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 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.Rogers(@ncdenr.,mv if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. ·wro4001 94
Forsyth County Health Dept.
David Brown (Yadkin We11 Co.)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Sincerely,
forg~A-~
Sup ervisor
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equ2I Opporiur.:ty Affirmative Acti:m Employ~~;
NOnehC,· 1· ,. orti.. aro. 1na
,lvaturall!f
Jun. 24. 2011 5:48PM
FACOMILE TRANSMUON FORM
DATE: t TIME: REF. NO.
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No.0498 P. 1
LOG NO.
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MESSAGE:
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'FOR ALL YOUR WATER NEEDS'
YADKIN WELL CO., INC.
19W KokwTOHVILLK ROAD
F4AMATONVILLE. NC 2702E
L�AVtp J. BROWN, V1CR PRE3.
TOLL RREE IWO) A".'5355
OFFICE 13UI 46GA440
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,�,i. 24. 201' 5:48FM
No.0498 P. 2
NORTH CAROLTNA
DEPARTMENT OF BTVIR4NMWT AND NATURAL RESOURCES (NCDENR)
N'OTMCATZON OFIN'T'ENT TO CONSTRUCT A. C.LOSEF-LOOF GEOTHERMAL
WATER -ONLY INJECTION WLLL SYST'.:
TYPE 5-QW WELL(S)
In Accordance with the prmislous ofl\TCAC Title i5A: 42C 02Q0. please
complete this no4vation aril x:aaU to address on tlke luck- page (please kdg or Ig infb=atloo.
DATES C-- � �o �l �Si �� Q� � �'4
0
B.
Wd l Type Caqflrtr atio x: Does the proposers system circulate potable -yurtcx (no additives) in
continuous piping that completely isolatrs the fluid from the environment (l,e.
closets-loao]?
Yes X . Continue completing this form-
No Do Not complcto this form. Complete other UIC application (barns for hwN ing
either a $A7 well open -loop well in potable %vater into the aquifer) or a 5QM well (closed -
loop Nvell come'»? g additive.. such as R-22, ethanol, or olhcr autifse= or corrosion irNbitoirs).
PROPERTY OWNER(S)IAPPLTCANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative tvlauthority fnr signature): fir► r.j_�g _ --
(1) MatlingAddress: 2,r F LJaag,rr_-i�'�� --
City: 1V in.) 4-0 n - .�cf le ey—State: A&-Tp Code:
Horneloce isle No : 3i 7 Z2. - S Cell No.:
Email Address: Webshe:
(2) Physical Andress of Well Site (if differant'than above):
City:
State: Zip Code: County:
Home/Office Teie No.: Cell No.:
AU=OXTZED AUNT OF OWnR, IF ANY (if the Permit Applicant does not Awn the subject property.
attach a letter Srvm the property owner autharixing Agent to install and operate MC wall)
CompaAy Name. -
Contact Person: - E;vIA_ Addles;
Address:
City;
State: Zip Code:
O MCe Tele No.: Cell No.:
WebsiteAddress of Company, if any:
AAum w7nTrr.,
,HUH 10 Eblt

Jun. 70. 201'i 5;4cPM No, 0496 P. 3
C, WELL DRi1•LER 1NIMMMON
CarrpxrgrNatne�� Ca. Jac.
NVOU Dritler Contractor's Napae: odv Mlln MRith"nrown Mitfon Cave
NC Contractor Cettil'ccatiailNo : 2572-P+ _--3036-A - 1548-6
Contactpexaori- �. _ �SAIL� ddmss: ai efddlfer ig�t�nm
Addrass:1908 iiamptauvllI* W.
City; �gamo= im�l$ N.0 Zip Codw 27020�-- - County; Yadkin
O fOw Tele No.: 336-468-4440 Call No.. �336-3744 73,6 _
D. HEAT PUAS CONT"CTAR WORMA'lii7N (if diffaent than dr ller)
CoolsO Peison., a 4 k+- wt'e MAI Addiesa,
Address; .E
City: �' r+,�s�e �% zip Code: 2-7.o r County: 1� .0C III
Office TeleNo,: —.3, !C 74 - 2-r2C Coll No,:
E. STATUS OIF aPPr,rCANT
Private: 1/ Federal: _ Commerolol-
State: Muntc4pal: Native Ameucsu Laws.
lx. TNTACTiON MOCEDIM, (briefly de,cxllte how the 4adoa ivcll(s) ivlR bfe us/ed)
G Y M TC W 4-Vd?P1%P-OjfeO ii L.6�
G. WRa CUl►l51` UCTiON ]DATA r - G 1
(i) Proposed date to be construcied;�--� Number of borings: _ ?
Approximate depth of cash boring (feat}: 90
(2) Type of tubing to be used (capper, PVC, etc): �t QP4 K OR
(3) Weil cwiDg. Is the wafl(s) cased? (check e f wx (a,) Yes n (b) No belov�
(a) Yes 9f yes, urea pnorvido casing inforniL6on balow
Type; g91vR�lieed Steel biaok steel pissde other (spay)
Casing depth: Pram to feet (reforenoa to land stubce)
Casing oxftitds to above ground lathes
(b) No le
(4) Grout Info (matedal swovndfng well cosiagatdlorpipmS):
(a) Orout typo: Neat CerMat Bentouile if J Dlhes (4poify)
(b) Grout pItoement. FumpSnp_i_/ Fmssure Other
(o) Grant deptli of tubing (reference to Iand snrA.(A}; from to (NI)
lf�reli has casing. indicate �GUC depth; from "w to (&et)

Jun. 20. 2011 5:49PM k 0498 P, 4
It INJECTION -RELATE]? > QUTPM NT
Attach a diagram showing the engineering layout or proposed modification of the Neotion equipment and exterior
pipirgltubing associated with the injection operation. The manufacturer's brochure may provide supplementary
informallop. -
I. LOCATION OF WELL(fi)
Attach two copies of maps slowing the hallowing information:
(1) IncIude a Site Map (can be drawn) showing. buildings, property litres, surface water bodies; potential
sources of groundwater rontamination and the orientation of and distances between the propmd wet(5) acd
any existing well(s) or Nvaste disposal facilities such as septic tanks or drain tells located within 200 feet of
tlia geotTze =I heat pump NVeii system. Label all features olearly and include a r orth arrow.
(2) The Site Map must shoNv the subject property in relation to the surrovading area by using at least two fmed
reference points such as roads, streams, and/or highway intersections.
CERTIFICATION
Note: Thfs ftroli;t Ap&catiom must be signed by each parson appearing on the
recorded legal property deed.
"I hereby ceilify, render penalty of law, that I have personally axamiaed and am familiar with the information
subraitted in this doaumeat and all attachments thereto and that, based on my inquiry of those individuals
immediately reaponsiWa for obtaining said information, I believe that the iaformation is true, acc=te and complete,
I am aware that titer$ are sigalf cant pei alties, including the possibility of fines and impriso=ent, for submkaing
false information. I agree to cowt=t, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances lrs accordance a approve spent catio- n-S.. and conditiotts of'the Permit-"
grature of Property Owner/Applicant
-TIM -P, W 1 f ter
Print or Tj pe Pull Name and
Signature of Property Owner/Applicam
Print or Type Full Name and title
Signature of Authorised Agent, if any
Prh* or Type FVU Name and title
Plemse zeturn two copies of the completed Application package to:
North CarolinaDENR-l]WQ
Aquifer Protection Section-UIC Program
1636 Mail Service Corner
Raleigh, NC 27699-163 6
Telephone [phone] kjI.,i

1un.20, 2011 7:49PM
No.0498 P. 5
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JUN 2 4 2411
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