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HomeMy WebLinkAboutWI0400205_GEO THERMAL_20110809Permit Number Program Category Ground Water Permit Type WI0400205 / Injection Wate.r Only GSHP Well System (5QW) Primary Reviewer michael.rogers Coastal SW Rule Permitted Flow Facilit Facility Name Laura Goings SFR Location Address 628 Woltz Atkins Rd Mount Airy Owner Owner Name Laura Dates/Events NC 27030 Goings Orig Issue 08/09/11 App Received Draft Initiated 08/03/11 Re q ulated Activities Heat Pump Injection Outfall t\i ~h . Scheduled Issuance Central Files: APS_ SWP_ 08/09/11 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 Surry Facility Contact Affiliation OwnerType Individual Owner Affiliation Laura Goings 256 Mills Rd Mount Airy Public Notice Issue 08/09/11 NC Effective 08/09/11 27020 27030 Expiration Waterbody Name Stream Index Number Current Class Subbasln Beverly Eaves Perdue Governor Laura Goings 256 Mills Road Mt. Airy, NC 27030 AVA NCDEHR North Carolina Department of Environment and Natural Resources Division of Water Quality Coleen H. Sullins Director 8/9/2011 Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System Permit No. WI0400205 628 Wottz Atkins Road, Mt. Airy, NC 27030 Dear Ms. Goings: Dee Freeman Secretary On 8/3/2011, th_e 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 .021 l(u)(2). Additionally, you should contact the Surry 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 (919) 715-6166 or Michael.Ro!.:!:ers (a),ncdenr.f!ov if you have any questions. cc: Winston-Salem Regional Office -APS APS Central Files -Permit No. WI0400205 Surry County Health Dept. Yadkin Well Co, Inc. (David Brown & Tim White) AQUIFER PROTECTION SECTION 1636 Mail Service Center, Raleigh, North Carolina 27699-1636 Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604 Sincerely, fo/'2~~-~ Supervisor Phone: 919-733-3221 \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Custcmer Service: 1-877-623-6748 Internet: www.ncwaterauality.org An Equa! Opportuniii' Affirmative Aciion Employer N~rth Carolina /,7aturaltu Aug. 3. 2011 10:17AM No. 0786 P. 2 \ l NORTII CAROLINA DEPARTMENT OP BNVIllONMBNT AND NATURAL RESOURCES (NCDBNR) NO'l1FICATION OF INTENT TO CONSTRUCT A CLOS'A)-LQOP GEOTHERMAL WATER-ONLY INJECTION WELL SYSTEM: TYPE 5-0 W WELL (S} In Accordance "!1th the l)to,1.Wons ofNCAC nrie 1SA: 02c.0200: please complete tllis notification aiicl mail to address on the back page (please J![b![ or Im.t info.tmation). DATE: S-!1.. 20.JL u.,..lL04-0 000:, Well Type Co1,jirn1atio,z: Does the proposed system circulate potable water omx (no additives) in continuous piping that completely isola.te.g the .fluid from the envil·oiunent (i.e. closed ... loo p}? Yes _X~ Continue completing this form. No ___ Do Not complete this form. Complete other UIC application forms for installmg either a SA7 well (smn-loop well iJlieetipg potable water jnto the aquifer) or a SQM well (closed- loop well containing· additives such as R-22, ethano~ Ol" other antifreeze or coltosion inhibitors), A~ PROPERTY OWNER{S)/APPLICANT(S) List each Property Owner listed on property deed (if owned by a business or government agency~ state name of entity and a representative w/aufh:ority for signature): b g:y v a (,r o i fl ~ r (l) Mailing Address: 2 S6 H, If r R.J City! 11 f • A , ,,. 7 Siate: LL. Zip Code: 2 1 D g O Coun~ S ClV' v k Ho:me/0ftic~ Tele No.: Cell No.:3,U-7/o .. ,2 ::ii Email Address:, ______ ~ .... W __ e=bs__.ite==:..-...---------- (2) Physi~lAddress ofWellSite(ifdifferentthanabove): ( 2. 8 l!Jolf&A-fh,";.,1 h..J City: f14:,. 4iv:y Staie: '1£:,_ Zip Code: 2. 7 o J: o CoUllty: Jh v ~ y Home/Office Tele No.: Cell No.: ~ B. AUTHORIZED AGENT O:B' OWNER, DF ANY (if'thePe.nllitApplicantdoes not own thesubjectpropertyJ attach a letter ftom the property owner authodzing Agent to install and operate UIC wtll) CompanyName:~---~-------------------- ContactPerson~: -------~--~~-.... B;;:.:.,M_..A..,;;IL;:.;;..;;.;;A=ddres=--... s: ________ _ Address: ________ ~----------........ -~~---- City: ------------.....----Stati,: _Zip Code: ~-~~-County: ______ _ Office Tele No.: --------~~----C=e=ll:....::..N=o.!!,..: _______ ~- \V ebsite Address of Co~pany, f!any: ____________ ,E,CEIVEO / DENR / OWQ AQUIFf:R·PROTFr.r,oN SECTION AUG'O 3 20U Au g, 3. 2011 10 :17AM No. 0766 P. 3 C, VML DIZILL'ZR INFDIMAnON Company Namc--V-r a Ca. hn�. We(I DAller Cbrttraator's Name Jody Mul13s 'I4iEAM Brown 14�iifott {:eve NC Contractor Ccrtifoxtim1No : Z72-A 3036--A — 354-8'►A , Cnataci]Persotl: i?stiid J. Brown 21. A„ MJQAddress ;mitiaffdrii[er msn.oatn Address: 1949 Hamptcnville City; }3anretoMd;1e X C. -- � Zip Code: 27020 O ffice T ak Na.: 336-4 68-4440 Cell NW Cnutit)Yadkin► W-374-8736 D. Hr, AT I'UbX CONTMCTOR URTa tYMAUDN (if dif[ wani than drift) Company Name: `.�� ;' ' i u if [ a — L., i —. C4atACt Per$ot1' M f;J a rac1 + Q City: ZJD Coda_ conty: OflSot rekNo.: C41N0.9 E. STATUS OF A ICAI"i 1' Private: zI/ Federal: Cammucinl; State: _ lvlwcipal; Native American Lands: F. iN3mcnoN`rnoC.i3I3v= (May desGribfe fhow the 4 c6on weU(s) will b e ascd) G. WELL CONSTRUCTION DATA yo lit (I)Proposed date to beeonsbmcted: �gr�� Number ofbuinga: 2 App=huate depth of oachborlrg (f$ct): S 85-0 r (a) 'Type ofttabingto be used (copper,l?VC, etc): -5-6,9 -14 Z� n 1_ (3) Well casing. is the well(s) eased? (check either (R) Y$s pr (b,) No below) (1) Yes if yes, then ptbvidc casing information below Type;[lvauixad steel Mack steal plastic ollrer (specify} Casing daptli; From to Feet (reference to land svrfRce) Casing cAonds to above ground inches (b) No '-' (4)GrcutInfo (tnatarialsurroundingwell casWgauditpipiqs): %� 'AG red �,��r� !�) (a) Grout type; Neat Cernant 1Bcntoalt$ Oilier(spe e' (b) RTRPt placament: f umping 1L- pressure Other (c) Q rout depth oftutb nsg (mAf enaa to laid svtfate}, frtam 3 6 to (feet) If Sven }ems cussing, jnd(c$ts grout ciepfl7: from to —(fed) �tkovtY u' Z+[ lYr _ ACXV.r�, r-nr►+�, ,F. 1u AUG D 3 2011 ·Aug. 3. 2011-10:17AM _ __,_---1;..._-=-------------No. 0786-P. 4 ll:, ll'iJECT.ION-ImLATED EQtJI?MEt'tt Attath a diapain sho\viog the cmglmaring layout '1t ,PrOposcd modification of the ,uuection equipment end ~lor ptp1ngftubiJlg associated wtth tho iqectlon opma.1ion. The mamdllctarffs brodwr~ may provide sui,pleinentary infbrmaliou. I. LOC.4.TIONO:FWELL(S) Attach two coples afmapsshowiDgthe m11owlng ~~ (I) lnol'ade a Sito Map (cm be dtawta) show;ing: 'bulldJngs, pw_perf)' lincs.11 surfflce water bodie.s; J)Otential sources of groundwater contamination and the orientation of end distlncea behveeJJ 1be p?oposed we1l(s) and ;11'1,y exiatfog weU(s) at ,vasto disposal :lamlitle.s. snob. as septic 1anb or dmin fi~ds loc,ied ,vithi,Q 200 feet of the gaother-1 heat pump well a)'mn. Label all hMa cteat'(yudjylpdea norfharrq, (2) The Site Map m11sf show thJ subject p.ropeny in ieJatlon to the surrouu.ding a.tea by 1lSi.ug at least two fixed retere.uce poin!S such as.roads, streams, and/or highway inteneotlons. J, CERT.m.CATION Noto: ThisPermitA.ppllcadon u111st1Je sr,pe.a by!U!9!lpe.l'aon sppearlng on. tbe recorded legal property deea. c'l htreb)r ~erlify. undor ~ of law, fhat 1 have. psrsonally examined and am familisr wlth the in.fotmfttion sob:mitttd in tftls doeunwit and all aUachmcnts thtreto 811d thatl' based on. my inquiry of those indtviduals J.muu,diately responsible. tbr obUlinldg said information, I bellm tbat the mtormafl~ is tnie, &CCUQ\te and complete. I ain awato that tficro are s!gnfru:ant peu=thies, btclud"mg tho poSS11illlty of fines and impr!sonmont, :for aubmitfing ftlse infonnlldon. I agree to codStrl!Ct o~ meinhibt~ xcpak, and if ap_plica~ abandon tho J~<>D 'WCI] aJld all related apputtemnces Jn acoordance with tilt ap_proved specifications and (I01Jdnio11s of tho Permit.>' ~~~()~ LaY.-ra B-&oh1:t5 owt,cr Prlnt tit Typiliiitt'Naa agd 1itl SiJnature of Prope.tly Owl1tf/Applioent Ptint or Type .'.FnD Name aod title SJpa'11m of AutbodzedAgent, if any ~tor Ty_pe Pull Name aod title Pleue return two copies otthe completed Apptlcatiou. paqo to: North Catolina D'.mNR-DWQ .A.gulfra• Protection Bection .. mc :Program 1636 Mail Serric:a Center hleigh, NC 2769.9-.. 1636 Telephone (919) 715 .. 6935 RECEIVED/ DENR, owa AQUlFJ:R·PROTFr.TtON SECTtON AUG ·OS 2011 ., ""' "' ·-·-··"·-•-"----··--·.' --··-..... __, ...... ""' '"" ' __ ...... ···-·-·-....... ,,,,,,,. __ _.___,, Aug. 3. 2011 14:18AM laakk 0; f �YPL Oev 6ayOfA- NOCAS e- tLO r n 1 RtL;tIVEij I VENh � uvvtj AQU FFR'PRO TF( TION SEC-P()N AUG 0 3 2011 Aug. ?, 2 011 10 : 17 AU FMINULE TRMMWON FORM No.0786 P, 1 E 96 w d DATE, !? TIME: -------REF. NO. LOG NO.. T0. r �l -7 Cc 9? COMPANY NAME FAX NI d aF�� ATTIAMON f - DEPL FROM: J- (2iX ) Ali - �Za� COMPANY NAME FAX NO. PLEASE o� - - __ ❑ RUSH FIEFLY INDIVIDUAL OEPT. RMSER OF PAGES INCLUDING THIS SHEET Kim REPLY KIASEY ORIGINATOR'S SIGNATURE MESSAGE; / fry I� ni'r C'g�1 Dn� r h-��D liL4,� T,L� FOR ALL YOUR WATER NEEDS' LDYADKIN WELL S CO., IN. igg6 HAMP70MVILLE ROAD FiAivll�TpNVILLE. NC 27020 RECEIVED I DENR I DWQ ,4V10 J. BROWN, VICE PRIES. r TOLL FREE I$00I 2dE-'9.355 OFFii"E (336) .2 -6440 FAX t3351 468.404E RES i336 d6B afi35 •6eQp NGw'i AMNAICA • 609 LOYCS VOtr PLEASE [NFORM US IMMEDMILY IF YOU 00 NOT RECEIVE FA{STMU W FULL