WI0400224_GEO THERMAL_20111027

Permit Number WI04002~4
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (SQW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
William A. Yow SFR
Location Address
1429 Country Lk Dr
Greensboro
Owner
Owner Name
William
Dates/Events
NC 27406
A Yow
Scheduled
Orig Issue
10/27/11
App Received Draft Initiated Issuance
10/25/11
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall NUL;__
Central Files: APS_ SWP_
10/27/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Kerri Yow
1429 Country Lk Dr
Greensboro NC
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Faclllty Contact Afflllatlon
Owner Type
Individual
Owner Affiliation
William A. Yow
Owner
1429 Country Lk Dr
Greensboro
Public Notice Issue
10/27/11
NC
Effective
10/27/11
27406
27406
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
SAM.
ftcDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coieen H. Sullins
Governor Director
10/27/2011
William A. Yow
kern Yaw
1429 Country Lake Dr.
Greensboro, NC 27406
Subject: Acknowledgement of intent to Construct Type SQW Injection Well System
Permit No, W10400224
1429 Country Lake Dr.
Greensboro, NC 27406
Dear Mr. Yow:
Dee Freeman
Secretary
On 10/25/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onl\
geothermal injection well system for the operation of a ground -source beat 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 niet:
The injection well system contains only potable water,
The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Tide 15A Section 2C Subchapter .0213, and
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 ISA Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Guilford 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.Rogersfu ncdenr.zov if you have any questions.
Sin rely,
for Deb \�-atts
Supervisot•i
cc; Winston-Salem Regional Office - APS
APS Central Files - Permit No. WI0400224
Guilford County Health Dept.
Billy Yow (D & Y Well Drilling, Inc., 1426 Country Lake Dr_ Greensboro, NC 27406)
ACUTER PROTECTION SECTION
1635 Mail Service Center, Ralegh, North Carolina 27699.1636
Location: 2728 Capital Boulevard. Raleigh, North Carolina 27604
Phone: 9t9.7333221 I FAX [phone]$; FAX 2:919-715.6048 I Gustamer Service. 1.877-6236748
Internet. www.ncwaterquali V.aro
An Equal ❑ppoMnih ti Affirmative Action Gmalover
�arthCarolina
Naturally

10125I2011 0� O 3366746271 DYWELL DRILLING PAGE 01105
D & Y Well Drilling Inc.
1426 Country Lake Tyr. • Greensboro, NC 27406 - 336-674-9198
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DATE:
TIME:
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1ei12512011 09:46 3356746271 DYWELL DRILLING- P E 02I05
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NORTH CAROLINA, DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF VENT TO CONMUCT OR OPERATE INJECTION W'LLLS
In Accordance With the Provisioils of 15A NCAC 02C ,0200
11I%14
A.
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water anIy as part of a geotharmaI beating and cooling system.
These welly are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Print or Type Inror•mation and Mail ra the address an the Last Page,
20 PEItNM NO.
STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence X
Government: State Munieipal
(to be filled in by DWQ)
B u s i.n es s J4 rgan i zati. on
County federal
B. WELL OWNER - For individual residences, list each owner on property deed, For all others, state name of
Qr L cnt tyland name of person delegated autho6ty to sign on behalf of the business or agency:
Mailing Address, VA 2.5 C"DL%_" 2
City: r Sbarca State: tA(!- Zip Code, 2__1 40 G County: Gu%\-VC Va
Day Tele No.: 3 Z6 J 1-14 -a t C\ 42) Call No,; 3 3 t. — 3'1 a,- 4U S,-
EMATL Address: � pyu1 �. _P +R6�L. ►L�. �a..rt Fax No.: (e - 4_1 - X:� I
C. LOCATION OF WELL SITE- Where the injection wells are physically located:
(1) Parcel Identification dumber (PIN) of well site: County: it,
(2) Physical Address (if different than mailing address):
City: State: NC Zip Code:
D. WELL DRILLER MORMATION
Well Drilling Contractor's Naive: � � 1k +. t7 %,s—
NC Well Drilling Contractor Ceilification No.: t DO
Company Namc :_]� Y�[ �� �]'r �♦�► Wit: _
Contact Person: i tib u3` _ EA�IA I1_ Address �8�DU41 -f eZ4 . .0 ow -
Address;
City: ,^lr t. G.r,?1ra a r o _ Zip Code: �"�1 40� State: taG County: ui \ r {�
0Mcc TeIe No.: Cell Fax No.: (a-
OPi, MC 5QW Notificadoe (PW1sed3118l201 I] rage :

ia/25/2011 09,:46 3366746271 DYWELL. DRILLING PAGE 63/65
E. HE AT FUNM CONTRACTOR MORMATION (if different than driller)
Company Name:
Contact Person: EMAII. Address, -
Address:
City;
Office Telc No.:
Zip Codc: State: County;
Cell No.,
W11A ru
o-s
F. WELL CONSTRUCTION DATA 1�
Fax No.
4y � �► � t�
{1} Number of borings to be constructed*- Depth of each boring (feet): 3 +
'' If existing water mppIy wells will be used they provide the information in item (4) below,
(2) Type of tubing to be used (Steel, PVC, etc):
(3) Well casing. If the we;)(a) will use easing then provide the ty a (steel, PVC, etc,), di eter, depth,
and extent of casing appearing above ground;
0A la �zt
(4) Grout (material surrounding well casing and/or piping,): s , 1
(a) Grout, type; Cwnent Sentonite* r - other {specify}
ny 5eloodfig bertornite grout. a varianeo is hersby mquoIP4 to t 5 A NCAC ZC-021.(d)(9(A), which requires a wMont type grout.
(b) Grout depth of tubing (refemce to land surface): from 0 to S 44t (feet)
If well has casing, indicate grout depth: from to (feet)
C. WELL LOCATIONS -- Maps must be scaled or otherwise accurately indicate distartecs and orientations of
features Iocated within 1000 feet of the injection well(s), Label aR .(eaturci clearlYand include a north arrow.
(I) Attach a site -specific map showing the locations of the following;
* Proposed injection wells * Buildings * Property boundaries
Surface water bodies " Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 114 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: Inmost cases, an aerial photograph of fie property parcel showing ing property tines and structures can be
obtrrtrted and downloaded from the applicable county GIS webs[te. Typically, the property can be searched by
owner narrne or address. ne location of the wells In relation In property boundaries, hor4tat, septic tanks, oilier
wells, etc. cart their he drawn In by !terra Also, a 'layer' can be ,telecied showing topographic contours or
elevation data.
c64 gerk Aqf� fk,m or, rJ f ill!
4PU MC 5QW Notirio; ion (Revised 3f18M11) Paget

I0125I2011 59,.46 3366746271 DYWELL DRILLING PAGE 64105
H. CERTIFICATION (to be signed as required heiow or by that person's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
I.. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official.;
4. for all others: by the well owner (which means ell r aeons listed on the property deed).
if an authorizer] agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
" 1 hereby certify, under penalty of law, that i have personally examined and am familiar with the inforration
submitted its this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, 1 believe that the information is true, accurate and
complete. 1 am aware that there are signs ficant penalties, incit4ng tlse possibility of fine.G and imprisorimcnt,
for submitting ralse information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances, in accordance with the approved specifications and conditions of
the Permit."
Signature o c wnerfApplicant
�Ull
G
Print or �Pe
Applicant
Prism or Type Full
Signature of Authorized Agent, if any
Print or Type. Full Name
Submit the complete application package to -
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
R1+CE1VED 10+NR eobV'
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GPUAMC 5Q W Notification (Revisad 311 V2011) Pap 3

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10/2,5/2811 09:53 3366746271 DYWELL DRILLING PACE 01/05
D &YWell Dfilling Inc.
1426 Country Lake Dr. • Greensboro, NC 27406 ■ 33&674v-9198
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DATE: a I
TI ME:
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Na OF PAGES:
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10/2~/2011 09:53 3366746271 DVWELL DRILLING PAGE 02/05
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NomICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
Jn Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED .. LOOf WATER-ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a. geothennal heating and cooling system.
TI1ese wells are 11permitted by rule" and do not require an individual pennit when they are constructed i.n
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Print or 1ype Information and Mail to the Address on the Last Page.
DATE: _____ ~ _ _; 20_ PERMIT NO . ..-------~{to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non-Government: Indivldual Residence~ Business/Organiza.tion _
Government: State Municipal_ County___ Federal
B. WELL OWNER -For individual residences, list ~ owner on property deed. For all others, state name of
\ '"B· l \ entity and name of person delega~d authority to sign on behalf of the business or agency:
' l)) _\J,.\ 'd\i.;,..'N'.'\ J\ , .. k -c:..n i ~o v,.I.
MailingAddt'ess: \L\-2G\ Co\)...'rn'~ ~e... ~\"',
City: Gar c. c...-s \cc.V"O. State:~ c. Zip Code: 2...1 4o ~ County: Gu.\ \~QVd.
DayTcleNo.: ,3~~ ... t,.1 a..\,•q\q€) Cell No.: 3?)Lo-3 1~ .. 4~~S
EMAIL Address:$~o~ a, e ..\--1\.\dd..~¥-R-, ~ Fax No.: 33l,-G,1 + .-·t., ~~ l
C. LOCATION OF WELL SITE-Where the injection wells are physically located:
(I) Parcel Identification Number (PIN) of well site: Counfy: 8\,1. \ l Fb.,d
(2) Physical Address (if different than maiJing address):----------~---
City:----------~----State:~ Zip Code: _______ _
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: _____ \:>_\_\_\_\.."""'l--~-+·-b_~------~------
NC Well Drill.ing Contractor Certification No.: _..::;.1.=i)!::..:D=:...;;;;.O_~_.;._ ____________ _
Company Name:""1:l"t \\, 'V---\~\\ ~,.\ \\\'!::'] ::S:~c.. .
ContactPerson : ~\\\'-\ ~Ou.Y · EMAU ... Ad4~Jls:Y»\ou\~-hi..:t~.R"~c.~
Address:~ ~,..._!!Lj ~~. (by-•
City: ~""',s\oQ"'~ Zip Code: l 1 I.\O\P State: ~C., County: Gu.., \~o-c""d..
Office Tele No.: '3.:> \c .. ~14:-~ \~ i Cell No.: ~~1.-"\<'l~'S' Fax No.; 3 :> "-~,:\-.. k 1'1)
RECEIVED/ DENR / DWQ
GPU/UIC 5QW Notification (Revised 311812011) Aquifer Protection Section
OCT 2 8 2011
P~el
10/2~/2011 09:53 3366746271 DVWELL DRILLING PAGE 03/05
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: ______ ~-~----------------~---~
Contact Person1;_; ----~-~------..1;EillMA~JILY:;_uA~d~dillre~s~s: __________ _
Address=------------~-----------------~-
City: -------~-Zip Code _: ____ State: _ ..... CoW1ty: ----~----
Office Tele No.: Cell No.: ~Ea~x!LlN~o!!.!.•L: --~~--
F, WELL CONSTRUCTION DATA
(l) Number of borings to be constructed*: _____ Depth of each boring (feet):. _______ ~
* If existing water ,ju_pply wells will be used then provide the infonnation in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc)~ _____________ _
(3) Well ca.sing. If the well(s) will use casing then provide the !Y~ (steel, PVC, etc.), diameter, dcm,b,t
and~ of casing appearing above ground: ----~------------
( 4) Grout (material surroundin.g well casing and/or piping):
(a) Grout type: Cement_ .Bcntonite** __ Other (specify) ______ _ *"' By selecting: bc11tonhc grout, a variance is hereby requested to lSA NCAC 2C ,021.3(d){l)(A), which requires a cement t:;vpc ,trout.
(b) Grout depth of tubing (reference to land surface): from ......__..._ to ___ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection wel1(s). Label all features clearlv and include a north arro,.w.
(1) Attach a. site-specific map showing th'e locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
"'Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site tha.t indicates the
fa.cility,s location and the map name.
NOTE: J,i nwst ca.,es, an aerial pltotog,aph of tlte property parcel showing property lines and structures ca,i be
obtained a,id downloaded .from the appllcable countJ, GJS website. Typically, the property can be searched by
ow11er nanie or address. 17tc lo(!ation o.f tlie wells in relation. to .Property bou1id11.ries, liouses, septic tank.,, otl,er
,11ells, etc. ca,i the11 be. drawn itr hy hand. AL'io, a 'layer~ cm, be selected showt,ig to11ogra_p!lic. contour.it nr
elevation data.
GPU/UIC 5QW Notification (Revised3/18/2011) Page2
1©12612@11 09:53 3366746271 DYWELL DRILLING PAGE 04/05
g. CirRTIF'ICATION (to be signed as required below or by that person's authorized agent)
t SA NCA.0 02C .4211(b) requires that all permit applications shall be signed as foliow.g:
I . for a aorperation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: try either a principal executive
officer or manking publicly elected ofcial;
4, for ail others: by the well owner (wltich means 1l crsoms Iistc�d on the ro deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter sighed by the
appiicnot that names and authorizes their Rgeni to sign) this application on their hebiaif.
"I hereby certify, under penalty of law. that T have personally examined and azn familiar with the information
submitted in thus document and all attachments thereto and that, beard on my inquiry of those individuals
Immediately responsible for obtaining said information, 1 believe that the information is true, accurate and
complete. 1 am aware that there are significant penalties, inciudin.g the possibility of fines and imprisonment,
for submitting false information. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the
Injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit,"
I
signature a ei _ wncrlApplicant
Print or Type uuII Niue
S en ure of Property�wn�erlAgplicant
t
Print or Type Full , ane
Signature of Authorizcd Agent, if any
Print or Type Full Name
Submit the Complete application package to:
DWQ - Aquifer Protection Sectiou
1636 Mail Service Center
Raleigh, NC 27699-1636
Telepborle [phone].
R►ECEiUEiD
-Aquifwp, ,DVjO
GPUIUIC 5QW Nniirtmdon (R4wixed 3/19/2011) PAP I

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