WI0400233_GEO THERMAL_20120124

Permit Number
Program Category
Ground Water
Permit Type
W10400233 :/
Injection Water Only GSHP Well System (5QW}
Primary Reviewer
eric.g.smith
Coastal SW Rule
PermlU.d Flow
Facility
Faclllty Name
Todd Walker SFR
Location Addre11
100 Crest Hill Rd
Jamestown
Owner
Owner Name
Todd
Dates/Events
NC 27282
Walker
Scheduled
Orlgl .. ue
01/24/12
App Received Draft Initiated laauanc•
12/02/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
01/24/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Cla11lflc1tlon
Individual
Permit ContaGt Afflllatlon
David J. Brown
1908 Hamptonville Rd
Hamptonville NC
Major/Minor
Minor
Regio n
Winston-Salem
County
Guilford
Faclllty Contact Afflllatlon
Ow ner Type
Individual
Owner Afflllatlon
Todd Walker
100 Crest Hill Rd
Jamestown
Publlc Notice l11ue
01/24/12
NC
Effective
01/24/12
27020
27282
Expiratio n
Waterbody Name Stream Index Number Current Cla11 Subbaaln
AVA
NCDENR
North Carolina Department of Environment and· Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Todd Walker
100 Crest Hill Road.
'Jamestown, NC 27282
Charles Wakild, P.E.
Director
1/24/2012
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400233
I 00 Crest Hill Road, Jamestown, NC 27282
Dear Mr. Walker:
Dee Freeman
Secretary
On December 2, 2011, the Aquifer Protection Section (APS) received notification ofyour 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 I.SA 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 vi.9lation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subehapter .021 l(u)(2). Additionally, you should contact the Guilford County Health
Dep~ent 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 Rog~rs at [phone] or [e-mail] if you have any questions.
cc: Winston Salem Regional Office -APS
APS Central Files -Permit No. Wl0400233
Guilford County Health Dept.
Yadkin Well Company (David Brown)
Blaze Air (Bob Boone)
AQUIFER PROTECTION SECTION
1'636 Mail Service Center, Raleigh, North Carolina 276~9-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phpne: 919-807-6464 \ FAX: [phone]
Internet www.ncwaterquality.org
An Equal Opportunity \ f\ffirmative Action Employer
Sincerely, Otoirt IL B<Jau.
ftJr Debra Watts
-Supervisor
Ni~~hCarolina -~--··i·· .. ··~~--. · 'h "t.1'11'/'I · · : . : "-:1. ~,,~j JI
De�. 2, 2011 5; 84PM No. 1418 P. 2
NORTH CAROLDTA
MPARTMMC OF E VMONI l T AND NATURAL ABSOURMS (=BM
N0T1 cAT10N Ole RNTENT TO CONSTRUCT A CLOM)ZOOP G20TH MlAL
[WATER Q Rim, CTION iiWELL SYSfi :
Z'3_]PE 5-Q'W MV] U(8)
$t Accorfutca 11Uft t4e,pra%dA ns of NCAC Title 1.5A: 02C.O200, please
complete dis no0cadon and =2 to nddms an We bnci; page {pleased er Jxge h*MM =).
;Ye1[ 2ype Con flrinali'Da: Ones tht prep ed system circulate potablet#ater (no addif Val) in
continuous piphig that completely isolates the fluid fmm the anviro==t (i.e.
d9afid:1007
Yu Jif�Contiizue awriplet9ssg this form.
No Do No[ complete this f u. Campleto other MC application farms for i0stalflgg
ehher a 5A7 ivell 2M-10op wall ia'e i potable ivater�lnto (be aquifer) or a 5QM)vell (closed -
loop well cantn,Wog ds ads such ss R 22, a snel, or attics anfid'reeza or aarrosian in bitoa s).
A. PROPERTY OWNLR(S)IAPPMICANT(S)
List egg property Owner listed on propcAy deed (iPo�vned 6y a bus4aess. errrgovers to agency, stale iipmc o E
entity and a repreaent$tiva Woutbority inr signature):
(1) MalliagAddresat
city
Zip Cade: County:
HomrJ0ffic0Tt1,sNo.: , —. Cell M'..
Email A,ddiress•,
(2) 1 Wc� lAddress ofWell Site (if diVereutthauabove): L�6Lc.iI LbY 1;?�
City, `-- wr• Slate: Zip Cade: -21 U 2- CIDWl - v
HomNOffice Telo No.: - - Cell uo.:
B. A ITHO=M AGMXT OF UWM, IF ANY (if thv Permit Applicant 4 ,es�ot myn the subject Ixopuly,
att ah a letter fiom file property owner autharb* Ageat to iastaii and operatc = woi1)
ComponyName:
ContactPersom: _ _. _ SMAR; Address: _
Address:
City: State' Zip Coda; County;
OfOoe Tele No.: 001 No.: _
Wabsite-Addrass ofCompany, many:
DEL 0 Y, 1011

Dec', 2. 2011 51OPM
No, 1418 ¢. 3
C. ►UL ARULER iM OR1V & Trt7X
t'OF7ijiP11y 8ipb�.11�C i1rS Ctl Co.In4..
tiYetiprlEler Contraetar's Name: d wa MIN11cave
NC ContrnalnrCertifitafiaaNa: �S7�-A -._ 303d- 8-A .
�'ott#neI PCCS4I�: )•?RVf� �. ero�m W, A- -- _dr;-G�cidtiflersrgp�
McItess:1909 HattaplbnAlleRd,_ - _
city; mp[amrltfc. N.C. E1pCcdc: 27020 Cfluntp; Yndi{ln v
otf3ceCeieNu.: 336-46&-444 CeUNm.t 3[i-374-S73G
D. AEA AN PUMR CONTA40MMCRMATrOX(if diftbAt WRY dri f")
t;csapanyNa,no• -
coulact 1'eriow r 8 ddr s; —
Mdress• I H 0 i n7 O-"? " M 1�
city. 0/'L Vp Cod a: a-110 _ Cott:
alRce7steNa.; 3?*� Z� =33�Z " WI 3 L, 3•S = a_Z 3 �
Cr. STABS OV APFJJr,ANT
private �! PadmL Con=L-eclni•
Sta[a'�. MunlaipAl;� �IaIfYCAmE�oartY,e�pda;____,
]�. IN.CTj0N)?Jx0 (�s UR2 (brlofly daseribe Imw Am injxtlon wcll(s) wIII ba tissd)
a NMT 0VSTIWCTICNDd'rrA A ?-n ( k
(1) Prapmsed data to ba Constructed: u� �. Numbr of borings:.
Appruximat$ depni of each boring (fq4. 2 tip
(a) Type of tfjtztng tm be tucd (Copper, P VG ate)7 f f-
{3} �Vcll casing. � t$� �vell{s} caascd2 (dhaok aiihcr (n� i'es nr {b� Nu bclrnv]
(a) yes ;fy�, itzen provlr3e crtcing Infmrcna4iam h�toiv
Type: ___jalvn44ed steel Ulnak sltei_plastlo ,__alh�r (specky3
Caslr 6PIh: From to ��.�hai (rcftireiacCtalaud snr&ce}
G�sing vKtcnds toahove ground ;noes
(�} Grautln'fa(matarlatsutroundin�Neil caSlt�pmdlaxpt�tf�tgj: �� ►�rfl� ������
(a) (irbut typal Neat cement
(b) [grout pIacerst+ nt: Pttxaping �'
r
BentMalta L'/ Q ther (apaeiry)
Presaura Other
{c} r3ronEdeptZ� ad'tabing {ref'rrance to }aad�rj�at}: frca��-`�� ta��(Feat}
If wall has w11% L I M($ gout depth! from t4 (festj

Deg. 2. V11 7;a0°M No. 141$ ?, 4
M UjJMCT'SON-RTLATED iQ=MST
Math a diagram ahowing fhe engiMuing layout or proposed mod'ifcatien of the injection equipment and exterior
giplttgltabiog associated with Ilia i�ectien operation, Ths manitiaotu�r's 1>m�hury �z7ay provlrle supplementary
infvxrnaizou.
I. LOCATION OF WILL(S)
Attt+eh tsvo rnpiea ofrnaps showing ttm f❑llciving h tbsmation:
(1) laaludo a Site Mall (caa be drawn) showing: buildings, property lines, surface water bodies; poteuftl
sottrees of groundwater oantasninatiaP and the urieztatioa of and dislaMes bahveea the proposed W41(3) and
any existing Wcll(s) or haste disposal faaiIlttes suoiz as sapfla tanks or drain fig1d located rvitltin 200 feet of
the gaotbers ml heat pump well system. Label O flhatvres clearly mud oluds a aortherrow.
(2) The Site Nlap must stow the sQject property in relariort to the suttoanding area byuslrsg at least ttivo fixed
roferenra points such as ABds, streams, a0or WShlvay interseedoas.
'T. ft, RT MCATION
:iota: xhfa) admit Afrplication must be sigacd by egich person nppearing va t119
raaorded legal property dear.
"1 hopby+ certify, under penalty of lave, that I have psrsomily =a.inined and am fan.Har with tt►e information
subruitmd %a Us daouazent and all atts"jents thereto find :bat, based on my incintry of those Individuals
lmraediateiyresponsibie '(vr abtalm. 9sa!d ]nforinabon, I believe tot the iliforinatidra is true, Accurate and completo.
I am aware thei fligtg era .61114ficant PeAftl ies, including tits pgssli M7 of fEnas and impriaanment, for subrazttntg
false fnform Bon, I agree to construct, operate, maintain, repair, pad iffapplicable, abandon the Injocdon frail and
n3i related appurtenanaea in accardariec Sviththe gppri�*ed s ecificatia ,s an onditions of the Permit"
Sigr[atcre o t l'rat�erty thvrier1A13D11c8�t —
-7'o-dd kla Aker awn e r
Print ar TYP6 Pull Name and title
Signatuie oMoperttiy 0voWAppl]cPjnt
Print or Type Full Nume and title
ftenture ofAuthor]xadAsont, Ifazwy
Pdd or spa Full Noma dud tittle
Pleas aretwntwo copims of the completed App]laationpaokage to;
North CA.roha 1)1W ; J)WQ
Aquifer Pntectipn Section-mc ?rogrdm,
163dnag Ssz-ice Center RECEIVED r LENR I DVyU
lWeigh, NC 27699-Y63ti A�llifer ��1Pt-l;rnd:an
Telephone [phone]
DEC 0 2 2011

Dee, P 11 5'OOPM
No. 1418 P 5
-�-� CLI wat�Av'
Cvfl.4 J �
C'mo
— 'col M j k
Ll

arc, 2. 2011 4,59PM
No, 1418 P. 1
FAGS ILE TRANSIMON FORM
DATE: .�- TIME: REF NO.
TO:
LOG NO.
COMPANY NAME
FAX K.
EASE
l o h v q
� r CJ / , c, -
_ .
❑ dEaw►I�IAULM
TT:Ir
►q mllnom f
FROM: y� � -
(- l ^ cj� L� G�
DEPL
t ,� a��
- A AA
COMAW NAME
`
ClI:� C
FAX ND.
R.WE
MM
❑ REPLY
IN3WIOIJAL
DEPT
NUMBEA OF ME$
INCLUDING THIS SHEET
PLEASE
KEW BY
OAIGINATDn
S1GF[AiiiRE
MESSAGE:
6&--->
rr
`4.r T A
Twg,
—
"FOR ALL YOGA WATER NEEDS'
YADKIN WELL CO., INC.
190 HAMPTONVILLE ROAD
14AMPTONVII LE. NC 27020
OAVID J BROWN, VICE PR£B.
TOLL FRET ISM 2A&9=5
OFFICE s'. 361 A644440
FAX 13361 A"4044
RE$ (3WI 468-A659
^wav µn,s AwemlcA • gap uaas vou-
L II
PLEASE IWOR M US IMMEL?MMY iF I OU I)O NGC Fi6CEIV6lM8p W N SJLL