WI0400237_GEO THERMAL_20120201

Permit Number
Program Category
Ground Water
Permit Type
WI0400237
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g;smith
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Paul Cheong SFR
Location Address
3390 Kirklees
Winston Salem
Owner
Owner Name
Paul
Dates/Events
NC 27104
Cheong
Scheduled
Orig Issue
02/01/12
App Received Draft Initiated Issuance
12/22/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
02/01/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville Rd
Hamptonville NC
Major/Minor
Minor
_Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Paul Cheong
3757 Verbena Way
Clemmons NC
Public Notice Issue
02/01/12
Effective
02/01/12
27020
27012
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Paul Choong
3759 Verbena Way
Clemmons, NC 27012
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
.Division of Water Quality
Charles Wakild, PE
Director
February l, 2012
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400237
3390 Kirklees, Winston Salem, NC 27104
Dear Mr Choong:
Dee Freeman
Secretary
On. 12/22/2011., 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 grourid-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 wen 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 .02ll(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 rµles and ·regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michae1.Ro gers @ncdenr.gov if you have any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. WI0400237
Forsyth County Health Dept.
Yadkin Well Co., Inc. (David J. Brown)
Webb HVAC{JeffSessoms)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterguality.org ·
An Equal Opportunity \ Affirmative Action Employer
n~~. A. &lJlt
forD~
Supervisor
One ........ . .N_ijftli.Carobna
:/Yfit.11:r.a/lV
12,0 e C. 22. 2011: '. B: 5 1 AW69995ad3
WEBB
NORTH CAROLINA
No, 1519 P. 2= 02/04
DEPARTMU OF'-ZNVMONbMT AND NATURAL RESOURCM Q�WDMM)
NOTWCATION OFINTENT X`O CONSTRUCT A. C:LQS - OP GROTMRIUL
WATER o St INJEC 11ON Vn= SY'STM
TYPE -910 LU
InAxordawe WA the prari51QW UMCAC Title 1.5A: 07C O20, pl=
complete this notl5;c4on and msl1. to address ors flx ba&page please rat az �e ls��tiom}.
RECEIVED / nPuc ,
PATZ: '`'uvff1WRprtn�gr rri tia IpN
Wdl Type Col y1rmarfen: Does the proposed apte= cimulato potable ("&tge� go t,
condnuoua piping that oo=plet4y lsoWes do1Md from Lho cAvIronsacmt (Le -
se -tea
Yes __ ..,, Continue completing this fa7m.
1ju, _Do Not compleba this farm Complete other MC applfoatim fhrms for iastalling
vibes a $A7 %yell (wrn--loop %yell i nlecing potable seater into the aquifer) or a 5QM well (closed -
loop Ivell coata;� a d' i suet as R-A t0anuL or other anf&ame or corrosion inWbftm).
List Mh Property Q ►vaer listed on prod" deed Of own by a business or goverment ageuy, state name of
entity and a representative wfkufharffy far sigaaturz): r4k
(1) MailingAddress. - 375J�U r, W -� y
Gitr r_�c emn, -" State: 1Je- zip Code: 7-700 Y cmty:
H0M910fGce Te1e N0.: � - �� °� _ Cell NO.:
Email Address; Nebsite:
(2) Physical. Address O WtZ S itc (i£ differeatthan above): 3 3fn I e—� 'r4e. e-
City:
gomelOffacTaleNa: Ce o.:
B. AUTHOR= AGENT OF OWNER, TFANY Cif the Permit A.pplk-,wt does not own the snbjecgropem'
attach a letter &^our the groputy owner autho�wog Agent to %atop And opera 1AC Wea)
Company Name:
ConlectPersan: �_ - STv;An. Addm
Address:
Cety: Mate Zip Code: Cavnty:
Office sale No.: Cell Aid.:
W ebsite Address of Comp=y, if any:

12/Dec.12. 2011 . 8 : 52469965443
WEBS No, 1 y 1 9 P. 3= 03/04
C. WMT, Iazzuaam mo=iXWX
Comparry33amm• of c Inc.
RECEIVEo / DEHR I DWaQ
►�Otllrxl�ls�r�r. *rrnu w-rIOH
DEC 2 2 2011
�Ye)l IIrlEler Caniteator's Nand Iada y MZ mig ,M,t�m 18'rQm War[ Cave
We Conmolor Cectifl0etbmX0.: 257Z; A 3Q?�6-A . 4;3•A= .�
GUat�ail'ersoti 7. H r : ehigmIcOrmil.cm
Add";1908 R nptanvilt0 Rd.� _
City; n RQ Z12 Code: 27020OMMY, Yadkin_
O€flooTole ITo,: 336-4684440 CollNa.; 336374,V36
D. AFtT iUAM CWTACTOR MORII AMON (if Mao that tlaicr)
company NAlw, W a-G y -tV
CuntuctPecaon: �S trn� s BNJ[Ajl,rs: �:� e-S sc .-.4sb Lv�,c. w+►,�
Address: 7 0
city.- + 1p Gods: 2-? W 6 Cauuty:
0t5oeTe*Iallo.: P I4 E -V-z4_--_, wxor 336 S 73
R. STATUS OF APP.TC.+ NT
.Private; Federal,; Coumerolal:
Stn1c: MtmidpaL• 'Native AmudcanLauds:
0 INJBCT Olq =OCEDI= (briegy durle bow tk W ecdcA wcD(s) zvlll be nand)
d",leC;4 lit40- we �ele +kJ'.c<c. [U
G. WELL C0XIST`RUCTI ON DATA �4(
(l) Proposed dare, to Nutuber of borings:
Approximate ds$h ofoRohborIng(tlsat);
(2) Type of tublzg to be ascd (Gppper' PVC, ew):
(S) WOLI CaS15g. la dm well(a) cased? (aheok eiilmr (FL) Yes n=r (b.) No belmv)
(a) Yes ifye;, ftn praricicasing Id0r=d'QuWjoW
Typo: ---plyaniDed steel blxok ater ,pfas8a athcr(spso*)
Centres dapik ZX= to at (ref4mo to lend smjf cc)
Caslug extends to abovo ground__----.i3ch1s
(e) N4
(4) Grautbt'o (maWki surmuadW well raslag and/or plpfcV;
rX�rinc�
(a) Griout type; Neat Ceromt Bentonllc t/ 411gr (speotfy)
0) OrOMpSneamank Fumpingje/— Promr$ Other
(cj [3roaE dep4k a£fu%iflg {re£ereu¢e to lead str11�49): Emm -,I — to., Q (rtet)
If wolf has u4ng, ttt&Ww 9rout depth: irm_ to (ac*

12D —'22. 201 i; 8:7203599S$443 WEBB No. 1519 F. 4E 04104
RECFJvED I DENA 10
V, INJECTION RELATED XQU,IF=NT ,tom j1mR PmT1ArTr1N A -4
Attach a diagram showing the eagineerlug layout or proposed tuvdi$catim oflifDJ `�' 6ment and oderlor
pipiagltoblag aasoclated with tho iWecdom vparatlornn. The manttihctuWs brochm may provide supplementary
itrf'oa�oaatia+3. .
1. 1,OC,'TION47mu(s) `
Attach two copies of maps showbgthe fbllvwing 9n#brmat1ooa:
(1) botude a site Map (c%D be ftwo) sbowiar. Wlftp, propettY lines, suribee water bo&s; potential
sources of grooadwatar contaminat1cm and tbm crienbdm of and drbnvea bat►veeatke proposed weu($) sad
auy existing well(s) of waste disposel faclliHes suaas septic tanb or drain -4plds located within 200 feet of
to geatbermei hest pomp Well system, Label au Features clearly aad include
(2) The Site leap must show the subject propert}► iu relation to Le s=omading area by using at Ieast tvm fixed
rafuance points siicb as xoads, smarms, andlor bigbnray intersmcdons.
J. CF,RT37rMCATION
Note: This permit Application mast be sigued by each parson appearing ontha
recorded lcgalproperty deed.
`'I hereby cerdty, vuder pcaatty of law, that i have perscmally examined and am familiar with the Wftmatian
subm fined im this dom ra and all aMrhments thutto and that based oa my inquiry of those individuals
immedlataly respo=Ue for obtdniaoogsaid liftma lM I believs that the irr ormadon iaftA accurate and complete.
I can mare that there are s%mlticant peuWties, including fe pmibilsty of ftes amd imprri2o=ant, for submitting
f4he information. I agree to construct o2ezaV, rmirrlaiai. , and if applicable, abaudaa &a h4ection well and
all related appurtenaaocs in accordance with the sp specifications_Vd-,-a ditsons of the Permit.°'
tur o Psopmly OwnedApplfcaut
Prlat or Tye Fa Nanx and title
5iwatuxe ofFroperV ftamalAppllcaut
Piiru or Typo FUli Name and title
Signature of Authorized Agents if any
Priru or Typq NU Nam and tide
FImsc retran two copies of the c ompleted Application passe to.
Nor$ Cm ollua DZNR DNVQ
Aquitferrrotectiva Section-DIC Program
1.636 Mat l coke Center
R-iieigh, NC 27699-1636
Telephone [phone]

Dec, 22. 2011 8:52AM
No. 1519 P. 5
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Dcc, 22. 2011 $;51AM
No, 519 P. 1
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F=MILE TRMMMoH FORM
OAYE: I it mi TIME: REE NO. LOG NO.
COMPANY NAME FAX NO.
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❑ RE+[E W DELY
FROM: � (t Co (ar) P%7 - �/-o feg
COMPANY NAME FAIL NO. PL EAR
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REPLY
INWOUAL
NUMBER 5 G� S
lNOLJDf4G NIS SHEET lay "=
MESSAGE:
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"FQFR ALL YOUR WATER N@EOS`
YADKIN WELL CO., INC.
I" HAM MWILLL ROAD
14AMPTONVILLE, NC 27020
OAVID J. BROWN, VICE PRES.
TOLL. FRr6t (IM) 24&9355
OFFICE [phone]
FAX t33d1 440.40"
RE8 i33d1 sN+4fi39
-GQW wgw3 Amdalc^ • COO LaVmf Ye.,•
PLEAN MM uslUmE amy IF1Vlt DO NCiiA[wrOM P IN FULL