WI0400241_GEO THERMAL_20120224

Permit Number
Program Category
Ground Water
Permit Type
WI0400241
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Herb~rt A Parunak SFR
Location Address
344 Brook Ln
West Jefferson
Owner
Owner Name
Herbert
NC 28694
A Parunak
Scheduled
Orig Issue
02/~4/12
App Received Draft Initiated Issuance
02/23/12
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files: APS_ SWP_
02/24/12
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Afflllatlon
Herbert A. Parunak
Owner
344 Brook Ln
West Jefferson NC 28694
Major/Minor
Minor
Region
Winston-Salem
County
Ashe
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Herbert A. Parunak
Owner
344 Brook Ln
Public Notice Issue
02/24/12
Effective
02/24/12
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
North Carolina Department of Environmen� aria Natura
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E.
Governor Director
02/24/2012
Herbert A. Panmak
Tammy D. Parunak
344 Broom Ln.
West Jefferson, NC 28694
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10400241
344 Brook Ln,
West Jefferson, NC 28694
Dear Mr. Parunak:
Resources
Dee Freeman
Sec+etary
On 02/23/2012, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -off
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:
The injection well system contains only potable water,
The injection well system is constructed in accordance with well construction standards specked in North
Carolina Administrative Code Title 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 Constn etion Act and North Carolina
�r nrtl '"1 f,+ '� h f' �. !.
■ ,Eielri ; �'_. 'il�e)F;;l- ll..t 1{! �!'=.� Rrii'�+ li:;�l S1zC?ill;i
inuniaipai rules aria reguiations tnay result in uie assosszncnt of clvir penalties,
Please contact Mike Rogers at [phone] or Michael.Rogem p.nedenr.gav if ou have any questions.
erely,
for ❑ ra am
Stip ervr- or
cc- Winston-Salem Regional office - APS
APS Central Files - Permit No. W10400241
Ashe County Health Dept.
David 3 Brown (Yadkin Well Co., Inc., 1908 Hamptonville Rd., Hamptonville, NC 27020
Mike Carter (Scott Brothers Heating & Air, Inc., 1870 Liberty Grove Church R&., Fleetwood, NC 28626
1638 Mall Service Center, Rale�h, No+th Carolina 27699-1636
Lmalion: 512 N. 5ailshuty 5L Raleigh, North Carolina 27604 One
Rhone: 9IW7-64641 FAK 919.807-6496 NorthCarolina
Internet: www.ncwat0igAJ.or_Q Naturally
An Equal Opportunity %IVfirmaU6AoVan Employer

Feb, 22. 2012 8:39AM
NO, 1901 F. I
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DATE. L TM: REF NO.
LOG NO.
TO: p e rr q) 907
COMRrNY NAME FAX la PLEASE
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MESSAGE:
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-FOR ALL YOUR WATE1% NEEoi"
YAOKIN WELL CO., INC.
10M HAMPTONVILLE ROAD
HAMPTONVILL11. NC 27010
DAVI❑ J. ]BROWN, VICE PRES.
TOLL FAEB (800) 3A1"MM
OFFICE WO) a61lm4"O
FAX t33M 466.4040
RES t3MI 468,""
K.ddO Ng" AMERIGII • doe LOW$ VOW
PLUM » Lid RAMUwAmY tPYou DO Nor RECOVE PO®1AMLE IN F=

Feb, 22, 2012" 8; 39AM No. 1981 P. 2
NORM CAROLWA--
DEPARWENT OF MMONMENT AND NA'i"'lf1LAL RESOURCES (11=14-R)
NOTMCATXON O.V MTENT TO CONSTRUCT A 9L0SBD_7L.00P_ GEOTXWXMA.L
WATM ONLY INJEC1ZON WEUSYSTEM
Sat Accordsace ►►'ftlt tht ploOd ms of NCAC Title I5A: 02C;o204_ ,plesM
cowlete d{ s =tificatiou and snail to address on the back page (please FAnr or MLpe Faform Q.
DATE: 9-- 22- ta 20
WcUxype Caitrrmuliow Does thapmposed system circulate potable wa#-q-only (no add! dyes) in
r.anti uous piping that compictely laolatea the fluid from the enviroitmeut (La
I�g§%Ll=)? -
Yea X, ;_ Continue completing this form.
No Do Not complete this farm_ Complete other irlC application forms far installing
either SA7 woIl (OM -loop well i potable water into tha qu fer) or a 5QM %wll (olased-
loop .veil containing a ['vas such as It Z, ethanol, or athor antiirccae or corrosion lzbbitmx).
A. TROPERTY OWNER( /AZPLICANT($)
LjzWj ,FMaM Owner Ijstect as property deed (if owned by a busium or gover t ageacy, state r+ame of
entity acid a reprw t$tiva wlauthority for sigoatt�a): �3 i2T .to
.I"M r4 K- �-
1240h*Ir . Pg 12G1A,0.4K
(a) MailiagAddreas; l 010'1 2>Za a K Lr4" 6
atr Vdrr 3 6 PAS IE vvAP $fats: N C Zip Code: -Z %d 4 y County � rH 19
HamdOl cc 'deNo.: 33�-Zy�- �aZ . .77 C -�77-'Ce
Email Address: 6,1.
{2} Physical Address of Well Site (if different thm above):
City: I Sb*.- Zip Cods• County.
Home(Offiee Tele No.: Call No.-
S, AUMOR=D AGENT OF OWNER, TF ANY (if the Permit Applic=t d, oas ,net own dui sabjectpsaperty,
aftuh a letter Tram the property owner aullm6ziuS Agent To iushll and opmn TIC well)
Compaay Name:
CoritactPsrsan d ass
Address:
City: State: Zip Coda: counfr
Office TeleNo.:Cea No.:
iV"to Address of Cnmpny, if Lay- -

r eb, 22, 20121 8:39AM
'tin, 1901' F, 3'
C. WML DZlILLM SIM= TIQIq
CRmpx�vNa�a;Y. �F�_ty�liCa � _
Weg DrDer Contmotoet Name: Jody MUk Nlatihsw Rmm _Mwoa Caw
NC Contractor Ce f ca�ibn IiQ., 2572 A 3,36. -A
Contacf2ersmn. D v1d 3,���,� a VdAX Mftg: ebiaidriStcr MM,-00-m
Address; 1908 Igsmptmz vJII6 Rd._
Cfty: Agmtonvillel Tp Wo; 27020 Claud . Ynd &
C1t 4TeleNo.: 3364634444 CeIINo.: 33&174-W36
D, i33W Mho CMUCTOROr,CR UZON (Mao at th uu &'u=)
C=PRny Nwm; S -
ti01it8Ci� jjf f
'iL T ■ GSd' ti �
�IdLZC4S3: � d i
City. Z!� Coda 2$6 _z� Comty.
Office TdaNc 2* as-1,7b -2-- Cell Nc.; j � R� - 5► a z,^
X, STATZW OF AMICAN't`
prlvaw / a oriel-t: Cammeraiat•. _
State: ^ MunIdPI: Nate Amedma Lands:
Ir. ]Ii=TION CC�UI 4brlr. y descsi�Gho►vziseigy:ctian�cvoll�S3ivirlrrlbe usedy
t L. DC v
Q% e
0. VM'LL COWRVC ION DATA
(f}Propased date to be caas�rcted: �.■ - Number ofbarings;
Apprvxhmts depth of esch boring • .T.JD R
(a) Type of tubing to berwad (copper, PVC, etC)= _ &- . &--Yl
M Wert rasing,. is the %YaV(s) cased? toheck e111ier [ L) Yes ax (b) lea bela%Y)
(a) Yes wyes, then provide cull$ IVW=don Wim
Type: g�alvavixedstecl black steel ptasbia ai6ar (speclSy)
Casing depth: Y= t4 ___--feet (rcferenma to land mhrffice)
Casing oxfords m aabavc ground melees
(b) No ✓
(4) Groutinfo tmaf&iaL s► movndLDS welt caslagaadlcr pfpirig}: ,���,.,a 1� n►`+
(a3 Grout typo: Nrct Cesneat Bcntanitc� attaer (9p.C�']
} D=aut plarema3t: P apingr praS=6 Clzher
(e) Graxsf depth p tv6aag [rG#ereuct to tad surfer a}: from
If NVall Us cling, indicate grant delrth: from

r'Feb.22. 20121 8,40AM No.1901, P, 41
V. 1W=CU01q titLATRD'EQUMMWT
At c.b a diagram shorting the ea&eering Iayout or proposed madifi.�tf an of the i:rjoctsrni equi�xnptt at]d extariof
pipmViubing associated with the injecdDn aparaflarL The manufactmW s brochum may provide supplementary
hiftmallon. -
I. LOCATION OF WELL(S)
A.ttacb tw copies of maps 4towb4the s!allo+vistg Mien:
(1) Laobxle a SN Map (can be dram) sho%viag buUdings, propaly lies, surfaco watai bodies; potential
sources of groundwater contarrdnatton and tha orientation of and distances B etween the proposed wa (s) and
any existing wells) or waste. disposal UfitYas suah.ss septic teaks or drgin 5PI& located wift 200 feet of
Liza geotherasal heat pimp Wall syaTem. X.abei, al! features dearly sad inc a ►v
(2) The Site Map must stow the subject propeny in relatfoa to the sw mnft rice by using at least Wm fixed
rafsreme poiats such as roads, streams, sndtar WA vty ivwtw ions.
3, CUTIRCA'IxON
Note: Tbis ParmU Application must be sigaed'by q_ah parson appaWng bm the
recorded legal property $eed.
"I Eby cep', under pamityy of 1mv, that I have pw&om ity examined and errs familiar with the infbMAtlon
submitted in f ais doaumeut and all attachxoants thhrdo and that, based ca nca fn t*y of those indh idvsts
imaaediately respomibls fbr o?aInasg said irifD mxdon, I beJicvo that the mfarlr anon is true, acamate and complete.
I am awaxt that that, arc signifrzant penalties, including the posszbility of tines and impriscument, for sobMf ft9
Bill informadoa. I go= to cnnstt of operate, melatain, xepait, and ifapplicaW abatadon tiro lWeodou WOO and
all rotated appwteauaces in accordaueo w6tho approved spa ficadons d caaditia�gs of the Permit:"
Signature ofProperty 0W7Y 4P;&tetat
14E Ye. d 9 rt Cr )4. d"A 12 U �VA� Jam!!
Mat or Type M Name said title
t ��.rr�1 � 1�_j�"f�ldd►� �.
Sipsium ofFxq=V Ow nerfAppll aW
Print or Typo InIl Name and He
igature of AutboxiimdA&W, if azy
Pxtat or Type kill No= and title
Please room tiro eopim of the completed Application package to:
Worth CaroU= DZNR I WQ
Aquifor r "otoction Secdou-Mc Program
1636 Mai] Service Cwer
Ra1e19'b, NC 2y699-1636
Teolephfte. [phone]

Feb, 22, 2012 8:40AM
No, 1901 P, 5
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