WI0400245_GEO THERMAL_20120409

•
Permit Number W10400245
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Injection Water Only GSHP Well System (SQW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Carl Edwin Seager SFR
Location Address
8 Elm Rdg Ln
Greensboro
Owner
Owner Name
Carl
Dates/Events
NC 27408
Edwin Seager
Scheduled
Orig Issue
04/09/12
App Received Draft Initiated Issuance
03/19/12
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULt
""
Central Files: APS_. ·_· SWP_
04/09/12
Permit Tracking Slip
1.00 Individual
Permit Contact Affiliation
Carl Edwin Seager
Owner
8 Elm Rdg Ln
Greensboro NC
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Faclllty Contact Affiliation
Owner Type
Individual
Owner Affiliation
Carl Edwin Seager
Owner
8 Elm Rdg Ln
Greensboro NC
Public Notice Issue
04/09/12
Effective
04/09/12
27408
27408
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
Govemor
Carl Edwin Seager
Leigh Seager
8 Elm Ridge Ln.
Greensboro, NC 27408
W
1 4) r) .fir I +V
.-�1 �� r' i-
Director Secretary
04/09/2012
Subject: Acknowledgement ofIntent W Construct Type 5QW Injection Well Systtrn
Permit No. W10400245
8 Elm Ridge Ln.
Greensboro, NC 27408
Dear Mr, Seager:
On 03/19/2012, 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 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 .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 Miehael.Ror*ers amcdenr, ov if you have any questions.
inecrely, ` Q
for eb `a Watts
Sup rv' car
cc: Winston-Salem Regional Office - APS
APS Central piles - Permit No. W10400245
Guilford County Health Dept.
David I Brown (Yadkin Well Co., Inc., 19,08 Hamptonville Rd., Hamptonville, NC 27020)
❑tens Vorontdova (Green Horiwn, 619 Foster St., Durham, NC 27701)
AQUIFER PROTECTION SECTION
1636 Mail Service Canter, Raleigh, North Carolina 27699.1636
Lvcatron; 512 N. Salisbury SL, Raleigh, North Carolina 276p4 One
Phone: 919-8Q74464 � FAX:919M7-6a96 N��th�aro�il�a
Intemat ww�M1 R�wg 9�jG8fItY,4�4 r
An EVal OpponunRy +Amrmn&e Adon Fmpkyer r ' - - - - -- - -LF

Mar. 19. 2012 10:21AM
No.2030 P, 1
.a
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4
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FACSIMILE TRANDLSSION FORM
DATE: �� TIMe REF NO. LOG NO,
COMPANY Nwt
T_ n ►
PLEASE
❑OELNER
IMMEDIATELY
COMPANY NAME �FAx No. PLEASE
1) � &f R� L� �e W �n ❑ REPLY
INDIVIDUAL DEn
NUMBER OF PAGES PLEASE Ip(iQ___-IH�CB
INCLUDING THIS SHEET Rev 6Y-
MESSAGE:
-FOR ^66 YDUK WATER N$ECS'
YADKIN WELL CO., INC.
IWO NAMPTONVIL.L.E ROAD
14AMPTONVILLE. NC 27d2O
DAVID J. BROWN. VICE PRES.
TOLL FRIEC 1W01 Z4"355
OFFICIr t3361 468a440
FAX [phone]
nE5 133a, 4a.b4859
`6000 mrwirs hNENICA • 000 6Qv1& V"Y
a
FAX NO
AR 1 9 Z012
-►4quiter Prote0on Section
PLEASE INFORM US IMMEOMMY IF VDU DO NOT RECEIVE fACP1nAIN FU +. �-
` CI- NG DENE F&a pool/gas

Mat. q, 2012 10:21AM C 2- No.
ht[NORTH CPY O'L OVA
DEPAR?MLNI T OF ENVIRONMENT AND NATURAL RESO URCES (KCD]rNR)
it]�J uf u.'1'ENT TO CONSTRUCT EL
i Pe'r1T:ER t3?►iLY It �fi3:L�'CI'Y4]N -V'4'EL 5if$TT+.I>:
TYPE 5-OW IELL(s)
la1 f�tCnffla�lC? �!` [I] thiP pr6S'15:L'^c of NIl l' !7 1-:ti? 15 .
coi�pic[e lies ;:atidraGoai. mid mai! to address on tl,C au�k pogo (pfecse 1v[W o. TAiutautior}.
DATE: _ . A A941'4 +' ik � 26J_
Well Typs CoVirmatiou: Does me proposed s. sip circulm potable Wter only (no additives) in
aoetauous piping that conipl-rely isolates the ikJid from d1c onvko:mii—Alt (Le.
Close,�lo42)?
Yes �XL Contimur. coniple.ing this form.
No Do Not co,-Dpletetrjs fNo jn. Complete other TIC eppl:radan forms for iz�staliiag
either a SA7 well (operl loop well iDlect+ pota.blo water into the aquifer) or a 5Q1M well -,'closed-
loop weli contaWng 'vs such as R-22, ethsnoL or Wu r act&cara or corrosion inhibitors}.
A. PROPERTY OWNER(S)IAPPL;CANT(S)
List Mh Properry 0%vner lasted oa property dead (if owimd by a b ens or gov==ont agency, sWe name of
entity and a rsnresentstjVe wlsvtbority far slgnsture): L<3i41 "NaE FI C�,�„4! � —aga
(1) WUM3 Address;
C t; : 1«� _ 5tatc: C ;p Code:, �' Koh County:_ 6 4uc .Lax,-) .
HomelOfSaa Te10Na.: 9 s' - iV ;�
EmaV F ddrass: Webtite:
(2) PvyTicM Addn= of We11 Site (ifciSffor�t tban Above):
Cite:
Ho-M1ei0ft1CG TCIe No•: _. .
State: Zip Code: County,
B. AUTAO1.IUD A{r'E L OF OWNER, IF ANIZ ;if 410 Pcrmit Applicant Boas not own the subj:.et property,
attaob a lever from the properly oivner $atbariAng A Seat to ir_stall and operate VIC %veil)
CompanpName; , _
Coutact P Qrson:
Address:
City: � wr.. SWC. Zip Code: ,. Cooaty:
Of6coTeieNo.: — C 111 No..,
Website Address of Co,mpuy, i; ny:
RECEIVEMENUM
MAR 19 NU
R�E�+EIV 01 ��ryry ,�_. ' � �W910tection 5cc t/oo5
it ri,�� Ik�'J�'r� �: ��

Mar, 19. 2012 10:22AM No. 2030 P. 3
C. WELL DTICLUR ]INFORMATION
compelnY NMe:_Y�d[c�i �t31 G0. W.
Well Driller Car+traozer's Nanin t�l s MaftZ BrawnMill Cava:
NC Cozaieacter C:crti cat;on Na.; 2572-A 3t33ti-A 48-A .
L:oni&�i Pa rs4�3; David 1. FDrown 2..1Q5. i y , _ ....i 9 Adtirm: _,� iliefdtille c Ea
Addtez:1908 HarAptonville Rd. .. �_.
City., Z12 Cade: 77020. County: YAdkln
Ql'tiae TelOZo.: 336-468-4440 Cell No.: 336-374-V36
D. TEAT PUiV r CONTRACTGR LYFDRMATION (if different lbo a driller)
CvmpanyName:__,_ 6� 4_EW a�LZI _
ContactPerson UQ1Z C,&Mb0V.4 -L,'�d,P,.>Z-Mress: ki-C6 ! 00_r &.' . zoo cem
city: Zlp Cods: ^ ' .' County: b tl4kt9` V!
OfficereleNo'; -'A- J�1- _4rfr GerlNo.. j':" � - 24* - G;c�
& STATUS OF APPLICANT
Slate. mvale3ipal: — native AmwiaanLauds:�
F. EVECTIGN Y3' O�CLDURLi (briefly describe how the iojec5ou walls) will 'be used)
et -La
rrr�ry
G, VMLL CONSTRUCTION DATA Z� r � 7-0 1 Z
(1) Proposed data to be catwatnWcd: Fiw -Number of boxings: _
Approxlntate depth of each boring (feet): 110
CZ) Type oftublag to be used (copper,PVC, eta): #PLIE A?
(3) Well rasing- Is the wv O(s) rased? (check eithEr (A.) Yes g_r (b.) No balow)
(a) Yes _ if yes, then providocasing 3nforwa6m below
Type: _____galvaifted steel. ____black stecL_,.,plasHc other (specify)
Casing deptlti: Pxars_ to �Jteel (refbronce to fa+�d snrfaee)
Casing "ads to shave ground ioeW
(b) N6 f
(4) Grout Info (materiAt surround[ng %wall owing tradlar pipin8): 7t,ra•t 619, R^ikv^ "A
(a) Grant type.- Neat Cameat 13ca anitc Z orher (s}xoify)
(b) L3rout pis=eat: hropi4g-./o 1?RWUM 01han
(a) {trout depth of tubing (rc&aence to land su &w): {feet)
if well ltas casing, iurllcate groin(dept4t: frow ,..— to (feet)
REG MED 03-19-' Zz 08:5T' FROCK- TO- NC DENIM P&S POOV005

Mar. 19. 2012 10 : 22AM
No.2030 P. 4
S. IN3EC'TI0A43ZrI,kTRD EQVnWI NT
Attach a shoving the ea??aatring lawlat or r rapos4d t3lc
piptngi(IWIlIg 4:5uciai_d witil Sle injection apt-atios). The manusaatur;0s brochure may provide supplerrwntary
info:mation-
i. LOCATION OF W Lr.(S)
Aftcb Mo cop;rst of nUps shMVLM the following
information-
,; 14c10u:s r. Site: 24ap (cIIi ue ulaV::ii snowing: buildings, prop�-iy lines, surraoe Wa,= bodies; potential
satt:ca of groutkdwater co:tamirladon ar,d the orientaum of and distances betwmn the prop as0 wel,(s) and
any esisring �iai1[s) or waste disposal ±actlltirs such as soptic ianb or drain i~elds located ivIt1]in 200 fbo of
rho gaothe!'wal Feat pump rv,7ii system. Lahti all features clearly and imlude a a2 nt_ L—Laq,
(2) The Site Map must short+ the subject pmperty in relation to the surrounding veer, by usir-g at le"t hvo fixed
rel�sanee ppirt5 such as roads, st Tsurd, and/or. Wghway interstWoms.
I CER7"YF c4TI0\11
Note: ThioPoY►:ait AppUwfon must be sued by eAAt person appesiIng on the
recorded iaa$1 property dead.
"I hereby certify, tmder p,W1ty of laky, that i have pYrsocally ensinked and am fainivar .rith ine 1dformatiot
submitted in this docmacrtt and nl1 atta6miants thewo and that, basac'. on fny inqu3ry of tliese individuat5
immedletoiy responsible for obtaining said iitfbmlatiets, I believe that the fn£ortmtion is true, accon"tc and complete,
i am a►vare fart flare are significant penold% ine,ud ;g the possibility of fines and Imp-isohmet:t, for submitting
false information. 1 z^rea to cons'rum, opener maintain, repafr, and If applicable, aba.odon tho 1-njoodon w4l and
tr11 related appurte ms,aes In secorrlance with the app ved spy fsau"Ons V4 conditions o3 thy Permf!:'
of Propetty QN►rrrorlApplicarw
Print or 7')po YiA Name and title
84nu4mipertyi �vnexlApp]fcant
e-f —_ �r
i?n'It e ' erns mull Ns, a and title
Si�ftayura o Au�hurlped Apnt, if any
PdM wT3y^►,aFul►Name aadlisia
Please rotors two coplos of tnz compleaea Agpll^don paakege to.
Korth cftrolsna DZNR-f3WQ
Aquifer'Protectcun Sactfoa-UIC Frograu.
1636 M"011 So co Center
Raleigh, NC 27699-1636 RECEIVFDID NRID
TelEephon (9f,�� 7715-6935 F wQ
MAR92D11
' qu4r PM L.,W l Syrian
FECEN FROM- TO- NG DEM FPS F0941M

Mar.19. 2012 10:22AM
.-! ..
() ·-t f I<..,~~
Gvct./1\J "•vo , JJ.c.
No. 2030 P. 5
RECEIVED/DENR/DWQ
MAR l 9 2012
Aquifer Protection Section
TO-NC DENR P&S P005/005.