WI0500267_GEOTHERMAL_20100609

Permit Number WI0500267
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (SQW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Mike Yeska SFR
Location Address
3916 Rowan Walk Ext
Hillsborough
Owner
Owner Name
Mike
Dates/Events
NC 27278
Yeska
Central Files: APS_ SWP_ >
Permit Tracking Slip
Status
Active
Project Type
New Project
06/09/10
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Mike Yeska
Owner
819 W Pine St
Johnson City
Major/Minor
Minor
Region
Raleigh
County
Orange
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Mike Yeska
Owner
819 W Pine St
Johnson City
TN 37604
TN 37604
Orig Issue
06/09/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
06/09/10
Effective
06/09/10
Expiration
06/03/10
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
NA
NCD ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
Dee Freeman
Secretary
Mike Yeska
819 West Pine St.
Johnson City, TN 37604
6/9/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0500267
3916 Rowan Walk Extension
Hillsborough, NC 27278
Dear Mr. Y eska:
On 06/03/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
geothennal 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 .021 l(u)(2). Additionally, you should contact the Orange 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.Ro gers ramcdenr.1w v if you have any questions.
~~~D
forDebra~
Supervisor
cc: Raleigh Regional Office -APS
APS Central Files -Permit No. WI0500267
Orange County Health Dept.
Bobby King (Scoggins & Co., Inc., P.O. Box 3050, Durham, NC 27715)
Kevin Letchworth (N.W. Poole Well & Pump Co., P.O. Box 1958, Wendell, NC 27591)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard. Raleigh, North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportuniiy I Affirmative Action Employer
Ni~hCarolina
/Vaturall!f
,.
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RECEIVED Nf '1514(1
AOUIFFR PPIITFt'flr SFCt!OMI
.SUN a Ma
`;'rs i t ill al►i OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5[,0W WELLi$
In Pu:eordance With the Provisions of NCAC Title 15A 02C-0200
Prou or type the required information and mail to address an the back page.
.6)10 a y�
Carlrmation: Does the proposed system circulate potable water onb (no additives) in
continuous piping that completely isolates the, fluid from the environment (i.e.
closed -loop)?
✓ Continue completing this form.
Do Not complete this form. Complete other UIC application forrus for instilling
either a 5A7 well (open -loop well intecung potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
OWNER(S)/APPLICANT(S)
_ ,s>' z:N_11. Property Owner listed on property deed (if owned by a business or goverrunent agency, state name of
6% r dd
wsi [L i11[3 a representative w/authority for signature): t1 !tom
mailing Address: B r q _oar RAIE ,5 . city: +i-OHM`�r !-1 CI Tr State_ ,DJ Zip Code: _SU 014 County:
Ilome/Office Tele No,; Cell No.: (128)
Email Address: It161:-e.. SliCu @ridic 7.r0,Website:
Physical Address of Well Site (if different than above): _.I/4 EIr'#14 pi/41.X Eh7 Ti-17/Cs+/
City. H1LL53RDaG 4 State: NC Zip Code: 7.) ZS' County: - MG
l-forne/Office 'Telex No.: _ Cell No.: Ce 2f s - CSQ 2
ilT11OR.1ZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property
owner authorizing Agent to install and operate UIC well)
Cu_nipa1»' Name,: _ 64 0_06 4a� > ea, /i1-4 �.
+votritu Person: Zoi3Br A
'PC/R.-HAM State: /JC Zip Code: 7745- County: UJt 4AP 1
EMAIL Address: SO4: vCe:K611 r(es1411-091.1
GF.dc.eTele. 3,8Z— 01
rhsi to Address of Company, if any:
au No.: lit - - ` 8r7
of Intent Form (Revised 8/2008) Pabt. 1

C.
DRILLER INFORMATION
Nalne
RECEIVED r DENR I DM
AQU gR •PRear- 'T N gFCfl
ON
JUN 0 3 2010
r.de Contractor's Name.: 1Y. I.1 P€. t- t'LLL 4- pow? Co
Certification No.: 257'14
. _.„_ _ erson_. -&'4/04 Ljurcht tacg.,711 EM.Ark Address: Li 7Q/ 1-Ji // e - /d W iPea.6 0./at
,.:7 P.0300 19,8- -- - `'►
to ELL_ Zip Code: 2-7517 I County:
c;Y `gin. gig- - 9z23 Cell No.:
-.- . '::Tali CONTRACTOR INFORMATION (if different than driller)
Louroativ Name: SC06&/,-I5 d co. 114C,
-_;:iltaLrPerson: goti j Y 4*1 err EMAIL Address: 11 k1►JG S we-6/Ni e Ace. Cc101
:'.attf a tis: 1�. O- a93i SOS-0
n- ?.046 if/u1 Zip Code: _ Z77/5- County: ZA/''1 N
fete No.: 1 �38Z—Q534'7► Cell No.. 1- 730-Szig,
y::_:'L-tJS OF APPLICANT
Federal:
Municipal:
Commercial:
Native American Lands•
PROCEDURE (briefly describe how the injection well(s) will be used)
CONSTRUCTION DATA
-t=q,. i ed date to be constructed: 4.70i 200 Number of borings:
Approximate depth of each boring (feet): 2? P
fype of tubing to be used (copper, PVC, etc): p C<
W e.I1 casing. Is the well(s) cased? (check either (a_) Yes (b.) ?lo below)
k,A, its if yes, then provide casing information below
Typo: galvanized steel black steel plastic other (specify)
Casing depth: From to feet (reference to land surface)
( smg extends to above ground inches
x
Grout tufo traterial surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite Other (specify)
(h) Groutpiaceraent: Pumping X. Pressure Other
(e)
Grout depth of tubing (reference to land surface): from 0 to 2-00 (feet)
if well has casing, indicate grout depth: from to (feet)
N ^+in ation u{ 3niesS Form (Revised 8t2008 i
Page 2

RECEIVED f DENR I DWa
MUM PRl1TF(..TIM gFCT IO 1
JUN 0 3 2010
_, -RELATED EQUIPMENT
.. diagram showing the engineering layout or proposed modification of the injection equipment and exterior
b i associated with the injection operation. The manufacturer's brochure tray provide supplementary
..:; : t�` WELL(S)
Copies of imps showing the following information:
.,>_Itscte a Rite Map (can be drawn} showing: buildings, property lines, surface water bodies, potential
ticces of groundwater contarrrinatiun and the orientation of and distances between the proposed wefts) and
a.: Cxisting well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
gv3 i ai-rn i1 heat pump well system. Label all features dearly and include a north arrow.
_ ie Sire ivlap roust show the subject property in relation to the surrounding area by using at least two fixed
c_i;:rence points such as roads, streams, and/or highway intersections.
oThis Permit Application must be signed by each person appearing on the
cei.�rrded legal property deed.
"t c v certify, under penalty of law, that I have personally examined and am familiar with the information
si.i•mizted itt this document and all attachments thereto and that, based on my inquiry of those individuals
lrt'.L.x!iakly rc-spoasible for obtaining said information, I believe that the information is true, accurate and complete.
,_ w:'.rc that there are significant penalties, including the possibility of fines and imprisonment, for submitting
if3 srraation. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
appurtenances in accordance with the approv spe ftcati tel cpnditions of the Permit."
�.�
Signature of Property Lwner/Applicant
f c 14 L L V(5}'C4
Prier or Type Full Name and title
Signature of Property Owner/Applicant
Print or Type Full Name and titic
Signature of Authorized Aunt, if any
Rae -ET Lao -WO a. ►.rg
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699.1636
Telephone [phone]
N/fi!Y,._, 6.03 ui imam Morro {Revised 8/2002) Page 3

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RECEIVED / DENR / DWO
AQUIFER PRflT-f W*J S Cfl N
JUN 43 2010
NORTH CAROL NA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
v: `_-Tffr ICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5OW WELL(S)
In Accordance With the Provisions of NCAC Title 15A 02C.O20O
Print or type the required information and mail ro address on the back page,
t::anfrmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.c,
closed -loop)?
Yes Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open loop well infecting potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
_A. PROPERTY OWNER(S)IAPPLLCANT(S)
Li. 4auh Property Owner listed on property deed (if owned by abusiness or government agency, state name of
idly and a representative wlauthority for signature): MiKa. i CS
Mailing Address: gig 065T FP -IC 57
City. tri2/1M410l-1 C!7'f State: TM Zip Code: 76 07 County:
Home/Office Tele No.: ,,11 Cell No. (8 8) S-�I�- a�'[7 Z.
Rmait Address: _i 1+ 1(441tSl@-'I1.iog,ta.Website:
Physical Address of Wei] Site (if different than above): 3 !1 ‘ 1201.4foci wll< (7G_47Ic/
City: 11LL k6R,Q614 -- state: Zip Codef. 7f County: 0P-40Q E
Home/Office Tele No.: Ceti No.: 0210 sits-- a5 2 2
B. AUTUOR[ZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: �C 0661ji,4 C& */ G, - - -
Cantkia Person: e 3 5t X 11•1� EMAIL Address; BO* sag-ci'/4s Ia.WM
Address: pa.Beht .0,5C
(14: paSlate: flC Zip Code: Z7715 County: FilZi-Wei
Office Tele No.! 519 — 382 - Y 3 51 Cell No.: j 1- - 0
Y?5'tbsitt Address ofCornpany, if any:
Naritiiatioa of Intent Form (Revised 8C2008) paw

RECEIVED I DENR t OWO
AQUIFl=RPRnTi::f.TION SECTION
JUNO 3.2010
DRILLER INFORMATION
. ~J,•:),my :·~mni:': N. Wf ~ lt!tftl."" pw,p co,
:!, Un lkr Contractor's Name: /II , 1,../. P(X)LG 1,./£1.£ ~ P</Mi> CO,
... ,_:)l!crn<.:wr Certification No.: ---~2£i~~l_'-/~A~----------------
_ ,;;::,:, ?ernon:,__«(I/H (.17 4{ W(/;L 71/ EMAIL Address: L l:7ct/~H 4-NIJPt,{J(,Cl,Jt;Jl
.··_,.:~•,·,,< ____ P.O:..f.,()x..~~iq ___ 5"8~-------------~
i,Ji.£;../0!£Ll-Zip Code: Z.7$:1 J County: ___________ _
::,:'i::1;'[ciei\'o.: qJ9-2"-q22,3 Cel!No.: _______ _
... _ .. ':i:'':::1\fP CONTRACTOR INFORJ.\,IATION (if different than driller}
;,_~c,mpa11y Name: S COG-v/NS J-CO, /1...JC,
,:.:ouiau Person: BO-e,B T JLl✓..J G-EMAIL Address: OK.IN? SC06.fr/N~£ M.COM
_.\-:l.d.re.s~: 'P.fl. '8{.hL 30S-O
Cit: 'J)(.lµIIIM Zip Code: 217 IS" County: ~W,~· ~rg._~· ~H._,_,,'ll-=-11.....__ ____ _
C'L'i s:;.: leleNo.: ~J.8-Z-05"3'1 Cell No.: '-II'[-130 '"S:iec}
STii. TUS OE' APPLICANT
' ..... -Federal: Commercial:
Municipal: __ Native American Lands: __
•• [,i1, PROCEDURE (briefly describe how the injection well(s) will be used)
CONSTRUCTION DATA
i'ruposed date to be constructed: J(I/J/i:. 2Plb Number of borings: ___ _
il..pproximate depth of each boring (feet):___ 2ft) Ff,
Type of mbing to be used (copper, PVC, etc): ~P~tl_C-__________ _
Well casing. fa fhe well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes if yes, then provide casing information below
Typ~: -~galvanized steel __ black steel __ plastic __ other (specify)
Cm;ing uepth: From ___ to ___ f.eet (reference to land swface)
(:a8iJ1g extends to above ground ___ in.ches
fo 'l No X,_
Grout lnfo (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite Other (specify) _____ _
(h) Grout placement: Pumping_}(_ Pressure __ · Other __
(c) Grout depth of tubing (reference to land surface): from O · to ~(it} (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
C !'!J II of Intent Form (Revi$!d 8/2008) Page 2
aELATE17 EQUIPMENT
- -i :.: diaEram showing the engineering layout or proposed modification of the injection equipment and exterior
'.'ollnne associated with the injection operation. The manufacturer's brochure may provide supplementary
RECEIVED DEW f OM
JUN 43201D
JP WELL(S)
�ti 3 conies of reaps showing the following information:
.:elude a Sire Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
• ounces of groundwater contamination and the orientation of and distances between the proposed well(s) and
wcisting well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
veotherrnal heat pump well system. Label all features clearly and include a north arrow.
rve Site Map rnust show the subject property in relation to the surrounding area by using at least two fixed
/rat: 'Alec points such as roads, streams, and/or highway intersections.
'lhitic Permit Application ntust be signed by each person appearing an the
recorded legal property deed.
l:rretmv certify, under penalty of law, that I have personally examined and am familiar with the information
a ;~^tined in this document and all attachments thereto and that, based on my inquiry of those individuals
i:i:,_?r� iatety responsible for obtaining said information, I believe that the information is true, accurate and complete.
•i anti: iwa;:: Lhat there are significant penalties, including the possibility of fines and imprisonment, for submitting
L.,: information_ I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
appurtenances in accordance with the appro spe4.jfications • d c nditions of the Permit"
Signature of Propertywnar/Applicant
J1n C. EL VE,51 -
Print or Type Full Namne and title
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Aunt, if any
Print or Type Fill Name and title
Pease return two copies of the completed Application package to.
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
ailment Form (t;evi. d $RUGS] Page 3

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