WI0300170_Regional Office Historical File Pre 2018

Permit Number W10300170
Central Files: APS SWP
03/28/11
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SVV Rule
Permitted Flow
Facility
Status Project Type
Active New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Jason Shade Burgess
Owner
717 Mt Vernon Ave .
Charlotte NC 28203
Facility Name
Jason Shade Burgess SFR
Location Address
723 Mt Vemon Ave
Charlotte
Owner
MajorlMinor Region
Minor Mooresville
County
Mecklenburg
NC 28203 Facility Contact Affiliation
Owner Name
Owner Type
Individual
Jason Shade Burgess Owner Affiliation
r:atelEvpnts
Orig issue
03/28/11
App Received Draft Initiated
03/11/11
Regulated Activities
Scheduled
Issuance
Jason Shade Burgess
Owner
717 Mt Vernon Ave
Charlotte
Public Notice Issue
NC 28203
Effective Expiration
03/28/11 03/28/11
Heat Pump Injection
Private residence. single family
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin

03:`2:8, 2011
fasc�n Shade Burgess
Elizabeth Donaghy Burgess
717 Mt. Vernon Ave,
Charlotte;,, NC 28.3t733
0edgement of intent to Construct Type 50W Injection \Veli S stem
W'10300.170
ernon Ave,
Charlotte. NC 28203
Dear Mr, and Mrs, Burgess:
On 0311112011. the Aquifer Protecttotr Sectiort (A3'S1 received n _.
geothermal injection well system for the operation of a ground -source lte.at pump loea.ted at the address referenced. above, n
individual permit is not required for the c"onstruc.tion and operation of thra type of geothermal injection well system as long as the
following, conditions are met:
1. The injection well system e.crntains only potable wyater.
The injection ct"t Il' ss
Carolina .Adrninistrat
constructed in accordance with well construe
1 SA Section 2C Subchapter .0213. and
3. The required notification t"orm and associated maps have been completely and accurately submitted.
Failure to compl,with all of these coatlitivns constitutes a of the North Carolina Well Coruction Act atetd North Carolina
Adtninistrattve Code Title 15 i, Section 2C Subchapter .021 llu$(2' Additionally, you should contactthe Meckienhurg County Health
Department as they may have additional requirements for this type of y'stem. Noncompliance with applicable: state, count. or
municipal. rules and regulations may result in the
P&ease t.c ntact Mike Rogers at (91.9) '
ytc oresv'rtte K.et t[rtrat alit"tc
APS Central F ilei . Permit No. W10300170
ltlecklenburg County Health Dept.
David J. Brown (Yadkin Well Co., Inc., 1'708 llamptonvilic Rd., Hampton
Geoff Eloge (Ross SiWitmer, inc.. 4620 Rczzeiies Ferry. Rd., Charlotte, NC 28216r

Mar.11.' 2011 8:06AM YADKIN WELL
No. 7170 P. 1
a
8
AMPAD llEOFiDERNO. 23-031
FACSINIILE TRANSMISSION FORM
DATE: -g / i / *2)3t.(TIME: .: REE NO.
TO: Pc b
FROM:
COMPANY NAME
QAertGv G (.i +a
ATTENTION
COMPANY NAME
DaG,'
�rowtl
LOG NO.
)q23 - 7 14/3
FAX NO.
DEPE
PLPASE
n pawn
L I IMMEDIATELY '
Mttc,. (2K) fice - cid S'
FAX NO.
DERE
NUMBER OF PAGES , C PLEASE ORIpNASO� INCLUDING THIS SHEET REPLY BY SIGNATUREbarj
MESSAGE: '
INDMDUAL
so Jo
- Ear
PLEASE
LI RE
97
l-L
"FOR ALL YOUR WATER NEEDS"
YADKIN WELL CO., INC.
+9p8 MAMPTONVILLE ROAD
HAMPTONVILLE. NC 27020
DAVID J. BROWN. VICE PRES.
TOLL FREE (ROO) Zs8=9355
OFFICE [phone]
FAX [phone]
R9 ;336) 46B-4659
•"coa0 NEWS PMERIO0. • GOD y4YE5 YOU
PLEASE INFORM US IMMEDIATELY IFYOU DO NOTREC1 FAc-SIMILE TN FULL

• Mai,11. 2011 8:07AM YADKIN WELL
r lD Na.71J0 P. 2
NORTH CAROLINA
DEPART ENT OF INVIRONMENr AND NATU ,1, RESOURCES (NCDEMit)
NO UC&TLON O17INTP' TO CONSTRUCT A cLOStNLOOP GEOOAL
WATER-OMWATER-OMV I NJECiTON NM/SYSTEM:
TYPE 5-OW WELL(S)
In. Accordance vith tte provisions ofNCAC Tile 15A:82GONQO,
compl* thisno4fation and mall to address milt pege(pleaseNat ).
DATE: -7 20 i1
Well Type CanjirmmYair Does the proposed system, circulate potable watier oltiv(no adthtives) la
continuous piping that completely isolates the florid from the environment (Le.
elascd laop)"
Yes X . Continuo completing this form.
No . Do Not complete titss.fosm Coroplete other UIC application forms for in t ling
either a SA7 well (r p 400p will iQ i g potable water into the aquifer) or a SQM we1J (c10 d-
loop well containing additives such as k 22, ethanol, or other antifreeze or cc zTc lion inhibitors).
A J ROFERTY OWN (S'j(APPL/CANT(S)
List Property Owner listedottptopt ,deed owned bya busirs govezamentagenessmxsomeof
entitytad s rept rotative era o y firsignature): v or, .7 e1ack Bv.t
(l} maw Adams: V VI. : V gyp\ OA AVE,
city: C. sttam G ,2:p Cote: �� 2 03 coupty;111.1Ail6trj
limn:fOfacWo-3-3`1 `1 - G No: di� 5.33-a2
BanalIAddress: jsSor%):"k 0 et •Lc + Washer .
•
(2)' FhysicaAdamsofWellSite(f£d'i fezuntThanabove):1M \ .rnor Ave -
city, C G stet. Caip Code: a7203 c y:l e.clilkiA\ON
Rome/Office Tale No.:'}Di-33•7- -Rs 4Liz Goalw0=-OM-C33--2.yt;3'
B. AU HORUZZD AGENT OF OWNER, IF ANY (iflhe Pcr,Ztit Appiizint does_not own the sabj ogpxoperty,
attachaletter front the pv?wty ewattr autfiathingAgentto 9asra11 ei i bp9-40 XITo well)
CompanyNtmus:
Contact PersonEM6,3I„ 4ddress:
Address:
Ckty: State: Zip Code: City:
OffrceTek.No.: -- Cell No•
WebsitoAddr ss ofCompany, if any-,

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• ' Mir. 11.+ 2011 8:07AM YADKIN WELL
No.7170 P. 4
II INJECTION -RELATED XQUIEMENT
Attach a diagram sbowing the epgineerig layonf or proposed modid on of the injection cquipmcmtand e,dor
piping/tubingmeted with tie injectiMi operation. T ratcaufacturefs b ochm•e may protade supplementary
L L$CAT M OF WELL(S)
Attach two copies ofagaps shOwiug the fallowing information:
(1)
include a Site Map (can be therm) shall/kw buildings, property fines, surface water bodes; potential
sources of groundwater contamination and the orientation wand cbces btiveeathe proposed well(s) and
any mining well(s) or waste disposal facilities such as septic tabs or drain fields located -vitf 200 feet of
the geothermal mat wall system. Label all Raman et:* and denude a'Kalb tnrpnw.
• (2) The Site hilitp toast slow the subject pa:petty i 114W:ion to the sairoamdiag areaby ruing atleash.fixed
tegreacepoints such as roads, streams, asidfor highway int ons,
T. CERTWICATION
Notes This Permit �cm• =t t be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, tinder penalty of law, that I have personally examined and am famiilia'r with the infOonation
s> eel in this da ument and all attachments thereto and that, based oa my ingniry of those individuals
immediately responsThle for obta dagsaid information, I believe thatihe informaticutis true, accurate and complete.
I am TM= that there are significant penalties, including the pity of EONS and impriseamam for robing
false information- I age= to cuastruct; operate, mania, repair, and if applicable, abandon the injection well, and
all related appurtenances in accord= ' cations and conditions of to Permit
Sig riatme�f ropetty 0 - Applicant
t' �reSS
.has S
Type Pull Nam d title
Sigaadue • ' operty ch er/App1i
E1 1i J L- r ej.5
Rri or Type ult name and tit
Signature of Authorized A g n ifs,
PriOt at Type PullName =d title
Please retool two copies of the completed Application package to:
North Carolina DENR DWQ
Aquifer Protection Section-TiIC Program.
1636 Mali Service Center
Raleigh, NC 216991636
Telephone (919) 71S-6935

Mar. 11. 2011 8:08AM YADKIN WELL
No. 7170 P. 5
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Mar.11. 2011 8:08AM YADKIN WELL
No.7170 P, 6
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Phone Nor:
Address:
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