WI0500322_GEO THERMAL_20101202

Permit Number
Program Category
Ground Water
Permit Type
WI0500322
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
David and Cynthia Foster SFR
Location Address
108 Chandler Ct
Littleton
Owner
Owner Name
David
Dates/Events
NC 27850
Judd Foster
Orig Issue
12/02/10
App Received Draft Initiated
11/30/10
Re a ulated Activities
H e at Pump Injection
Outfall II.II I! p. r.
Scheduled
Issuance
Cent ral Flies : APS_ SWP_
12/02/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville
Major/Minor
Minor
Region
Raleigh
County
Warren
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
David Judd Foster
1863 Turner Rd
Mebane
NC
NC
Public Notice Issue
12/02/10
Effective
12/02/10
27020
27302
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
ATA
NCDENF .
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Direptor Secretary
1 _':'2 2010
David Hester
C)nithia Foster
1863 Tunier Road
Mebane. NC 27302
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10500322
1 D'a' Chandler Court. Littleton. NC 278501
Dear Mr. & Mrs. Foster:
On 11130/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onl
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:
i . 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(02). Additionally, you should contact the Warren County Health
Department as they rnay 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 (919) 715-61 fi6 or Michael.Ro2ersattncdenr,eov if you have any questions.
Sincerely,
ihr Debra Warts
Sunerv-isor
cc: Raleigh Regional Office - APS
APS Central Files - Permit No, WlO500322
Warren County Health Dept.
Y arlkin Well Cornpunv (David Brown)
Lodi Fleming & Cool ink Service, Inc f Louis April utto)
Corbin Construction (Sitr Cutts)
AQUIFER PROTECTION SECTION
1638 Mail Service Center, Raleigh, North Carolina 27699-1836
Lora on.2728 Capital Boulevard, Raleigh, Non'ri Carolina 27604
Phrsne: 915 733-32_'. l FAX 1' 919-715.0588. FA:; 2 9Z-715-6048 Customer Service: 1.877.62 3-6745
Internet: wwrw.ncwalerauaif'•.or.
wn Enua! ODperiuV.'.y , Afrrmriyd.•.t! . i mnloye:
NorrhCarol na
Xaturaiiij

Pant or (ype the respired Warmarion and mail to address ore the bask page, •
October 5
, 20 O cr5 3 .
C /VIC SQw Notifiutivn of 'wag Fora CiLevised 8/2 O )
Nov. 30. 2010 9:00AM YAOKIN +ELLNG COOLING
11/24/200S 20:50 33$-578-01E3 D, VID i FOSTER
•
.No, 639.8 •
RECEIVED 1 DEN f
R
Aquifer Protection'-
NOV 3 0 2O•f .
NC,RTE1 CAROLINA
DEPARTMENT OF ENVIRONMENT ANDNATURAL R.ESOURCES
NDTIFiCATniO i OF IIy7 rJT TO CO1~YSUtTJCT A CLOSED-��DDP
WATER.-ON.LY DL ECTION WELL SYST y
•'��.5
•::c
TYPE 59W WELLS
In Accordance With the Provisions of NCAC Title 15A 02C.0200
DATE:
Well Type Confirmation: Does the proposed system circulate potable war mix (no additives • • :
continuous piping that completely Isolates the fluid from the & Oei)t-
vlosed-1ocp)? P W_a r:;.�. •
Yes 1� Continua completing this form,
Nu Do Not complete this form. Complete other UIC application fare s, inst in ''
sr' _
sifter a SA7 well (a2em-Ioop wdi inlecling potable water into the aquifer) or a5Q 4 vdll (c loop well well containing additives such R 22, ethanol er er antifreeze or co
� S h a5 oth sro-szOt
•
A. PROPERTY OWNER(SyAPPLICANT(S)
List each Property Owner lived on property deed (if owned by a business or government ageiteri pktikrkktigq
entity and a xepres.entative w/aud orlty for signature): David Jn d Foster and Wife. C a r'-. _
(1 j Mai ling Address: i 363 Ipmer It
City Mebano tarn: NC Zip Code: 27302 County: = r_
Home/Office TeleNo.: 336-578-T295
&mail Address: avid f • ¢;bellsouth.rtet Website: ?•"
ft
(2) Physical Address of Wei Site (if different them above): I OS Chandler Court
.a.r:
city: __,Littleton_ State: _NC zip Code: 27854
i.
Hotnol4 ce Tole No,. 33 fr57$.1298 Cell I�o•Y 1fa 3 .9S: _ --, _
D. A.UTROR T.ED AGENT OF OWNER, IF' ANY (if the Permit Applicant drw not.dwn t - 1i*
=c1.1 a letter from the property owner autariz:ing Agent to instiall aotl operate i..i;C weir_ •
Company Name: Cott/MI-ill Construction
Comet Person: S-El Curts t;MA[L Address: c rb tzitiTl end rr:co -- .._
Address: 941 Meadow Lane
City: ktender3on State: NC Zip Code: g7536 Cotmt
.
Office Talc No.: 252-438-420) Cel l No.; 2_79-816 d+44& '.' •
Website Address of Company, if any: www.corbitthi1Is.corn 1. ; i . r- .
sY`. r- f•
Page,1

Nov.30. 2010 910AM YADKIN WELLNG & COCL}NG
11/24/2009 22:5e 3 6-tilts-f11ft DAVlb J FOSTER
IND, 6398: EP:. $3ia
C. WELL DRILLER ]NPORMNTION
Company Name:
Yodkin W:11 Cvmoam, (oc.
Well Driller Contractor's Names David Brown,
NC Contractor Certification No. 2 t ?SA
coma Pers'vn; David E3rstwn
Admit 1 �i1S F(mt tonvtile Road
City: F.Afontonville Zip Code: NC County:
Office Tele No.: -4o Cell No_:
D. EAT RCM? CONTRACTOR INFORMATION (if different tbiazr drfIea)
Company Name: _Louis Heating and Ceoliaz Service. Inc_
Contact Perso t i ss: atrisair l el
Address: 5813 Lease Lane
E.
City: Rale•i,zh. NC Zip Code: 27617 County: wake
Oita Tele No.; _ 919-78I-8455 Cell No.:
STATUS OF APPLICANT
Prime: . Federal:
5taty -- — M'micxpal:
F. INJECTION iitt)CEDT RE (briefly describe how the injection well(s) witl, be used) -
C Ir'CG Iai_. a -1• 4,- oin ly
G. W.PLL CONSTRUCTION DATA
[l.) Proposed date to be constructed_ Ott.c. 2'' Number afborings: -+
Approximate depot of each boring (feet): 3 0 i}
(2) Type of robing to be used (copper, PVC, etc): ) "pc- r i + S�
(3) Well casing. Is the wells) eased? (check either (a.) Yes,as (b.) No below)
(a) Yes if yes, then pcvvide casing informaaian below
Typeaalvaxiized steel _ —black steel plastic other (specify)
Casing depth: From to feet (r±.ferettce to Jand surface)
Casing eistends to above ground •___, inches
• (b) No
(4) Grout tufo (material surrounding well casing and/or piping): 1_Lc
(a) Grout type: Neat Cement $entonite , Other (speu�fp}
(b) Groat placement: Pumping 2‹ Pressure other
(c) Grout depth of tub ng (ret"es'ence to land surface): from 3to _ -
Uwe has casing, indica= grout depth: from . to
GPXJNIC SOW Nen5mtion of taw Form (Revit.a 8f2.648)

Nov. 30, 2010 9:00A3M1 YADKIN WELLNG & COOLING
11/2a/2005 20tSEJ 336-bf1J-b4ted DAVID J FOSTER
H. INJECTION -RELATED EQUIPMENT
No. 639E
Attallh a diagarn sb,owitsg the engineering layout or proposed modifca ion of the injec3io,t equi rdeii'and tenor
pipinpubing associated with the injection operation- The manufacturer's brochure may provide suppternensasy
information.
L LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Inctude a Site Map (can be drawn) showing buildings, property lines, surface i odies, • potential
sources orgraundwater cotarstinalion and the orientation of and distances between the*pae wetl(.$) at d
any existing wells® or w'a3te disposal facilities such as septa tanks or drain fields lvcUpwit Oct feet of
the geothermal heat pump well system. Label all features eiezrly and incligle a north .arro* -_ .
•
(2) The Site Map must show the subject property in relation to tine surrounding arca by'using 01 least two. fixed
reference points such as roads, streams, and/or highway intersections. .
a CERTIFICATION
Nett: This Permit Application roust be signed by eneh person appearing on the - �•
recorded Jc ai property deed.
"I hereby certify, under penalty of law, that I have personally examined and ern fandar With the itifotrAation
submitted in this document and all attachments thereto and that, based on my inquiry o#'=t;Fsase lud[v!iduanit
immediately responsible for obtaining said information, l believe that the information its axe, aec ate lad iplete.
1 am a.ware that there are significant pehzalties+ including t sskbthty of fakes and tin rtsonm
Fn P �bma�$
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon they-injeotf it and
all related appurtenan es ifs accordance with the approved specifications a:k�j. cbndiiions of the -Pi rm>~t"' ;•_ : '
RECEIVED / DENR J AWO
Aquifer Protection Section
NOV 3 0 2010
Signature of Property nor/Applicant
Paint or Type Full Nal= and title
Silts of Property Owner/Applicant
� a ,4,LM / #4r
Prukt Type Pull Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
please return two copies of the completed Application package to:
North Carolina DENR DWQ
Aquifer Protection Section-VIC Program
1636 MaU Service Center
Raleigh, NC 2769-i636
Telephone {919) 733-3221
OPVII,TIC 5QWNoiitaalion of intent Farm (Revised 8/2008)
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Nov, 30. MO 9: DIAM YADKIN WELL
O r'p-
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No. 6198
•
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DK1N WELL,
Nov, H. 241 4�_ (YAYA 4 J ijrje.
43
ADinESS: yam' 0 / LE.1i-e, L..
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ans NUMBER: �1 ' -- ��� $ Nr
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No. 639E
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Nov.30, 2010 8:59AM YADKU WELL ,
FACSIMILE TRANSMISSION FORM
DATE: al / &/i D TIME: REF. NO. LOG NO..'
TO: D
COMPANY NAME -
ATTENTION
FROM: C%kt POP ( C
COMPANYE _
INDM>7L
DER
WAWA OF PAGES PLEASE ORIGINATOR'S Y a
INCLLID1NG THIS SHEET REPLY BY GNATURE
MESSAGE:
•
"FOR ALL YOUR WATER NEEDS'
YADKIN WELL CO., INC-
1906 HAMMPTQNvILLE ROAD
1•lAMRTONVILLE. NC 27020
DAVIO J. BROWN, VICE PRES.
TOLL FREE L9QQ- 246&9355
OFFICE (3351 4E54440
FAX (336) d684048
RES (3351 435•46S9
COD NEWS AMER1CA • COD LOYGS YDt!'
1%r I DEN R r nrA:= • 7:
NV/ go srur.
Coro_
J-•ti.
PLEASE INFORM u5 RamEDWILY {FDo tor ieC IAC64F1A.1:; .,