WI0500323_GEO THERMAL_20101221

Permit Number
Program Category
Ground Water
Permit Type
WI0500323 /
Injection Water Only GSHP Well System (5OW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Stephen & Lori Evans SFR
Location Address
10204 Swan haven Ct
Raleigh
Owner
Owner Name
Stephen
Dates/Events
NC 27617
Doug! Evans
as
Scheduled
Central Files: APS_ SWP_
12/21/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Billy Clayton
4137 Moores Mill Rd
Spencer
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Stephen Douglas Evans
10204 Swan haven Ct
Raleigh
VA 24165
NC 27617
Orig Issue
12/21/10
App Received Draft Initiated Issuance Public Notice Issue Effective
12/21/10
Expiration
11/23/10 12/21/10
Re q ulated Activities
Heat Pump Injection
Outfall l\'.J:...L
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Stephen Douglas Evans
Lori Ellen Evans
10204 Swanliaven Court
Raleigh, NC 27617
NA
NCDENR
North Carolina Department of Environment and Natural Resouices
Division of Waier Quality
Coleen H. Sullins
Director
12/21/2010
Subject: Acknowledgement oflntent to Construct Type SQW Injection Well System
Permit No. WI0500323
10204 Swanhaven Co u lt, R aleigh , NC 2 76 17
Dear Mr. & Mrs. Evans :
Dee Freeman
Secretary
On 11/23/10, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onh
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 .02ll(u)(2). Additionally, you should contact the Wake 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.Ro2:ers ra{n cdenr.2:ov if you have any questions .
cc: R alei gh Regional Office -APS
APS Central Files -Permit No. WI0500323
Wake County Health Dept.
Aquadrill (B illy Clayton)
All America n Heating & Air(Stratton Lobdell)
AQUIFER PROTECTION SECTION
i 636 Mail Service Center, Raleigh , North Ca rolina 27699-1636
Locat ion: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Sincerely,
Q \} --k, f\ _W---. I
for Debr a Wa;~ ~
Supervisor
Phone : [phone] FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Cusiomer Service: 1-877-623-6748
Internet: www .ncwaterquality.org None , C ,. ortn arouna
/Vat11ral!t1 An Eq ual Opponur.i'.y I Afiirma::ve .ilc:·on Employer ,,
Nov 22 10 08:54a
Lothridge Plumbing 353572951
I'OV.17,2810 9:14AM DUNS I'iCI5
NO.O2i
NORTH CAROLINA
DEPARTMENT OF ENVIRONBANT AND NATURAL RESOURCES
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NOTIFICATION OF WENT TO COMNUCT d GF
WATEt-ONLYINJECTION WELL SYSTEM
TYPE SOW WELLS]
In Accords= With the Provisions ofNCAC Tilt tSA.t)i2C.0a0o
Prig ar titre At ►kritiradrxfarar an madtttai!to ellipsis cot& back page.
DATE: November 9, 201.0
O5 00323
Weg 231ie Q urfsm then: Dada the aiYCttlite' potable =WWI Om
continuous piping that caiplaely isolate, the fluid from the env€raatnit ciAt..
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Yes X Continue complain' E this Sam.
No Do Not complete this fora. Cotoplote ate UIC applicaticet forms for i ilil `' -
either a 5A7 well (ones) -loop wolf isle ig potable now into the squirm) or aSOM (o .' d
!flopwe1c such as R-22, ehaaol, or either antifreeze, or aoroeioa
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A. PROS OV/NR1Z(S)APPLICAN'lQ r`
Lis' Property Owner listed on pmapesty dead (if owned by abusiners os Savanna= Wmq►,-slyti, ' ,
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entity spd a xqx ►e wlautharityy far sign ` S rcf,s e l "11.t., a . . IS t '' . _ _ - -
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Lb w u.EN EvA
(1)
hinging AWWiess: (b 0ce SW* Vhkt\! CT
Cuy: "C.19 41-- Sim:14Grtpc 2-76f Cof (3 &. _.
Ham Te1e N•n : 9 ct gcR' -OS Deli Nei Imo€ 7;71- T;
rr ,
Email Addtett tort -� S�S�41 1,C= 'e
(2) Physical Address of Well Sits (irdsffr aborrts):
City; _ Stab: tip Cod
fkanneffice Tele Noz Cali No;
:.=
S► 41UTOORIZE AGM' 01F OWNER, IF ANY Clem Permit rs ppli,cani ¢cZ i own ilacsuti t P nYA'-
arch a letter freet the pity em-cr norboriting A imsrall and OVICIN CSC well] :•
Caixpiy Name-
Coronet EMAIL A4ciass:
Add/Mt
City: Siam Zip Cn CowRy_ _ ti ' .• _
Office Talc Nor: CdI No.:
WebsigeAar arCompany, ifawr. ..y _
C,1 u .flC SQW Notifs:stiaa orbital Rom (R vfsad Ratios)
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Nov 22 10 O6s54a Lathridge Plumbing• 3363572951
C. WELL DRILLER INFORMATION
Company Name: Aquadrill
Well Driller Contractor's Name: Billy Clanton
NC Contractor Certification No.: 2241 A 2839 A
Contact Person: Billy Clayton
Address: 4137 Moore Mill Road
Br an Lille+
EMAIL Address:
aouadrillfjL cs:net'
r'r
City: Spence, VA Zip Code:
Of5ce Tele No.: _336 767 0747 Cell No.: _336 871 9747
County: Henry
I7. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: All American Fleatingf. Air
allamerican(a�nri'.rcin} -
Contact Person: Stratton Lobdeil EMAIL Address:
•
Address: 8817 Westgate Park Drive
City: Raleigh, NC Zip Code: 276I7 County:
Office Tele No.: 919-782-6242 Celt No.: 919-622-1552
E. STATUS OF APPLICANT
Private: X Federal:
State: Municipal:
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection wells) will be used
Closed loop water onl% for beat pump
C. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: Number of borings; 2
Approximate depth of each boring (feet):
(2) Type of tubing to be Used (copper, PVC, etc): _HDPE
(3) Well casing. Is the well(s) cased? (cheek either (a.) Yes or (b.) No below)
(a) Yes ^ if yes, then provide casing information below
Type: _galvanized steel black steel plastic other (specify)
Casing depth: From _O to _375_feet (reference to land surface)
Casing extends to above ground inches
(b) No X
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement _ Bentonite X Other (specify)::_ -.
(b) Grout placement: Pumping Pressure
Other
(c) Grout depth of tubing (refcn once to land surface): from _375_ to _0_ (feet)
If well has casing, indicate grout depth: from to
(fC
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Nay 22 10 09:54a Lathridge Plumbing
3363572951 _, ":'` d=
Nov.17.221e S 14 It DUNS MC;IS
4O 21
13. R1f3LCfl01-ETli.ATED tr.QTIndorr , , ... , � :
Attachs diatom showing the engineering layout or ixoposaed rorxtifacauino of the injection equipment aria e> cr•,s- . r
pipia big associated with the injection man. The mananctUroes hzoelaue may patwid ar, . ti, -
information.
1. LOC'.ATiOntof WiMUS)
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Minch two copies of=spa s)ow ng the foilCW lg boa: -
(1) Include # Site Map (cam bo drawn) binzdings, property meat water bodkaa, _:
9ourcea &Funstiwiter eoutambsedaa and the Driontation ofaml distances between the proPenediYell(s),en , .'
any misting well(s) or waste disposal tbaWei= each as scpptio'tsoics or dry fields leaned w11ithri.2QQ cv0f • a'.
the gal halt putter vrcil systcm. Label all l6etlrres duty de a d include a:vow, ,; +'' {
(2) The She Map most show the subject property in relation to the surrounding area by using at lest nye , P.
reference posers saute as roads, mums, andtar highway tatersectioa s.
f CE&tIITICJTION
Ni'e This Permit on set be aped hy 1Y =�6 on the ' s _ z e. "t .
recorded legal prnpertzr deers.
"I hereby certify. under resualty of taw, that nave personally examined rood ant thaniliar tbdia ci i ,•
sttbwitted in this datum= and all macluncula ti>acto and threw based Can my talgtta ► Ofdale 114> 4
immediately neepm able for obtaiiiimg said iafaotadoa, I bdiere tied the infareaelian is rree,aceuratte ii1 6as1p64m-
I am aware that there are sib peomides. ineludi>ig thus pidebeiv of SACS and imprisonment; fleattOoffitiopfl
false mffrgradon. I agree to construct. operate, maw, repair, and if appiicable,'bander the m ec i!a+4atati ,
all itixrcd anunaannoca in aoaaardatco li4yeti cgecitteatica s and conditions at' the Plait:" ' -•
Signature of Properly OwaaserlAppl cant
Not or Type Pall Name andthic
Signatureof PropertyOwaccApplicant
Loy ear. gtrir-NS
Print orType lull Nemo and tide
siszantreof Authorized Agent, if soya
fintar or Type Fall Name and tide
None return two copies of the stenpleted Application package for
North Citoiitaa DENR DWQ
Aquifer Protte€iou Section-tJLC Program
1636 Mail Service Comer
Raleigh, NC 27699-1636
Telephone [phone]

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Nov 22 10 09:53a Lothridge Plumbing 3363572951
25 Years of Quality Service
4,%430Vofflqi6A
Dear Sir or Madam,
Lothridge Plumbing
To:
Date : _November 22, 2010
Time:
y
# of pages including cover : ,_,5 pages `: r
919 715 0588
Cover sheet only .`A
Following is a Type 5QW Well application for processing. Thank you
attention to this matter.
Sincerely,
.L
Tina Yate
Comptroller
P4 Box 249
Linwood, NC 27299
Phone: [phone]
Fax: [phone]
Email: [e-mail]
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