WI0500335_GEO THERMAL_20110112 (2)

Permit Number
Program Category
Ground Water
Permit Type
WI0500335
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Eric F. Robinson SFR
Location Address
8009 Millenium Dr
Raleigh
Owner
Owner Name
Eric
Dates/Events
NC 27614
F Robinson
Orig Issue
01 /12/11
App Received Draft Initiated
12/10/10
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Scheduled
Issuance
Central Files : APS_ SWP_
01/12/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Eric F. Robinson
Owner
8009 Millenium Dr
Raleigh
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Eric F .. Robinson
Owner
8009 Millenium Dr
Raleigh
NC
NC
Public Notice Issue
01/12/11
Effective
01/12/11
27614
27614
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
A7,11
NCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H, Sullins Dee Freeman
Governor Director Secretary
01/12/2011
Eric F. Robinson
Erica M. Robinson
8009 Mi]lenium Dr,
Raleigh, NC 27614
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W I0500335
8009 Millenium Dr.
Raleigh, NC 27614
Dear Mr. and Mrs. Robinson:
On 12/10/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-oni‘
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 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.Rocer-sru•ncdenr.2ov if you have any questions.
Sin�ly,
for Debra(W
Supervisor-'
4Sp
cc: Raleigh Regional Office - APS
APS Central Files - Permit No. W10300335
Wake County Heath Dept.
Billy Clayton (Aqua Drill, 4137 Moores Mill Rd., Spencer, VA 24165)
Stratton Lobdell (All American Heating & Air, 8817 Westgate Park Dr., Raleigh, NC 27617)
ADU1EER PROTECTION SECTION
1636 Maif Service Censer, Raleicth, North Carolina 27699-1636
Location 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phon„! 919-733 3221 I FAX 1' 919-715.058B: FAX 2:919-715.80481 Customer Service:1-577.623-574S
Internet: onyvo.ncwatercua$tv.oro
One
Nor hhCaroh1Ila
4n hues wpeormily 1 Af n?:.,uE Acizn'Employer

Dec 10 10.08:13a Lcthridge Plumhine 3363572951
P - 1
T
25 Years of Quality Service
1___4tTr4WinSECOE
Dear Sir or Madam,
Lothridge Piumbingl inc.
To
Company : _NCDENR
Sent By : _Tina Yates'
Date : _December 9, 2010
Time :
# of pages including cover : ,__ 5,pages
919 715 0588
Cover sheet only :
•
e
•ii •
Following is a Type 5QW Well application for processing. Thank you for your
attention to this matter.
S iicerely,
Tina Yat
Comptrpller
PO Box 249
Linwood, NC 2T299
Phone: [phone]
Fax: [phone]
Email: [e-mail]

Dec 10 10. ❑8:13a
Lothridge Plumbing 3363572951 p.2
2010-12-07 12:26 usrtpla9 919543757E . P 1/3
NORTH CAROLINA
DEPARTMENTOF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED.LOOP GEOTHERNAL
WATER -Mx INJECTION WELL SYSTEM
TYPE SOW WELL(r
In Accordance With the Previsions of NCAC Title 15A 02C.0200
Arid or type there wired Worounion and mail ro addrary on the kook Imo.
DATE: N ova mherJ4_ MO_
Well Zip, Confirmation: Dots the Proposed system circulate potable water only (no additives) in .�
continuous piping *tat completely isolates she fluid from the environment (Le.
cloy -loot)?
Yes 7( Continue comp Ictatg this foam.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 wcII (..4221400p wci l in' potable water into the aquifer) or a 'QM well (closcd-
looP well containing additives such as R 2 . ethanol or other antifreeze or corrosion inhibitors).
A, PROPERTY OWNEE(S)/APPLICANT(S)
List ,eat, Property Owner listed on property deed Of owned by a business or government agency, State isnme of
entity and a representative wtwitthority for signature): Priic F. Robinson, Erica M. Robinson
(1)
Marling Address: - - 840U Millenimn Dr
City: Ratwbh Ststk NC Zip Code: 27614 County: WAKE
Homc/Office Tele No.: 9I9470-8347 Cell Na.: 414.744-513s
Email Address: rfrureGiihmail.iecm Met re! n/a
(2) Physical Address of Weil Site t?(different than abore)-
City: Sty: _ Zip Code: County:
Home./Office Tele No.: Ca
B. AUTHORIZED AGENT OF OWNER, IT ANY (if the Permit Applicant clm not own the subject wooers).
attach e. letter from the property owrtcrnutho -izir g Agent to install clad operate UJC weii)
Company Nome:
Contact Person: EMAIL Address:
Adds S:
City: State: _ 21p Codc:
Office Tele No.:
County:
(7::11 No.
Website Address of Company. if any. -
GPtl►UIC 5QW IYnli f eutiom MFldiem. Fano (Revised Palle t

Dec i.0 10· 08: 14a Lothrid~e Plumbin~ 3363572951 p.3
2010-12-07 12:27 usrtpla9 9195437575 » p 2/3
C. W!.U. DRILLER INFORMATION
ConiJIGI')' Name: Aq uadri l]
Well Driller Co~•• Name; .,..,B..,.U ... ty._.C1,..a:yton'-"=------=8~1li::•=Li::.:l lqy.:,i.. _______ _
'NC Concractor Ccrtif'ication 'No.: __ 22..i.i ... 7 l-:,A ______ ...:l§J:a,:.,:9~A:a..-________ _
CcntDGt Person: Billy Claytos,. EMAIL Addrm: eglf!dn11@hughes .QC!
Addtess: 4137 ~ Mill RQSd
City: Spencer. VA Zip Code: ____ Couniy: _ .... H..,.cn,....n _______ _
OfficcTeleNo.: _3367670747_ Cel1N0.:_j368719747_
D. HEAT PUMP CONTltACI'Oll INPORMADON (if clill'emat lllu clriDl:r)
Cara)Jan)''N.unc: AU AmerjCM Hearin g & Air
Contact P~-l.o=bd=al.__l -----------=E;:.;:M_,A_lL__,A=dd...,res=!r.,..,,_ __ =al=lam=en...,'can@nc.='-"o~=rr=•CQ_..__.m
Address : 18 17 Wsst,rat; P,d: Drive
Ci~: Raltigh, 'N C ZipCodc: 27617 Ccuny: _________ _
Offlcc Tete No.: _919-782-6242 ____ Cell No.: _919-622~1552 _______ _
E. STATUS OF APPUCANT
,.
G,
Pri~ _x_
Smtc:
Federal:_
ML1t1icip1I: _
Coml~~:-
N3tive Annan Lands:_
INJEC1'ION PllOCIDU.RE (briefly describe how 11ic ia,jec:tian well(s) will be used)
Closed loop Wftlet only for lg nump
W.ELLCONSTRUCTIONDATA
(J) Pl'oposed date to be~red: _____ Nwnl'la' ofbotmgs: _2 __ _
Approximate deptft Gf ¢11eh bori. (feet):. _____ _
(2) Type of tubing to be used (COJ)l.'ltr. PVC, etc): _HD.PE. ________ _
(3) Wdt cum;. ts tllc well(s) cased? (chedtcltllet (L) Yes!! (b.) NO below)
(a) Yes __ if yes.then provide casing mfOJ'Olation below
Type: ___g~ slCCl _black steel_plastic_othcr (specify)
Casi11g deJ)th: From _o_ttJ _ 40S_feet (reference to hand surface)
Casi.ng, exte1'1ds ro above sround _. __ 1_11eltcf
(b) No _x_
(4.) Orout Info (nwetial SUfflNndins well cuing and/or piping):
(a) Crout typt: 'Nc:st Cemont __
(b) Csovt ~t PUffll)irc__
.8cr,.ton1~_X_ Othcr(l!pCCi~) _____ _
Prcssw,:_ Other_
(,;) Ot'OUtdepth of tubing (rcfcm1ec ta land surface): ftom ,.405_to _o .. (feet)
11wcll has casi~, indicale gro11r depth:_ from ___ to ___ (feet)
CM.tl(;IC SQW fllovlkaion c,tlnima l'OIIII (~vlftd 81Z008)
Dec •10 10 0e:14a Lothridge Plumbing
3383572951 P•4
2010-12-07 12:27 usrtpla9 9195437575 s), p 3/3
H. 1IN CflON-RELATED EQUIPMENT
Attach a diem showing the engii caring layout or proposed modification of the injection equipment and =Teri&
piping/tubing a soriated whet► the injection operation. The mhsnuiscturrer brochure may provide supplementary
infonnstion.
L LOCATION OF WELLiS)
Attach two copies of maps showing the fellowieg information:
(1) Include a Site Map (rant be drawn) showing buildings, property fines. surface water bodies. potential
worsts of groundwater contamination and the orientation *fend distances between the proposed well(s) and
any aXisting well(s) or wash: disposal facilities such as septic tarots or drain fields Ineamd within 200 feet of
the geothermal heat pump well system. Label all features clearly and include a north anew.
(2) The Site Map must show the sabject property in relation to the sower nding area by using at lecsr two fined
reference points such as roads, statutes. and/er highway imertestions.
J. CERTIFICATION
Note: Thb Permit Appllmtion must be sped by ita person appariag as the
recorded legal property deed.
"I hereby certify, under penalty of law, that 1. have personally examined and am familiar with the iafonnatirrn
submitted In this document end all attachments therein Bind TIME. based an my inquiry of theft iodhiduais
immediately responsible for obtaining said information. t believe that the information is true. accurare and complete.
I am aware that there are sigtsifcarn pemat>lea, Intruding the possibility of fines and imprisonment. for submitting
false Inibrmation. 1 agree to comma. operate, maintain, repair. and i?'applleable, abandon t a injection well and
all related appurtenances in accordance with the approved specifications and condldens of the Permit"
Sigoillan of Propergi OwoorlApplic&nt
Print or Type Foil Name and dent
•i•ri-�'c�lhLia
Signature of Property Applicant
s11a� r. I v1 1_6143K
Print or Type Full Name and tilit:
Signature of Authariaed Agent, if any
Print or Type Full Beanie and rile
P1mic return two topics of the completed Application package to:
North Carolina DEI R-DWQ
Aquifer Prottoion Section-VIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telepbose [phone]
GPLE/ MC Silty p ifiree4nn of intent Farm iReviscd ROAM Psnc 3

Dec 10 10 08:14a Lotteridge Plumbing
3363572951
P..5_
0
50
100
200 Feet
6E :a WV D 1 330 01
!_,; NuttDMMn8P a4I '
Field
Value
PIN
0891402986
Real Eatate ID
0267098
Map Name
089103
Owner
ROBINSON. ERIC
FRANCIS
ROBlNSON. ERICA
MARIE
Mailing Address 1
8009 MILLENIUM DR
Mailing Address 2
RALEIGI I NC
27614-7803
Mailing Address 3
Deed Book
08643
Deed Page
0698
Deed Date
07/28/2000
Deeded Acreage
1.26
Assessed Building
S301,349.00
Value
Assessed Land Value
5100.000.00
Total Assessed Value
5401,349.00
Billing Class
INDIVIDUAL
Property Description
LO10 ANNIE'S
WOODS SUB
BM1999-1623
Heated Area
2948
She Address
8009 MI,LENILIM DID
City
Township
BARTONSCREEX
Year Hull!
2000
Tors/ Sale Prico
S330.000.00
Said De7e
712&2000 12:00:00
AM
Type and Use
Single Family
Design Style
Conventional
Land Class
RESIDENCE-s 10
ACRES -HOME SITE
Old Parcel Number
211-00000-0000
WAKE
COUNTY

ESIDEMULiig11,CONS'f12UCTTi1At:Rg,
7votiftCartiiina Deparlr eni r•egpvireiimefltand Manta] Ri edui es- Division ai-Wafer Quality
WELL CONTRACTOR CEI fT A ilf#=TCWC 9-A
1.1.4ELL cown/ACrOtii
Brian L;iley:
Well C nfractor (individual) Name .
A4i Dril[. Inc. - .
Well ContractorCampany Name
4i::37iitogres Mill Road,
Street Address
Spencer:.
City or Town
{35 y°•?=OTC}=
Area code. xPhone number
2. WELL INFORMATION:
4-1N0J, CONSTRUCTION PERM T#.
OTHER ASSOCG°� i P +frf�P( x-
.: SY7E WE1L to 1(dspp ebf6 :.
1 WELL USE (Check.] p afite$p):..•lEFesiiie*Iyyater•.SuppI 0
i gTE.DRILLED !:1.;Z 1 -
TIME ooMPt:ETiD 5; e76
at0hreC l LOCATION:
G1F 1 F)4 ►
(Street Name, Nernbers,:Carirrprnity. Subdivision, Lot No.. PareeLZo_Code)
TOPOGRAPHIC 1> D SETTING - at�p9 '
C1Srape ©ValIeY aFiat. ORIdts6I Lifter
LATITUDE as,SS o '40 3 : u S oft 374-:xxaasxrot&rTi1=:_:
LONGITUDE WIS -". _. $, DIMS OR 7X.XxXxXxxXX
•
Latitude71nngihide;source:;: 123 • :lifopographic map
(location of weilrrrusf be Sown ce-e.USGS typo map andattgFhaii-[D'..
thin form if not using GFSS
S. WELL OWNER
72(--)edi 1ay.A
Owner Nettie
, i/Lk -xi1UNi
Skeet Address
City orTown
L 1 .
Area code Phone number
S. WELL DETAILS;
:TOTAL: !EP'tH:
a-DOESV4MREPLACE-Fa3Ttr We :Ip` ES6:'NO
1:-4c. • HATER LEVEL Beloly, rhpof Caeirlg'.• _: --
11Use'+" If Atia► op af' asingy'•-,
d. TOP OF CASING IS t J 11 , :...._F -Above Cand Surface` .:
'Top aT rasing terminated odor below- fend surface may require
a variance micordance Alt 15A NGAC 2C .04 18.
e. YIt'sLD fgptit):;. {v �6r.1 .ETHOt OF TEST• .•
..
f. DISINFEilIOL Type. =-.- -. • Arnount
. 2426.14
)7in'' Cade :.
Tog - Bottom
T. _ BotInm
•Tt. Bottom
Vile nessl
7_ :CASING: -Depth, Oianiefeii- Weight
Top 0a ZDQ.Z1
Tap
Fop _ r ;,� Bbifolrif :�.. FL
8:;.GROUt, i
To - - oiif�
Talk_ .- 8affarin FL
l�P - Sodom - FL -
$: SCREEid•;. • Depth, Oliilltleter' Slot-elMalarial
Tap, � BdHro1n FL in: in.
Top eSt ftamt Ft. .. _ j. In.
Tap ,.. - ,.• „Staudt • fii.- Jhs In,
ip:S•AP4piGTRAVEL PAS
Trip_. -av1 Xi '
1.1:.01/fl4 G:LOG.
Tot Sotto*
Zn .1.. = a..:.
.d.-SWATtitiailES (depth).
` ap, .sutlarr Z 7 S.
Top Idr
TopBoll--
-i t
Mt I
Material• Method
r -FfathatisSCription
f L
'Se; ri-tedkk
•� ��,-ram- . -.
20
REMARKS:
f +J -•i
ti1Q fERI YCERTIFYTHAT 111SWELL_W S'CONSTRUCTEOIN
WIT
H TH 15A NCAC 2C, WELL:CONSTRUCTION
$ fA • , S, AND Tl • COPY OF THIS RECORD HAS BEEN
TO TH OWNER.
-BYTE ii - L CONTRACTOR DATE
Brian May, - ... -
PRINTED NAME OP -PERSON CONSTRUCTING ThE WEL1_
Suiattiit within 30 days- sit completion to: Division of Wmtsr Qualify - information Processing,
1.61711/1ait Service Center,Raleigh, NC 27699461, Phone [phone]
Form GW=i'a
Rev. 2199

1, LYEu :C ACTOR:
Briars 4ille::
Well contractor (Individual) Name
Aqua Drift, lit ;
Weft Contractor Coprpany Name
4137: MooresMill Road
Street Address
Spence: -
City orTown
767--o747
Area cod , Phone nlirnber
2: YELL eNFORMAT1ON: 1
WELL CONSTRUCTION PERM1,•j°`s4
• •: rfTEhEFi ASSOCIATE15ARR rF# Ti gpOtt
SITE WELL ID ISO sppiic •j- ..
1.--,WELL USE [Check Appii
DATE DRILLED f L7:—•%a:::• . .
T{ME CMIK Ito 5:,t16
CATION:
& rt.,> s4.4 Art. -. - 2.1 4i,'r 4
(Street Name, Numbers,.Community. Butarthrision, IA No., PaiCel,MOlpode}` :
TOPOGRAPHICtLANO SET77NG: "[cinekapprerprr boxy :
❑ Slope £ Valiey t. CDRidgfer n Oilier
LATITUDE *SS " ' . ' ..":QMS OR 3x.xxxxX)yxx o[i._:.
LONGITUDE +F1/ .'..' - . :*.ONES OR 7x.xxxxxxxxx a13.-.
Latitudeilangitude, s `. GAPS; QLopagraphio map
(location of Iva must .tie 'ovin an a I SGS topo map andhed i _
this farm if not using GPS) -
State
24.165:
Zip Code
5 WELL OWN6R
ownee'Nsme
De.
1 Andress
City Or Town
Area code Phone number
S. WELL DETAILS:
a., :fOITU DEPTH: 4 7..�f). .
b_ tOtSliiiitLREtstAttiktStilia 10E1. : ' - ,ES-Ii.. ;NO t1
c. WATER.k-EVEL 8eicivi=T�#tasir g:. IN : '.. FT. , .
4Use'}' i{ Abdvat'Dasin0) :' :,,
d- TOP OF CASINO IS 1`+! A -=. FI Above LandSurfac e'
*Top of cacing:terrninai coSNai h.eiou�r'{and 5urtace may require
a variance in scctirdenCE:.with 15R NCAC 2C .0118.
D. YIELD. (gpmf:-t+,. METHOD OF=T ST:::.- .:
f. DISINFECTEORIT3 °-.; Aniou ' :::
NJc 2.74 f
State `7;p Code '. -::.
501i3
tare1iha Deparit>e t,afEavironmed AmiSSra l pones- Division of Waiter Quality
*di f: ONirizAc 'o C'tR rin64, x'` 0$. #:VCWC 2&3 A
f} '.'- ivret OIiiEs (depth)
Top '" - ;,: om . 7 CS Top Bottom
Top BOOM ' Ttlp Bottom
Top. B Too Hatiosh .
Thickness!
7- CASING:- epth.. Dientliter. Weight
Top..76 FL..6,.:. SDe.7
Too - *dere x Ft.
TOp_: _ 8tiitoin� F.
8.:, PROM Depttl Material- Method
Top - •: Totiorm4Z Ft t MS P
Material
i op ;- 'Bottom Ff �r-f b'J r
Top _ . 8ottorri. Ft.
8. 3CR . N::-Yreptit - Die rneier Slot Size Matertat
Top _ •'8attorn FL . in, , In.
Top So€t i = FL jai in_
T6p Boltern -.Ft1 An: in. _
f& Si4N 'Pam:
Depth - • Val
Ito -Bottom'. .T Ft --
Top _ . Iottaftl . _ . . - ter
T - 'Bottom' " , Flute
mudi c _boo
rop i3a_
7�
?sue / 47:
I
12. REMARKS:
-1 DO HEREBY CERTIFY.TFtA' TF{ISWELLWAS CONS RUCTEtrIW
J CORDANC;E WITH 15A'NC3AC 2C, vow.. CONSTp )b t!m13
STANDARDS, AND THAT A COPY OF THIS RECORD HASBEEN
..:PR ■ •ED'TOTFi LLOWNER.
FbefiabOna§csipf3vn
a
14
RE IFIEO WELL CONTRACTOR DATE
Brian Liiiey.; :
PRINTED NAME OF PERSO ''CONSTRUCTING THE WELL
Submit within 30 days of completion to: Aivis#on of Water Quality information Processing; -
1617 Mail Service Center, l aIe g1N NC .2 '69 .461, Phone :.(919) 80T-6300 '
Form GW i*
Rev. 2100