WI0500415_GEO THERMAL_20110809

Permit Number
Program Category
Ground Water
Permit Type
WI0500415 / Central Files: APS_ SWP_
08/09/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (5QW)
Version
1.00
Permit Classification
Individual
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Terry Labombard SFR
Location Address
189 Miranda Ln
Roxboro
Owner
Owner Name
Terry
Dates/Events
NC 27574
Labombard
Orig Issue
08/09/11
App Received Draft Initiated
08/03/11
Re q ulated Activities
Heat Pump Injection
Outfall '. .'J ;_~_
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville
Major/Minor
Minor
Region
Raleigh
County
Person
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Terry Labombard
189 Miranda Ln
Roxboro
NC
NC
Public Notice Issue
08/09/11
Effective
08/09/11
27020
27574
Expiration
Stream Index Number Current Class Subbasin
A77/1
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
8/9/2011
Terns LaBombard
189 Miranda Lane
Roxboro, NC 27574
Subject: Acknowledgement of intent to Construct Type 5QW Injection Well System
Permit No. W10500415
189 Miranda Lane, Roxboro, NC 27574
Dear Terry:
On 8/312011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onlh
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 .Person 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.Rogers:cr'incdenr.Qov if you have any questions.
Sincerely,
wr Debra Watt,
Supervisor
cc: Raleigh Regional Office - APS
APS Central Files - Permit No. W10500415
Person County Health Dept.
Yadkin WeIi Co (David Brown)
Green Horizon (Brant Warsterl
AQUIFER PROTECTION SECTION
1636 Mail Service Center. Raleigh, North Carolina 27$9n•1636
Walton, 2725 Capital Boulevard, Raleigh, North Carolina 27664
Phone: [phone] FAX 1: 919-715-0586: FAX 2: 91s-71 E-6Q48 i Customer Service 1 7-523-c748
Internet www.newateroualitv.o^
[Miley{ {''� �j
V i.n��iS--� �a a
AA Equar Ooaano7 l Amrmai+ue A .mni Employer

NORTH CP>:ROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOS)W-LOO1 GEOTHERMAL
AL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-OW WELUSA
Ia Accord al= With the provisions of NCAC Title f SA: O2CO2DO please
complete thisnotifrcation and mall to address on the back page (please Mat or Tie iufbi tioa).
DAM- 0 S / V2 20 11 u_ D SOCD Lt./5
Well Type Cap fumathon: Does the proposed system circulate potable water orsly (no additives) in
or n[inunus piping that completely Isolates the fluid from tho environment (i.e.
eloaett 1oop)7
Yes X_ Continue completing this form.
No Do Not complete this form. Complete other triC application forms for installing
either a 5A7 well (open -loop well infecting potable water into the aquifer) or a 5QM well (closed-
loop well coutainioS Adr:145M sock as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. 'PROPERTY OW1V (S)IAIPPLICANT(8)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a represetthttive tu/azrtharity fbz aignatare): T i 12-'f L 6-i A-th
(1)
(2)
Mailing_Ad.dress: (f1 Avit.4-N�M
City: A Kai:12» stator PIC- ip code: 11-7q coantr Pa -SOP
Home/Office Tete No.- 35(p -7-2.3 - 4S"1.=9.rJI Na.;
Email Address: i5-1 -Re P4M 4Ld 'ebsite
Physical Address of Well Site (if different than above):
City: State: Zip Code: - County:
Home/Office Tele No.: Cell Na'
$. AUT15ORTZEl3 AGENT OF OWNER, IF ANY (if the Permit. Applicant does not o►vn the subject property,
attach a letter from the propty ovrn.er authorizing Agent try install and operate UIC well)
Company Name:
Contact Personr EMAIL Address_
4.ddsesa:
City: State! Zip Code: County:
Office Tole Nos; Cell No,:
Website ,address of Corny,. #'lay:
RECEIVED i DENR / DWQ
AQUIF7=R'PRnfFrTlON SECTION
AUG 0 3 20f1
(18L4 'aN ITV E:b ll4Z

C. WOW, DRILLER INFORMA TION
Campatlyklaute:Yudlcirt_Weti Co. Inc.
Well Driller Coatraatar's Nemo: 7txZtM1111h Malifavi' ln,wn gift= Owe
NC Contractor Carti:zcatsysnXo,; 2512-A r,;r,. a, 3;4s-A .
Coe:eelPerso dJ. I3 •vn PAL Ad r�ss; cllFetdrnsn.eo�
Addie : 1963 Heap [anvil Rd.
City: Ekcolorivina ' Zip Code: 27020 County: YRdkkii
COka Tale No,: 336468-4440 Cel)Na.: 336 374-n36
D, CcouR.4crcrit TtTETIRlVLAMEON Of ardent t1aan drMPiet')
Comomny Narne.: & yr e e tx
Cooled POISON Wyr --e P EMAILAdr1tto.
Address; /'l r'°,s w
City: Ow, 1-1.4_4 . zit Cade: 2) 1i CQm 41,f✓ h 6n
t7 Ger9 -311- 19g.Ccea fl.. 9161- 9_ 0- 0q
I . STA.TITS dFAPPLICANT
Private + }>z'edarul: Commercial:._
Stele: :uaioipat: ,.. Native American Lands:
F. INJECTION PRO C.X.T VR (briefly describe how the kieetion wc1Y(e) AA IC be esed)
,live 64 mI4 y ci--11.0ra44y 4- ci C (ei+r (t'.d F+.Gel
9 e. f k..a r'.....►it1 s i0_, -
G. WELL CONSTRUCTION DATA 240
(I) Proposed date to be coustmOad: y •f Nuarber of borings;
Approximate depth of each boding (feet):
(2) Tyasoftubing tobelined (coppir,PVC, SDR ?i I E i
(3) Weil casing. Xs the wet(e) cased? (obeak eiiher (a) Yes 15 (b.) No below)
(a) Yes if yes, then provide cashaginformadoabciow
Type: _gaiva:tlzed Sieei bisck sfeel phisticother (spacify)
Casing depict: PP1[= to feet (rCarotCetO land surface)
t aslnng oxtrstdxt6 61)6ground, Inet S
(b) No
(4) Grout Info (materiel aUraatt>AdIttgwetl erringazdlar pipsrg): 1 e w (4y 6,0A veic'd
(a) Omit type: Neat. Cement &nwits 1/ Other (specify)
{b) Gzavtplace:ner Pumping rV Press+srt: Ma -
(a) Cruet depth ri tubing- (Tottence to laud sarfkce): Gans 3,1 S o _3 (feet)
if well has mSs5Al1,, indicate grout depth: faun fx: _(feet)
RECEIVED (OENR I DWO
AO]IFR.PRfW(TION SECTION
AUG 03 2011
E 'd /80 '0N INV E:6 ! LH InV

Fl.
tNJECTIa %RELATM EQUiellIENT
4 Uacd3 a diagram shotivingtie engiseerbig layout or proposed modt5rrattion ofthe injection egoipxnentand exlerfor
ptOtettibing associated -with the injection operation. Thanufactw is brochure niy provide supplementary
T. LOCATION' OF WELL(S)
Attach two copies of maps showiovibe fallowing infomaalicer
(1)
C2)
Include a Site Map (can be drawn) showing: ng: huildh gs, property lines, snare water bodes; potential
smote elf groundwater contamination ; r,the orientation of and di aaces between the proposed weil(s) and
any emoting wel1(s) oar waste disposal •T 4I ttc5 Michas septic tanks or drain fields located within. 200 feet of
the geothermal heatpump well system. Labai all features clearly tad Include a north
The Site Map moat sham the sid,ject property to relation to the surrounding area by using at least two fcc ed
rafter= points such as roads, streams, and/or highway intarc c ions.
S. CERTIFICATION
Plate: This recruit Apptisattoi mast he signed by ei_A person appearteg on the
recorded l I p nepert y deed.
"'I hereby artily, under penalty of law, tin I have personally exaxniaert and am familiar wilt the information
subm[tTd. in this document and all attachments thereto and that, based on My inquiry of those irtdividneLs
immediately respons & for obtaining sale information, I believe that t The intl:sr/natian is true, =nate end complete.
I am aware that there are significant fifties, including the pmszlaility o£'' nes and imprisonment, for submitting
false iah' nnatten. 1 agree to constuet, operatic, rnaintaba, ram, and if applicable, abandon ffhe irzjectton well and
all related appurtenances ha accordance 7ith approved cation &n4c cps attic Y'35letit'°.
Si=e of ProperGy Owner/Applicant
pre or t4.pe Pail Name
Signature of Property Owner/Applicant
Print or Type Full Name andthle
Sigoettne ofAntboeized Agent, if any
Print or Typo Pull Name nod -tilde
Please retuxu two copies ottbe otmapleted Applicafcon package to:
North Carolina Dot-DWQ
Aquifer Protection Section -131C ?rogmm
1636 Mail Service Center
Raleigh, NC 21699 4616
Telephone [phone]
RECEIVED / DENrI'I DWQ
AQUfFFR ppraFf`-TION SFf:TiON
AUG 0 3 2011
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RECEIVED /OENRI uho
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AUG '0 3 20ii
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FACSIMILE
TRANSMISSION
FORM
DATE: 3 / 3 I (I TIME; _ REF NO. — - LOG NO.
TO: 4/R
COMPANY NAME r
[..anti o.-Itflh
ATTENTION
FROM. Ktdk1w cOeCo
DEFT
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FAX NO. FL2ASE
❑ AiNED1ATEIY
3 z) 76r -
COMPANY NAM /� FAX NO. RUSErCTU r d era w JA
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INomouu
NuMsEA OF PAGES
INCLUDING THIS SHEET
MESSAGE: CA) Oca4.1J'CA#(21
DEPTPLEASE
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RFPLY BY O�fATURE $ "'
rake y A 0-64.
-FQR ALL YOUR WATER NEEDS"
YADKIN WELL CO., INC.
'we YIAMPTONVILLE R4A0
HAMPTONVfLLE. NC 27020
DAVID J. BROWN, VICE PRES.
TOLL. FREE taco] z 8 333
OFFIC£ t3364 468-4440
FAX [phone]t749
RES i53M 4884059
•UOOa Maws AMERICA - rva LBvdS YOU'
REGEWED 1 ULII .
nIRl1'L7Qi1Trn-r — r ^ r
MUSS INFORM US iMMMAMMY IFSW BO NOT REDEfVE FACAMI{.ERI FVU.
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