WI0500452_GEO THERMAL_20111122

Permit Number
Program Category
Ground Water
Permit Type
WI0500452
Injection Water Only GSHP Well System (SQW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Larry & Linda Ford SFR
Location Address
862 Cranbrook Rd
Raleigh
Owner
Owner Name
Larry
Dates/Events
NC 27609
Ford
Scheduled
Orig Issue
11 /22/11
App Received Draft Initiated Issuance
11/03/11
Regulated Activities
Heat Pump Injection
Outfall Nu: .. L
Central Files : APS_ SWP_
11/22/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Afflllation
Glen A. Darch
13109 Bold Run Hill Rd
Wake Forest
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Larry Ford
862 Cranbrook Rd
Raleigh
NC
NC
Public Notice Issue
11/22/11
Effective
11/22/11
27587
27609
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Larry Ford
Linda F ord
862 Cranbrook Road
Raleigh , NC 27609
·sA
MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. SuHins
Director
l li23 /2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0500452
862 Cranbrook Road , Raleigh, NC 27 609
Dear Mr.& Mrs . Ford:
Dee Freeman
Secretary
On November 2,2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
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 Micbael.Ro gers ra>.ncdenr.irnv if you have any questions.
cc: Raleigh Regional Office -APS
APS Central Files -Permit No. \VJ:0500452
Wake County Health Dept.
Glen A. Darch Well Drilling (Glen A. Darch)
Bowman Mechanical Services, Inc . (Steve B owman)
AQUIFER PROTECTION SECTION
1636 Mail Serv ice Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Bouievard, Raleigh, North Camiina 27604
Sincerely,
fe,Qeb~ .&m
Supervisor
Phone: [phone] I FAX 1: 919-715-0588; FA X 2: 919-715-6048 \ Custom er Sen;:ce: 1-877-323-6748
Internet: www.ncwaterauali .oro
k:1 Equ?.I Opportun:;;· \ Affirmativs f.!.c ::on Employe~
l\TOne 1 C 1. 1'\Jort11 . aro 1na
J\Jaturally
11/02/2011 11:29 9197799294 PAGE 02/06
NORTH CAROl.,lNA DEPARTMENT OF ENVIRON1\1ENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION Wl!:LLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED~LOOP WATER-ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part ofa geothermal heating and cooling system.
These wetls are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is ~uhmitted prior to construction.
Print or Type Information and Mail to the Address on the Last Page .
DATE:_,__/+-/ ---=-2, __ _,, 20 // PERMIT NO.~\ tt{X)Y,SZ (to 1:,e filled in by DWQ)
A. STATUS O:FWELL OWNER (choose one)
Non"Govemment: Individual Residence V
RECEIVED / DENR / DWQ
AQUIFFRPROTFr.TION SECTION
Dusiness/Organizalion _ NOV O 2· 201l
Government: State Municipal _ County _ Federal
B. WELL OWNER -For individual residences, list each owner on property deed. For all others , state name of
entity and name of person delegated authority to sign on behalf of the business or agency :
L ;,Ja h. Ft>vJ arvl. l.a.w y C. &) . .,._· ---
c.
D.
Mailing Address: &.6.J. c~vt Dr-b_o~g_/J,__o~;J~· ·-------------,...--
City: £/ ~,qk, State~ Zip Code: :J..16{)tj County: /Jt /!e.
Day Tele No.: q /1--7S/--JLJJ Cell No .: 09-'/IJh-4bD6
EMAIL Address: L t!.~tJ /?b S @mn1J~cy ,l!fj . <l,;tM No,; J..SJ. -1/$'"1-l,tu., I .
LOCATION OF WELL SITE -Where the injection wells are physically located:
County: ---=--/J;.__.,!(g,...:.::. =---~ (1) Parcel identification Number (PIN) of well site: f1t> (,3</-~ 1$"8
(2) Physical Address (if different than malling address); -~~~~-'fJJ~-1-e...____~----__ _
City:------~---~--State: N.t, Zip Code: _______ _
WELL DRXLLER INFORMATION
Well Drilling Contractor's Name: @ el\. f+ ~C C,i w..e L{ -J),<l l--y1 LLC
../ NC Well Drilling Contractor Certification No.: 8 q 00 .,,. 4 __,_...._._w:...;~~-=---.,_-----------
CompanyNameB l-t '\ A ~c.h w-e I,( br, I t.½ l .L c_ '
Contact Person: 81 f I] A: Dttrc Vl EMAIL Address :~d lue l ld (/ I l (. Yl '@._ aul . (s))
Address: 1··2109 J¾oJcL., Tiufl ld<U f2 cL. . ____ _
City: \,'2a\lf 1YVes.-\--Zip Code: ~'75~1 State:YlL.county: _l)..KL---=-a=~=.,..,.......__-__
Office Tele No.¥!(9 S:=W::fl5,'( Cell No.':1(vt q }a-qq 91 F:u. No.: q{q 55(;., :3 v' 3'7
GPU/U\C 5QW Notification (Revised 3/1 sno11) p.,,. .. 1
PAGE 03/06
11/02/2011 11:29 9197799294
E. HEAT PUMP CONTRACTOR INFORM.A TION (if different than driller)
Company Name: Bowro.a.n Mechanical Service a, Inc.
Contact Person; 5 fe f.l'(.. 'B;)wr'I 0,,,... EMA lL Address : b owmanmechanical@bellsouth, net
Add 145 Technical Ct. re~s : _________________________________ _
City: Garner Zip Code: 27529 State: _NC~Coimty: _w_a_k_e!! __ ___,..._. ____ .,...,,...,,__
OfficeTeleNo.:<919)772-2759 CelJNo.: ________ FaxNo,:_(9_1_9_)_7_79_~_9_2_9_4 _
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constrncted*: Z... Depth of each boring (feet): 3 () 0
* 1fexisting water supply wells will be used then provide the information in item (4) below .
(2) Type of tubing to be used (steel, PVC, ~tc): ~---------------
(3) Well ca.sing. If the well(s) will use casing then provide the~ (steel, PVC, etc.)i diameter, depth,
and extent of casing appearing above ground: ----------------~-
(4) Gi·out (material su1-:rounding well casing and/or piping): .,
(a) Grout type: Cement__ Bentonite *"' ..L_. Other (specify)---~----"* By sel1:cilng bcntonite grout,~ vatianc~ is hereby requested to 15A 'NCAC :ic .0113(dlli)(A), which requires a cement type gi-0~1t.
(b) Grout depth of tubing (reference to land sttrface): froin S' /..;.,C{o :J OO (feet)
If well has casing, i11dicate grout depth : fro1n ___ to _____ (feet)
G. WELL l ,OCA TIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clear] an d inc lude a 110rt1, arr ow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells
~ Surface water bodies
* Buildings • Property boundaries
>1< Water supply wells
"' Septic tanks and associated spray irrigation sites, drain fields , or repait areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending l/4 mile from the injection well site that indicates the
facility's location and the map name .
NOTE: /Ir most cases> arz aerial pflotograpls of the property parcel. slitnving property lines and structures clIJI be
obtained an,1 dow11loadf!d from tile applic111Jle co1111ty GJS website. Typically, the properly ca,i be searched by
owner name or adclress. Tlte locatio1t of the wells i11 relation to property bowzdaritz~, houses, septic t,mks, other
we/1.J, etc. can tlte,i be drllWJt in by ham!. Al.so, a 'layer' cart be se/(l.cted s/J(}Wil!g topogtap1lic contQlltS or
ele11ati1J1t data.
GPU/UIC SQW Notitkation (Revised 3/18/2011 \
RECEIVED I DENR t uwu
AQUIJ:f:R·PRnrr,rt,N• ~r:1;r1n":
NOV OJ tUH
11/02/2011 11:29 9197799294
PAGE 04/06
XX. CERTIFICATION (to be signed as required below or by that persons authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall he signed as follows:
1, for a corporation: by a responsible corporate officer;
2, for a partnership or sole proprietorslrip: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons lasted an t e e rue ),
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"1 hereby certify, wider penalty of law, that 1 have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. l am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information_ 1 agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Submit the complete application package to:
�rgnature of Property Owner/Applicant
LIcia. 6. Fb
Print or Type Full Name
Signature ogroperty Owner/Applicant
_,ate e rei
Print or Typ/Full Name
Signature of Authorized Agent, if any
Print or type Full Name
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, tit 27699-1636
Telephone [phone]
RECEIVED 17ENR t [Iwo
AjlFFP'1"+RrcrTifM SRCTriN
NOV 0 2 2011
GPl]I111C SQW Ni9t fkatiorL (Tieviaid 3/12/2011)

11/02/2011 11:29 9197799294
PAGE E5/06
0 12.5 26 50 Fees
RECEIVED r ORR / DWQ
AQuiFFrt PPni-Frrom SECTION
NOV 022011
Pf4 170634675a
Heal Estate ID
0054032
Map Name
1701314
owner
FORD, LARRY 0 Si
UNDA D
Melling Address 1
4704 RADCLIFF RD
H ailing Address 2
RALEIGH NG
27609-5315
Mailing Address 3
Deed Boo!
Deed Page
a
Deed Date
14272
1229
2/17/2011
Deeded Acreage
D.52
Assessed Building
Value
$0,00
Assessed land Value
6160,000.09
Total ASSAssec Value
$160,000.00
Billing CIOAS
INDiVIAuAL
Prepory Description
L012 CHESTNUT
Hiu.s a�F
BM1954-04038
Heated Area
Site Address
662 GRANBROOK
Rn
Gay
Raleigh
Tmenghlp
RALEIGH
Year Built
0
Total Sale Price
$170,000.00
Sate Dale
type and Use
22/17/2011
beeign Style
Land Gass
VACANT
old Parcel Number
407-000001047
W E
COUNTY

PAGE 06 06
0114101-42
i e2 201
0 4 00 ROD
1800 Feat
tiOZ s6 0 AON
N003S NULCOJISidd t3 inov
oma Iwo / CHA12338
NW.
WAKE
COUNTY
NoIrTm €A1.021w,

11/02/2811 11:29 9197799294
PAGE 61/ 6
mmommin 001111144/
r Mechanical
Services, Inc
HEATING & AIII.CONIITIVNPNG cUNTRACTORS -.
145 Technical Court • Garner, NC 27529 • [phone] • Fax [phone]
FAX COVER SHEET
SENO TO
At 6 D /viz _
From A /
Attention
cLI-Lc47r64-----
bate
//
///
Fax #
Phone #
Urgent Reply ASAP _ Please Comment Please Review ,For Your In#ormatlon
Total pages, Including cover

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C _0200 and this Notice is submitted prior to construction.
Print or Type Information and Mail to the Address on the Last Page.
DATE: ' / , 20 /( PERMIT NO.
(to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non-Oovernment: Individual Residence Business/Organization RECEIVED i IENR 1 L»VO
Government: State Municipal County Federal AOI1IPPRPRil'f [';lfi rSr��l
NOV 43 201!
B. WELL OWNER - For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
bat bF1 lawy Fird
Mailing Address:
City: � �ec�j State:jj . Zip Code: c Z7 O9 County: Wee.
Day Tele No.: 7 /q- Cell No.: CPI.- - 6
EMAIL Address: ,1. eF 2f2AS InilylSp►39 , C$1>MNo.: 15 Z - 9-'44.72
g62 efouriiwocg Roetei
C. LOCATION OF WELL SITE - Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 1766 61-s1 County:
(2)Physical Address if different than mailingaddress): tin
Y ( ) c
City: State: NC Zip Code:
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: -: I e rl A- h LJ -et i L LC
NC Well Drilling Contractor Certification No.: rr ��. [i (O -T, 4_
Company Name:6 k' ikvC G'l W . R :bl- 5 L L
Contact Person: tC i t'r'l A 1)/k 7"t f'L EMAIL Address:Cy uje< (J.il , 1 ( Yt 1 ead COY -
Address: I )) I c ij,�1 �� , L ( 12 City: l . Jq 1L P j tr PS� Zip Code_ 2"75(g7 State:I?/LC- County: _ [�-
Office Tele No ll cc/ L` t'4{ CeI1 No.gl(6l qq I Fax No.: gLGL SS, 3 Q 3
GPUMC SQW Notification (Revised 3/18/201 i) Page 1

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: __ -:B_o_wm_a_n_M_e _c _h _a_n_i _c_a_l_S_e_r_v_i_· c_e_s_, _I_n_c _. _______________ _
Contact Person: Sfe v-e.. 8t>-w~ ~ EMAIL Address: bowmanmechanical@bellsou th. net
Address: ___ 1_4_S_T_e _c _h _n _i _c _a _l _C_t _. ________________________ _
27529 NC Wake City: Garner Zip Code: State: __ County: -----,------~,----
[phone] [phone] Office Tele No.: -Cell No.: ----------~F~ax~N~o~·=--------
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: 2, Depth of each boring (feet): 3 0 0
* .if existing water supply wells will be used then provide the information in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc):
(3) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground:
(4) Grout (material surrounding well casing and/or piping): /
(a) Grout type: Cement__ Bentonite** ___L__ Other (specify) _______ _
** By selecting bentonite grout, a variance is hereby requested to !SA NCAC 2C .02l3(d)(l)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from > FCto 3 O O (feet)
If well has casing, indicate grout depth: from ____ to ____ (feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearl y and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected slwwi~g topographic contours or
elevation data.
GPU/UIC 5QW Notification (Revised 3/18/2011) Page 2
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
1 SA NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the jropen deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete_ 1 am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
I�
' 441
.nature of Property Owner/Applicant
Print or Type Full Name
Signature o' = roperty Owner/Applicant
C.F&J
Print or Typ/Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPUIUIC 5QW Notification (Revised 3,18/201 I) Page 3

0
12.5
25
50 Feet
Field
Value
PIN
1706346756
Real Estate ID
0054032
Map Name
170614
Owner
FORD, LARRY C &
LCNDA D
Mailing Address 1
4704 RADCLIFF RI]
Mailing Address 2
RALEIGH NC
27609-5316
Mailing Address 3
Deed Book
14272
Deed Page
1229
Deed Date
2/17/2011
Deeded Acreage
0.52
Assessed Building
$0.00
Value
Assessed Land Value
5160,000.00
Talal Assessed Value
$160,000.00
Billing Class
INDIVIDUAL
Property Description
L012 CHESTNUT
HILLS BLF
BM 1954-00036
Heated Area
Site Address
862 CRANBROOK
RO
City
Raleigh
Township
RALEIGH
Year Built
0
Total Sale Price
$170,000.00
Sale Date
2/17/2011
Type and Use
Design Style
Land Class
VACANT
Old Parcel Number
407-00000.1047
WAKE
COUNTY
NON!!! LAR(}L1NA

nr
Sh. k1
L.rkv
:•t�rllr�
.1k r
$ es toms
Hill Greens;Ct
leZtenti corps
W Ibroofa RA
�71 1 1p1l S
Aft
&IP Ionia In
6- 0 it* e eadila rf. I
* * #
NI Mar 41i,
ill
Tok
wir 'a 4 0,. de,
N, iolik its .-
i11111I _► +
11Y attr
'
® i
■i fy 4111
J■■.r
4
0
1
1
400
800
G�t=:rnrYrsan lrl
4 M
Mende t It
1600 Feet
Elementary
haw
offmit
WIr
1
O
Rr-
al]1ICr
2G�cnGy'Ct--�
CcP
r
Grp Rtl
Dr
Rcso
Green
Road
Elemenimy
4111141
�
■
lir
1
000111
David's St y
Gasivii'Rd
i
d WtdnwoodrCf
N v: th,C1rl,
GlenValley0 ` )
NgrthWood.O'
`Northliel
7 f
LVrSiIY[!{iC(3r
Ellw4pd'or,..,a
7
��� plly Ncirtbbraak'Dr
ti
0°1-s
WAKE
COUNTY
Y;]RTfl T.A&GLJ NA