WI0500457_GEO THERMAL_20120124

Permit Number
Program Category
Ground Water
Permit Type
WI0500457 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Milton Kendall SFR
Location Address
811 Watts St
Durham
Owner
Owner Name
Milton
Dates/Events
NC 27701
Kendall
Scheduled
Orig Issue
01/24/12
App Received Draft Initiated Issuance
11/09/11
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files: APS_._ SWP_
01/24/12
Permit Tracking Slip
Status
Active
-Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Milton Kendall
Owner
811 Watts St
Durham
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Milton Kendall
Owner
811 Watts St
Durham
NC
NC
Public Notice Issue
01/24/12
Effective
01/24/12
27701
27701
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman
Governor Director Secretary
01/24/2012
Milton Kendall
Elizabeth Kendall
811 Watts St.
Durham, NC 2770 ]
Subject Acknowledgement of intent to Construct Type 5QW Injection Well System
Permit No. WI0500457
811 Watts St.
Durham, NC 27701
Dear Mr. Kendall:
On 11709/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
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 1 5A 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 I5A Section 2C Subchapter .0211(uX2). 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.Rogers ez:nedenr.av if you have any questions.
cc: Raleigh Regional office - APS
APS Central Files - Permit No. WI05004 57
Wake County Health Dept.
David 7 Brown (Yadkin Well Co., inc., 1908 HamptonviIle Rd., Hamptonville, NC 27020)
Brant Wurster (Sustainable building Solutions DBA Green Horizon, 619 Foster St., Durham, NC 27713)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699.1636
Location: 512 N. 5alisbuiy SL Raleigh, North Carolina 27604
Phone: [phone] FAX; 919-807-6496
tetemet: wuvw.ncwateraualiity.ore
An Equal Oppn1unity \ Affirmative Action Employer
One
Carolina
Wuxi!,

Nov. 9'' 2011 11:59AM No, 1319 P,
NUMBER OF PAGES
INCLUDING, THIS SHEET
MESSAGE:
FACSIMILE TRANSMISSION FORM
DATE: 1/' / 0 '? / 1 / TIME- REE NO. LAG NO
TO: ,i-c, / •1/Z. (I/ 7r -6 e e
COMPANY NAME
111..ea o.- /
44
ATTENTION ' DEPI
FROM. Vadki4 GIe ra rptc_.
COMPANY NAME
INDMDUAI, DP
E
REP3YgBY_ OPAGINATDR'fti"
SSJGM TTURRE N "''
FAX NO. PLEAS!
LaW
) - PS
FAX NO. PLEASE
❑ PUSH
REPLY
-r vex
r --
•
"FqR ALL YOUR WATER NEEDS'
YADKIN WELL CO.. INC.
1908 HAMFTONYILLE ROAD
WAMPTONV1LLE. NC 21O2O
DAVID .i. BROWN. VICE PRES.
TOLL FREE (OW) 24y9355
OFFICE (3 6) c6B-444O
FAX (5 6) AGO.4O4B
RCS i3361 46841$59
-GOOD N6*$ wrl RiER . GOD r.GVSS
L.!
PLEASE INFOFaM US immEOIPS>:1Y IF YOU PO NOT AEC6NE FAMAILE IN PJLL

Nov, 9.' 2a 1 i 1 I : 59AM
No. 1319 P. 2
-)5;o 5-
NORTH CAROL]NA
DEPARTMENT OIENIMONMENTAND NATURAL RESOURCES (NCORNR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSJD4,0OP: GEOTHKRIVIAL
WATER -ONLY INJECTION' WELL SYS TM
TYPE 5-QW WELLS)
in. Aoeordance with ttie prus9sions at NC,AC Titre I5A: 02CO200, pled
tiomptete this notification anxd mail to address on the back page (please Print or= Information).
DATD: O 7 .20 I
Well Type Confirmation: Does the proposod system. ciroulato potable -Wet. only (uo additives) in
vontinuous piping that completely isolates the fluid fiord the environment (i.e.
dosed -loop)?
Yes X; Continue completing this form.
DID ]Do Not complete this form. Complete other UIC application farms for installing
either a 5A7 wali (Qr en -loop i 'acting potable water into the aquifer) or a 5QU well (closed -
loop well containing additives savi as R 22, ethanol, or offer antifreeze or corrosion inhibitors).
A. PRO PARTY OWNER(S)IAPPLICANT(S)
List eAGh Property Owner listed ou property deed (if owned by a business or government agency, state time of
entity and a representative wlaut o ity for signature); - Y.-Le is) c4
(1) Mailing Address: 1 Irter" +5 SiV At -d—
eity: ( ) d ( 6- t". state: iu `Zap Code; _ O'County: ' As
Honte/Of ce Tele No.: L (9
Email Address: Website:
i Y
Physical Address of Wen Site cif different than above):
City: State: — Zip Code: - sty:
Horne/Office Tele No.: Cell No.:
(2)
B. AUTIOR1h, I] AGENT of OWNERM ANY (tithe Penult Applicant PvO not, own the subjectproperty,
attach a Letter from the property owner authorizing Agent to install and opexate UIC well)
CompanyNatne: - -
Contact Person: EMAIL Address:_
Address:
City;
Office Tele No...
State: Zip Code: County:
Cell No.:
Web site Address of Company, limy; -
AQUSiq Pjl it Tr .
ccTION
Nov 0 9 2011

'Nov. 9'. 2011 11:59AM
No, 1319 P,
C. WELT, PBJLL sR i4 EO1t:ThLTIO.N
company Virra ',Ystain Well Co, Inc,
Well Millet Contractor's Cam : Zodt' Malt Marbly Brows Miltso Cava
NC Contractor Certl icat'tcnNo.: 2572 A ? 036-A , 354$-A
CoutactPetso Divide Br tw- 2i i 5 i • Chi e
Address:1908 Hamptonvill a Rd. _
Ci +: Eggtpto vilie Cotio: 27020_ County: Yadkin
Office Tole No.: 336-4158.4440 Cell -No.: 33 6 274-$736
D. BEAT PUMP CONTRACTOR Il'ttTORMg74Y (if different than drRicx
ComperyName; 7.( --5 4.4 k•i
Contact Person:, .( e•i-j- t..9 �r.rs � f' EMAIL Address-,_� U' J 5 � ( �.F � •, � � . `; � .
Address: f v 9 v r 5±re-e
Cl:tyZtp Code: 1 court VS
O ce Tete - 3 /1, 5 S Kf Celt No.; ° °f . a 4'J
aw, STATUS 07 APPLICANT
Private; )' Adele]: Co arciRl:
State: Mi]nicsipRlt i+lati American Lands:
INJECTION FRO CZTJ1.Tit.G (briefly desarihe how the injectlou)vell(s) xviil b t uacrl)
J it-(r.(o [a�f'LTY�LF f�:a►�S/ �*�br_' y i 1�1' L�?J�/j
g �w Erci .f..�' -Q K.--
G. WELL COMTRUCT]r[ N'DA.TA 7 t t_ 2 3
(I) Proposed date to be constructed: r + I _ I•lu bar of borings: 9
Approximate dept}t of Each boring (feet): q-
(2) Type of tubing to be 'aged (copper, PVC, etc) 14 D ICE S 0 —1 t 1 Y�
(3) Well casing. Is the well(s) cased? (check either (a) Yes aX €b.) No below)
(a) Yes ifyes, then provide casing information below
Types __galvanized steel black steel?lotto other (specify)
Casing depth: Fran to fear(reiztence to laud surface)
Casing oxtestds to above ground inctzes
(b) Na
(4) Grant Into (material grmaurtdiug well casing eitaor Isipittgj: ays ��. sue► are ��.
(a) Grout types Neal Cement Bentonite V Other (apecify)
(b) Got placement: Pumping ttr'; Pressure Other
(c) Grout dep1h attnhing (referecce to Ss ad surface): PM, (t7 to 0 (feel)
If well has casing, indicate grout depth: from to — (feet)

Nov. 9' 2011 11 59AM
No. 1319
INTECTION-11SLAT2.11 EQuipMErrr
Attach a diagram showing the engineering layout of proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation, The manufacturer's brochure may provide supplementary
information.
z. LOCATION Op WELL(S)
Attach two copies of maps showing the following information:
(I) Include a Site Map (cans be drawn) showing buildings, property lines, surface water bodies; potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain *ids located with 200 feet of
the geothermal heat pump well system. Label all features clearly and include a nort arrow.
(2) the Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, strea;r_v, and/or highway intersections.
L CERTIFICATION
Note: This Permit Applications must be signed by each person appearing on the
recorded legal properly deed.
"I hereby certify, tinder penalty of law, that I have person�iy examined and am familiar with the information
submitted ia this document and all attachments thereto and that, based on my inquiry of Close individuals
immediately responsible for obta-inarg said information, I believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the passibility of times and ix prisottxiaent, for submitting
false information. I ogee 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.'
Signahs: afproperty Owner/Applicant
Print or Type ]I Nate and title
er4QA:
Signature ofProperty Owner/Applicant
H Cr! S,i' kQ.,ckg1
Print or Type ) b1F Name and title
Signature of Antborired Agent; if nay
Print or Type Pull Name and title
Please return two copies of the completed Application pac1tage to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mal Service Center
Raleigh, NC 27699-1636
Telephoua (919) 71.5-6935
NOV 492011

dov. 9. 2011 11: 9AM
No. 1319 P, 5
Ids
on ke.A,i6LA
Fri( Q .4-Srt e,4
°u. ha ��-
aw.a �► S'
N
l
C