WI0500506_GEO THERMAL_20120409

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AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Ryan Smith
Toll Brothers Inc.
10404 Lumley Rd.
Raleigh, NC 27617
Charles Wakild, P.E.
Director
04/09/2012
Subject: Acknowledgement oflntent to Construct Type 5~W Injection Well System
, ;;,:: 1-.:0. '.Vl05J050u
7613 Summer Pines Way
Wake Forest, NC 27587
Dear Mr. Smith:
Dee Freeman
Secretary
On 04/03/2012, 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 w:ater,
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 .021 l(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 [e-mail] ifn u ,have any questions. 3 -,,._ J;;fx/J,x ~P
cc: Raleigh Regional Office -APS
APS Central Files -Permit No. WI0500506
Wake County Health Dept.
fo,D ~--.. ,
Supe~
David J Brown (Y ad.kin Well .Co., Inc., 1908 Hamptonville Rd., Hamptonville, NC 27020
Louis Agnolutto (Louis Heating & Cooling Svcs. Inc., 5813 Lease Ln., Raleigh, NC 27617)
tDU!H:H PHOTECT!O:·~ SECT!JM
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]
Internet: www.ncwaterquality.org
An Equal Opportunity\Affirmafive Acfion Employer
One . -. . ._ North Carolina JVatura!lg
Permit Number WI0500506
Central Files: APS SWP
04/09/12
Permit Tracking Slip
nragrarn Category
Ground Water
Permit Type
Injection Water Only GS}-IF Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Summer Pines Way
Location Address
7613 Summer Pines Way
Wake Forest NC 27587
Owner
Status
Active
Project Type
New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville Rd
Hamptonville NC 27020
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Name
Toll Brothers Inc
Dates/Events
Owner Type
Non-Govemment
Owner Affiliation
Ryan Smith
7613 Summer Pines Way
Wake Forest NC 27587
Orig Issue App Received Draft Initiated
04/09/12 04/03/12
Regulated Activities
Scheduled
Issuance
Heat Pump Injection
Private residence, single family
Outfall NliLl
-
Public Notice Issue Effective
04/09/12 04/09/12
Expiration
Waterbody Name
Stream Index Number Current Class
Subbasin

ti.� a -+ �.
NCDRITI
North l" amlina neplrtrrrpnt of Fn,rnrnnrnPft anri trpi RAcnt,trrpq
Division of Water Quality
Beverly Eaves Perdue Charles Wakiid, P.E. Dee Freeman
Governor Director' Secretary
04/0912012
Ryan Smith
Toll Brothers Inc.
10404 Lumley Rd.
Raleigh, NC 27617
Subject: Aclmowledgernent of Intent to Construct Type 5QW Injection Well System
Permit No. W10500506
7613 Summer Pines Way
Wake Forest, NC 27587
Dear Mr. Smith:
On 04/03/2012, the Aquifer Protection Section (Al'S) 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 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 [e-mail] if ou have any questions.
S cerely, 2
y(10.1
for Di.na. 1' atts
Super
cc: Raleigh Regional Office - APS
APS Central Files - Permit No. W10500506
Wake County Health Dept.
David J Brown (Yadkin Well Co., Inc., 1908 Hamptonville Rd., Hamptonville, NC 27020
Louis Agnolnttn (Louis Heating Re: Cooling Sxrns. rnc„ 5R13 Lease Ln., Raleigh, NC 7761.7)
1636 Mail Seriice Center, Raiaigh, North Caroline 27699-1636
Locatiorr. 512 N. Saisbury Si., Raleigh, North Carolina 27604
Phone'. 919-807.6464 +I Mk 919-847- 496
lnterase www.ncwatercuality.Eta
An Equet Oppwiuni[ylAtfirr uhteActon£mpiuyer
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Apr. 3. 2012 10 : 38AM No. 2125 P. 1
FACSIMILE TRANSMISSION FORM
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DATE if / / / 2 TIME: REE NO. LOG NO.
TO: Ali G figA (q(9)1,Pa7 - C
COMPANY NAME FAX O. Flew
TIMAy Op 911 A _ ❑ DATELY
ATTENTION OWE
FROM:
Yetd kip, Wet{ C.
COMPANY NAME
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INDIVIDUAL arc
NUMBER OF PAGES PLEASE ORIGINCIR'S
INCLUDING THIS SHEET REPLY BY SIGNATURE
MESSAGE:
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(3JC) flirt - Pi
NIX Ho. PLEASE
a REEPP1Y
e.fil eh C'J
jo-C._ )14-1 - _et f s 4..spc ifJ oLILL_
-FOR ALL YOUR WATER NEEDS'
I949 HAMPTONVILLE ROAD
HAMPTONVILLE. NC 27d20
DAviD J. BROWN. VICE PRE$.
TOLL FREE 16OO 248:9355
0FFiGE 13361 466.4440
FA% 1336! 468.4048
RE5 13361 4G0.4659
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REOe1VEo,DLN /D Q
'?t i F1'otection Section
RECEIVED 0413'.g [ -9 ;15 FROM -
PLEASE INFORM US 1MINCOATELY IF %CCU DO NOT Rl4EIVe MC$IMIL6IN MIL
TO- NC DENR P001/005

rAar, 3. 2012 10:38AM LUU15 I1tA11NU t'" WU 1NU
No, 2125 P. 2/4
NOR B CAROLINA.
DEPARTaffINT OF ENVIRONMENT MD NATURAL R=SQURc53 (NCD
RECEIVED/DENR/DWQ
APR 032012
NOTIFICATION OF NT TO CONSTRUCT A aigandeQQE GgOMERMAL
WATER.- a x ]NJECTLONWELL SYSTEM
TYPE S.AJW WELLS)
to Aceandeuoe with the ptoadstrn s of NCAC Title 15A: 02CO20a, gaze
complete tins edification sad mall to addaeas osa the base }fie (pleessPl ut armlefilime400.
f Sectio P
DAM L`f CCk�'aa , 2O 0
?jape Carirmadoatr Does tiro proposed system circa/Me polablo water only (ao additives) in
continuous piping that completely isolates the amid from tbo environment (i.e.
closed -lop)?
Yes es Continea completing this %rot.
No Do Not complete this firm. Complete other UIC application forma for instal*
either a 5A7 w.li (gm -loop welly 1 g potable water 3no tits aquifer) cc a 5QM well (alered-
loop ali cantaining adfitsg sock se R 2, ethanol, cc ether antifreeze or mrrasion inhibitors).
A. PROPERTY OWNERS)/APPLICANT(S)
List Property Owner lined on praper[y deed (gowned bya business pr overman n agency, state name of
ont$y and t representative wfautbority for eoliths): • t - �
(1)
MaimsAddtea nbx% & cs L>�a••{ .
car Lie.For^ - srste: C Z '-wk Cuy (- OM
Home/0M&oa Tel. No : C 5541- CV 1 Cell b
B=il Address: Wel�siti}r
(2} ihysiad Address of WU Rite (if di sent than above):
City; _ gtatb: Zp coda: Coliaty;
kloracfOfce Tete No.: Cell No,
B. AUTHORIZED AGENT OF OWNER, IF ANY (Mho PercaltApigkant tea= owtt the subject property,
attach slater from the prapecty owner aulltivitSi gAgora to Install and operate UIC wig)
CoaopgnyNetae;
rc�
OfiseeTeleNe.: '-Nig1-` 44sr '
Na.:
%bslte Address of CoIpany. inter,
}3ECETVEU;-O403—`12 09:15 FPOM—
TO- NC DENR P&S

'Apr, 3, 2012'10:38AM LuUIa (lt$J IIU13 t•JULIl'A3
No.2125 'P, 3'
C. WBLL DEFORVATION
compagy Nem vacffek Nell Co.:teo
Wail Driller wer's Name; .briviabtitis lioditto_yie Stan cm
i►TC Cot DerttfoaticmNa: 257-A _os6-fl _ °,^,�,_
Coot:mg/ea
Addee : Z4(8 Hamptaealils Rd-
Ci#y, Iimegortville x « 2 p Code; 27020 County: Yadkin.
Ofllco Tale Ne, 336.468-4444 — Cell Noe: ...3 4. 74.8735
r,,
: I .4 •- -
.I.. , i , w,., Vir,,,,
D. BEAT rube CONTRA.CTOR INIORftlATION (if di@keat than artier)
()mow Naar, k-.CA''ke` Pk k r-%t. Qcx \ %,r►%c&) S . G
CofltaelPeru , teak. c- DVAA-c a ' 1, cl‘. 5,.10ic &CZ \pe!X.1.5c-
aty: - a ],eA-dp _ Zip Code: At'-t Comte: e
altincc'reza Wo.: `421\"1:1 \%X ' Ce Btar.:
E. STATUS aPArPLIcANr
P im= ,/ Feduese l: _ Cemarolak
i laid ale Native American Land
INJECTION FROM =ER Oddly describe hnvshe h e tiaa > (l)Rln ba used)
+ doe .a c1 C,ps
LCorssna1CaON DATA 71 V
(1) Proposed duo to be cosetweted: A
Approximate depth of each boa* Oa*
(2) Typo ot'ttsb3pg'to be mod (copper, PVC, ete)t
i z1
Iltieberafboring <\
pi 40')+'
(3) Well call* Is the weO) waled? (o ssak a (a) ]bra e� (b. Cc -'Lk
00 Yee - seYyaR, t;b,n Dravida cseleg to btroad s below
lrpe: _gsrtr r ud steel Slack stead ,plastic aver (opecl*)
Wog depd t Frain __to _Pet (reference to laud aurlhte)
Wog Ada DJabove roue d,„.„loches
Coot using aadlet /31043: c„ ,a l/? 64
/
Bentonite °der (speoli)) -
chnftt dernbatubism (voit-teacc to Ind foirface), °fines. 00 to `P OW)
(a) Grout type: Neat Ce: et
(b) Mout ment Pumpin
f�?
RECEIVED g4- 3-'12.09:15 FPOi-
TO- NC DENR P&5 P003/005-- "'""'

tAp r. 3. 2012 f 0 : 38AM LUU 15 NtP r t ilb ai LUUL i III
INo. 2125
4/ 4
g. IMECTIONAIMATED xQ�
Attach a diagram showing the engineesing tayont or proposed modt$coa, of the injection equipment and exterior
pipit:Writhing associated with the Wectiea operation. The manufacturer's kudos mayy provide supplementary
Inihrmtation.
LOCATION ORS/MUM
Attach two coptiea of traps showing the falinwlng information:
(1) Include a Site Map (coo be drawn) ehoFwing: buildings, propene fiaaa, sytrItte6 water bodies; potential
somas or Egfnundwincr cont8minmion and the ortentatton°tend distaii es behveen the pmponed nee l(s) and
wedging ettall(s) or ve;stc disposal facilities such ea septic tuts or dram fields located within 200 feet of
the geothermal beat pump welt syste , label au ibet um clearly and include a,nenhprrow
(2) The alto Mep must Mow the subject property m tclatioo.ko the surtaw ug area by using at lost two reed
resto s pelt* snob as roads, streams, aadler highway Wks ectiona.
X CERTIFICATION
Mkt This Permit Applscalion must be stood by mail person appearing en the
recorded keg property deed.
"1 hereby ce dfy, wider polity of law. rho i have personally wined sad am familiar with the information
sub -mixed in this ddcnmez and all attachments thereto and that, based on ray tngttby of those individuals
immediately tearper:dihle The obtaining said informetiett, I believe that the irdlarmation is true, esonrate and complete.
I am aware that those arc sigaisaant petoeldes, including the poasibity of Ems and insluismananti for submitting
Stine infortuat to I wee to construct; opetste, maintain, repair, cud if applicable, abandon the isjecdoo arc# ead
ae related eppurtettocee in accordance with the approved specification And coodltions of t1PPermit."
Sigof Property O 5r a
Pried oeTypoAdage=ond ti
Signattnt of Praparty owne r/Applicata
l�titit ar Type Bu tWarne end title
Sig ndttae of . rued Agent, Fan,
> crType Pull Nance cud tide
Mom roam tWo copies oftba completed Applica sa pie io
North CtroVas D -DWQ
a .,r ifer'elmtCr ion Sectiin1e-DtT(_ Program
Raleigh, NC 2769f 1636
Telephone (9p) 715-6935
RECEJVED/DENRIDWQ
APR 4.3 2O12
Aquiver Protection Section
RECEIVED 04-43-' 12 .09 ;15 FROM-
TO- NC DEAR P&S P004/ 5

Apr. 3. 2012.10: 39AM
No.2125 P. 5
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RECEIVED 04 -ga. ' 12 -09:15 FBOCI-
�:��. _
TO- NC DENR P&S
P005/005