WI0600078_GEO THERMAL_20110719

Permit Number
Program Category
Ground Water
Permit Type
WI0600078 /
Injection Water Only GSHP Well System (SQW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
St. Joseph of the Pines
Location Address
305 Rockingham St Extension
Carthage NC
Owner
Owner Name
St Joseph of the Pines Inc
Dates/Events
28327
Orig Issue
07/19/11
App Received Draft Initiated
07/13/11
Re gulated Activities
Heat Pump Injection
Outfall NULL
Scheduled
Issuance
Central Files: APS_ SWP_
07/19/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville NC
Major/Minor
Minor
Region
Fayetteville
County
Moore
Facility Contact Affiliation
Owner Type
Unknown
Owner Affiliation
Russell Pait
100 Gossman Dr Ste B
Southern Pnes NC
Public Notice Issue
07/19/11
Effective
07/19/11
27020
28387
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
A7A
HCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
7/19/2011
St. Joseph of the Pines_ Inc.
Russell Pait, VP of Human Resources
100 Gassman Drive — Ste B
Southern Pines, NC 28387
Subject Acknowledgement of'lntent to Construct Type 5QW Injection Weil System
Permit No. W10600078
305 Rockingham Street Ext., Carthage, NC 28327
Dear Mr. Pair;
On 7/13/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-nnit
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.
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 Moore 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.Roserstaincdenr_aov if you have any questions.
Sincerely,
0
Jor Debra Watts
Supervisor
cc.. Fayetteville Regional Office - APS
APS Central Files - Permit No. W]0600078
Moore County Health Dept.
Yadkin Well Co., (David Brown)
Pilot: Mechanical_ lnr_ (Jon Faries)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699.1636
Location: 2728 Capital 9oulevard, Raleigh, North Garolina 27604
Phone- 919-733-322 I FAX 1: 919-715.058B: FAX 2: 919-715 8048 t. Customer Service1.877-6Z3-6748
Internet uvww.ncwatercualitv.oro
An Eo4ai iinnenunrr i A mnaaue ActTov Employs
__One
dl"th Carolina
Natural*

L 1. 13. 2011 11: 22AM No. 0665
NORTH CAROLINA
D PA1c'tMENT AP' 41PTELONitaNT AND NATURAL R$SOt7RCES (NCDE? R)
NOTLVICATxoN O77'TNTFNT TO COMM-UCT A tLQSLwb L at GEOT1r r.+RMAL 1
WATER -ONLY INTEMON WELL SYSTEM
TYPE 5-OW WELL(
xi, hCNrdancr wltli the provIO.Ons of NCAC Tltle .ISA: O7G02(1Or please
coatplete this notifirgtle4 * nd wall to address ott the beck pogo {I:bea Z.at or lype tniarnntInn).
DATE: 2- * _ . 20_4
T'relf 2)we Coe flrrnalke+: Dors the proposed system circulate potable?vlltcc.1niv (o additives) to
continuous piping that compictoly is❑IItes the fluid ion the environment (Let
clgse�[ loop?
Yes _�S Continuo completing this form.
No Do Not complete this foraz. Complete other UIC application forms for ilutctling
either a 5A7 ‘vei1 foam--iocp well }alootingpr,table watcrinto the aquifer) or a SQM )vr 1(oloscd
Loop well containing additives such os R 2Z eihanol, or other antifreeze or corrosion hilribitors).
PROP,LRTY /OR(S)MAPPLIC.ANT(S)
LIst2jr Property Owner listed on property deed gowned byn brines or gorcrtuuant ago N, slat° minx of
oath), and a rcpresan rlI w/oulburitigor igttatur ! t- . �y � �a�. p' 1L,..
11 —{� s
i �� Lrr
(]) main $ddresa: I r n 554M Ad 5f ;Cr .1 r z�
city; 3 Al r t- C State: p Cade: vl -1r7 County: C\OD re
Home10f6ae Telo No.: {'li d L - 2. I .LA G .Na.: C0,0 — 6 'Q It
Email Address:FOMIT S.W. 0126 Wet -site: '7 2A
(2)
physitaAddr.ss of Wel( Site (if different than above): So 5 P-+ r..., )) r2s, .4..
City. _Carjat.i2 a _ Stato:,11 Zip Code: PZ 5 32.7 County. Moo
Ho dO Ett TeleNo: all No.:
R. WT11DRIZBD AQTOV OV'NNR, IV ANY (If tiro Permit Applicant doss not own the subject property,
awl a idler From the property rnmcr CM tuOtiting llgusstlo install and ope.rale WC well)
CompauyNems: _- _
Coaled Prison — - )3MAIL Address:
Add.oss:
City: States Zip Code: County:
Ofilca Th o.: Cgtlk`o.:
i�cbsiteAdacc=of Company, ifony:

13. 2C 11 11:22AM No. 0565 P. 3
'WEN, railist,FitINFOrMAXION
ConlpaityNnoscej Ain' Well Cg too.
Wo1i DxB r Contruotor's NEMO: jayMI thaw Brown Dlfff ran Cava
MC Contractor Cortlftcalt :t'Io.: 2572-A r3[A !::4 -A
CoubsciFersoALQxtjd3,i3r¢t t Pd95 A _ j� Art+r : Gf3Ic 4r rii5[[,co!
Address: 19f Et tratnplarlviiid Id;
City: AraolOilvilio }I.C, Zip Co do: 27070 County: Yndkiu
°Ente nteNb.: 336.46.8 4440 _ Cal/No.: 336-374- 734
D. ]FILA1113MT COTMLA =ORIMOI MATI:ON(ff dil3era,nt ti n driller)
Coign! Pt nor' v, 4 t WAIL �dress: ��FLfj' G6y.
Moron; 146Firi1 7 v t,4
City: %, I co rn ZIp codo! 2 -7 ° (County:
06ficeteleNo.: - 1_,CSr fi73 CaliNo.;
2. STATUS OF 4LPPUC4 N T
PI:hot= Federal:
State: Mwdolpai:
�}$tIvc Arrlcricen Lands: —
BITSCTIQNP o O WU� (briot�y dascr'Ehe boy dui Wootton' vicEt(s) wllt be user])
rr
_ }• �... � 1, • - �i Y 0 ." (At '1— - :: '&ail C› c.
Cyr e
G. WELL CO N.S31WCTION DATA -01 I' 1
(I)Tmposed dainty Ellaconsfruated: -($ Nutabt r ofGorfr> Tt� 4 C /
Approximate deplll of cub badng (coat): 2 v
(2) Typo of Nang tabo-used(copper,PVC, o(¢): A.d1) F/ S) - l• l l
(3) wcl t CrmiDg. Js i1:a wcll(s) eased? (oheak clam (c,) Yes p5 (b) Na below)
(a) Yes Uyos, then provide CYtting Lufomotion below
Taps:__galvn+t3zcdotoal_awl;aloct_plestIo ctlscs(epoolfy')
Coxlxg depth; Prom t Teel (rcfb► etc to in] surlhco)
Caslug ax [ends to bare ground Incites
(b)Ia
(4)13mot Ltfh (txnterl sL skim:ondlug well casing andlar piping t
(a) Grout typo: 'Nret Content &medic J
(b) GrAutglatflmz:tl: Ptuaping :% FrasSare
tiff)
n,d l r� art keel o cA
Ctftcr (away)
GI4F
{lrcutdspIEt of tubing (roaxo ota krirtaoho): from 20 era C+ (!!re
Iftins oasiug, ludlcMegrout dap 11: ftoul 10 (NO

Ju l. 13. 2011 11 : 2 2AM No. 0665 P. 4
JI, 1N.mcnoN-J.mUT.ED EQUIPMENT
Auacl.i a d1agnun showing tbe (?Jlgh1eeriug layout or pro_poscd modlficatioo t1f am ;nje¢fion ~quip:mentMd exterior
piplnytublng 8iSOcialeil wlth t11c inJectlM optratlon. 111D ma1\u!i\ctnt(!f s brochure. may provide supp1ernentary
in.torlllatlon.
l , LOCATION OF' WELL(S)
.Attach trni copies of maps tlow!ng the !ollowfag !nfarwatlon:
(l) Includ1;1 a Silo Map (can be drawn) showing: bulldln_gs, propc1-ty linos, surface water bodie:s; pctcnlial
$0Urws of troundwulcr 1:onlamlnaU011 and the 01lentation ofaltd dWancea heiw~~g, 1lio proposed ,vell(s) and
a1\}' cxlsling wcl.l(s) or wa$to disposnl .ficiJlties such as septic 1:w:s Cl' drain fi!l!t[s lo~aled wilbin 200 rtct of
the 11,eothcrmnl heat pump well sys1em, Label ;ill features clearly and in:::lnde MOtlh Rm>W,
(2) Tho Sito Map mus~ show fhe subject property ic 10lation to lbc surrc11ndiog areiL by usi.og at lease hvo fixed
rdw:ence poillts such as road$, sirea111S, nnd/cc hlgf~rJa.Y lntetstctions,
J. CBRTIPICAT!ON
Note: l'IJls rcrmit Applka(lon ni 11st be. slg11ed by .!!!!1!, pOt"son l'I ppol\ri11g ou tho
l'CCOtdccl legal -property dccll.
"l horcby corlliy, under psnally of law, th.at l h.tvo personally exammcd and am famllir.r with 1!io fo.f'crrnAllan
:iubmittod ill Ibis dooumtut and all ottll.cbJllcn!s thereto and l'.hid,_ bused . oil my Inquiry of lhoso lndlvlduals
J.mmecllately toSpomible for 0bt..inln5snid l1lfur.1J1atioo~ l bolleve lhn.l the iJlformatlon iz tn,o:. ac(juratc end complete,
I nm aware tb1lt tha-e are slgnUicant pM.uies~ Including tlic possibillty of fini!$ and illlprlsonment, for submitting
iilba informntlan. I age~ to co:r.sltuot, openitc, 1DJ-in!ill•_Efalr, ~ i! -\J)jlllcablo, abandon. tht lll]ection fflll aud
all related appurtenanc~ bl-nt:c01tlat\CC with tho nppto e:d j;,;;ific,1iJns and c:omlllioxis 1>t'the Porm!1."
x , 'j{,v¼
Sigt 11rc of1r0~ly Owne:r/ApplJ~l
X \¼.<:.Se\.\~~~~\)~ o~\~,.M,N ~'.:OJlc..~s
Pt!Jlt orTypeiJ!ulINa1nt1 and tl~
Sigllil(Ut'O orFto_pcrly Own11;/Applloant
l'.rlilt or Typo lqill Na0:1e ond tftlo
Signatlll'c of .An,thormd Agcn,t, ff any
:Prwt or Ty,0e Full N11D1B and tit.le
l'J,asercturn f.wo copies of the completed.App!lgi1ioo packago to:
Noi·lh C."trolfoa D~NR-DWQ
Aquifer Protection Scctlon-UIC::Pt'og1"ruU.
1636 Midi .Scmce Ce&tttl"
Raleigh, NC27699-1636'
Telepl1ouc [phone]
RECEIVED/ DENR I DWQ
Aquifer ProtP'iion Section
JUL 1 3 2011
Jul. 13. 2011 11: 22AM
NO, 0565
P.1
f? (J J ei c Piece. V ' U
PRO]ECP BENCHMARK 41
BOLT CLOSEST TO 'IV kN
OPEN ELEVATION: 67.511'
12' RCP (REDUCED FLOW]
6-.0
INLET PROTECTION {7rP] �\
1
0VERHE*b Own' UNE
[R/W mint UNKCNOWNm
t— ....--_ Tom'
-' -'•Iris T WATER r. IR+ `a" , ,,,, -'E._� _ _ _»- __w _ _ »--`
`.yL... .1_•�.'Fy n -E :'T-'...-' ��n Vs..� T' •S _ ., ~- �rww�'.. 47--y. - ^ -` - -
.,,�._..,. ,, . .�_�,, ._,,.Rrra,.,, , 7.5 ---� - -i ; ..1^'r"- 4..,,.,-,. S.ti
SEDIMENT
_ BMRRIER-c)-
-------_,_*`f'WEiRaa. E
WI* VIM
am G4ROFA'-
AGTIOM EllVATIOlI;�,O • `y
UNDERGROUNM LIII;;L1I@5
• -- '---(SL1C SHEET S4) !
•
E . crest'..Do
ENFORCED
SWALE
ROSS SOTSON
LAB 3026 PG 37B
INLET PROTECTION rTYP;
. CULVERT INLET
` 1 OLm.ET [TYF)
'.7~``• -.�T' - .,. L1MFf5 OF DI570R9ANGE� �+ i
` [JONSTRUCiIQN SEQUENCE �`. •, ++ ,'•
i L CUMIN ALAN ARPAOVML W M OTHER APPLICABLE Psztur5, \ `ti \
1 1. Li
i 1INTrALL S+W SEDIMENT AJEL -'
M MAL 5 SITE 's
4 SYOC7CML! TOMEON SITE `` •y •. .� i i
S. straws AND "REES No' ar'.e FOR M r:ww: , FORE QIIPPO . \ ,
I MA O= &KITE FOR KACIAL
i S. EXCAVATE RAM CARDEN AHD 1HF'(LTPATOGH TRINCK AREASAHCIIS[ '•• ', \ •, I, \It.AS SEDIMENT TINES, t+'' % ' \
s -
r. GRADE SRC. SWpESTO AN STAaE=AMR CRAM NG, KIM TO . y , ti '1
F [NSTALL oupeass MO STORM D A1NAGE ❑4AN 1 I57i1 BA , 'V 'y ` ,
RISTALLED W1TN DTPCM UNMAN") VEGETATION. • \ •\ ', ti
4.1NSTALLTEMPORARY t:G`_7ATION ON EIPASEO SLOPES WITFEN li 's
CALENDAR DATE POWELAP PiETNE Cr1NPLrrioN OP ANY PYAS3 Op ,::•1 'y ,'V '`''A �, •1
_ \
P+>11AINSTALL ANENT VEGETATION ON ALL p NUM AREAS w MAN '•,1 ', .', \+ \
SEI CALENDAR
RT. OATS FOLLOWING COM MNTION OP CON5TRI1CTRON OR '\ . 'sy S, 5+ V 5
:I. Lms TALL RASH WOOS AuO INFRIRATION FEATI:R 5 IS1CY+,FT,R y •�% 1�'y y7 1
Nit 35 STABILMEO. '`' \ yr , •`y, ,Iy y 1 VA 'Ll, 5A
tl. RC{wp,R TETIPORMIr MLU' 11W ES EMT AFTaL SITE IS 5TRJ> FJ7 y. +, y . L 1 L
LEGEND
"'UP.," PROPOSED CO
''r=R.-r CASTING CON'
- - - _ - PAn=wA
METING WAr
7l9AJIERTIIAF
WIZ PROTECT
•.— WARS OF GET
AOOF DRAINS
11,E
't1;
i1.,1
, ‘
Il t ./ lV 1
hip 1 Ceti,. ` • RGROUNDi
el AISEEr SEE EHEET 541
C4NSTRUCT
MIRw1.3
WEIA 1S.!
TOP szvlOarM-
INF[LT A O 4 �fT
salrom ULNA -ION rs.7 �-^"
\* R OUTLET Q I
E1
1
welt w1O rM 1'
EI$.ATTOI, 752
CARRIER MP)
\ FUTLIRETRACT2
1 5
Km',whits bOlo V.
Gall befOfa ycxl dJg.
•1

Jul.134 2011 11:21AM NQ.0b65 P. 1
FACSIMILE TRANSMISSION FORM
DATE; / f Z / 11 11ME• REF NO. LOG NO.
TO: t-, p .a ( s?) 6-0 g
FROM:
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FAX NO. PLEASE
Oimma❑ sa1A1E(
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MESSAGE:
Q ) 4611 l egt hefrt e/ (iV € e 004
PAI V(4 F, !' ICsrGE- "11ah- r ,? /- L i$r4 Q / 1162.. .
{AIC _
^FOR ALL YOUR WATER NEEDS'
YADKIN WELL CO., INC,
1908 HAMPTONYILLE ROAD
kAMPTGNV1LLE. NC 27020
nAVID J. BROWN. V1Cev PRES.
TOLL FREE MO, 24E4355
OFFICE (336) d68+1A40
FAX Saab} 4G0.4044
RE5 [336! 468-46139
•C65E NEWS AMSRIG - GOO LOWS vow
PLEASE INFORM US gdU801►6EL5'WI% DO war RECEIVE FACSIMILE ICI euLL