WI0501033_Permit (Issuance)_20190918

tvortn t.arouma uepartment of v,tivironmentai yuaftty — umastou of water mesources
NOTIPLCATIi1Pr TO CONSi1IRtiCT I IIEIVNIAI ('ONIll jCTIVITV TESI WELLS
Thermal conchiciivit) trtt weUs ore used to rl eter-rnina the umount of heat that the suficwfhce mal,
trap and A vixen depth itawmal fa- tint pwptr of desi;lliiig,, geodavmal heutini;'uul , oolhrg sysrcors.
Pursuaru tit 1 A NVAC 0200130, thermal mummy rest mills shall he subject to the reguhnory
r-eduirernents applicable to geotherinot aqueous or ilVilf eXpansic%n naiad-lonp i t its desigraecl to serve
single, ?P ily I t sShknc:es_
I'h,�su u'elh are '),ermined h), rule - and clo not requir; an indir ;duol permit ar h, it ( ot;structect ill
mxmy army, wh Hie r uk; of 114 1t it 02t tt_M),
71ris rrt�tice Hurst be stdrrrritted nt least ttvo (2/ batsinessdaps pt_ior to corrs7ri�ction
Print Ckwhr or Pype In(onnrrtion. 117egihle,Suhnduals W711 Be Returned, Is Ineornplete.
DATE: 5 '` ._ J0 , 2oIll ._( PF] NO. oil 05.0103 3 We umTkied by F)WR)
A. TYPE OF THERMAL (MONDUC'TIVITY I LS-h WELL "ISO BE CONShRV('I ED
(1) Aqueous to per ',. NL M Wc Kay V _-- ;x' wwr of wei's
(2) Direct Expansion (as per .sA NQ „t. 02, (CIO Number of cvea. __...
R STATUS OF Yi'ELL OWNER (choose one)
(1) Single Family Residence
(2) I1uw nesK)rgamcaeion
(1) Govenmtem: State a:-- M_micipal County Iederta;
C. WFAA, OWNERS) -- For single family real knees_ list all persons Amm on die propeny deed. For all otims.
Am name of Bummsdibovernmen ed Agency and name of peisor, slid tAle with dc.le pted aulAorAy to si6n:
%lad ng Addrecs: L A a ZU.' ��-.._�x'� " �c ,j A -(.' F1 � _to; 43 `+°7A '`AWAY AAA/1
A) 3
0_�',~�.�,�,-�
F'MA11_ Address: Fax No.:
D. PHYSICAL LOCATION OF WELT, SITE
(1) Parcel Idonti Imm km Numkr 01N) of M site:_ it �. ; ' 7 S fl --
Counts: ....�._._ -
(2) Ph) ic.alAddress (i/fdiffcprenidaanmtifingaddrss) I"'t_'.4U (c�P..+��aan�.l _--�Ilk,wer
CAI:
Counly ��� � `£. Vp Code
Tk mA Corducti%Test ldoeillt OM low NOW, Pape t

F. IMAPS, PLANS, AND SPECIFICAJ IONS
(1) Maps must b, scaled or of noise arc irately indicate Mimes as orientations to tar ums It sated
Min 250 Awt of he irgc lion M(si Label all fe atur clev l} and i ch de a north a,i�my, Aftaeh a
slo"pecitic map showing rite location, of the fr (low ing:�--
m Proposed a jeetion well locations a peptic s� tenas and a s� crated npr w iniganon sites,
• Buildings drain fields, or repair areas
• Property boundaries
o Surface "war bodies a ) I KY N p(sential ,ource: of groundymer
o Watet suppl) wells comarn ration
(2) Plans and specifications of the suMm and subsut n ice . o an m tin detail A dw "oh system.
> ;
< �; F C< -E e,/ S<e r t",
E'. 'f YPES AND C'ONCENT'RATIONS OF ADDITIVES -- fist any additives that will be used and their
concerarations. Only aididves that the Department of Health and Human Services' [TvISIJn of Public 11caidi
determines do not adversel) affect human he: Itn shah lie rased. A Its of approved ada uses can he found online
at Ing d . po ahow Myn"N "M Ot . l U is :iU t . j x
other additives squire approval pnir to use.
G. WELL DRILLER INFORMATION Jf lmowa)
1
llit,C'on!ractn"sRanrc: r4dr e� h`.��1� �,� ye.;�r�,,, /+-r; ,�Ctv+c4
NC Well I) _Ming; Cortiactor Certification No
Company 'v ntu '�/<_% Wk'I/ Crtrl'"' f ,�' e. Contact Person: i 3 r', y-{ ->
C its ,F(7esm�a-,ty3v;k, �1F' — Stair A) C Zip C ode
)a} fcicNo.: 365 It Lxtr,[rit) c'ellNn 53 37etf
FAIAII Addicsv =foist lax tio:.73���'
H. HEAT PUMP CONTRACTOR INFORMATION
CompamY
Contact PCtsnn__—__.
Address:
t-t;v Zip Code. State: County.
Office I cle No Cell No-_ Gar Vo
I t,.ernml Co'oki !y 1 v,aAoG3catirnIt, I-26If, Me

K.
PRfl'r1:CTI0N — Provide abrie; description of how (I) water supph wells; 12) _urfacee water hod es: and Q
septic systems and associated spray irrigation sites,drain hulds, or impair areas within 250 to of the proposed
injection v+ells' soih be protected during construction of the aw'clls:
V A R I A NC I, Persuant to . AA Wt 1 the Dilectnr of the Dk idori of Water liccources may grant
a variance from applicable well construction ct operation standard, provided hat:
0) use of the wells) will not endanger human Sall mid wtlfit or Aw gwi ndwmer; and
(2) Mat consu uction or opar w on in accordance with the staracards is not f clinically i'eadble or the
proposed construction or wades e wd or hNwr protection of the sz;o.tr:chvaYer.
Any variance request should aeco npany suhmil al of this no I'IcaSm to expedite evaluation of the request,
hhe variant: )agues. Rnm can he a"wswd omu c ra HT t ;a, n „ r do,mm, into re,. nn ;titrtc),.
SIGNATURES — Ile endowing Won is to be wnTlt ad as mco e.d below or by that ierson's aulhorized
anent, 15A NCAt Owl, 021 _(� requires signatures as kilk"'s:
(a) for a corporation: by a responsible corporate officer;
bj for it p Irtncrship or sole propric wrship: by a gcnen, partner or the portion , respectiveh;
to for a municipality or a mmtn Wool, or oiner public agency: by either a prnicipal executive
officer or ranking publicly elzcwd official:
(dj for all others: by the well owner;
(e) for any other person rauihoriled to act in' 1 e0114 of the applicant: documentation shall be
submitted WTI the° W011 4m that cl ally identifies the person, grant them sigratutl�
authority; and is signed and dated by the applicant.
l h it ein (r If" penal) oI i t;:, that i En loan>-ar x 'y' r ratm r„t and am f urtiAar IrtUt the inturmaiion
tur.n,an:d in this docuu,ent and oil thereto onJ thai, hasf'd oft my fngzdr)gi those indhiduals
Pluticd<aten r,.ypansihh! k»• olooneng said ndnrr.aa.l ul I hCh"ra chat the i bbl;nation is true. actraro, and
eoPrnaetc. lure rnrare thcl there n >tf,a„'�r�.nt penalties r hedin,:{ the po.>aipihi i, c1'ines and rrnprtsontneat,
r subrPPA by Ase itffornintion. 1 ay2 c,! to Cons 0 x_t. _ IJ's r ace, lllainlab I r spair. :lnd i1 applicobl€, ah(I, OfaI thr
inicetm a eR and all rehan, d cgn7ur tenances i , adeo d_ nce It th , 1 t 4'CRC; 02C020), Pules. "
SI rltwa of apart} OwnerrApplicarN
P�fl
mt or Type I'll[] Name vnd Tilly
Signature of An It orized Agent, if any
Punt or Type [ uti Nanie and 110,
3g l 26ao 7
w¢i1 CoOtdP a _jV,5% 3 -_M (43M
wail foIlusas-?Oa y
3S0 vt1-
ii canal t o Iu, uoLs I t "+)titic<sion Rey. 3-1-2O t, Iota, 3

L. SC7mm Al, INS' RUC ION`5 - 4uhloiT one. copy oft lie Conn dclo ! nceilm on p adcago to the each of tfx
followmim .
(2)
Ile Division of Water Rummirces Rel Tonal (We u.r ing ilharea in which the in)crlion well'acilby
will be Amed:
eINSTON-SALEfVI
9,l nv� RALEIGH
„
ASHEVILLE F I WASHINGTON
,,-- ,daQRESVILL.,
��wFAYETTEVILL
Asheville Regional Off -ice
2090 U.S. I ligltln2ly 70
S' annanoa. NC 28778
'Ielephone:(8-8) 296-4500
Env (828)290-704
Fayetteville Regional Office
'125 (;Ice;) Street, Sure 711
Favett::ville, NC 28301.5043
l"clephone_ [phone]
Am [phone]
Mooresville Regional Office
610 Fast Centel Avenue, Suite 3M
ivlooresville, NC 28115
"telephone: [phone]
fix: (704) 663M.10
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC. 2Ri99-1628
Telephone: [phone]
Fax: [phone]
AND
Washington Regional Office
943 Wa4mgton Symm N511
Washrngtom NC 27889
Telepbone:(2.52)046-6481
too: (25 )07 -3716
VF'ilmington Regional OMce
127 Cardinal Drive Extension
h9minWom NC 2TM5
.1..elephore: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W.l lanes Mi11 hd, SuMe 300
Wirsta • Salem. NC' 27105
Prone: (3 36) 77h-9800
Fax:[phone]
Coune,13nvironmenial Health, Dcpamnom lu vrlilch lho injection v;�cfi facilnv vn'll be located
I hernlsl('onductiI Ii 'I est AOtifimewn Rev. 3-1-20n, panel

sqqoj VNS
\
Ir
I
IN

Vertical Test Bore and Formation Thermal Conductivity Test
Scope of Work:
A. vertical born shall be installed accordirl, to this scope of icrk. The co-r preed hore shall he located so
that it may he incorporated into the fina; ground -loop heat r xchanger design. A completed ve, rticel Yes;
bore shall consist of the vertical bore with an approved polyethylene i b Ind assr ��bly installed to the
completed bore depth with an approved grouting, material installed in the Lore
Bore Depth:
< 350 feel
Pipe and 1=ittings:
I lDPE pipe — ASTM D3035
Molded PE fittings— ASTM D2683 or ASTM D3261. ASTM 1-10,55 P, resin, socket, butt -fusion or
electro-fusion type, made to match PF i;lpe dimensions and class.
U-Bend Assembly — Factoryfsf rcated and pressure tested v, t n,busst�d depth stamp every
36 inches (min)
Borehole Backfiil:
• seal Material: Bentonite clay with thermal conductivity l;reater than 1.07 Btu(h x so. ft, x deg
according to ASTPA 0.5334,
< fenneability: Not more than 1 nm!s auordin„ to ASTM D5034
• Grout manufacturer and percent solids shall ne reported immediately following bore
con-ipletion.
Drilling contractor shall provide a detailed teat bore report. The report 5ha=1 include the following
information:
• Fach formation type encountered (c:riil log)
o Each formation depth (in feet)
• Depth of any significant cracks, fissures or caverns encountered
• All water bearing zones and if encountered:
• Zone depths
• Estimated flow rate
w Type of drilling equipment used (i.e. mud -rotary, air -rotary, air -hammer, etc), and rig model
number
Bag quantity of drill mud used if applicable
® Total time to drill the test bore excluding shut -downs to obtain water or mechanical break-
downs.
• A completed, signed report shall be supplied irnmediateht at the conchisiors of the drilling
process.

1 onnetion TnennaI Conductivity Test
4 Time Before Testing — Dependent on drill type used. 48 hours for mudr,Lary m 120 hours for
Or harm ter.
• The testing device shall be designed so that a cons ant rate of heated wager is suppled in an
uninterrupted fashion to the a -bend assemhy-
• The minimum combined arcs racy of the Wmpet store sensor and dat,aki her shall be 011
Loop fluid temperature readings shall be taken with temparatura sensors mounted in the fluid
stream. The tempeKature sensor and cat ;ogger accuracy shad be vended on an annual bads
with an instrument traceable to the National Institute of Standards and Iechnology {NIS?}.
• Power transducers shall have a r humum accuracy of -: ?.o'%of reading. 7 Ile call:aicgc,er and
power transducers shad be calibrated at least every, two years by the manufacturer using
recognized national or mien etional measurement standardssuch as those maintained by NISI.
• The enure testinh device shall he designed to prevent as touch heat loss to tie em✓ironment as
yowls e The testing device shall have an ecqumalent insulation 1.0" fiberglass. Each end of the
whend assembly shall he insuieterl with a 0.5" c:oseMell muldshwi to, prevent heat loss or heat
gain.
o Undisturbed "torn ation temporal -We SON he h tged for the loot, pr ko to the start of the test for
a period of 20 mint teas. Data shall he recorded at a maximum interval of 15 seconds during this
period.
• Testing data shall recorded every 5 minces thro,ighout the dw anon of the thermal conductivity
test. Data collected shall consist of tire following as a minimum:
Temtpecratum into the loop
Tenificrature out of the loop
Ambient air temperature within the test unit conrpartrneni
A;nhient outdoor air teurperatur'e
Input heat rate.
• The average heat input shall be between 15 watts and 25 watts. The average input heat rate
shall be reported in the final analysis.
• The duration of the formation thermal condt-WIVIty test shall be 411 hours.
® Data analysis shall follow current IGSHPA (Irvernationai Ground Source Heat Pump Associafion)
standards.
Drilling contractor shad he responsible for all per -units and following all applicable codes and
regulations. Where any discrepancy exists between local codes and regulations aid this specification,
the more stringent of the two documents prevail.
Drilleng r, onwactor shall take all necessary precautions to protect the site from er y damage resulting
from the drilling operation.