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169 King Arthur Ln � -� � Central Files: APS SWP . RECEI��i�o Permit Number WI0400126 Permit Tracking Slip MAR 0 9 2010 PrOgCam CategOry StatUS P�Oj�.RW'�jr��UNTY HEALTH DEPARTMENT Ground Water Active New Project Permit Type Version Permit Classification Injection Water Only GSHP Well System (5QW) 1.00 Individual Primary Reviewer Permit Contact Affiliation michael.rogers Tom Linkous Owner Coastal SW Rufe . 169 King Arthur Ln . Advance NC 27006 Permitted Fiow F�cilit�+ ` Facility Name Major/Minor Region Tom Linkous SFR Minor Winston-Salem Location Address ._;_ . County 169 King Arthur Ln - Davie Advance NC 27006 Facility Contact Affiliation Ov�rne; Owner Name Owner Type Individual • Tom Linkous Owner Affiliation Tom Linkous ` Owner , 169 King Arthur Ln Advance NC 27006 D�tes(�uents Scheduled Orig Issue App Received Draft Initiated �ssuance public Notice Issue Effective Expiration 03/05/10 02/11/10 03/05/10 03/05/10 Reaulated Ac�ivitie� Heat Pump Injection . Private residence,single family Outfall r��.�� Waterbody Name ''�" Stream Index Number Current Class - Subbasin ' � i . ► `� �� RECEIVED ��. North Carolina Depa�cment of Environment and Naturai Resour�� 0 92010 Division of Wat°I'QUality �AVIE COUNTY HEALTH DEPARTMENT Beverly Eaves Perdue Coleen H. Sullins Dee Freeman Gavemor Director Secretary 3/5/2010 Tom Linkous 169 Kin�Arthur Ln. � Advance,NC 27006 Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System Permit No. WI0400126 169 King Arthur Ln. � Advance,NC 27006 Dear Mr.�Linkous: . . In accordance with the application submitted to the Underground Injection Control(LJIC)Program that was received on 02/11/2010,the Aquifer Protection Section(APS) acknowledges your intent to construct a closed-loop geothermal water- onlv injection well system for the operation of a ground-source heat pump located at 169 King Arthur Ln.,Advance, Davie County,NC 27006. This system is deemed permitted by rule(North Carolina Administrative Code Title 15A, `Subchapter 2C, Section.0211(u)(2)). ' However, it is recommended that you contact the Davie County Health Department, as they may have additional construction or permitting requirements for this type of system. If you modify your system at any time, including the addition of antifreeze,corrosion inhibitors, or any other substances to the circulating fluid,you must contact the APS to verify compliance with applicable rules. , Thank you for submitting this notification. If you have any questions please call me at(919)715-6166. Since �-�A � � V/l� 1 for Michael gers Environmental Specialist GPU-Aquifer Protection Section cc: Winston-Salem Regional Office-APS APS Central Files -Permit No. WI0400126 . � _ � Dayie.County Health Dept: 1:_.:.___ . Jeff Sessoms (Webb Heating&Air Conditioning Co.,Inc, 170 Webb Way,Advance,NC 27006) AQUI=ER PROTECTION S�CTION 163o Mail Service Center,Raleigh,North Carolina 27n99-1E3o Loation:272E Capital Boulevard,Raleigh,North Carolina 27604 One Pnone:919•733-3221 1 FAX 1:919-715A58S;FAX 2:919-715-60481 Customer Service:1-8i i-623-6748 NOI`C�l�c`1xOIl11�1 Internet:www.ncwateroualitv.orq An Equul Opportuniry 1 Affvmative Action Empioyer ��?�� .r.e _ , `�-� , RECEIVED NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES MAR O 9 ZO�O DA IE 0 ALTH D PARTMENT NOTIFICATION OF INTENT TO CONSTRUCT A CLOSE�-�� GEOTSERMAL WATER-0NLY INJECTION WELL SYSTEM � (GROUND COUPLED HEAT PUMP) Type 5QW Wells . In Accordance with the provisions ofNCAC Title 15A:02C.0200 Complete application and mail to address on the back page. TLis is not the proper form to be used for injection wells in an oaen-loon�eothermal system. Do not use this form for systems that cir�enlate anv snbstances other than water. TO: DIRECTOR,NORTH CAROLINA DIVISION OF WATER QUALTTY DATE: � 20�0 A. SYSTEM CLASSIFICAT'ION Does the proposed system circulate potable water in continuous piping that completely isolates the fluid from the environment? YES � If yes,then continue completing this form. NO ff no,do not complete this form. Form GW-57 HP,Application For Permit To ConstructAnd/Or Use A Well(s)For Injection With A Heat Pump System,should be completed. B. SYSTEM FLUID Will any additives be introduced to the system's circulating heat.transfer fluid? This includes,but is not limited to corrosion inhibitors and/or antifreezes. YES If yes,do not complete this form.Form GW-57 HP,Application For Per�nit To Consm�ctArrd/Or Use A Well(s)For Tnjection With A Heat � Pump System,should be completed. NO � If no,then continue coinpleting this form. , C. PROPERTY OWNER Name: �U�1 �/.�2/jf �1S Address: b� %G��t/l-, �V T�f 0/1- L� . City: �Q�/,�r}�clGG- State: �t/C, �ZipCode: ZZOP(, County: �.�-tJ�C- Telephone: �Ei � Z�� ' �� 79 - D. STATUS OF PROPERTY OWNER Private: ,� Federal: Commercial: , State: MunicipaL• Native American Lands: . RECEIVED 1 DENR 1 DWQ Revised 7/06 GW/[JIG57 CL A��FR'PRnh�T1(�!$ECT1�Page 1 of 4 FEB �'� 2Qf0 , . . _ , . , RECEIVED E. FACILITY(SITE)DATA (Fill out ONLY if the Status of Owner is Federal,State,Municipal or Commercial).MAR O 9 2010 Nall]8 Of BUSIIIBSS Or F1Cllll�: DAVIE COUNTY HEALTH DEPARTMENT Address: City: State: � Zip Code: County: Telephone: Contact Peison: Standard Industrial Code(s), SIC,whieh describes cornmercial facility: F. HEAT PUMP CONTRACTOR DATA Name: �C4�✓ ife�'i��G 11N4� /�/2 Gb•J�I.Y iiU�U/NG Co , .�/Lc. _ � Address: 7 d t,u�R �i t,✓�!�f City: �Qj//�N� State: �/C- Zip Code: Z2od County: �J/�=vlt- Telephone: 3.�� "��J�—Z-!1-/ Contact Person: �TC,F� S��Sc�s G. CONSTRUCTION DATA(check one) "..�' -.�-. EXISTIl�TG WELL,(S) being proposed for use as a ground-coupled heat pump well(s). Provide the information in (1) through (3) below to the best of your ` laiowledge. Attach a copy of Form GW-1 (Well Construction Record) if available. _�. PROPOSED WELL(S)to be constiucted for use as a ground-coupled heat pump �. well(s). Provide the information in (1) through (3) below as PROPOSED construction specifications.Submit Form GW-1 after construction. (1) WellDrillingContractor'sName: /,��'�✓ G��.t.Ey o� �E�r.('sC-�/ �✓C[.��+�N� � W • NC Contractor Certification number: z-�3 s� Z.L`f/ !$ Date to be constructed: APp�o�-?�l.��Number of borings: � Approximate depth of each boring(feet): 2 O O (2) Well casing: Is the well(sj cased? . , - (a) YES If yes,then provide the casing information below. � Type:Galvanized steel Black steel Plastic Other(specify) Casing depth: From to ft.(reference to land surface) Casing extends above ground _ inches ro) No �/ (3) Grout(grout the vertical length of the borehole to a minimum depth of 20 feet b".l.s.): (a) ' Grout type: Cement Bentonite Other(specify) T�/�st�i/IL �Raui (b) Grouted surface and grout depth(reference to land surface): 3 S� L�s' S•�-�/J �p �'o�S � �around closed loop piping,_from C) to ZOQ (feet). ��UT��j around well casing,from . to (feet). NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLYTf�DATA FOR ETTHER EXISTWG OR PROPOSED WELLS�TFIIS INFORMATION IS UNAVAII,ABLE BY OTHIIZ MEANS. Revised 7/06 GW/(JIC-57 CL Page 2 of 4 � � RECEIVEp H. INJECTION-RELATED EQUIPMENT MAR O 9 ZO�d Attach a diagram showing the engineering layout of the injection equipment anc�'��1�t+'pigi,Ag/�� associated with the injection operation. The manufacttuer's brochure may provide supplementary MENT information. ' I. LOCATION OF WELL(S) Attach two maps. � (1) Include a site map(can be drawn)showing. buildings,properly lines surface water bodies, potential sources of groundwater contaznination 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 fields located within 200 feet of the ground-coupled heat pump well system. Label all features clearly and include a north arrow. (2) location map referencing the site to two nearby permanent reference points(such as roads, streams and highway intersections). J. . PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site. , Examples include: . , • ' (1) Hazardous Waste Management program permits under RCRA J (2) NC Division of Water Quality Non-Discharge permits (3) . Sewage Treatxnent and Disposal Permits K. CERTIFICATION � "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. I 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 ground-source heat pump system and all related appurtenances in accordance with the approved spacifications and conditions of the Permi�" /2'�,� �L��.�, ,� -�GC--J� (Signature of Well Owner or Authorized Agent) If authorized agent is acting on behalf of the well owner, please supply a letter signed by the owner authorizing the above agent. tiE�E►VEU I DENR!DWQ � ��1��P�n�cnoN SECYtO�E r�t� ��12�t�. Revised 7/06 GW/UIG57 CL Page 3 of 4 .. RECEIVED L. CONSENT OF PROPERTY OWNER(Owner means.any person'Who holds the feeMoAr otffe9 pr�o��erty � rights in the well being constructed.A WBI�IS 1'8�pPO�TLy 3ll(I It.S COIIStTII��H OEPARTMENT ownership in the landowner in�e absence of contrary agreement in writing.) If the property is owned by someone other than the applicant,the property owner hereby consents to allow the applicant to construct each injection well as outlined in tius application and that it shall be the responsibility of the applicant to ensure that the ground-source heat pump system's well(s) conforms to the Well Construction Standards(Title 15A NCAC 2C.0200) /�C�2�1.-�✓ ccl G�.AY?o�,� -�GE-✓% (Signature Of Property Owner If Different From Applicant) Please return two copies of�the completed Application package to: 1 ' UIC Program . _ Aquifer Protection Section � � � North Carolina DENR DWQ 1636 Mail Service Center � Raleigh, NC 27699-1636 Telephone (919) 733-3221 - RECENED�T1(�1 SECZtON A�t�F�EB 1�12010 Revised 7/06 GW/UIG57 CL ' Page 4 of 4 . RECEIVED MAR 0 9 2010 DAVIE COUNTY HEALTH DEPARTMENT � " � �aa'`� �lSB�� Gc� � � wc�.. r-�G�a , � � l46Y'�y �/1'�Up'�' �(�cJE-'� f, , �c�y�ti /S�r° � . � • . G�N,� 1 . � . . . � � � 7�i/ !'��.$C-GS/�f' � ��c'�3w` � s��c.�: f " -� S i5 �. � L� � � J , �� N" «/N(� ��r��pF2._,L,� ,,./ � .� �� ' . Feb Ud 1u ul:�sp inrormauon aervices � • • .�,.. �� DAVIE CO'JN:Y EWIRQNhiENTAT..E�ALTEI — . RECEIVED . P.O.Box 848�1G Hospital St�eet- . . . Mocksy7lle,�T� 2;028. MAR 0 9 2010 (3i6i751-87b0 FFuc#�336)75:-87$6 . DAVIE COUNTY HEALTH DEPARTMENT AL'THUItIZATIO�!FOR I�F�ASTE�i�ATER SYSTE1bI C011STRliCTION 4 ' AC.^.�i1Ri #: 990004052 i Fx pffil.��H#: 5861-42-8662 Billed Ta: Thomas Linkous � � SubdiYis�on lnia: . � Raterer.ce Name: ' " Lac��oniAdarrss: Redland Drive-27006 u Proposed Facit'r�y: Residence P�o�:eriy Size: 3Acres ATC Numb�r. 4985 � , • Site Type:_�'cw ORepaa OExpansion *'vOTE'�*T3is Auth�r.zation to Coasuuct(ATG7 NILIS"T BE ISSUED by the Davie Couaty Envuonmernal Healih Section prior to issuance of ary building pezmit(s},(in compliance w:th Ardcle 31 of G.S.Chapte;130A Wa.ste�vatu Systenos,Section.I90t?Seaage Treatmcnt and Disposal Systems). THIS AIJTHORIZATION�O r COI�fSTRUCT IS VALID FOR A PERIOD OF FIVE YE.4RS. This�i.TC is subject to revocation if site plans,plat � , � or the intended�se change. ' Itesiden�l SpecifirsEioas: #$cdrooms�:�Batlirooms��People�Baszment0 Basemcnt ptumbiag0 Nqn-Residenti�l5pecifications: Fac+:li:y Typc �People ' �Seats . Square footag�(or D'uncnsi�as of Facilit;+) . Lot Size � �G - � 'Type of Wsccr Supply: �ounry/City ��Well �Coaunnniry V�ell Si+stem Specificatioas: D:sign Wastewatas Flbw(GPD)�_Tank�ize 1�tA� GA.F..Pu�np Tank GAL. . ,' Trer.:ch Width � t Vizx.Trench Depth �� Rocg Depth I 2�� .Linear Ft 581 '• lts atated i� 1�A i�CAC �8A.15a9(S` ' Site ModEficationstCan�itioasiOtner: acceQted System.s rnay a�so be use� � �cdlan � r. Contac[the Darie County Envirnnmental Health Sec�on for final inspection ot tbls system between . • a.m.on t e a o � �` � � �iY1[S�Op' X 3j � ' - . � � 1 �i��t 1fi`'X3, . ��\ � a � � ��.` � , � : � :: �, � � c��,�-�—�,� ��,r�it.�r ' � � ' i . . • � ' � I 3ZZ, � . E�virom-nen�IHea]thSpeciaGst�li�f`��Lti� Datc:__�'S"C�j _11l�IST 1 t fA�l6....:,....i: � - � / . . � RECEIVED MAR 0 9 2010 DAVIECOUNTY HEALTH DEPARTMENT D�U3R010 To Whom it May Concern: Per your requested information aad registration request,l Thomas Linkuus$«e permission for Bi11y Clayton with Aquadrill,Inc»Petm�ston to act as my agent for ilte well drilling on my propecty at 169 KinB Arth�r L�,Advance NC 27006. 'I'tiank You. omas Liakous ProPertY Owc►e�' C