WI0300176_GEO THERMAL_20110628

Permit Number Wl0300176 /
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Lake Norman State Park
Location Address
159 Inland Sea Ln
Troutman
Owner
Owner Name
NC 28166
NC DENR Division of Parks and Recreation
Dates/Events
Central Files: APS_ SWP_
06/28/11
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
Mooresville
County
Iredell
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Erin Lawrence
Engineering Supervisor
1615 Mail Service Ctr
Raleigh NC
27020
276991615
Orig Issue
06/28/11
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
06/28/11
Effective
06/28/11
Expiration
06/24/11
Re g ulated Activities
Heat Pump Injection
Waterbody Name Stream Index Number Current Class Subbasin
AVA
MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
NC DENR Division of Parks and Recreation
Attn: Erin Lawrence, P .E., Head, Engineering Program
1615 Mail Service Center
Raleigh. NC 27699-1615
Coleen H. Sullins
Director
6/28/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0300176
Lake Norman State Park
159 Inland Sea Lane
Troutman, NC 28166
Dear Erin :
Dee Freeman
Secretary
On Jwie 24, 2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
geothermal injection well system for the op~ration 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 geothennal 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 .021 l(u)(2). Additionally, you should contact the Iredell 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.Roeers<@ncdenr.!mv if you have any questions.
cc: Mooresville Regional Office -APS
APS Central Files -Permit No. WI0300176
Iredell County Health Dept.
Yadkin Well Company (David Brown)
AQUIFER PROTECTION SECTION
1636 Mail Service Center. Raleigh , North Carolina 27699-1636
Location : 2728 Capital Bou levard, Raleigh. North Carolina 27604
Sincerely, ~ ~I.,...,..,
{~ ~C>'L
for Debra Watts
Supervisor
Phone : [phone] \ FAX 1: 919 -715-0588: FAX 2: 919-715-6048 \ Customer Service : 1-877 -623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity \ Affirmative Action Employer
NOn~t..C 1· aru1 . aro. 1na
,Natura/!;1
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of I5A NCAC 02C .0200 y
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
c
c
These wells are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Print or Type Information and Mail to the Address on the Lust Page.
DATE: June 23 . 2011 _ PERMIT NO. 1 J/ a 76 (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence Business/Organization
Government: State X Municipal County Federal
B. WELL OWNER — For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
NC DENR Division of Parks and Recreation
Mailing Address: 1615 Mail Service Center
City: _ Raleigh _ State: NC Zip Code:27699-1615 County: Wake
Day Tele No.: [phone] Cell No.:t919f 218-8751
EMAIL Address:erin.lawrencg-,iijncdenr.,2ov Fax No. :t 9I9] 715-5076
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: 4720-56-9709 County- Iredell
(2) Physical Address (if different than mailing address): Lake Norman State Park
159 Inland Sea lane
City Troutman State: NC Zip Code: 28166
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: David
NC Well Drilling Contractor Certification No.: NC 2195A
Company Name: Yadkin Well Company -
Contact Person: David Brown EMAIL Address: chiefdrilienairnsn.com
Address: 1908 Hamptonville Rd_ - --
City: Hamptonville Zip Code: 27020 State: NC County: Yadkin
Office Tele No.: [phone] Cell No.: 1336)374-8736 FaxNo.: I3361468-4048
GPUfUIC 5QW Notification (Revised M81201 l) Page 1

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
CompanyName: ____ to_b_e _d_et_erm __ in_e_d ________________________ _
Contact Person_: _______________ E_MA __ I_L_A_d_dr~e_ss_: ___________ _
Address:---------------------------------
City: _________ Zi_p Code: ____ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: ----------=-=~"-'--'--------
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: one Depth of each boring (feet): __ -4~50 __________ _
* If existing water supply wells will be used then provide the information in item (4) below.
(2) Type of tubing _to be used (steel, PVC, etc): _P_V_C_· _____________ _
(3) Well casing. If the well(s) will us~ casing then provide the~ (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground: 6" steel depth to be determined 24" above grade
( 4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite** ___x_ Other (specify) _______ _
** By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from _O~ __ to 450 (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
G. WELL LOCATIONS-Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
( 1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 inile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
GPU/UIC 5QW Notification (Revised 3/18/2011) Page 2
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211 (b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectiv~_ly;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the prop erty deed).
If an authorized agent is signing on· behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under pen1;ilty of law, that I have personally examined and am familjar 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
injection well and all related appurtenances in ace~ the approved specifications and conditions of
thePermit." ~----~---
ignatur f Property Owner/ Applicant
RECE\\IED I [)01R i O~
Aquifer ProtediOn Section
JUN 2 4 201\
Erin Lawrence P .E.
Print or Type Full Name
Signature of Property Owner/ Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ -Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notification (Revised 3/18/2011) Page3
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NC STATE PARKS- PARKS & -RECREATION
DESIGN &DEVE LOPM ENT -CO NSTRUCTION
ARCHDALE BUILDING— ROOM 824
512 N SALISBURY ST
RALEIGH NC 27604
UTTER Of TRANSM
DATE: June 23, 2011 RECEIVED 1 DENR I OM
Aquifer Pratedion Se,*rt
PROJECT: Project Description: Lake Norman State Park: Visitor Center and West District Of 2 4 2011
Notification of Intent to Construct or Operate Injection Wells
Budget Code; 40916 Fund: 41<77 SCO ID#: 09-08107-01
TO: Mr. Michael Rogers
DWQ — Aquifer Protection Section
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
FROM: Jennifer Goss, DAIV
WE TRANSMIT:
x herewith ❑ under
FOR YOUR:
Phone#: [phone]
e-Mail• [e-mail]
rate cover I ❑ in accordance with your request
X use
X execution processing
❑
❑ review & comment
❑
❑
X forwarding
❑
THE FOLLOWING:
X Notification of Intent
Design Amendment No.
❑ Samples
. ❑ Informal Contract
Letter of Agreement
n Submittals
❑ Drawings
Shop Drawing Prints
Product Literature
,r, As Builts
Shop Drawing Repros
Design Contract
#Contents
Description
1
Signed Notification of Intent to Construct or Operate Injection Well at Lake Norman
State Park for the Visitor Center and West District Office project.
COMMENTS
Copy to: Lance White, Project Manager
Erin Lawrence, P.E., Head, Engineering Program