WI0400096_GEO THERMAL_20080502

Permit Number WI0400096
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Permitted Flow
F cititv
Facility Name
Charlotte Hawkins Brown Museum
Location Address
6163 Burlington Rd
Sedalia
wner
Owner Name
NC 27342
Division of North Carolina Historic Sites
natM/Events
Scheduled
Central Files: APS_ SWP_
05/02/08
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Andren a Coleman
PO Box B
Sedalia NC
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Keith Hardison
Mail Service Ctr 4620
Raleigh NC
27342
27699
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
04/29/08
eauiated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
Michael F. Easley, Governor
William G. Ross Jr„ Secretary
North Carolina Department of Environment and Natural Resources
Coieen H. Sullins Director
Division of Water Quality
May 2, 2008
Keith Hardison
Division of North Carolina Historic Sites
NC Dept of Cultural Resources
109 East Jones St./Mail Service Center 4620
Raleigh. NC 27699
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0400096
Charlotte Hawkins Brown Musuem
6163 Burlington Road
Gibsonvitle, NC 27342
Dear Mr. Hardison:
In accordance with the application submitted to the Underground Injection Control (UIC) Program that
was received on April 29, 2008, the Aquifer Protection Section (APS) acknowledges your intent to
construct a closed -loop geothermal water-oniv injection well system for the operation of a ground -source
heat pump located at the site referenced above. 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 Guilford 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) 7 t5-6166.
Michael Rogers
Environmental Specialist
GPU-Aquifer Protection Section
Enclosures
cc: Winston-Salem Regional Office - APS
APS Central Files - Permit No, W10400096
Guilford County Health Dept
David Black — HagerSmith Design PA
Ryan Brazil! — Brazil! Drilling Co.
NorhCarolina
'aiurally
Aquifer Protection Section 1636 Mail Service Center
Internet: www.newaterquain Location: 2728 Capital Boulevard
An Equal Opportunity/Affirmative Action. Employer— 50% Recycled/10% Post Consumer Paper
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
Customer Service; [phone]

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP
GEOTHERMAL WATER —ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
In Accord2nce with the provisions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
This is not the proper form to be used for injection wells in an open -loop geothermal system.
Do not use this form for systems that circulate any substances other than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DAI'h: 'f &Sl re' . 20
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES X. If yes, then continue completing this form.
NO if no, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/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
NO
If yes, do not complete this form. Form GW •57 HP, Application For
Permit To Construct And/Or Use A Well(s) For Injection With A Heat
Pump System, should be completed.
If no, then continue completing this form.
C. PROPERTY O �� IT SAS
p(U(x�R
No 9p / '
Name: N. lid .da p "its r d tut'Uiz/ft• SO TES
Address: B q o .,, fb1Ues cT /mow5 u( e J i
City: f State: G Zip Code: z762 T t -
County: _14441. Telephone• f i q -7N- I gk
D. STATUS OF PROPERTY OWNER
Private: Federal: Commercial:
State: ] Municipal: Native American Lands:
Revised 7/06 GW/UIC-57 CL Page 1 of 4

3 � a�
E.
FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Fe feral State. M iciBal or �o rn mall]. or � G
Name of Business or Facility:glivirteve— J.4 nun
Address: Rb PAX _II
City: b Pr State: /V. {;, Zip Code: i- 4 2 County: 0
Telephone: Wsit '44 45 Ve Contact Person: it- 89L#CA
Standard Industrial Code(s), SIC, which describes commercial facility: _ _
)~ HEAT PUMP CONTRACTOR DATA Tar tau, 6N Ji'f
Name: a6oiliei4fAi.. + owe `i �4r� a -{ ,
Address: p-+fii, fox . (' fit3
City: 136 kf L71(A, gate: NC. Zip Code: 2� Tq County: U c.�L�iB�
Telephone: LSZ$J z..tS 'T l @ i Contact Person: eft jAktniki
G. CONSTRUCTION DATA (check one)
(1)
EXISTING 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
knowledge. Attach a copy of Form GW-1 (Well Construction Record) if
available.
PROPOSED WELL(S) to be constructed 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. nn��}}r t
Well Drilling Contractor's Name: _ P1 g g'Z � LA-,2ft24L ,V124 W Ate{
NC Contractor Certification number: 2122
Date to be constructed: 7 Number of borings:
Approximate depth of each boring (feet): 4s0 pf,
(2) Well casing: Is the well(s) 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
(b) NO X
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)
b5i7WEL
(3)
(b)
Grouted surface and grout depth (reference to land surface):
X around closed loop piping; from 0 to (feet).
around well casing; from to (feet).
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
Revised 7/06 GWIUIC-57 CL
Page 2 of 4

I•
.H. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELL(S) Attach two maps.
J.
(1) Include a site map ( can be drawn) showing: buildings, property lines surface water bodies,
potential sources of groundwater contamination 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).
PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
.NO~~
( 1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment 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 specifications and conditions of the Permit."
Revised 7/06
(Signature ofWel wner or Authorized Agent)
Y-e r-1-h a. /-lard,· so~
If a'utfz~rized agent is acting on behalf of the well owner,
please supply a letter sign,ed by the owner
authorizing the above agent.
J) i /' .e_ C -fv 7-r -+le_
~ lv~ ,;t)~ 1 Mc Hl ~+-z,-v ·Lc9J~
GW /UIC-57 CL Page·3 of 4
L. CONSENT GF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the 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 this application and that it shall be
the responsibility of the applicant to ensure that the ground-source heat pump system's well( s)
coil.forms to the Well Construction Standards (Title 15A NCAC 2C .0200)
Revised 7/06
(Si~~tFromApplicant)
Please return two copies of the completed Application package to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW /Uic.:.57 CL Page 4 of 4
Tremie Line
Hose Re
Flexible HDPE
T.remie Tube
Steel Pipe
Section
Grout/Slurry
Pum
Remove tremie line with
re& as grout or slurry is
injected into annulus.
Grout/Slurry
Mixing Tank

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1-Visitors Genter
2-Bethany United Cbloch f Christ.
3tCtlades*. Eliot Hall
4-Reynolds Half.
S-Brice-Halle
'11-$rightside & Grea Cottages
7-Cana rye.
$ 4odItatlon.Altar
9. GraveEite
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Hwy 70
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41111.
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1 1.-1(411 ball Hall
12-Galen Stone -Hall
14-Massach use Cottage
14-US'Posi-Offtce, Sedalia
,15-Picnic shelter
16-PMJ Athletip Field
&watertower.
1.i-Bell lower
18-Fire House
19-Tea House
2O-Stouffer Hall
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HagerSmith
_SIGN P.
Architecture
Landscape Architecture
Interior Design
Historic Preservation
Food Service Consulting
300 South Dawson Street
Raleigh, NC 27602
Phone' [phone]
Fax: [phone]
_ Jo z �
632 6
RECEIVED1DENR/DWQ
Aquifer Protection Section
APR 292008
Transmittal
Date: 28-Apr-OS
Project Number: 500-036
To: UIC Program
Aquifer Protection Section/NCDENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Attn:
From: David R. Black, AIA
Project: Charlotte Hawkins Brown Museum at Historic Palmer Memorial Institute
We Are Sending You:
❑ Submittal
Plans I Specifications
El
Change Order
Bulletin Drawing
Pay Request
❑ Clarification
VIA: Mail
❑ RFI Response
# Copies: I Description:
Notification of Intent to Construct a Closed -Loop Geothermal Water -only Injection Well System
(Ground Coupled Heat Pump)
TRANSMITTED AS CHECKED BELOW:
❑ Approved as Submitted ❑ For Your Approval ❑ For Your Records
ElApproved as Noted / Corrected ❑ For Your Review / Comment ❑ As Requested
❑ Returned Without Action ® For Your Action ❑ Refer to Submittal Review
ElReturned - Action Complete ❑ For Your Use ❑
Comments:
Copy:
www.hagersmith.eom

RE: Test Well, Charlotte Hawkins Brown Museum, Sedalia
1 of2
Subject:, RE: Test Well, Charlotte Hawkins Brown Museum, Sedalia
From: "David Black" <[e-mail]>
Date: Fri, 2 May 2008 14:39:03 -0400
To: "Michael Rogers" <[e-mail]>
The street address is:
6163 Burlington Road
Gibsonville, NC 27342
It's a Gibsonville address, although located across from the Sedalia
post office in Sedalia.
David R. Black AIA/APT I Project Architect
HagerSmith DESIGN PA
300 South Dawson St. I PO Box 1308
Raleigh, NC 27601
P: [phone]
C: [phone]
D: [phone]
F: [phone]
www.hagersmith.com
30 Years. Innovation. Service. Vision
-----Original Me·ssage-----
From: Michael Rogers [mailto:[e-mail]]
Sent: Friday, May 02, 2008 2:32 PM
To: David Black
Subject: Re: Test Well, Charlotte Hawkins Brown Museum, Sedalia
OK, thanks. What is the street address of the site?
David Black wrote:
Mr. Rogers-
The well will not be lined. The steel pipe will be withdrawn as the
bentonite/sand mixture is poured. Thank you.
5/2/2008 3 :28 PM
RE: Test Well, Charlotte Hawkins Brown Museum, Sedalia
2 of2
* David R. Black AIA/APT * I *Project** Architect*
* HagerSmith ** DESIGN PA*
300 South Dawson St. I PO Box 1308
Raleigh, NC 27601
P: [phone]
C: [phone]
D: (919) 838-~105
F: [phone]
www .hag ersmith.com <http ://www.hag ersmith.com/>
30 Years. Innovation. Service. Vision
5/2/2008 3:28 PM
RE: info
Subject: RE: info
From: "chb" <[e-mail]>
Date: Fri, 2 May 2008 16:56:45 -0400
To: "'Michael Rogers' <Michael.Rogers ncmail.net>
That zip is Sedalia and is only for Post Office Boxes at the Sedalia Post
Office. Physically, we are located in Gibsonville with the Gibsonville USPS
delivery ZIP code.
Charlotte Hawkins Brown Museum
T- 336.449.4846
F- 336.449.0176
Visit our website, www.chbrownmuseum.nchistoricsites.org
E-mail to and from me, in connection with the transaction of public
business, is subject to the North Carolina Public Records Law and may be
disclosed to third parties. The Charlotte Hawkins Brown Museum is owned and
operated by the State of North Carolina as an agency of the Division of
State Historic Sites and Properties, North Carolina Department of Cultural
Resources.
- Original Message
From: Michael Rogers[mailto:Michael.Roaers�ir,ncmail.net]
Sent: Friday, May 02, 2008 4:34 PM
To: chb
Subject: Re: info
Thanks. Is the zip correct? I have 27342.
chb wrote:
Send Fed Ex packages to
CHB Museum
Hwy 70-Sedalia
6136 Burlington Road
Gibsonville NC 27249
95g0
1 of 2 5/5/2008 8:42 AM

RE: info
2 of2
Charlotte Hawkins Brown Museum
T-336.449.4846
F~ 336.449.0176
Visit our website, www.chbrownmuseum.nchistoricsites.org
E-mail to and from me, in connection with the transaction of public
business, is subject to the North Carolina Public Records Law and may
be
disclosed to third parties. The Charlotte Hawkins Brown Museum is
owned
and
operated by the State of North CaroHna as an agency of the Division of
State Historic Sites and Properties, North Carolina Department of
Cultural
Resources.
-----Original Message-----
From: Michael Rogers [mailto:[e-mail]]
Sent: Friday, May 02, 2008 2:28 PM
To: [e-mail]
Subject: info
would you please send me your street address for sending Fedex
package.
thanks
5/5/2008 8:42 AM