WI0400219_GEO THERMAL_20111021

Permit Number
Program Category
Ground Water
Permit Type
WI0400219 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Richard Heller SFR
Location Address
3704 Deerfield Dr
Burlington
Owner
Owner Name
Richard
Dates/Events
NC 27215
Heller
Scheduled
Orig Issue
10/21/11
App Received Draft Initiated Issuance
10/05/11
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall !\!UL!_
Central Files: APS_ SWP_
10/21/11
Permit.Tracking Slip
Status
Active
Proj&ct Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Richard Heller
Owner
3704 Deerfield Dr
Burlington
Major/Minor
Minor
NC
Region
Winston-Salem
County
Alamance
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Richard Heller
Owner
3704 Deerfield Dr
Burlington
Public Notice Issue
10/21/11
NC
Effective
10/21/11
27215
27215
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
ALr
HCDElNR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves perdue Coieen H. Sullins
Governor Director
10/21/2011
Richard Heller
Lynn Heller
3704 Deerfield Dr.
Burlington, NC 27215
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10400219
3704 Deerfield Dr.
Burlington, NC 27215
Dear Mr. Heller:
Dee Freeman
Secretary
On 10/05/2011, the Aquifer Protection Section (APS) received aotifxcation of your intent to construct a. closed -loop water-on1%
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:
1. The injection well system contains only potable waster,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title I SA Section 2C Subchapter ,0213, and
1 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 Wake 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 Michaei.R_ogersra-ncdenr.eov if you have any questions.
Sincerely, D
for Debra Watts
Supervisor
cc: Winston-Salem Regional Office - APS
APS Central Files - Permit No. W10400219
Aiamance County Health Dept.
Glen A. Darch (Glen A. Darch Well Drilling, LLC, 13109 Sold Run Hill Rd., Wake Forest, NC 27587)
Steve Bowman (Bowman Mechanical Services, Inc., 145 Technical Ct., Garner, NC 27529)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699.163E
Location: 2728 Caplral Boulevard; Raleigh. North Carolina 27604 ne
Phone: [phone] FAX 1: 919.715-0588; FAX 2: 919-715-60481 Customer Service: 1-877-G23£748 W Ca.Dftna
Internet vrww.nmaterauaiiti.or;
M Pqual Cppmunhy ti Affirmative Amon Employer �atu��ili/

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NORTI-1 CAROL INA DEPARTMENT or FNVIRON MENT AND NATURAL ItESOURCES
NOTIFICATION OF WTE• NT TO CONSTRUCT OR OPERATE INJECT]ON WEI. LS
In Accordance With the Provisions of 15A NCAC 02C .0200 -
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS �
These wells circulate potable water only as part of a geothermal heating and cooling syIstcm.
These wells are "permitted by rule" and do not require an individual perniit when they ve constructed in -
accordance with the rules of [ 5A NCAC 02C .i 200 and this Noticc is submitted prior to construction,
Prim W. 7),pe 1nfw-mation and AYail io lhe.4ddr•eas on the Lev Page.
DATE--- [_ � � 20_/ PER-MFF NO. to be fulled in by DWQ)
,
A. STATUS OF WELL OWNER (choose one)
Non -Government— Individual Residence u BusirtesslOrganization
Governlncnl: State Municipal � County — Federal
S WELL OWNER — For 'individual residences. list each Owner on property deed. For all others, state name of
entity name oipersnn d le aced authority to sign on behalf of the busialass or agetvcy:
Mailing Address: f� — `..'� t
Cite- F _,r i .t l i?: y State::A/LZip Code:_ • — County: -s,C
Day Tele No.: R --_-- _ Cell No.: 3_= � E � � '7' C- I _�
EMAIL Address: ['a\ No.: -- -
--
C. LOCATTOIti OF WELLS [TE — Where the injection weds are physically located:
(1) Parcel ldentilicalion Number(PIN) of well site:� County:
() Physical Address (if different than mailing; address):
City: — _ State: �K Zip Code-
D. WELL DRILLER INFORMATION
Wet Dri11ing Contractor's Name: ( 1ie - _ [� L:e-1I
XC Well ❑riiling Contrra+cttor Cerlilication No.;
Company Name:+ U�-C� _ .-_ ►t%Al_ C _ �'i.'!_ l �r
Contact Person; P � _._ EMAIL Address:_
Address: �Q `� [OIL+ C Lary f city: ��e _%_r_ l Zip Code_ _? 7S Z State: /V&County: M/41�'G
Office Tele No.: 1 S`sd- 9s eu t,. 1 � 5�7-�` 3 Faxyn.: k-�5 d x
GPINi:[C 5QW NouIteatuon ittevised 3.18.r-WI I r page i

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Bowman Mechanical Services Inc.
Contact Person.-'-: -----------~E=MA~·=IL~A~d=dr~e~ss~:_b_o~w~m=a~nm~e~c~h=an=i_c_al.....,@,.....b_e~ll=s~ou~th~.n'-'---et
Address: 145 Technical Court
City: Garner Zip Code: 27529 State: NC County: Wake
Office Tele No.: [phone] Cell No.: ________ Fax No.: [phone]
F. WELL CONSTRUCTION DATA
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(1) Number of borings to be constructed*: __ '-___ Depth of each boring (feet): __ .,_J_ •-----
* 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): HDPE
(3) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground: _________________ _
(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 Sfc to 3SO "(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 mile 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 G/S 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
elevatio.n data.
GPU/UIC 5QW Notification (Revised 3/18/2011) Page2
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H. C URTI FICAT.ION (to be signed as required below or by that person's authorized agent)
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15A NCAC D2C .0211(b) requires that all permit applications shall be signed as follows: �
i . for a corporation: by a responsible corporate officcr_
?. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively,
3. ror 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 wh ch means all persons listed on the prQoer r deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed: by the
applicant that names and aathot'izes their agent to sign this application on their behalf
"i hereby certify, under penalty of law-, that 1 have personally examined and am familiar with the intrmatioR
submitted in this document acid all attachments thereto acid that, based on my inquiry of those individuals
immediately responsible for obtaining said information, l believe that the information is true. accurate and
complete. 1 am aware that there are signiFicant penalties, including the possibility of fines and imprisonment,
for subsnittiitg False intorsnatio.n. 1 agree to construct, operate. maimain, repair. and if appiitab le, abandon the
injection well and all related appurtenances in accordance with tare approved specifications and conditions of
the Permit." ,,-7
Signature of Property Q4vi3errAppliye,
- f Print ❑r TyrpL)f{ill blame��
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Signature ,St Property cynerr//Applicant
Print orType Fui I game
Signature of Authorized Agent, if any
Print or'type 171.111 Name
Submit the complete application packave to:
l?'d' Q - aquifer Protection Section
1636 ;Mail Semice Cotter
Raleigh, NC 27699-16i36
Telephone [phone]
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ConnectGlS Feature Report
Page I of
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OCONNECTGIC Inaccuracies in the information provided regardless of how caused; or any decisions made or actloris taken a notx..
WEB HOSxINC or data fumished hereunder. The user knowingly waives any and a[I claims for damages against any and aii of 60-:
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ALAMANCE COUNTY HEALTH DEPARTMENT
A1, ENVIRONMENTAL HEALTH SECTION
'
- ,
1 Existing System Check - Type E
- {Construction of outbuildings, swimming pools, etc,..}
Inspector's Worksheet
Tax Map Number GPIN Application Date Permit Number
2-9-74 884289705I 10/712008 53DESCEOS
Site Address 3704 DEERFIELD DR. BURLINGTON, NC 27215
Directions 62 SOUTH TR PORTER SHARPE ROAD TR DEERFIELD LANE DEAD END AND DRIVE ON THE RIGHT
Requestee CHAPMAN BOYD Owner HELLER RICHARD C & LYNN P
PO BOX 1803 37p4 DEERFIELD DR
BURLINGTON, NC 27216 BURL INGTON, NC 27215
Phone [phone] Phone (336) 263-SZ74
Fax Fax
Other Other
Email [e-mail] Email
Existing Structure : Addition(s)
Type of Structure HOUSE Addition Type I GARAGE
Number of Bedrooms 4 Addition Size 1 28 X 35
Number of Occupants 0
Basement No
Basement Plumbing No
Type of Water Supply WELL
Projected Dally Flow 480 GAD
Application Notes / Additional Information to find any septic permits front when the system was originally Installed or repaired [name of
builder, septic system Installer, location of septic system, dates, etc...)
WITH POWERINO WATER
Request to meet EH5:
CALL BOYD CHAPMAN I HOUR IN ADVANCE 0 336-360-1625
Application Taken By : Teresa Overman
Inspection Date: a i J 62 9
Requested Liss; `( k 7 C,
Authorization granted to use Existing Wastewater Systom for requested use.
Z k 3 S AP /-r, C t, C4 r-a u Noe ta,
Not Approved for requested use. J J
Notes;
Well Permit Number;
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ConllectGIS Feature Report
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Welcome to the Alamanoe County GI Site, THIS IS N Q T A LEGAL DOCUMENT, Namance County Shalt assume
(:O N rti1 E C T GI S fneccuracies in the information provided regardless of how caused; or any declsicns made or actions taken or not
furnished The knowingly
•.vEE k::sri»�. or data hereunder. user waives any and all claims for damages against any and all of the
GIS SYSTEM that may arise from themapping data.
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