WI0500091_GEO THERMAL_19970602

GROUNDWATER SECTION
June 2 , 1997
Mr. James A. Broaddus
50 Flower Orchard Road
Littleton, NC 27850
Dear Mr. Broaddus:
In accordance with your notification dated May 26, 1997, we are
acknowledging your intention to construct a closed-loop
geothermal water-only injection well system for the operation of
a ground-source heat pump. The system as described in your
notification will not require an injection well permit and is
deemed permitted by rule (North Carolina ·Administrative Code
Title 15A: 2C.021l(u)2). If you modify your system, please
contact the Groundwater Section to verify compliance. Thank you
for submitting this notification.
If you have any questions regarding your geothermal heat pump
borehole(s) please feel free to contact me at (919) 715 -6166.
cc: UIC Files
RRO Files
Sincerely,
~ ~ Jj:;::;:J
Marcus A. Geist
Underground Injection Control Program
C:\WPDOCS\PERMIT\TRANSQW.WPD
June 2, 1997
Mr. Moulton Bailey
Halifax County Environmental Health Department
PO Box 10
Halifax, NC 27839
Dear Mr. Bailey:
A copy of the current Well Construction Standards: Criteria and
Standards Applicable to Injection Wells and copies of the
brochure: Permit Requirements For Ground Source Heat Pumps are
enclosed. I have also included a copy of the letter which I sent
to Mr. James Broaddus of Littleton, NC, who has spoken with you
about permitting his ground-source heat pump well.
If you have any questions regarding the rules please feel free to
contact me at [phone].
cc: UIC Files
Enclosures
Sincerely,
Marcus Geist
Underground Injection Control Program
C:\OFFICE\WPDOCS\MEMOS\SENDRULS.WPD
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NORTH CAROLINA
ENVIRONN�NTAL MANAGEMF_NT COMMISSION
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED --LOOP
GEOTHERMAL-W INJECTION WELL SYSTEM
(GROUND -SOURCE HEAT PUMP)
In accordance with the provisions of NCAC Title 15A: 02C.0211
complete notification and mail to address on the back page.
This is not the nrarer form for injection wells to be used in an 4 e��
ground -source heat pump system. Do not use this farm for systems,that
re -circulate any substances other than water below.the ground surface.
Type 5QW Wells
w -
� _a
Tip DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUAL= x�
DATE: M o_ti 2. . I9 c? 7
Please type or prins clearly. _N
A- SYSTEM CLASSIFICATION Does the proposed system re -circulate potable y _ -
water in continuous piping which isolates the fluid from the environment?
YES If yes, then continue completing this form GW-57 Cl- .
NO If no, do not complete this form. A form GW-57 HP
(Application For Permit To Construct And/Or Use A Well
For Injection With A Heat Pump System) must be completed.
B. SYSTEM FLUID Will any additives be introduced to the system's subsurface
piping, including but not Limited to corrosion inhibitors or antifreezes?
YES _ If yes, do not complete this form. A form GW-57 HP
(Application For Permit To Construct And/Or Use A Well For
Injection With A Heat Pump System) must be completed.
NO 29_ If no, then continue completing this form GW-57 CL.
Name: a,� M e, i �,A r) r7 D* RD �fl 0. 4Jt-k_5
Address: ,.Jr' • o � o k� t- o 1- G N c,t4 Roac
City: s! i T Tl I o ki Zip code: `78 So
County: _ -� CA! I R?L Telephone:
GW-57 CL (March 1997) Page 1 of 4

A
D. STATUS OF PROPERTY OWNER
Private: K Federal:
State: Public:
Commercial: Native American Lands:
E. FACII= (SITE) DATA (Fill out ONLY if the Status of Property Owner is
Federal, State, Public or Commercial).
Name.of Business or Facility:
Address:
City: Zip code: County:
Telephone: Contact Person:
Standard Industrial Code(s) which describes Commercial facility:
F. HEAT PUMP CONTRACTOR DATA
Name: C c-, Ic� f � ckf- o f` En T-�- r Z7 i-1 _Se 3
Address: t7 1 a. +_�1 r �, LA t- 7'
City: m ' �1 CA VS, lip code:
County: Telephone: ` 7�, - 76 y 4j►
Contact Person: 0'.- 0 C- �&ag. rt
G. WELL USE Will the system well(s) also be used as the supply well(s) for
your personal consumption?
YES NO_
H. CONSTRUCTION DATA (CHECK ONE)
EXISTING WELL(S) being proposed for use as a ground -source treat
pump well(s). Provide the information in (1) through (4) below to
the best of your knowledge. Attach a copy of Form GW-I (Well
Construction Record) if available.
PROPOSED WELL(S) to be constructed for use as a ground -source
beat pump well(s). Provide the information in (1) through (4) below
as PROPOSED construction specifications. Submit Form GW-1 after
construction.
GW-57 CL (March 1997)
Page 2 of 4

(1) Well Drilling Contractor's Name: Moseley f/1/g,.s J..i E V) 1e t:p~t's ~s 1 .I ..,e,.
NC Driller Registration number: _ ____;::2,_0_-=-/ _______ _
(2) Date to be constructed: · ·.:Ju.. Yl '4t 1 ·1 Cf Cf"?
~ ~!'·' Approximate depth of each boring: __ ,=--_'-'_Q.. ____ _
Number of borings: __ 4-__ _
(3) Well casing: Is the well(s) cased?
(a) YES ___ . If yes, then provide casing information below.
Casing type: Galvanized steel _ Black steel _ Plastic J/.
Other (specify) _______ _
Casing depth: from _____ to __ ft. (reference to land surface)
(b) N) > .x.
.(4) Grout (material sU1Toundingwell casing and/or piping):
(a) ·Grout type: Cement_; Bentonite~;
Other (specify) _____ _
(b) Grouted surface and grout depth (reference to land surface):
_ around closed-loop piping; from~ to G ·c; ft.
around well casinsz; from '--~ -to -ft. -._ /
NOTE: THE WELL DRILLING CONTRACTOR C.Al'-1 SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER IvIEANS.
H. LOCATION OF WELL(S) Attach two inaps.
(1) a site map ( can be drawn) showing 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-source heat pump well system.
(2) a location map referencing the site to a labeled road intersection.
GW-57 CL (March 1997) Page 3 of 4
I. CERTIFICATION
"I hereby -certify, under penalty of law, that I have personally examined ..__
and am familiar with the information submitted in this dqcument 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
well(s) and all related appurtenances in~c ordance with Title 15~CAC. ~ \.
Subchapter 2C Section .0200." ,._,.~ °'-/;~~
~c;p .lJ~--
(Signature of Owner or Authorized Agent)
Please supply a letter signed by the owner
·authorizi.ng the above agent, if authorized agent is signer.
J. CONSENT OF 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 land owner in the absence of
contrary agreement in writing.) ·
If the property is owned by someone-other than the operator, the property
owner hereby c·onsents to allow the operator to construct a ground-source heat
pump system as outlined in this notification and that it shall be the responsibility
of the operator to ensure that the ground-source heat pump system's well(s)
conform to the Well Construction Standards (Title 15A NCAC Subchap~2~.0v ~20vQ~)~.
2
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GW-57 CL (March 1997)
a_ Q.&~~~
(Signature of Property Owner if Different From System Operator)
Please _ return the completed Notification package to:
UICProgram
Groundwater Section
North Carolina DEHNR-DWQ
P.O. Box 29578
Raleigh, NC 27626-0578
(telephone: [phone])
Page 4of 4
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