WI0300125_Regional Office Historical File Pre 2018

Michael F. Easley, Governor
o__— .
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
September 16, 2008
Bill Wagoner
Fisher Street Theater
131 E. Fisher Street.
Salisbury, NC 28144
Coleen H. Sullins Director
Division of Water Quality
1 C�
�Eo[n)
SEP 1 8 2008
NC DENR MRD
DWQ - Aquifer Protection
Subject: Revised Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0300125
131 E. Fisher Street
Salisbury, NC 28144
Dear Mr. Wagoner:
In accordance with the revised Notification of Intent submitted to the Underground Injection Control
(UIC) Program that was received on September 15, 2008, the Aquifer Protection Section (APS)
acknowledges your intent to construct a closed -loop geothermal water -only injection well system for the
operation of a ground -source heat pump located at the above referenced address. This system is deemed
permitted by rule (North Carolina Administrative Code Title 15A, Subchapter 2C, Section .0211(u)(2)).
The permit has been revised to reflect Richard Simmons Drilling Co., Inc. as the driller for this
project (NC Certification #3588).
However, it is recommended that you contact the Rowan 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 [phone].
cc:.
``(
Michael Rogers
Environmental Specialist
GPU-Aquifer Protection Section.
f o esvz�l�le, ii epic n 10 : " �.Jattatrthia, F -
APS Central Files - Permit No. WI0300125 w/attachments
Rowan County Environmental Health Dept. w/attachments
Stephan Brooks — Richard Simmons Drilling Co., Inc. (sent via,fax and U.S.P.S.) w/out attachments
City of Salisbury w/out attachments
NorthCarolina
Naturally
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone: [phone]
Internet: www.ncwaterquality.org Location: 2728 Capital Boulevard Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper Customer Service: [phone]

J
Richard Simons
CIO EULL.Ieta
Richard Simmons
Drilling Co., Inc.
60 Drill Rig Drive
Buchanan, VA, 24066
P. [phone]
F.[phone]
FAX TRANSMITTAL - 5 pages
including this page)
September 15, 2008
TO: Michael Rodgers - NCDENR - DWQ
RE: Notice of Intent - Geothermal Test Well - Salisbury, NC.
FROM: Stephen Brooks
As discussed last week the attached form is being submitted by Simmons Drilling after the
previous drilling contractor failed to perform the work. All information remains the same with
the exception of the drilling contractor.
If possible, we ask that "Acknowledgement of Intent to Construct" be faxed to us at (540-254-
1.268) so we may expedite our services for the client.
If you have any questions, I can be reached at [phone].
Thank you,
Stephen Brooks
Geothermal Manager
A.
RF:CErvEQ ! of ' D IL
:u EP 15 Z008
S EP 15 2�4

Federal:
013/24/2008 15:53 7046377091
WAGONER CONST
NORM CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF zrrE TO CONSTRUCT A CLOSE ..0OP
GEOTHERMAL WA'EB 1ONLY T TJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
PAGE 01
Tyipe SQ'W Wells
In Aecoadance with the *visions ofNCA.0 Tale ISA: 02C.0200
Complete application lad wail to address on the hack page.
This is sat the proper form to be used for i nieetion wells in an onwloog geothermal system.
Do not use this form for systems that cat; calate env substannetother than 'lye
TO: DIRECTOR, NORM CAROLINA DIVVStON OF WATER QUAI.1TY
DATE: . July 16, 2008
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
pipicigthat completely isolates the fluid from the environment?
YES X If yes, then continueicampleting this form.
NO Milo, do not complete this farm_ Form OW-57 HP, Application For
Persnit To Construct A►kllOr Use A Well(s) Fo' InJectlon W M A Heat
Paw System, should be completed.
R. SYSTEM i .Um Will any additives {be introduced to the system's circulating heat transfer
fluid? This includes: but is not limited to c6rtosf on inhibitors and/or antifreezes.
YES Kral, do not ample* this Ran. Form GW-7 RP, Application For
Permit To Construct Anil/& Use A Wells) For Injection Wirth A Heat
Pump System, should bd completed.
NO X Wm, them continue complotins this form.
C, PROPERTY OWNER
Name: G
ry
.i
City: _ / State: NC Zip Cale: _
County: Telephone:
D, STATUS OF PROPERTY OWNER
Private_
Sty: Municipal: x •
•
Commercial:
Native American ids: —
OW-57 CL (,Ina, 2000) j rage 1 of 4

08/24/2008 15:53 7046377091
WAGONER CONST PAGE 02
E. JOB (SflE) DATA
Name: Ft O g aR 4 -ra, �wr `i4 mom *rt.
Address. _ r e r? .
City:�� a State:_NG ZACode:?4 County: S,pw i
Telephone: (. Contact Person ; '"5 t (f a-9 o nQ. #-___
F. HEAT PUMP CCJNTRACTOR DATA
N,a�otre;. .. _ N/A _Note: This is fora borehole and thermal oou� iuctivity teal,
Address:
City: _ State:_ . Zip Code: Cody:
Telephone: - Contact Penton:
G. CONSTRUCTION DATA (check one)
E.7CISTING WELL(S) being proposed for use as a gentmd-coupled heat pump
wdll(tt), wide the innfonuation in (1) through (44) below to the best of your
larowledge. Attach a copy of Form Caw 1(Well Construction Record) if available:.
X PROPOSED WELL(S) to be constructed.for use as a ground -coupled heat pump
well(e) . Provide the itifonnuttiou in (1) through (4) below as PROPOSED
oonstruction specifications. Submit Form GW f after construction.
(1) Well Drilling Contractor's Name: R,} rrror o 1),g r t e Mij CO., N c .
NC Contractor Certification number: fit.. ..o 3_5',, --
Date to be constructed: Seel". 41.8 Number of boriugd; •____I,._„
Approximate depth of each boring (feet):30O 0 • ,
(2) Well Ming: Ie the wells) cased?
(a) YES - If Yes, then provide the casing information below.
Type: Galvanized steel Black'steel Plastic Other (specify)
Casing depth: From to it (reference to land surface)
Casting extends above ground inches
(b) NO X
(3) Grout (grout the vertical length of the borehole to a minimum depth *fit) feet b.Ls.):
(a) Grout type: Cement - 1 entonite _ Other (scpeaify) —
(b) Grouted surf ce and grout depth (reference to land surface):
around closed loop piping; from to _ 200 (feet)•
aroused well casing; from to (feet).
NOTE: THE WELL DIWIIND CONTRAC:roR CAN SUPPLY TH OATA FOR a rtHBR most G OR
PROPO.4EP vials WTI= LNPORMAi1ON TS UNAVAEANt.R I3X oTNIA MEANS,
GW-57CL (Jan, 2000)
Page 2 of 4

08/24/2888 15:53 7846377891
1
K. CERTIICATIO*i
WAGONER CONST PAGE 03
17. JNJECT ON R LAi D EQUIPMENT
Ash a diagram showing the engineering layout of the injection eciuipment and exterior piping(t lbing
associated with the iuje tiof operation. The manufac urer'a brochure may provide supplementary
information.
I_ LOCATION OF WELL(S) Attach two malls.
(1)
C2)
Include a site map (can be drawn) showing: buildings, property lines surfuce water bodies,
potential sources of groundwater contamination and thy orientation of and distances between: the
proposed well(s) end 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 gym. Label all features
clearly and include a north arrow.
location map ,efet encing the site to two nearby permanetrt reference points (such as roads,
streams end highway intersections).
FERMIT LIST: Attach a list of all permits or coustruction that are related to the site.
$ 1Jat oe - ,t, c(ak� s 4�mj 15 tR Jer.stgK pi►a.s�,
Examples include_ at,ai -fir$ , - WtY.i! 15 {w,
(1) Hasardous Waste Menagenrnent program permits under RCRA (riln t wx. �it 1 r 9
(2) I4C Division of Weser Quality Non-Dieeherlga permits o; irs�td,4
(3) Sewage Tmatmcnt and Disposal Permits
ga off► enitke.1
lay s 4-03%
"I hereby certify, under penalty of law, that I have personally examined and tun familiar with the
information aobmiitted in this document and all tettachments thereto and that; based on my inquiry ammo
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, 1. , repair, and if -
applicable, abandon the grand -source heat pinup system and all related in accordance
with the approved specificsdions and conditions of the Permit" •
GW-57 CL (Jan,. 2000)
• If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
Page 3 of4

08/24/2008 15:53 7048377091 WAGONER CONST PAGE 04
L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is teal property and its constructions on land rests ownership in
the landowner in the absence of contrary agreement in writing,-)
lithe 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 applicant to ensure that the ground -source heat pump system a well(s) conforms to
the Well Construction Standards (Title 15A NCAC 2C .0200)
Please return two copies of the completed Application package to:
U1C Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
(IVlr_57 CL (Jan, 2000) Page 4 of 4

o' A 7- 94
.O a G
J
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins Director
Division of Water Quality
July 23, 2008
Piedmont Players Theatre
Attn: Reid Leonard
213 South Main Street
Salisbury, NC 28144
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0300125
131 E:Fisher Street
Salisbury, NC 28144
Dear Mr. Leonard:
In accordance with the application submitted to the Underground Injection Control (UIC) Program that
was received on July 18, 2008, the Aquifer Protection Section (APS) acknowledges your intent to
construct a closed -loop geothermal water -only injection well system for the operation of a ground -source
heat pump located at 131 E. Fisher Street, Salisbury, Rowan County, NC 28144. 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 Rowan County Health Department, as they may have
additional constructionor 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 [phone].
Sincerely,
tfi t
41.0A-,
Michael Rogers
Environmental Specialist
GPU-Aquifer Protection Section
cc: Ll octres4Yil'le Regional S a
APS Central Files - Permit No. W10300125
Rowan County Health Dept.
Coastal Geothermal — Bruce Brazill (102 Middle Street Jacksonville NC 28546)
Aquifer Protection Section 1636 Mail Service Center
Internet: www.ncwaterquality.org Location: 2728 Capital Boulevard
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper
Nne
orthCarolina
Naturally
Raleigh, NC 27699-1636 Telephone: [phone]
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
Customer Service: [phone]

JUL 1 8 2008
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 Accordance 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
DATE: July 16, 2008
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.
C.
YES 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.
NO X If no, then continue completing this form.
(i` PROPERTY OWNER ir t l l LJ �z
Name: 64y 4 �jc* t/ry
Addre s P © 8 4Y. 479
City: v0.4,61400 State:
County: ,'QW frA/
t
D. 'STATUS OF PROPERTY OWN1rR
Private:
State:
GW-57 CL (Jan, 2000)
NC Zip Code: Z$ /4
Telephone: 744. (err s, 52 70 s G r ('� y
Tive
Federal: Commercial:
Municipal: x Native American Lands:
R. i l r+/ff�.
t3 N\A,, ,zd-
Page 1 of 4

5
JUL 18 2008
E. JOB (S11'h) DATA.
Name: Ft 14ER. ' tR 'E T i� EAT at;
Address: 131 E , Fr 6Icz. ! Gj -1-4
City: 'cx.tiS 6c,.ry State: NI ZipCode: T44 County: fZeWa►_ti
704. Telephone: �, 1,, 1431 Contact Person ; If( a_ o na.. Y
F. HEAT PUMP CONTRACTOR DATA
Name: N/A Note: This is for a borehole and thermal conductivity test.
Address:
City: State: Zip Code: County:
Telephone: Contact Person:
G. CONSTRUCTION DATA (check one)
EXISTING WELL(S) being proposed for use as a ground -coupled heat pump
well(s). Provide the information in (1) through (4) below to the best of your
kndwledge. Attach a copy of Form GW-1 (Well Construction Record) if available.
X PROPOSED WELL(S) to be constructed for use as a ground -coupled heat pump
well(s) . Provide the information in (1) through (4) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
(1)
Well Drilling Contractor's Name: Coastal Geothermal 910-353-0926
NC Contractor Certification number: NC — 2723 Bruce Brazill
Date to be constructed: Aug. 2008 Number of borings: 1
Approximate depth of each boring (feet):300'
(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
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.l.s.):
(a) Grout type: Cement Bentonite X Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
X . around closed loop piping; from 0 to 200 (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.
GW-57 CL (Jan, 2000) Page 2 of 4

JUL 18 2008
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.
(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).
J. PERMIT LIST: Attach a list of allpermits orrrconstruction
r approvals that are related to the site.
4 MI. Oa- 44.117 C=t: T Jxt. F /tj 44k l.5 ti'1 dtr-$1941 (WIZ0...)
Examples include: a.hal thr6 !k4 1
(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, intain, 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."
Caa1
wne
ricaartin MI. - s(b1(�.Y
of "�"y7..2. p (ct km
ciao V-t eritv+a.4 14 VFl-G
oriz
geI1.t) Z
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
7& 6
GW-57 CL (Jan, 2000)
( o )
Page 3 of 4

JUL 18 2008
L. 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 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) conforms to
the Well Construction Standards (Title 15A NCAC 2C .0200)
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW-57 CL (Jan, 2000) Page 4 of 4

A
Vccan41 ra4ol..4 164* et-I15174411/ 11
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Rowan Co, NC -- Printable Map
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Rowan County GIS
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