WI0500094_GEOTHERMAL_19981229

GROUNDWATER SECTION
December 29, 1998
MEMORANDUM
--To: -Jay -Z-immerman --------
Groundwater Section
Raleigh Regional Office
From: Mark Pritzl f,'\if [e-mail]
Hydrogeological Technician II
UIC Group
Groundwater Section
Raleigh Central Office
Re: Receipt ofNotification for a Closed-Loop Geothermal Water-Only Injection Well
System.
Notification to construct and operate an injection well system for a geothermal heat pump system
has been filed by Randy Jones of Smithfield, North Carolina and a copy of the Notification is
enclosed for your files. This injection well system is deemed permitted by rule (NCAC Tl SA:
2C.21 l(u)2) and no regulatory action is necessary. If you have any questions, please contact me
at [phone] or Amy Axon at [phone].
cc: UIC Files
Enclosures
ATA
NCDENR
JAMES B. HUNT JR..
GOVERNOR
WAYH! McDrVITr
SECRETARY
A. PRESTON NioWA/so,
JRryPE.
[71RRGTOR
=.
s.
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
December 18, 1998
Randy Jones
PG Box 991
Smithfield, NC 27577
Dear Mr. Jones:
In accordance with the notification submitted on your behalf by Climate Control
Heating and Cooling Co., Inc. dated November 23, 1998; the Groundwater Section
acknowledges your intention to construct closed -loop geothermal water -only injection
wells 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.O211(u)(2). The
Underground Injection Control Group has added your site to our inventory. 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 geothermal heat pump wells please feel free to
contact me at [phone] or Amy Axon at [phone].
Sincerely,
/1464 /Q
Mark Pritzl
Hydrogeological Technician II
Underground Injection Control Program
cc: UIC Files
RRO Files
GROUNDWATER SECTION
P.O 90X 29578, RALEIGIN, NC 27628-0578 - 2728 CAPITAL B1_vO., RAL6IOH, NC. 27904
PHONE [phone] FAX 91 9-7I 5-0588
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLEo/10% POST-CONBUMgR PAPER

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 Welts
In Accordance with the provisions of NCAC Title 15A: 02CA20(}
Complete application and mail to address on the back page.
TO:
This is not the proper form to he used for injection wells in an open -loop geothermal system.
Do not use this form for systems that circulate any substances other than water
DIRECTOR, NORTH CAROLINA Di7ON OF WATER QUALITY
DATE: / J- 2- 3 . 197
0.0
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES %1
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 Wells) 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 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 Y\ If no, then continue completing this form.
Al
C. PROPERTY OWNER �! hSrC ,' �,��
Name: ��N�{. .Jdl��jr T'tit�,t'�J'c�l ■" �
Address: ,I '', tt • 8 ,/ r ,
City:.]�� tTFc 1 State:Av Zip Code: 2-7577
County: as rti/l.�' Telephone: jq I.3'-/^ 91(
D. STATUS OF PROPERTY OWNER
Private: _ Federal:
State: Municipal: _
Commercial:
Native American Lands:
GW-57 CL (May 1998)
Page 1 of 4

'•
E. FACILITY (SITE) DATA
F.
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: ______________________ _
Address: _____________________________ _
City: _________ State: __ Zip Code: _____ County: ____ _
Telephone: __________ Contact Person: ____________ _
Standard Industrial Code(s), SIC, which describes commercial facility: ________ _
HEAT PUMP CONTRACTOR DAT A.
Name: Climate Control Heating & Cooling Co., Inc.
Address: 269 Center Street
City: Jackson:vi]] e State:NC.__ Zip Code: 28546 County: Qnsl aw
Telephone: [phone] Contact Person: Mi cbaeJ Had] ey
G. CONSTRUCTION DATA (check one)
X
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
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 (4) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
(I) We11 Drilling Contractor's Name: Cljmat,e, Control Heatina 8< CooHni Co,, los..
NC Driller Registration number: _1_6_3_3 _________________ _
Date to be constructed: /i;Jr-tJ-qr(' Number of borings: __ (,---"--------
-,,,.."' r Approximate depth of each boring (feet): __ ~ __ u _____________ _
(2) Well casing: Is the well(s) cased?
(a) YES · If yes, then provide the casing information below.
Type: Galvanized steel ____ Bl~ck steel __ -_.Plastic_-__ .. Other(s~ecify) _____ _
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.):
NOTE:
(a) Grout type: Cement__ Bentonite )( Other (specify) _______ _
(b) Grouted surface and grout depth (reference to land surface):
K.__ around closed loop piping; from 2-0 to O (feet).
__ around well casing; from __ to __ (feet).
THE WELL DRILLlNG CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
GW-57 CL (May 1998) Page 2 of 4
NO \/ L ,) ' 'j ◊ 1 u . L 4 1 ·,w • IJ I,.) Lf t· • u L
P04
H. lNJECTlON•RELATED EQUIPMENT
Attach a diagranl showit,g the engineering ht)'out of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
l. LOCATION OF WELL(S) Attach two maps.
(1)
(2)
Include a .sitci map (c,u, be drawn) showil1g: buildings, property lines surface water bodies,
pote11tial sour1.ts of groundwater contatnlnation and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal facilities auch as septio tanks
or drain fields located within 200 feet of the ground-coupled heat pmnp well system. Label all
features clearly and include a north arrow.
location map refere1\cins tht site to two nearby permanent reference points (such as roads,
streams and highway intersections).
J. PERMIT UST: A~ta~h a list of all permits or construcdo11 ~pprovals tl,at are related to the site.
Ex.amples include:
( 1) Hazardous Waste Management p1·osrllm permits under RCR.A ..
(2) NC Division of Water Quality Non.-Cischar1 • permits
(3) Sewage Treatment and Disposal Penn its
K. Ct:.RTlflCATlON
0 1 hereby ce11ify, under penally of law, that I have personally examined and am familiar with the
information submitted hi this document and all attachments thereto and that, based on my inquiry of
those individuals Immediately responsible for obtaining said informationJ.,I believe that the informatlon
ls true. accurate and complete. I atn aware that there are s•ignificant penalties, 1noluding the possibility
of fines and imprisonment~ for submitting faJse inror,nation, J agree to construct, operate. maintain,
,.epair, and ifappJicnblc, ubandan the around-source heat pump syetem and all related appurtenances in
accordance with the approved ~pec1ficatlot\s and conditions of thcr Pem1it. 0
lf authQrized ug,nt Is acting on behalf of th, well owner,
pleaJ·1 supply a letter signed by the own,r
authorizing the abov, ag,nt.
L. CONSENT OF PROPERTY OWNER (Owner means nny person who holds the fee or other property
rights in the well being constructed. A wel I 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 applic3:tion 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)
GW-57 CL (May 1998)
(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
P.O. Box 29578
Raleigh, NC 27626-0578
Telephone [phone]
Page 4 of 4
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