WI0500255_GEOTHERMAL_20100510

Beverly Eaves Perdue
Governor
John Linton
Cynthia Linton
6113 Dresden Lane
Raleigh, NC 27612
NA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
5/10 /2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0500255
6113 Dresden Lane, Raleigh, NC 27612
Dear Mr. & Mrs. Linton:
Dee Freeman
Secretary
On 4 /29 /2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl y
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 water,
2 . The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3'. The required notification form and associated maps have been completely and accurately submitted.
Faiiure 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 .021 l(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 Michael.Rogersrci\ncdenr.gov if you have any questions.
Sincerely,
for £2a~~
cc : Raleigh Regional Office -APS
APS Central Files -ermit No. WI 1:rn1~.-
Wake County Health Dept.
Supervisor
Steve Bo\~'rnan (Bowman Mechnical -145 Technical Court,.yarner, NC '27529)
AQUIFER PROTECTION SECTl0f'!
1636 Mail Seivice Center, Ra leigh, North Carolina 27699-1636
Location: 2728 Capital Bouievard, Raleigh. North Carolina 27604
Phone: [phone] i FAX 1: 919-715-0588; FA X 2: 919-715-6048 \ Customer Seivice: 1-877-623-6748
Interne t: www.ncwaterguality.org
/:,1 Eqllal Opport1m;'.f \ Affirrna;ive .l\c:'on Employer
No1:.S.i.c .. 01.w arotma
/Vatural~lf
Permit Number WI0500255
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
John & Cynthia Linton SFR
Location Address
6113 Dresden Ln
Raleigh
Owner
Owner Name
John
Dates/Events
NC 27612
Linton
Orig Issue
05/10/10
App Received Draft In itiated
04/29/10
Re g ulated Activities
Heat Pump Injection
Outfall NUL'._
Scheduled
Issuance
Central Files : APS_ SWP_
05/10/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Steve Bowman
145 Technical Ct
Garner
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
John Linton
6113 Dresden Ln
Raleigh
NC
NC
Public Notice Issue
05/10/10
Effective
05/10/10
27529
27612
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELL(S)
In Accordance with the provisions ofNCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or Type information).
0
DATE: - 1r
. 20 i
Well Type Confirmation: Does the proposed system circulate potable water onl• (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loot')?
Yes )( Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well injecting potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY O WNER(S)IAPPLICAN T (S)
List each Property Owner listed on property deed (if owngd. by a business or government agency, state name of
entity and a representative wlauthority for signature): ' L-1 z{-��r 44" i .{i
Cn a
f
(1) Mailing.Address: L r ' 1)T� e� 'I�' Ln,
City: j\ , , n `` State: IA_ Zip Code: : lt,' f 1- County: C
Home/Office Tel No.: q (.1 `� - 1 T r0 r Cell No.:
Ttt
Email Address: •,! �� ';'rlti,
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code: County:
Home/Office Tele No.: Cell No.:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City: State: Zip Code: County:
Office Tele No.: Cell No.:
Wehsite Address of Company, if any:
rlEDEAR not)
PDa Secton
APR 2 9 ?oto

C. WELL DRILLER,#FORMATIU , j
Company Name: i�') r r , ` i r' I ( s n {
Well Driller Contractor's Name: H. \ CI ►i 1 14 -1: n uT r 1
NC Contractor Ce cation Na: J / 0 T
Contact Person: ‘1 Gt1. "i rill tr 1 EMAIL Address: r 'r , , it 10-C " „ir; � ).,�y t:crl-
Address:71 1.0k 1-6(' L'41,-)
City: 6 0 .. t l7 Zipr� Code: County:
Office Tele No.: 9I It 7 7l 1 Le Cell No.: Il "1 • . ? - 4 03 a
D. HEAT PUMP CO TRACTOR INFORMATION (if different than driller)
Company Name: 5'1 Et i1 G i7G I b L a
Contact Person: ti v' C Phr•: 4.9'1i [ I EMAIL Address: �a'' `� } iry�` '? Ca fe4 NC1' th4
Address: 1 Lib jet.110,/ A C 1.
City: L_. ,r int!r
Zip Code: 7 Y) County; r 1`
Office Tele No.: %T-' ( Cell No.:
E. STATUS OF APPLICANT
Private: Federal: Commercial:
State: Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA �]
(1) Proposed date to be constructed: '1 _ e' Number of borings:`
Approximate depth of each boring (feet): 44, 7
(2) Type of tubing to be used (copper, PVC, etc): '-1 Er b? e
(3) Well casing. Is the wells) cased? (check either (a.) Yes or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: _galvanized steel black steel plastic other (specify)
Casing depth: From to feet (reference to land surface)
Casing extends to above ground inches
(b) No X
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite') Other (specify)
(b) Grout placement: Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from to ;c 5 (feet)
If well has casing, indicate grout depth: from _ to (feet)

D. IINJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification 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 copies of maps showing the following information:
(1)
(2)
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 geothermal heat pump well system. Label all features clearly and include a north arrow.
The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"1 hereby certify, under penalty of law, that 1 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.
1 am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved speciicati n an conditions of the Permit."
Signature of Properly Owner/Applicant
John F. L [ Kto
Print or Type Full Name and title
Sign ure of Proper weer/Applicant
a. O. L °Tit el
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-U1C Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECBVED 1 DENR ► Dlllda
Aquifer Prntertion Section
APR 29 2010