WI0500256_GEOTHERMAL_20100510

,
Beverly Eaves Perdue
Governor
Geoffrey K. Krummel
Rachel Krummel
222 J River Park Drive
Wake Forest, NC 27587
A~A
s,;,,_·;.1-_. _.1_
CDEMR
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. WI0500256
2221 River Park Drive. Wake Forest, NC 27587
Dear Mr. & Mrs. Krummel:
Dee Freeman
Secretary
On 4/29/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onh
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.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title ISA Section 2C Subcbapter .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.Ro2:ers rZimcdenr.2:ov if you have any questions.
cc: Raieigh Regional Office -APS
APS Central Files -Permit No. \VJ050025o
Wake County Health Dept.
Sincerely,
.forQ~A-~
Supervisor
Steve Bowman (Bowman Mechanical Services -J 45 Technical Court, Gamer. NC 27529)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2i28 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity\ Affirmative Ac'ion Employer
None r ,. orth ;,_,arouna
Jvaturallg
Permit Number WI0500256
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
Geoffrey & Rachel Krummel SFR
Location Address
2221 River Park Dr
Wake Forest
Owner
Owner Name
Geoffrey
Dates/Events
NC 27587
Krummel
Orig Issue
05/10/10
App Received Draft Initiated
04/29/10
Re ~ulated Activities
Heat Pump Injection
Outfall ,L
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
Geoffrey Krummel
2221 River Park Dr
Wake Forest
NC
NC
Public Notice Issue
05/10/10
Effective
05/10/10
27529
27587
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
• .-...L vy_ a
NORTH CAROLINA
DEPARTWIT OF ENVIRONMENT AND NATURAL RESOt]KCES (NCLIEW
NO CATION OF INTENT TO CONSTRUCT A CI OS -1 OQF GEOTHERMAL
WAS -ONLY DEJECTION WELL SYSTEM:
TYPE 5-OW WEJ,1,(S)
In Accordance with the provisions orNCAC Title 1$A: MC-0300, please
complete dtls notiffaation and mad to address on the back page (please r�mt or Ivpe information).
L
DATE: A
Wcii Type Ce irmarian: Does the propos4 system circulate potable, water oQly (no additives)
coatw &ots piping that aoimplestely isalaw the fluid from the cnvixonme t (Le.
cloSedktau)?
Yea 75 _ _Continue cornplcting this form.
No Do Not complete this firm. Comply other VIC application forms for installing
either a 5A7 wail (Loop well Wig in& potable water into the aquifer) or a SCAM well (closed -
loop well ortataining Wag= such as R-22, eel, or other antifreeze or corrosioninhibitors).
A. PROPERTY OWNEI b ARI UCA,l' T(S)
List each Property Owzicr lusted on propaity deed of owned by a bu it c. or government may. state name of
entity and a representative wfamhori y fear
)
{1)
G2i
Mailing Address: 2 )-2- 1 2 vc--e
City kI4 State: AIL Zip Code: 7 5 • may: (4 r4
Horne/Office Tele No.: i Z 7 3, i S o. i7 ; b76 colt No.: /. 'mac 6'
Parma Address;
.c M 0 / ' '.11^'ue if we tc:
c,...-,
physical Address 4f WeII Site ordlffrsent thlin above):
City: State: Zip Code: - County:-
Home/Olfice Tele No.: Cell 1vti_•
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not marl the subject property.
attach a letter from tbe property Owner authorizing Agm+t to install end operale MC well)
Company Narne:
Cceetim=tPaxsn- EMA11 Adrivels: Address:
City: City Slane: Zip Code' County. - ----
Office Tele No.: Call No.:
Website Address of Company, if any.
GPu1LTIC 5QW Nod&rion of Inroet Farm VIM)
RECEIVED I DEW 10WQ
Aquifer Protection Sorion
APR292010
Pies I

(1) Proposed date to be constructed: Nusnber of borings:
Approximate depth of each boring (feet):
(2) Type of tubing to be used (copper, PVC, etc): RE 3408
polyethylene rr
(3) Well casing. Is the well(s) cased? (check either (a.) Ves or (b.) No below)
(a) Yes if yes, then provide casing i ntormation below
Type: gal van i icd steel black steel ilastic other (specify)
Casing depth: From to feet (rr/ference to land surface)
Casing extends to above ground inchel
(b) No X _
(4) Grout Info (material Burro
ding well casirO, and/or piping):
(a) Grout type: NealCement
(b)
(c) Grout depth of tubing (reperence to land surface): from. to
(feet)
Bentonite X Other (specify)
(feet)
Grout placement: Pumping X_ Pressure Other
If well has casing, indicate grout depth: from to
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the Ongineering layout or proposed modification of the injection
equipment and exterior pip bing associated with the injection operation. The
manufacturer's brochure mprrovide supplementary information.
L LOCATION OF WELL(S)'
Attach two copies of maps showing the following information:
(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 wells) 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.
(2) 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.

C. WELL DRU.I.ER INJl'ORMATION
Company Name:GlenA Datch Well Drilling
Well Driller Contractor's Name: Glen Dareh
NC Contractor Certific.ation No.: 3900A
Contact Person.=-: ~G=len=:..=:D=an:=h'-. ___ ----.:=EMAIL=·-=· =.a:..A=ddr,==ess~: c:,,gd=w.,_,,e=lldri=il,,,,,lin,...,g~~==l.co=m
Address: 13109 Bold Run Hill Rd.. ____________ _
City: Wake Forest __ .,zip Code: 27587 _____ County: Wate"-----
Office Tele No.: (919) 55~5959 Cell No.: [phone] __ _
D. HEAT PUMP CONTRACTOR INfflRMATION (if different than driller)
Company Name:Bowman Mechanical Services Inc
Contact Person: Steve Bowman EMAIL Address:
[e-mail]
Address: 145 Technical Ct. __
City:. Gamer_ Zip Code: 21529 _____ County: Wake_
Office Tele No.: [phone] _____ Cell No.: [phone]
B. STATUS OF APPLICANT
Private: _x_ Federal: Commercial:
State: Municipal:·__ .. Native American Lands:
F. INJECTION PROCEDURE (briefly desm"be how the injection well(s) will be used)
G.
To operate a beat pump for)1,sidetrtial beating / cooling / domestic water heater
WELL CONSTRUCTION DATA , Jl
(l) Proposed date to be constructed: ~ .l. ... J.f-8 Number of borings: J_
Approximate depth of each boring (feet): _ _,c,;l=---/.__'5.._ __ _
(2) Type of tubing 1o be used (copper, PVC, etc): _RE 3408 polyethylene
(3) Well casing. Is the well(s) cased? (check either (a) Yes!!! (b.) No below)
(a) Yes ___ ifyes, then provide c;asiog information below
Type: __gal\lanized steel_. black steel___J)la&ic_other (specify)
Casing depth: From ___ to ___ feet (reference to land surface)
Casing extends to above grotmd __ ~inches
(b) No _X_
(4) Grout Info (material sum>l.Dlding well cming and/or piping):
(a) Grout type: Neat Cement__ Bentonite _X_ Other (specify) __
(b) Grout placement: Pmnping_X_ Pressun:__ Other __
(c) Oruut depth of tubing (.roference to land SUifa(»): from __ to_ (fc:ct)
If well has~ indicate grout depth: from ___ 1o ____ (feet)
Company Name:Glen A Darch Well Drilling
Well Driller Contractor's Name: Glen Darch
NC Contractor Certification No.: 3900A
Contact Person: Glen larch
Address: 13109 Bold Run Hill Rd_
City; Wake Forest Zip Code: 27587 \ County; Wake
Office Tele No.: [phone] 1T Cell No.: (919) 422- 931
D. HEAT PUMP CONTRACTOR INFORMATION (if different than riller)
Company Name:Bowman Mechanical Servicesc
Contact Person: Steve Bowman EMAIL Addrr..s:
bowmanmechani cal (a)bet l south.net
Address: 145 Technical Ct
City: Garner Zip Code: 27529 County: Wake _
Office Tele No.: [phone] 'e11 No.: [phone]
8. STATUS OF APPLICANT
Private: X Federal: Co mercial:
State: Municipal- _ Nati e American Lands:
EMAIIJ Address: [e-mail]
F. INJECTION PROCEDURE (brief
Too erate a heat um u for
describe how the inj
sidential heatini / coolin
G. WELL CONSTRU IN DATA
(1) Proposed date to be constructed: umber of borings:
Approximate depth of each boring (feet):
(2) Type of tubing to be used (copper, PVC, etc): RE 3 08 polyethylene
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes _ if yes, then provide casing inforr ation below
Type: __galvanized steel black steel plastic
tion well(s) will be used)
domestic water heater
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 TX__ Other (specify)
(b) Grout placement: Pumping_X Pressure Other
fc) Grout depth of tubing (reference to land surface): from to ` (feet)
if well has casing, indicate grout depth: from to (feet)

12/02/2009 15:10 9197799294 PAGE 07/11
H, INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
pipingftubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1)
(2)
Include a Site Map (cart 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 fee of
the geothermal heat pump well system. Label all features clearly and include a north arrow,
The Site Map must show the subject property to 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.
"I hereby certify, udder 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, 1 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 injection well and
ail related appurtenances in accordance with thc approv specifications and conditions of the Permit."
Sigzetufe of Property Owner/Applicant
'fd3F it�.
Print or Type Fult•4ame and title
Signature of Property Owner/Applicant
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-D'WQ
Aquifer Protertiioo Section-U1C Program
1636 Mail Service Centex Cffin
c�1�1� 1 ��Mp1
ecttion
Raleigh, NC 27699-1636 Rita PrRtpcitnn
Telephone [phone] Q VA
GpUILFtc 5QW Notification of indent form (Revised 8l294g)
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