WI0500290_GEO THERMAL_20100923

Permit Number WI0500290
Program Category
Ground Water
Permit Type
Central Files : APS_ SWP_
09/23/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (5QW)
Version
1.00
Permit Classification
Individual
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Mary Obenshain SFR
Location Address
6-7 Sec 2 Poplar Rdg P27/123
Hillsborough NC
Owner
Owner Name
Mary B
Dates/Events
27278
O,benshain
Orig Issue
09/23/10
App Received Draft Initiated
09/15/10
Re gulated Activities
Heat Pump Inj ection
Outfall NULL
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Orange
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Mary B. Obenshain
389 St Mary's Rd
Hillsborough NC
Public Notice Issue
09/23/10
Effective
09/23/10
27278
Expiration
Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Mary B. Ob enshain
389 St. Mary's Road
Hillsborough. NC 27278
NA
NCDEN
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
9/23/2010
Subject: Acknowledgement oflntent to Construct Type SQW Injection Well System
Permit No. WI0500290
6-7 Sec 2 Poplar Ridge P27/123, Hillsborough, NC 27278
Dear Ms. Obenshain:
Dee Freeman
Secretary
On 9/15/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-on!
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 Subchapter .021 l(u)(2). ,Additionally, you should contact the Orange 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:ersrro.ncdenr.e ov if you have any questions.
cc: Raleigh Regional Office -APS
APS Central Files -Permit No. Wl0500290
Ornnge County Health Dept.
Sincerely,
fo,Q~~
Supervisor
Mark D. Obenshain -1529 Poplar Lane, Hillsborough. NC 272i8
AQUIFER PROTECTION SECTION
i636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capita l 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.ncwaterquality.org
An Equal Opportunity\ Affirmative Action Employer
One .
North Carolina
Jvaturall!f
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5QW WELL(S1
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Print or type the required information and mail to address an the back page,
c=,
rn
DATE: 5 ep f 4- . 20 10
Well Type Conftrnuition: Does the proposed system circulate potable water only (no additive }iin
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes >t" Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well in'ectin potable water into the aquifer) or a SQM well (dosed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state narne of
entity and a representative wlauthority for signature): M "I c r y B. ° i e et 5 [.:a
(1)
Mailing Address: 3 8'1 S4. Met
City: [4 I: t t b o ro 1A. State: O C. Zip Code: L7 Z 7B County:_ 0 ra h, e
Horne/Office Tele No.: :`119 - 7 3 Z— 17 4 S Ce11 No.: 9 19 -- $ I Z- 41 Zl
Email Address: Kai ® Website:
coo eiNra :Ack.55oc:a1-e5.0519 pp
(2) Physical Address of Well Site (if different than above): (p -7 sec 2. Topt....r R:c c P Z,71123
City: 1:115bo ro L'4L, State: fd C zip Code: 2-7Z78 County: 0 ccomi e
Horne/Office Tele No.: k e ct 5 e 6 a ue 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.:
Website Address of Company, if any-

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WELLDRILLERINFORMATION ,,,.,,,,,.,.,., 1,·+ recei11e, ~c bEN ..... 4 c O"v ft 'J~
Company Name: ____________________________ _
Well Driller Contractor's Name: ____________________ _
NC Contractor Certification No.: _______________________ _
Contact Person .... : -------------=E=MAIL==..;.A=d=dr=es=s=: _________ _
Address: ______________________________ _
City: _________ Zip Code: ____ Collllty: ____________ _
Office Tele No.: Cell No .. ----------
HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
CompanyName: Jv1o.r le. D. 'Dl,e~s'-'4~"' (H-1 4 H-3 \:ce~~eJ "'-~+:"'.'-co~<JD,)
ContactPerson: 'Sz'?\~ EMAILAddress: Mobel'1s"'q;tf\@ t<l,(',Uf\(,ed-,c
Address: \ 5 29 Pop far LA.
City: t\ :\\ ~ '20 rou~ L, Zip Code: NC. Coun1jl: or ... ~,e
Office Tele No.: Cfl1 • ':lfo z. ... 4722.cell No.: 1ti .. 883 -840
STATUS OF APPLICANT
Private: ✓ Federal: Commercial:
State: Municipal: __ Native American Lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
c to e;eJ {oof
WELL CONSTRUCTION DATA e4.r('j Zo l(
(1) Proposed date to be constructed: :full Zolo of Number of borings: -~----
Approximate depth of each boring (feet): __ Z._o_O ____ _
(2) Type of tubing to be used (copper, PVC, etc): f' 0 (':1 e.±V\ :y le ~e
(3) Well casing. Is the well(s) cased? (check either (a.) Yes m: (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 V-
( 4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite V--Other (specify) ______ _
(b) Grout placement: Pumping ........... Pressure__ Other __
(c) Grout depth of tubing (reference to land surface): from O to 2c::>O (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC SQ~ Notification of Intent Form (Revised 8/2008) Page2
H. INJECTION-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
infonnation.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information: -(1) IncltJde 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.
(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.
"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, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conditions of the Permit."
~~.~
signatureProperty Owner/ Applicant
#ar~ 8. 06e11sl,a,~1 owner
Print o;ype Full Name 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-DWQ
Aquifer Protection Section-me Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
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Orange County GIS
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· Area Map for Proposed Geothermal Installation
Mary B. Obenshain, property owner
Area Map for Proposed Geothermal Installation
Mary B. Obenshain, property owner
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 50W WELL(S)
In Accordance With the Provisions of NCAC Title I5A 02C.0200
Print or type the required information and maid to address an the back page.
)
►n
DATE: ' e p + A- 20 I ❑
Well Type Confirmation: Does the proposed system circulate potable water on1\ (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop i?
Yes ►r' 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 OWNER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): M tkr y ❑ b e vi s
(1)
Mailing Address: 3 tr, Sf , of t 5 •
City: 14 i5 too ra aosk State:. NC... Zip Code: 2.7 Z 78 County: 0 r4R. e
Home/Office Tele No.: I+ 11111—Z3R-6174S CellNo.: 9Cc- 41Z- 412.11
Email Address: ;1'Cct!l Website:
a b evxstAu• vIcL55cc:ale 5 .Co
(2) Physical Address of Well Site (if different than above): (p —7 S Cc Zr 'o pia. r 0 e P g.71123
City: _ ;1 iPo ro U� IN State: N C. Zip Code: Z7Z78 County: Or K J e
Home/Office Tele No.: 4% a cc 5 et ili o o e Ce11 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.:
Website Address of Company, if any:

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WELLDRILLERINFORMATION ~,A;,., 1,-+ rece,'IJtPS 1'JC bEN it 4~1',Aoc.vl~cJ4'-='""'ec.t
Company Name:. ____________________________ _
Well Driller Contractor's Name: ____________________ _
NC Contractor Certification No.: ------------------------
Contact Person.'-: --------------=E=MAIL=~A=d=dr=e=ss=-=-: _________ _
Address: ______________________________ _
City: _________ Zip Code: ____ County: ____________ _
Office Tele No.: Cell No.: ----------
BEAT PUMP CONTRACTOR INFORMATION (if different than driller)
CompanyName: Jv1g.r· Jc. D. 'Dl,e~ >""'-~~ CH-I cl H-3 \:ce~~eJ tA~.J.;~~ O)~do,)
Contact Person: 5B wue,, EMAIL Address: Mobe~s"'g;A@ ~(". U"1\(',6:M
Address: 15 2.9 Pop fa, r LA,
City: to\:\\ ,, loc /"o '-''j Lt Zip Code: N c.. County: --=o:;_;r◄;__C\.___:__~=+---~==------
Office Tele No.: 'lt,-&f <,,2---4722.CellNo.: 't/i .. B83 -8405
STATUS OF APPLICANT
Private: ✓ Federal: Commercial:
State: Municipal: __ Native American Lands:
INJECTION PROCEDURE (briefly describe how the iajection well(s) will be used)
cfo&;eJ {oof
WELLCONSTRUCTIONDATA e4.r('j Zoll
(1) Proposed date to be constructed: fu.H Zolo of Number of borings: -~----
Approximate depth of each boring (feet):_---'-'2.._o_O ___ _
(2) Typeoftubingtobeused(copper,PVC,etc): po (':Je.±~y lel'\e.
(3) Well casing. Is the well(s) cased? (check either (a.) Yes.!!! (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 V-
( 4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite v' Other (specify) ______ _
(b) Grout placement: Pumping ....,..-Pressure__ Other __
(c) Grout depth of tubing (reference to land surface): from O to zoo (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Fonn (Revised 8/2008) Pagel
· Area Map for Proposed Geothermal Installation
Mary B. Obenshain, property owner
· Area Map for Proposed Geothermal Installation
Mary B. Obenshain, property owner
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Orange County G I S
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