WI0500291_GEO THERMAL_20100923

Permit Number WI0500291
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
2412 Smokerise Court
Location Address
2412 Smokerise Ct
Raleigh
Owner
Owner Name
Richard
Dates/Events
NC 27615
Patterson
Central Files : APS_ SWP_/
09/23/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Glen A. Darch
13109 Bold Run Hill Rd
Wake Forest
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Richard Patterson
2801 Blue Ridge Rd
Raleigh
NC 27587
NC 27607
Orig Issue
09/23/10
App Received Draft Initiated
Scheduled
Issuance Publ ic Notice Issue
09/23/10
Effective
09/23/10
Expiration
09/14/10
Re gulated Activities
Heat Pump Injection
Waterbody Name Stream Index Number Current Class Subbasin
NA
NCDEMR
North Carolina Departmen t of Environment and Natural Resources
Division of Water Quali ty
Bever ly Eave s Perdue
Governo r
Rich ard Patterson
Julie Patter son
28 0 1 Blue R idge Road
Suite G l O
R al eigh, N C 27607
Coleen H. Sullins
Directo r
9/23/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI050029 1
2412 Sm okerise Co urt, Ralei gh, NC 27 615
Dear Mr. & Mrs. Patterson:
Dee Freeman
Secretary
On 9/14/2010, 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:
I . 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 s ubmitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrativ e Code Title 15A Section 2C Subchapter .021 l(u)(2). Additionally, you s hould 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.Rogers1amcdenr. sw v if you have any questions.
Sincerely,
O\rlfl~
cc: R aleigh Regional Office -APS
APS Central Files -Permit No. WT050029l
Wake County Health Dept.
for Debra Watts
Supervisor
Glen A. Darch-13109 Bold Run Hill Road. Wake Forest, NC 27587
Steve Bowman -Bowma11 Mechanical Svcs, lnc., .145 Technical Court, Gamer. NC 27529
AQUIFER PROTECTION SECTION
1636 Mai! Seivice Center, Raleigh, North Carolina 27699-1636
Location : 2728 Capital Boulevard , Raleigh. North Carolina 27604
Phone : [phone] I FAX 1: 919-715-0588 ; FAX 2: 919-715-6048 I Customer Seivice : 1-877-623-6748
Internet: www.ncwaterguality .o rg
An Eq ual OpporiJn ity I Affirmaiive Acti on Employe r
~OnehC 1· N ort . aro 1na
Jvaturall!f
DATE: cK 30
.20o OSOODAI
Well Type Confirmation: Does the proposed system circulate potable water only (no
additives) in continuous piping that completely isolates the fluid
from the environment (Le. Closed -loon )?
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 OWNER(S)VAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government
agency, state name of entity and a representative wlauthority for signature):
(1) Mailing Address: C 1 -So �`d S ' I D
City: 1� • , t c_.y j State: at 7 C. Zip Code: 6 D 1 County: .
Home/Office Tele No.: 9‘ 3 L1 Cell No.: . c# to -1 tit.3
Email Address: Cv , Website:
(2) Physical Address of Welt Site (if different than above): Oil 12- SfrI otpri C 4
City: State: j Zip Code: - 1 S County: u--cL(
Home/Office Tele No.: Cell No.: 9 • . ! D
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 iJIC well)
Company Name:
Contact Everson: EMAIL Address:
Address:
City: State: Zip Code: County:
Office Tele No.: Cell No.:
Website Address of Company, if any:
RECEIVED NR
Aquifer Protection SW4 e
SEP 14 1010

09/15/2010 15:55 9197799294 , '!W·." ,, .... , ~
C. WEIL DRlLLER INJl'O:RMATION'
Company Name·:GJen A Darch Well Drilling
Well Driller Contraci:or's Name: Gleo.Datob
NC Contracl91' Certification No.:' 3900A
Contact Peison: Gleo ~ EMATL J\ddress:gdwetldrilling@.aQl..omg
Address: 13109 Bold Run Hill Road
City; Wake Forest Zip Code: 27587 County: Wake
Office Tele No.: [phone] Cell No.: [phone]
D. BEAT PUMP CONTRACTOR INFOllMATION (If dttterent tun drD.lt )
Company Name;Bowman Mec}'Janical Sern,ces Inc
Contact Person: Steve BQl'llllan EMAIJ,,. h,ddress: bQl1J!WAA ;meclwucal@bell 1uth.net
Address: !4.S Techniegl Ct
Ci1y: Garner Zip Code: 27529 County: Wake
Office Tele No.: ('919) 772-2759 Cell No_: (919) 427~1425
Sl'ATUS OF APPUCANT
Private: X Federal: Commercial:
State: Municipal:__ Native Americ:an Lands:.
F. · INJECTION PROCEDUU (briefly describe how the injection well(s) wi be used) • ,Io o_perate I heat pnmp fu.t regdential heating/cQoling/domestic water tmai:1
G. WELL CONSTRUCTION DATA
(1) Pr~ dale 1o be CQ11SU'Ucted: _'1i ..... (_1 / ... ID"'----....---. Nwnber ofborinfl J...
Approximate depth of each boring (feet): :\t&) ► .
2 Type of tubing to be used (copper, PVC, etc): ______ _
(3) Well ca3ing. Is the well(s) cased? (~kei$er(a.) Yes,m:(b.).No belo,
(a). Yes if yes, then provide-ca'Sing infonnation below
Typi::; __»lvanizcd steel _black stcel__plastic_otber (specil I
Casing depth: From ___ to --~f.cet (reference to land surface)
casing extends to above ground _-------'inches
(b) No X
(4) Grout hlfo (material surrounding well casing :and/or piping):
(a) Grout~: Neat Cement__ Bentonite X Other (.;p ;ify) __
PAGE 02/02
(b) Groutplacement! l'ump.ing )'.'. Pressure~ 0d t~-
(c) Grout ~pth of tubing (reference to land surfac:e): :from ___f _ to 8 00 1
Tfwell has casing, indieategroutdepth: from ___ to ~(1 ~)
RECEIVED/ DENR / DWQ
Aquifer Protection Section
SEP 15 20tO
B. 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 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 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, s1reams, and/or highway
intersections.
J. CERTMCATION
Note: This Permit Application most be signed by .mg_ 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" Sir,rz ~
~r-;ype Full Name and title
~\\e.., ~o.W,~ Q-...0\'\e.r
Sl£.W-°7t~-~
f/<11,tt-l>PFintocTypeFullN~ p~~
Signature of Authoriz.ed Agent, if any
Print or Type Full Name and title
North Carolina DENR-DWQ
Aquifer Protection Section-lHC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED/ DENR I DWQ
Aquifer Protection Section
SEP 14 2010
1
x'°
f r
56 ` -ter
"cf
T
5b'
eatel:
1
1') irfini--?L.
Yi
a--- Cpo
5

C. WELL DRILLER INFORMATION
Company Name:Glen A Darch Well Drilling
Well Driller Contractor's Name: Glen Darch
NC Contractor Certification No.: 3900A
Contact Person: Glen Darch EMAil.. Address:[e-mail]
Address: 13109 Bold Run Hill Road
City: Wake Forest Zip Code: 27587 County: Wake
Office Tele No.: [phone] Cell No.: [phone]
D. BEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:Bowman Mechanical Services Inc
B.
F.
G.
Contact Person: Steve Bowman EMAIL Address: bowman [e-mail]
Address: 145 Technical Ct.
City: Gamer Zip Code: 27529 County: Wake
Office Tele No.: [phone] Cell No.: [phone]
STATUS OF APPUCANT
Private: X Federal: Commercial:
State: Municipal: __ Native American Lands:
INJECTION PROCEDURE (briefly descn"be how the injection well(s) will be used)
To o_perate a heat pump for residential heating/cooling/domestic water heater
WELL CONSTRUCTION DATA
( 1) Proposed date to be constructed: CJ( 1 / 1 V Number of borings: j_
Approximate depth of each.boring _ ..... _....,_,....(_feet_):--.--~-&) >
2 Type of tubing to be used (copper. PVC. etc): ______ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes m: (b.) No below)
(a) Yes ___ if yes, then provide-casing infonnation below
Type: __galvanized steel __ black steel__plastic __ other (specify)
Casing depth: From ___ to ___ f.eet (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 X Other (specify) __
(b) Grout placement: Pumping Pressure__ Other __
(c) Grout depth of tubing {reference to land surface): from ___ to
Ifwe11 has casing, indicate grout depth: from ___ to __ (feet)
T
funA
130'
/
141,K,
T
4-4)
5b'
it Ili
i_f-o-ii....
lii rimf---k.
4
p
Lig
1 y
s es —
co'

Ro gers, Michael
From: Rogers, Michael
Sent:
To:
Tuesday, September 14, 2010 4:11 PM
'BOWMAN MECHANICAL'
Subject: Patterson Geothermal well
Attachments: Bowman Mech submitted form.pdf; 5QW Notification Form.pdf
Steve-
We received a SQW Notification. However, there are some deficiencies. I scanned in and attached the form. So, you
would know what I am talking about.
1. The top of the form is blank. In other words there is no indication if it is a SQW, SQM, SA7 etc. I was able to figure it
out though by the questions asked on the form.
2. The names of the property owners were missing on the 1st page.
3. The grout information is missing. I am pretty sure that you will be grouting borings from top to bottom, but we need
the grouting depth for the record. Please provide the grouting depth.
We will go ahead and process this time, but for future submittals, please use the appropriate form with the correct
letterhead and fully completed. Below is the link to the webpage with forms. Also, attached are the SQW forms for your
future use.
http ://portal.ncdenr.org/web /wq /a p s /gwp ro /permit-a pp lications#geothermApp s
Thanks
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://portal.ncdenr.org/web/wq/aps/gwpro/permit-applications
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
1
09/15/2010 15: 55 9197799294
PAGE 01/02
/0014/
MOM=
liensomm Machaninal
11•11.11•11 ServiCeS, Jnr
1111•111M
Mine
111=11111111
ItiekiiivaiVittit.COUTIITIONIEVE.COVOIMIntiSi'•en
145 Technical Court 6 Garner, NC 27529 a {919) 772-2759 Fax [phone]
FAX COVER SHE_ET
SEND TO
,eVe 72e.ivR -Dm) 62_
Attention
M /YE 4. -Ciere-li° 5
From
/4013rEer
Offirv-locadvn •
• Pat Welber
Ofilc4 looston.
Phone Plumber
ri Urgent Real, ASAP ID Mane. =2gnenent Please review 9
6pr ;cif infornsatlen
rote! pages, including cover:
'COMMENTS
ek77-ir-C•
1 1
,f5e-pc
I tie' f fiVp9g Irtn.r).
. ei=tregP.
WI ....... .
kkk
"00,4ate •
RECtivtu DENR / DWQ
Aquifer PrOtection Section
SEP is 2E0