WI0500302_GEO THERMAL_20101021

Permit Number
Program Category
Ground Water
Permit Type
WI0500302
Central Files : APS_ SWP_
10/21/10
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
920 Split Rail Lane
Location Address
920 Split Rail Ln
Hillsborough
Owner
Owner Name
Tim
Dates/Events
NC 27278
Albaugh
Orig Issue
10/21/10
App Received Draft Initiated
10/12/10
Re gulated Activities
Heat Pump Inj ection
Outfall
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
Billy Clayton
4137 Moores Mill Rd
Spencer
Major/Minor
Minor
Region
Raleigh
County
Orange
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Tim Albaugh
920 Split Rail Ln
Hillsborough
VA
NC
Public Notice Issue
10/21/10
Effective
10/21/10
24165
27278
Expiration
Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governo r
Ti m Albaugh
920 Spli t Ra il L ane
Hi ll sboro ugh. N C 27278
•~A s_,,,1.~•
~CD ENR
North Carol ina Departme nt of Env ironmen t and Natural Resources
Div ision of Wate r Quali ty
Coleen H. Su liin s
Directo r
10/21/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0500302
920 Split Rail Lane, Hillsboro ugh. NC 27278
Dear Mr. Albaugh:
De e Freema n
Secreta ry
On 10/12/2010, 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 comple~ely 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 15A Section 2C Subchapter .021 l(u)(2). Additionally, you should contact the Orange County Health
Department as the y 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 M ichael.Ro !rnrs@.ncdenr . Qov if you have any questions.
Sincerely,
0~ ~
cc : Ralei gh Regional Office -APS
APS Central Files -Permit N o. WI0500302
Orange County Health Dept.
f'm· Debra Watts
Supervisor
Aquadrill (Billy Clayton) 4137 Moore Mill Rd, Spencer, VA 24165
Boer Brothers (Brian Boer) l 13 e. Union Street, Hillsborough , NC 27'278
AQUIFER PROTECTIOt~ SECTIO ~;
1636 Mail Service Cenier, Raleigh , North Carolina 27699-1636
Locaiion: 2728 Capital Boulevard, Raleigh . North Caroiina 27604
Phone: [phone] IFAX 1: 919-715-0588; FAX 2: 919-715-6048 \Customer Service: 1-877-623-674 8
Inte rn et: www .ncwatera ual ity.org
An Equ~I Opport'rn ity I Affif'lla'ive i\c•:on Employ~,
Ni~ih Carolina
!Vatural~I/
Oct 12 lO O9:18a Lothridge Plumbing 3363572951
p.2
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE SOW WELL4S)
In Accordance With the Provisions of NCAC Title 15A 021021200
Print or type the required information and mail to address on the ball` page.
DATE: October 8, 2010_ r—) (_ ' r l .-3
Well Type Confirmation: Does the proposed system circulate potable water onh• (no additives) in
continuous piping that completely isolates the fluid from the environment (Le.
closed -loop)?
Yes JC 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)/APPLICANT(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): Tim Albaggh
(1) Mailing Address: 920 Split Rail Lane
City: Hillsborausth State: NC Zip Code: 27278 County:
Home/Oilice Tele No.: 919-451-7328 Cell No.:
Email Address: :2b u;:ii:z; Website:
(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 n 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.

Oct 12 10 08: 18a Lothridge Plumbing 3363572951 p.3
C. WELL DRILLER INFORMATION
Company Name: A quadrill
Well Driller Contractor,s Name: _B_i_ll_v_C'-l=ayt~on _______ B~ry~an_L_ill~e~v _________ _
NC Con1ractor Certification No.: -~2=2c...c4=l~A=-----------=28=3:..;;9-'A'-"------------
Contact Person: Billv Clavton EMAIL Address: [e-mail]
Address: 4137 Moore Mill Road
City: Spencer. VA Zip Code: _____ County: __ H~emv~---------
O.ffice Tele No.: ____ Cell No.: _2-9931 ______ _
D. REA T PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: __ ~B=oer=~B="=oth=ers~--------------------
ContactPerson~= ~B=a=·an~Boer~~---------~E=MAIL===A=d=dres=s=: __ ~boe~rn~ro~th=ers=@--=.nn.=rr=·=co=m
Address: -------'l=--=0'-'-4-=R-=H=wy--=-54-=---a..W'-#"--=-33=--=3'--____________________ _
Address- 104 R Hw. 54 W E 333
City: Carrboro, NC Zip Code: 28514) County:
Office Tole No.: 919-929-9886 Cell No.: 919-619-8477
E. STATUS OF APPLICANT
Private: X Federal:
State: Municipal:
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe bow the injection well(s) will be used)
Closed loop water only for heal numn
G. WELL CONSTRUCT1ON DATA
(1) Proposed date to be constructed: Nnrnbcr of borings: 2
Approximate depth of each boring (feet): 220"
(2) Type of tubing to be used (copper, PVC, etc): _HDPE
(3) Well casing. Is the well(s) 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 _X_ Other (specify)
(b) Grout placement: Ptunping Pressure Other
(c)
Grout depth of tubing (reference to land surface): from 220 to _4 (feet)

Oct 12 10 08:16a Lothridge Plumbing 3363572951 p.4
fl, 1INJF£TION-RELATEi] E:QUI1P,MENT
Attach a diagram.. sIw - in;, the erigineerin.. 1ii}itut or proposed modification of the injection rit.lipntem and exterior
piysiiteznubing associated with Luz iIIIcet.on Operation_ nut n1aitllractu 't.w ti brochure Iii:s• provide MipplCartcnlary
in!'nFinal Oft.
I. 1.00ATION OF W E 1. 14S 1
Attach tvo capie, ur intip.s showing the to?lct►►iota: information:
rII
[2i
litchidr a Site Map real) he dra►►n1 slowing: Intilitint2.1c.. propetiv ►hire iu:ilie potential
sources or groundwater contamination and the orientation of and distances lzeluCcu the proposed 14,ellta) art►1
and tin . ►■•en(S1 or ►■aids" distuisal facilities such as septic tanks or drain Ii-.Ads toasted within 200 lies of
the geothermal heat pump well sl';tent. Label ail Features clearl) and iltrlti It a milli arrives..
The Sity I11arr must slitm ilia- suhiL-c property in relation to the surroulullirg area by using at leas: two Iiixoi
rclirence points sucIi 4, roads. s[re;ln►s_ anij!►,r I[i=elma} intersections.
1 ('ERTiFiCAIION
Note: This Permit AppIic'ation miss1 be signed b'i trcb p rsori at>'ponring on alit
recorded legal property deed.
" 1 hereby cer[ifi, under I,wna1i) of I:iu . that I ha+e Iei.c mill} examined and am lamiiia: uilh the information
submitted in tali, document and :ail attticllitle;ils thereto arid that_ based on tn) inquiry of those :ridititkm1y.
imn1edia[el► reilnmsible For ohtziinine said inlim7n;atiun. I believe that die intones:tiiutt [roc.'izc:urate oral ci mnleIe.
! eon aware that there are tzi iliiicalu penalties. including the ps►-sihilil► of tales :ind intpri.nnl,Ieztt- f+a submitting
false information_ 1 amrce to construct. operate. maintain. repair. and if applicable. abandon the injeciion well and
all rrlaied appurtenances ill accordance with the approved spccilir:attinns trite conditions of the Pirriiil.
.J
Signature of Prl►pe .i OOwrier'App1lkant
Timothy John Albaugh
Print or T pc Full Name at id title
Signature of Property U►►•ner,Appiicant
Print or l ►pe Full Name and side
tie isaturr [+f.ltithorixeai Agent. it';an)
Print or Type roll N.nite and tint
Please return two copies of the con tpleteil Application atiiln paekaue to:
North C iroii([a DE;NR-DWI)
Aquifer Prsfttttiort Section-UIC Program
I.636 Masi Service Center
Raleigh, NC' 27699-1636
Telephone (9I91733-3221
til'[t'11t: 5011 Zed;Ike;:iian' flItrill:arna[Rx►i,,..cill'inl'li

Oct 12 10 08:18a
Lothridge Plumbing 3363572951
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Oct 12 10 08:17a
Lothridge Plumbing
3363572951 p.1
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25 Years of Quality Service
Dear Sir or Madam,
Lothridge Plumbing, Inc.
To :
Company : _NCDENR
Sent By : _Tina Yates
Date : October 12, 2010
Time :
*of pages including cover : _5 pages
919 715 0588
Cover sheet only :
Following is a Type 5QW Well application for processing. Thank you for your
attention to this matter.
Sincerely,
Tina Yat
Comptroller
Po Box 249
Linwood, NC 27299
Phone: [phone]
Fax: [phone]
Email: [e-mail]