WI0500332_GEO THERMAL_20110107

Permit Number
Program Category
Ground Water
Permit Type
WI0500332 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Joyce Lewis SFR
Location Address
257 3 Forks Ln
Pittsboro
Owner
Owner Name
Joyce
Dates/Events
NC 27312
0 Lewis
Orig Issue
01/07/11
App Received Draft Initiated
12/08/10
Re g ulated Activities
Heat Pum p Injection
Outfall 1-..l'.Jt l
Scheduled
Issuance
Central Flies: APS_ SWP_
01/07/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Glen Adam Darch
13109 Bold Run Hill Rd
Wake Forest NC
Major/Minor
Minor
Region
Raleigh
County
Chatham
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Joyce 0. Lewis
78 Lauren Rose Ln
Pittsboro NC
Public Notice Issue
01/07/11
Effective
01/07/11
27587
27312
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
ATA,
NCDENI
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Cole.en H. Sullins Dee Freeman
Governor Director Secretary
1, 7i2011
Joyce O. Lewis
78 Lauren Rose Lan
Pittsboro. NC 27312
Subject: Acknowledgement of intent to Construct Type 5QW Injection Well System
Permit No. WI0500332
257 3 Forks Lan_- Pittsboro, NC 27312
Dear Joyce O. Lewis:
On 12/8/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
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 Iong as the
following conditions are met:
1. The injection well system contains only potable water,
?. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 1 SA 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 1 SA Section 2C Subchapter .021 1(uj(2). Additionally, you should contact the Chatham 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.Rocers(Foricdenr.env if you have any questions_
Sincerely,
forOW
Debra Warts
Supervisor
cc: Raleigh Regional Office - APS
APS Central Files - Permit No, W1.0500337
Chatham County Health Dept.
Glen A. Daroh Well Drilling (Glen Dnrch - 13109 Bold Run Hill Rd- Wake Forest. "C 27587)
Bowman Mechanical Se vices (Sieve Bowman -- 145 Technioai Court. Gunter, NC 27529)
AOUIFER PROTECTION SECTION
1536 Mail Service Carrier, R&feign, North Carolina 27699.1636
Location, 2728 Capital Boulevard. Raleigh, North Carolina 27604
PharrL.: 919-73S-3221 l FAX [phone]n585; FAX 2: Si': 715-5048 } Customer Service. 1-877.623-5748
Internet www.ncwaterouallty.erq
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 50W WELLS)
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Print or type the required information and mail to address on the back page
DATE: { ,1
. 20 {�� � cc) < 2_
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes X 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(SyAPPLICANT(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):
II,
(1) Mailing Address:
City: YI ' -5,)70 T 0
Home/Office Tele No.: 1q
Email Address: OA
Li u r ,•' � G�
$ � Zip coat : c 3/c County: C/i di
-• - Ce11 No.:
W ehsite:
(2) Physical Address of Well Site (if different t n above):
City: P1 -4-S r i d
Home/Office Tele No.:
'7 3 6 lk _& .-
State:N C Zip Code: e 7 = 1
Cell No.:
County: c rrld.
E. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the pnaperty owner authorizing Agent to install and operate UIC well)
Company Name: - -
Contact Person: EMAIL Address:
Address:
City State: Zip Code: - County:
Office TeleNo.: Cell No.:
Website Address of Company, if any.
CiPUIt1TC SQ W Notification of lutcnt Form (Revised $12005)
Page 1

C. WELL DRILLER INFORMATION
Company Name:Glen A Darch Well Drilling
Well Driller Contractor's Name: Glen Darcb
NC Contractor Certification No.: 3900A
Contact Person: Glen Darch EMAIL Address:gdwelldrill [e-mail]
Address: 13109 Bold Run Hill Road
City: Wake Forest Zip Code: 27587 County: Wake
Office Tele No.: (919) S56-5959 Cell No.: [phone]
D. HEAT PUMP CONTRACTOR INFORMATION (if different tllan driller)
Company Name:Bowman Mechanical Services Inc
Contact Person: Steve Bowman EMAIL Address:·bowman [e-mail]
Address: 145 Technical Ct
City: Gamer Zip Code: 27529 County: Wake
Office Tele No.: (919)-772-2759 Cell No.: (919) 427~1425
& STATUS OF APPLICANT
Private: X Federal: Commercial:
State: Municipal: __ Native American Lands:
F. INJECTION PROCEDURE (briefly descn'be ·how 1he injection well(s) will be used)
To o perate a heat pump for residential heating/cooling/domestic water heater
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: 11 { lJd ) 0 Number of bo~: :;)__
Approximate depth of each boring (feet): __ * ..... 50~---
2 Type of tubing to be used (copper. PVC, etc): RE 3408 polythylene
(3) Well casing. Is 1he 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 _____ feet (reference to land surface)
Casing extends to above ground inches
(b) No X
( 4) Grout Info (material SUff'Ounding well casing and/or pip.Ilg):
(a) Grout type: Neat Cement__ Bentonite X Other (specify) __
(b) Grout placement Pumping_X Pressure__ Other
(c) Grout depth of tubing (reference to land surface): from J.~ to .E._
If well has casing, indicate grout depth: from ___ to __ (feet)
f. 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.
I. 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, sirens, 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 tnue, 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 oonditiuus of the Permit"
Jr- �'6 94`u .d r_T
Signature of Property Owner/Applicant
O'c)/I f e 0, Lie•-. 1.t Is
Print or Type Ftd1 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-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
OPU/UIC 5QW Notification of Intent Form (Revised S/2OO$) Page 3

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