WI0500362_GEO THERMAL_20110328

Permit Number
Program Category
Ground Water
Permit Type
WI0500362 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facili V
Facility Name
Larry Scott Loftin SFR
Location Address
2700 Southwinds Run
Apex
Owner
Owner Name
Larry
Dates/Events
NC 27502
Scott Loftin
Scheduled
Orig Issue App Received Draft Initiated Issuance
03/28/11 03/08/11
eg ul ated Activities
Heat Pump Injection
Pri vate residence, single family
Outfall NULi..
Central Files: APS_ SWP_
03/28/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Larry Scott Loftin
Owner
2700 Southwinds Run
Apex
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Larry Scott Loftin
Owner
2700 Southwinds Run
Apex
NC
NC
Public Notice Issue
03/28/11
Effective
03/28/11
27502
27502
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
03/28/2011
Larry Scott Loftin
.loan Taylor Loftin
2700 Southwinds Run
Apex. NC 27502
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10500362
2700 Southwinds Run
Apex, NC 27502
Dear Mr. and Ms. Loftin:
On 03/08/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onl•
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:
l 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 15A Section 2C Subchapter .021I(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.Ro2ers + ncdenr.gov if you have any questions.
Sink. eiy,
for Debra Watts
Supervisor~
cc: Raleigh Regional Office - APS
APS Central Files - Permit No. WI0500362
Wake County Health Dept.
Bruce Brazi]1 (Brazil] Drilling, Inc., 72 Wester Way, Bunn, NC 27508)
Stephen Bowman (Bowman Mechanical Services. Inc.. 145 Technical Ct., Garner. NC 27529)
AQUIFER PROTECTION SECTION
1536 Mall Servim Center. RalerZh, North Carolina 27699-1636
Locarbn:2728 Capita! Boulevard. Raleigh, North Carolina 27604
Phoric 915, 735-32211 FAX f:919.715-0568: FAX 2: 919-715-6048 Customer Service:143 7-bn-674a
merrier www,nomaterquaiitv.011
co-i I fiDdrrer' -Amur^n 4'-, :r cr r=mo!irsri
N orthCarolina
„ Vaturall

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELL(S)
In Accordance with the provisions ofNCAC Title iSA: 02C.0200, please
complete this notification and mail to address on the back page (please Print or Type information)_
DATE: 3 • 1 , 20 f J
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,
closcd-1oo1)?
Yes )1 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): _ 1- tr+ )CA-t (k rL, J oar,
"f c, LaJ _, - �O-( i►�
(1) Mailing Address: 00 SoI.L4Ni 1 ads I,(n
City: ` ; . State: NJ dip Cade: = 5 County: i
Home/Office Tele No.: o 1 l — 391 — 3403 Cell No.:
Email Address: Website:
(2) Physical Address of Weil Site (if different than above): .,::larYNe--
City: State: Zip Code: _ County:
Home/Office Tcle No.: 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 U1C well)
Company Name:
Contact Person: EMAIL Address:
Address:
City: State: Zip Code: County:
Office Tele No.: Cell No.:
Website Address of Company, if any:
GPUIUIC 5QW Notification of intent Fonn (Revised 8/2008) Paee 1

PAGE 02/02 02/15/2011 08:45 9197799294
C. WELLDRlLLERINJrO~ATION~~/ j
Company Narne; __ -..'/~-=..:"-'-:i+=~F---.c-,"-"":c=..:~:::.;;::::-.-_-,__..:#f1-l_.._,_,i==---.;=---
We;ll Dritler Contractor's~ ~ -------
NC Con1raolor ~onN: d7a-3 t=~ ~·
Co-t Per.;on: ~~ BMAlL Add ;,,..Jf,.I!ht,£-2 t!&Y--
Address: :-J/J. c,./~.l:---1c::: . ?✓ ~< .
City: ~~ Zip Code: J/ (Y, County: ,£4,:.;~~
Office Tele No.: 9./9_-t-/94: e!J5&:3 Cell No.: qJ g,-!-/9,=2--37¥'~
D. HEAT PUMP CONTRACTOR INFORMA UON (if different than driller)
CompanyName: :6mnnan Mechanical Services_,. Inc:.
· . bowmamnecn an:tcal ~b e llsouth.net
Contact Person: Stephen Bowman EMAI L Address~
Address: 145. Technical Ct•
27529 Wake City'. Garner · Zip Code: ____ Co\lnty: ___________ _
Office Tele NQ.; 919-772-275 9 Cell No.: ----
E. STATUS OF APPLICANT
Fedetal: Commercial: Private; L
State: Municipal: __ Native American Lands: ~
F. INJECTION PROCEDURE (briefly describe how the injection wett(s) wHl be us~d)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed; _______ Number of borings; _ _,J._ __
Approximate depth of each boring (feet): 30 Q
(2) Type of tubing to be used {copper, PVC. etc): //v, r!_.
(3) Well casing. Is the welJ(s) casedY (check either(a.) Y~ ru: {b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: ___galvanized steel _blaek steel__plastic_other (specify)
Casing depth: From ___ to ___ feet (reference to. land surface)
Casing extends to above ground __ inches
(b) No /.
(4) Grout Info (material surrounding weft easing and/or piping): /
(a) Grout type: Neat Cement__ Bentonite ~ Other (specify) ______ _
(b) Grout placement; Pumpin~ Pressure_
(c) Gn:,ut depth of tubing (reference to land surface): 'from
Other
12-~, -l D () (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPtJ/UIC 5QW Notification oflntent Form (R.,.vi• .. A vnMo,
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
information.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(I)
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, 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. 1 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."
L4Iis �r
Signature Property Owner/ pplicant
Print or Tlpe Full Name and title
f1 AOAryi
Signatu e of Property Owner/Applicant.)
ti} oart -1-0Lilor
Print or Type Full Narne :end 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]
GPU/U1C 5QW Notification of Intent Farm (Revised 8/200g) Page 3

ace
5—YerT—,Q 4PAL
ti

fo L1411.
51(1)t,6-W r
-L-
6/711-