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Home My WebLink AboutWI0500377_GEO THERMAL_20110426Permit Number Program Category Ground Water Permit Type WI0500377 I Injection Water Only GSHP Well System (5QW) Primary Reviewer michael. rogers Coastal SW Rule Permitted Flow Facility _ Facility Name (\@f\~ Matthew Staton & d aiFe Simmons SFR Location Address 620 W Cabarrus St Raleigh Owner Owner Name Matthew -oates/Events NC 27603 David Staton Orig Issue 04/26/11 App Received Draft Initiated 04/26/11 Re Qulated Activities Heat Pump Injection Outfall i . !._'. Scheduled Issuance Central Files: APS_ SWP_ 04/26/11 Permit Tracking Slip Status Active Project Type New Project Version 1.00 Permit Classification Individual Permit Contact Affiliation Steve Bowman Contractor Heat Pump 145 Technical Ct Garner Major/Minor Minor Region Raleigh County Wake Facility Contact Affiliation Owner Type Individual Owner Affiliation Matthew David Staton 620 W Cabarrus St Raleigh NC NC Public Notice Issue 04/26/11 Effective 04/26/11 27529 27603 Expiration Waterbody Name Stream Index Number Current Class Subbasin gA NCDENR North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Governor Matthew David Staton Jennifer Claire Staton· Simmons . 620 West Cabarrus Street Raleigh, NC 27603 Coleen H. Sullins Director 4/27/2011 Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System PermitNo . WI0500377 620 West Ca barrus Street, Raleigh, NC 27603 Dear Matthew & Jennifer: Dee Freeman Secretary On 4/25 /2011 , 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 Administmtive 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 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 (919) 715-6166 or Michael.Ro2ers (tV.ncdennwv if you have any questions. cc: Raleigh Regional Office -APS APS Central Files -Permit No. WI0500377 Wake County Health Dept. Brazill Drilling (Bruce Brazill) Bowman Mechanical Services (Stephen Bowman) AQUIFER PROTECTION SECTION 1636 Mail Service Center, Raleigh, North Carolina 27699-1636 Location: 2728 Capital Boulevard. Raleigh. North Caroiina 27604 Sincerely, fo,DQW;ft A·~ Supervisor Phone: 919-733-3221 I FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Customer Service: 1-877-623-6748 Internet: www.ncwaterguality.oru An Equal OpportJnity \ Affirm2'.ive Action Emp loyer One North Carolina "?Vaturall!I NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR) RECEIVED! DEW, DWQ Atltafar Prmtediun Sec on APR 2 5 1011 NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM: TYPE 5-9W WELL(S) In Accordance with the provisions of NCAC Title 15A: 02C.0200, please complete this notification and mail to address on the back page (please Print or Type information). DATE: 4— 2a _ , 20 a♦ H \NTS-- U Q3lfl 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 -low)? 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)/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 w/authority for signature): _ 4y' .5 Rhin , ;Try. _ C!fir Snkur. 6h.f (1) Mailing Address: G 2 0 WeA- L L,o re%di City: 'k2 e i k State: NL Zip Code: 2_1-Gc13 County: wilt KE Home/Office Tele No.: qvc----yen Email Address: fA fir+ e1 (2) Physical Address of Well Site (if different than above): City: State: Zip Code: County: Horne/Office Tele 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 UIC weil) Company Name: Contact Person: EMAIL Address: Address: City: State: Zip Code: County: Office Tele No.: Cell No.: Website Address of Company, if any: GPUIiIIC 5QW Notification of Intent Form (Revised 8/2008) Page I C. D. WELL DRILLER INFORMATION CompanyName: ~ D ~ Well Driller Contractor'~~ D~ NC Contractor Certification No.: .... d&...S.-..... 1 ..... d...,__.__3~-------------------- Contact Person: "x)nua ~ c.ll EMAIL Address: Address: '7/). k)p.ofp, ~ City: }:)ur:rv:r::, Zip Code: (/)C, County: _..,,,j.~0 ...... ~""----'-"''--=~ol-· ____ _ OfficeTeleNo.:qJq L/q'7-J:J333 CellNo.: q,q #45 -3,z'<f'L/ HEAT PUMP CONTRACTOR INFORMATION (if different than driller) Company Name: Bowman Mechanical Services t I_n_c_·-----=----------,--..---.,,...._--=-=---...,.... bowmanmecb anical@b e l1s ou th.net Contact Person_: __ S_t _ep_h_e_n_B_o_wm_a_n ______ ~E=M=A~IL~A~d_d~re~ss~: ___________ _ Address: 145 . Technical Ct• City: Garner Zip Code: 27529 Wake County: _____________ _ Office Tele No.: 919-772-2759 Cell No.: __________ _ E. STATUS OF APPLICANT F. G. Private: V State: Federal: Municipal: __ Commercial: Native American Lands: INJECTION PROCEDURE (briefly describe how the injection well(s) will be used) WELL CONSTRUCTION DATA (1) Proposed date to be constructed: t-/-;? 5.,... / ( Number of borings: _ol ___ _ Approximate depth of each boring (feet):~~"""'"'d""'-'-""""""----- (2) Type of tubing to be used (copper, PVC, etc): t\-D ~ £., (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 V (4) Grout Info (material surrounding well casing and/or piping): (a) Grout type: Neat Cement__ Bentonite Y Other (specify) ------- (b) Grout placement: Pumping~ Pressure Other (c) Grout depth of tubing (reference to land surface): from O to d« 5 (feet) If well has casing, indicate grout depth: from ___ to ____ (feet) GPU /U1C SQW Notification oflntent Form (Revised 8/2008) H. IN.TECTION-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: (I} (2) 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. 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. CtR T IFICATION 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. 1 am aware that there are significant penalties, includin;; the posbility of fines and imprisonment, for submitting false information. I agree to constrict, operate, ma t- n, repai nd if applicable, abandon the injection well and all related appurtenances in accordance with the ap o�ied s .ecii, i ns d.itions of the Permit." weer/Applicant i {4.-1-ti .ti . _54.ua v1 Print or Type Full Naive and title L&iLSfr, nature ofl?roperty Owner/Applicant 11 rCercif �r-,e ss 4 5-1A44 0/1i 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 RECEIVED i O IyR r p� q R Telephone (919) 715-6935 Aquifer F�mieMl�R 5ccfr,�n APR 25 20P GPU/WC 5QW Notification of Intent Forni (Revised 8/2D08) Page 3 r()gi-f'kec,i skew+on Na0 �.J CciVAD4ros • Ai .7)< 4 in Ao-ose— L�Y'Sk C ck \ocArr S • c_ t�- Calbpa4s.:5'C 0 12.5 25 50 Feet 6iMd tootle PIN 1703470183 Real Estate ID 0033814 Map Name 170310 Owner STATON, MATfHEW 0 STATON SIMMONS. JENNIFER C Mailing Address 1 520 W CARARRUS ST Mailing Address 2 RALEIGH NC 27603-1914 Mailing Address 3 Deed Book 11654 Deed Page 1505 Deed Date 1012712005 Deeded Acreage 0.15 Assessed Building $120,678.00 Value Assessed Land Value $190,000.00 Total Assessed Value $310,878.00 Billing Class INDIVIDUAL Properly Description 620 W CABARRUS STREET Heated Area 1284 Site Address 620 W CABARRUS ST City Raleigh Township RALEIGH Year Built 1920 Total Sete Price 5269,000.00 Sale Date 10/2712005 12:00:00 AM Type and Use Single Family Design Style Conventional Land Class RESIOENCE•< 10 ACRES -HOME SITE Old Parcel Number COO1-00004-0026 WAKE COUNTY KOATX CA ROL]NA '��' �' `ate of el'. �. Lis � �Q- 1 College Pl 47 ki Jelo Dri y :[l,l M whip Hih cr �IlI llltllllU IL 4,04 w Nc th'1SzJ t iie'st Hillsborough st i!RE `u: r ugl, W'Hargett:S t-�, ito Mcculloch St AOKI 41, Mr Citcatead Dr pgeton iD on oft arri mew r- •i An Atm sda- i '4E41 JgnJelIs St_= g Sar W Lertoi r St' 1111 emu' 1N'Sou tl1_g t �f 1s AIM 8 'Io H R (AI stsr !IF t, ri 1Ii •. 1 `—JWiane:5t� p � 6 .g — zrs a,f 1 LW Edet+to'rt St—' iJL1[ FT]�Niorg' �n Sty L L L W Davl W'Cabarrus St esterh a/y d I � • 7'o` t ( Mount HOW Gm dent M4.617 LEI lha* kin g Jt ' ,is1 n9tort Pentaly 4 0 400 8110 1600 Feet PIN 1703470183 Real Estate ID 0033814 Map Name 170310 Owner STATON, MATTHEW ❑ STATON SI11 MONS, JENNIFER C Mailing Address 1 820 W CABARRUS sT Mailing Address 2 RALEIGH NC 27603.1914 Mailing Address 3 Deed Book 11654 Deed Page 1505 Deed Date 10/27/2005 Deeded Acreage 0.15 Assessed Building Value $120,678.00 Assessed Land Value $190,000,00 Total Assessed Value $310,6.78.00 Billing Class INDIVIDUAL Property Description 620 W CABARRUS STREET Heated Area 1284 Site Address 620 W CABARRUS ST City Raleigh Township RAT-1=IGH Year Built 1920 Total Sale Price $269,000.00 Sale Date 10/27/2005 12:00:00 AM Type and Use Single Family Design Style Conventional Land Class RESIDENCE-r 10 ACRES -HOME SITE Old Parcel Number C001-00004-0026 WAKE COUNTY m K n LAIMkINA