WI0500395_GEO THERMAL_20110719 (2)

Permit Number
Program Category
Ground Water
Permit Type
,.
WI0500395
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Greg Taylor SFR
Location Address
2501 Wrightwood Ave
Durham
0 n r
Owner Name
Greg
Da e s /Events
NC 27705
Taylor
Scheduled
Orig Issue
07/19/11
App Received Draft Initiated Issuance
07/11/11
Reaulated Activities
Heat Pump Injection
Outfall NIJL;_
Central Files: APS_ SWP_
07/19/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Kevin Letchworth
Driller Well
PO Box 1958
Wendell NC
Major/Minor
Minor
Region
Raleigh
County
Durham
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Greg Taylor
2501 Wrightwood Ave
Durham NC
Public Notice Issue
07/19/11
Effective
07/19/11
2759 1
27705
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Greg Taylo r
2501 Wrightwood Av e.
Durham, NC 27705
NA
NCDE NR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
7/19/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0500395
2501 Wrightwood Avenue. Durham, NC 27705
Dear Mr. Taylor:
Dee Freeman
Secretary
On July 11, 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 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 .021 l{u)(2). Additionally, you should contact the Durham 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.Ro2:ers@ncdenr.2:ov if you have any questions.
cc: R al eigh Regional Office -APS
APS Central Files -Permit No. W I05003 95
Durham County Health Dept.
Letco Inc cl/b/a NW Poole W ell Co.
Ev ang elist Service Company
AQUIF ER PROTECTION SECTION
ts•rely, ~ •~
fo r Deb~ V\..(_
Supervisor
1636 Mail Service Center, Raleigh, No rt h Carolina 27699-1636
Location: 2728 Capital Bou levard, Raleigh, North Caroli na 27604
Phone : [phone] \ FAX 1: 919-715~0588; FAX 2: 919-715-6048 \ Cu stomer Service : 1-877-623-6748
Internet: www .ncwateraualitv.o ro
A~ Equal Opportunity I Affirmative Action Employer
None . C .. orth ~aro1.1na
,?vatutall!I
NORIB CAROLINA
DEPARTMENT OF ENVIRONMENT AND NA TlIR{\L RESOURCES
· NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM
TYPE 50 W WELL{S)
In Accordance With the Provisions ofNCAC Title 15A 02C.0200
Print or type the required information <md mail to address on the back page.
DATE : 1-'1 20.!E_ uSCOSl?039 5
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 / Continue completing this fonn.
No ___ Do Not complete this form. Complete other UIC application fonns for installing
either a SA 7 welJ (open-Joop weJI iniecting potable water into the aquifer) or a SQM weJI (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): _________________ _
Gi r\.te G ]:A 'ft., I> ti-
(1) Mailing Address: 2. ~() I W~IGJt1 WOOO ,J.v(,
City: bua.t+~. State: tv C..Zip Code: ~")')O.) County: Pun JJ,/11 t"I
Home/Office Tele No.: °' 15 . l/0 , _ v2s-2-Cell No.:
Email Address: Website:
(2) Physical Address of Well Site (if different than above): ______________ _
City: _________ State: __ Zip Code: ______ County: ____ _
Home/Office Tele No.: ___________ _,,C=e=ll -"-N=o=.:'------------
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 well)
Company Name: ____________________________ _
ContactPerson~=-------------~E=MAil.,===A=d=dres==s~=-----------
Address: _______________________________ _
City: _________ State: __ Zip Code: ______ County: _______ _
Office Tele No.: Cell No.:
Website Address of Company, if any:. ______________ _
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 1
C. WELL DRILLER INFORMATION
CompanyName: Lehu k db4 /Ju }/WR /tk/16>,
Well Driller Contractor's Name: __ T ()./Jte~ A1 · _ ::rOfle.S ~~~----------
NC Contractor Certification No.: z1g3 4
Contact Person: /ltv,~ Ud.-~_____,-1'...,l~t.=----'---E-MAIL--A-d_dres_s_: ---------
Address: 3S't:D {21,/e5<,,i/le gp
City: WerJeU Zip Code: 2'759 / County: _..:.,../J.......=1«=....k ...... e ______ _
Office Tele No.": {c/l 'f ) 2LC,-q(23 Cell No.:
;, ----------
D. BEAT PUMP CONTRACTOR INFORMATION (if different than driller)
CompanyName: £Vlj/lJ<oe,,sr g,L"•Ge C.0 ~~
ContactPerson: ~""" €111:u>fof!c.rs;-EMAIL Address: eu11i"3:t,/1y 0 ~/f~.,J..,.e1--
Address: t I I , € 4-1C f.\ f!lc...~ ~ "a.D
City: t4::(>cr)C'i Zip Code: ~-,n ,3 County: _e_H_ff'T_ll~"~~--------
Office Tele No.: q,.o,_ 3bZ-?8tO Cell No.: 'hJi-21$-?VZZ.
E. STATUS OF APPLICANT
Private: -1!__
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE {briefly describe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: '1 } n../1 I Number of borings: ----=3=-----r ~_?A, Approximate depth of each boring (feet): __ ~u ~.;x.,., ____ _
(2) Type of tubing to be used (copper, PVC, etc): _ ___._y..,Lo=...,_P__:_£ _________ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes m: (b.) No below)
(a) Yes ___ ifyes, thenprovidecasinginformationbelow
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 ✓ Other (specify) _S.'--qtt__,._J ___ _
(b) Grout placement: Pumping )I Pressure__ Other __
( c) Grout depth of tubing {reference to land surface): from 0 to 300 1
(feet)
If well has casing, indicate grout depth: from ·-to ____ (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page2
S. 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 dearly and include 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. 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_„
r--
Signature ot;L apL'l ty Owner/Applicant
c� A•]air
Print os'Cype Full Name and tall,
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signatum 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]
GP'U/UIC SQW Notification of Intent Form (Revised 8/2008) Page 3

Evangelist Service Co.
Apex, UC
6-22-2011
Greg Taylor
2501 Wrightwood Ave.
Durham, NC 27705
Sewer
Easement
Back of
House
❑ ❑
NOT TO SCALE
A
Three 400' boreholes of 1.25: HDPE
pipe. Trenching is 2-3' deep.
AC 26'
AD 36.5'
AE 26'
BC 31'
Biz 44.5'
BE36'
BF 12"
Sewer Easement