WI0500438_GEO THERMAL_20111021

Permit Number
Program Category
Ground Water
Permit Type
WI0500438 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Manjusri Chatterjee SFR
Location Address
114 Saybrook Dr
Cary
Owner
Owner Name
Manjusri
Dates/Events
NC 27518
Chatterjee
Scheduled
Orig Issue
10/21/11
App Received Draft Initiated Issuance
10/05/11
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files: APS_ SWP_
10/21/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Joshua Niles Robertson
Driller Well
8228 Kerr Chapel Rd
Elon
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Manjusri Chatterjee
Owner
114 Saybrook Dr
Cary
NC
NC
Public Notice Issue
10/21/11
Effective
10/21/11
27244
27518
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NA
MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Manjusri Chatterjee
Swadesh Chatterjee
114 Baybrook Dr.
Cary, NC 27518
Coleen H. Sullins
Director
10/21/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0500438
114 Baybrook Dr.
Cary, NC 27518
Dear Mr. Chatterjee:
Dee Freeman
Secretary
On 10/05/2011, 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:
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 .0211(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.Ro !!ers(a mcdenr.eov if you have any questions.
cc: Raleigh Regional Office -APS
APS Central Fiies -Pem1itNo . ~~I0:50 043 llt
Wake County Health Dept.
,:£Z'.~\Jl,_i~
for~ a Watts
Sup~or
Joshua Robertson (Triad Drillers, 8228 Kerr Chapel Rd., Elon, NC 27244)
Tom Paonessa (Warren Hay Mechanical, Inc., 214 Millstone Dr., Hillsborough, NC 27278)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwateraualitv.oro
An Equal Opportu:1ity P.ffirmative Ac1.:ion Employe~
None, C .. ortn ·arouna }vatura//t,t f . tJ
3,4311a5/281q 159:4s
9197328660
WARREN HAY
PAGE 81/05
214 lvt sore give
Hillsborough NC 27278
Ph: (919) 72-4,352
Fax: C219) 732 ]
Fax
Warren -Hay
Mechanical
Contractors, Inc.
Fa= G Lo % ( pages: e
% -3 / + WI/
© Urgent ❑ Few Review © Please Gar meet 1:3 Please Reply I! Plea sta Recycle
I'
Pleazx--
o w/
RECEIVED 1 DENR / DWp
Aquifer Protection Section
OCT 05 2011

I0/b5/20Ii 09:48 919732865e WARREN HAY
1050D(13Y,
AGE 0205f
NORTH CAROLJNA
DEPARTMENT OF Et3VMONMENT AND NATURAL RESOUR
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-J OOP.GEk THERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE SOW WELLIS
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Prirrr or type the required information and mail to address on the bark page,
DATE:
20 M
Well Type Confirmation: Does the proposed system circulate potable water only' (np additives) in
nti mous piping that completely isolates the fluid from the environment (Le.
ifCOfltt�ll
completing
Yes this form.
No Do Not complete this form. Complete other UIC application torms 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 auti£rccie or corrosion inhibitors):
A. PROPERTY OWNER(S)!API'LICANT(S)
List. each Ptvperty Owner listed on. property deed Of owned by a business or government agency. state name of
entity and a representative wlauth,otity for signature]:
IYIa v r i Swro.��5�'► Cln�. +
�r'. (EUS
(I) MAiiiriE Address: J/q g O •
City: State. " Ip Code: 7 j 7 g County:4-4
Tele No.: Cell N , ^' 7 L�i
Home/Office � -
Email Address'
Website:
(2) Physical ,Address of Well Site (if diffcrottt 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 not own the subject property,
attach a'letter from the property owZter authorizing Agent to install and operate UIC v�ell)
Company Name:
Contact Person: EMAIL Address:
Address_
City: State: Zip Code: County:
Office Tele No,: Cell No.:
Websitc Address of Company, if any
OPUIt71C 5QW Notitcatian of intent Form (Revised 812AIO8)
k-tiVED / DEN/ D Aquifer Protacion S
OC T 0 5 Section
2011
Pagel

10195/201F1 09:48 9197328660
WARREN HAY
PAGE 03/05
C. WELL DRILLER INFO ATION
Company Nam: rZ 1
Well Driller Contractor's Name:
NC Contractor Certification No
Contact Person:
Address:
City: 7 —
Office Tele No.: 3 1 2'1 • CtlI No_: 3 3 - S3 - .27.
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:
Contact Person:
'MA t 4}
d. Lice
Lox/ Zap Code: P-12. L 'aunty: ' elms
Address: 2 '( in/k'f/14 40 • r1�']- i
City. '1//if e 2 4� ip Code: „ ;aunty: &2
Office Tele No.: 9l4�� - y3� ell No.: ql q� d i P
E. STATUS 0
Private:
State:
PPLICANT
Federal:
Municipal:
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(S) will be uses_
3; / +
G. WELL CONSTRUCTION DATA (1) Proposed date to be constructed: /49 6j
Approximate depth of each boring (feet):
(2) Type of tubing to be used (copper. PVC, etc):
Number of borings: S
(3) Well easing. Is the well(s) cased? (check either (a.) Yes 21 (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 hand surface)
Casing extends to ve ground inches
(b) No
(4) Grout info (material surrounding well casing and/or piping): j (a) Grout type: Neat Cement_ BentOnite Other (specif)i)
(b) Grout placement: Purnpiria Pressure Oth . f
(c) Grunt depth of tubing (r .ference to land surface): from to (feet)
If well has casing, indicate grout depth,: from to (feet)
GPUNIC 5017 Notification of Intent Form (Ikhrised 6.2OO )
Page 2

10/05/2011 09:40 9197328660 WARREN HAY
PAGE 04/05
tTt. 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 rnanufactuxet'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, sur:ace water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed w0ll(s) and
any existing wells) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal beat 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.
CERTIFICATION
Note: This Permit Application must he signed by each person. appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that l have personally examined and am f irn.iliar with the informal ort
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, repab, and if applicable. abandon the injection well and
all related appurtenances in accordance with the approved specifications and condition. of the Permit-"
Signature of Property Owner/Applicant
e ~
Print or Type Full Nam and title ja
Signature of Property Owner/Applicant
Print or Type F. , Nature 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-U1C Program
1636 Mail, Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPTJ/UIC 5QW Noeifcation of Intent form. (Revified 8t OOs)
RE«!Efl I fl�tin 5�Dc�i
mECti tent rrP rotepp 4
V CI A 6 now
Page 3

10105/ 2015.L 09: 48
9197328660
WARREN HAY
PAGE 05/05
RECEIVE131-DENR r eltt
Aquifer Protection Section
OCT 05 2011