WI0500501_GEO THERMAL_20120405

Permit Number WI0500501
Program Category
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Robert Keith Daniel SFR
Location Address
2607Willis Ct
Wilson
Owner
Owner Name
Robert
Dates/Events
NC 27896
Keith Daniel
Sched u led
Orig Issue
04/05/12
App Received Draft Initiated Issuance
03/15/12
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files: APS_ SWP_
04/05/12
Permit Tracking Slip
Status Proiect Type
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
John H. Boyette
1109 Nash St Nw
Wilson
Major/Minor
Minor
Region
Raleigh
County
Wilson
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Robert Keith Daniel
Owner
2607Willis Ct
Wilson
NC
NC
Public Notice Issue
04/05/12
Effective
04/05/12
27893
27896
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
/rile
NCDEWIR
North Carolina Department of Environment and Natural Resources
njuicFnr of tiA/9t:yr OtrAitv
04/05/2012
Robert K Daniel
2607 Willis Court
Wilson, NC 27896
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Puri -nit No. WI0500501
2607 Willis Court
Wilson, NC 27896
Dear Mr. Daniel:
On 03/15/2012, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onl'f
geothermal injection well system for the operation of a ground -source beat 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 Wilson 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.
Si r cerely,
for Deb
Supervis'
cc: Raleigh Regional Office - APS
APS Central Files - Permit No, W10500501.
Wilson County Health Dept.
r1r 11,1 • r.. tt r: }. i,,, '.•r . -I- 111A
jr 1 �Y =;IN
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Raleigh, Noah Carolina 27699-4636
Locatnn: 512 N. Salisbury St, Raleigh, North Carolina 27604
Phone: [phone] I FAX: [phone]
lntemet: www.newaterpmaiitv.or -
North Carolina
An Egad Opportunity i Affirmative Ac[icn Employer

02/20/2007 17:45 FAX [phone] $0YETTE WELL
t4i 001
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A VlaQS.ED-LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5QYV WELL(S)
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Print or type the required irfarrnarion and mail to address on the back page.
DATE: _)thrc 1 fir , 10 ha
Well Type Confirmation: Does the proposed system circulate potable watef 921y (no additives) in
continuous piping that coinpletehi isolates the fluid from the environment (i.e,
closed -loop)?
Yen; / Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well ( r' -loop well injuring potable water into the aquifer) or a 5QM well (closed -
loop well containing additive such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List a ok Property Owner listed on property deed (if owned by a business or ❑vernrxtent a ncy, state eme
or entity and a representative wtauthority for signature): f 'rtt r we : vor*1 c� A IG,
(I)
Mailing Address: io i 1 \i,S
City: LL)11 - i State: MC.Zip Code: r -idle County: lg-Zl..Sdn
Home/Office Tele No.; s r� -c39'�• -):12LQc.3 Cell No.((5)-' LL % - : Vpt. r
Email Address: Website:
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code: County:
Horne/Office Tele No.: Cell Tin.:
A. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant doeuot own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name•
Contact Person: EMAIL Address:
Address:
City: Stare: Zip Code: County:
Office Tele No.: Cell No,
Website Address of Company, if any:
RECEIVEDIDENNIOWQ
MAR 15 201Z
Aquifer Protection Section
CPUPUIC 51:2W Notification of livteat Form (Revises! 8/2068)
Page 1

02/20/2007 17:45 FAX [phone] BOYETTE WELL
LI 002
B. WELL DRILLER NFORMATION
Company Name: tC l?
Well Driller' Contractors Name: Et-1 r.
NC Contractor Certifi ' tion No.:
Contact Person: ��-.. h
Address: P
City: r Zip Code: 3 County: 4'6o--
Office Tele No.: 3 7-3,, x Cell No. (l& ) 4 T —D4 / z
C. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: 4, ,r P vm4i#75 f GarStarc.
Contact Person, /f Fth•n►��r l EMAILA¢d ss: ?MfIf �►,V��i .
Address .51 7 Air Ae /3/4
City: ► ,Serr /('G Zip Code_ Or P4 County: _ 14/,Zr 4
Office Tele No.: 23,4,•A37-5T7r Cell No.:,A5,-31S`C3tY
D. STATUS OF APPLICANT
Private: Federal: Commercial:
State: Municipal: Native American Lands:
RECEIVED/DENRIDWQ
MAR 1 5 2012
E. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONSTRCUCTION DATA
(1) Proposed date to be constructed: 01.4L j712OSZNwilier of borings: L4
Approximate depth of each boring (feet): 3 �
(2) Type of tubing to be used (copper, PVC, etc): lao� i„
(3) Well casing. is the well(s) cased? (check either (a.) Yes (b) lot )
(a) Yes if yes, then provide casing information be ow
Type: r3elvanized steel black steel plast44 other (specify)
Casing depth: From to feet (reference to land surface)
Casing extends to above ground inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping): 4-60 (6 4- S Ji
(a) Grout type: Neat Cement Bentonita V Other (specify)
(b) Grout placement: Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from-3 55 to ~ (feet)
If well has casing, indicate grout depth_ from to (feet)
N, 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 soritaminatiaii and the orientation of and distances between the proposed welt(s) and
any existing well(s) or waste disposal facilities suuh as septic tanks or drain fields located within 20D feet of
the geothermal heat pump well system. Label all features clearly and include a north+ arrow.
GFURJLC SQW Notification of tnton Form (Revised B/2008) rage 2

02/20/2007 17:45 FAI 2522930955
BDYEUE WELL
Lict 003
(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 road streams, and/or highway intersections.
J. CERTWI.CATION
Notes 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, 1 believe that the information is true, accurate and
complete. 1 am aware that there are significant penalties, including the possibility' of fines and imprisonment, for
submitting faise information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection.
well and all related appurtenances in accordance y 'th the approve} speeificaticy and co Mons of the Permit."
Signature of Property Owner/Applicant
Atfar,71
Print or Type Full Name and title
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Foil 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]
RECENEDIDENRIDWQ
MAR 1 5 2012
Aquifer Protein Section
GU/WC 5QW Notilicatiott of intent Form fRevisrd $n008)
Psao 3

02/20/2007 17:46 FAX [phone]
BOYETTE WELL
4004
t
�►(E,5 CL
t..
RECE(VED1DENWDINQ
MAR 15 2[]IZ
Aquifer Protection Section