WI0700073_GEO THERMAL_20041215

.:: Mary Lee and Daniel Wilkerson
111 Oakdale Drive
Moyock, NC 27958
December 15, 2004
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
RE: Notification of intent to construct Type 5QW injection wells
Dear Mr. and Mrs. Wilkerson:
In accordance with the notification you submitted to the Underground Injection Control (UIC) Program
on December 14, 2004, we acknowledge your intent to construct [6] closed-loop geothermal water-only
injection wells for the operation of a ground-source heat pump. The system as described in your
notification is deemed pem1itted by rule (North Carolina Administrative Code Title 15A: 2C.021 l(u)(2))
and will not require an injection well permit from the state, but you should check with your county
health department prior to constructing the system because they may have additional constmction or
,:. permitting requirements for this type of system. If you modify your system at any time, including the
addition of antifreeze, corrosion inhibitors, or any other substances to the circulating fluid, you must
contact the Aquifer Protection Section to verify compliance with applicable rules.
Thank you for submitting this notification. If you have any questions regarding geothermal heat pump
wells or injection well rules please contact me at [phone] or Evan Kane at [phone].
cc: David May, Washington Regional Office
UIC-CO files
Aquifor Protection Section
Internet: http://h2o.enr.statc .nc.us
1636 Mail Service Center
2728 Capital Boulevard
Best Regards,
Thomas Slusser
Hydrogeological Technician II
UIC Program
One N.pflhCarolina
;v11t11ml/y
Raleigh, NC 27699-1636
Raleigh, NC 27604
Phone [phone] Customer Service
Fax [phone]
Fax [phone]
An Equal Opportunity/Affirmative Action Employer -50% Recycled/10% Post Consumer Paper
03/18/200,1 13: 4 919-715-0588 H DE,ShI IOATER t UAL
PAGE 02
J`'I��
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT ANEJ NATURAL RESOURCES
NOTFF CATION OF INTENT TO CONSTRUCT A CLOSED -.LOOP
GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
In Aaca dance with the provisions of NCAC Title 15A: 02 C.02OO
Complete application and mail to address on the back per.
This is gjthe proper torca to be used for injection wells in an oxen Ioon geothermal system -
Do
not ut : this form for systems that circulate any subsi nsrthe than w tee.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: i —ism - , 20 ❑ 5�
A. SYSTEM CLASSIFICATION Duey the proposed system circulate parable water in continuous
piping that completely isolates the fluid from the environment?
YES
Xif yes; then continue eotnplenug this form_
NO If no, do not complete Ibis form. Form GW-57 EP Application For
Permit To Const+uct4ndlOr USE A Welk(s) For injection With A Feat
P irnp System, should be complete&
Ei. SYSTEM FLUID Will any additives be introduced to the system's aircuIattng heat transfer
fluid? This includes, but is not limited to contagion inhibitors and/or antifreezes.
YES
If yes, do not complete this form. Form GW-57 HP, Application For
Permit To Construct Andi&r Use A Wellt's) For Injection With Heat
Furnp System, should be completed-.
NO _ if too, then continue completing this form.
C. PROPERTY OWNER.
Name: 11r:1, (4 !i't44+2_-I
Ver.3r01
1
Address: , ; ; r ? r: Ol
City:te., ;at fi lo,yvc K State: N.C. Zip Code: Z` 5"L
County 7 C:11��? �� Telephone:
STATUS OF PROPERTY OWNER
Private: ( Federal: Comme7rcial:
State: Municipal: Native American Lands:
GWATIC-57 CL. Page 1 of 4

03/18/2004 13:44 919-715-0588 NCDE&NR/i . .JATER QUAL PAGE 03
E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Fede~ State, Mnnicipal or Commercial).
Name of Business or Facility: _________ ~-----------
Address: __
City: -~------State: __ Zip Code: ____ County: ____ _
Telephone: · Contact Person: ___________ _
Standard Industrial Code(s), SIC, which describes commercial facility: _______ _
F. HEAT PUMP CONTRACTOR DATA
Name: G, Ider .S le.e.lt'.e &0¥? $ \.J1;,4 TAic.
Addn:ss: ;L(pS:..i ::J:":f t>u'.:\N Rw e.r Re\..
City: C ~f:Sll tF: A k \c:.,. S1ate: \/4....._ Zip Code: :2-33,:i,e County: ____ _
Telephone{ 7$7) Nil, I-:ZB le 7 Contact Person: 1:1.,A(luJ a€, ::IA k E
0. CONSTRUCTION DATA (check one)
'
EXISTING WELL(S) being proposed for use as a ground--coupled heat pump
well(s). Provide the information in (1) through (3) below to the best of your
.knowledge. Atta.ch a copy of Form GWftl (Well Construction Record) if
avwla.ble.
PROPOSED WELL(S) to be constructed for use a6 a ground-coupled heat pump
well(s). Provjde the infoffl'lation in (l) through (:3) below as PROPOSED
construction specifications. Submit Form GW-1 after COl18truction.
(1) WellDrillingContractor'sName: ?.G:, W EST rrc, _ vJ ts-r v-l r+T&,gw~u .. ()Q.1Lc.1'iJ
NC Contractor Certification number:--=:;:l.....;;;...=S;,_,;;;~--2:------=::;"--------------
Date to be constrUCted: /2 -,-a '-I Number ofboring:s: __ G,_,___ _____ _
Approximate depth of each boring (feet):___,,:1-=a=o:..._:_F..:.-r ___________ _
{2) Well casing: Is the well(~) cased?
(a) YES If yes, then provide the C8filllg information below.
Type: Oalvanized steel_ Black steel __ Plastic __ Other (specify) ____ _
Casing depth: From ___ to ___ ft. (reference to land surface)
Casing extends above ground ____ inches
(b) NO _19_
(3) Grout (grout the vertical le.o.gth of the borehole to a n::rinimum depth of20 feet b.Ls.):
(a) Grout type: Cement__ Bentonite __ Other (specify) ______ _
(b) Grouted surface-and grout depth (reference to land s'Urface ):
Varound closed loop piping; ttom O to :loo (feet).
-around ~u casing; from --to -(feet).
NOTE; THE W'a..J,.. :OlULLINGCONTRACTOR CAN SUl'PLY Tim DA'l'A FORB!THBR EXlSTlNG OR
PROPOSED WELLS 'tJ' lltlS INFORMATION JS UNAVAILABJ..E BY OTHER. MEANS.
Vcr.3/01 GW/u"IC-57 CL Pa,gc2 of4
lc■uo��x IDM 14:0D rhS fa/10141)0X
DEC --OE -2004 1 J : 24
ay11Qer teeve
UA. MACH TECH CENTER 757 422? 55F P.02
Fa
uui
12 13159
e 1a3t12e0, 23:44 919-715-859a
saes./ ate GIAL
Amrr a dwirn ig uss Alin Wow a1`
iMOrcull with the isdageloo gglowariaa. Mill trdraar d %WIMP coypra 1arwiriligata,.
iiaied
L LOCATION OF 'MUM And& 1"
() faaiah a Nita S [ter. ipe 4ip ihosizis , prupeaeg►iria+i Ni
,pixecom4 aawra vamodoweeleOOZOIOrielidelk tho adenzioloi Druid
eivE procesol w►tli[p) oxd say Whew ems) aerwsmrawn.' Inapt swi oir a>* amp
wldilr< 70D *wed* iconsill401011111101gral. won MN& Lsb a in
Sari away -wild badmit.211Boodi aR r
id e_aa oup sasubzwing fie ohs tree asistv jr - 1 airerei'#'- "0113.
add }.
PERMIT usr: Ana& &BA of NB pandem w-'oa arporeib dot arsMost up*warm
PammOklakmdmim
(1) lVaas.lolisagosset pops= wavily indict ROM.
Dfi*ieia snifie rQ fty
(3) SE.141a Tssmem ett eoi Doi feral Pemba
5roiiby er+ waligPanaltf of kw, I Uwe pano■■3y cuar Ill nd meDan !~iis•r with +tio
subomissid Jo *is dommem a■ • di a■`i.aeAr *mow awd ent. !'ommi aw IVY inglir, o[
far. Wiwi dumb for _1raien mid fraftemars. x ea;owe inc tsar fatmziriem
is Miev same iy Oaialpiek. I as rime t+riw tte +ilpiI& possirir', �►
ofhomo.dImpioomorni. terbduYliwmsa•doo. 1 Rpm Q.woMP■q o'•, m i►
•.d rawiliaisig, abgerim a. gworiSwwee boas poop eon= aed PR _Jiead iginiffemase=8in
+caortioca midi to Iffiterbli O&I ttr s■d Cralafirillt dribs Vier
w
i'awiFier ird Vint a iiw eig a e ba�e+�of Nib~welt ownrr,
Awe .a ly a law slimed by tlir ~sr
agarrori die :shwa wawa.
G 1M3C-67Q 1344
12 -08 - 2004 11:52 GRAHAM 2523572032
TOTAL P. 02
PAGE1

03/18/2004 13 :44 '319-715-0588 NCDE&NR/WA TER QUAL PAGE 05
L. CONSENT OF PROPERTY OWNER (Owner means i:W.Y person whg holds the fee or other propeny
right.sin the well being constru~. A well is real property end its oonstruetion on land rests
o,;vnership iu the landowner in the absence of contrary agreement in writing.)
Ver.3/01
If the property is owned by someone other than the applicant; the propeny owner hereby consents to
allow the appl~t to constnwt each injection well as outlined in thi, application and 'tmft it shall be
the responsibility of the appliC8ll.t to ensure that the ground-source heat pump system's well(s)
conforms to the Well Construction Standard$ (Title lSA NCAC 2C .0200)
(Signature Of Property Owner If Different From Applicant)
Pl~ rctum two copies of the completed Application package to:
UICProgram
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
OW/UIC-57 CL Page4of4
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Secnon
WELL CONTRACTOR (INDIVIDUAL) NAME (print ?E 1 i y CERTIFICATION
WELL CONTRACTOR COMPANY NAME 1A-1 'J [ f�tL 3 C! i l .J Al & PRONE # 0 Z
SPATE WELL CONSTRUCTION PERMIT* ASSOCIATED WQ PERMIT* — -
(if applicable,, (if applicable)
1.
WELT USE (Check Applicable Box): Residential 0 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use GiCU 1 t2_01/1-L Lae.) S
2- WELL LOCATION:
Nearest Town: /'VLF /(C Coorsry L:u�2r �uC
Cc i}'z9 t3 tf: r . r r i 41 !A ' � .
(Staid Name h CG mite, Sttbdiviiiosi, Lot No.., Zip Code)
3. OWNER: D vlt�xr c r/
Address /) l Oa K D
(Sired or Rona: No.i
)Sif
City Town Sax Zip Code
Q-S2)- +° —1� a•--7
Area code- Fume number
4. DATE DRILLED / 2.-7^ ©'f
5. TOTAL DEPTH: � J�
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO gi
7. STATIC WATER LEVEL Below Top of'Casing. r(1 4 FT.
(Ilse "+" iF Above Top of Casing)
S. TOP OF CASING IS N/ —
T. Above Land Surface*
.Top *teasing aertLtaated a N/A-
bvia w l,ad arias moires *
violate* to wavordtanee with 15A NCAC 3C .0118.
9. YIELD (gpm): /VIA METHOD OF TEST
10. WATER ZONES (depth): _
11. DISINFECTION: Type AO /14
12. CASING:
Amount
Wall ihiet-ness
Depth Diameter or Weight/FL Maimed
From 0 T o 7- 2 ?J Ft p'9 FbL
From To Ft.
From To Ft.
GROUT: Depth Materiel
From 0 To 2oc Ft kt.A.J Giro -A --
From To Ft
SCREEN. Depth
From To
From To
SAND/GRAVEL PACK:
Dep
From To N
From
16. REMARKS:
Dialer
t, in.
in.
ToppgraphiciLand setting
ORidge OSlope ❑Valley °Flat
(check appropriate box)
Latitude/longitude of well location
N36 4 3O'I2.4' Wb 74,°42 '4S. 4,4
(degrea(nuaue kot.a+ds)
Latitude/longitude source:OGPSOTopographic map
DEPTH
From To
1 t%J
c: _W
r1
1.�-- _fir
��- Ci
( )
DRILLING LOQ
Formation Description
/t2 &oc t_
� 6 Cc.f
C Z -z, tie
%�Nr w►t=►n
CLAY
1E
T ( C>at-t F
LOCATION ETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
— 9G CL y
Method. — ICCQ £L' 141 S71"f CMS
rCC—i.S7 ►t
Slot Size Material
in.
in.
Size Materiel
If Ij
1tlr�
/ S c — 2082 1-6/vs Er e rr s 6.
S.4ruA.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

07/21/04 WED 14:29 FAX [phone] Gildersleeve
JUL 1E0 2004 06:52 FR PiRTh4X: YD
446 031? TO 9. 46 E2
P. 02
SM/404--fr.5
C4e.5 11
1
Wairer-SDP%3v
1414:44.vr 4-3
LOT 8 BRAWlEW ACRES'/1114( 1*'tor,
DANIEL & MARY LEE W1L tE SON
T Pl LOCATION
i ICAL* 1'Ier
1