WI0700079_GEO THERMAL_20040506

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
May 6, 2004
To: Willie Hardison, Regional Groundwater Supervisor
Groundwater Section
Washington Regional Office
From: Thomas Slusser-:z:I5
Central Office
Re: Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection Well
System. (Type 5QW.):
Mr. and Mrs. Banks at 1391 Soundneck Road, Weeksville, in Pasquotank County, has filed a
NOTIFICATION OF INTENT To CONSTRUCT AND OPERA TE A CLOSED-LOOP, WATER 0NL Y INJECTION
WELL SYSTEM FOR A GEOTHERMAL HEAT PUMP (TYPE 5QW INJECTION WELL). A copy of the
notification is included with this memo. This injection well system is deemed permitted by rule
(15A NCAC 2C.021 l(u)2) and no further regulatory action should be necessary. If you have any
questions about this notification, please contact me at [phone].
cc: CO-UIC Files
Enclosures
Michael F, Easley, Governor
Williarn G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E, Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of Water Quality
May 6, 2004
Ruth and David Banks
1391 Soundneck Road
Weeksville, NC 27909
RE: Notification of intent to construct Type 5QW injection wells
Dear Mr. and Mrs. Banks:
In accordance with the notification you submitted to the UIC Program dated May 1, 2004, the
Groundwater Section acknowledges your intent to construct 3 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 perniitted by rule (North Carolina Administrative Code Title 15A:
2C.0211(u)(2)) and will not require an injection well permit from the state, However, you should
check with your county health department prior to constructing the system because they may have
additional construction 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 Groundwater 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 meat [phone].
cc: Willie Hardison, Regional Groundwater Supervisor
Washington Regional Office
UIC-CO files
Sincerely,
Aitux2A
Thomas Slusser
Hydrogeological Technician II
Underground Injection Control Program
N. C. Division of Water Quality / Groundwater Section
1636 Mail Service Center Raleigh, N.C. 27699-1636
Phone: [phone]l Fax: [phone] interact: ht1p://gw.ehnr state.nc.us
Customer Service
1.877-623-6748

03/18/2004 13: 44 919-7} '-•8588
NC7E&MRIWATEP .r IAL PAGE 02
NORTH CARQLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF IIN'TENT TO CONSTRUCT A CLOSED.LQQ?
GEOTHERMAL WkTER —ONLX INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
In Acaordalcv with the previsions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
This is nr the proper form to be used for injection wells in as ooen-loon geothermal system.
D..qwig this form for systems that circulate spy sabataoces other than w .
TO: DIRECTOR, NORTH CAROL]NA, DIVISION OF WATBR QUALITY
DATE S- I- , 20 o 41
A SYSTEM CLASSIFICATION Does the proposed system circulate potabk water m continuous
piping that completely isolates the fluid from the enviro nt?
YES V If yes, then continua completing this form.
NO Tf na, do not complete the form. Form GW-57 I P, Apphcatian For
Pormit To Construct 4ndfOr flsa A Well(s) For Injection With A Heat
.Pin System, should be completed.
13. SYSTEM FLUID Will any additives be introduced to the system's circulating heat transfer
fluid? This includes, but is not limited to corrosion inhibitors and/or antifreezes.
YES If yes, do not comply this form. Form 33W-57 HP, Application For
Permit To Construct And/Qr Use Well(i) For Infection With d Heat
Pump System, should be compiete~d.
NO If no, then continue completing this form.
C. PROPERTY OWN&&
Name: Awil] ?4h1 k
Addrois:
City: r.,c, State: r . Zip Cade: 2 40 9
Cotmty: F, cq uo7A JK Telephoner,) . 3 0 -
D. STATUS OF PROPERTY OWNER a
Private: 1"---- Femoral: C.oncr+eial:
State: Municipal: Native Auzer cen trends:
cri
ru
cn
Ver.31 L OW/UIG57 cL Page i of 4 cn

03/18/2004 13:44
913-71 `-a5$B
MCDES31R/WATER .F&iAL PAGE e3
E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Coirunereia1).
Name of Business or Face i
Address:
City: Static: Zip Code: County:
Telephone: Contact Person:
Standard Industrial Code(s). SIC, which describes commercial facility:
P. BEAT PUMP CONTRACTOg. DATA
Nom Ca JLA€St vE WC41. t
Address; G S a. N h i 4-J JP-) v R R�
City. 1I►4 g ate: VA- Zip Code: ._33 S county.
Tel onet( S Contact Person: M* b aR EA-gf-61
O. CONSTRUCTION DATA (hack one)
EXISTING MEWS) being proposed for use as a gr+o md-coupled heat pump
walks). Provide the hdbrateti.cm in -(1) 'through (3) below to the best of your
knowledge. Attach a copy of Form GW-1 (Well Construction Record) if
available.
y-r~ PROPOSED WELL(S) to be constructed tier use ass beet pump
well(s). Provide the inihrmath:m in (1) enough (3) blow as PROPOSED
construction specifications. Submit Form OW-1 after construction.
(1) Well Drilling Contractor's Name: A-rU b -ULI 0,162,
NC Contractor Cetilfca#on number: _ - 2
Diez to be constructed: S- ( - v 41. Number o£boringa: _ .3
Apprcodniato depth of each boring (feet): D...oes Fr
(2) Wei cuing,: Is the wells) cased?
(a) YES If yea, duct provide the cgRirE information below.
Type: Galvanized steel Black steel Plastic Other (spccllY)
Casing depth: From to ft(reference to land she)
Cesieg Mends above ground inches
(b) NO
(3) Grout (gnat the vertical length of the borehole to a minimum depth of 20 Ica b.L5.):
(a) Grout type: Cement Eentonite v Other (specify)
(b) Grouted ce axrd grout depth (retidrenc c to land surface):
around closed loop piping; from 0 to 7-.0y (fbet).
aroand well Ong; from to (feet).
HOME: THE Wt. DRILLNOeoRTRAMOR CAN sIJYPI.Y THE DATA FOR arnma ocsTrgo O:a
PROPOSED WBL.L5IP THr2 INFORMA1ION I8 UNAVAILABLE BY OMER MEANS.
YCr3fO) GW/tJJC-57 CL Page 2 of 4

03t18/2ee4 13:44 913-73588
MCDE/NR/WATER0r `4L
PAGE e34
INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment nt and exterior pipirotuhing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
L LOCATION OF WELL(S) Attach two maps.
(1) Include a site trap (can be drawn) showing: buildiegs, property lines surface water bodies,
potential l sources of groamdwster won and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal facilities such es septic tanks
or drain fields located within 200 feat of tlx ground-cotwp1ed heat ptxwp well system label all
resume 'dearly and include a north arrow.
(2) location impretrench* the site to two nemby permancza refermec paints (such as rams,
stroema and highway intersections).
Pam` UST: Attach a list af'all permits or conStre tion approvals that arc related to the site.
Examples include
(I) Hazardous WASte Msaagement props= permits under RCRA
(2) NC Division of Water Quality Non -Discharge
(3) Sewage Treatment and Disposal Permits
K. CER.TIFICA`t'ION
Vor.3/01
"I hereby certify. u deerpe salty of law, that I have personally a ia' eland. art 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 b Ueve that the information
is true, accurate and complete. I sin aware that there are significant penalties, including the possibility
of fines and imprisonment„ for submitting false infbrrisatioll. I agree tO construct, operate, teh4
repair, and if applicable, mbar:Wen the ground -source heat pump system. and all related appurtenances in
accordance with the approved specifications and conditions atilt Permit„
„in ii-c,044:11—A-7—
(Signature of Well Owner or Authorized Agent)
If authorized agent r$ acting on 6e hal(of the well owner,
pre= supp& a letter signed by the owner
authorizing the above agent.
OW/W ..57 CL Pages 3 of 4

0311s12004 13: 44 919-1r -~-05aa NCDE&MR/WATER ,r.it ,JAL PAGE 05
L. CONSENT OF PROPERTY OWNER (OWtletmeaas any person who holds the fee or otlm propmy
rigbts -in 1m. wdl beingC011SffllCted. A well .is ftllllpoperty-and i.t8: 1=0DltrUCtionon land rests
oWDCilhip in the landowner in the ablence of coubaiy agroemeat in. writing.)
-Vcr.3/81
lftbe propeny m owned by someone othertban the applica:u.t, tm, property awnerhmeby QODIJeSl1f.$ ta
allowiheapplbntto ~ eaehqectionwell u outlined intldt applieadcmand1hat it wllbo
tho respondrility of the applioam to ensute ibat the ground-souroo beat pump system's well(s)
ccmfurms to tho Well Co~ Standanls (T'rtle lSA NCAC-lC .0200)
(Sianatme Of Property Owner lf Diitenmt From Applicant)
Pleasoretum. two copies of the completed Application package to:
UICProgram
Groundwater Sec:tton
North CaroHna DENR-DWQ
1636 Mail Servlce Center
Ralelgb, NC 27699-1636
Telepllone ·(tl9) 715-6165
OW/UIC-S7 CL Pap4of4
1E Lcc�. :j'..
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