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HomeMy WebLinkAboutWI0700259_GEO THERMAL_20120125Permit Number WI0700259 · Program Category Ground Water Permit Type Injection Water Only GSHP Well System (5QW) Primary Reviewer eric.g.smith Coastal SW Rule Permitted Flow Facili Facility Name Richard Douglas SFR Location Address 120 W King St Edenton Owner Owner Name Richard Oates/Events NC 27932 Douglas Scheduled Orig Issue 01/25/12 App Received Draft Initiated Issuance 11/10/11 Regulated Activities Heat Pump Injection Outfall NULL Central Files: APS_ SWP_ 01/25/12 Permit Tracking Slip Status Active Project Type New Project Version 1.00 Permit Classification Individual Permit Contact Affiliation Percy Graham Ill 159 Hunt Club Tri Hertford Major/Minor Minor NC Region Washington County Chowan Facility Contact Affiliation Owner Type Individual Owner Affiliation Richard Douglas 120W King St Edenton Public Notice Issue 01/25/12 NC Effective 01/25/12 27944 27932 Expiration Waterbody Name Stream Index Number Current Class Subbasin A�� MCDE R North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Charles Wakiid, P.E. Governor Director 1/25/201 1 Richard Douglas 120 West King Street Edenton, NC 27932 Subject: Acknowledgement of Intent to Construct Type 5QW Injection. Well System Permit No. W10700259 120 West .Kings Street, Edenton, NC 27932 Dear Mr. Douglas: Dee Freeman Secretary On l I110/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water orn % geothermal injection well system for the operation of a ground -source heat pump Jocated 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: The injection well system contains only potable water, 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 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 Chowan 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 (919) 807-6406 or Michael. RogersQnedenr.gov if you have any questions. S- cerel ', .jor Debra 'acts Supervisor cc: Wask ftlou Regional Office - APS APS Central Files - Permit No. W10700259 Chowan County Health Dept. American Well & Pump (Percy Grahtun West III) AQUIFER PROTECTION SECTION 1636 Mai[ Service Center, Raleigh, North Carolina 27699-1636 Location: 512 N_ Salisbury St.: Raleigh, Nor[h Carolina 27604 Phone:91MOT-64641 PAX 91MW-6496 Intemet vvww.%wa1erq0,a11ty.o An Equal appoftu* I Affirmative A*n EmplaW One N Caro ' a a-AmaR NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM (GROUND COUPLED HEAT PUMP) Type SQW Wells In Accordance with the provisions ofNCAC Title 1 SA: 02C.4200 Complete application and snail to address on the back page. This is not the proper form to he used for injection wells In an oven -loop geothermal system. Do not use this form for systems that circulate any substances other than water TO: DIRECTOR, NORTH CAROLINA DIVISIO�N`O, FF -aurWATER QUALITY DATE: "~ 9: , 20� W0 1 0() or'6I A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous piping that completely isolates the fluid from the environment? YES If yes, then continue completing this form. NO _ If no, do trot complete this form. Forms GW-57 HP, Application For Permit To Construct AndlOr Use A Well (s). For Injection With A Heat Pump System, should be completed. B. 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 complete this farm. Forms GW-57 HP, Application For Permit To Construct AndlOr Use A Well(s) For Injection With A Hear Pump System, should be completed. NO If no, then continue completing this form. C. PROPERTY OWNER Name; !,�I t !-� t (�� ,7G'�J�- - - - — Address: I,7rJ ►n1 A t /u r. Sr City; k�-bY iu jj, JSL State: 1 jr, C, Zip Code- County: C H ipyy rI nl Telephone: a.5 ,Z — Z33—&FE J _ D. STATUS OF PROPERTY OWNER Private: )L Federal' State: Municipal: Revised 5105 GWfMC-57 CL Commercial: Native American Lands: Page 1 of 4 0 E. FACILITY (SITE) DATA (Fill out ONLY if the Status of Owner is Federal, State, Municipal 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. HF.AT PUMP CONTRACTOR DATA Name: UN KNGKI N Address: City: State: Zip Code: County: Telephone: Contact Person: G. CONSTRUCTION DATA (check one) 1'• 1/ 14 l R I I 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. Attach a copy of Form GW-1 (Nell Construction Record) if available. PROPOSED WELL(S) to be constructed for use as a ground -coupled beat pump weli(s). Provide the information in (1) through (3) below as PROPOSED construction specifications. Submit Form GW-1 after construction. (1) Well Drilling Contractor's Name; f y?Cy 67RA 44 oN 1� _ZF _ NC Contractor Certification number: Al W � �ZS 7 eZ Date to be constructed: if - —ZLp Cj_ Number of borings: f _� Approximate depth of each boring (feet): 2Cx7 1 0 a8 0 f T (2) Well casing; Is the well(s) cased? (a) YES If yes, then provide the casing information below. Type: Galvanized steel Black steel Plastic Other (specify) Casing depth: From to fit. (reference to [and surface) Casing extends above ground inches (b) NO _X (3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.l.s.). (a) Grout type: Cement Bentonite Other (specify) (b) Grouted surface and grout depth (reference to land surface): around closed loop piping; from �_ to p7—O (feet). around well casing; from to (feet), NOTE: THE WELL DPJT T..ING CONMACTOR CAN SUPPLY THE DATA FOR EITHER F.X.ISTING OR PROPOSED WELLS IF THIS INFORMATION LS UNAVAILABIX BY OTI-ER MEANS. Revised 5105 GWAJIC-57 CL Page 2 of 4 H. INJECTION -RELATED EQUIPMENT Attach a diagram showing the engineering layout 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 maps. (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 weli(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of the ground -coupled heat pump well system. Label all features clearly and include a north arrow. (2) location map referencing the site to two nearby permanent reference points (such as roads, streams and highway intersections). J. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site. Examples include: (1) Hazardous Waste Management program permits under RCRA (2) NC Division of Water Quality Non -Discharge permits (3) Sewage Treatment and Disposal Permits K. CERTIFICATION "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 ground -source heat pump system and all related appurtenances in accordance with the appro d specifications and.conditions ofAlie Permit" Signature of Well Owner or %diortzed Agent) !f authorized agent is acting on behalf of the well owner, please supply a letter signed by the owner authorizing the above agent. Revised 5105 GW/UIC-57 CL Page 3 of4 ~.cCi=ivEu / DENR; DWQ Aquifer Proter.ti::in Section ,~ov 1 o 2011 L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property rights in the well being constructed. A well is real property and its construction on land rests ownership in the landowner in the absence of contrary agreement in writing.) If the property is owned by someone other than the applicant, the property owner hereby consents to allow the applicant to construct each injection well as outlined in this application and that it shall be the responsibility of the applicant to ensure that the ground-source heat pump system's well(s) conforms to the Well Construction Standards (Title 15A NCAC 2C .0200) _, ' Revised 5/05 I J' Please return two copies of the completed Application package to: UICProgram Aquifer Protection Section North Carolina DENR-DWQ 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 715-6182 GW/UIC-57 CL Page 4 of4 NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES RE~EIVED I DENR I DWQ Aquifer Protection Section l~OV 1 0 2011 NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL WATER-ONLY INJECTION WELL SYSTEM (GROUND COUPLED HEAT PUMP) Type SQW Wells In Accordance with the provisions ofNCAC Title 15A: 02C.0200 Complete application and mail to address on the back page. This is not the proper form to be used for injection wells in an open-loop geothermal system. Do not use this form for systems that circulate any substances other than water . TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY DATE: II -9 - . 20Jj_ A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous piping that completely isolates the fluid from the environment? YES -)/._ If yes, then continue completing this form. NO If no, do not complete this form . Form GW-57 HP, Application For Permit To Construct And/Or Use A Well(s) For Injection With A Heat Pump System, should be completed. B. 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 complete this form. Form GW-57 HP, Application For Permit To Construct And/Or Use A Well(s) For Injection With A Heat Pump System, should be completed. NO _x__ Ifno, then continue completing this form. C. PROPERTY OWNER Name: K l C H 4 R I \ '1>c 1u Cn I I± S. Address: /;;J..o W K.1 1V f71 ~I City: E.,"(>f: NToAI State: ~. Zip Code:~---------- County: CHD \Al,31\l Telephone: .;l5 ,-;t. -3..3'3-88/i/ D. STATUS OF PROPERTY OWNER Private: L State: Revised 5/05 Federal: Commercial: Municipal:__ Native American Lands: GW/UIC-57 CL Page 1 of4 E. FACILITY (SITE) DATA (Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial). Name of Business or Facility: Address:. _ _ _ City: — _ _ — State: Zip Cods: County: _ Telephone: -- - - Contact Person: Standard Industrial Code(s), SIC, which describes commercial facility: F HEAT PUMP CONTRACTOR. DATA Name: UN K(VUMJ /4. Address: _ City: _ — _ _ State: — — Zip Code: — - County: Telephone: _ Contact Person: G. 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. Attach a copy of Form GW-1 (Well Construction Record) if available. ' PROPOSED WELL(S) to be constructed for use as a ground -coupled heat pump well(s). Provide the information in (t) through (3) below as PROPOSED construction specifications. Submit Form GW-I after construction. (l ) Well Drilling Contractor's Name: PC PA W 57 ,77- NC Contractor Certification number: NC inl 4 _ w -$ Z-3� Date to be constructed: J1 r 1,g 20 [(- Number of borings: IC, _ Approximate depth of each boring (feet): aS 0 1 "r (2) Well casing: 1s the weil(s) cased? (a) YES If yes, then provide the casing information Mow. Type: Galvanized steel Black steek Plastic Other (specify)__ Casing depth: From to ft. (reference to land surface) Casing extends above ground inches (b) NO _X (3) Grout (grout the vertical length of the borehole to a minimum depth of20 feet b1s.): (a) Grout type: Cement Bentonite X Other (specify) (b) Grouted surface and grout depth (reference to land surface): around closed loop piping; from } to P-Lo� (feet). around well casing; from to (feet). NOTE: Tim WELL DRILLING CONTRACTOP CAN SUPPLY THE DATA FOR EITHER EXISTING OR PROPOSED WELLS IF THIS INFORMATION Is UNAVAILABLE sY OTHi3R M.AN& Revised 5105 GW/WC-57 CL Page 2 of H. INJECTION-RELATED EQUIPMENT RECEIVED / D!:::~R I DWQ Aql"'f -Prrt~r.tion Section NOV 10 2011 Attach a diagram showing the engineering layout 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 maps. ( 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 ground-coupled heat pump well system. Label all features clearly and include a north arrow. (2) location map referencing the site to two nearby permanent reference points (such as roads, streams and highway intersections). J. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site. Examples include: ( 1) Hazardous Waste Management program permits under RCRA (2) NC Division of Water Quality Non-Discharge permits (3) Sewage Treatment and Disposal Permits K. CERTIFICATION "I hereby certify, under penalty oflaw, 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 ground-source heat pump system and all related appurtenances in accordance with the appro d specifications j:onditions o f, he Permit." r' ,,,,_.,,.___. Ju . ~-0 Revised 5/05 Signature of Well Owner or If authorized agent is acting on behalf of the well owner, please supply a letter signed by the owner authorizing the above agent. GW /UIC-57 CL Page 3 of4 RE~EIVED / DENR I DWQ Aqu,fer Prot~ction Section NOV 10 2011 L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property rights in the well being constructed. A well is real property and its construction on land rests ownership in the landowner in the absence of contrary agreement in writing.) If the property is owned by someone other than the applicant, the property owner hereby consents to allow the applicant to construct each injection well as outlined in this application and that it shall he the responsibility of the applicant to ensure that the ground-source heat pump system's well(s) conforms to the Well Construction Standards (Title 15A NCAC 2C .0200) Revised 5/05 Please return two copies of the completed Application package to: UICProgram Aquifer Protection Section North Carolina DENR-DWQ 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 715-6182 GW/UIC-.57 CL C�ZANVaLE 6T 777 --------• �- .. --- —-----••----------�----�-------- x -------------------------------- } ---- --- ---------- • 1 •�P'P�P' W 3PA E9' i 4 Doe" lm4h— w1L C1� leewlw