WI0700266_GEO THERMAL_20120213

Permit Number
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (SOW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Doug Tyler SFR
Location Address
315 Hyman Rd
New Bern
Owner
Owner Name
Doug
Dates/Events
NC 28561
Tyler
Scheduled
Orig Issue
02/13/12
App Received Draft Initiated Issuance
01/19/12
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files: APS_ SWP_.
02/13/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Doug Tyler
Owner
PO Box 13462
New Bern
Major/Minor
Minor
NC
Region
Washington
County
Craven
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Doug Tyler
Owner
PO Box 13462
New Bern
Public Notice Issue
02/13/12
NC
Effective
02/13/12
28561
28561
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NCDE
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Beverly Eaves Perdue Charles Wakild, N.E. Dee Freeman
Govemor Director Secretary
02/13/2012
Doug Tyler
P.O. Box 13462
New Bern, NC 28561
Subject: Acknowledgement of Intent to Construct Type 5QW Infection Well System
Permit No. W10700266
315 Hyman Rd.
New Bern, NC 28561
Dear Mr. Tyler:
On 01/19/2012, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
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 Craven County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal riles and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Rocers,y ncdenr�ay if you have any questions.
Sin rely,
far Debra WattsN
Supervisor's
cc: Washington Regional Office - APS
APS Central Files - Permit Nu. WI0700266
Craven County Health Dept.
Mike Hadley (Climate Control floating Sc Cooling Co., Inc., 102 Middle St., Jacksonville, NC 28546)
AQUIFLR PROF ILGTfON SE=GI ION
1636 Mail Service Center, RAh, North Carolina 27599-1636
Location: 512 N. Salisbury 5t„ Ralgh, North Carollrra 27604 C)rZe .
Phone; 9IM07-6464 l FAX! 9IM07-6496 ly O.fth Carohna
Inlsrnet www.acwaterQuality.ory
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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED-LOOP WATER-ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed m
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.r
Print or Type Information and Mail to the Address on the Last Page.
0
DATE: 18 Janua ry 2012 PERMIT NO. ________ (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non-Government: Individual Residence X Business/Organization __
Government: State Municipal __ County__ Federal
-..
B. WELL OWNER -For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
DOUGTYLER
Mailing Address: PO BOX 13462
City: Nnv BERN State: NC_ Zip Code:28561 County: CRAVEN
Day Tele No.: ---------------=C=el=l N:....:.=o•c:....: ...,,2=5=2i.____=6l,._,7'----·-8=40=0
EMAIL Address: Fax No.: ---------------''-=='-"-'-':c=...--------------
C. LOCATION OF WELL SITE -Where the injection wells are physically located:
(I) Parcel Identification Number (PIN) of well site: __________ County: CRAVEN
(2) Physical Address (if different than mailing address): 315 HYMAN_ ROAD
City: NEW BERN State: NC_Zip Code: 28561
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: SANFORD SWEETING
NC Well Drilling Contractor Certification No.: 2082
Company Name:_COASTAL GEOJHERMAL
Contact Person: MIKE HAD=LEY~---~E=MA=I=L~A=d=d""re=ss=:___,,m=h=a=d=l ,..,,,_,.=b=~=ec.=rr=.co=m~-------
Address:
City: Jacksonville_ Zip Code: 28546 State: _NL County: ONSLOW
Office Tele No.: [phone] Cell No.: [phone] Fax No.: 910J =35=3~-1=0=60~-----
GPU/UIC SQW Notification (Revised 3/18/2011) Pagel
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Climate Control Heating & Coaling Co.. Inc.
Contact Person: MIKE HADLEY EMAIL_ Address:_ mhadley@bizeGrrfrom
Address:102 Middle Street
City: Jacksonville Zip Code: MW State: NC County: ONSLOW
Office Tele No.: [phone] Cell No.: [phone] Fax No.: (9101353-1060
F. WELL CONSTRUCTION DATA s C�-) 1i
(1) Number of borings to be constructed*: _ Depth of each boring (feet): 2 SO �
* .lf existing water supply wells will be used then provide the information in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc):
(3) Well casing. If the well(s) will use casing then provide the =ee (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground:
11�U r �L
(4) Grout (material surrounding well casing and/or piping):
4
(a) Grout type: Cement Bentonite** -X— Other (specify)-,,
** By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(1)(A), which requires a cement type grout
(b) Grout depth of tubing (reference to land surface): from _ U to f o (feet)
If well has casing, indicate grout depth: from to (feet)
G. WELL LOCATIONS — Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(2)
Attach a site -specific map showing the locations of the following:
* Proposed injection wells
* Surface water bodies
* Buildings
* Water supply wells
* Property boundaries
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
Attach a topographic map of the area extending l /4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: Inmost cases, an aerial photograph of the properly parcel showing property lines and structures can be
obtained mtd downloaded from the applicable county GIS wehsite. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic ranks, other
wells, etc can then be drawn In by hand Also, a `layer' can be selected showing topographic contours or
elevation date.
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GPUIUIC 5QW Notification (Revised 3MV2011)
Page 2

H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .021 l(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner which means all ersons listed on the ro e deed .
If an authorized agent is . signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined arid 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
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit." --fft---J~/~
Signature o r Owner/ Applicant
:De ~a-s Lt:(~
ype ~ ame {
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ -Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notification (Revised 3/18/201 I)
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