WI0800104_GEO THERMAL_20041103

Angela and Bobby Sheegog
168 Audubon Drive
Jacksonville, NC 28546
November 3, 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. Sheegog:
In accordance with the notification you submitted to the UIC Program on November 2, 2004, the Aquifer
Protection Section acknowledges your intent to construct 12 closed-loop geothermal water-onl y injection wells
for the operation of a ground-source heat pump system. This system is to be constructed at 129 Hawkens
Landing, Jacksonville, in Onslow County, according to the Notification submitted. The system as described in
your notification is deemed permitted 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 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 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: UIC-CO files
A qui fer Protection Section
Internet: http://h2o.enr.state.nc.us
1636 Mail Service Center
2728 Capital Boulevard
Sincerely,
~~.
Thomas Slusser
Hydrogeological Technician II
Underground Injection Control Program
Raleigh, NC 27699-1636
Raleigh, NC 27604
Ni~hCarolina ;vnt11rnllu
Phone [phone] Customer Service
Fax [phone]
Fax [phone]
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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 5QW Wells
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
This is not the proper form to he 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:
A
C
DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: Z - d , 2004
SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES X If _yes, then continue completing this form.
NO If no, do not complete this form. Form GW-57 HP, Application For
Permit To Construct A-ndlOr Use A Well For Injection With A Heat
Pump *tern, should be completed.
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 AndlOr (Ise A Wells) For Injection With A Heat
Pump Systems, should be completed.
NO X If no, then continue completing this farm.
PROPERTY OWNER
Name:
Address: I &S' /� cc A, S cjr►1 _
City_ State:
County: Telephone: _
STATUS OF PROPERTY OWNER
Private. X Fc dcral: _
State: Municipal
G Zip Code -
Commercial:
Native American Lands:
Ver-1/01 GW/UIC-57CL Page 1 of 4
.Zz�
w

E. JOB (SITE) DATA
(Fill ettt ONlX if the Status of Owner is Feeeral, State, Mwricipal m Commereiol}.
Name efBusiryess orFaQi~: //Mj e/4 {-BJ'3b!t -Ske€4,tJ "i
Address: 2 1/2 .,JkeN'~ L /Jdl,V c. I r /
City: J,tc. '$,.c>/IJ lli1 e... State: ,Jc_ Zip Code: s O County:
Telephone: '1//J,.. .3 't(p ~ 5 '11 9 Contact Person: __________ _
,Js cJc..;v
Standard Industrial Code(s), SIC, which describes commercial facility : _______ _
F. HEATPUMPCONTRACTORDATA
Name: Climate Control Heatin g & Cooling Co., Inc.
Address: 102 Middle Street
City: Jacksonville
Telephone: (910 ) 353-9040
State: NC Zip Code: 28546 County: Onslow
Contact Person: =Mi=·c=hae=l~Hadl==e..cy _______ _
G . CONSTRUCTION DATA (check one)
Ver.3/01
____ EXISTING WELL(S) being proposed for use as a ground-coupled heat pump
well(s). Provide the infonnation in (1) through (4) below to the best of your
knowledge. Attach a copy of Form GW-1 (Well Construction Record) if available.
X PROPOSED WELL(S) to be constructed for use as a ground-coupled heat pump
well(s) . Provide the infonnation in (1) through (4) below as PROPOSED
construction specifications. Submit Fonn GW-1 after construction.
(1) Well Drilling Contractor's Name: =Sanfi=o=r:=d ~L~. =Sw~ee=nn=· ._.g ________ _
NC Contractor Certification number: N=--.,_:C'-----'2=0e...:8=2 __________ _
Date to be constructed Jf t5r./ Number of borings: -~/_Z-____ _
Approximate depth of each boring (feet): __ 200 ____________ _
(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 ___ 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 of 20 feet b.l.s.):
(a) Grout type: Cement__ Bentonite__L Other (specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
_x_ around closed loop piping; from .J!__ to 200 (feet).
__ around well casing; from __ to __ (feet).
NOIB: THE WELL DRil.LING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF TIIIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
GW/UIC-57CL Page2 of4
G. 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.
H. 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).
(3)
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
Ver.3/01
''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 appu nances in accordance
with the approved specifications and conditions of the Pe
~
If authorized agent is acting on belullf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
GW/UIC-57CL Page 3 of4
L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
Ver.3/01
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)
(Signature Of Property Owner If Different From Applicant)
Please return 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]
GW/UIC-57CL Page4 of4
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