WI0300103_GEO THERMAL_20120518

Beverty Eaves Perdue
Governor
AVA·-_-----·--RcbE MR ______ ---
North Carolina Department of Environment and Natural Resources
Division of WaterQuality-··
Charles Wakild,-P~E.--
Director
May 18, 2012
Joan Summerhays
16822 Lakeshore Drive
Cornelius, NC 28031
Subject: Notification of Rule Revisions-Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0300103
Dear Ms. Summerhays:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells .
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rnle." Therefore, you are no longer required to renew your current permit
and the permit will be valid indermitely as long as the wells are active and are operated in
accordance with the revised rules referenced above. Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http://portal.ncdenr.org/web/wq/aps.
If you have any questions regarding your:current permit or-the-rule-revisions, please feel free-to
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] \FAX: 919~07-6496
Internet www.ncwaterquality.org
An Equal Ojiportunity I Affirma~va Action Employer
Ni11%:i Carolina
Jvnturall!f
Permit Number WI0300103
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Fa cm
Facility Name
Joan Summerhays SQM SFR
Location Address
16822 Lakeshore Dr
Cornelius
Own er
Owner Name
Joan
Dates/Events
NC
C
28031
Summerhays
Orig Issue
02/15/05
App Received Draft Initiated
Scheduled
Issuance
06/24/10
Central Files: APS_ SWP_
09/03/10
Permit Tracking Slip
Status
Active
Version
2.00
Project Type
Renewal
Permit Classlficatlon
Individual
Permit Contact Afflllatlon
Major/Minor
Minor
Region
Mooresville
County
Mecklenburg
Facility Contact Affiliation
Owner Type
Individual
Owner Afflllatlon·
Joan C. Summerhays
16822 Lakeshore Dr
Cornelius NC 28031
Public Notice Issue
09/01/10
Effective
09/01/10
Expiration
08/31/15
-'--R;..;;_e.._Q""'u""'la=t=e =d..;;..A""'c:;.;;t.;;.civ'-'-lt=ie"-s:;__ ___ ~----------~R=e-q=u=e=st=e=d~/R~e=ce~•~ve=d=E~v~e=n=ts~----------
Heat Pump Injection Region comments on draft requested
Region comments on draft received
Outfall t .J; Jt__
Waterbody Name Stream Index Number Current Class
07/28/10
07/28/10
Subbasin
Permit Number WI0300103
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (50M)
Primary Reviewer
john.mccray
Coastal SW Rule
Permitted Flow
Facillt1r
Facility Name
Summerhays, Joan -SFR
Location Address
16822 Lakeshore Dr
Cornelius
Owner
Owner Name
NC
Joan C
Dates/Events
28031
Summerhays
Orig Issue
02/15/05
App Received Draft Initiated
Scheduled
Issuance
06/24/10
Rea ulated Activities
Heat Pump Injection
Outfall
Central Files: APS_ SWP_
07/15/10
Permit Tracking Slip
Status
In review
Version
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Mooresville
County
Mecklenburg
Facility Contact Afflllatlon
Owner Type
Individual
Owner Afflllatlon
Joan C. Summerhays
16822 Lakeshore Dr
Cornelius NC 28031
Public Notice Issue Effective Expiration
Waterbody Name Stream Index Number Current Class Subbasln
AWA .;;z;;;::;;.~."--~CDEM R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Joan Summerhays
16822 Lake Shore Dr.
Cornelius, NC 28031
Coleen H. Sullins
Director
September 1, 2010
Dee Freema n
Secretary
Subject: Issuance of Injection Well Permit
Permit No. WI0300103
Dear Ms. Summerhays:
Issued to Joan Summerhays
Mecklenburg County
In accordance with your application received June 24, 2010, I am forwarding Permit No. Wl0300103 for
the continued operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well system
located at 16822 Lake Shore Drive, Cornelius , Mecklenburg County, NC 28031. This permit shall be
effec;:tive from the date of issuance until August 31, 2015, and shall be subject to the conditions and
limitations stated therein.
Please pay special attention to Parts IV,1 and VII.2.A oftbe permit in which the Permittee is required
to notify the Regional office in any event that the system performs unusually or unsatisfactorily,
including any repair to the system .
Additionally, your UIC system is subject to inspection by the APS and at the time of the inspection must
display a permanently affixed identification plate in accordance with.requirements of2C .0213(g). Please
insure this is completed in accordance with permit condition Part 1.6 of this permit issued September 1,
2010.
In order to continue uninterrupted legal use of th.is well for the stated pUIJ)ose, you should submit an
application to renew the permit three months prior to its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Quality. If you have any questions regarding your perm.it or the Underground Injection
Control Program please call me at [phone].
cc: An.drew Pitner -Mooresville Regional Office
Central Office File -WI0300103
Mecklenburg County Environmental Health Dept.
Enc: Permit WI0300103
Sincerely,
~~,4~.
_7 John.McCray, 7
Environmental Specialist
,
' NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSlON
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR lNJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Joan Summerha.ys
FOR THE CONTINUED OPERATION OF 10 TYPE SQM INJECTION WELLS, defined in Title lSA North
Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed-loop
geothermal-mixed-fluid heat pump system. This system is located at 16822 Lakeshore Dr, Cornelius,
Mecklenburg County, NC 28031 , and will be constructed and operated in accordance with the application
received June 24, 2010, and in conformity with the specifications and supporting data submitted, all of which
are filed with the Department of Environment and Natural Resources and are considered a part of this permit.
This permit i s for Construction and Operation only, and does not waive any provisions of the Water Use Act or
any other applicable Laws;_Rules, or Regulations. Operation and use of an injection well shall be in compliance
with T itle 15A North Carolina Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date ofits issuance until August 31, 201 s; and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the L day of ~(2010.
Coleen H . Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
PART I· WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200). Any noncompliance with
conditions ofthls permit constitutes a v iolation of the North Carolina Well Construction Act and is
grounds for enforcement action as prov ided for in N .C.G.S . 87-94.
2 . This permit shall become v oidable unless the facility is constructed in accordance w ith the conditions of
this permit, the approved plans and specifications, and other supporting data.
3 . Each injection well shall not hydraulically connect separate aquifers.
4 . Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concav e s lope, alluv ial or colluvial soils, gullies, depres sions, and
drainage w ays.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
6 . Each geothermal injection well sy stem shall have permanently affixed an identification plate on a nearby
building or other permanently fixed structure indicating the location and presence of underground UIC
wells according to 2C .0213(g).
7. A completed Well Construction Record (Form GW-1 ) must be submitted for each injection well to :
Aquifer Protection Section-UIC Staff
1636 Mail Service Center
Raleigh, NC 27699~ 1636
and
Aquifer Protection Section -Mooresville Regional Office
610 East C enter A venue, Suite 301
Mooresville, NC 28115
(704) 663 -1699
GW-ls must be submitted within 30 days of completion of well construction. Copies of the GW-1
fonn(s) shall be r etained on-site and available for inspection.
8. Well construction records must also be submitted for the existing water supply wells on-site as well as a
sit e map sh owing any water supply wells on adjacent properties as specified in NCAC .021 l (d)(l)(D).
PA RT II -WELL CONSTRUCTION SPECIAL CONDITION S
1. At least forty-eight (48 ) hours p rior to constructing system, the Pennittee shall notify the Aquifer
Protection Section's Underground Inj ection Con trol (UIC) Program Central Office staff, telephone
number (919) 715-6 168 and the Mooresville Regional Office Aqu jfer Protection Section Staff, telephone
number [phone].
WI030 0 103 2
2. Boreholes shall not connect separate aquifers which have differences in water quality (e.g., shallow
surficial aquifers1 saprolite, fracturecl bedrock, etc.) as specified in 15A NCAC 2C .0213(d)(8)(C) and
shall be filled with bentonite w.out from the lowermost water bearing zone to land surface as specified in
the permit application.
PART III-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data ..
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a des ire· for the facility to change ownership, or there is a
name change of the Permittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3 . The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which µ:i.ay be imposed by other local, state, and federal
agencies, which have jurisdiction. Furthermore, the issuance of this permit does .not imply that all
regulatory requirements have been met.
PART IV -PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3 . The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
groundwater resulting from the operation of this facility.
PART V -OPERATIONS AND MAINTENANCE REQUIREMENTS
l. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit. ·
3. At least forty-eight (48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UTC)
Program Central Office staff, telephone number (919) 71S-6168. Notification is required so that Division
staff·can inspect or otherwise review the injection facility and determine if it is.in compliance with permit
conditions.
WI0300103 3
PART Vl -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of detennining compliance with this pennit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
PART Vil -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection, will be established and an
acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
ocCWTence, to the M ooresvil1e Regional Office, telephone number [phone], any of the following: .
(A) Any occurrence at the injection facility that results in any unusual operating circumstances ;
(B) Any ·failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures ;
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect in.formation submitted in said application or in any report to the Director, the relevant and
correct facts or information snail be promptly submitted to the Director by the Permittee.
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII-PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension.
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a wen for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(I ), Well
Construction Standards.
WI0300103 4
2. When operations hav e ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to the following:
(A) All casing and materials may be removed prior to initiation of abandonment procedures if
the Director finds such removal will not be responsible for, or contribute to, the
contamination of an underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing. if the Director determines that
failure to do so could lead to the contamination of an underground source of drinking
water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the
well through a pipe which extends to the bottom of the well and is raised as the well is
filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been
removed, the casing shall be perforated opposite the gravel pack, at intervals not
exceeding l O feet, and grout injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement of
fluids into or between underground sources of drinking water and in accordance with the
terms and conditions of the permit.
{G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in
15A NCAC 2C .02 l 3(h)( 1) within 30 days of completion of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
WI0300 10 3-
Aquifer Protection Section-UIC Program
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
5
Mccray, John
From:
Sent:
To:
Pitner, Andrew [andrew.p [e-mail]]
Wednesday, July 28, 2010 1:26 PM
S chutte, Maria; John McCray
Subject: RE: SQ M permit appl ication
11m fine if it is renewed with something highlighting the permit requirement to report losses.
Andrew
From: Schutte, Maria
Sent: Wednesday, July 28, 2010 12 :29 PM
To: John McCray
Cc: Pitner, Andrew
Subject: FW: SQM permit application
John,
Looi<ed at this permit file this system i s a composed of copper tubing, so I inquired about a ny sys t em issues. Per Ms.
Summerhays she had a leak about two or more years ago, but did not have any paperwork on it, so said it was okay if I
spoke wit h her system con tractor d i rectly. Per Dwayne Akers, about 3 ½ years ago, there was an above surface issue, an
elbow fitting at the compressor needed to b e replaced and the refrigerant recharged. Sounded like it would be unlikely
that Mr. Akers could l ocate paperwork on the repair to send a copy. I am okay with the verbal conversation, if Andrew
and you are? I do not see any reason for a site visit. Per her perm it, she is supposed to notify us w h en a loss of
r efrigerant and recharge is performed. Might be worth" mentioning that in her cover letter.
Marla
From: Pitner, Andrew
Sent: Wednesday, July 28, 2010 10:47 AM
To: Schutte, Maria
Subject: FW: SQM permit application
Summerhays renewal; let me know i f we need more time to delve into this for review or not. Thanks,
A
From: Mccray, John
Sent: Wednesday, July 28, 2010 10 :07 AM
To: Pitner, Andrew
Subject: SQM permit application
Dear Mr. Pi tner,
Attached is a copy of SQM permit application WI0300103 for a system located in Mecklenburg County. Please provide
our office with your preference on how to proceed with the iss uance.
Best Regards,
John McCray
1
Mccray, ·John
From:
Sent:
Schutte, Mari a [[e-mail]]
Wednesday, July 28, 2010 12:29 PM
To:
Cc:
Subject:
Attachments:
John,
John McCray
Pitner, Andrew
FW: SOM permit application
W !0300103.pdf
Looked at this permit file this system is a compqsed of copper tubing, so I inquired about any system issues. Per Ms.
Summerhays she had a leak about two or more years ago, but did n ot have any paperwork on it, so said it was okay if I
spoke with her system contr actor directly. Per Dwayne Akers, about 3 % years ago, there was an above surface issue, an
elbow fitting at the compressor needed to be replaced and the refrigerant recharged. Sounded like it would be unlikely
' that ML Akers could l ocate paperwork on the repair to send a copy. I am okay w ith the verbal conversation, if Andrew
and you are? I do n ot see any reason for a site visit. Per her permit, she is supposed to notify us when a loss of
refrigerant and recharge i s performed. M i ght be worth mentioning that in her cover letter.
Maria
From : Pitner, Andrew
Sent: Wednesday, July 28, 2010 10:47 AM
To: Schutte, Maria
Subject: FW: SQM permit application
Summerhays renewal; let me know if we need more time to delve into this for review or not. Thanks,
A
From: Mccray, John
Sent: Wednesday, July 28, 2010 10:07 AM
To: Pitner, Andrew
Subject: SQM permit application
Dear Mr. Pitner,
Attached is a copy of SQM permit application WI0300103 for a system located in Mecklenburg County. Please provide
our: office with your preference on how to proceed with the issuance.
Best Regards,
John McCray
1
Mecklenburg County, NC POI.ARIS http://polaris.mecklenburgcountync.gov/servlet/com.esri.esrimap.Esri ...
1 of 1
Mecklenburg County, North Carolina
POLARIS
Property Ownership Land Records Information System
Date Printed: Wed~ 01 2010 12:02:40 GMT-0400 (Easter~2'._Jight Time)
001$7"9'
@ CKLE N3 URG COvt,.-Y G I S -----
,JThis map is prepared for the Inventory of real property within Mecklenburg County and is compiled from recorded deeds, plats, tax maps, surveys,
, ptanimetric maps, and other public records and data. Users of this map are hereby notified that the aformentioned public primary infonnation sources
should be con~~~r!fication. Meck_!!_~g County and Its mapping~~ assume no leg~e,c?n~i~i~r the information contained herei~
9/1/2010 12 :05 PM
AV'A
NCDEMR
North Carolina Department of Environment and Natural Resources
DiVlsion of Water Quality
Beverly Eaves Perdue
Governor
Coleen H. Sullins
Director
July 15, 2010
Joan Carol Summerhays
16822 Lakesbore Drive
Cornelius, NC 28031
Subject: AcknO\vledgement of Application No. WI0300103
Summerhays, Joan ~ SFR
Injection Mixed Fluid GSHP Well System (SQM)
Mecklenburg
Dear Ms. Summerhays:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt ofyourpennitapplication and
supporting materials on June 24, 2010. This application package has been assigned the number listed above and will be reviewed by
John McCray.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional infonnation requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 • 90 days after receipt of a complete
application.
If you have any questions, please contact John McCray at 919-715-6168, or via e-mail at [e-mail]. If the reviewer is
unavailab.le, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To review our
new organizational chart, go to http://h2o.enr.state.nc.us/documents/dwcr ornchart.u df
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT,
Sincerely,
O\¾ ~
for Debra J. Watts
Supervisor
cc: Mooresville Regional Office, Aquifer Protection Section
Pennit Application File WI0300103
AQUIFER FROTECTION SECTION
1B36 Mail Service Cemei, Raleigh, North Carolina 27699-1636
Location-2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0688: FAX 2: 919-715-6048 I Customer Service: 1-8TT-623-6748
Internet www.ncwateroualitv.org
Ao Equal 0pportun11y I Affirmative AGIIOo i;mplOyer
~~Carolina
/\latural/!f
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverfy Eaves Perdue
Governor
Coleen H, Sullins
Director
July 15, 2010
Joan Carol Summerhays
16822 Lakeshore Drive
Cornelius, NC 28031
Subject: Acknowledgement of Application No. WI0300103
Summerhays. Joan -SFR
Injection Mixed Fluid GSHP Well System (SQM)
Mecklenburg
Dear Ms. Summerhays:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supportmg materials on June 24, 2010. This application package has been assigned the number listed above and will be reviewed by
John McCray.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional information requests.
Please be aware that the Division's Regional Office, copied below, must pro\ljde recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 -90 days after receipt of a complete
application.
If you have any que.stions, please contact John McCray at 919-715-6168, or via e-mail at [e-mail]. If the reviewer is
unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To review our
new organizational chart, go to http://h2o.enr.state.nc.us/documents/dwo ornchart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT .
Sincerely,
()~~
for Debra J. Watts
Supervisor
cc: Mooresville Regional Office, Aquifer Protection Section
Permit Application File WI0300103
AQUIFER PROTECTION SECTION
1631\ Mail Service Center, Ri!ielgll. North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh . North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet www.ncwatergualijy,org
Ao Equal Oppominlty I Affi1111ative Actton Employer
Ni~hCarolina
/Vat11rall11
DATE:
RECSVEDtDENR/D\\Q
Aquifer Protection Sectfor,
DEPARTMENT OF ENVIRO= ~~~~~ RESOURCES (NCD~)LJN .2 4 2010
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL BEAT PUMP SYSTEM FOR:
TYPE 50M WELL(S)
New Permit Application OR X Renewal (check one) -----~-~--
PERMIT NO. W ~ O 3 0 0 I O 3 (leave blank if NEW permit application)
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): Jo <LO C . S \LO,Q1f,r:h<l'J S
(1) Mailing Address: I G g 2. 1 La. k e $ b P:f"f; Dr t I/ e..
City: ~ov-ne.l I ltS State: N_C..Zip Code: .1So 31
Home/@ffiee-TeleNo.: 3:o ~ -fcS5-o (p~~ Cell No.:
EMAIL Address: j C Su.n,n,et:@ heilsou"fei . ne.±
(2) Physical Address of Site (if different than above): --':5 ....... c1,n1,......,'-"E....__ _________ _
City: ________ State:_ Zip Code: ______ County: ____ _
Home/Office Tele No.: ----------~C=el=l N~o·~= _________ _
EMAIL Address: ______________ _
B. AUTHORIZED AGENT OF OWI\'ER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: _ ____.N'-=-'A-'-'-------------------------
Contact Person -: ------------~E=MAll,==A=ddr~es=s~: _________ _
Address: _____________________________ _
City: ________ State: __ Zip Code: ______ County: ______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: _____________ _
C. STATUS OF APPLICANT
Private:.)(_
State: ·
Federal:
Municipal: _
GPU/UIC SQM Well Pem:ut Application (Revised 7/2008)
Commerfal: _
Native American Lands;
Page 1
D.
E .
F.
G.
WELL DRILLER INFORMATION ( Geo-the,,-""a.,' C,.01').\-r(lc.-br)
Company Name: Ake.rs C.us+cni to •n+o-r:t) r nc I
Well Drilling Contractor's Name: -~J)~VJ-=-'-<l.""""'1+--'--h-'--'e. __ -"-'A ... k~e=r-__.S..,___ ____________ _
NC Contractor Certification No.: _?_. _______________________ _
Contact Person: D\A.l ~ nt A k e,¥.S
Address: I .;\ ~ G o:r:d O':l-:> Dr i \le>
EMAIL Address:
City: $:to kt..S J. oJ e.. Zip Code: .l 1: 3S + County: _?;__ _________ _
Office Tele No.: _______ Cell No.: 3 3 C, -~ i I -~ 4 q"
HEAT PUMP CONTRACTOR INFORMATION (if different than driller) L( k n ri " w.,
Company Name: ______________________________ _
Contact Person'--: --------------~E=MAIL='---="'---A"--=d=dr=e=ss"'-: __________ _
Address:----------------------------------
City: _________ Zip Code: ____ County: ____________ _
Office Tele No.: Cell No.: _________ _
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Pn xo.:\e b o me.. b enh n:1 o 411 c1 ~o oL rlj
WELL CONSTRUCTION DATA (Skip to Section H if this is a P ermit RENEWAL)
_______ Number ofborlngs: --------"-.,,,,, ,,,..-
~imate depth of each boring (feet):________ .,,, __,,,/
to be used in closed-loop system (only those chemi~-indicated have been approved):
___ R-22 __ _.r ylene glycol ___ ethanol __ .,....../ _____ other (other additives will
(3) Type of tubing to be used (co
(4) Well casing. Is the well(s) cas
(a) YES
depth, and extent of cas ·
(b) NO
use)
rial surrounding well casing and/or piping):
Grout type: Cement __ Bentonite
h as~ (steel, PVC, plastic, etc.), diameter.
Other (specify) ______ _
(b) Grout depth of tubing (reference to land surface): from ___ to ___ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
u. JNJECTION-RELATEDEQUIPMENT ~D ~h.~n.9es ·f 0 r,re."tou~ a.pphca.--h<h-'\ s~-\--e.,.
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
GPU/UJC 5QM Well Permit App)jcation (Revised 7/2008) Page 2
No+e.: · \t ~-e., '"Ro~e,--,r ~\ & t'l'le.. -+o <:\, sre. ~M-~
L LOCATION OF WELL(S) ~ •• S Sec..to-,-, •
Attach two copies of maps showing the following information:
(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 1000 feet of the
geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
J. POTABLE WATER WELL(S)
Are there any potable water well(s) on the subject property or adjacent properties? __ YES _x_No
If Yes, than indicate location on attached map(s).
K. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the recorded legal propel_'ty deed.
"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 ftie injection well and
all related appurtenances in accordance with the approved specifications and conditions.of the Permit."
RECENED/OENR/OWCl
~ulf8' pro,ect10n seoton
JUN 1• 20 \0
~MC'.kL~ ~ture of Property Owner/Applicant
Jo O,\-"\ C. accl Su.mmet:~tUf S:
Print or Type Full Name
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC SQM Well Permit Application (Revised 7/2008) Page3
iittlte o!North Carolina
Department of Environment and Natural Resources
· Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: WI 0 3 00 t 0 3
PermitteeName: joo,o C.. P)l.1mrnev: ~a.y s
Address : I Gg2J. La.h e.shoYe. Dr , v:e. ; Lo r n e-L· us I tJ C. +2 803 I
RECEIVED/ OENR I DWQ
AquifBr Protactlon Sectfon
JUN J4 2010
Please check the selection which most closely describes the current status of your injection well system:
1) ~ Well(s) still used for injection activities, or may be in the future.
2) □ Well(s) not used for injection but is/are used for water supply or other purposes.
3) □ Injection discontinued and: a) D WeU(s) temporarily abandoned
b) □ WeU(s) pennanently abandoned
c) D Well(s) not abandoned
4) □ Injection well(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, irrigation, monitoring, etc), including pumping rate and other
relevant information.
Well Abandonment
If you checked (3)(a) or (3)(b ), describe the method used to abandon the injection well. (Include a description of how the well
was sealed and the type of material used to fill the well if pennanently abandoned):
Permit Rescission:
If you checked (2), (3), or (4) and wm not use a weU for injection on this site in the future, you should request rescission of the
permit. Do you wish to rescind the pennit?
C, Yes ,( No
Certification:
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the infonnation submitted
in this document, and that to the best of my knowledge the information-is true, accurate, and complete."
~f-~ S1 ature Date ' '
Revised 5/06 GW/UIC-68
NA
MCDEMR
North Carolina Department of En vironment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Joan C. Summerhays
16822 Lakesbore Drive
Cornelius, NC 28031
Coleen H. Sullins
Director
May 24, 2010
Subject: Notice of Expiration (NOE)
SQM Geothermal Injection Well
Permit No. Wl0300103
Mecklenburg County
Dear Ms. Summerhays;
Dee Freeman
Secretary
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Quality (DWQ) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above-referenced operating permit for
the underground injection well system, which was issued on February 15, 2005, and expired on
February 15, 2010, has not been renewed. If you wish to keep this permit and operate the
injection well system, the permit must be renewed and issued in your name. Our records do not
indicate that the well system has been plugged and abandoned.
In order to comply with the regulatory requirements listed under North Carolina Administrative
Code (NCAC) Title 15A, Subchapter 2C, Section .0211, you must submit one of the following
fonns:
A. Application for Permit (Renewal) to Construct and/or Use a Well(s) for Injection with
Geothermal Heat Pump System for Type 5QM Well(s) if the injection well system on your
property is still active.
-OR-
B. Status of Injection Well System if the injection well system is inactive or has been-temporarily or
permanently abandoned.
If there has been a change of ownership of the property, an Injection . Well Permit
Name/Ownership Change Form must also be submitted.
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Customar Service; 1-BTT-623-6748
Internet www.ncwateiuuality.org
An Equal Opporiunl)y \ /\ffirmabve /\ction Employe r
~1rthCarolina
/vatural/11
If the injection well system is no longer being used for any purpose, it must be permanently
abandoned according to the regulatory requirements listed under NCAC Title l SA, Subchapter
2C, Section .0214. When each well is plugged and abandoned, the weU abandonment record
(Form GW-30) must be submitted to our office to certify that the abandonment was properly
conducted. If the injection well system is still active and you wish to renew your permit, the
renewal application must be submitted within 30 calendar davs of the receipt of this letter to:
Aquifer Protection Section
Groundwater Protection Unit
UJCProgram
1636 Mail Service Center
Raleigh, NC 27699-1636
Failure to submit these forms in a timely manner may result in the assessment of civil penalties
in accordance with North Carolina General Statute 87-94. For your convenience, a renewal
application and a UTC well system status form are attached along with a self-addressed envelope.
The above referenced forms are also available on-line at the DWQ website at
http://h2o.enr.state.nc.us/aps/gpu/forms.htm.
Thank you in advance for your cooperation and timely response. If you have any questions,
please call me at [phone].
Sin cerely, ·
!2. l) hrn4
Eric G. Smith, P .G.
Hydrogeo1ogist
Attachments
cc: Moore sville Regional Office APS w/o enclos ures
APS Central Files -Permit No. WI0300 103 w/o enclosur es
2
Michael F. E«sley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Dwayne Akers
Akers Custom Comfort.
128 Garden Drive
Stokesdale, NC 27357
January 1 O, 2008
Subject: Geothermal Well Installation Data
Dear Mr. Akers:
Coleen Sullins, Duector
Division of Water Quality
In review of our records concerning closed-loop geothermal mixed-fluid injection weU systems,
classified as SQM type permits, we have found the following records have not been submitted
for permits where your company is listed as the heat pump installers:
• Well Construction Record (GW-1)
• Triangulation Data
• Mechanical Integrity Pressure or Vacuum/Leak testing data
In order to assist your clients (those who hold SQM permits) in meeting the condition of their
permits, we request your assistance to provide the above information no later than February 29,
2008. For future reference, we recommend you provide this information to your clients as soon
as construction is complete to assist them in meeting the condition of their permits. Also, please
remember their permits require them to keep this information on-site as well.
To assist you, we have attached a list of permits where you are listed as the heat pump installer.
We have also attached a form to fill out the results of your mechanical integrity tests. Thank you
in advance for your cooperation and timely response. If you have any questions regarding this
letter, please call me at [phone] or Michael Rogers at (919) 715 -6166.
Attachment(s)
Sincerely,
~~~
Debra J. Watts
Environmental Supervisor
Grounc;iwater Protection Unit
cc: APS:Cen~al Files (copy to each permit file on attached list)
Each Permittee on attac)led list
Aquifer Protection Section
Internet www.ncwarcroualitv.org
1636 Mail Service Center
Location : 2728 Capital Boulevard
An Equal Opportunity/Affirmative Action Employer-50% Recycled/10% Post Consumer Paper
Raleigh, NC 27699-1636
Raleigh, NC 27604
Telephone :
Fax 1!
Fax2:
Customer Service:
N%>"iThCarolina ;vatura/111
[phone]
(919) 71S-0588
(9 I 9) 715-6048
[phone]
Issued Permits with Akers Custom Comfort Listed as Heat Pump -Contractor
January 10, 2008
Permit No. Name Date Permit Issued
WI0400038 Charles Collins · 4/14/2004
WI0400039 Jason Mohom · 4/14/2004
WI0300103 Joan Summerhays , 2/1 5/2005
W I0300109 Dan Hurlbut '3/31 /2006
W I0400088 Marianne Janssen 8/13/2007
WI0300119* Da vi d Revelle 11 /27/2007
*Permit recenUy Issued.
I
Mechanical Integrity Test Record
(For SQM Geothermal Heat Pump Injection Well System)
Owner/Permittee Name: Permit Number: WI -----------------'-'--'--------
Facility Address: ____________________________ _
Home Phone: Cell Phone: --------------------==-=a..=...:=="------------
H eat Pump Contractor Name: _________________________ _
Office Phone: Cell Phone: ----------------=-==--=-=~-----------
Test er Name: ______________ Signature: ______________ _
Oate of Test: --------
Loop Initial Pressure (usi) Final Pressure (usi) Duration (minutes)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Any additional loop testing add to back of this form
Comments:
Pass (Y es or No)
--------------------------------
Other Test Methods and Results:·
This form mu.st be filled out and sjgned by the tester. The record must be received by Aquifer Protectjon Section 24 hours
prior to the initiation of the operation of the facility. You can send the form by mail: UIC Program, Mail Service Center 1636,
Raleigh, NC 27699 or by fax: [phone].
Mechanical Integrity Test Form 11/2007
A QUIFER PROTECTION PERMITTING INFORMATION TRANSMITTAL MEMO
Date: February 15, 2005
To: Andrew Pitner
:MRO-APS
Copies Sent: 1 J/ __
E!:Qm: Evan Kane4fuii-er Protection Section
Telephone: [phone]
E-Mail: [e-mail]
Subiect: Permit Number WI0300103
Fax: [phone]
The attached documents for the subject pennit application are being transmitted to you for:
For RO:
X Additional information for your files -no review is necessary
D Additional information for your review -please update Form NDSRR and returtl.
D Additional information for your review -please complete Form NDSRR.
D Additional information for your review -attach Attachment B for Certification.
D Documents misdirected -for you to take action as appropriate.
For co-reviewers:
D Additional information for your files -no review is necessary
D Additional information for your review -please update the appropriate review form.
D Additional information for your review -please return the appropriate review form .
Thanks to you and Kevin Bubak for your assistance with this permit.
I
FORM: APPITM 040928 Page 1 of 1
. WAi: ·
.. '111;
•·t;j y > ..... , ___ c
·--i o"C==~~--<
Ms. Joan C. Summerhays
16822 Lakeshore Drive
Cornelius, NC 28031
Dear Ms. Summerhays:
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
February 15, 2005
Alan W. Klimek, P.E. Director
Division of Water Quality
In accordance with your application submitted on January 24, 2005, we are forwarding Permit Number
Wl0300103 for the operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well
system at 16822 Lakeshore Drive in Cornelius, North Carolina.
This permit shall be effective from the date of issuance until February 15, 2010, and shall be subject to the
conditions and limitations stated therein. In order to continue uninterrupted legal use ohbis well for the stated
pUipo se, you should submit an application to renew the permit 120 days prior to its expiration date. As
indicated in the .permit, this permit is not transferable to any person without prior notice to, and approval by, the
Director of the Division of Water Quality.
Please read the permit carefully to be sure you understand all its conditions before constructing and
operating the injection well system. If you have any questions regarding your permit, please call me at
(919)7 15-6182.
Evan 0. Kane, P.G.
Underground Injection Control Program Manager
cc: fi1e
Mooresville Regional Office
Akers Custom Comfort
Aquifer Protection Section
Jntemet: http://h2o.enr.state.nc.us
1636 Mail Service Center Raleigh , NC 27699 -1636
2728 Capital Boulevard Raleigh, NC 27604
An Equal Opportunlty/AfflrmatiVe Action Employer-50% Recycied/10% Post Consumer Paper
N~Carolina
/\ltl/ldtl/lfl
Phone [phone] Customer Service
Fax [phone]
Fax [phone]
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, ~ORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and
other applicable Laws, Rules, and Regulations
PERMISSION rs HEREBY GRANTED TO
Joan C. Summerhays
FOR THE CONSTRUCTION AND OPERATION OF A TYPE SQM INJECTION WELL,
defined in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of
operating a vertical closed-loop geothermal-mixed-fluid heat pump system. This system is
located at 16822 Lakeshore Drive, in Cornelius, Mecklenburg County, North Carolina, and will
be constructed and operated in accordance with the application submitted January 24, 2005, and
in conformity with the specifications and supporting data submitted, all of which are filed with
the Department of Environment and Natural Resources and are considered a part of this permit.
This permit is for Construction and Operation only, and does not waive any provisions of the
Water Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an
injection well shall be in compliance with Title lSA North Carolina Administrative Code 2C
.0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well construction and
use.
This permit shall be effective, unless revoked, from the date of its issuance until February 15,
2010, and shall be subject to the specified conditions and limitations set forth in Parts I through
IX hereof.
Permit issued this the ((.~ day of f Jo{ U.f>(7f , 2005 .
t Ted L. Bush, Jr., Chief
Aquifer Protection Section
Division of Water Quality
By Authority of the Environmental Management Commission.
PermitNo. WI0300103
5QM.J>X ver. 2/05
PAGE lOF/1
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided
for in N.C.G.S. 87-94.
2. Th.is permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall be constructed in such a manner that water from land surface
cannot migrate into the grave) pack or well screen.
5. Each injection well shall be secured to reasonably insure against w1authorized access and
use. Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each wellmustbe secured with a locking cap.
6. Each injection well shall be afforded reasonable protection against damage during
construction and use .
7. Each injection well shall have permanently affixed an identification plate.
8. A completed Well Construction Record (Fonn GW-1) must be submitted for each injection
well to, DENR-Division of Water Quality, Aquifer Protection Section VIC-Staff, 1636
Mail Service Center, Raleigh, NC 27699-1636, within 30 days of completion of well
construction.
PART TI -WELL CONSTRUCTION SPECIAL CONDITIONS
1. Prior to constructing the injection well system, the permittee or his agent shall test the pH of
the soil at a depth of three feet at the planned well location. If the resulting soil pH is less
than 6 standard units or greater than 11 standard units, the well system shall be equipped with
a compatible cathodic protection system.
2. At least forty-eight (48) hours prior to constructing each injection well, the Permittee shall
notify the Aquifer Protection Section-Undergrowid Injection Control (UIC), Central Office
staff, telephone number (919) 715 -6182 and the Mooresville Regional Office Aquifer
Protection Section Staff, telephone number [phone].
3. All underground tubing shall be refrigeration grade copper tubing.
PennitNo. WI0300103
5QM-DX ver. 2/05
PAGE20F7
4. Prior to installation. all tubing to be placed in boreho les ("loops") shall be checked for leaks
by pressurizing the loop to a gage pressure of at least 350 pounds per square inch (psig),
immersing the loop in water and examining it for leaks. Loops with leaks shall not be
installed. A copy of the l eak test record (quality control tag) shall be submitted to the Aquifer
Protection Section within 30 days of completion of well construction.
5. Prior to installation, each loop shall be visually inspected for damage such as kinks, dents,
and scrapes. Each loop shall be checked to verify that the nitrogen charge applied to the loop
by the manufacturer before shipping is still present at a pressure of at least 300 psig. The
loop manufacturer shaJl be notified in the event of damage or pressure loss, and the
manufacturer's instructions shall then be followed. The nitrogen charge may be released only
when the loop is installed and ready to be connected to the manifold.
6. Boreholes shall be of sufficient size to allow for insertion of the loop as well as a tremie pipe
for grouting.
7. After insertion of the tubing into the boreholes, an approved grout (as defined in Title ISA
North Carolina Administrative Code 2C .0100) shall be pumped via tremie pipe into the
annular space of each borehole so as to completely fill it from bottom to top.
8. All tubing junctions shall be brazed using lead-free brazing material. The brazing material
shall have a galvanic potential as close as practicable to that of the tubing material.
9. Dry nitrogen shall be circulated through the tubing during brazing to prevent oxidation of the
tubing.
10. After installation and prior to operation of the system, a mechanical integrity test shall be
conducted by pressurizing the injection well system to 400 psig with dry nitrogen and
monitoring for leaks using an ultrasonic or other leak detector of equal sensitivity and
monitoring pressure in the system for at least 2 hours. Any pressure fluctuation other than
that due to thermal expansion and contraction of the testing medium shall be considered a
failed mechanical integrity test. Any leaks shall be located and repaired prior to charging the
system with refrigerant.
11. The location of each of the system manifolds shall be recorded by triangulation from two
permanent features on the site (e.g., building foundation comers). The permittee shall retain a
copy of the triangulation records. The permittee shall also submit a copy of the triangulation
records to the Aquifer Protection Section within 30 days of completion of well construction.
12. The written docwnentation r equired in Part II, paragraphs (4) and (1 1) shall be submitted to:
Permit No. WI0300103
SQM-DX
Aquifer Protection Section--UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
ver. 2/05
PAGE30F7
PART Ill -OPERATION AND USE GENERAL CONDITIONS
1. This pennit is effective only with respect to the nature, volume of materials and rate of
injection, as described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to
change ownership, or there is a name change of the Permittee, a formal permit amendment
request must be submitted to the Director, including any supporting materials as may be
appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of
complying with any and all statutes, rules, regulations, or ordinances which may be
imposed by other local, state, and federal agencies which have juriscliction. Furthermore,
the issuance of this permit does not imply that all regulatory requirements have been met.
PART IV-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there
is no contamination of groundwater which will render it unsatisfactory for normal use. In
the event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility.
2 . The Permittee shall be required to comply with the terms and conditions of this permit
even if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for dam~ges
to surface or groundwater resulting from the operation of this facility.
PART V • OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection fac i lity shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the
Director of any planned physical alterations or additions in the permitted facility or activity
not specifically authorized by the permit.
3. At least forty-eight ( 48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Aquifer Protection Section-
Underground Injection Control (VIC), Central Office staff, telephone number (919) 715-
6182 . Notification is required so that Division staff can inspect or otherwise review the
Pennit No. WI0300103
SQM-DX ver. 2/05
PAGE40F 7
injection facility and determine if it is in compliance with permit conditions.
PART VI -INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place on
or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained
under the terms and conditions of this permit, and may obtain samples of groundwater,
surface water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided
for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary
by the Division of Water Quality to insure surface and ground water protection, will be
established and an acceptable sampling reporting schedule shall be followed.
2. The Permittee shall report by telephone, within 48 hours oftbe occurrence or first
knowledge of the occurrence, to the Mooresville Regional Office, telephone nwnber
(704)663-1 699, any of the following:
(A) Any occurrence at the injection facility which results in any unusual
operating circwnstances;
(B) Any failure due to known or unknown reasons, that renders the facility
incapable of proper injection operations, such as mechanical or electrical
failures;
(C) Any loss of refrigerant in the system, regardless of the origin of the Joss ;
(D) Any recharging of the refrigerant system.
3. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said application or in any report to
the Director, the relevant and correct facts or information shall be promptly submitted to
the Director by the Pennittee.
Permit No. W10300103
SQM-DX ver. 2/05
PAGE50F7
4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall
take such immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
The Permittee shall, at least 120 days prior to the expiration of this permit, request an
extension.
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of
an injection well. Such a change would include the discontinued use of a well for
injection. If a well is taken completely out of service temporarily, the Permittee must
install a sanitary seal. If a well is not to be used for any pwpose that well must be
permanently abandoned according to 15A NCAC 2C .0213(11)(1 ), Well Construction
Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
pwpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0214, including but not limited to the following:
(A)
(B)
(C)
(D)
(E)
(F)
PennitNo. WI0300103
5QM-DX
All casing and materials may be removed prior to initiation of
abandonment procedures if the Director finds such removal will not be
responsible for, or contribute to, the contamination ofan underground
source of drinking water.
The entire depth of each well shall be sounded before it is sealed to insure
freedom from obstructions that may interfere with sealing operations.
Each well shall be thoroughly disinfected, prior to sealing, if the Director
determines that failure to do so could lead to the contamination of an
underground source of drinking water.
Each well shall be completely filled with cement grout, which shall be
introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
In the case of gravel-packed wells in which the casing and screens have
not been removed, the casing shall be perforated opposite the gravel pack,
at intervals not exceeding 10 feet, and grout injected through the
perforations.
In those cases when, as a result of the injection operations, a subsurface
cavity has been created, each well shall be abandoned in such a manner
that will prevent the movement of fluids into or between underground
PAGE 60F 7
ver. 2/05
sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30)
as specified in 15A NCAC 2C .0213(h)(l) within 30 days of completion of
abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be·submitted to:
Permit No. WI0300 103
5QM-DX
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh. NC .27699-1636
ver. 2/05
:i>AGE70F7
'
DMSION OF WATER QUALITY
GROUNDWATER SECTION
February 11, 2005
MEMORANDUM
TO:
FROM:
RE:
Debra Watts 6-) @ ·
EvanKane lfl
Injection Well Permit for Direct Expansion Heat Pump:
Summerhays, WI0300103, Mecklenburg County
Joan C. Summerhays has applied for a permit to construct and operate closed-loop, mixed-fluid
geothermal injection well system as part of a vertical direct expansion (DX) heat pump system at a
residential site. I recommend that the requested pennits be issued and offer the following summary
to assist you in evaluating this recommendation.
Direct Expansion Background : A vertical DX heat pump system entails burying copper
refrigeration tubing in vertical boreholes connecting the tubing to a heat pump and circulating
Freon 22 (R-22) through the subsurface portions of the system in order to exchange heat directly
with the ground. According to the manufacturers, direct expansion heat pump systems are much
more efficient th.an traditional air-to-air h eat pump systems, which exchange heat by passing
outdoor air over refrigeration coils, or even water-source heat pump systems, which exchange heat
by circulating water through a heat exchanger. Under the injection well regulations in 15A NCAC
2C .0200, vertical DX systems meet the definition of a "closed-loop geothermal-mixed-fluid heat
pump injection well system" (15A NCAC 2C .0209(E)).
Site Description: This site is an existing home served b y c ity water but with an onsite septic
system. Maps submitted with the application and the site inspection conducted by Kevin Bubak
indicate that the proposed injection well locations comply with the required minimum separation
distances from the septic system. Ten injection wells wµl be drilled to approximately 50 feet each.
Each borehole will be grouted from 5 feet bls to 50 feet bls after insertion of the copper tubing
loop.
Special Permit Conditions: I have incorporated several changes to the standard SQM injection well
permit conditions in the attached permits. These are the same special conditions that we used in
the first two DX system permits we issued in April 2004 and are incorporated into the "SQM-DX"
shell on the I: drive:
1. Part II -Well Construction Special Conditions:
a. Soil pH testing m u st be performed prior to system installation and cathodic
protection must be installed if pH is less than 6 or greater than 11.
b. All underground tubing shall be constructed ofrefrigeration grade copper. This
ensures a minimum standard for the quality of the copper tubing used.
l of2
c. Tubing must be leak tested prior to installation.
d. Tubing must be inspected before insertion into the borehole, including checking fo r
a factory-applied pressure charge.
e. Brazing material (solder) must be lead-free and must have a galvanic potential as
close as practicable to that of the copper tubing. This is to prevent a galvanic
corrosion reaction between dissimi lar metals at soldered joints.
f. Nitrogen must be circulated through the tubing during brazing (soldering) to prevent
oxidation corrosion of the tubing.
g. The system must pass a mechanical integrity test prior to being charged with
refrigerant.
h. Manifo ld (tubing header) locations must be recorded by triangulation. Records of
this must be retained by the permittee and submitted to us for our records. This is to
aid in locating leaks or damaged portions of the system.
2 . Part VII -Monitoring and Reporting Requirements: In addition to the standard
re-quirements that the pennittee report system malfunctions and system modifications to us,
I have added conditions that the permittee report to us any 1oss of refrigerant from the
system, regardless of the origin of the loss, as well as any recharging of the refrigerant
system. The purpose of these reporting requirements is to ensure that if a leak occurs, we
are informed before the leak is "repaired" or diagnosed simply by repeatedly recharging the
refrigerant. In this way, any leaks that might impact groundwater will be limited in volume
(so long as the applicant complies with these permit conditions).
fu summary, I believe that through a combination of quality control and installation standards and
the testing, installation and reporting requirements of the permit, groundwater quality can be
protected from potential impacts of a vertical DX system at this site. Therefore I feel it is
appropriate to issue this permit.
2 of2
,.
MOORESVILLE REGIONAL OFFICE
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
February 9, 2005
0
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GJ
MEMORANDUM -0 :::::
To:
From:
Enclosed:
Evan Kane Central office
Kevin Bubak Hydro Tech 1
r:::,
N c..n
Aquifer Protection Staff Report Site review for Proposed UIC closed
loop system for Jody Summerhays
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AQ UIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: January 24. 2005
0 LandonDavidson, ARO-APS
0 Art Barnhardt, FRO-APS
l2J Andrew Pitner, MRO-APS
0 Jay Zimmerman, RRO-APS
0 David May, WaRO-AfS
0 Charlie Stehrnan, WiRO-APS
0 Sherri Knight, WSRO-APS
From: Evan Kane , Groundwater Protection Unit 1.i-
Telephone: (919 } 715-6182 · Fax: [phone]
E-Mail: [e-mail]
A. Permit Number:
B. Owner: Jodv Summerhavs
C. Facility/Operation:
l2J Proposed D Existing D Facility D Operation
D. Application:
1. Permit Type: D Animal O Surface hrigation D Reuse D H-R Infi1tration
D R ecycle O 1/E Lagoon D GW Remediation (ND)
l2J UIC -(SQM) closed loop mixed fluid geothermal "Direct Exp ansion" heat
pump svstem
For Residuals: 0 LandApp.
0 503
0D&M
D 503 Exempt
0 Surface Disposal
D Animal
2. Project Type: 181 New O Major Mod. 0 Minor Mod. 0 Renewal D Renewal w/ Mod.
E. Comments/Other Information: D I would like to accompany you on a site visit.
S vstem circulates R-22 (Freon} in copper tubina . We have permitted two other s vstems of this type in the
Winston-Salem Region. I have attached a copy of one of these permits so y ou can see the type of sp ecial
conditions we·have req uired in the p ast.
NC DEPT Of ENVIRONMEN I
Attached, you will find all information submitted in support of the abo~~W'-ilfai~~ for your
review, comment, and/or action. Within 30 calendar days, please take the.followmg actions:
~ Return a Completed Form APSSRR. JAN 2 ~ 2005
D Attach Well Construction Data Sheet.
0 Attach Attachment B for Certification by the LAPCU. MOORESVILLE REGIONAL OFFICE
0 Issue an Attachment B Certification from the RO*. DWO-GROUNOWATER SECTION
• Remember that you will be re sponsible for coordinating site visits, reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person
listed above.
RO-APS Reviewer: __________________ Date: ____ _
FORM: A.PSARR 09/04 Page 1 of 1
AQUIFER PkvTECTION REGIONAL STAFF REPORT
JV. INJECTION WELL PERMIT AP PUCA TJONS (Comp lete these two sections for all systems that use injection
wells, including closed•Joop growidwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well{S) And Facilities -New, Renewal, And Modification
t. Type ofinjection system:
D Heating/cooling water return flow (5A7)
~ Closed-loop heat pump system (SQM/SQW)
D In situ remediation (SI)
0 Closed-loop groundwater remediation effluent injection (SL/''Non-Discharge")
0 Other (Specify: )
2. Does system use same welJ for water source and iajection? D Yes
3. Are there any potential pollution sources that may affect injection? 0 Yes !Kl No
What is/are the pollution source(s)? . What is the distance of the injection welJ(s) from the pollution
source{s)? ft.
4. What is the minimum distance of proposed injection wells from the property boundary? ---=ft.-=
5. Quality of drainage at site: ~ Good D Adequate D Poor
6. Flooding potential of site: ~ Low D Moderate D High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes O No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: __
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? ~ Yes or O No. If
no or no map, please attach a sket.ch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
In jection Well Permit Renewal And Modification Onlv:
1. For heat pump systems, are there any abnormalities in beat pump or injection well operation (e.g. turbid water,
failure to assimilate injected ·fluid. poor heating/cooling)?
D Yes D No. If yes. explain;
2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? D Yes i, No. If yes. explain:
3. For renewal or modification of groundwater remediation permits (of any type). will
continued/additional/modified injections have an adverse impact on mhrration of the plume or management of
the contamination incident? D Yes D No. If ves, explain:
4 . Drilling contractor: Name: __
FORM: APRSR040929· J •staff report template.doc 4
-· .•
.•
.. ...
I
AQUIFER P .n.OTECTION REGIONAL ~ .t 'AFF REPORT
Address:
Certification number: __
5. Complete and attach Well Construction Data Sheet.
FORM: APRSJl040929-1-staffreport template.doc 5
AQUIFER P ... JTECTION REGIONAL S Jl AFF REPORT
V. EVALUATION AND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application.:
2. Attach Well Construction Data Sheet -if needed infonnation is available
3. Do you ' foresee any problems with issuance/renewal of this permit? D Yes ti No. If yes, please explain
briefly. ---"
4. List any items that you would like AP$ Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:.
Item Reason
5 . List specific Permit conditions that you recommend to be removed from the permit when issued, Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each ~cial condition:
Condition Reason
7 . Recommendation: D Hold, pending receipt and review of additional infonnation by regional office; D HoJd,
pending review of draft permit by regional office; D Issue upon receipt of needed additional information; i1
Issue; D Deny. If deny, please state;,;o~:
8. Signature of report preparer(s): --'-/-=-~--'-,-....;----P,---1---.--=~~,f'~=-t~:::::::::::_-----
Signature of APS I gional supervisor.
Date: -i_ \ C\ oS-
'
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: APRSR040929-l-staff report template.doc 6
North Carolina Division of Water Resources
Grolllld Water Section
Attn. Mr. Evan Kane
1636 Mail Service Center
Raleigh, NC 27699-1636
January 19, 2005
~
Akers Custom Com.fort, Inc.
128 Gordon Dr. Stokesdale, NC 27357
Office [336) 427-7882 Fax [336) 427-6750
Re: Application for Permit; DX Geothermal Heat Pump Loop [Vertical] installation
.Mr. Kane,
0 c.n
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O>
Enclosed is an application to perm.it and install two DX Geothermal Heat Pumps at the residence of Mrs. Joan "Jody" Summerhays at
16822 Lake Shore Dr. in Cornelius, NC. The first application was sent Decem~ 23, 2004. I received the damaged documents back
today and I am resubmitting the application.
This is an existing home and is a .retrofit application. The installation will follow the guidelines ~ previously established in the other
DX installations [pressure/tank testing and grouting procedures]. Enclosed are two copies of the application, site survey map, topo-
graphic map and installation specifications. Soil tests reveal a pH of 6.0. The home is on public water as are all homes in the area. The
septic field is in the rear of the home and exceem the minimum fifty-foot distance requirements. The proposed loop field is in the front
of the home at the left front comer. Underground Locators have been contacted to locate the utilities and ensure safe minimum
distsnces to the loop field. The loop field will be marked on the lawn fur the local inspector to observe during bis site visit once UL
bas completed their work.
If you have any questions, please contact me at 336-681-8496. I look forward to talking with you soon.
Sincerely,
Dwayne Akers
Akers Custom Comfort
1
TO:
A .
B.
C.
D.
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A
WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM
Type SA7 and SQM Wells
ln Accordance with the provisions ofNCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
DIRECT~, ~JlTH CAROLINA DJsf ION OF WATER QUALITY
DATE: l -I , 20 I
SYSTEM CLASSIFICATION Please check column which matches proposed system.
(1) Type 5A7 wells inject water used to provide beating or cooling for structures.
(2) _t Type SQM wells contain a subswface system of continuous piping, that is
(3)
isolated from the environment and circulates a fluid other than potable water.
This includes systems that circulate additives such as antifreezes and/or corrosion
inhibitors.
Type 5QW wells contain a subsurface system of continuous piping. that is
isolated from the environment and only circulates potable water. H you selected
this wen type, then comp letefonn GW-57 C L, Notification Of Intent To
Con:rtnlct A Closed-Loop Geothermal-Water Only Injection Well System.
PERMIT APPLICANT
Name: mes I -:::;oD~ ::i-rrm~~ (aka, Joan c. SvM~h~
Address: 11, g;p L4h;: ~:ih~ ~-
city: Ctue/i:;Ls State: bC.. Zip C.ode#io3/ County/YI~~
Telephone: 1M: /;,SS"'-(7(,ilQ
PROPERTY OWNER (if different from applicant)
Name: ________________________ _
Address : _______________________ _
City: ________ Sate: __ Zip Code: ___ County: ___ _
Telephone: ________ _
STATUS ~PLICANT
Private: + Federal: __ Commercial:
State:__ Municipal: __ Native American Lands:
GW-57 HP (Jan, 2000) Page I of4
E. FACILITY (SITE) DATA
F.
G.
H.
1
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: _________________ _
Address: _______________________ _
City: ________ Zip Code: ____ County: ______ _
Telephone: _________ ContactPerson: ________ _
HEATPW.P CONTRACTORDAT~~
Name: /dl(L;gs C 1;, ~ ~t!1!!l?r:
Address:, JZ~ ~hU<. ~ - -
City: :5r4eotlf'. Zip Code: /I C County: :
Telephone: 33'r f./:71-1182: Contact Person: L:1.,~ i
INDJECTION PROCEDURE (Briefly describe how the injection well(s) will be used.)
. :X bfr1mdrnAI 1./mr: /Jv~
WELL USE Will the injection well(s) also be used as the supply well(s) for the following?
(J) The injection operation? YES 'f NO --c---
(2) Personal consumption? YES -= NO ~
CONSTRUCTION DATA (check one)
(1)
(2)
(3)
.EXlSTJNG WELL being proposed fof use as an injection well. Provide the data in
(1) through (7) below to the be6t of your knowledge. Attach a copy of Fonn GW-
1 (Well Construction Record) if available.
'k PROPOSED WELL to be constructed for use as an injection well. Provide the
data in (1) through (7) below as PROPOSED construction specifications. Submit
Fonn GW-1 after constru~n. ·? _ _ ...,_
Well Drilling Contractor's Name: + lo'd f) U. ~
NC Contractor Certification number: ....;;.~_1/........,.S'-'3""'--------
Date to be constructed: . I -30-05 Number ofborings: _._{-=-0 __
Approximate depth of each boring (feet);_-=5◄-'0"------
WeD casing: ls the well(s) cased?
(a) YES lfyes, 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 ~
GW-57 HP (Jan, 2000) Page2 of4
(4) Grout (material surrounding well casing and/or piping):
(a) Grouttype: Cement__ Bentonite __ Other(specify) G...12 /¾o ~
(b) Grouted snrlace and grout depth (reference to land surface):
V aro\Dld closed loop piping; from 5 to ::Jo (feet).
__ around well casing; from __ to __ (feet).
(5) Screens (for Type SA 7 wells)
(a) Depth: From ....fi_ to~ feet below ground surface.
(6) N.C. State Regulations (Title ISA NCAC 2C .0200) require the permittee to make provisions
for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) and
effluent (fluid being injected into the well) lines is required. Will there be a faucet on:
(a) the influent line? yes--X_ no_·_ (b) the effluent line? yes_L no __
(7) SOURCE WELL CONSTRUCTION INFORMATION (if different from injection well).
Attach a copy of Form GW-1 (Well Construction Record). If Fonn GW-1 is not available,
provide the data in part K ( 1) of this application form to the best of your knowledge.
NOTE: TliEWELLDRllJ.JNGCONTllACTORCANSUPPLYTHEDATAFOREITHEREXISTJNOOR
PII.OPOSED WELLS IF THIS INFORMATION IS UNAV All.ABLE BY OTif.ER MEANS.
J. PROPOSED OPERATING DATA {for Type SA7 wells)
(l) Jnjection tate: Average (daily) gallons per minute (gpm).
(2) .Injection Volume: Average (daily) gallons per day (gpd).
(3) Injection Pressure: Average (daily) pounds/square inch (psi).
(4) Injection Temperature: Average (January) ° F,Average(July) __ ° F.
K. INJECTION FLUID DATA
(t) Fluid source (for Type SA7 wells) I f underground, from what depth, formation and type of
rock/sediment unit will the fluid be drawn (e.g., granite, limestone, sand, etc.).
Depth:. _____ Fonnation: _____ Rock/sediment unit ____ _
(2) Chemical Analysis of Source Fluid (for Type SQM wells)
Pr~de a compl~ lis~ng of all chemicals added to the circuJating heat trans.fer fluid:
"'. tlfJ i:{~i:GJrt,
L. INJECTION-RELATED EQULPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior pipinw"tubing
associated with the injection operation_ The manufacturer's brochure may provide supplementary
infoanation.
GW-57 HP (Jan, 2000) Page 3 of4
M . WCATION OF WELL(S) Attach two maps.
( 1) Lnclude 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 1000 feet of the geothermal heat pump well system. Label all
features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name.
N. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(I) Hazardous Waste Management program _permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits
O. CERTlFlCATION
u1 hereby certify, under penalty of law, that l have personally examined and am familiar with the
infonnation 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. 1 am aware that there are significant penalties, including the posS1oility
of fines and imprisoament, fur submitting false information. J agree to construct. operate, maintain,
repair, and if applicable, abandon the injection well and all related appurtenances in accotdance with
the approved specifications and conditions of the Pennit."
~:h.n~)
If authorized agent is acting on behalf of the well owner.
please supply a letter gigned by the owner authorizing the above ~ent.
P. CONS.ENT OF PROPERTY OWNER (Owner means any person who boJds the fee or other property
rights in the well being constructed. A well is reaJ property and its constroction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
Jf 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 Uiat it shall be
the responsibility of the applicant to ensure that the injection well(s) confonns to the Well
Construction Standards (Title 15A NCAC 2C .0200)
GW-57HP (Jan,2000)
(Signature Of Property Owner 1f Different From Applicant)
Please return two copies of the completed Application package to:
UJC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mall Service Center
Raleigh, NC 27699-1636
Telephone (919) 71S-6165
Page4 of4
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BASE FLOOD ELEV. • 761.0'
ARST FLOOR El.V. • 764.0'
LO'ift:ST ADJ. Et.V. • 763.8'
2.No FLOOR av. -n2.5'
HIGHEST ADJ ELV. • 770.8'
GARAGE ELV. .. 771.0 '
A/C a£VATION .. 76 11.1 '
LAKE NORMAN
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l>ATB ot: Physical Survey of
SurYey 04/12/01
l>ralfinc 04/12/01
lob No: 2311
1 6822 LAKE SHORE DRIVE
CORNELIU S, NORTH CAROLINA 28031
EIP
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File: 168221.AKE
o,,o.,, by. l(O( LEMLEY TOWNSHIP, MECKLENBURG COUN1Y
'vlCINITY MAP -Not to Soole
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CurrenUv Owned bv; Vernon CurtlH Smith & Jana Reed Smith To be Conve.,..d to Brion P. Llnde llt KathlHn Lind•
Print Map
Map for 16822 Lake Shore Dr 28031
L ocation of 16822 Lake Shore D r 28031
1:12,000
Lake Norman South
7 .5-minute Quadrangle Index map
NC SPCS E: 436618.7, N:189778.5 meters (NAD83)
Long: -80.9056470 W, Lat: 35.4458224 N (NAD83)
http://gis.enr.state.nc.us/topoviewer/ gisprint.j sp
Page 1 of 1
1/10/2005