WI0300184_GEO THERMAL_20111018

Permit Number WI0300184
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Jacob Deal SFR
Location Address
1113 Gregory Ln
Statesville
Owner
Owner Name
Jacqb
Dates/Events
NC 28677
Deal
Scheduled
Orig Issue
10/18/11
App Received Draft Initiated Issuance
10/07/11
Regulated Activities
Heat Pump Injection
Outfall t·c1ULL
Central Files: APS_ SWP_
10/18/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Randall Cutter
6105 Rest Home Rd
Claremont NC
Major/Minor
Minor
Region
Mooresville
County
Iredell
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Jacob Dea·I
1113 Gregory Ln
Statesville
Public Notice Issue
10/18/11
NC
Effective
10/18/11
28610
28677
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Jacob P. Dean
1113 Gregory Lane
Statesville, NC 28677
• t •
A;;h
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
10/19/2011
Subject: Acknowledgement oflntent to Construct Type SQW Injection Well System
Permit No. WI0300184
1113 Gregory Lane, Statesville, NC 28677
Dear Mr. Dean:
Dee Freeman
Secretary
On October 7, 2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onlv
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 ISA Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Iredell County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please .contact Mike Rogers at [phone] or Michael.Rmi:ers(@ncdenr. uov if you have any questions.
cc: Mooresville Regional Office -APS
APS Central Files -Pennit No. Wl0300184
Iredell County Health Dept.
Go! Green Drilling, Inc (Randall Cutter)
JP Plumbing & Heating
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location : 2728 Capital Boulevard, Raleigh. North Carolina 27604
Sincerely,
O~A-~
for Debra Watts
Supervisor
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service : 1-877~23-6748
Internet: www.ncwateraua litv.o ro
An Equal Opportunity I Affirmative Action Employer
N°1!S.1-..c 1· 01. u1 aro 1na
v1Vaturall{I
C. WELL DRR,LER INFORMATION
Company Name: G o! Green Drilling, Inc.
Well Dpller Contractor's Name: __ ___:;Ra=n=daJ==-..;.l E=.'-'C=utt=er-=----------------
ii
NC Co.1).tractor Certification No.: --~2'-=-8=18"-'·A=-=--------------------
Contact Person: Randall Cutter EMAIL Address: randy@g oi!reendrilli ng .com
Addres~: 6105 Rest Home Rd.
~
City: :: Clarem ont Zip Code: 28610 County: __ C~ata=--'w-'---'b'---=a ______ _
Office f ele No.: ___ 8_2_8-...... 3 ...... 67_-~12=9...c..3 ____ Cell No.: 828-228-1695
'
D. HEAT ~UMP CONTRACTOR INFORMATION '(if different than driller)
Compaby Name: JP Plumbing & Heating
Conta~Pers~n.: ___________ E.MAIL Address: ____________ _
Addrest: 235 North Center Street
)
City: Statesv ille Zip Code: 28677 County: ---=Ire=-==de=ll"'--. ___________ _
Office Tele No.: [phone]
!
Cell No.:. ____________ _
E. STATUS OF' APPLICANT
I
Private:\ X Federal: __ _ Commercial:_
State:~ Municipal: __ Native American Lands: __ _
F. INJECi:nON PROCEDURE (briefly describe how the injection well(s) will be used)
Water ONLY closed Joop geothermal verticaJ loops
G. WELLCONSTRUCTION DATA
(1) ProJ1osed date to be constructed: 10/10/2011 Number of borings: __ 4'-----
\ Approximate depth of each boring (feet): ___ 1 __ .7 __ 0' _____ _
;
(2) Type of tubing to be used (copper, PVC, etc): High Density Polyethelene
(3) We!! casing. Is the well(s) cased? (check either (a.) Yes _.2.[ (b.) No below)
(a) ::ves __ if yes, then provide casjng information below
!r
Typei: ____galvanized steel _black steel _plastic _other (specify)
Casi~g depth: From ___ to ___ f.eet (reference to land surface)
)
Casitg extends to above ground __ inches
(b) !No _x_
(4) Gro*t Info (material surrounding well casing and/or piping):
;(a) Grouttype: NeatCement__ Bentonite.X... Other (specify) Thermal-Enhanced
j
i (b) Grout placement: Pumping _x_ Pressure __
\(c) Grout depth of tubing (reference to land surface): from
j
Other __
0 to ..l1Q_(feet)
If well has casing, indicate grout depth: from ___ to __ (feet)
GPU/UIC SQW No~fication of Intent Form (Revised 812008) Page2
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELL(S)
In Accordance with the provisions of NCAC Title BA: 02C.0200, please
complete this notification and mail to address on the Back page (please Pint or Type information).
DATE: October 6 , 20 11
A.
L.
Well7, pe Confirmation: Does the proposed system circulate potable water on1Y (no additives) in
continuous piping that completely isolates the fluid fimm the environment (i.e.
closed -loot)?
Yes X Continue completing this form.
No _ Do Not complete this form. Complete other LIC application farms for installing either a
SA7 well o n-loop well injecting potable water into the aquifer) or a 5QM well (closed -loop
well containing additives such as R-�2, ethanol, or other antifreeze or corrosion inhibitors).
PROPERTY OWNER(S)IAPPLICANT(S)
List'each.Propefty Owner listed o i;pi operty. deed (if awned by a business or government agency, state name of
entity and a representative wlauthority for signature):•
(1) Mailing Address:1113 Greyory Lane
City: Statesville State: NC Zip Code: 28677 County: Iredell
Home/Office Teie No.: Cell No.: [phone]
Email Address: 'aeobra7' s h.com Website:� www�,sph.corn
(2) Physical Address of Well Site (if different than above): Same
City: State: Zip Code: County:
Home/Office Tele No.: Cell No.:
AUTHORIZED AGENT OF OWNER, 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 UC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City:
State: Zip Code:
County:
Office Tele No.: Celt No.:
Website Address of Company, if any:
GP[IIUIC 5QW Notification of Intent Form (Revised 8/2008)
t :,t+VE0, 37^A►D%VO
1 IgFa Pon,if miff, SFMON page I
6M

... ,....... ··········-··---· .. ---i..'
H. INJECTION-RELATED EQUIPMENT
Attach ~ diagram showing the ei:igineering layout or proposed modification of th.e injection. equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATict)N·OFWELL(S)-
A ttach ~o copies of maps showing the following information:
( l) Jn.clude a Site Map ( can be drawn) showing: buildings, property Jines, surface water· bodies, potential
~ources 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.geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) ~he Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFIFATION
~~~~Jfll11r~lllfH~lit•~~;~~'!\~:mt
~'I hereh certify, under penalty of law, that I have personally examined and am familiar with the informati.on
submitti:d · in this document and all attachments thereto and tha~ b~ 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 rela~ appurtenances in accordance ~~appro~ved ec~_;, of the Pennit.~
~· 'b ,1 / ~-~ tatur~ ~erty Owne(Applicant
t/~-(' )(ud<J ,:;: o ~~
PrinT or Type Full Name and title
Signature of Property Owner/ Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
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 SQW N1ficatlon of Intent Fonn (Revised 8/2008)
RECEIVED / DENR / DWQ
AQUIFt=R·PROTFr.TION ~rr.TION
OCT O 7 2011
Page3
•. I
I
I
Apr
x_
, V
'01, ry
rti A
OFF
r.
. Jacob Deal
1113 Gregory Ln.
Statesville, NC 28677
Boreholes will be 2W apart. No existing water wells or septic system on this site. City sewer
and water.
RE;1R.W�C� M GMA
AQUt� 7 MIOCI

Ro g ers, Michael
From:
Sent:
To:
Subject:
Attachments:
Mike,
Randall Cutter [[e-mail]]
Friday, October 07, 2011 9:10 AM
Rogers, Michael
5-QW application for deal residence
Deal -5QW Geothermal Well Application -Water.pdf; Deal -Borehole Layout.pdf
I have been trying to fax the attached 5-QW to Tonya but she said their fax is not working and to email it to you.
Please see attached.
Thanks,
Randall E. Cutter, CGWP
IGSHPA Accredited
Go! Green Drilling, Inc.
6105 Rest Home Rd.
Claremont, NC 28610
828-367-1293 (office)
828-228-1695 (cell)
ra nd y@g o greend rillin g.com
www.GoGreenDrilling .com
1
Rogers, Michael
From:
Sent:
Randall Cutter [[e-mail]]
Friday, October 07, 2011 1 :15 PM
To: Rogers, Michael
Subject: RE: 5-QW application for deal residence
Michael,
Boreholes GL-3 & GL-4 are 16.51 from the utility building. GL-1 is 30+' from the house.
If you need anything else, please let me know.
Thanks,
Randall E. Cutter, CGWP
IGSHPA Accredited
Go! Green Drilling, Inc.
6105 Rest Home Rd.
Claremont, NC 28610
828-367-1293 (office)
828-228-1695 (cell)
randy@ gog reendrilling.com
www.GoGreenDrilling.com
From: Rogers, Michael [mailto:[e-mail]]
Sent: Friday, October 07, 2011 11: 56 AM
To: Randall Cutter
Subject: RE: 5-QW application for deal residence
How far are the borings from any structures? We prefer at least a minimum of 15 feet.
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality-Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://portal.ncdenr.org/web/wq/aps/qwpro/permit-applications#qeothermApps
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
From: Randall Cutter Tmailto:rand y@g o qreendrillin q .com ]
Sent: Friday, October 07, 2011 9:10 AM
To: Rogers, Michael
Subject: 5-QW application for deal residence
Mike,
I have been trying to fax the attached 5-QW to Tonya but she said their fax is not working-and to email it to you.
Please see attached.
Thanks,
1
Randall E. Cutter, CGWP
IGSHPA Accredited
Go! Green Drilling, Inc.
6105 Rest Home Rd.
Claremont, NC 28610
828-367-1293 (office)
828-228-1695 (cell)
[e-mail]
www .GoG reen Drilling.com
2
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOT;D'ICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
~ WATER-ONLY INJECTION WELL SYSTEM:
~
~
I TYPE 5-0 W WELL(S )
l
l
I In Accordance with the provisions of NCAC Title 15A: 02C.0200~ please
cOlf1plete this notification and mail to address on the back page (please~ or~ information).
DATE: °4"'' 6 ' 20...Jl u...,a: C ~ 0 0 I~ 4 t Dl-4> ~)
W~II ~ Conjlnnatlon: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid ftom the environment (i.e.
closed-loop}?
· Yes __x__ Continue completing this fonn.
l
No_ Do Not complete this form. Complete other UIC application forms for installing either a
SA 7 well (Qsm-loop well injecting potable water into the aquifer) or a SQM well ( closed-loop
wen containing additives such as R-22, ethanol,, or other antifreeze or corrosion inhibitors).
A. PROPP.TY OWNER(S)/APPLICANT(S) ===~~:J ::u0ri1:jagency. smtenmneof
!
(I) Mailing Address:. ___ 1~1~13::....=Gr.!.):e~go=-ry~L=an=e ________________ _
City: Statesvme State: ~Zip Code: 28677 County:.-Ired==e __ n ____ _
Home/Office Tele No.: __________ C=-e=ll::...::N..;.::o=-=.: [phone]
Email Address: jacob@ip§pb.com Website: ___ www~-'-"'•.....,fo=-s p=IL=--co~m'-----------
(2) Physical Address of Well Site (if different than above): --=Sam=e-=---------------
} City: ________ State: __ Zip Code: _____ County: ____ _
; ! Home/Office Tele No.: __________ Cell No.: _________ _
t
~
l ;
B. AU~OIUZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject pr~perty,
I
attach t letter from the property owner authorizing Agent to install and operate UI.C well)
Compf'y_Name: __________________________ _
Contaqt Person: EMAIL Address:
' Addre4s: ___________________________ _
;
City: ! State: __ Zip Code: _____ County: ______ _
Office !Tele No.: Cell No .:
Websife Address of Company, if any:. _____________ _
I
GPU/UIC SQW N4,tification of Intent .Form (&."Vised 8/2008)
l
~
RECEIVED/ DENR / DWQ
Aquifer Protection Section
OCT 10 2011
Page 1
C. WEL) DRILLER INFORMATION
Company Name:_ _ _Goo Green ❑riliin¢. Inc.
Well Dtilier Contractor's Name. Randall E. Cutter
NC Contractor Cerdfication No.: 2818-A
Contaclt Person: Randall Cutter _ EMAIL Address: nady&aWpmdrill_irtg.com
Addre-4. 6105 Rest Home Rd -
City: CIaremont Zip Code: 28610 County: Catawba
Office Tele No.: 528-367-1293 Cell No.: 928-228-1695
D. HEAT �UMT CONTRACTOR INFORMATION (if different than driller)
Company Name: _JP Plurnbing& Heating _ �i"j ►� � it 13
Contact Persom a k,J,�q j1r t-_L ,EMAIL Address: s :. ? Q
1
Addres$. 235 North Center Street
City: Statesville _ Zip Code: 28672 _ County: iredell
Office Tele No.: (70 4) 872-5486 Cell No.:
E.
F.
a
STATUS OF APPLICANT
Private X Federal:
State:— Municipal:
Commercial:
Native American Lands:
I NJEC*ION PROCEDURE (briefly descn-be how the injection well(s) will be used)
Water' ONLY closed loop Peothermal vertical loops
W ELUCONSTRUCTION DATA
(1) Proposed date to be constructed:_ 10110/2011 Number of borings: 4
1 Approximate depth of each boring (feet): 170'
1
(2) TYpe of tubing to be used (copper, PVC; etc): Hi h Density Pof ethelene
(3) Welf casing. Is the well(s) cased? (check either (a.) Yea or (b.) No below)
(a) : Yes if yes. then provide casing information below
Typq:--alvanized steel _ _black steel ­p1astsc ____other (specify)
Casing depth: From to feet (reference to land surface)
Cas" wands to above ground inchcs
(b) ! No x
(4) Groat info (material surrounding well casing and/or piping):
a
(a) Grout type: Neat Cement 13entonbe —X— Other (specify) Thermal-Enhaneed
f(b) Grout placement: Pumping IC Pressure Other
1(c) Grout depth of tubing (reference to land surface): from 0 to 17Q (feet)
If well has casing.. indicate grout depth: from to (feet)
GPUtUfC SQW N*—Eon of 3n►ent Form C evised &12M) Page 2

I
R. YMJEMPN RELATED EQl n'MENT
J.
Attache diagram showing the engineering layout or proposed modification of tie injection equipment and exterior
pipmg4ubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
LOCATION OF WELLS)
Attach iwo copies of maps showing the following information:
(1) aclude a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
Sources of groundwater oontmd Cation and the orientation of and distances between the proposed well(s) and
4ny existing well(s) or waste disposal facilities such as septic tanlrs or drain frekds located within 200 feet of
the geothermal treat pump well system. label all features clearly and include a north affow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
teference points suet as roads, streams, and/or highway intersections.
"i hsre�y certify, tinder penalty of law, that 3 have personally examined and am far u'liar with the motion
submit iri this document and all attachmetrts thereto and that, based on my inquiry of those individuals
imnmed ly ressponst'bte far obtaining said information, 1 believe that the information is true, accurate and compleft
l am a that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false i4ormation. l agree to construct, operate, maintain, repair, and ifappBeable, abandon the injection well and
all mlatd appurtenances in accordance with approved if d conditions of the Permit"
otSoperty Owner Applitmt
CltR
Print or Type Full Name and title
SiVwture of Property Owner/Applicant
Print or Type Full Nam and We
Signature of Authorized Agent, if any
Print or Type Foil Name and title
Please return two copies of the completed Application package tRIECEIVED I ��HR North Cambia DENR DWQ AQUIfer pral�t� / OM
Aquifer ProteWon Seedon-LTIC Program OCT secuan
1636 Mal Service Center 2Q II
Raleigh, NC 27699-1636
Telephone [phone]
GPUARC SQW No�fiicadon of Intent Farm (Revised VMS) FiV 3

Jacob Deal
1113 Gregory Ln.
Statesville, NC 28677
Boreholes will be 20' apart. No existing water wells or septic system on this site. City sewer
and water.
Permit Number · WI0300184
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Jacob Deal SFR
Location Address
1113 Gregory Ln
Statesville
Owner
Owner Name
Jacob
Dates/Events
NC 28677
Deal
Scheduled
Orig Issue
10/18/11
App Received Draft Initiated Issuance
10/07/11
Regulated Activities·
Heat Pump Injection
Outfall NULL
Central Flies: APS_ SWP_
10/24/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Randall Cutter
6105 Rest Home Rd
Claremont NC
Major/Minor
Minor
Region
Mooresville
County
Iredell
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Jacob Deal
1113 Gregory Ln
Statesville
Public Notice Issue
10/18/11
NC
Effective
10/18/11
28610
28677
Expiration
Waterbody Name Stream Index Number Current Class Subbasin