WI0300187_GEO THERMAL_20111122

Permit Number
Program Category
Ground Water
Permit Type
WI0300187 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
C~astal SW Rule
Permitted Flow
Facilit
Facility Name
City of Charlotte -Westinghouse Blvd
Location Address
2227 Westinghouse Blvd
Charlotte
Owner
Owner Name
City of Charlotte
Dates/Events
NC 28217
Scheduled
Orig Issue
11/22/11
App Received Draft Initiated Issuance
10/28/11
Regulated Activities
Heat Pump Injection
Outfall f\'ULL
Central Files: APS_ SWP_
11/22/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
. Individual
Permit Contact Affiliation
Janice Scott
8275 Tournament Dr
Memphis TN
Major/Minor
Minor
Region
Mooresville
County
Mecklenburg
Facility Contact Affiliation
Owner Type
Government -Municipal
Owner Affiliation
Michelle Haas
600 E 4th St
Charlotte
Public Notice Issue
11/22/11
NC
Effective
11/22/11
381250851
28202
Expiration
Waterbody Name Stream Index Number Current Class Subbasln
Beverly Eaves Perdue
Gove·rnor
City of Charlotte
Michelle Haas·
600 East Forth Street
Charlotte, NC 28202
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
11/22/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0300187
2227 Westinghouse Boulevard, Charlotte, NC 28217
Dear Ms. Haas:
Dee Freeman
Secretary
On Octo~~r 28, 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 15A Section 2C Subchapter .021 l(u)(2). Additionally, you should contact the Mecklenburg 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 [e-mail] if you have any questions.
cc: Mooresville Regional Office -APS
APS Central Files -Permit No. Wl0300187
Mecklenburg County Health Dept.
Midsouth Geothermal (Janice Scott)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
~c~ly, /o./Jrui;_
forDe~s
Supervisor
Phone: 919-733~3221 \ FAX 1: ~19-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterauali 1.or
An Equal Opportunity\ Affirmative Action Employer
NOns_i..C 1· 01. u.1 · aro. 1na
lvaturaltu
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED-LOOP WATER-ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal _heating and cooling system.
These wells are ''permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Print or Type Information and Mail to the Address on the Last Page.
DATE: __ l~0/~12 ____ --7 2011 PERMIT NO.~ 0~00181 (to be filled in by DWQ)
A. STATUS OF WELL OWNER ( choose one)
Non-Government: Individual Residence Business/Organization __
Government: State Municipal _x_ County__ Federal
B. WELL OWNER -For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
City of Charlotte
Mailing Address: 600 East Fourth Street
City: Charlotte State: NC
Day Tele No.: 704-336-3654 (Michelle Haas)
EMAIL Address: mhaas @ci.charlotte.nc.us
Zip Code: ----'2=-"8'-=2""""'02=--__ County: Mecklenbur g
Cell No.:
Fax No.:
C. LOCATION OF WELL SITE -Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: __________ County: Mecklenburg
{2) Physical Address (if different than mailing address): 2227 Westinghouse Blvd .
. City: Charlotte State: NC Zip Code: --=2-=-=82=-"l'-'-7 _____ _
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: _T=i=m:=...cH=am=by.,___ ___________________ _
NC Well Drilling Contractor Certification No.: -=--N:....=:C:.......;-3:=;..:l=--=l=--=8=--=A=-------------------
Company Name: Midsouth Geothermal
Contact Person: Janice Scott EMAIL Address: j scott@midsouth geothermal.com
Address: 8275 Tournament Drive . Ste. 185
City: _M_e_m_p_h_is _____ Zip Code: 38125 State: TN County: ----=-=Sh=-=e==lbc....<-y _____ _
Office Tele No.: 901-748-9095 Cell No.:~~-----==----'Fax==---=N'---'---'o"----'--'. :'-------=--90"'----=l'-----'-7'---'4-=-8--=-9-=09"-'7_
REC_EIV ED / DENR / DWQ
Aquifer Protection Section
GPU/UIC 5QW Notification (Revised 3/18/2011) OCT 28 201t Page 1
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: _______________________________ _
Contact Person~: _______________ E_MA __ I_L_A_d_d_r_e_ss_: ___________ _
Address: __________________________________ _
City: _________ Zip Code: ____ State: __ County: ________ _
Office Tele No.: Cell No.: _________ c=-Fax~N~o~._: ______ _
F. WELL CONSTRUCTION DATA
(1). Number of borings to be constructed*: 37 Depth of each boring (feet):_~4~5~0~-----
* If existing water supply wells will be used then provide the information in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc): -~H_D_P_E_P_i __ p_e ______________ _
(3) Well casing. If the well(s)will use casing then provide the.~ (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground: ___ N_o_n_e ___ ~--------------
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite** _x __ Other (specify) _______ ~--
** By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from -~O __ to 450 (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GJS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
GPU/UIC 5QW Notification (Revised 3/18/2011) Page2
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .021 l(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the property deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit." ..
, tfulYlliiL Utiaa
Signature of Property Owner/ Applicant
/L 1 I t'~/u /le. Ha,~
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
Submit the complete application package to:
DWQ -Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notification (Revised 3/18/2011)
RE~EIVED / DENR I DWQ
Aquifer Protection Section
OCT .2 8 2011
Page 3
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•
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATI.JR.AL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED-LOOP WATER-ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Print or Type Information and Mail to the Address on the Last Page.
DATE: --=-10"'-'--/l=-=2~---~ 2011 PERMIT NO. ________ (to be filled in by DWQ)
A. STATUS OF WELL OWNER(choose one)
Non-Government: Individual Residence Business/Organization __
Government: State Municipal ~ County __ Federal
B. WELL OWNER-For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
City of Charlotte
Mailing Address: 600 East Fourth Street
City: Charlotte State: NC Zip Code: 28202
Cell No.:
County: Mecklenburg
Day Tele No.: 704-336-3654 (Michelle Haas)
EMAIL Address: [e-mail] Fax No.:
C. LOCATION OF WELL SITE -Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: __________ County: Mecklenburg
(2) Physical Address (if different than mailing address): 2227 Westinghouse Blvd.
City: Charlotte State: NC Zip Code: _2_82_1_7 _____ _
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: _T_1_·m_H_am~b_y ___________________ _
NC Well Drilling Contractor Certification No.: -~N~C_-3_1_1_8_A _______________ _
Company Name: Midsouth Geothermal
Contact Person: Janice Scott EMAIL Address:[e-mail]
Address: 8275 Tournament Drive. Ste. 185
City: Memphis Zip Code: 38125 State: TN County: -~S~he~lb-=c..y,___ ____ _
Office Tele No.: 901-748-9095 Cell No.: Fax No.: 901 -748-9097
GPU/UIC 5QW Notification (Revised 3/18/2011)
-------~
RECEIVED/ DENR / DWQ
Aquifer Protectkm Section
OCT 2 8 2011
Page 1
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: _______________________________ _
Contact Person:=._: --------------~E~MA~I=L~A=dd=r~es=s ...... : __________ _
Address: _________________________________ _
City: _________ Zip Code: ____ State: __ County: _________ _
Office Tele No.: Cell No.: Fax No.: ------------~~-------
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: 37 Depth of each boring (feet): __ 4_50~-----
* If existing water supply wells will be used then provide the information in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc): _...i,-'-HD~P_E_P1 ___ ·p_e _______________ _
(3) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground: __ ..FN ___ o--=n~e---~--------------
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement_·__ Bentonite** _x __ Other (specify) ______ ~
** By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from __ O~_ to __ 4_50~_ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can he
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. · The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
GPU/UIC 5QW Notification (Revised 3/18/2011) Page2
H. CERTIFICATION (to be signed as rer}uired below or by that person's authori7zd agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
I. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the property deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"l hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
IrLL
Signature of Property Owner/Applicant
;; ,I, H"51
Print or Type Full blame
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECENED1DEW 1DW
Aquifer Pr&wton 5"oq
OCT 28 2011
GPUItIIC 5QW Notification (Revised 3/18/201 l) Page3

uim I

•
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED-LOOP WATER-ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Print or Type Information and Mail to the Address on the Last Page.
DATE: __ l _0/_12 ____ ~ 2011 PERMIT NO. ________ (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non-Government: Individual Residence Business/Organization __
Government: State Municipal _x__ County __ Federal
B. WELL OWNER -For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
City of Charlotte
Mailing Address: 600 East Fourth Street
City: Charlotte State: NC Zip Code: 28202
Cell No.:
County: Mecklenburg
Day Tele No.: 704-336-3654 (Michelle Haas)
EMAIL Address: mhaas@ ci.charlotte.nc.us Fax No.:
C. LOCATION OF WELL SITE -Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: __________ County: Mecklenburg
(2) Physical Address (if different than mailing address): 2227 Westinghouse Blvd.
City: Charlotte State: NC Zip Code: ---=2-==82=-=1:....:..7 _____ _
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: _T_i_m_H_am_b y ____________________ _
NC Well Drilling Contractor Certification No.: __ N_C_-3_1~1~8~A _______________ _
Company Name: Midsouth Geothermal
Contact Person: Janice Scott EMAIL Address:j scott@ midsouthgeothermal.com
Address: 8275 Tournament Drive. Ste. 185
City: Memphis Zip Code: 38125 State: TN County: -~S=he=lb-=-y,___ ____ _
Office Tele No.: 901-748-9095 Cell No.: ------~-F~ax==--=N~o:....:...:~90~1----7 ___ 4'-=8-"--9--"-0~97"--
RECEIVED I DENR' owa
Aquifer Protection Section
GPU/UIC 5QW Notification (Revised 3/18/2011) OCT 28 2011 Page 1
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: ________________________________ _
Contact Person . .,_: _______________ E=MA==IL==-cA=-==d=dr=---=e=ss=: ___________ _
Address: _________________________________ _
City: _________ Zip Code: ____ State: __ County: _________ _
Office Tele No.: Cell No.: ---------=--F=axc:....N~o=·=-------
F~ WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: 37 Depth of each boring (feet): 450 ______ _
* If existing water supply wells will be used then provide the information in item (4) below.
(2) Type of tubing to be used (steel, PVC, etc): -~HD~P~E=--=--P =,cip-=-e-~-------------
(3) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, etc.), diameter. depth,
and extent of casing appearing above ground: __ ..,;::.N--=-o=n=e;..__ _________________ _
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite** _x __ Other (specify) ______ _
•• By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from _~O __ to _450_ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
GPU/UIC 5QW Notification (Revised 3/18/2011) Page2
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(b) requires that all permit applications shall be signed as follows:
I. for a corporation: by a responsible corporate officer;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all p-mons_listed on the property deed}.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined 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 arm aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit.,"
Signature of Property Owner/Applicant
•,'tie, Ile yf�S fit]
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
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED/ DENR 1 DAG
Aquifer ProlpzWn Sec;llon
OCT 282011
GPUIWC 5QW Notification (Revised 3118/2011) Page 3

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