WI0500086_GEO THERMAL_20030906

DIVISION OF WATER .QUALITY
GROUNDWATER SECTION
August 6, 2003
MEMORANDUM
To: Jay Zimmerman, L.G. Regional Groundwater Supervisor
Groundwater Section
Raleigh Regional Office
From: f"'x>.. Mark Pritzl · [e-mail]
Hydrogeological Technician Il
UIC Program
Groundwater Section
Raleigh Central Office
Re: Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection Well
System (type 5QW injection well.)
Notification to construct and operate 2 wells for a closed-loop geothermal heat pump system has
been filed by John Richard & Mary F. Weston-Jones in Chapel Hill, and a copy of the
Notification is enclosed for your files. This injection well system is deemed permitted by rule
(NCAC T15A: 2C.21 l(u)2) and no regulatory action is necessary. If you have any questions,
please contact me at [phone].
cc: CO-UIC Files
Enclosures
W A TF Michael F. Easley, Governor
O119 William G. Ross Jr., Secretary
4[� North Carolina Department of Environment and Natural Resources
rAlan W. Klimek, P. E. Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of Water Quality
August 5, 2003
John Richard & Mary F. Weston -Jones
250 Amberwood Run, P.O. Box 5007
Chapel Hill, NC 27514
RE: Notification of intent to construct Type 5QW injection wells
Dear John & Mary:
In accordance with the notification you submitted to the UIC Program on August 5, 2003, the
Groundwater Section acknowledges your intent to construct 2 closed -loop geothermal water -only
injection wells for the operation of a ground -source heat pump. The system as described in your
notification is deemed permitted by rule (North Carolina Administrative Code Title 15A:
2C.0211(u)(2)) and will not require an injection well permit from the state, but you should check
with your county health department prior to constructing the system because they may have
additional construction or permitting requirements for this type of system. If you modify your
system at any time, please contact the Groundwater Section to verify compliance with applicable
rules.
Thank you for submitting this notification. If you have any questions regarding geothermal heat
pump wells or injection well rules please contact me at (9 1 9)715-61 66.
Mark Pritzl
Hydrogeological Technician
UIC Program
cc: RRO-UIC files
CO-UIC files
fa,
N. C. Division of Water Quality / Groundwater Section
1636 Mail Service Center Raleigh, N.C. 27699-1636
Phone: [phone] Fax: [phone] Internet: http://gw,ehnrstate.nc.us
Customer Service
I-877-623- 748

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP
GEOTID!RMAL WATER -ONLY INJEcrION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type SQW Wells
In Accontmce with the provisions of'NCAC Title ISA: 02C.0200
Complele application and mail to address Oil the back. page..
This Is not the proper form to be used for injecdon wells in an opp-loop geothermal system.
Do pot u,e tilts form for sy1tem1 that circulate MY 1pbstapce1 other than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: ~-( 20 0.3
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES £ If yes, then continue completing this form.
NO If no, do not complete this form. Fonn GW-57 HP, Application For
Permit To Construct And/Or Use A Well(s) For Injection With A Heat
Pump System, should be completed.
B. SYSTEM FLUID . Will any additives be introduced to the system's circulating heat transfer
fluid? This includes, but is not limited to corrosion inhibitors and/or antifreezes.
YES If yes, do not complete this form. Form GW-57 HP, Application For
Permit To Construct .A.nd/Or Use A Well(s) For Injection With A Heat
Pump System, should be completed.
NO £_ If no, then continue completing this form.
C. PROPERTY OWNER
D.
Ver.3/01
Name: ..le~ ~~~R 2-J\,\9. ¼" f: Lue&b -j OJL&5
Adchess: :Z5o AIN\b,ec LL>oa:J 'Ru...n CP. o ."Bo.x S o o 7)
City: C.-h:. p e l Id i l ( State: 1J..c_ Zip Code: _:,2_7:_s __ ,_LJ _____ _
County: Ct,a...\-b)., Telephone: _'t ____ r q ...... .,_'f'-"'~~":/ ____ -...... 3_r:1: ___ lf.._:l _______ _
STATUS OF PROPERTY OWNER
Private: L Federal:
State: Municipal: __
..... •:·
-:~;1~ ....
GW /UIC-S7 CL
Commercial:
Native American Lands:
Page I of4
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E. FACILITY (SITE) DATA
(FiII out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: ___________________ _
Address: _________________________ _
City: ________ State: __ Zip Code: ____ County: ____ _
Telephone: . Contact Perso~: ___________ _
Standard Industrial Code(s), SIC, which describes commercial facility: _______ _
F. HEAT PUMP CONTRACTOR DATA
Name: £ tJ 14. ~ toe,, ~r SE It we.~ Co
Address: p .. p. 60,c 3 6~
City: f1 pf:,c State: NC. Zip Code: !Z,.fo2 County: cHtrtHll1tt
Telephone: q14-'1'12-'19/o ContactPerson: 8tlA.. Eu1ult;,F(1,,-
G. CONSTRUCTION DATA (check one)
(1)
EXISTING WELL{S) being proposed for use as a ground-coupled heat pump
well(s). Provide the information in (1) through (3) below to the best of your
knowledge. Attach a copy of Form GW-1 (Well. Construction Record) if
available.
X PROPOSED WELL(S) to be constructed for use as a ground-coupled heat pump
well(s). Provide the information in (1) through (3) below as PROPOSED
construction specifications. Submit Fonn GW-1 after construction.
Well Drilling Contractor's Name: lAllf VJdrL.(G'1 W•(.(. 4), , ~C •
NC Contractor Certification number: !2.2' f -----------------
Date to be constructed: ~ -l't • 0) Number of borings: __ 2 _____ _
u" r1 Approximate depth of each boring (feet): ____ ,=----.1.._:> _________ _
(2) Well casing: Is the well(s) cased?
(a) YE& __ If yes, then provide the casing infonnation below.
Type: Galvaniud steel __ Black steel __ Plastic __ Other (specify) ____ _
Casing depth: From ___ to ___ ft. (reference to land surface)
Casing extends above ground inches
(b) NO L
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.1.s.):
(a) Grout type: Cement__ Bentonite _L 0th~ (specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
✓ around closed loop piping; from O to I oo (feet).
__ around well casing; from __ to __ (feet).
NOTE: THE WELL DRJLLlNG CONTRACTOR. CAN SUPPLY THE DATA FOR. EITHER. EXISTING ori""
PROPOSED WELLS IF THIS iNfoRMATION IS UNAVAILABLE BY OTHER. MEANS. , -: >.&=-
Ver.3/01 •:-:GW/UIC-57 CL Page 2of4
A. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
L LOCATION OF WELL(S) Attach two maps.
(I) Include a site map (can be drawn) abowing: buildings, property tines surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed works) and any existing well(s) or waste disposal facilities such as septic tanks
or drain fields located within 200 feet of the ground -coupled heat pump well system. Label all
features clearly and include a north arrow.
(2) location map referencing the site to two nearby permanent reference points (such as roads,
streams and highway intersections).
J. 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
K, CERTIFICATION
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the
information submitted in this document and all attachments thereto and that, based on my inquiry of
those individuals immediately responsible for obtaining said information, I believe that the information
is true, accurate and complete. I am aware that there are significant penalties, including the possibility
of fines and imprisonment, for submitting false information. I agree to construct, operate, maintain,
repair, and if applicable, abandon the ground -source beat pump system and all related appurtenances in
accordance with the approved specifications and conditions of the Permit."
,
(Signature of Well O► er-oLA the r d Agent)
if authorized agent is acting on behalf of'the well owner,
please supply a letter signed by the owner
authorizing the above agent.
eAr
Ver.3/01 A.'GWILJ'1C-57 CL Page 3 of 4

L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the ground -source heat pump system's well(s)
conforms to the Well Construction Standards (Title 15A NCAC 2C .0200)
(Signature OfPr ty fl►v Di er►=i�am Applicant)
Please return two copies of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Vcr.3/01 G WIUIC-57 CL Page 4 of 4

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