WI0500087_GEO THERMAL_19980911

GROUNDWATER SECTION
September 11, 1998
MEMORANDUM
To: Jim Greer
Groundwater Section
Raleigh Regional Office
From: Mark Pritz! ff.() [e-mail]
Hydrogeological Technician II
UIC Group
Groundwater Section
Raleigh Central Office
Re: Receipt ofNotification for a Closed-Loop Geothermal Water-Only Injection Well
System.
Notification to construct and operate an injection well system for a geothermal heat pump system
has been filed by Cimarron Homes and Sherri Rosenthal of Durham, North Carolina and a copy
of the Notification is enclosed for your files. This injection well system is deemed permitted by
rule (NCAC TISA: 2C.21 l(u)2) and no regulatory action is necessary. If you have any
questions, please contact me at [phone] or Amy Axon at [phone].
cc: UIC Files
RRO Files
Enclosures
·:.-:?:· ;; :i JiMES B. "HUNT..Jrt·~
''/ ·:<.o:V~RNOR .
.·-.. _I,..; .. _· /t
. ··,,
'1·
WAYNE MCDEVITT'
SECRETARY
A.-PRES~N HOWARD~
. .JR;, P.E •.
DIRECTOR
Mr. Bill Evangelist
Evangelist Service Company
P.O. Box362
Apex, NC 27502
Dear Mr. Evangelist:
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
August 21, 1998
On August 7, 1998 the Groundwater Section received your notification of intent to construct
20 closed-loop water-only geothermal systems for Cimarron Homes in Durham County. This
notice was submitted incomplete and several months after the systems were constructed.
Per our phone conversation, to complete your notice please submit a Topographic Map that
indicates were the site (Cimarron Homes) is located and a GW-1 (Well Construction Record)
for each well constructed.
Please note that NCAC Title 15A Subchapter 2C, Section .0211 requires that a person
responsible for the construction of an injection well system shall submit a GW-57 CL Form
(Notification of Intent to Construct a Closed-Loop Geothermal Water-Only Injection Well
System) notification prior to construction of such systems. A GW-1 form must also be
submitted for each well constructed and can be obtained and copied from the Driller. These
forms must be complete and contain all information that is requested. I have enclosed a copy
of both forms for your use in the future construction of such systems and also note that these
forms can be downloaded from the Groundwater Section's Website:
http ://gw .ehnr .state.nc. us/
and can be viewed and printed with Adobe Reader 3. 0.
If you have any questions regarding geothermal heat pump wells please feel free to contact me
at [phone] or Amy Axon at [phone].
cc: UIC Files
RROFiles
Sincerely,
Mark Pritzl
Hydrogeological Technician n
Underground Injection Control Program
GROUNDWATER SECTION
P.O BOX 29578, RALEIGH, NC 27626-0578 • 2728 CAPITAL BLVD., RALEIGH, NC, 27604
PHONE [phone] FAX [phone]
AN EQUAL OPPORTUNITY/ AFFIRMATIVE ACTION EMPLOYER· 50% RECYCLED/10% POST-CONSUMER PAPER
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP
GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
in Accordance with the provisions of NCAC Title 15A: 02C.4200
Complete application and mail to address an the back page.
This is not the proper form for injection wells to be used in an oven -loon geothermal heat pump system.
Do not use this form for systems that circulate any substances other than water below the ground surface.
Type 5QW Wells
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE; April 23 1998,
Please type or print clearly.
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in contfdani-
piping that completely isolates the fluid from the environment?
YES }; If yes, then continue completing this foram.
NO
if no, do riot complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Use A Well(s) For h jection With A Neat
Pump System, should be completed.
13- SYSTEM FLUID Will anyadditives be introduced to the system's circulating heat transfer
fluid? This includes, but is not limited to corrosion inhibitors and/or antifreezes.
YES !f yes, do not complete this form. Form OW-57 HP, Application For
Permit To Construct And/Or Use A Well(s) For Injection With A Heat
Pump System, should be completed.
NO X if no, then continue completing this form.
PROPERTY OWNER
Name: Cimarron Homes
Address: P n 2k57
City: Durham Zip Code: 27715
County: Durham - Telephone: [phone]
GW-57 CL (February 1998) Page 1 of 4

D. STATUS OF PROPERTY OWNER
Private: X Federal: Commercial:
State: Municipal: Native American Lands:
E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipai or Ccunrnercial).
Name of Business or Facility:
Address: _
City: , . Zip Code: . County:
Telephone: . Contact Person
Standard Industrial Code(s), SIC, which describes commercial facility: -_ - - -- - -
F. HEAT PUMP CONTRACTOR DATA
Name: Evangelist Service Company
Address: P.O. Box 362
City: Apex , Rip Code: 27502 County:
ChatFaam
Telephone: 9I9-362-7810 . Conthcl PersonBlll Evangelist
CONSTRUCTION DATA (check one)
EXISTING WELL(S) being proposed for use as a ground -coupled heat pump
well(s). Provide the information in (I) through (4) below to the lest of your
knowledge. Attach a copy of Form GW-1 (Wei! Construction Record) if available.
PROPOSED WELL(S) to be constructed for use as a ground -couples heat pump
well(s) , Provide the information in (1) through (4) below as PROPOSED
construction specifications. Submit Form GW-I after construction.
(1) Well Drilling Contractor's Naine: R . A -
988
Simmons Wrilling Company, Inc.
NC DI liter Registration number: -- -_
Date to be constructed/7/98-4/ 1 6/98 Nurrmber of borings: _ 7
Approximate depth of each boring (feet): 5@295 , 2@365'
6/1/98-6-5-98 added 7 boreholes
7@365'
GW-57 CL (February 1998) Page 2 of 4

H.
(2) Welt casing: Is the well(s) cased?
(a) YES If yes, then provide the casing information below,
Type: Galvanized steel_ . ..,..,__ Black steel __ Plastic __ ._ Other (specify) _____ _
Casing depth: From ___ to _____ ft. (reference to land surface)
Casing extends above ground ____ inches
(b) NO X
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.1.s.):
NOTE:
(a) Grout type: Cement,,___. Bentonite ~ Other (specify) _______ _
(b) Grouted surface and grout depth (reference to land surface):
. . Ground Surfqce to Total Depth _ x around closed loop p1p111g; from ___ to . tteet).
__ around well casing; from __ to __ (feet).
THE WELL DRlLUNG CONTRACTOR CAN SUPPLY THE OAT A FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
INJECTION-RELATED EQUIPrviENT
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.
I. LOCATION OF WELL(S) Attach hvo maps.
J.
(I)
(2)
Include a site map (can be drawn) showing: buildings, property lines surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal facilities such as septic tanks
or drain fields located within 200 feet of the ground-coupled heat pump well system. Label all
features clearly and include a north arrow.
location map referencing the site to two nearby permanent reference points (such as roads,
streams and highway intersections)".
PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(l)
(2)
(3)
Hazardous Waste Management program permits under RCRA
NC Division of Water Quality Non-Discharge permits
Sewage Treatment and Disposal Permits
GW-57 CL (February 1998) Page 3 of 4
K. CERTIFICATION
"i her certify, under penalty or law, that 1 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 infornmation, I believe that the information
is true, accurate and complete. I an, aware that there are significant penalties, including the possibility
of fines and imprisonment, for submitting false information. I agree to construct, operate, maintain,
repair, and if applicable, abandon the ground -source heat pump system and all related appurtenances in
accordance with the approved specifications and conditions of die Permit."
7
(Signature of Owner or Authorized Agent)
Please supply a letter signed by the owner
authorizing the above agent, if authorized agent is sinter.
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.)
l r the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injections well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the ground -source heat pump systemrs's well(s)
conforms to the Well Construction Standards (Title I5A NCAC 2C .0200)
(Signature Of Property Owner if Different From Applicant)
Please return two copies of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
P.O. Box 29578
Raleigh, NC 27626-0578
Tetephotte [phone]
GW-57 CL (February 1998) Page 4 of 4

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TUESDAY ,:4/7/98
LOT# 11
BORE HOLE DEPTH 365FT
1-1/4 INCH -LOOP INSTALLED
BENTONITE GROUT FROM TD TO SURFACE (PRESSURE PUMP.ED )
FROM TO ·•FORMATION DESCRIPTION
GROUND -14 CLAY SURFACE
-14 -18 GRAVEL & SAND
-18 -21 WEATHERED ROCK
-21 -92 GRANITE (SHALEY)
-92 -146 GREY GRANITE
-146 -148 PINK & RED ROCK
-148 -171 GRANITE
-171 -172 WHITE ROCK w/RED SEAMS
-172 -209 GRANITE
-209 -210 PINK & RED ROCK
-210 -365 GRANITE
TUESDAY .:-4/7/98
LOT #03
BORE HOLE DEPTH 295 FT
1-1/4 INCH -.LOOP INSTALLED
BENTONITE GROUT FROM TD TO SURFACE (PRESSURE PUMPED)
FROM TO FORMATION DESCRIPTION
GROUND -9 GRAVEL & SAND SURFACE
-9 -46 GRANITE (SHA.LEY )
-46 -47 BROWN & RED ROCK
-47 -62 GRANITE
-62 -63 BROWN ROCK
-63 -163 GRANITE
-163 -164 PINK & RED ROCK
-164 -295 GRANITE
WEDNESDAY 4/8/98
LOT #05
BORE HOLE DEPTH 295 FT
1-1/4 INCH -LOOP INSTALLED
BENTONITE GROUT FROM TD TO SURFACE (PRESSURE PUMPED)
FROM TO FORMATION DESCRIPTION
GROUND -6 GRAVEL & SAND SURFACE
-6 -11 BROWN SHALE
-11 -16 GRANITE (BLUE & SHALEY)
-16 -17 BROWN SHALE
-17 -48 GRANITE (SHALEY)
-48 -49 BROWN ROCK
-49 -81 GRANITE·
-81 -82 BROWN ROCK
-82 -159 GRANITE
-159 -162 SOFT GREEN GRANITE
-162 -271 GRANITE
-271 -272 WHITE FLINT ROCK
-272 -295 GRANITE
/
WEDNESDAY ' 4/8/98
LOT #07
BORE HOLE DEPTH 365 FT
1-1/4 INCH -LOOP INSTALLED
BENTONITE GROUT FROM TD TO SURFACE (PRESSURE PUMPED)
FROM TO FORMATION DESCRIPTION
GROUND -4 GRAVEL & SAND SURFACE
-4 -6 BROWN SHALE
-6 -54 GRANITE (SHALEY)
-54 -76 GREY GRANITE
-76 -77 BROWN ROCK
-77 -81 GRANITE
-81 -82 BROWN ROCK
-82 -115 GRANITE
-115 -116 PINK & RED ROCK
-116 -299 GRANITE
-299 -301 PlNK ROCK w/RED SEAMS
-301 -365 GRANITE
I
THURSDAY' 4/9/98
LOT #09
BORE HOLE DEPTH 295 FT
1-1/4 INCH -LOOP INSTALLED
BENTONJTE GROUT FROM TD TO SURFACE (PRESSURE J>UMI>ED )
FROM TO FORMATION DESCRIPTION
GROUND -5 GRAVEL & SAND SURFACE
-5 -10 BROWN SHALE
-10 -96 GRANITE
-96 -98 BROWN ROCK
-98 -113 GRANITE
-113 -115 BROWN ROCK
-115 -295 GRANITE
_i
THURSDAY 4/9/98
LOT# 12
BORE HOLE DEPTH 295FT
1-1/4 INCH -LOOP INSTALLED
BENTONITE GROUT FROM TD TO SURFACE (PRESSURE PUMPED )
FROM I TO FORMATION DESCIUPTION
GROUND -8 CLAY SURFACE
-8 -12 SAND & GRAVEL
-12 -55 GRANITE (SIIALEY)
-55 -58 BROWN ROCK
-.58 -69 GRANITE (SIIALEY)
-69 -75 BROWN ROCK
-75 -84 GRANITE (SHALEY)
-84 -90 BROWN ROCK
-90 -92 GRANITE
-92 -100 BROWN ROCK (SOFT)
-100 -120 GRANITE
-120 -125 BROWN ROCK
-125 -290 GRANITE
-290 -291 FLINT ROCK
-291 -295 GRANITE
MONDAY ,:4/13/98
LOT #04
BORE HOLE DEPTH 365 FT
1-1/4 INCH -LOOP INSTAt;LED
B.ENTONITE GROUT FROM TD TO SURFACE (PRESSURE PUMPED )
FROM I TO I FORMATION DESCRIPTION
GROUND -9 CLAY SURFACE
-9 -16 SAND & GRAVEL
-16 -20 WEATHERED ROCK
-20 -46 GRANITE
-46 -48 BROWN ROCK
-48 -114 GRANITE
-114 -116 WHITE & RED ROCK (BROKEN UP )
-116 294 GRANITE
-294 -298 PINK & RED ROCK
-298 -365 GRANITE
TUESDAY··· 4/14/98
LOT# 10
BORE HOLE DEPTH 295 FT
1-1/4 INCH -LOOP I.NSTALLED
BENTONITE GROUT FROM TD TO SURFACE (PRESSURE PUMPED)
FROM TO I FORMATION DESCRIPTION
GROUND -8 CLAY SURFACE
-8 -12 SAND & GRAVEL
-12 -14 BROWN SHALE
-14 -22 GRANITE (SHALEY)
-22 -24 BROWN SHALE
-24 -38 GRANITE (SHALEY)
-38 -42 BROWN ROCK
-42 -51 GRANITE
-51 -56 BROWN ROCK
-56 -109 GRANITE
-109 -111 PINK & RED ROCK
-111 -132 GRANITE
-132 -136 BROWN ROCK
-136 -295 GRANITE
TUESDAY .~-4/i4/98
LOT #21
BORE HOLE DEPTH 295 FT
1-1/4 INCH -LOOP INSTALLED
BENTONITE GROUT FROM TD TO SURFACE (PRESSURE PUMPED)
FROM I TO FORMATION DESCRIPTION
GROUND -6 SAND & GRAVEL SURFACE
-6 -11 BROWN SHALE
-11 -26 GRANITE (SHALEY)
-26 -28 BROWN ROCK
-28 -54 GRANITE (SHALEY)
-54 -56 BROWN ROCK
-56 -87 GRANITE
-87 -90 BROWN & RED ROCK
-90 -183 GRANITE
-183 -185 WHITE & RED ROCK
-185 -212 GRANITE
-212 -214 WHITE & RED ROCK
-214 -293 GRANITE
-293 -294 BROWN/YELLOW ROCK
-294 -295 GRANITE
TU ES.DAY ,:, 4/14/98
LOT# 19
BORE HOLE DEPTH 295FT
l-1/4 INCH -LOOP INSTALLED
BENTONITE GROUT FROM TD TO SURFACE (PRESSURE PUMPED)
FROM TO I FORMATION DESCRIPTION
GROUND -5 SAND & GRAVEL SURFACE
-5 -12 WEATHERED ROCK
-12 -19 BROWN ROCK
-19 -23 GRANITE
-23 -35 BROWN SHALE
-35 -88 GRANITE
-88 -91 BROWN SHALE'
-91 -107 GRANITE
-107 -109 BROWN & RED ROCK
-109 -121 GRANITE
-121 -123 BROWN & RED ROCK
-123 -192 GRANITE
-192 -194 BROWN/YELLOW ROCK
-194 -292 GRANITE
-292 -294 BROWN/YELLOW ROCK
-294 -295 GRANITE
WEDNESDAY 4/15/98
LOT #22·
BORE HOLE DEPTH 295 FT
1-1/4 INCH -LOOP INSTALLED
BENTONITE GROUT FROM TD TO SURFACE (PRESSURE PUM:PED)
FROM TO FORMATION DESCRIPTION
GROUND -9 CLAY SURFACE
-9 -15 WEATHERED ROCK
-15 -18 BROWN SHALE
-18 -32 GRANITE" (SHALEY)
-32 -36 BROWN ROCK (VERY SOFT)
-36 -82 GRANITE (SHALEY)
-82 -83 BROWN ROCK
-83 -144 GRANITE
-144 -145 BROWN/RED ROCK
-145 -202 GRANITE
.:.202 -204 WHITE/YELLOW ROCK
-204 -258 GRANITE
-258 -261 BROWN/RED ROCK
-261 -283 GRANITE
-283 -284 BROWN/YELLOW ROCK
-284 -295 GRANITE
WEDNESDAY 4/15/98
LOT #20
BORE HOLE DEPTH 295 FT
1-1/4 JNCH -LOOP JNSTALLED
BENTONITE GROUT "FROM TD TO SURFACE (PRESSURE PUMPED)
FROM TO FORMATION DESCRIPTION
GROUND -8 CLAY SURFACE
-8 -16 WEATHERED ROCK
-16 -19 BROWN SHALE
-19 -24 GRANITE (SIIALEY)
-24 -26 BROWN/RED ROCK (BROKEN UP )
-26 -58 GRANITE
-58 -59 BRO\iVN SHALE
-59 -141 GRANITE
-141 -146 BROWN SHALE
-146 -184 GRANITE
-184 -185 BROWN/RED ROCK
-185 -202 GRANITE
-202 -204 YELLOW/RED ROCK
-204 -229 GRANITE
-229 -232 WHITE·ROCK w/RED SEAMS
-232 -267 GRANITE
-267 -269 YELLOW/RED ROCK
-269 -295 GRANITE
W.EDNESDAY. 4/15/98
LOT# 18
BORE HOLE DEPTH 295 FT
1-1/4 INCH-LOOP INSTALLED
BENTONITE GROUT FROM TD TO SURFACE (PRESSURE PUMPED)
FROM TO FORMATION DESCRIPTION
GROUND -6 SAND 7 GRAVEL SURFACE
-6 -14 BROWN SHALE
-14 -18 GRANITE (SHALEY)
-18 -27 BROWN SHALE.
-27 -60 GRANITE
-60 -61 BROWN· SHALE
-61 -117 GRANITE
-117 -119 BROWN SHALE
-119 -158 GRANITE
-158 -160 WHITE/PINK ROCK
-160 -212 GRANITE
-212 -215 WHITE/RED· ROCK
-215 -217 GRANITE
-217 -219 BROWN/RED ROCK
-219 -222 GRANITE
-222 -226 GRANITE (VERY SOFT)
-226 -295 GRANITE
f.
MONDAY 6/1/98
LOT14
BORE HOLE DEPTH 365 FT
1-1/4 INCH LOOP INSTALLED
BETONITE GROUT FROM TD TO SURFACE ( PRESSURE PUMPED )
FROM TO FORMATION DESCRIPTION
GROUND -2 DIRT/CLAY SURFACE
-2 -12 SANDSTONE
-12 -82 SHALEY GRANITE
-82 -365 GRANITE
TUESDAY 6/2/98
LOT16
BORE HOLE DEPTH 365 FT
1-1/4 INCH LOOP INSTALLED
BETONITE GROUT FROM TD TO SURFACE ( PRESSURE PUMPED )
FROM TO FORMATION DESCRIPTION
GROUND -4 DffiT/CLAY SURFACE
-4 -13 SANDSTONE
-13 -83 SHALEY GRANITE
-83 -201 GRANITE
-201 -204 BROWN ROCK
-204 -214 SOFT GRANITE
-214 -365 GRANITE ·
-,..
I
WEDNESDAY 6/3/98
LOT23
BORE HOLE DEPTH 365 FT
1-1/4 INCH LOOP INSTALLED
BETONITE GROUT FROM TD TO SURFACE ( PRESSURE PUMPED )
FROM TO FORMATION DESCRIPTION
GROUND -8 DIRT/CLAY SURFACE
-8 -18 SANDSTONE
-18 -80 SHALEY GRANITE
-80 -223 GRANITE
-223 -227 BROWN ROCK
-227 -365 GRANITE
WEDNESDAY 6/3/98
LOT24
BORE HOLE DEPTH 365 FT
1-1/4 INCH LOOP INSTALLED
BETONITE GROUT FROM TD TO SURFACE ( PRESSURE PUMPED )
FROM TO FORMATION DESCRIPTION
GROUND -8 DIRT/CLAY SURFACE
-8 -18 SANDSTONE
-18 -83 SHALEY GRANITE
-83 -365 GRANITE
THURSDAY 6/4/98
LOT2
BORE HOLE DEPIB 365 FT
1-1/4 INCH LOOP INSTALLED
BETONITE GROUT FROM TD TO SURFACE ( PRESSURE PUMPED )
FROM TO FORMATION DESCRIPTION
GROUND -8 DIRT/CLAY SURFACE
-8 -17 SANDSTONE
-17 -86 SHALEY GRANITE
-86 -365 GRANITE
,..
THURSDAY 6/4/98
LOT6
BORE HOLE DEPTH 365 FT
1-1/4 INCH LOOP INSTALLED
BETONITE GROUT FROM TD TO SURFACE ( PRESSURE PUMPED )
FROM TO FORMATION DESCRIPTION
GROUND -8 DIRT/CLAY SURFACE
-8 -17 SANDSTONE
-17 -85 SHALEY GRANITE
-85 -365 GRANITE
THURSDAY 6/5/98
LOTS
BORE HOLE DEPTH 365 FT
1-1/4 INCH LOOP INSTALLED
BETONITE GROUT FROM TD TO SUl{FACE ( J>IlESSURE PUMPED )
FROM TO FORMATION DESCRIPTION
.
GROUND -8 DI.RT/CLAY SURFACE
-8 -19 SANDSTONE
-19 -83 SHALEY GRANITE
·83 -365 GRANITE
'
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMlSSlON
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP
GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
This is not the properformfor injection wells to be used in an ope,1-loop geOthermal heat pump system.
Do not i,se this form for systems that circulate an v substances other than water beloiv the ground swface.
TO:
A.
Type 5QW Wells
DIRECTOR, NORTH CAROUNA DIVISION OF WATER QUALITY
DATE: April 23
Please type or print clearly.
0
~ \.0 0 co §3.?'-:' ~ s~ er, ~~m
I o:2
0' :r-rri )>0
-0 ~ ...... :x :X:,.??i
SYSTEM CLASSlfICATION Does the proposed system circulate potable water in cont'il,\1ou~~
piping that completely isolates the fluid from the environment? CJ1 =!
U) C)
%
YES _--A_ If yes, then continue conipleting this form.
NO If no, do riot complete this form. Form 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 FL_l)ID 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
NO X
C. PROPERTY OWNER
If yes, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Use A Well(.s) For Injection 1.f'ith A Heat
Pump S)1Ste111, _shot!ld be completed.
If no, then continue completing this form.
Name: Sherri Rosenthal
Address: 8 0 5 Green Street
Durham, NC City: _________ _ Zip Code: _2_7_7_0_1 __ ~-----
County: Durham Telephone: 6_8_8_-_6_6_3_.6_· ____ _
GW-57 CL (February 1998) Page I of 4
D. STATUS OF PROPERTY OWNER
Private: X
State.
Federal:
Municipal:
Commercial:
Native American Lands:
E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Narne of Business or Facility'
Address:
City: . Zip Code: . County:
Telephone: Contact Person:
Standard Industrial Code(s), SIC, which describes commercial facility:
F HEAT PUMP CONTRACTOR DATA
Name: Evangelist Service Company
Address: P.O. Box 362
City: Apex, , . Zip Code: 27502 , County. Chatham
Telephone: [phone] Contact Person: Bill Evangelist
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 (I) through (4) below to the best of your
knowledge. Attach a copy of Form GW- I (Well Construction Record) if available.
PROPOSED WELL(S) to be constructed for use as a ground -coupled heat pump
well(s) . Provide the information in (I) through (4) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
Well Drilling Contractor's NameR.A. Simmons Drilling Company, Inc.
NC Driller Registration number: 988
Date to be constructed4/7/9 8— 4/ 1 6/9 8 Number of borings: 6
Approximate depth of each boring (feet): 5@ 295, 1 @ 365'
GW-57 CL (February 1998) Page 2 of 4

H.
(2) Well casing: Is the well(s) cased?
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel_ Black steel_ Plastic __ Other (specify)_. _______ _
Casing depth: From to ft. (reference to land surface) ------
Casing extends above ground ----inches
(b) NO X
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.l.s.):
NOTE:
(a) Grout type: Cement_ Bentonite -~-Other (specify) _______ _
(b) Grouted surface and grout depth (reference to land surface):
Ground Surface to Total Depth
~ around closed loop piping; from ____ to___,_ __ (feet).
___ around well casing; from _____ to __ (feet).
THE WELL. DRILLING CONTRACTOR CAN SUPPLY THE OAT A FOR EITHER EXISTING OR
PROPOSED WELLS IF Tl 11S INFORMATION IS UNAVAILAil.LE BY OTHER MEANS.
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.
I. LOCATION OF WELL(S) Attach two maps.
(I) Include a site map (can be drawn) showing: buildings, property lines surface water bodies,
potential sources of groundwater contamination and the orientation of and distances between
the proposed well(s) and any existing well(s) or waste disposal facilities such as septic tanks
or drain fields located within 200 feet of the ground-coupled heat pump well system. Label all
features clearly and include a north arrow.
(2) location map referencing the site to two nearby permanent reference points (such as roads,
streams and highway intersections}.
J . PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
( 1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits
GW-57 CL (February 1998) Page 3 of 4
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I'
K. CERTIFICATION
"I hereby certify, raider penalty of law, that I have personally examined and ant familiar with the
information submitted in this document and all attachments thereto and that, based on my inquiry of
those individuals immediately responsible for obtaining said information, I believe that the information
is true, accurate and complete, I am aware that there are significant penalties, including the possibility
of fines and imprisonment, for submitting False information. I agree to construct, operate, maintain,
repair, and if applicable, abandon the ground -source heat pump system and all related appurtenances in
accordance with the approved specifications and conditions of the Permit."
(Signature of Owner or Authorized Agent)
Please supply a letter signed by the owner
authorizing the above agent, if authorized agent is signer.
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.)
1 f 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 welts)
can forms to the Well Construction Standards (Title 15A NCAC 2C .0200)
raperty Owner if ❑ifferent from Applicant)
Please return two copies of the completed Application package to:
UIC Program
Groundwater Section
f1i(fl• ► Carniii,:1 JLTst;;-►D\V
P.O. Box 29578
Raleigh, NC 27626-0578
Telephone [phone]
GW-57 CL (February 1998) Page 4 of 4