WI0500089_GEO THERMAL_19990326

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•. ~-. North Carolina. Department of Environment _ and Natunl Resources
Division ·or Water· Quality-Groundwater Section
PRECONSTRUCTION INJECTION FACILITY INSPECTION
REPORT-FORM A
INJECTION WELL PERMIT NO. WI -----DATE. 9 9 D3 ~v
NAMEOFOWNER_. ~A~Ni"--'-'--~~C~e_h2~--------'pJ __ /~~'~~~-----------
ADDRESS OF OWNER 6~ o .:2 /Y? p ~-k..,-c d Cc,,_~ & &1 ~
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(Street/ road or fot and suddivision, county, town) 7
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LOCATION OF PROPOSED INJECTION WELL (and source well(s), if applicab~ c/:wi.e_ ~
(Street/ road or lot and suddivision , county, town, if different than owner's address, plus description of location on site)
Potential pollution source -£--~-~-~~;-~+----Distance from well
Potential pollution source ~~ L Distance from well
Potential pollution source _________ Distance from well ___ _
/ Minimum distance of proposed well from property boundary __ ;--'-· 7J __
Quality of drainage at site _______ Flooding potential of site ___ __,,,_
~dequate,poor) (high,moderate€i})
DRAW SKETCH OF SITE
(Show prop~es, buildings, wells, potential pollution sources, roads, approximate scale, and north arrow.)
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PRECONSTRUCTION INJECTION FACILITY
INSPECTION REPORT - FORM A (cont)
COMMENTS
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INSPECTOR
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MEMORANDUM
GROUNDWATER SECTION
March 9, 1999
To: Jay Zimmerman
Groundwater Section
Raleigh Regional Office
From: Mark Pritzl /t1(J [e-mail]
Hydrogeological Technician II
UIC Group
Groundwater Section
Raleigh Central Office
Re: Receipt of Notification for a Closed-Loop Geothermal Water-011.ly Injection Well
System.
Notification to construct and operate injection wells for a geothermal heat pump system has been
filed by Andrew Mitro of Chapel Hill, 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
ATAA
NCDENR
3AMEs H. HuNTJR:
GovE R N OR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
March 9, 1999
Andrew Mitro
6302 Monterrey Creek Drive
WAYNEMCAEVITT'.
SECRETARY Durham, NC 27713
A. PRESTON HOWARD,
JR., PE.
DIRECTOR
Dear Mr. Mitro:
DIVISION OF WATER QUALITY
In accordance with the notification submitted on your behalf by Evangelist Service
Company dated March 3, 1999; the Groundwater Section acknowledges your intention
to construct closed -loop geothermal water -only injection wells for the operation of a
ground -source heat pump. The system as described in your notification will not
require an injection well permit and is deemed permitted by rule (North Carolina
Administrative Code Title 15A: 2C.0211(u)(2). The Underground Injection Control
Group has added your site to our inventory. If you modify your system, please contact
the Groundwater Section to verify compliance. Thank you for submitting this
notification.
If you have any questions regarding geothermal heat pump wells please feel free to
contact me at [phone] or Amy Axon at [phone].
Sincerely,
Ark
Mark Pritzl
Hydrogeological Technician II
Underground Injection Control Program
cc: L'IC Files
RRO Files
GROUNDWATER SECTION
P.0 Box 29578, RALEIGH, NC 87625-OS78 - 2728 CAPITAL BLVD., RALEIGH, NC, 27004
PHONE [phone] FAX 919-71'5.0588
AN EQUAL OPPORTUNITY I AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLE0110% POST -CONSUMER PAPER

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP
GEOTHERMAL WATER —ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
TO:
This is not the proper form to be used for injection wells in an open -loop geothermal system. r
Do not use this form for systems that circulate any substances other than water, c
t-iT
( .-7
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in contitiuous
piping that completely isolates the fluid from the environment?
DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: g - 3 , 19 if,
YES X If yes, then continue completing this form.
NO If no, do not 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 FLUID WiII 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 And/Or Use A Wells) For Injection With A Heat
Pump System, should be completed.
NO ) If no, then continue completing this form.
C. PROPERTY OWNER
6,46,4
Utti
Name: 4+tiC--,.." ffn 11.rw
#Address: /00 k'rFSI►4 cl" 9A •
City: C MPC._ I4j L L State: NC Zip Cod
County: Oug44.4 .i Telephone: (qlq 3for — 0662-
40'60-2-
L
D. STATUS OF PROPERTY OWNER
Lotat ikiN Private: X Federal: Commercial:
"_` State: Municipal: Native American Lands:
GW-57 CL (May 1998)
Page 1 of 4

E. FACILITY (SITE) DATA
(Fill 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 Person:
Standard Industrial Code(s), SIC, which describes commercial facility:
F. HEAT PUMP CONTRACTOR DATA
Name: 640►NGe-c i S i VE Rvn t o C, -
Address: P-0, go), 3(o —
City: x State: NC Zip Code: 2-7 .]"?'z County: c-kfrFrOP
Telephone: `)11- 3C, e Contact Person: 13► "- E'V ► 114eiti-r-
G. CONSTRUCTION DATA (check one)
EXISTING WELL(S) being proposed for use as a ground -coupled heat pump
well(s). Provide the information in (1) through (4) below to the best of your
knowledge. Attach a copy of Form GW-1 (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 (1) through (4) below as PROPOSED
construction specifications. Submit Form GW- 1 after construction.
(1) Well Drilling Contractor's Name: R- A . i St ►gn,ort+5 Wets ,gouiroc
NC Driller Registration number: �g
Date to be constructed: 3- ti Number of borings:
Approximate depth of each boring (feet): 3001
(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
Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.1,s.):
(a) Grout type: Cement Bentonite X Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
xaround closed loop piping; from400 to 0 (feet).
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
(3)
GW-57 CL (May 1998) Page 2 of 4

H. 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.
1. LOCATION OF WELL(S) Attach two maps.
(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 NO feet of the ground -coupled heat pump well system. Label all
features clearly and include a north arrow.
(2) location reap 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 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 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 Well Owner or Authorized Agent)
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
GW-57 CL (May 1998) 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)
GW-57 CL (May 1998)
(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 .0. Box 29578
Raleigh, NC 27626-0578
Telephone [phone]
Page 4 of 4
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