WI0500092_GEO THERMAL_19970610

NORTH CAROLINA
ENVIROMvlENT AL MANAGEivIENT CO1\1MISSION
DEPARTMENTOFENVIRONMENT,HEALTH,ANDNATURALRESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP
GEOTHERMAL-WATER-ONLY INJECTION WELL SYSTEM
{GROUND-SOURCE HEAT PUMP)
In accordance with the provisions of NCAC Title 15A: 02C.0211 \.0
complete notification and mail to address on the back page. -J
c:: _.,,.
This is not the pro per form for injection wells to be used in an ii,en~-lo~p
ground-source heat pump system. Do not use this form for systemsJhat
-~ .·. re-circulate any substances other than water below.the grounifiurj~e.
Type SQW Wells
TO: DIRECTOR, NORTH CAROLINA DMSION OF WATER QUALITY
DATE: (}1 Y½f _30 , 19_£_z_
Please type or print clearly.
A. SYSTEM CLASSIFICATION Does the proposed system re-circulate potable
water in continuous piping which isolates the fluid from the environment?
YES ✓ If yes, then continue completing this form GW-57 CL.
N) If no, do not complete this form. A form GW-57 HP
(Application For Permit To Construct And/Or Use A Well
For Injection With A Heat Pump System) must be completed.
B. SYSTEM FLUID Will any additives be introduced to the system's subsurface
piping, including but not limited to corrosion inhibitors or antifreezes?
YES If yes, do not complete this form. A form GW-57 HP
(Application For Permit To Construct And/Or Use A Well For
Injection With A Heat Pump System) must be completed.
_✓rr° no, then continue completing this form GW-57 CL.
C PROPERTY OWNER
Name: f. i ty O L /? 6 q M /4: l<,y, -d{.
Address: /?O /,b, f 8
Zipcode: 22 8:20
-..
N
N
City: lf'oe.nake
County: /-/4 k ~ Y Telephone: (919 ) ~.JS--6 B 'I B
GW-57 CL (March 1997) Page 1 of 4
D. STATUS OF PROPERTY OWNER
Private: - Federal: f
State: Public: f/
Commercial: Native American Lands:
E. FACILITY (SITE) DATA (Fill out ONLY if the Status of Property Owner is
Federal, State, Public or Commercial).
Name_of Business or Facility: i'r I i,� C�! r�� GEC„ Lcfro, -
Address:
City: ,fry
00 /-Gf,-.'1710,
Telephone: (9I9) c35- 45ea
r
)±.
Zip code: 2 County: %J / 4 v
Contact Person: A e E
Standard Industrial Code(s) which describes Commercial. facility:
F. HEAT PUMP CONTRACTOR DATA
Name: //1i-arn . f X 17 dtf .
Address: i cf CU�.
City: 3002/ - /9) ' 4 c Zip code: 2-/' .r.-
County: A#-m,- ,c Telephone: _ (J") - 5-32i - 77 Z
Contact Person: /4. r i1 c-=
G. WELL USE Will the system well(s) also be used as the supply well(s) for
your personal consumption
YES NO
H. CONS"IRUCTION DATA (CHECK ONE)
EXISTING WELL(S) being proposed for use as a ground -source 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 (Weil
Construction Record) if available.
PROPOSED WF[.r (S) to be constructed for use as a Bound -source
heat pump well(s). Provide the information in (1) through (4) below
as PROPOSED construction specifications. Submit Form GW- 1 after
construction.
GW-57 CL (March 1997) Page 2 of 4

(1) WellDrilling _Contractor'sName: ~~~ ~t::")p ~~
NC Driller Registration number: __ t_6_f _____ (p ______ _
(2) Date to be constructed: · ~ -3 -q 7
Approximate depth of each boring: ___ ,3_~----
Number of borings:_--+----
(3) Well casing: Is the well(s) cased?
(a) YES ~ If yes, then provide casing information below.
Casing type: Galvanized steel v-13Iack steel _ Plastic _
Other (specify) _______ _
Casing depth: from 2-+ to /31 ft. (reference·to land surface)
(b) ID
. ( 4) Grout (material surrounding well casing and/ or piping):
(a) ·Grout type: Cement /4entonite_;
Other (specify) _____ _
(b) Grouted surface and grout depth (reference to land surface):
_ around closed-loop piping; from _____ to ___ ft.
/4ound well casing; frqm () to '2,.tO, ft.
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER lvlEANS.
H. LOCATION OF WELL(S) Attach two maps.
( 1) a site map ( can be drawn) showing 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-source heat pump well system.
(2) a location map referencing the site to a labeled road intersection.
GW-57 CL (March 1997) Page 3 of 4
I. CFRI1h1CAT1ON
"I hereby certify, under penalty of law, that l 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
well(s) and all. related appurtenances in accordance with Title 15A NCAC
Subchapter 2C Section .0200."
(Signature of Owner or Authorized Agent)
Please supply a letter signed by the owner
authorizing the above agent, if authorized agent is signer.
J. 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 land owner in the absence of
contrary agreement in writing.)
If the property is owned by someone other than the operator, the property
owner hereby consents to allow the operator to construct a ground -source heat
pump system as outlined in this notification and that it shall be the responsibility
of the operator to ensure that the ground -source heat pump system's well(s)
conform to the Well Construction Standards (Title 15A NCAC Subchapter 2C .0200)
(Signature of ProperfTi Owner if Different From System Operator)
Please return the completed Notification package to:
U1C Program
Groundwater Section
North Carolina DEHNR-DWQ
P.O. Box 29578
Raleigh, NC 27626-0578
(telephone: [phone])
GW-57 CL (March 1997) Page 4 of 4

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State of North Carolina
Department of Environment,
Health and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
AVA
DEHNR
GROUNDWATER SECTION
July 10, 1997
Mr. Jeff Dillard
Environmental Health Supervisor
Halifax County Health Department
Courier No. 07-43-06
Dear Mr. Dillard:
I appreciate your telephone inquiry into the geothermal heat pump
project in Roanoke Rapids. I am awaiting a return telephone call
from Michael Barlow who is the driller supervising this project.
I will instruct him to contact you to discuss your county well
ordinance requirements. The notification of intent to construct a
closed-loop geothermal heat pump system form and well
construction record for the initial test bore are enclosed. I
spoke with Mr. Barlow on Ju~e 3, 1997 and instructed him that the
test well would have to be abandoned in accordance with the
state's well abandonment standards NCAC T15A: 2C.0113. He told
me that the well would be fully grouted from bottom to top.
I will notify you upon speaking with Mr. Barlow. If you have any
questions regarding the standards or notification please feel
free to contact me at [phone].
Sincerely,
~tz--~
Marcus A. Geist
Underground Injection Control Program
cc: UIC Files
Enclosures
Groundwater Section,
P.O. Box 29578, Ralelgh, North Carolina 27626-0578
2728 Capital BJvd., Raleigh, North Carolina 27604
NOC ,,,,.,.,
C:\WPDOCS\MEMOS\RULETTR.WPD
Voice 919-733-3221 FAX [phone]
An Equal Opportunlfy / Affirmative Action Employer
50% recycles/ 10% post-consumer paper
UIJO[][TI~
T.M.
Corporation ... a Geot•1rmal Cam,any.
PROJECT: Geothermal Well Field Investigation
LOCATION: Kirkwood Adams Community Center
CITY.STATE: Roanoke Rapids, N.C.
CLIENT: City of Roanoke Rapids/ Mr. Chris Wicker
0' 1' Light brown sandy soil
1' 14' Red clay
14' -21' Red moist clay w/ corase sand and gravel
21' -26' Redish brown moist coarse sand and clay
26' -52' Brown coarse sand and pea gravel
52' -62' White silty clay
Fi le I
DATE 6/3/97
G.W.DEPTH
62' -92' Brown coarse sand and medium gravel w/ white clay
92' -118' Coarse sand and orange clay
118' -120' Soft blueish gray weathered rock
120' -123' Medium hard blueish gray granite rock
123' -131' Soft blueish gray weathered granite rock
131' -300' Hard greenish gray to gray granite rock
Water yield of boring 1 g.p.m. + or -
Boring started at 11:00 a.m. Completed at 6:15 p.m.
Weather: Cloudy, misty rain and cool.
912 Fawn Court ♦ Joppa, Maryland 21085 ♦ Phone: [phone] Fax: [phone]
P. O. Box 38 • Roanoke Rapids, M.C. 27870
[phone] FAX [phone]
OFFICE: WEEKDAYS 1:00-5:00 (FOR BOOKING)