WI0500093_GEO THERMAL_20030508

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
May 8, 2003
To: Jay Zimmerman, L.G., Regional Groundwater Supervisor
Groundwater Section
Raleigh Regional Office
From: Mark Pritzl ,n.-P. [e-mail]
Hydrogeological Technician II
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 a well for a closed-loop geothermal heat pump system has
been filed by Mr. Fowler in Raleigh, 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].
cc: CO-UIC Files
Enclosures
North Carolina
Mr. Tim Fowler
1169 Page Road
Raleigh, NC 27603
RE: Notification of intent to construct Type 5QW injection wells
Dear Mr. Fowler:
Michael F. Easley, Governor
William G. Ross Ir., Secretary
artment of Environment and Nature! Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
In accordance with the notification you submitted to the UIC Program on May 7, 2003, the
Groundwater Section acknowledges your intent to construct two 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 [phone].
cc: UIC-RRO files
UIC-CO files
d�Q
i]ENR
Customer Service
1 800 623-7748
Sincerely,
Mark Fritz!
Hydrogeological Technician
LTIC Program
Division of Water Quality 1 Groundwater Section
1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet: http://9w,ehnr.state.nc.us

D. STATUS OP 1,OPERTY DWNP
Private: Federal; — Commercial:
State: — Municipal: Native American Lands:
'+: er.3101 GW/WC-57 CL Page 1 of 4
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOO.P
GEOTHERMAL WATER --ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type SQW Welk
In Accordance with the provisions ofNCAC Title 15A 42C.0200
Complete application and mail to address co the back page.
This is not the proper form to be used for injection welts in ars open-loomsgeothermal system.
Do not use this form for systems that circulate env substances other than water,
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: 4 -7-z 20 03
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid Bom the eavirozunent?
YES ' If yes, then continue completing this fora.
NO If no., do not complete this form, Form GW-57 I-1P, Application Far
Permit To Construct And/Or Use A Well(.') For Injection With A Hear
Pump System, should be completed.
B. SYSTEM FLUID Will any additives be introduced to the systemn's circulating heat transfer
fluid? This includes, but is not limited to corrosion inhibitors and/or antifreezes.
YES
If yes, do not complete this farm. Form GW-57 HP, Application For
Permit To Consenter An& r Use A Well(s) For Injection With A Hear
Puntp System, should be completed.
NO ' if no, then continue completing this form.
C. PROPERTY OWNER [I Az
Name:
�r' FD J1e
Address: 1 1 �e- Rd 2
ril
tip
Cary: R4 et' I, State: NJ. C. Zip Cade: 1-7103 cofnZ
County: 3hf Telephosae. -- — - a Ica
n
G
z

Ub/lb/2002 16:47 919-715-0588 NCDE&t-.lR/ ~)ATER QUAL PAGE 03/05 ..
E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Nume of Business or Facility:------------~--------Address: ___________________________ _
City: ________ State: __ Zip Code: ____ County: ____ _
Telephone: _________ ContactPerson: ___________ _
Standard Industrial Code(s)1 SIC, which describes commercial facility: _______ _
F. HEAT PU.MP CONTRACTOR DATA
Name; 6,A) Mq I) . tv\e..~an1 ca I Sel<V, (. IE I :I:,.Jc. •
Address: \ l\ C:i Tec.h l\,·cA I Co'-'r t
City: G-a rf\e.R. State: "1 ·' • Zlp Code: ':\ '1S2 ~ County: W'a.Ke.
Telephone: 9 1q ... y % I ... "'45 oe Contact Person~ s .\-eve e;'OW M g J
G. CONSTRUCTION DATA (check one)
(1)
(2)
(3)
NOTE:
Vc:r.3101
EXISTING WBLL(S) being proposed for 'Ilse as a ground-coupled beat pump
wetl(s). Pro,•ide the infonnation in (l) through {3) below to the best o.f your
knowledge;:. AtU\ch a copy of Form GW-1 (Well Construction Record) if
ava.ilablc.
PROPOSED WELL(S) to be consttucted for use as a ground-couple.cl hea:t pump
well(s). Provide the infonnation in (1) through (3) below as PROPOSED
construction specifications. Submit Form GW-1 after conatruction.
WettDrillingContracior'sName: B,·n3~ We.lJ Dr,·u,hj :GJc.
NC Conmu:tor Certification numbc:r:._d.=_o_Ca_2 _____________ _
Date to be consn-ucted: S-11-03 Number of borings: -~----..::=-------------
<oo' Approximate depth of each boring (feet):_-=-->=--c=---------------
Well casing: Is the well(s) cased?
(a) YES V Ifycs, then provide the casing information b~low.
Type: Galvanized steel V Black steel Plastic Other (specify) --::--, , , ~ ------
Casing depth: From -J to /Of,' ft. (reference to land sw:fiu:c)
~ing e~ten.ds above ground JI' /A inches
(b) NO
Grout.(grout the vertic~l length of the borehole tQ a minimum depth of20 feet b.1.s.):
(a) Grout type: Cement__ :Sentonite ✓ Other (specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
✓ around ciosed loop piping; from -5 to /00 , (fe~).
~<nmd well casing; from -..5 to "° (feet).
Ttti: W:Et.l DRll.LJNO CONTRACTOR. CAN SUPPL Y'THE DATA t=OR J;lTHER £XJSTING OR
PROPOSED WELLS lF TIDS INFORM./\ TtON lS U'NAVAJLABLS BY 0Tt1.~ MEANS.
GW !UIC-51 CL Pase2 of4
NORTH CARO.LINA
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.4200
Complera applicsttioc and Mail to eddxess nn the hack page.
This is not the proper form to be used for injection wells in an QDen-Io a geothermal system.
Do not use this form for systems that circulate an% substances other than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: 4 `1-2- 20 03
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environmem? w
Z =
YES I.-- If yes, then continue completing this form. = m
x�
NO lino, do not complete this form. Form GW-57 HP, Application For —I *si*r
Frrm,t To Construct And/Or Use A Well(5) For Injection With A Heat ZEP n,
Pomp System, should he completed. = Xtrr_-,
cox
B. SYSTEM FLUID Will any additives be introduced to the system's circulating heat transfer r
fluid? This includes, but is not limited to corrosion inhibitors and/or antifreezes. cr. a
x
YES
NO
If yes, do not complete this form. Form GW-57 HIP, Application For
.Permit To Construct And/Or Use A Well(s) For Injection With A Hear
Pump System, should be completed.
If no, then continue completing this form.
C. PROPERTY OWNER
Name: '►n I b%J teR
Address: 1 i �e�d
City: Ra C► State: V. L. Zip Code: 114 A3
County: �Qhsr5-..1 Telephone:
D. STATUS Of P,#tOPERTY OWNER
Private: L Federal: Commercial:
State: Municipal: Native American Lends
Ver.3/01 OW/U1C-57 CL Pap t of 4

08/16/2002 15:47 919-715-0588 NCDE&NR/WATER QUAL PAGE 03/05
E. FACILITY (SITE) DATA
(fill out ONLY if the StatUs of Owner is Federal, St:..te, Municipal or Comme.rcial).
Name of Business or Facility: ____________________ _
Address; __________________________ _
City: ________ State: __ Zip Code: _____ County:-~----
TeJephone: _________ ContactPerson: ___________ _
Standard Indu~trial Code(s), SIC, which describes commercial facility: _______ _
F. HEATPUlvJP CONTRACTOR DATA
Name; e~\)/'Ylq(). > MecJ..gA,l,Q,/ SelU,c:e-I :I:,.Jc .
Address: \ '-' c; Tec.h"•·ce I Co u rt
City: G-art\e.R, State: ~-Zip Code: ~'1S2.CJ County: LJa.Ke.
Telephone: 91q ... UB, ... 'iisoe Contact Person; S.\-e.ve ~MgJ
G. CONSTRUCTION DATA (check one)
(1)
(2)
EXISTING WELL(S) being proposed for lise as a ground-coupled beat pump
welt(s). Provide the infonnation in (l) through (J) below to the best of your
knowledge. Attach a copy of Form GW-1 (Well Construction Record) if
available.
PROPOSED WELL($) to be consttucied for use as a ground-coupled hea:t pump
well(s). Provide the infonnation in (l) through (3) below a.,i; PROPOSED
construction specifications. Submit Fonn GW-1 afte1 coJl$truction.
WeUDrillingContracto1'sName; B,·ng& WelJ Dr,'11,hj ~C •
NC Contnictor Certification number: do oCo L -=-----------------
Date to be constructed: S-11-03 Number of borings: ____,;~:;;..___;:'----------
500 /
Approximate depth of each boring (feet): ___ ~=----------------
Well casing: Is the well(s) cased?
(a) YES If yes. then provide tru: casing information b~low.
Type: Galvanized steel __ Black steel __ Plastic_ Other (specify) ____ _
Casing depth: .From ___ to ___ ft. (reference to land surface)
Casing extends above ground ____ inches
(b) NO __
(3) Grout.(grout the vertical length of the borehole to a minimum depth of 20 feet b.1.s.):
(a) Grout type: Cement__ Bentonit.c __ Otl1e.r (specify) ______ _
(b) Grouted surface and grout depth (reference to land surface): .
__ around ciosed loop piping; ftom __ to_ (fed).
_ around well casing; frorn __ to_ (feet.).
NOTE: Ttiij WJ:Ll DRn.LINO CONTRACTOR CAN SUPPLY TKE DATA rOR ElTHE'R EXISTING OR
PROPOSED WELLS lF TfllS INFORM.t\ TION lS UNAVAILABLE BY OT~Ek MEANS.
Vcr.3/01 GW/UIC-57 CL Pagel of4
vb/ ►b/dtalle lb:47 919-715-0588
NCDE&NR/WATER DUAL PAGE 04/05
H. INJECT/ON-RELATED EQUIPMEIsIT
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.
LOCATION OE WELL(S) .Attach two maps.
(I) Include a site reap (can be drawn) showing; buildings, property lines surface water bodies,
potential sources of goundwater contamination and the orientation Gland distances between
the proposed well(s) and any existing well(*) or waste disposal facilities such as septic tanks
or drain fields located within 200 feet oldie 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).
PERMIT LIST: Attach a list of all permits or construction approvals that ate related to the site.
Examples include:
(I)
(2)
(3)
Hazardous Waste Management program permits under RCI)A
NC Division of Water Quality Non -Discharge permits
Sewage Treatment and Disposal Permits
K. CERTIFICATION
"I hereby certify, under penally of taw, that I have personally examined and am familiar with the
information submitted in this document and all attachments thereto and that, based Oil 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 arc 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 -soiree heat pump system and sit related appurtenances in
accordance with the approved specifications and conditions of Permit" /1
7/e ' ti'
(Sign,(we of Well On. or Authorized Agent)
1f aurhori~ed agent is acting on behallol the well owner,
please supply a letter signed by the owner
authorizing the above agent.
Ver.3141 GW/LJIC•I7 CL Pose of 4

09/16/20B22 16:47 919-715-a588
NCDE&NR/WATER QUAL PAL* uw ah
i. CONSENT OF PROPERTY OWNER (Owner ratans any person who holds the fee or other property
rights in the well being eonstrucred. A well is real property end its construction on land .rears
ownership in the landowner in the absence of contrary ao cement 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 systern's well(s)
conforms to the Well Construction Standards (Titl�15A NCAC 2CO2413) �)
(Signature O/Property Owner4f Different Fiom Applicant)
Please return two oopies of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
vera,o t GW(WG-57 CI- Fags 4 os

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