WI0500101_GEO THERMAL_19980129

GROUNDWATER SECTION
January 29, 1998
:MEMORANDUM
To:
From:
Jim Greer
Groundwater Section
Raleigh Regional Office
Marcus Geist fl} Ab
UIC Group ·
Groundwater Section
Raleigh Central Office
Re: Notification form for Closed-Loop, Water-Only Geothermal Injection Well System.
I have enclosed a copy of the Notification forin submitted by Mr. Mark Lassiter of A&E Drilling for a geothermal injection well system located at 205 Chimeneas Place in Chapel Hill. This is considered a Type 5QW well and is deemed permitted by rule (ISA: 2C.021 l(u)(2)). No further action is necessary from either the Central Office UIC Staff or Regional Office Staff. Retain these documents for your files. If you have any questions please contact me at [phone].
Cc: UICFile
RROFile
Enclosures
NCDENR
JAMES S. HU NT JR.
GOVERNOR
WAYNE MCDEVITT
SECRETARY
A- PRESTON HOWARD,
JR., RE.
DIRECTOR
NORTH CAROL!NA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
January 29, 1998
Peter Gruber Foundation
205 Chimeneas Place, Lot 8 — The Reserve
Chapel Hill, NC 27514
To Whom It May Concern:
In accordance with the notification submitted on your behalf by Mark Lassiter of A&E
Drilling and dated January 22, 1998; the Groundwater Section acknowledges your
intention to construct closed -loop geothermal water -only injection well systems for the
operation of ground -source heat pumps. 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). 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 (919) 715 - 6166 or Amy Axon at [phone].
Sincerely,
Marcus A. Geist
Underground Injection Control Program
cc: LUC Files
RRO Files
GROUNDWATER SECTION
P.0 90% 293713, RALEIGH, NC 2762E-0579 - 2728 CAPITAL BLVD., RALEIGH, NC, 27604
PHONE [phone] FAX 91 9.7 f 5-0558
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLED(I O% POST -CONSUMER PAPER

-1$
A.E. DRILLING SERVICES INC.
Two United Way
Greenville, SC 29607
Phone [phone]
FAX [phone]
January 23, 1998
w ram,
w
ZZIO
Mr. Marcus Geist ter)
L1IC Program :Ns c rn
Groundwater Section _
North Carolina DEHNR-DWQ 7
P.O. Box 29578
• m
Raleigh, NC 27626-0578 r
W rri
Re: Gruber Residence
Geothermal Wellfield
Chapel Hill, NC
Dear Marcus:
Enclosed please find completion and application records for the Gruber project. Please
accept my apologies in being delinquent on the application portion.
Sincerely,
A.E. DRILLING SERVICES, INC.
Mark Lassiter, P.G.
President
M Llacl

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
NO'nFICATION 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.4211
complete notification and main to address on the back page.
This is cent the proper form for injection wells to be used in an oven -loon
ground -source heat pump system. Do nor use this form for systems'that
re -circulate any substances other than water below the ground surface.
Type 5QW Wells
TO DIRECTOR, NORTH CAROUNA DIVISION OF WATER QUALITY
DATE: 1 1 r:•. , 19 t' B
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.
£1=1 lid 9Z U 86
NO 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 HF
(Application For Permit To Construct And/Or Use A Well For
Injection With A Heat Pump System) must be completed.
MD If no, then continue completing this form GW-57 CL.
CI
sc.
rim
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Trt
C PROPERTY OWNER
Name: V. .- cA,:,u. L- t.s k-r%t_-
Address: 1-C E
City: C ems- Zip code: :I,1 , �}
County: ( ).2 tv,) Telephone: CA 1 CL hi 113
GW-57 CL (March 1997) Page 1 of 4

D. STATUS OF PROPERTY OWNER
Private: - - , •- Federal:
= State:
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: _
Address:
City: Zip code: County:
Telephone: Contact Person:
Standard Industrial Code(s) which describes Commercial facility:
F. HEAT PUMP CONTRACTOR DATA
Name: C ,t1 tiT
Address: V c, i3u `-A S
City: Zip code: I.-t -1\ , - "VA 5 =S
County:
Telephone:
Contact Person: lr,�.
G. WELL USE Will the system well(s) also be used as the supply well(s) for
your personal consumption?
YES NO J
H. CONSTRUCTION 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 (Well
Construction Record) if available. -
PROPOSED WELL(S) to be constructed for use as a ground -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

.I
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(1) Well Drilling_Contractor's Name: t?\6-~'it-,'-'--,'"'1J
NC Driller Registration number. __ q_· _G\_3 _______ _
(2) p~e to be c~nstructed: · ·, \ \g:,
\ : _. Appro~te depth of each boring: ___ 1-.. ........ o_o_· ___ _
Number of borings: -'l.o
________ (3) _ Well -~~ing: Is the well(s) cased?
YES __ If yes, then provide casing information below.
C~ing type: Galvanized steel_ Black steel _Plastic_
Other (specify) ______ _
Casing depth: from. __ to __ ft. (reference to land surface)
(b) ~ N) . ~. :·:
.( 4) Grout (material surrounding well casing and/or piping):
(a) ·orout type: Cement_; Bentonite..:J.;. ·
Other (specify) ____ _
(b) Grouted surface and grout depth (reference to land surface):
=J_ around closed-loop piping; from ')a? to Q ft.
_ around well casing; frqm __ to __ ft.
NO'IE: THE WELL DRILUNG CONTRACTOR CAJ."\J' SUPPLY THE DATA FOR EIIBER EXISTING OR
PROPOSED WELLS IF TIIlS INFO&'vfATION IS UNAVAILABLE BY 01HER MEANS.
H. LOCATION OFWEµ.(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
L CpRIII-ICATION
-- "I herebycertify, 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
si>mtcant 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 Tide 15A NCAC
Subchapter 2C Section .0200."
- L
(Signature of Owner or Authorized Aent)
Please supply a letter signed by the owner
authorizng 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 I5A NCAC Subchapter 2C .0200)
(Signature of Property Owner if Different From System Operator)
Please. return the completed Notification package to:
UIC Program
Groundwater Section
North Carolina DEENR-DWQ
P.D. Box 29578
Raleigh, NC 27626-0578
(telephone: [phone])
GW-57 CT_ (March 1997) Page 4 of 4

North Carolina - Department of Environment, Health, and Natural Resources
- Division of Environmental Management • Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27526-0535
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: ptE
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: ci co PERMIT NUMBER:
OR OFFICE USE ONLY
QUAD NO SERIAL NO.
Lat. - - - Lang_ R
Minor Basin
Basin Code
Header Ent. GW-t Ent
1. WELL LOCATION: (Show sketch of the location below) _
Nearest Town: �l �t + + L-- County' rp�Pi t%c
(Road, Community, or Subdivision and Lot No.)
2. OWNER Pe: 2.e_- f c 1 t~.z Covtv.ce r.c s•7
ADDRESS 1,0
(Street or Route No.)
�y
1 L
City or Town State Zip Code
3. DATE DRILLED No)) - I'L USE OF WELL ]traP
4. TOTAL DEPTH r9 `
5. CUTTINGS COLLECTED YES ❑ NOZ
6. DOES WELL REPLACE EXISTING WELL? YES NOR.
7. STATIC WATER LEVEL Below•Top of Casing: FT.
(Use "+” if Above Top of Casing)
8. TOP OF CASING IS 1N/4\ FT. Above Land Surface'
*Casing Terminated atlor below land surface is illegal unless a variance Is issued
in accordance with 1SA NCAC 2C .0118
9. YIELD (gprn)' IVA- METHOD OF TEST
10. WATER ZONES.(depth): Lw!
11. CHLORINATION: Type \ / Amount
12, CASING: NJ Qr-
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To Ft
From To Ft.
From To - Ft.
13. GROUT:
Depth Material Method
From 0 To Q Ft. time arrarare-r T .w,i r=.
From To Ft
14 SCREEN:
Depth Diameter Slot Size Material
From To Ft _ in. in -
From To Ft. in. in
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From _- To Ft.
16. REMARKS:
DEPTH DRILLING LOG
From To Formation Description
'In L el o ►1e-P-3301itte
0-40r--V-00` \J N4reclii=6ywt
t 1•1-it4 t tJtt4xZ.tTG.
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Ic�TPtc we
�:wc_ W t-A.A..s J aR1
bR>> a tQ Pr 0' 4?i t]
41— Cc., ...► r J V
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
GW-1 REV. 919t
, 151 A,
SIGNATURE OF CONTRACTOR OR AGENT DATE
Submit original to Division of Environmental Management and copy to well owner.

US %5_,
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VICINirr MAP
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WEL.L PERMIT
APPLICATION
CLANCY & TREYS
TEE DAV 15 ,
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P.Q. BEd. %ill, 31113-G Revery' Read
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