WI0500104_GEO THERMAL_19980212

GROUNDWATER SECTION
February 12, 1998
MEMORANDUM
To:
From:
Jay Zimmerman
Groundwater Section
Raleigh Regional Office
Marcus Geist 11/t(,
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 Mr. Richard Averitt in Raleigh; a copy of the Notification is enclosed for your
files. These injection well systems are 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: UICFiles
RRO Files
Enclosures
C:\WPDOCS\SHELLS\PERMIT\SNDPER.MM:.WPD
ATA
NCDENR
JAMES 8. HUNT-1M1,
GOVERNOR
WAYNE McDEvlrr
SECRETARY
A. PRE Trott HOWARD,
JR., RE.
DIRECTOR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALIFY
February 12, 1998
Richard Averitt
702 Glenwood Avenue
Raleigh, NC 27605
Dear Mr. Averitt:
In accordance with the notification submitted on your behalf by C.W. Bing's Well
Drilling and dated January 2, 1998; 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 15 A: 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,
Fea,te,46 me;d--
Marcus A. Geist
Underground Injection Control Program
cc: MC Files
RRO Files
GROUNDWATER SECTION
P.0 SOX 29578, RALE[GH, NC 27626-0578 - 2728 CAPITAL RLVD., RALEIGH, NC, 27604
PHONE [phone] FAX [phone]
AN EQUAL OPPORTUHITY /AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLEDI10% POST -CONSUMER PAPER

Type 5QW Wells
Tla DIRECTOR. NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: -r- , 19 ga.
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.
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 systems 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.
ND �If no, then continue completing this form GW-57 CL.
G PROPERTY OW NER I (9[7 5- U? r?
Name: /IIC/%G� 'edf /
Address: 70.a. 6Lvivillood Ave
City:
jA live.
Zip code: 276 6 05
County: Wet 6 Telephone: a 9-7 6,27 I
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
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
complete notification and mail to address on the back page.
This is not the proper form for injection wells to be used in an open -loop
ground -source heat pump system. Do not use this form for systems that
re -circulate any substances other than water below the ground sift -lace.
w
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GW-57 CL (March 1997) Page 1 of 4

D. STATUS OF PROPERTY OWNER
Private: V Federal:
State: Public:
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: in can/ E/e C7�►G Co/y9.2n�
Address: P Q • 6or a c
City: M7 r q, 1 ALC - Zip code: 75-15I
County: Telephone: 9/9 " 6 3 i - 0774
Contact Person: L Vezee
G. WELL USE Will the system well(s) also be used as the supply well(s) for
your personal consumption?
YES NO l7
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
. f Construction Record) if available.
PROPOSED WELL(S) to be constructed for use as aground -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) Well Drilling Contractor's Name: /3i(!J 1.s tJ el I Dr;)/, iJ I I NC. '
NC Driller Registration number: --'-/ S=--¢ _____ tj ________ _
(2) Date to be constructed: _/_-_~_-_C/_8 __
,,...,c-,l) I Approximate depth of each boring:------=o<~v'---"-i ____ _
Number of borings: ___ ~---
(3) Well casing: Is the well(s) cased?
(a) YES ff yes, then provide casing information below.
Casing type: Galvanized steel _ Black steel _ Plastic _
Other (specify) _______ _
Casing depth: from. __ to ___ ft. (reference to land surface)
(b) l'O
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement_; Bentonite~
Other (specify) _____ _
(b) Grouted surlace and grout depth (reference to land surface):·
~ound closed-loop piping; from O to ~S: ft.
_ around well casing; from.__ to __ ft.
NOTE: THE WELL DRILUNG CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELI.S IF THIS INFORMATION IS UNAVAILABLE BY OIBER :MEANS.
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 ---•-·-........ a4'!t.'" .,. ...,...,,. '" •• •
I. CERTIFICATION
"I hereby certify, 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
s gnificant penalties, including the possibility of Imes and imprisonment,
for submitting false information. I agree to construct, operate, maintain,
repair, and if applicable, abandon the ground -source heat pump s s PM
well(s) and all related appurtenances in accordan - • ' Tide A NCAC
Subchapter 2C Section .0200."
�r
(Signature of Owner or Authorized Age t)
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 Subchapte
(Signatue of Property Owner if Different From System Oper
Please return the completed Notification package to:
UIC Program
Groundwater Section
North Carolina DEHNR-DWQ
P.G. Box 29578
Raleigh, NC 27626-0578
(telephone: [phone])
GW-57 CL (March 1997)
Page 4 of 4

0-1. I.•
FR01.1
North Carolina • Dopartmoni of Enviror1zTionf, Hon11h, and Natural R000urcva
Divi&ion of EnvironmonIol Mann runt • Groundwatar Soclion
' P.O. Box 20535 - RaloiO 1, N.C. 27G2G-0535
Phony (019) 33.3221
WELL CONSTRUC ION RECORD
DRILLING CONT1kACT013:
DRILLER REGISTRATION NUME3ER:^ .r> S/T
STATE WELL C 1 STRUCT1DN
PERMIT N U M i3 4 R':
1. - WELL LOCAT{. :,• -to Sketch of Olio location below'
Noar9st Town: • 1 • County:
SRaod, Cont�`nit , or S txliv °loft no(' Lof,No,)
2. OWNER e9 Fiom To
ADDRESS_70a. woo_ D Z
j�� i5[rr vt or u[o •lo.) °276os—
I[�' �o
Ci.y o own vlato d
r Zip o a too QS.0
3. DATE DRILLED /-2-5Y USE DF WELL Cefl O°
4. TOTAL DCPTiT{ RSo idtli
5. CUTTIfrGS COLLECTED YES [ }l ND[1..F1
G. DOES WELL F EPLACE EXISTING VELL? YES n NDf
7. STATIC WATEIR LEVEL Elofow•Top a Casino: — FT.
(U5o " " II Abovo Top of Casing)
8. TOP OF CASING IS PT. Above Land Surfaco"
' Cooing Tor'mina[od nilor balm)/ land aurlato to Wog al tinlbaa n vnrloncn In IUnuorl
1n accordance with 154S CA 20 .0110__—_-_._.,_._._�...__.•_�..____.
9. YIELD (00prn):. METI-ice OF: TEST IQt F ii
10. WATER ZONES (doplil): V 1
1
11. CHLORINATJON: Type - Amount
12: CASING:
1]Rlt.t.lf\75 1.0G;
I=ormalio�n DoscripI' n
If addili.7nni cpac* 17. noodod usn back of form
Ijk u jar u -•- --•r �: _-�� ..._�rlfT.,.•••=. _..
i Wall Tilicknnss
Dapth Diamo4ar ❑r WoiuhVFC. il,ti[orlal
From fro Pt, -.;- —�
From To-._ f:t, I
From To Ft, 1
13. GROUT:
Dopllt Afv�ckE r+al
Ft.
From To
14.'SCREEN:
From
From
From
fvlo 1 od
DWI) DIaniolor Sci!. Sizi.) t,1alci'i;1l
To Ft in, in. _________
To Ft. iri. _ in.
1'0 w Ft. ..... in, ______ in,
1
Depth Si'l.ol Material
l
Frgm 7'o Ff. - rL.
From
16. M iMAR <S:
15. SANDIpRAVE=L PACK:
CW•1 REV,
r
T4 _ Fr. __l
I 00 THEREBY Ct-FITIFY THAT THIS WELL WAS COALS ALICTED iN ACCORDANCC VJ1 T f-I 15A NCAG 2C, WELL.
CONSTRUCTION STANDARDS, AND Tl- AT A COPY OF THIS RECORD HAS SEEN PROVf0ED TO THE WELL OWNER.
9N1 I
LOCA'l'ICN SKETCH
(Shove riiroclion and dItItanco from 01 loo;l two Spnia
Road!, Or olhnr map roforonco poinis)
640.1406(
tinifr'w�
41.1.
._... •
SIG NATURE 0E= C0r4TS. L.TOR C)il AGENT
Submit originar 16 Division of Ciwironn]onl.l 1,llino[Ionsor,[ ntnt copy 1. wall ot':nnr DATL

.1I
4
1
I Wall Thicknoss
Depth Dismo{or or WaigtitlFt. Malarial i
To • Ft. I- -
To Ft.--1
To Ff,
13. GROUT: i
Dt1pII7 rvjatari I Motel_
From 0 To as Ft
From To F(
14.'SOREEN:
0,I.1v,1J9u
FRO 1•t
North Ctirolina • Dupartmont of Environer{onl, Honith, arrd Natural Rasourcoa
Division of Erwironmontni Manag meet • Groundwatar Soclion
' P.O. Box 29535 • Raint° ., N.C. 2762G-0535
Phone [phone]
WELL CONSTRUCTION RECORD
ti
DRILLING CONTF�ACTOR: 1 I C J� 1 i +Miin /'G .
STATE WELL C jNSTRUCT(ON
DRILLER REGISTRATION NUMBER: I5 i PERMfi NUMBgR
1. WELL LOCATIO ❑w ketch of trio location below)
Nearest Town: County.
LrlWo ao/+raar Baer j j .
(Road, Com fly,prlS.;'visl and .}
2. OWNE-ER �,r�y„}i
AC]
3.
5,
6.
7.
OS -
Zip Coda
E7E P`f'N
From To
FWELL Cased63a �
2-
YIELD : METH
NO !vet'
DOES WELL REPLACE EXISTING V�ELL? YES NO1,►�'
STATIC WATdR LEVEL Boiow•Top o Casino: FT.
(U4-o " " it At�ova Top of Casing)
8. TOP OF CASING iS FT. Pbove Land Surface
• Caolrlg Tormtrlatod at/or bolow land aurfnca le !JIogal unions a vnrlanco la lashed
In ocoordnnco with 151' NGAC 20 .0110
m
S
igp ) OD OR TST -� ;t
10. WATER ZONES (depl.h)• 7b
11. CHLORINATION: N: 7`...... Arno__,
12. CASING:
From
From
From
DFtESS.��a� � 0•��
(Stroet or Rout()
c
City or Ttwn Stato
DATE DRILLEp - �� • - USE
TOTAL DEPTH aso
CUTTINGS COLLECTED YES
r
1
Sr.oJ
Frgm To . Ft _ 1—
Frorn To Ft. __ _
16. R1MARFCS:
1
Depth Dianlotor { Stu! Siva Material
From To Ft iri. _ in
From To Ft. it'. _ In
From To Ft. ._ In. in
15. SAND/RAVEL PACK: !
r- Depth
Material
DRILLING LOG
Imp on Oo9criplto
1I additional cpaco Is noodad usa back at torus
lit ••'�•--•-_,. RarcirL'Cfa.iCf.'.L�
LOCATION SKETCH
(Show diroction and dlstanco from at toast Iwo Stnto
Road:, orothor map raforonco points)
CI
t DO HEREBY C RTiFY THAT THIS WELL WAS CONSTRUCTED iN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTFON STANDARDS, AND ST A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL CWNEf .
GW•1 REV. PR71
U
SIGNATURE OF GONTRAC
Submit original to Division o
22 ci
R CWI AGENT DATE_
avironrnontal !Ylnnagomonl and cop 10 wail ownor,

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