WI0500106_GEO THERMAL_20021001

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
October 1, 2002
To: Jay Zimmerman, L.G., Regional Groundwater Supervisor
Groundwater Section
_ Raleigh Regional Office
From: Mark Pritzl fl 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 Jeff & Amy Camp 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
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
November 12, 2002
Mr. & Mrs. Camp
8925 Weaver Crossing Drive
Cary, NC 27512
Dear Mr. & Mrs. Camp:
In accordance with your notification received on September 24, 2002; the Groundwater Section
acknowledges your intent to construct a closed-looj geothermal water -only injection well
system for the operation of ground -source heat pump. This 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
(UIC) 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 Evan Kane at [phone],
cc! CO-UIC Piles
RRO-UIC Files
N'DNM
Customer Service
1 800 623-7748
Sincerely,
Mark Pritzl
Hydrogeologi.cal Technician
UIC Program
Division of Water Quality / Groundwater Section
1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet http:llgw.ehnr.state.nc.us

NORTH CARO.LINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOUR.CES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED--LOOP
GEOTHERMAL WATER --ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type SQW WeDs
Jn Accordance: with the provisions ofNCAC Title isA: 02C.0200
Complete applfoation and mail to address on the back page.
This is oot the proper form to be used for injection wells in an open-loop 1eotherm1I system.
Do not use this form for systems that circ.late any substances other than water.
TO: DIRECTOR., NOR.TH CAR0LlNA DMSI0N OF WATER QUALITY
DATE: 7 -d.{p . 20 &
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable wa&er in continuous
piping blt completely isolates the fluid from the environment'?
YES 'd_ lfyes, then continue completing thi, fonn.
NO If no, do not complete this fonn. Fonn GW-57 HP, A.ppacation For
Permit To Construct And/Or U.,e A WelJ(s) For Injection With A Heat
Pump System, should be completed.
B. SYSTEM FLUID Will any additives be jntroduced to the sy~tem ·s circulating heat transfer
fluid? This includes, but i~ not limited to conosion inhibitors and/or antifreezes.
YES
NO ✓
If yes, do not complete this fo1m. Form GW--57 HP, Application For
Permit To Construct And/Or Use A. w~ll(s) For ln_jection With A J-leat
Pump Systemt should be completed.
If no, then contmue completing this fonn.
C. PROPERTY OWNER
Name: ~+{ Q_('(1 ~~ t {)
Addres~_Wis t.Ji<i{,t,c C.iri~ rYr 1".e,
City: \<-.a:f'U gb-State: Zip Code: _;;.l.-=-'--=s--','--~-------
County: 'w alu Telephone: _CID_,q ________ a_~--=l'----~-'~4 ...... O ________ _
D. STA11JS OF PROPERTY OWNER
Private: V Federal: Commercial: 0
State: Municipal: __ Native American Lands:
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Ver.3/01 GW/UlC-57 CL
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E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commucial).
Name of Business or Facility:-~---------~--------
Address: _____________ ~---------------
City: ________ State: __ Zip Code: _____ County= _____ _
Telephone: _________ ContactPerson: ___________ _
Standard Industrial Codc(s), SIC, which describes commercial facility: --~-----
HEAT PUMP CONTRACTOR DATA
Name; M~ Ko {{~ ~ ~~,oJe-o
Address: 11 3 ~~d Dri-J £
City; B~,ri}v State: tJ~ Zip Code: .l""1 v,0_3 0:>unty: W4-,ki;
Tclephonc:(j(~ 7 -i9 -~ \91 Contact Person; ----J...Al~~-L------G=o:;.a(..-1--r _____ _
F.
G. CONSTRUCTION DATA (check one)
(1)
(2)
(3)
NOTE:
Vcr.3/01
EXISTING WBLL(S) being proposed for use as a ground-coupled heat pump
well(s). Provide the information in (l) through (3) below to the best of your
knowledge. Attach a copy of Form GW•l (Wen Construction Record) if
/ available.
__ \/_____ PROPOSED WELL(S) r.o be constructed for use as a ground-coupled heat pump
well(s). Provide the infonnation in (l) through (3) below a:; PROPOSED
construction specifications. Submit Form OW-1 after construction.
Well Drillin& C,,ntnu:10r's Name: f>i ~ v-lill Dr i I I / OlJ , L nc...
NC Contractor Certification number:._~-=-.:..:0::::._...:(Q:!;_~~-----------
Date to be coostxuctt.-d: i \ 9.-cl Qd-.-. Number of borings: __,~---------
500' Approximate depth of each boring (feet): ___ _;__ __________ _
Well casing: Is the well(s) cased?
(a.) YES V If yes. then prov:ide the casing infonnation b~l<>W,
:Type: Galvanized steel __ Bia.ck steel __ Plastic ✓ Other (specify) ____ _
Casing depth: FJ'Qm -3 to 33 ft. {reference to land surmcc)
Casing extends above ground O inches )
(b) NO __
Grout· (grout the vertical length of the borehole to a minimum depth of 20 !eet b.l.s.):
(a) GroQt type: Ccmeat_· _ Bentonite ~ Other (specify) ______ _
(b) OroujFd surfa~e and grout depth (reference to tand surface): .
V 1:r:oui11:l closed loop piping; f.rom -31 to '-/.0 (fed).
/ around well casing; from ~3 to M_ (feet}.
Ttl~ WELL DRII.LINO CONTRACTOR CAN SUPPLY THE DATA PO(t ElTHER EXISTING OR
PROPOSEO WELLS~ THIS INFOR1'4r\ TION lS UNAVAILABLE BY ortt:~ MEANS.
GW /UIC-57 CL Pase2 of4
Rug 16 02 05:12p
(252] 430-1771 p.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
infurenation.
LOCATION OF WELLS) Anach mu maps.
(I) Include a site map (can be drawn) showing! buildings, property lines suthec water bodies,
petrutial sources of groundwater contamination and the orientation of and distances between
the proposed well(s) and any existing well(a) ❑r waste disposal facilities such as septic tanks
or drain fields located within 200 feat of the ground -coupled heat purnp well sybtcrn. Label all
Features clearly and include a north arrow,
2) zocsticsn map referencing the site to two nearby permanent reference points (such as roads,
streams and highway intersections).
J. PERMJT MIST: Attach a list of ull permits or construction approvals that are related to the site_
Examples include:
(1)
(2)
(3)
Hazardous Waste Management program permits under RCRA
NC Division of Water Quality Non -Discharge permits
Sewage Treatment and Disposal Permits
K. CERTIFICATION
] hereby certitY, under penalty of law, that I have personally examined arid am familiar with die
information submitted in this document and all attachments thereto and that, based on my inquiry of
those individuals immediately rtrsponsihle for obtaining said information, I believe that the information
is true, accurate and complete. I am aware that there arc signitcant penalties, including the passibility
of fines and imprisonment, for subrnitting false information. I agree to construct, operate, maintain,
repair, and if applicable, abandon for ground -source heat pump system and nil related appurtenances in
netordance with the approved specifications and conditions of the Permit."
V)oq
(3ignature ,.rf Wcfi Owitcr or aized A cnt)
If authorized agent is acting on behalf of the well owner,
please supply o latter signed by the owner
authorizing the above agent_
Vcr 314f GW/ULC• 37 C.L. Pak.: 3 of 4

Aug 16 02 05:12p
[phone]
P.5
L. CONSENT or 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, ou land rests
ownership in the landowner in the absence of contrary agreement in writing.)
lithe 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 is shall be
the responsibility of the applicant to ensure that the ground -source beat pump system's well(s)
conforms to the Well Co stYuction Standards (Title 1SA NCAC 2C .0200)
II A1(_; ihWt. :i4e3
(S,re Of Propzrty Owner If Dig ar•nt From Applte
Please arum two topics of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Vrr.3101 GWIt.1]C-57CL Page4aC4

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