WI0500102_GEOTHERMAL_20040416

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
April 16,2004
To: Jay Zimmerman, Regional Groundwater Supervisor
Groundwater Section
Raleigh Regional Office
From: Thomas Slusser#
Central Office ~
Re: Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection Well
System. {Type SQW.):
Mr. Eric Sills at 106 Stoneybrook Drive, Orange County, has filed a NOTIFICATION OF INTENT To
CONSTRUCT AND OPERATE A CLOSED-LOOP, WATER ONLY lN~CTION WELL SYSTEM FOR A
GEOTHERMAL HEAT PUMP (TYPE SQW INJECTION WELL). A copy of the notification is included with
this memo. This injection well system is deemed permitted by rule (ISA NCAC 2C.021 l(u)2) and
no further regulatory action should be necessary. If you have any questions about this notification,
please contact me at [phone].
cc: CO-UIC Files
Enclosures
QFr1ER lamosset ; Governor
WilG. RssJcetay
QG North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Director
y Division of Water Quality
Coleco i-1, Sullins, Deputy Director
Division of Water Quality
April 16, 2004
Eric Sills
106 Stoneybrook Drive
Chapel Hill, NC 27516
RE: Notification of intent to construct Type 5QW injection wells
Dear Mr, Sills:
In accordance with the notification you submitted to the UIC Program dated April 10, 2004, the
Groundwater Section acknowledges your intent to construct 3 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. However, 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 systern. If you modify your system
at any time, including the addition of antifreeze, corrosion inhibitors, or any other substances to the
circulating fluid, you must 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].
Sincerely,
je--o--/L6 Atttilkit
Thomas Slusser
Hydrogeological Technician Il
Underground Injection Control Program
cc: Jay Zimmerman, Regional Groundwater Supervisor
Raleigh Regional Office
UIC-CO tiles
N. C. Division of Water Quality / Groundwater Section
1636 Mail Service Center Raleigh, N.C. 27699-1636
Phone: [phone] Fax: [phone] Internet: httpl/gw,ehnr.state.nc.us
Customer Service
1-877-623-748

NORTH CAROLINA
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.0200
Complete application and mail to address on the back page.
This is not the proper form to be used for injection wells in an open -loop geothermal system
Do not use this form for systems that circulate anv substances other than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: Y- 10 . 20 0y
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES }[ If yes, then continue completing this form.
NO
If no, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Use A Well(s) For Injection With A Heat
Pump System, should be completed,
B. SYSTEM FLUID Will any additives be introduced to the system's circulating heat transfer
fluid? This includes, but is not limited to corrosion inhibitors and/or antifreezes.
YES If yes, do not complete this form, Form GW-57 HP, Application For
Permit To Construct And/Or Use A Well(s) For Injection With A Heat
Pump System, should be completed.
NO )X If no, then continue completing this form.
C. PROPERTY OWNER
Name: ERIC gr cLS
Address: to Pt00E1 Brook D.
City: C y 4 pc . H, L State: N c Zip Code: 27 S► fa
County: Qttriabe Telephone: qlq- ct6S-I39v
D. STATUS OF PROPERTY OWNER
Private: X. Federal: Commercial:
State: _ Municipal: Native American Lands:
Ver.3/01 GWIUIC-57 CL Page 1 of 4

E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: _____________________ _
Address: ____________________________ _
City: ________ State: __ Zip Code: ____ County: ____ _
Telephone: _________ Contact Person: ____________ _
Standard Industrial Code(s), SIC, which describes commercial facility: ________ _
F. HEAT PUMP CONTRACTOR DATA
Name: G° \J-,N ~ f<.1ST' S'f",e"'9Cf (a.
Address: 1 \I, 8 AT c f1 ",o.e rZo.-I»
City: f1fc:,c State: NC. ZipCode: 4'7S'~J County: ~tt,-f.4'41111
Telephone: q I,-U:,2-,r,, o Contact Person: 81c.t. tf t1,.,H,et.1ST
G. CONSTRUCTION DATA (check one)
(1)
EXISTING WELL(S) being proposed for use as a ground-coupled heat pump
well(s). Provide the information in (1) through (3) below to the best of your
knowledge. Attach a copy of Form GW-1 (Well Construction Record) if
available.
X PROPOSED WELL(S) to be constructed for use as a ground-coupled heat pump
well(s). Provide the information in (1) through (3) below as PROPOSED
construction specifications. Submit Form GW-1 after construction. (2S).~ 1J.3-b3 I/
WellDrillingContractor'sName: L.ct~t Vt4UE'1 Dttu.,,,uc, ~., :t'"NC•
NC Contractor Certification number: 22. " 9 -chqv n c~ ~ I+. ~%~tr
Date to be constructed: Y-2f-o'{ Numberofborings: __ 3 ______ _
Approximate depth of each boring (feet):_~3_oo_' ____________ _
(2) Well casing: Is the well(s) cased?
(a) YES If yes, then provide the casing information below.
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 of20 feet b.1.s.):
(a) Grouttype: Cement__ Bentonite~ Other(specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
1___ around closed loop piping; from o to 100 (feet).
__ around well casing; from __ to __ (feet).
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMAnON IS UNAVAILABLE BY OTHER MEANS.
Ver.3/01 GW/UIC-57 CL Page 2 of 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
information.
I. LOCATION OF WELL(S) Attach two maps.
(1) Include a site map (can be drawn) showing: buildings, property lines surface water bodies,
potential sources of groundwater contamination and 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-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).
J. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
{l) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits
K. CERTIFICATION
Ver.3/01
"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 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 and all related appurtenances in
accordance with the approved specifications an? oa t."
(Signature of Well Owner or Authorized Agent)
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
'bW/UIC-57 CL Page 3 of 4
L. 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 landowner in the absence of contrary agreement 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 system's well(s)
conforms to the Well Construction Standards {Title 15A NCAC 2C .0200)
Ver.3/01
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UICProgram
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
•:•ow/UIC-57 CL Page4of4
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.NGE COUNTY R EALTR DEPARTMENT
WELL PERMIT SITE MAP SCALE: 1 "=40'
PERMIT# W04-00040 TMBL 7.I14B.B,4
LOCATION; 106 Stdneybrook Rd
(Lai ill M1 Sloneybrook)
APPLICANT/OWNER: Eric & Denise Sins
BY: Philip R. Vils<ro, R.S. 3/22J04
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Orange County Health Deportment
Environmental Health Division
P.O. Box 8181, 306-C Revere Road
Hillsborough, NC 27278
Phone [phone] Fax [phone]
www.co.orange.nCAIS
WELL PERMIT
Pin:
Application Date:
9768851372
02/10/2004
TMBL: 7.11413.13.4
Permit number: W04-00040
APPLICANT: SILLS ERIC
ADDRESS: 106 STONEYBROOK RD
CHAPEL HILL NC
27516
PHONE: [phone] /
OWNER: SILLS DENISE H
ADDRESS: 106 STONEYBROOK RD
CHAPEL HILL NC ,
27516-9040
PHONE: /
Property Desc: #41 Mi STONEYBROOK P23/i2$
Property Address: 106 STONEYBROOK RD OCPL
Well Type: GEOTHERMAL CLOSED LOOP
NEW WELL
Lot Size: 3.26
WW System: On -Site System
Comments/Conditions:
ISSUED: 03/22/2004
EXPIRES: 03/22/2009
PERMIT CONDITIONS:
* REFER TO THE ATTACHED SITE PLAN SHOWING THE WELL AND FACILITY LOCATIONS AND OTHER SPECIFICATIONS
* THIS PERMIT MAY BECOME INVALID AND MAY BE REVOKED IF:
* Ttie information submitted on the application is incorrect, falsified or changes,
• The site is allercd, or
* The well is not completed before the eipiration date.
" THE WELL SHALL BE CONSTRUCTED OR REPAIRED IN ACCORDANCE WITH:
Orange County Groundwater Protection Rules as adopted by the Orange County Board of Health.
NC Well Construction Standards, as applicable and
Orange County Environmental Health Division Policies
• THE WELL SITING IS BASED ON SETBACK DISTANCES FROM KNOWN FEATURES AND DOES NOT INDICATE NOR GUARANTEE THAT
ANY QUANTITY OR QUALITY OF WATER WILL BE PROVIDED BY A WELL CONSTRUCTED IN THAT AREA.
' The well must be located in well -drained areas that are not subject In flooding. Some of the setback distances include:
40 feet from any property fine,
50 feet from any building founcdation; sewer line; swimming pool, pump room, or storage area;or storage building,
100 feet from A septic system or repair area or other potential source of contamination.
It'll is not possible to achieve these distances,* reduced setback may be granted provided specific conditions are met.
• Ground surface should he matotnined to direct surfare water away from the well.
* Setbacks for Pnblic Water Supplies may he increased.
* Ail new or renairrd wells must be thoroughly disinfected after construction. All traces of chlorine must be flushed out of the system at least 48 hours prior to
sampling.
• Water samples may be taken upon request by submitting a proper application and appropriate fces_The Orange County Health Department does not
provide water sampling for use as a condition of purchase, loan approval, or a property transaction. These services are provided by the private sector.
* Any changes to the proposed plans must be approved by the OCHD
' Wells must be constructed, repaired, and abandoned by a person who bolds a valid certification from the State and who is also registered in Orange County
for well construction.
" A list of re istered well drillers is available upon request.
▪ The well construction must be inspected by OCHD at certain stages during the installation.
▪ The permilee is responsible far obtaining tlwe appropriate permits far the wiring of pump installations from the Orange County Building inspections Office
* It is the responsiblity of the well twatractor to call the OCHD to schedule the installation inspections.
• After the installation is completed, some settling of the grout material may take place. If it has settled substantially, please call the well contractor to
complete the grouting -otherwise, the void an be filled with cement grout when a slab is poured.
" The owner is responsible for marking ail property lines and corners. The Coatractar is responsible for ensuring that the well or septic system is installed in
the proper location and that ail setbacks are met. •
EI! WP 4/30/02 Pirk rip _ Mail t Fife
Reviewed