WI0500113_GEOTHERMAL_20030806

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
August 6, 2003
MEMORANDUM
To:
From:
Jay Zimmerman, L.G. Regional Groundwater Supervisor
Groundwater Section
Raleigh Regional Office
Mark Pritzl [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 3 wells for a closed-loop geothermal heat pump system has
been filed by Ms. Guthrie in Cary, and a copy of the Notification is enclosed for your files. This
injection well system is deemed permitted by rule (NCAC Tl5A: 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
NORm CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP
GEOTHERMAL WATER-ONLY INJECTION WELL SYSTEM
(GROUND COUPLED BEAT P UMP)
Type SQW WeBs
In Acconlance with the provisions ofNCAC Title ISA: 02C.0200
Complete application and mail to address on the back. page.
This is !!!!.the proper form to be used for injection wells in an open-loop geothermal system.
Do not use this form for systems that ci.-culate any substances other than water.
TO: DIRECTOR, NOR1H CAROLINA DIVISION OF WATER QUALITY
DATE: 8: -I . 20 o3
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES _j__ 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 1_ If no, then continue completing this form.
C. PROPERTY OWNER
~ §JP:J>cii~~·ti-r
City: CA:t'..:J_ State: ZJ.e Code:_c3-!..--!J$~/ / ___ _
County: ~ Telephone: ---~--_.K...,!5a.-=--....,,5 .. 75..,,-=:.;j.__ ______ --;=;;,.... 8
D. STATUS OF PROPERTY OWNER l>
C:
Ver.3/01
Private: .1_
State:
Federal:
Municipal: __
GW/UIC-57 CL
Commercial:
Native American Lands:
-~---.-, ...
·i;-.~£1:""
Page 1
en
I
CJl
-0
3:
~
w
0)
of4
-· .,
• >
; ,
;:-t
. -~ -::-:-.-:::.;i, ,_
fTJ .........
;:o~-
U':->'"
f'TI :::0 r,
C,
:.:::
E. FACILITY (SITE) DATA
F.
G.
(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: _______ _
HEAT PUMP CONTRACTOR DATA
Name: f V ll'JUfo (; uS-r S~ fl. v1 C t:-~
Address: e · o. &0)t 3b!2..
City: f:\f fl' State: IUC.. Zip Code: .t."7s'oz County: CHlfl'fflll""
Telephone: till q-~'1-"71'1 o Contact Person: 6, "' E"'•"''-ec.,s-r
CONSTRUCTION DATA (check one)
EXISTING WELL(S) being proposed for use as a ground-coupled heat pump
well(s). Provide the infonnation in (1) through (3) 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-coupled heat pump
well(s). Provide the information in (1) through (3) below as PROPOSED
construction specifications. Submit Fonn GW-1 after construction.
(1) WellDrillingContractor'sName: LAk~ Vt\u.f''1 t.t}e« f.o . .:C,-.>C .
NC Contractor Certification number:_~l ..;_2____.;.b_'I ____________ _
Date to be constructed: 1-ll -oj Number of borings: -=3 ______ _
ua'' Approximate depth of each boring (feet): __ ..... 1_....;..-,_., ___________ _
(2) Well casing: Is the well(s) cased?
(3)
NOTE:
(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 .:i:,_
Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.1.s. ):
(a) Grout type: Cement__ Bentonite ..K_ Other (specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
__ around closed loop piping; from O to 100 (feet).
__ around well casing; from __ to __ (feet).
;:;~~:~t::~::i!%~:~~:;~:~~-r;;:a~;AB~O~T==i~:~IN~.;~~;
Ver.3/01 ,:.;GW/UIC-57 CL Page 2 of4
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 surmce 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 beat 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:
(1) Hazardous Waste Management program pennits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Pennits
K.. 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 1hat there are significant penalties, including the possibility
of fines and imprisonment. for submitting false infonnation. I agree to construct, operate, maintain,
repair, and if applicable, abandon the ground-source heat pump system and all related appurtenances in
Ver.3/01
accordance with the approved specifications and itions of the Permit"
_.-.s:";
. ..:.!-~' .. :.
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
Page 3 of4
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 Constriction Standards (Title 15A NCAC 2C .0200)
(Signet uProperty Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Ver.3/O1 GWNIC-57 CL Page 4 of 4

WV"
P+,
164.960 &ova fwd.

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
Coleea H. Sullins, Deputy Director
Division of Water Quality
August 5, 2003
Ms. Ruth L. Guthrie
146 Lochwood West
Cary, NC 27511
RE: Notification of intent to construct Type 5QW injection wells
Dear Ms. Ruth:
In accordance with the notification you submitted to the UIC Program on August 5, 2003, 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, 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].
Sincerely,
Mark Pritzl
Hydrogeological Technician
UIC Program
cc: RRO-UIC files
CO-UIC files
474
N. C. Division of Water Quality J Groundwater Section
1636 Mail Service Center Raleigh, N.C. 27699-1636
Phone: [phone] Fax: [phone] Internet: httpilgw.ehnr.state.nc.us
Customer Service
1-877-23-6748