WI0500117_GEOTHERMAL_19980721

NA
NCDENR
JAMES B. HUNT.JR.
·G~VERNOR
WAYNE MCDEVITT
SECRETARY
A. PRESTON HOWARD,
JR.,.P.E.
DIRECTOR
..
Randall L. & Linda Marcuson
3001 Old Weaver Trail
Creedmoor, NC 27522
Dear Mr. & Mrs. Marcuson:
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
July 21, 1998
I
In accordance with the notification submitted on your behalf by Wesco Heating and Air
Conditioning, Inc. dated May 11, 1998; the Groundwater Section acknowledges your
intention to construct closed-loop geothermal water-onl y 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 15A: 2C.021 l(u)(2). The Underground Injection
Control 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 (919) 715 -6166 or Amy Axon at [phone] .
cc: UIC Files
RROFiles
Sincerely,
f"'1k4:#
Mark Pritzl
Hydrogeological Technician II
Underground Injection Control Program
GROUNDWATER SECTION
P.O Box 29578, RALEIGH, NC 27626-0578 -2728 CAPITAL BLVD., RALEIGH, NC, 27604
PHONI!: 91 9-733-3221 FAX [phone]
AN EQUAL OPPORTUNITY/ AFFIRMATIVE ACTION EMPLOYER -50% RECYCLED/I 0% POST-CONSUMER PAPER
. i
!
NORTH CAROLINA
EiWIRONMENTAL MAN:AGEJ.\.ffiNT COMMISSION
DEPARTMENT OF ENVIRONMEi'IT, HEALTH. AND NATURAL RESOURCES
NOTIFICATION OF LmENT 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 v rooer fonn for injection wells to be used in an oven-looo . ---
ground-source heat pump system. Do not use this form for systems·that
re-circulate any substances other than water below.the ground surface .
Type 5QWWells
'ID. DIRECTOR, NORTH CAROLINA DMSION OF WA1ER QUALITY
DATE:_.5-_-_// ___ ~ 199a_
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 L/'Jf~es,.tb.en continue completing this form GW-57 CL.
N) 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 ~ted 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.
V If no, then continue completing this form GW-57 CL.
C PROPERTY OWNER
Name: ~ L. ~ £,,.do..) 7n~ •
Address: /-6 7 /3 L~ ~ -::,001 Old Wto.uefl. Tt,~,/
~0/J '
City: lfa:t-ar .) , ,11, t, · Zip cod~~ __ 2 ?~ S"Z... "Z..-
C/uiJ11tJ.oo(l. County: ~-r Telephone: qJq~--~tg:. 11 Z-~
GW-57 CL (March 1997) Page 1 of 4
D. STATUS OF PROPERTY OWNER
Private: / · ·-
State:_.-·_
Federal:
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 _ofBusiness or Facility: ________________ _
Address: _______________________ _
City: ______ _ Zipcode: _____ County: _____ _
Telephone: _____ _ Contact Person:_. ________ _
Standard Industrial Code(s) which describes Commercial facility: ____ _
F. HEAT PUMP CONIRACTOR DATA
Name: /JE.SCO )/eg-/,°(>j -./-)/,'I!, u:ni'ho,z,3 .;;z:;.;c .
Address: p () . l,-o~ S~ q
City: 01-f#J:,.
County: 6~,
Contact Person: ~Ollj tw, ·~da l,
I •
.Zip code: ;?75&5
Telephone:. C/13, 37> R 3
G. WELL USE Will the system well(s) also be used as the supply well(s) for
your personal consumption?
YES.__ NO ✓
H. CONSTRUCTION DA.TA (CHECK ONE)
EXISTING WELL(S) being proposed for use as a ground-source heat
pump well(s). Provide the infonnation in (1) through (4) below to
the best of your knowledge. Attach a copy of Form GW-1 (Well
ConstruGti.on 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 2of4
(1) Well Drilling Contractor's Name: 8 Z) Illt
ter
NC Driller Registration number. 154LI
(2) Date to be constructed_ Jr— /3 9(
Approximate depth of each borinf,: •Soa
Number of borings: 2
(3) Well casing. Is the well(s) cased?
(a) YES If yes, then provide casing information below.
Casing type: Galvanized stews Black steel Plastic
Other (specify)
Casing depth: from to ft(reference to Land surface)
(b) ND IF
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cerneat: Bentonite l!;
Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
around closed-Ioop piping; from 0 to _ as fr.
around well casing; from to ft.
NOTE THE WELL DRILLLNG CONTRACTOR CAN SUPPLY Ti-I DATA FOR EITE R EXI$D iG OR
PROPOSED WELLS IP THIS INFORMATION T5 UNAVAILABLE BY OTHER MEANS.
H. LOCATION OF WELL(S) Attach two maps.
(I) 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 a. (March 1997) Paw 3 of 4

I. CER i IHCAT1LN
"I hereby,certify, under penalty of law, that I have personally exmrniued
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 obaaininCr said information, I believe that the
information is true, accurate and complete. I am aware that there are
sigmif cant penalties, including the possibility of fines and imprisonment,
for submitting fate 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 Title 15A NCAC
Subchapter 2C Section _0200."
(Signature of Owner or Authorized Agent)
Please supply a letter signed by the owner
authorizng the above agent, i f 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 an 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 pomp system's well(s)
conform to the Well Construction Stan itle 15A NCAC Subchapter 2C .0200)
(Siaature of Property Owner if Diferent From System Operator)
Please.return the completed Notification package to:
UC Program
Groundwater Section
North Carolina DEHNR-Dv Q
P.Q. Bog 29578
Raleigh, NC 27626-05 7 S
(telephone: [phone])
GW-57 CL (March 1997) Pace 4 of 4

3. DATE DRILLED
North Carolina - Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
P,O. Box 29578 - Raleigh, N.C. 27626-0578
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: trrmp.D 6.12.9.)
DRILLER REGISTRATION NUMBER: ]5
FOR OFFICE USE ONLY
QUAD. NO SERIAL NO
Lat, Long. RO
Minor Basin
Basin Code
Header Ent GW-1 Ent.
STATE WELL CONSTRUCTION
PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below) Il
Nearest Town: rrc"- County' -e
tzip.40eA_ tic 2--
(Road, Community, or Subdivision and Lot No.)
2. OWNER gaimirW ft?� _
ADDRESS 3001_ adi.J.Q'r •
(Street or Route No.)
C . 75Z2
City dr Town State Zip Code
r
5.9e USE OF WELL 6..e.0-111.my74 I
4. TOTAL DEPTH 500
5. CUTTINGS COLLECTED YES l NOT'
6. DOES WELL REPLACE EXISTING WELL? YES El NO
7. STATIC WATER LEVEL Below Top of Casing: — FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS — FT. Above Land Surface*
• casing Terminated atlor be{Ow Land surface is illegal unless a variance is issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm)' -- METHOD OF TEST
10. WATER ZONES (depth]
11. CHLORINATION: Type Amount -
12. CASING:
Depth
From To Ft
From To Ft.
From — To _ Ft
13. GROUT:
Wall Thickness
Diameter or Weight/Ft.
DEPTH
From To
0 5-
5
,
DRILLING LOG
Firm-ation Description
If additional space is needed use back of form
LOCATION SKETCH
Material (Show direction and distance from at least two State
Roads, or other map reference paints)
Depth M ferij Metho
From 0 To 30 Ft Q [DiAfr 1
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:
�/ ott,%\1!
CreeAmboR
wy
50
(►i{
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.
CULA 0-6(
SIGNATURE OF CON. ACTOR OR AGENT
Submit original to Division of Water Quality and copy to well owner.
GW-1 REV. 1/98
DATE

North Carolina - Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 27626-0578
Phone [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR:
DRILLER REGISTRATION NUMBER: 15
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat. Long. l=tO
Minor Basin
Basin Cade
Header Ent GW-1 Ent.
STATE WELL CONSTRUCTION
PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: CAJ P.-'&— County'
. - 1.c)ea
(Road, Com nity, 'r S s� ivision and Lot No.)
2. OWNER • •. %J►
ADDRESS .30o/ a/of lieQvedeTraii
(Street or Route No.)
c A/. .
7.5Z2
City ur Town State Zip Code %%
3. DATE DRILLED-5:/3-17g USE OF WELL 67JY
4. TOTAL DEPTH -Sad
5. CUTTINGS COLLECTED YES
6. DOES WELL REPLACE EXISTING WELL? YES
7. STATIC WATER LEVEL Below Top of Casing FT.
(Use ".' it Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface"
• Casing Terminated at/or below land surface is illegal unless a variance is issued
in accordance with 15A NCAC 2C .0118
9. YIELD (gpm)' — METHOD OF TEST
10. WATER ZONES (depth}
11. CHLORINATION: Type
12. CASING:
DEPTH DRILLING LOG
From To
0‘15-
c15 Son]
Formation escription
Amount If additional space is needed use back of form
Wall Thickness
Depth Diameter or Weight/Ft. Materlai
From To Ft
From To - Ft.
From To Ft
13. GROUT:
Depth Ma enal Method
From C� To 2S- Ft ae^^' Txi'"ege4
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 1ti" , ,
15. SAND/GRAVEL PACK: �J
Depth Size Material A.
wit
From To_ Ft We+l d( I 01,
From To F!
16. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads. or other map reference points) treed 1
'ivy so
64-cnv, Ik CCu
;Age. Car-
%1 W1-au .
I.
irn=1f
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS 'ECORD HAS BEEN PROVIDED TO THE WELL OWNER.
("VI* 5-10C;
SIGNATURE OF JONTFACTOR OR AGENT DATE
Submit original t Avision of Water Quality and copy to well owner.
OW-1 REV. 1198

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