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HomeMy WebLinkAboutWI0500177_GEOTHERMAL_20080102Permit Number WI0500177 Program Category Ground Water Permit Type Injection Water Only GSHP Well System (5QW) Primary Reviewer michael.rogers Permitted Flow Facilit Facility Name Gerda Stein SFR Location Address 221 W Park Dr Raleigh Owner Owner Name Gerda Dates/Events Orig Issue App Received 12/13/07 NC 27605 Stein Draft Initiated Scheduled Issuance Central Files: APS_ SWP_ 01/02/08 Permit Tracking Slip Status In review Project Type New Project Version Permit Classification Individual Permit Contact Affiliation Major/Minor Minor Region Raleigh County Wake Facility Contact Affiliation Owner Type Individual Owner Affiliation Gerda Stein 1226 Banbury Rd Raleigh NC Public Notice Issue Effective 1-/;z_fof 27607 Expiration Re gulated Activities Re q uested/Received Events -~--------------------- Heat Pump Injection RO staff report requested 12/17/07 12/27/07 RO staff report received Outfall NULL. Waterbody Name Stream Index Number Current Class Subbasin (' 'I . I I •. ' ' I., •<-1 ,,J ·, -11.r ;...O .. -... "► .... ' ..., .. ' ,... • ' ....... ' i ,· h . .,. l I ._. \. -~ ~ / '-'_-..,\J_J\..,.JJ Michael F. Easley, Governor William G. Ross Jr.. Secretary North Carolina Department of Environment and Natural Resources Coleen H. Sullins, Director Division of Water Quality January 2, 2008 Gerda S. Stein 1226 Banbury Road Raleigh, NC 27607 Re: Issuance of Injection Well Permit Permit No. WI0500177 Issued to Gerda S. Stein Dear Ms. Stein: In accordance with your application received December 13, 2007, I am forwarding Permit No. W10500177 for the operation of a vertical closed -loop geothermal mixed -fluid heat pump injection well system to be located 221 West Park Drive, Raleigh, Wake County, NC 27605. This permit shall be effective from the date of issuance until December 31, 2012, and shall he subject to the conditions and limitations stated therein. Please pay special attention to the bolded language in permit conditions in Part I, paragraphs 7 and 8, and Part II, paragraphs 1, 10, and 11 concerning your new system. Copies of the GW-1 forms shall be retained on -site for inspection along with all geothermal system pressure testing results. Also, a well ID plate must be affixed to the geothermal system. Your beat pump and well contractors should provide this information. Please retain these records so that in the event your property is sold or transferred, the new Permittee will have this information. In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an application to renew the permit three months prior to its expiration date. As indicated in the permit, this permit is not transferable to any person without prior notice to, and approval by, the Director of the Division of Water Quality. If you have any questions regarding your permit or the Underground Injection Control Program please call Mr. Qu Qi at (919) 715-6935 or me at (919) 715-6166. Best Regards, Michael Rogers, Envir� ental Specialist cc: Jay Zimmerman — Raleigh RC ,Central Office File — WI0500177 Monte JefTerson — Home Energy, Inc. Attachment(s) Aquifer Protection Section 1636 Mail Service Center Internet: htlp;l/www.ncwateruualitv.org 2728 Capital Boulevard Raleigh, NC 27604 An Equal Opportunity/Affirmative Action Employer- 50% Recycled/10% Post Consumer Paper Raleigh, NC 27699.1636 NorthCarolina ,Naturally Telephone: {919) 733-3221 Fax I: (919) 715-0588 Fax 2: (919) 715-6048 Customer Service: (877) 623-6748 NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES RALEIGH, NORTH CAROLINA PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR. INJECTION In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143, and other applicable Laws, Rules, and Regulations PERMISSION IS HEREBY GRANTED TO Gerda S. Stein FOR THE CONSTRUCTION AND OPERATION OF 21 TYPE SQM INJECTION WELLS, defined in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a "direct expansion" type vertical closed -loop geothermal -mixed -fluid heat pump system. This system is located at 221 West Park Drive, Raleigh, Wake County, North Carolina, and will be constructed and operated in accordance with the application received December 13, 2007, and in conformity with the specifications and supporting data submitted, all of which are filed with the Department of Environment and Natural Resources and are considered a part of this permit. This permit is for Construction and Operation only and does not waive any provisions of the Water Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an injection well shall be in compliance with Title 15A North Carolina Administrative Code 2C .0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well construction and use. This permit shall be effective, unless revoked, from the date of its issuance until December 31, 2012 and shall be subject to the specified conditions and limitations set forth in Parts I through DC hereof. Permit issued this the 1: J day of -jM1,1 , 2008 C U ati (9z1 Coleen H. Sullins, Director Division of Water Quality By Authority of the Environmental Management Commission. Permit No. WI0500177 Page 2 PART I -WELL CONSTRUCTION GENERAL CONDITIONS 1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified in Criteria and Standards Applicable to Injection Wells (ISA NCAC 2C .0200). Any noncompliance with conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is grounds for enforcement action as provided for in N.C.G.S. 87-94. 2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of this permit, the approved plans and specifications, and other supporting data. 3. Each injection well shall not hydraulically connect separate aquifers. 4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and drainage ways. 5. Each injection well shall be secured to reasonably insure against unauthorized access and use. Each well shall be permanently labeled with a warning that it is for injection purposes and the entrance to each well must be secured with a locking cap. 6. Each injection well shall be afforded reasonable protection against damage during construction and use. 7. Each geothermal well injection system shall have permanently affixed an identification plate according to 2C .0213(g). 8. A copy of completed Well Construction Record (Form GW-1) must be submitted for each injection well to: DENR-Division of Water Quality, Aquifer Protection Section UIC-Staff, 1636 Mail Service Center, Raleigh, NC 27699-1636, within 30 days of completion of well construction. Per the requirements of 2C .0213(h), the original form must be submitted to the address shown on the form. Copies of the GW-1 forms shall be retained on-site and available for inspection. PART II -WELL CONSTRUCTION SPECIAL CONDITIONS I. Prior to constructing the injection well system, the Permittee or his agent shall test the pH of the soil at a depth of three feet at the planned well location. If the resulting soil pH is less than 6 standard units or greater than 11 standard units, the well system shall be equipped with a compatible cathodic protection system. All testing results shall be kept on site available for inspection. 2. At least forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the Aquifer Protection Section's Underground Injection Control (UIC) Program Central Office Permit No. WI0500177 Page 3 staff, telephone number (919) 715-6166 and the Raleigh Regional Office Aquifer Protection Section Staff, telephone number (919) 791-4200. 3. All underground tubing shall be refrigeration grade copper tubing. 4. Prior to installation, all tubing to be placed in boreholes ("loops") shall be checked for leaks by pressurizing the loop to a gage pressure of at least 350 pounds per square inch (psig), immersing the loop in water and examining it for leaks. Loops with leaks shall not be installed. 5. Prior to installation, each loop shall be visually inspected for damage such as kinks, dents, and scrapes. Each loop shall be checked to verify that the nitrogen charge applied to the loop by the manufacturer before shipping is still present at a pressure of at least 300 psig. The loop manufacturer shall be notified in the event of damage or pressure loss, and the manufacturer's instructions shall then be followed. The nitrogen charge may be released only when the loop is installed and ready to be connected to the manifold. 6. Boreholes shall be large enough to allow insertion of the loop plus a tremie pipe for grouting. 7. After insertion of the tubing into the boreholes, an approved grout (as defined in Title 15A North Carolina Administrative Code 2C .0100) shall be pumped via tremie pipe into the annular space of each borehole so as to completely fill it from bottom to top. 8. All tubing junctions shall be brazed using lead-free brazing material. The brazing material shall have a galvanic potential as close as practicable to that of the tubing material. 9. Dry nitrogen shall be circulated through the tubing during brazing to prevent oxidation. 10. After installation and prior to operation of the system, a mechanical integrity test shall be conducted by pressurizing the injection well system to 400 psig with dry nitrogen and monitoring for leaks using an ultrasonic or other leak detector of equal sensitivity and monitoring pressure in the system for at least 2 hours. Alternatively, an equivalent vacuum test is acceptable. Any pressure fluctuation other than that due to thermal expansion and contraction of the testing medium shall be considered a failed mechanical integrity test. Any leaks shall be located and repaired prior to charging the system with refrigerant. This testing data shall be recorded on the attached Mechanical Integrity Test Record Form and submitted to the Aquifer Protection Section at least 24 (twenty-four) hours prior to the initiation of the operation of the facility for injection. A copy of this form shall also be retained on-site for inspection. 11. The location of each of the system manifolds shall be recorded by triangulation from two permanent features on the site (e.g., building foundation comers). The Permittee shall retain a copy of the triangulation records. The Permittee shall also submit a copy of the triangulation records to the Aquifer Protection Section within 30 days of completion of well construction. Permit No. WI0500177 Page4 12. The written documentation required in Part II , para gr aphs (1 0) and (11 ) shall be submitted to: Aquifer Protection Section-DIC Staff DENR-Division of Water Quality 1636 Mail Service Center Raleigh, NC 27699-1636 PART III-OPERATION AND USE GENERAL CONDITIONS 1. This permit is effective only with respect to the nature, volume of materials and-rate of injection, as described in the application and other supporting data. 2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a name change of the Permittee, a formal permit amendment request must be submitted to the Director, including any supporting materials as may be appropriate, at least 30 days prior to the date of the change. 3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying with any and all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all regulatory requirements have been met. PARTIV~PERFORMANCESTANDARDS 1. The injection facility shall be effectively maintained and operated at all times so that there is no contamination of groundwater that will render it unsatisfactory for normal use. In the event that the facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the_ injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective actions including those actions that may be required by the Division of Water Quality such as the repair, modification, or abandonment of the injection facility. 2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance requires a reduction or elimination of the permitted activity. 3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or groundwater resulting from the operation of this facility.· PART V -OPERATION AND MAINTENANCE REQUIREMENTS 1. . The injection facility shall be properly maintained and operated at all times. Permit No. WI0500177 Page 5 2. The Permittee must notify the Division and receive prior written approval from the Director of any planned physical alterations or additions in the permitted facility or activity not specifically authorized by the permit. 3. At least forty-eight ( 48) hours prior to the initiation of the operation of the facility for injection, the Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone number (919) 715-6166. Notification is required so that Division staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit conditions. PART VI-INSPECTIONS 1. Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon presentation of credentials, enter and inspect any property, premises, or place on or related to the injection facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or copy any records that must be maintained under the terms and conditions of this permit, and may obtain samples of groundwater, surface water, or injection fluids. 2. Department representatives shall have reasonable access for purposes of inspection, observation, and sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90. 3. Provisions shall be made for collecting any necessary and appropriate samples associated with the injection facility activities. PART VII -MONITORING AND REPORTING REQUIREMENTS 1. Any monitoring (including groundwater, surface water, or soil sampling) deemed necessary by the Division of Water Quality to insure surface and ground water protection, will be established and an acceptable sampling reporting schedule shall be followed. 2. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the occurrence, to the Raleigh Regional Office, telephone number (919) 791- 4200, any of the following: (A) Any occurrence at the injection facility that results m any unusual operating circumstances; (B) Any failure due to known or unknown reasons that renders the facility incapable of proper injection operations, such as mechanical or electrical failures; (C) Any loss ofrefrigerant in the system, regardless of the origin of the loss; (D) Any recharging of the refrigerant system. Permit No. WI0500177 Page 6 3. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any incorrect information submitted in said application or in any report to the Director, the relevant and correct facts or information shall be promptly submitted to the Director by the Permittee. 4. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such immediate action as may be required by the Director. PART VIII -PERMIT RENEWAL The Permittee shall, at least 90 days prior to the expiration of this permit, request an extension. PART IX-CHANGE OF WELL STATUS 1. , The Permittee shall provide written notification within 15 days of any change of status of an injection well. Such a change would include the discontinued use of a well for injection. If a well is taken completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used for any purpose that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l), Well Construction Standards. 2. When operations have ceased at the facility and a well will no longer be used for any purpose, the Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C .0214, including but not limited to the following: (A) All casing and materials may be removed prior to initiation of abandonment procedures if the Director finds such removal will not be responsible for, or contribute to, the contamination of an underground source of drinking water. (B) The entire depth of each well shall be sounded before it is sealed to insure freedom from obstructions that may interfere with sealing operations. (C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that failure to do so could lead to the contamination of an underground source of drinking water. (D) Each well shall be completely filled with cement ·grout, which shall be introduced into the well through a pipe which extends to the bottom of the well and is raised as the well is filled. (E) In the case of gravel-packed wells in which the casing and screens have not been removed, the casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout injected through the perforations. Permit No. WI0500177 Page 7 (F) In those cases when, as a result of the injection operations, a subsurface cavity has been created, each well shall be abandoned in such a manner that will prevent the movement of fluids into or between underground sources of drinking water and in accordance with the terms and conditions of the permit. (G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in ISA NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. 3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to: Permit No. WI0500177 Aquifer Protection Section-DIC Program DENR-Division of Water Quality 1636 Mail Service Center Raleigh, NC 27699-1636 Page 8 Mechanical Integrity Test Record (For SQM Geothermal Heat Pump Injection Well System) Owner/Pennittee Name: Permit Number: WI ------------'----"------- Facility Address: ____________________________ _ Home Phone: Cell Phone: Heat Pump Contractor Name: _______________________ _ Office Phone: Cell Phone: ------------------------------ TesterName: ______________ Signature: ____________ _ Date of Test: -------- Loop Initial Pressure (psi) Final Pressure (psi) Duration Pass (Yes or No) (minutes) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Any additional loop testing add to back of this form Comments: ______________________________ _ Other Test Methods and Results: This form must be filled out and signed by the tester. The record must be received by Aquifer Protection Section 24 hours prior to the initiation of the operation of the facility. You can send the form by mail : UIC Program, Mail Service Center 1636, Raleigh, NC 27699 orby fax : 919-715-0588. Permit No. WI0500177 Page9 Loop Initial Pressure <nsi) Final Pressure (osi) Duration (minutes) Pass (Yes or No) Permit No. WI0500177 Page 10 AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT Date: 1221//2007 To: Aquifer Protection Section Central Office Central Office Reviewer: Micheal Rogers Regional Login No: 05 County: Wake Permittee: Gerda Stein. Project Name: 59M Closed Loop System Application No.: W10500177 L GENERAL INFORMATION 1. This application is (check all that apply): ® New ❑ Renewal ❑ Minor Modification ❑ Major Modification ❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon ❑ Land Application of Residuals ❑ Attachment B included ❑ 503 regulated ❑ 503 exempt ❑ Distribution of Residuals LI Surface Disposal ❑ Closed -loop Groundwater Remediation ® Other Injection Wells (including in situ remediation) Was a site visit conducted in order to prepare this report? ® Yes or ❑ No. a. Date of site visit: 12/21/2007 b. Person contacted and contact information: Brad Scheel. Home Energy Inc.. ph.# 9193660261 c. Site visit conducted by: JGreer. RRO-APS d. Inspection Report Attached: ® Yes or ❑ No. 2. Is the following information entered into the BIMS record for this application correct? ® Yes or ❑ No. If no, please complete the following or indicate that it is correct an the current application. For Treatment Facilities: a. Location: b. Driving Directions: c. USGS Quadrangle Map name and number: d. Latitude: Longitude: e. Regulated Activities / Type of Wastes (e.g., subdivision, food processing, municipal wastewater): N/A For Disposal and Injection Sites: (If multiple sites either indicate which sites the information applies to, copy and paste a new section into the document for each site, or attach additional panes for each site) a. Location(s): 221 West Park Drive. Raleigh NC 27605 b. Driving Directions: See Map Quest Attachment: c. USGS Quadrangle Map name and number: Raleigh West-D24SW d. Latitude: 35.47.05 Longitude: 78.39.19 II: NEW AND MAJOR MODIFICATION APPLICATIONS (this section not needed for renewals or minor modifications, skin to next section) Description Of Wastei SjAnd Facilities 1, Please attach completed rating sheet. Facility Classification: FORM: W10500177.GS 1 AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT 2. Are the new treatment facilities adequate for the type of waste and disposal system? D Yes D No D NIA. Ifno, please explain: __ 3. Are the new site conditions (soils, topography, depth to water table, etc) consistent with what was reported by the soil scientist and/or Professional Engineer? D Yes D No D N/A. Ifno, please explain: __ 4. Does the application (maps, plans, etc.) represent the actual site (property lines, wells, surface drainage)? D Yes D No D NIA. Ifno, please explain: __ 5. Is the proposed residuals management plan adequate and/or acceptable to the Division. 0Yes0No0 NI A. If no, please explain: __ 6. Are the proposed application rates for new sites (hydraulic or nutrient) acceptable? D Yes D No D NI A. If no, please explain: __ 7. Are the new treatment facilities or any new disposal sites located in a 100-year floodplain? D Yes D No D NI A. If yes, please attach a map showing areas of 100-year floodplain and please explain and recommend any mitigative measures/special conditions in Part IV: __ 8. Are there any buffer conflicts (new treatment facilities or new disposal sites)? D Yes or D No. If yes, please attach a map showing conflict areas or attach any new maps you have received from the applicant t.o be incorporated into the permit: __ 9. Is proposed and/or existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring. parameters, etc.) adequate? D Yes D No D NIA. Attach map of existing monitoring well network if applicable. fudicate the review arid compliance boundaries. If No, explain and recommend any changes to the groundwater monitoring program: __ 10. For residuals, will seasonal or other restrictions be required? D Yes D No D N/ A If yes, attach list of sites with restrictions (Certification B?) IIL RENEW AL AND MODIFICATION APPLICATIONS (use previous section for new or maior modifi cation systems) Description Of Waste (S) And Facilities 1. Are there appropriately certified OR Cs for the facilities? D Yes or D No. Operator in Charge: __ Certificate #: __ Backup-Operator in Charge: __ Certificate #: __ 2. Is the design, maintenance and operation ( e.g. adequate aeration, sludge wasting, sludge storage, effluent storage, etc) of the treatment facilities adequate for the type of waste and disposal system? D Yes or D No. If no, please explain: __ 3. Are the site conditions (soils, topography, depth to water table, etc) maintained appropriately and adequately assimilating the waste? D Yes or D No. Ifno, please explain: __ FORM: WI0500177.GS 2 AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT 4. Has the site changed in any way that may affect pennit (drainage added, new wells inside the compliance boundary, new development, etc.)? If yes, please explain: __ 5. Is the residuals management plan for the facility adequate and/or acceptable to the Division? D Yes or D No. Ifno, please explain: __ 6. Are the existing application rates (hydraulic or nutrient) still acceptable? D Yes or D No. If no, please explain: __ 7. Is the existing groundwater monitoring program (number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No D N/A. Attach map of existing monitoring well network if applicable. Indicate the review and compliance boundaries. If No, explain and recommend any changes to the groundwater monitoring program: __ 8. Will seasonal or other restrictions be required for added sites? D Yes D No D N/A If yes, attach list of sites with restrictions (Certification B?) 9. Are there any buffer conflicts (treatment facilities or disposal sites)? D Yes or D No. If yes, please attach a map showing conflict areas or attach any new maps you have received from the applicant to be incorporated into the permit: __ 10. Is the description of the facilities, type and/or volume of waste(s) as written in the existing permit correct? D Yes or D No. If no, please explain: ____ _ 11. Were monitoring wells properly constructed and located? D Yes or D No D N/ A. If no, please explain: 12. Has a review of all self-monitoring data been conducted (GW, NDMR, and NDAR as applicable)? D Yes or D No D N/ A. Please summarize any findings resulting from this review: __ _ 13. Check all that apply: D No compliance issues; D Notice(s) of violation within the last permit cycle; D Current enforcement action(s) D Currently under SOC; D Currently under JOC; D Currently under moratorium. If any items checked, please explain and attach any documents that may help clarify answer/comments (such as NOV, NOD etc): ____ _ 14. Have all compliance dates/conditions in the existing permit, (SOC, JOC, etc.) been complied with? D Yes D No D Not Detennined D N/A.. If no, please explain: __ 15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit? D Yes or D No D N/A. If yes, please explain: __ FORM: WI0500177.GS 3 AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection wells, including closed-loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat pump injection wells.) Description OfWell(S) And Facilities-New. Renewal. And Modification 1. Type of injection system: D Heating/cooling water return flow (5A7) C8] Closed-loop heat pump system (5QM/5QW) D In situ remediation (51) D Closed-loop groundwater remediation effluent injection (5L/''Non-Discharge") D Other (Specify: ) 2. Does system use same well for water source and injection? D Yes C8] No 3. Are there any potential pollution sources that may affect injection? D Yes C8] No What is/are the pollution source(s)? NIA. What is the distance of the injection well(s) from the pollution source(s)? ft. 4. What is the minimum distance of proposed injection wells from the property boundary? 25 ft. 5. Quality of drainage at site: C8] Good D Adequate D Poor 6. Flooding potential of site: C8] Low D Moderate D High 7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program (number of wells, :frequency of monitoring, monitoring parameters, etc.) adequate? D Yes D No. Attach map of existing monitoring well network if applicable. If No, explain and recommend any changes to the groundwater monitoring program: NIA 8. Does the map presented represent the actual site (property lines, wells, surface drainage)? C8] Yes or D No. If no or no map, please attach a sketch of the. site. Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, and north arrow. Injection Well Permit Renewal And Modification Only: 1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water, failure to assimilate injected fluid, poor heating/cooling)? D Yes D No. If\·es. explain: NIA 2. For closed-loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance or last inspection? D Yes D No. If yes, explain: NIA 3. For renewal or modification of groundwater remediation permits (of any type), will continued/additional/modified injections have an adverse impact on migration of the plume or management of the contamination incident? D Yes D No. If y es. explain: NIA 4. Drilling contractor: Name: Boyd Well Drilling FORM: WI0500177.GS 4 AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT Address: PO Box 238 Wendell .NC 27591 Certification number: 2106 5. Complete and attach Well Construction Data Sheet. FORM: WI0500177.GS 5 AQUIFER PROTECTION SECTION REGIONAL STAFF REPORT V. EVALUATION AND RECOMMENDATIONS 1. Provide any additional narrative regarding your review of the application.: 2, Attach Well Construction Data Sheet - if needed information is available 3. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® No. If yes, please explain briefly. 4. List any items that you would like APS Central Office to obtain through an additional information request. Make sure that you provide a reason for each item: Item Reason 5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure that you provide a reason for each condition: Condition Reason 6. List specific special conditions or compliance schedules that you recommend to be included in the permit when issued. Make sure that you provide a reason for each special condition: Condition Reason 7. Recommendation: 111 Hold, pending receipt and review of additional information by regional office; ❑ Hold, pending review of draft permit by regional office; El Issue upon receipt of needed additional information; Issue; ❑ Deny. If deny, please state reasons: 8. Signature of report prepare tsj: Signature of APS regional s Isar: Date: )./V? —y .,_. 2.2.107 Cyr 4.s4/e7ary.a . • ADDITIONAL REGIONAL STAFF REVIEW ITEMS System is vet to be constructed in the back yard, City water & Sewers., FORM: W10500177.GS 6 Permit: WI0500177 SOC: County: Wake Region: Raleigh Effective: Effective: Contact Person: Gerda Stein Directions to Facility: System Classifications: Primary ORC: Secondary ORC(s): On-Site Representative(s): Related Permits: Inspection Date: 12/21/2007 Primary Inspector: Jimmie W Greer Secondary lnspector(s): Reason for Inspection: Routine Compliance Inspection Report Expiration: Expiration: Title: Owner: Gerda Stein Facility: Gerda Stein 221 W Park Dr Raleigh NC 27605 Phone: Certification: Phone: Entry Time: 09:00 AM Exit Time: 09:30 AM Phone: 919-791-4200 Inspection Type: Compliance Assistance Permit Inspection Type: Injection Water Only GSHP Well System (5QW) Facility Status: 0 Compliant O Not Compliant Question Areas: ■Other (See attachment summary) Page: 1 Permit: WI0500177 Inspection Date: 12/21/2007 Inspection Summary: Owner -Facility: Gerda Stein Inspection Type: Compliance Assistance Geo-Therm.Heat closed loop system is yet to be installed .. Other Comment: Reason for Visit: Routine Yes No NA NE Page: 2 A QUIFER PROTECTION SECTION APPLICATION REVIEW RE QUEST FORM Date: December 1 7 , 2007 To: D Landon Davidson, ARO-APS □ Art Barnhardt, FRO-APS □ Andrew Pitner, MRO-APS ~ Jay Zimmerman, RRO-APS □ David May, WaRO-APS □ Charlie Stehman, WiRO-APS □ Sherri Knight, W-SRO-APS From: Michael Rogers Groundwater Protection Unit Telephone: (919) 715-6166 Fax: (919 ) 715-0588 E-Mail: Michael.Ro gers@ncmail.net A. Permit Number: WI 0500177 B. Owner: Gerda Stein C. Facility/Operation: __ ~ Proposed D Existing D Facility D Operation D. Application: 1. Permit Type: D Animal D SFR-Surface Irrigation □ Reuse D H-R fufiltration D Recycle D I/E Lagoon D GW Remediation (ND) ~ UIC -(SQM) closed loop mixed fluid geothermal __ For Residuals : D Land App. D D&M D Surface Disposal D 503 D 503 Exempt D Animal 2. Project Type: ~ New D Major Mod. D Minor Mod. D Renewal D Renewal w/ Mod. E. Comments/Other Information: D I would like to accompany you on a site visit. NOTE: Attached, you will find all information submitted in support of the above-referenced application for your review, comment, and/or action. Within 14 calendar days, please take the following actions: ~ Return a Completed APSARR Form. D Attach Well Construction Data Sheet. D Attach Attachment B for Certification by the LAPCU. D Issue an Attachment B Certification from the RO.* * Remember that you will be responsible for coordinating site visits and reviews, as well as additional information requests with other RO-APS representatives in order to prepare a complete Attachment B for certification. Refer to the RPP SOP for additional detail. When you receive this request form, please write your name and dates in the spaces below, make a copy of this sheet, and return it to the appropriate Central Office-Aquifer Protection Section contact person listed above. RO-APS Reviewer: -------------------Date: _____ _ FORM: APSARR 07/06 Page 1 of 1 Michael F. Easley, Governor o William{. Ross Ir., Secretary North Carolina Department of Environment and Natural Resources Coleen H. Sullins Director Division of Water Quality December 14, 2007 GERDA STEIN 1226 BANBURY RD RALEIGH, NC 27607 Subject: Acknowledgement of Application No. WI0500177 Injection Water Only GSHP Well System (5QW) Wake County Dear MS STEIN: The Aquifer Protection Section of the Division of Water Quality (the Division) acknowledges receipt of your permit application and supporting materials on December 13, 2007. This application package has been assigned the number listed above and will be reviewed by Michael Rogers. The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete response to any additional information requests. Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the Division. Please also note at this time, processing permit applications can take as long as 60.90 days after receipt of a complete application. If you have any questions, please contact Michael Rogers by phone at (919) 715-6166 or by email at Micbael.Rogers@ncmail.net. If the reviewer is unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To review our new organizational chart, go to htto://h2o,enr.state.nc.usldocunlentsldwu orgchart pdf. PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT. Sincerely,._ For Dec ra J. Watts Supervisor cc: Raleigh Regional Office, Aquifer Protection Section Permit Application File WI0500177 Nam` Carolina Aaiurallij Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone: (919) 733-3221 Internet: www.ncwateruuality.org Location: 2728 Capital Boulevard Raleigh, NC 27604 Fax 1: (919) 715-0588 Fax 2: (919) 7I5-6048 An Equal OpportunitylAtfirrnaative Action Employer— 50% Recycled/10% Post Consumer Paper Customer Service: (877) 623.6748 NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR) APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR: TYPE 5-QM WELLS 1 ✓ New Permit Application OR Renewal (check one) DATE: P(1 PA 1 .zn�2 PERMIT NO. (leave blank if NEW permit application) A. PROPERTY OWNER(S)IAPPLICANT(S) List each Property Owner listed on property deed (if owned by a business or government agency, state name of entity and a representative wlauthority for signature): (I) Mailing Address: ! a icy Lci,---) 60(`, L ,C-1 City: 0(11 e i \,r. State: Zip Code: i?. b G" 7 County: t It l' HonnelOfftce Tele No.: 61 14') 7 /j ~ L )-i O I Cell No.: EMAIL Address: (2) Physi Address of Site (if different than above): (_ 5 { 6r. City: 1 \ State: /VC Zip Code: 7, i& 5 County: tav e- HomefOffice Tele N Cell No.: k v� EMAIL Address:( fit? S. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property, attach a letter from the property owner authorizing Agent to instal] and operate UIC well) Company Name: - - - - - - Contact Person: EMAIL Address: Address: City: — State: Zip Code: County: Office Tele No.: Cell No.: Website Address of Company, if any: GPU/U[C 5QM Well Permit Application (Revised 9r2007) Page 1 C. WELL DRILLER INFORMATION Company Name: p0.t9 Cl VtSi{{t I Too. Well Drilling Contractor's Name: ti i \ v r4 NC Contractor Certification No.: e=4 i Q. Contact Person: ;r L 1 A_ - I EMAIL Address: J i l J voa rist, Address: 0 e' x 23 e `x �- City: V'� e - '{.1 l Zip Code: ' 75e Count, 1_,.6 ii,C Office Tete No.: 1 ICI 3 Le oAh 1 Cell No.: 1 �-1 141 ` 7 D. HEAT PUMP CONTRACTOR 11 FORMATION (if different than driller) Company Name: Contact Person: EMAIL Address: Address: City: Zip Code: County: Office Tele No.: Cell No.: E. STATUS OF APPLICANT Private: V Federal: State: Municipal: _ Commercial: Native American Lands: F. INJECTION PROCEDURE (briefly describe how the injection wells) will be used) tO'7 J a C'�p Cr- F ► p'r-Nr r lk 1 erdt n erg G. WELL CONSTRUCTION DATA [Skirl to Section H if this is a Permit RENEWAL) (1) Proposed date to be constructed: _Ian tog Number of borings: t� Approximate depth of each boring (feet): "DC' `-- i . (2) Chemical additives to be used in closed -loop system (only those chemicals indicated have been approved): R-22 propylene glycol ethanol _ other (other additives will need prior approval by NCDENR before use) (3) Type of tubing to be used (copper, PVC, etc): e (4) Well casing. Is the well(s) cased? (check either (a.) YES or (b..) NO below) (a) YES if yes, then provide casing information such as type (steel, PVC, plastic, etc.), diameter, depth. and extent of casing appearing above ground: (b) NO [/" (5) Grout (material surrounding well casing and/or piping): (a) Grout type: Cement Bentonite t7 Other (specify) (b) Grout depth of tubing (reference to land surface): from _ _ to If well has casing, indicate grout depth: from - - to -- — (feet) GPUIUIC 5QM Well Permit Application (Revised 9)2007) Page 2 ll. INJECTION -RELATED EQUIPMENT Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary information. L LOCATION OF WELL(S) Attach two copies of maps showing the following information: (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 1000 feet of the geothermal heat pump well system. Label all features clearly and include a north arrow. (2) Include a topographic map of the area extending one mile from the property boundaries and indicate the facility's location and the map name. J. CERTIFICATION Note: This Permit Application must be signed by each person appearing on the recorded legal property deed. "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 injection well and all related appurtenances in accordance with the approved specifications and conditions of the Permit." r -77 Signature of Property Owner/Applicant G eia 5 r\ Print or Type Full Name Signature of Property Owner/Applicant Print or Type Full Name Signature of Authorized Agent, if any Print or Type Full Name Please return two copies of the completed Application package to: North Carolina DENR-DWQ Aquifer Protection Section UIC Program 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 715-6935 GPUMC 5UM Well Permit Application (Revi d 9/2007) Page 3 D3 LOOP SYSTEM 0 % t / 4 F t ds.. e. RASE OF 1V1NJKULCI I'll wry t D3-036 ' . _4r0 - (9 Loops) AO* 4B'+ 21 Ft OS ft 0 45. 45' O r 45' 4 rt Wait 45 J oFwor n` 1 �1?1r 45• \ FV E 45' RIDI ABOVE 5• � 45• D3-030 ° (8 s) - ISU-EL Appendix 2/06 Page 8 ISU-EL Appendix 2106 Page 9 MapQuest: Maps, Addresses, Business Directory & Satellite Photos Page I of 1 MAP (NEST 221 W Park Dr Raleigh NC 27605-1739 US Notes: Only text visible within note field will print. Gard PI 4, Pullen Park Clack Ave ,T 31 A e .��4 fit.. t�h1 CertIli means; No Worries. ►Learn more - _ r i) tk a+8 r W Peace st Park Dr sklIs Csy 2QU7'Mapauest Inc. AIM ah. aket -ice .,0 Park Or Tucker $r natom. 1 MO it tlamngtan w JQrsnsof St_ ao AL - D 0 o C7 1 i Wiikrrd PI . . F4lllsber tigbi5t a to _ m it uy Map Data 0 2C07 N10v7EQ ar Tele`AtIas HIli he All rights reserved. Use Subject to License: Co;,yright This map is informational only. No representation is made or warranty given as to its content. User assumes art risk of use. MapQuest and its suppliers assume no responsibility for any loss or delay resulting from such use. http:/fwww.rnapquest. corn/map slprint.adp?mapdata=GMCh6IT7s941%2 5 2fidj xMa%252b... 12/ 13/2007 MapQuest: Maps, Addresses, Business Directory & Satellite Photos Page 1 of 1 PAW 221 W Park Dr Raleigh NC 27605-1739 US Notes: Only text visible within note field will Iprint. MAPIN‘ST kr o, ite j k e. pat �.� c4 Calleae PI a 2307 Hap:uest Inc. � Map Data FJ 2007 NAV1 E4 or TeleAtias Ail rights reserved. Use Subject to license;Copyright This map is informational only. No representation is made or warranty given as to its content. User assumes ail risk of use. MapQuest and its suppliers assume no responsibility for any loss or delay resulting from such use. http://www.mapquest. com/maps/print.adp?mapdata=GMCh6ITzs941%252fidjxMa%25 2b... 12/ I3/2 007 �rlFrlrY t{� ti MINTY IMP iNTS LEGEND [P$im Malt 6P-Esadrm i+ri Pin Pi23-PriosAiiimk W Sal EPICRisaigi Pater -Kim Mil FP-Poar Pay OiP-0rar Find Pardo OCOnlir RANaklit at Went It-PinpolyLisa Lim Hx $umayd Owio:tr WivaRfR L) E LANTA NumBER BEARING LA INW5CIcW 7.SV L2 I N sinew w 7.6e L. 859-ar2sW 5M6' L4 S 59'4025' W Mar 1.6 S 59'4O"1"r W 9t1'9r L•FS , S 56 0 E 7!7• L7 rNS ra2G w 1.3R T.B. WOOD OD 5458, PG.6T5 G.W. MORDECAI RM. PA NI COMMON — ALLEY if 5Q 1"RW tit W N THU/RlIAAN ne 4530, PG. 9 AREA W I %900 S.F. LOT 02T3AC. AREA I 529 S.F. ALLEY 0.914 AC. PIMA 1704.1T 214023 TOWNSHIP: RALEIGH ZOt1E R-4 LOT 27 & NORTHERN HALF LOT 28, BLK.12. CAMERON PARK AS RECORDED IN BOM 1815. PAGE 199 W.C.R. WITH 7.5' TAKEN OFF FOR A COMMON ALLEY 4 awry 4 my tern mks. % raids vayivy suPeniiiMdirddiraipi nmoldedireaai _ prW.Om) Wiwi fralrado dmake) sa akti!ltdg44draadfiwrwala VICUIXt ire Fe bowl:Yi ►nalarm* wslums a s'rim from pelydtvrn kArd (SE REFIERB4Cri. VAawa rrtWOW woke', misYollOnrirri band sad rim. iya. 4Wa luta z 0 x PROPERTY OF EDWARD W. ERICKSON ANN B. ERICKSON VI W. PAW 150. VOICE a ISTY I ALEIG L ILC. BFJM.2 T'.F>v owe tt41001 . mole memo 0 8.LSCOTT&tco. til .t►rofeIVEICIIS MapQuest: Maps, Addresses, Business Directory & Satellite Photos Page 1 of 1 tiAiikPOVEST. 221 W Park Dr Raleigh NC 27605-1739 US Notes: Only text visible within note field will print. MskewcsT_ Clark Ave Chi Cirtifieci Meon5: Na Worries. > Learn 'nave 1Pr r 1 ft Garden PI R W A9dee St - aT Park Dr_ • o �s• 4P af�'ti a �ti� Q W Johnson lSt_ N itamnghon psH4l ��� Park Dr s c3 raker St. rn cei 4'1460,649, Sf a. } 4/ Aye rwir jwJpi u "j y Nillstao►vu ]ht PtrlJert �� ?, ¢ 9 Niflsbc Park 4 i Z P C an _ �. co s u, >g2{IU7't apQuest Inc. Map Data C 21X)? NPVTEQ or T (Atha All rights reserved. Use Subject to License/Copyright This map is informational only. No representation is made or warranty given as to its content. User assumes all risk of use. MapQuest and its suppliers assume no responsibility for any loss or delay resulting from such use. http://www.mapquest.comimaps/print.adp?mapdata=GMCh6ITzs441%252f djx.Ma%252b... 12/13/2007 MapQuest: Maps, Addresses, Business Directory & Satellite Photos Page 1 of 1 221. W Park Dr Raleigh NC 27605-1739 LJS Notes: Only text visible within note Meld will print. MANN1 T. The 2007 Satum AU RAT"' North American Car of the Year :Get Aura info . o� vi Liles Like atwsHaveys. r before. ititctest pppenc *" of ' aft t fan 4 sk ri-b, L 1 f� IS Ne 2007 hlapOuest Inc. Col leoe Pl Map Data IJ 2007 N * V EQ or TeleAtIOS All rights reserved. Use Subject to License/Copyright This map is informational only. No representation is made or warranty given as to its content. User assumes all risk of use. MapQuest and its suppliers assume no responsibility for any loss or delay resulting from such use. http:llwww.mapquest.comlmapslprint.adp?mapdata=GMCh6ITas941%252fidjxMa%252b... 12/13/2007 Ifft-Irtri Marl RP -Daft Inn Fri s' r Prrrurk*n Met 9911 Pe-Faair Pia Ottlx0aw Mal Puna RA 9ielerrar IFEPtatati tau thin lan eta..I.a EOMEANnet Cdepele Moamar! YICIi r v MAP ILT3 so 7e DCOA -eon. 1 f C;i T.B. WOOD s1e 6(56. AG.. ere G.W.MORDECAI an1.PG are COMMON - ALlEY a 2ff 87 W.N. TS UNMAN L444l0. AB. 9 LMB DATA Nl1B9t L1 BEARING ILwarm., w 7.51' L-2 1464'S47r W 7.54' Lr3 L4 L4 LAI LT S 89'ams- W 8 50'4O28' W s 59'4025' W 56511TE N 69'2520' W 5.51r 50.7r 7.5r t36 AREAIN S1900SF. LOT 0.Z73 AC. AREA 1l e9S.F. ALLEY 0.014 AC. PiN#:1704.97 214023 TOWNSHIP: RALEIGH ZONE: R-4 LOT 27 & NORTHERN HALF LOT 28, BLK. 72, C.ANEtON PARK AS RECORDED IN BON 1915. PAGE 199 W.CA WITH 7.5' TAKEN OFF FOR A COMMON ALLEY 1,aryLame,eeryOWhegag wto awn war nya¢.wnfon+{a+nokai mown nub i my slc.] Colimj, heed rata Of Indian Is ii7 >�1l��r ehe dmM1.1r memo. MN Ole uu.drfeanot armed asMown as9e online. paera gam iW raadt toed WSW 02FERE . vAVresayGoLindso .mitaaWnnate-end anal Itas___2722701-412202266 PROPERTY OF EDWARD W. ERICKSON ANN B. ERICKSON 221W.PMKo L WY9EC+OIMTY MAW KC. iNVAE roB 1:147E 11,20ee most mem9n 4, B. L 80717 & L^D. wr9l[ger9reLu.o MUMMY CFO Map created on 12/17/2007 3:04:06 PM. Copyright 2007 . City of Raleigh, Wake County. OLD PARCEL DO 18-D007 4-0030 NUMBER: RALEIGH SITE ADDRESSES 1 STREET NUM: 221 STREET SUITE: STREET DIR PRE: w STREET NAME: PARK STREET TYPE: DR STREET DIR SUF: ADDRESS TYPE: Parcel ADDRESS STATUS CODE ACTIVE DESCR: Page 2 of2 ,A/ Ralefghe Corttoun;f ;,/ Cary Etfl'i ContoursJ ;V WakeCo1 'elevation Contoursj SU.eta ■ Lakes □ Pamels Security 1 1U105BIW Orthopho' (ZC!Offl to ! 2t05Coh County-w sH) □ WakeC'oi Boundary http://imaps.co.wake.nc.us/imaps/printmap.asp?pin=l 704214023&pinext=&minX=2102087.2500105l&minY=740688.65633... 12/17/2007 .. Page 1 of 2 V+ Ali t. COUNTY ANO Tin CITY (Jr ►3AtE►GH IZAiI i& WAKE i'OH1w n Parcel Number: 1704214023 0020949 STEIN, GERDA STONEMAN 221 W PARK DR RALEIGH NC 27605-1739 REID: DWNER1. ADDR1. ADDR2: ADDR3: DEED BOOK: DEED PAGE DEED DATE: DEED ACRES: BLDG VAL: LAND VAL: BILLING CLASS: DESCRIPTION: MAP NAME: PIN NUM: PIN EXT: CITY: TOWNSHIP: YEAR BUILT: SALEPRICE: SALEDATE: TYPE USE: DESIGN STYLE: UNITS: LAND CLASS: 12427 0139 3/1/2007 0.26 291329 459200 INDIVIDUAL L027 PT 28 CAMERON DR BL12 170417 1704214023 000 RAL RALEIGH 1902 720000 3/1/2007 Single Family Conventional 0 RESIDENCE-‹ 10 ACRES -HOME SITE http://irimaps.co.wake.nc.uslimaps/printmap.asp?pin=1704214023&pinext=&minX=2102087.25001051 &rninY-740688.65633.._ 12/17/2007 221 w park drive, raleigh, ne - Google Maps Page 1 of 1 GoAddress ' 221 W Park Or Raleigh, NC 27605 GAY St. Get Google Maps on your phone 3 Text the word "GMAP5" to 466453 volts Forest SI F. Camelot) St ,s, Carnoron St st IA ilrsver9t x Sr N Hinsdale St lark Ave Ctar'tc Ave n 1C W Peace St ro WPeace St Y.' to Pask �r Pss k ❑ m z 0 � a mC S 4*1 „<e`5 gyp[ rcy, ai. r 7, ii„,_, e _.„.40 ,„„„,,s, . ,:„. eu *Re PI Ftint Pi i7 9.0 4„xr�`A W .iot7lt6c 1 St oo CoFlege Pt 5A y� n Ctitrf7x, W Joh nsor: Si [North W Jones S; Wilford Si Glenwood rive W 0rga 1 47 Googie - Map data f472OO7 tliLVTEQ"' - Temps WVr, r http://rnaps.google.com/maps?f q&h1=en&geocode=&time=&date=&[type=&q=221+w+pa... 1/2/2008