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Home My WebLink AboutWI0500182_GEOTHERMAL_20080325Permit Number WI0500182 Program Category Ground Water Permit Type Injection Water Only GSHP Well System (5QW) Primary Reviewer michael.rogers Permitted Flow Facilit Facility Name Pullen Memorial Baptist Church Location Address 1801 Hillsborough St Raleigh Owner Owner Name NC Pullen Memorial Baptist Church Dates/Events 27605 Orig Issue App Received Draft Initiated 03/11/08 Re g ulated Activities Church Heat Pump Injection Outfall r.JULL Scheduled Issuance Central Files: APS_ SWP_ 03/25/08 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 Non-Government Owner Affiliation Bonnie Stone 1801 Hillsborough St Raleigh NC Public Notice ls~e ~/. Effective 3/JSfof' 27605 Expiration Waterbody Name Stream Index Number Current Class Subbasin 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 March 25, 2008 Bonnie Stone Pullen Memorial Baptist Church 1801 Hillsborough Street Raleigh, NC 27605 Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System Permit No. WI0500182 1801 Hillsborough Street Raleigh, NC 27605 Dear Ms. Stone: In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on March 11, 2008, the Aquifer Protection Section (APS) acknowledges your intent to construct a closed -loop geothermal water -only injection well system for the operation of a ground -source heat pump located at the address referenced above. This system is deemed permitted by rule (North Carolina Administrative Code Title 15A, Subchapter 2C, Section .0211(u)(2)). However, it is recommended that you contact the Wake County Health Department, as they may have additional construction or permitting requirements for this type of system. 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 APS to verify compliance with applicable rules. Thank you for submitting this notification. If you have any questions please call me at (919) 715-6166. Sincerely, A:442 Michael Rogers Environmental Specialist GPU-Aquifer Protection Section Enclosures cc: Raleigh Regional Office - APS APS Central Files - Permit No. W I0500182 Aquifer Protection Section 1636 Mail Service Center Internet www.ncwaterquality.otg Location: 2728 Capital Boulevard An Equal Opportunity/Affirmative Action Employer-50%Recycled/10% Post Consumer Paper N 1)Carolina oNaturally Raleigh, NC 27699-1636 Telephone: (919) 733-3221 Raleigh, NC 27604 Fax 1: (919) 715-0588 Fax 2: (919) 715-6048 Customer Service: (877) 623-6748 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 ofNCAC 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 any substances other than water. TO: DIRECTOR, NORTH CAROLINA DMSION OF WATER QUALITY DATE: ·!>-L, , 20 0? 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. C. D. YES NO __ 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 P ump System, should be completed. ~f no, then continue completing this form. PROPERTY OWNER Name: r vi I e"" (}1 C t11 D t< Q \ [) C{ C 1' ,'s t ( ~ <.H'l. h Address: I O 1 I 1 1 / I 5 h i> -rov L, ' 1--:---t---~-~---~----,...-------,...,.....,,..,--=-------- City:cJ l y 1 \:J S~te: \\, L-Zip Code: _-_1_(,:,_o_::;-______ _ County: !JCl..kr~~ Telephone. _________________ _ STATUS OF PROPERTY OWNER Private: Federal: Commercial: i/' State: Municipal: __ Native American Lands: Revised 7 /06 GW/UIC-57 CL Page 1 of 4 E. FACILITY (SITE) DATA (Fill out ONLY if the Status ofO er i Federal, State, Municipa_\ or Commercial). Name ofBus~ess or FacjJity: \) / r fl )'\, ]c:,n , r 4 I C ~ Jr l ~ Address· I 'b , t\; )\ .s'\0r-o 5 1 ~ City: P, Q,\(. • \.'\ State: fJ L. Zip Code: •,... 1 L..... ff County: ____ _ Telephone: '1 I ,.. ~~ ') Contact Person: ____________ _ Standard Industrial Code(s), SIC, which describes commercial facility : --------- F. HEATPUMPCONTRACTORDATA Name: ____________________________ _ Address: ____________________________ _ City: _________ State: __ Zip C-0de: _____ County: ____ _ Telephone: Contact Person: ____________ _ G. CONSTRUCTION DATA (check one) (I) (2) (3) NOTE: Revised 7/06 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. PROPOSED WELL(S) to be constructed for use as a ground-coupled heat pump well(s). Provide the information in (l) through (3) below as PROPOSED construction specificatioi _Submit izorm GW-lDafter cons) tru) ction. R "f 4/l J1,o -z,' l l Well Drilling Contractor's Name: ,j 7 r' Ct L \ \ (1 , 1 l'1,, ~\ 9 / q-7) f / ''l -) LfO'f13 NC Contractor Certification number: ') 7 °' 0-------------------- Date to be constructed: 5 -J-O 7 Number of borings: --------- Approximate depth of each boring (feet):_--=3_?_S--__ f_T ________ _ 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 a ve ground ____ inches (b) NO Grout (grout the vertical length of the borehole to a minimum depth of20 feet b.l.s.): (a) Grout type: Cement__ Bentonite V Other (specify) ______ _ (b) Grout d surface and grout depth (reference to land surface : __ around closed loop piping; from O to S Z (feet). __ around well casing; from __ to __ (feet). 1lIE WELL DRD.,LING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR PROPOSED WELLS IF nns INFORMATION IS UNAVAILABLE BY OTHER MEANS. GW/UIC-57 CL Page 2 of4 H. INJECTION-RELAIBD 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: (1) Hazardous Waste Management program permits under RCRA (2) NC Division of Water Quality Non-Discharge permits (3) Sewage Treatment and Disposal Permits K. CERTIFICATION "I hereby certify, under penalty oflaw, 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 and con~ of the Permit." 1 \ Revised 7 /06 ell 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. GW/UIC-57 CL 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 tffe property is owned by someone other than the applicant, the property owner hereby consents to allQw the applicant to construct each injection well as outlined in this application and that it shall be the tesponsibility of the applicant to ensure that the ground-source heat pump system's well(s) confurm:s to the Well Construction Standards (Title 15A NCAC 2C .0200) Revised 7 /06 (Signature Of Property Owner If Different From Applicant) Please return two copies of the completed Application package to: UIC Program Aquifer Protection Section North Carolina DENR-DWQ 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 715-6935 GW/UIC-57 CL Page4of4 Page 1 of 2 iins I WAK COON Y'AND vets CITY or RAL WOW igt !7340133u6 57 74a12243] (671 7 70403a5c,r., a79359:52S ct- r14,a7'}41J7 7la '+3 T)4J172iv 70471525, 1 gaff 1730 1.513` f I\ WAKI~ COLIN II. Parcel Number: 1704005766 REID: 0089085 PULLEN OWNERI MEMORIAL BAPTIST CHURCH 1801 ADDR1 • HILLSBOROUGH ST ADDR2: RALEIGH NC 27605-1642 ■ ADDR3: DEED BOOK: 01516 DEED PAGE: 0388 .131,:;q1 DEED DATE: 12131/1962 DEED ACRES: 1.12 BLDG VAL: 2319722 LAN D VAL: 11221 1 BILLING CLASS: EXEMPT DESCRIPTION: EXEMPT MAP NAME: 170417 PIN NUM: 1704005766 PIN EXT: 000 CITY: RAL TOWNSHIP: RALEIGH YEAR BUILT: 1920 SALEPRICE: 0 SALEDATE: 4) TYPE USE: Church 4-1 DESIGN STYLE: Conventional UNITS: 0 LAND CLASS: EXEMPT +104 aP 72 OLD PARCEL NUMBER: D004-D0021-0020 Vas FLINT p1_ 74305137 1704100561110 Map created on 3/25/2008 1:28:32 PM. 50 http:/fimaps.co.wake.nc, us/imaps/printmap.asp?pin=1704005766&pinext=&minX=210013... 3/25/2008