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Home My WebLink AboutWI0500215_GEOTHERMAL_20120517NA NCDENR_-_· -- North Carolina Department-of.Environ men Land Natural -Resources Beverly Eaves Perdue-- Governor Rex Bentley and Eugenie"Komives 3518 Bluestone Court Chapel Hill, NC 27514 Division of Water Quality Charles Wakild, P: E.-~- Director May 17, 2012 Subject: Notification of Rule Revisions Affecting Closed-Loop Geothermal Injection Well Permit Holders Permit Number: WI0500215 Dear Mr. Bentley and Ms. Komives: Dee Freeman---- Secretary Our records indicate that you currently hold a permit for a closed-loop geothermal injection well system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative Code Title ISA Section 2C .0200 entitled "Well Construction Standards -Criteria and Standards Applicable Injection Wells" were revised. These revisions affect all permits issued for injection wells including geothermal wells. This letter is also to inform you that your closed-loop geothermal injection well(s) have become "permitted by rule." Therefore, you are no longer required to renew your current permit and the permit will be valid indefinitely as long as the wells are active and are operated in accordance with the revised rules referenced above. Please keep in mind that if you abandon the wells, a record of abandonment must be submitted to the Division of Water Quality. You may view the revised rules on our website at http://portal.ncdenr.org /web/wq/aps. If you have any questions regarding your current permit or the rule revisions, please feel free to contact our underground injection control staff at (919) 807-6464 . Sincerely, Eric G. Smith, P.G. Hydro geologist cc: UIC Permit File AQUIFER PROTECTION SECTION 1636 Mail Service Center, Raleigh, North Carolina 27699-1636 Location: 512 N. Salisbury St., Raleigh, North Carolina 27604 Phone: 919-807-6464 \ FAX: 919-807-6496 Internet: www.ncwaterquality.org An Equal Opportunity\ Affirmative Action Employer One North Carolina }Vaturall!f Permit Number WI0500215 Program Category Ground Water Permit Type • Injection Mixed Fluid GSHP Well System (5QM) Primary Reviewer michael.rogers Coastal SW Rule Permitted Flow Facilitv Facility Name Rex Bentley and Eugenie Komives SFR Location Address 3518 Bluestone Ct Chapel Hill Owner Owner Name Rex Dates/Events NC 27514 C Bentley Orig Issue 08/25/09 App Received Draft Initiated 08/07/09 Scheduled Issuance Central Files: APS_ SWP_ 08/26/09 Permit Tracking Slip Status Active Version 1.00 Project Type New Project Permit Classification Individual Permit Contact Affiliation Major/Minor Minor Region Raleigh County Orange Facility Contact Affiliation Owner Type Individual Owner Affiliation Rex C. Bentley 3518 Bluestone Ct Chapel Hill NC 27514 Public Notice Issue 08/25/09 Effective 08/25/09 Expiration 07/31/14 _R_e_..g~u_la_t_e_d_A_c_t_iv_i_ti_e_s ________________ Re a uested/Received Events Heat Pump Injection RO staff report requested RO staff report received Outfall NULL Waterbody Name Stream Index Number Current Class 08/14/09 08/17/09 Subbasin Permit Number WI0500215 Program Category Ground Water Permit Type Injection Mixed Fluid GSHP Well System (5QM) Primary Reviewer michael.rogers Coastal SW Rule Permitted Flow Faci · Facility Name Rex Bentley and Eugenie Komives SFR Location Address 3518 Bluestone Ct Chapel Hill Owner Owner Name Rex Dates/Events NC 27514 C Bentley Orig Issue App Received Draft Initiated 08/07/09 Re g ulated Activities Heat Pump Injection Outfall NULL Scheduled Issuance Central Files : APS_ SWP_ 08/20/09 Permit Tracking Slip Status In review Project Type New Project Version Permit Classification Individual Permit Contact Affiliation Major/Minor Minor Region Raleigh County Orange Facility Contact Affiliation Owner Type Individual Owner Affiliation Rex C. Bentley 3518 Bluestone Ct Chapel Hill NC Public Notice Issue Effective ~\95l~ Rea uested/Received Events RO staff report requested RO staff report received 27514 Expiration 7(3,J ,~ 08/14/09 08/17/09 Waterbody Name Stream Index Number Current Class Subbasin -~A North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Governor Rex Bentley and Eugenie Komives 3 518 Bluestone Court Chapel Hill, NC 27514 Re_: Issuance of Injection Well Permit Permit No. WI0500215 Coleen H. Sullins Director August 25, 2009 Issued to Rex Bentley and Eugenie Komives Orange County Dear Mr. Bentley and Ms. Komives: Dee Freeman Secretary In accordance with your application received August 7, 2009, I am forwarding Permit No. WI0500215 for the operation of a vertical closed-loop geothermal mixed-fluid heat pump injection well system to be located at 3518 Bluestone Court, Chapel Hill, Orange County, NC 27514. This permit shall be effective from the date of issuance until July 31, 2014, and shall be subject to the conditions and limitations stated therein. Please pay special attention to the bold_ed language in the permit. In addition, please submit copies of the Well Construction Completion form (GW-1) after construction as required in Part I paragraph 8. Please submit the data within 30 calendar days of receipt of this letter to the following address: Aquifer Protection Section (APS) Underground Injection Control (UIC) Staff 1636-Mail Service Center Raleigh, NC 27699-1636 Additionally, your UIC system is subject to inspection by the APS and at the time of the inspection must display a permanently affixed identification plate in accordance with requirements of2C .0213(g). Please insure this is completed in accordance with permit condition Part I, paragraph 7 of this permit issued August 25, 2009. 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 me at (919) 715-6166. Best Regards, .,I /: -I} /,1./vL~Y' /;<-ctec-------- • \ ✓7 Michael Rogers, P.G. (NC & FL) Environmental Specialist cc: Jay Zimmerman~ Raleigh Regional Office Central Office File -WI0500215 Orange County Environmental Health Dept. Home Energy Inc. -Anna Jeffreys (sent USPS and.faxed) Attachment( s) 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 Rex Bentley and Eugenie Komives FOR THE CONSTRUCTION AND OPERATION OF 18 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 3518 Bluestone Court. Chapel Hill, Orange County, NC 27514, and will be constructed and operated in accordance with the application submitted August 7, 2009, 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 July 31. 2014, and shall be subject to the specified conditions and limitations set forth in Parts I through IX hereof. Permit issued this the Zk day of , 2009. oleen H. Sullins, Director Division of Water Quality By Authority of the Environmental Management Commission. WI0500215 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 (15A 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 injection well shall have permanently affixed an identification plate according to 2C .0213(g). 8. A completed Well Construction Record (Form GW-1) must be submitted for each injection well to: Aquifer Protection Section-UIC Staff 1636 Mail Service Center Raleigh, NC 27699-1636 and Aquifer Protection Section -Raleigh Regional Office 3800 Banett Drive Raleigh , NC 27609 (919) 791-4200 GW-1 s must be submitted within 30 days of completion of well construction. Copies of the GW-1 form(s) shall be retained on-site and available for inspection. PART II -WELL CONSTRUCTION SPECIAL CONDITIONS 1. 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. WI0500215 2 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 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 corners). The Permittee shall retain a copy of the triangulation records. The Permittee shall also submit a copy of the triangulation records to the Aquifer Pr:otection Section within 30 days of completion of well construction. · 12. Boreholes shall not connect separate aquifers which have differences in water quality (e.g., shallow surficial aquifers, saprolite, fractured bedrock, etc.) as specified in 15A NCAC 2C .0213(d)(8)(C) and shall be filled with bentonite grout from the lowermost water bearing zone to land surface as specified in the permit application. WI0500215 3 13. The written documentation required in Part IL para graphs (10 ) 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. PART IV-PERFORMANCE STANDARDS 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 -OPERATIONS AND MAINTENANCE REQUIREMENTS 1. The injection facility shall be properly maintained and operated at all times. 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 WI0500215 4 staff can inspect or otherwise review the mjecti~n 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 in 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 of refrigerant in the system, regardless of the origin of the loss; (D) Any recharging of the refrigerant system. 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 RENEW AL The Permittee shall, at least 120 days prior to the expiration of this permit, request an extension. WI0500215 5 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. (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 15A NCAC 2C .02 l 3(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: WI0500215 Aquifer Protection Section-DIC Program DENR-Division of Water Quality 1636 Mail Service Center Raleigh, NC 27699-1636 6 Mechanical Integrity Test Record (For SQM Geothermal Heat Pump Injection Well System) Owner/Permittee Name: _________ Permit Number: _W_I _____ _ Facility Address: _______________________________ _ Home Phone: Cell Phone: Heat Pump Contractor Name: Office Phone: ------------------"""'C"'"'e"""II ___ P-'h-'-"oc..;.n=e..;_: _________ _ Tester Name: _______________ Signature: _____________ _ Date of Test: _______ _ Loop Initial Pressure (psi ) Final Pressure (psi) Duration (minutes) Pass (Yes or No) 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 or by fax: 919-715-0588 . Loop Initial Pressure (psi) Final Pressure (psi) Duration (minutes) Pass (Yes or No) Rogers, Michael From: Sent: To: Subject: Michael, Mccartney, Lin Monday, August 17, 2009 11 :39 AM Rogers, Michael WI0500215-Bentley, WI0500214-Barnhill I have discussed with jay about these two SQM residential geothermal well systems. We decided that we don't need to conduct pre-permitting inspections for these two systems . Please proceed to issue new permits to them. Thanks, Lin McCartney APS, Raleigh Regional Office 919-791-4243 ·E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties . 1 ~~A 9.i'~~ ~CDEMR North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Governo r Coleen H. Sullins Director August 12, 2009 Rex C . Bentley Eugenie Komives 35·18 Bluestone Court Chapel Hill. NC 27514 Subject:· Acknowledgement of Application No. WIOS00215 Bluestone Court SQM Injection Mixed Fluid GSHP Well System (SQM) Orange Dear Mr. Bentley: Dee Freema n Secretary The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and supporting materials on August 7, 2009 . This application package has been assigned the number listed above and will be reviewed by Michael Rogers. The reviewer will perfonn 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 at 919-715-6166, or via e-mail at michael.rogers@ncdenr.gov. 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 httn ://h2o.enr.state.nc.us/documentsidwq orn:chart.o df. PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT. Sincerf, \ j . () c---~~ r~/ jjf~Jr1-_) for Debra J. ~s Supervisor cc: Raleigh Regional Office, Aquifer Protection Section Monte Jefferson (Home Energy, Inc., P .O . Box 238, Wendell , NC 27591) Permit Application File WIOS00215 AQUIFER PROTECTION SECTION 1636 Mail Service Center, Raleigh, North Carol ina 27699-1636 Locaiion: 2728 Capital Boulevard. Raleigh, North Carolina 27604 Phone: 919-733-3221 \ FAX 1: 919-715-0588 ; FAX 2: 919-715-6048 \ Custome r Serv ice : 1-877 -623-6748 lniernet www.ncwaiercuality.o rg An Equa l Opportunii y , Ati1rmative Action Emoloye r N.OnehC . ort . · arol.ma lvatural~lf 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 5QM WELLjSj New Permit Application OR _ Renewal (check one) DATE: iJ l i 1 20 Cri 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 w/authority for signature): Re.' eeri4-1ey Kei Eft 6)emir, itowi s (1) Mailing Address: 3S1 Q ❑ ke5 pi a Coy City: Chat i j. [ 1 State: NC Zip Code: J-15t County: 0 Ira 1-Iome/Office Tele No.: 41 j - 6 S9 (fl Ce11 No.: PA ge e- °V 1 IA "LIP -5 . EMAIL Address: te>t, &LA + Ie r e eloAte (2) PhysicaI Address of Site (if different than above): Satw►C City: State: Zip Code: _ County: I-lome/Offce Tcle No.: Cell No.: EMAIL Address: B. 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 install and operate UIC well) Company Name: Contact Person: EMAIL Address: Address: City: State: Zip Code: County; Office Tele No.: Cg11 No.: W ebsite Address of Company, if any: C. STATUS OF PLICANT Private: Federal: Commercial: State: Municipal: Native American Lands: GP111t]1C 5QM Well Permit Application (Revised MOOS) RECEIVED DENR / OWO AQUIFFITPPrITFCTInN SECTIONage 1 AUG 0 7 2009 D. WELL DRILLER INFORMATION Company Name: K r n e ex �• I n z Well Drilling Contractor's Name: 1 i i u n+C JCL( e{ 5 c ►fl NC Contractor Certification No.: Berl I I Contact Person:an f YA„ EMAIL Address: tied Tbet kritr �ite►i ►�ir • c,iiM Address: Po 13y..< 23 r 3O. E Third 5f City: \&ef elee i Zip Code: 2 7S P j County: (Ain Office Tele No.: 9)9 3 kiv_-02-4,/ CeIl No.: E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller) Company Name:_ Contact Person_ Home Energy, Inc L Address: Address: P.Q. $ox 238 City: Wendell, NC 27591 :sty: Office Tele No.: l.GU ita•.. F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used) C Bathe I nevi' C: LOse'- (--oap AC. WI ow` -pi {) G. WELL CONSTRUCTION DATA (Skip to Section H if this is a Permit RENEWAL) (1) Proposed date to be constructed: Number of borings: = 1_B Approximate depth of each boring (feet): ± 15 _ (2) Chemic:additives di es to be used in closed -loop system (only those chemicals indicated have been approved): Lecrie- R-2 _propylene glycol ethanol _ _ other (other additives will need prior approval by NCDENR before use) (3) Type of tubing to be used (copper, PVC, etc): Cc2lipr.r— (4) Well casing. Is the well(s) cased? (check either (a.) YES or (bO low) (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 Other (specify) (h) Grout depth of tubing (reference to land surface): from 0 to 1 i D (feet) If well has casing, indicate grout depth: from I L1 to (feet) H. INJECTION -RELATED EQUIPMENT Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior pipingltubing associated with the injection operation. The manufacturer's brochure may provide supplementary information. OPU/U[C 5QM Welt Permit Application (Revised 7/2008) Page 2 1. 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. POTABLE WATER WELL(S) Are there any potable water well(s) on the subject property or adjacent properties? YES NO If Yes, than indicate location on attached maps). K. 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 1 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." Signature of Property Owner/Applicant CoI( Print or Type Full Name Signaiu of Property Owner/Applicant Ew5e t le, jlt ri t tom pith` 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 RECEIVED I DENR / DWQ AMOR PRnTFrTl »J RECVON AUG 072009 GPi;IIJIC 5QM Well Permit Application (Revised 7/2008) Page 3 I ,b~'4./J .f: ) C P;Y?J),A 8 t·t, }/t,..;<,.J ,i fY'~Ar✓ '1 . ..:Ji.!,. I 00 0 (i 0 - / I I , I ,I ,, ( . ~.~ ' Page 1 of 2 PIA e>vv��.tf0 C-5 NT ORA_ -CIL Research A Different Parcel Orange County Land Records Data Summary Information Page Summary 1 GIS Map j Buildings j Documents Pd'erty Prior Addresses Owners PIN#: 9873904952 TMBL#:5.27..45 TRACT#: 546397 Property Owner: BENTLEY REX C & EUGENIE M KOMIVES *NOTE: INTEREST OWNERS Owner's Mailing Address: 3518 BLUESTONE CT CHAPEL HILL NC, 27514-8227 Legal Description: #17 REC RICHARD & JANE HELWIG P60/108 Administrative Tax Account#: 183500 PIN Status: A Assessed Values Assessed Land Size: A2.94 2009 Land Value: $156905 2009 Total Use Value: Miscellaneous Information Buildings Assessed: 1 http://gis.co.orange.nc.usllandlqueries/account.asp?PIN-9873904952 8/20/2009 Assessors Status: A Rate Code: 00 Rate Code Information -······················································ ··---- (Revenue De t.) Descendants Ancestors $0 2009 Buildings Value: $434299 2009 Total Valuation: $591204 http://gis.co.orange.nc.us/land/queries/account.asp?PIN=9873904952 Page 2 of2 8/20/2009 You Count In Orange County Page 1 of 2 Orange County N.C. GIS Ma • •41 I , — 4 I c'':N...-------' \ . 41 ti f7, A elite\. gi ll This map contains parcels prepared for the inventory of real property within Orange County, and is compiled from recorded deeds, plats, and other public records and data. Users of this map are hereby notified that the aforementioned public primary information sources should be consulted for verification of the information contained on this map. The county and its mapping companies assume no legal responsibility for the information contained on this map. This Page Printed Thursday, August 20, 2009 10:05 am Parcels Current Thru 7/29/2009. Owner Information Current Thru 6/26/2009 Parcel Identification Number: 9873904952 F Summary r Building r Land I— Documents r Prior Owners htip://gis.eo.orange.nc.usfservleticom.esri.esrimap. Esri.map?ServiceName=YouCountGIS... 8/20/2009 You Count In Orange County Page 2 of2 Create Print Data Page http://gis.co.orange.nc.us/servlet/com.esri.esrimap.Esrimap?ServiceName=YouCountGIS... 8/20/2009