WI0500250_GEOTHERMAL_20100521

NA
NCDEN
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Phyliss Applekaup
3224 Seven Springs Rd.
Hillsborough, NC 27278
Coleen H. Sullins
Director
5/21/2010
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0500250
3224 Seven Springs Rd.
Hillsborough, NC 27278
Dear Ms. Applekaup:
Dee Freeman
Secretary
On 04/29/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-
only geothermal injection well system for the operation of a ground-source heat pump located at the address referenced
above. An individual permit is not required for the construction and operation of this type of geothermal injection well
system as long as the following conditions are met:
1. 'J:'he injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified
in North Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately ·
submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and
North Carolina Administrative Code Title 15A Section 2C Subchapter .021 l(u)(2). Additionally, you should contact the
Orange County Health Department as they may have additional requirements for this type of system. Noncompliance
with applicable state, county, or municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Ro iz ers(a),ncdenr.eov if you have any questions.
cc: Raleigh Regional Office -APS
APS Central Files -Pennit No. WI0500.250
Orange County Health Dept.
~erely, ~,QJ'fv
for~atts
Supervisor
Glen Darch (GlenDarch Well Drilling-13109 Bold Run Hill Rd., Wake Forest, NC 27587)
Steve Bowman (Bowman Mechanical Services -145 Technical Court, Gamer, NC 27529)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588: FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opporrun ity \ Affirmaiive Action Employer
NOnehC 1· ort. aro 1na
)Vaturnll!f
Beverly Eaves Perdue
Governor
Phyliss Applekaup
4$76'01 keTrail
Hills C 2727S
NCDENR
North Carolinaepartment of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Direct
S " 3Cf I0
Subject r, Acknowledgement of Intent to Construct Type
Permit No. W10500250
4826 Old Lake Trail. Hillsborough, NC 2727g
Dear Ms, Applekaup:
5QW Injection Well System
Dee Freeman
Secretary
dri�~
go'S
On 4/29/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Orange County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Roi ers.a?ncdenr.gov if you have any questions.
Sincerely, n
.-``--��
for Debra Watts
Supervisor
cc: Raleigh Regional Office - APS
APS Central Files - Permit No. W10500250
Onrnge County Health Dept.
Glen Darch (Glen Darch Well Drilling - 1311W Bold Run Hill Rd, Wake Forest. NC 27587)
Steve Bowman (Bowman Mechanical Service::— 145 Technical Court, Garner, NC 27529)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh. North Carolina 27699-1636
Location: 2728 Capital Boulevard. Raleigh. North Carolina 27604
Pnone: 919 733-3221 l FAX 1: 919.715-0588; FAX [phone],6048 l Customer Service:1-677-623-6748
Internet www.nonaternualitv.on
Au Equal {oparluruty i Affirmative Acucar Employer
NorthCairolina
Naturally

fv10-
NCDENR
North Carolina Department of Environment and Natural Resources
�;, -• Division of Water quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director • 6- Secretary
r `O I�
5/5/20 t 0
Phyliss Applekaup
4826 Old Lake Trail
Hiilsbor lift NC 27278
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI03 00250
4826 Old Lake Trail. Hillsborough, NC 27278
Dear Ms. Applekaup:
On 4129/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met:
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Orange County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Rorerstcr7,ncdenr.t2ov if you have any questions.
Sincerely,
for Debra Watts
Supervisor
cc: Raleigh Regional Office - APS
APS Central Files -Permit No. W10500250
Orange County Health Dept.
Glen Darch (Glen Darch Well Drilling — 13109 gold Run Hill Rd, Wake Forest, NC 27587)
Steve Bowman (Bowman Mechanical Services — 145 Technical Court, Garner, NC 27529)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] FAX 1: 919-715-0588; FAX 2: 919-715-60461 Customer Service: 1.B77-623-6748
Internet: www.ncwaterquality.orq
M Equal Oppodunity 1 Afirmalive action Employer
Nne
orthCarolina
NatyraII

ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
5'5,2010
Phyliss Applekaup
4826 Old Lake Trail
Hillsborough. NC 27278
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10500250
4826 Old Lake Trail. Hillsborough, NC 27278
Dear Ms. Applekaup:
On 4/29/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-oni�
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met:
1. The injection well system contains only potable water,
2, The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and- accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Orange County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Roeers,tuncdenr.2ov if you have any questions.
Sincerely,
.tar Debra Watts
Supervisor
cc: Raleigh Regional Office - APS
APS Central Files - Permit No. W10500250
Orange County Health Dept.
Olen Darch (Glen Darch Welt Drilling- 13109 Bold Run Rill ltd, Wake Forest. NC 27587)
Steve Bowman (Bowman Mechanical Services — 145 Technical Court. Garner, NC 27529)
AQUIFER PROTECTION SECTION
1636 Mail Service Came-, Raleigh, North Cartilfna 27699-1636
{_cotton : 2728 Capital Boulevard, Raleian, North Carolina 27604
Phone: [phone] \ FAX 1: 919.715.0688: FAX 2: 919.716-6048 I Customer Service:1- t77-623.6748
Internet www,ncwaterquality.org
+.n Equal Opnarlunily Affirmative .Aclian Employer
NorthCa oliria
;Valera/irk

Permit Number WI0500250
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Phyliss Applekaup
Location Address
4826 Old Lake Tri
Hillsborough
Owner
Owner Name
Phyllis
Dates/Events
NC 27278
Applekaup
Central Files: APS_ SWP_
05/05/10
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Steve Bowman
145 Technical Ct
Garner
Major/Minor
Minor
Region
Raleigh
County
Orange
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Phyllis Applekaup
4826 Old Lake Tri
Hillsborough
NC 27529
NC 27278
Orig Issue App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective Expiration
04/29/10
Re g ulated Activities
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
Flpr• 00 10 11:23a
12/02/2009 15:1ti //t . tJ4
p.2
r'-
GPUIUte 5QW Notification of Weal Form (Revised W2o03)
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL, RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM;
TYPE 54)W WELL(SS
In Accordance with the provisions ofNCAC Title I 5A. 02C.O2D11, please
complete this notification and mad to address on the back page (please Print or Type information).
DATE: 20
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
used -loop )?
Yes Continue completing this form.
No Do Not complete tins form. Complete other U]C application forms for installing
either a 5A7 well (open -loop well iniecting potable water into the aquifer) or a SQM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWDTER(5)/APPLICANT(5)
List each Property Owner listed on property deed of owned by a business or goverment agency, state name of
entity and a representative w/authority for signature): 17 r 16 4{
(1) Mailing Address; - e." Ctrs ca.1OO V )
City;
Home/Office Tele No.:
Email Address: Websitc
State: lip Code: County:
Cell No..
(Z) Physical Address of well 51te (i1' different than allow):
City: eik /I b Lcgk State:,Zip Code: 2 P72-'f7 County
Horne/Office Tele No.- I r .32D Cell No.:
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: JU'K'
Contact Person:
Address:
EMAIL Address:
City: State: Zip Code:
Office Tele No.:
Website Address of Company, if any:
RECEIVED ► DENR 1 OWO
Aquifet Prr,tprtipf Section
APR 29 Z0113
County
Cell No.:
Wipe 1

We appreciate your business
Payment is due upon receipt of invoice
Any payment over 30 days is subject to a 1 ½ % surcharge
..«. ..vvs a...e al.1 .Ji1r r JJcJ
PAGE @6/11
c.
WELL DRILLER I FORMATION
Company Nelne: Irj '� .! h i. L)d P �jt! 1Y1 L
Well Driller Contractor's Name: 'i C 1 (am•
NC Contractor Certification No.:
Contact Person: 41 e EMAIL Address: 5d Wet: &inky ,d mo t.
Address: 13) i ?4 fUr\ hh(2 j 1� ,
City: Vhke t"o{ddti
5t Zip Code: q6c4q. County: L ke
Office Tele No.: q j) S' L' DSc) Cell No.: 114 ( 5i43
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: bOWYW-141I V whorl, r_a �Al U t (� 1,(1L
Contact Person tJQ ?)b[nalrlgn EMAIL Address: far (Y,*, t� l�?Fli (a� Q rf 56
Address: '45 1ez_6-1‘1-�\ C*
City: 6Qv nor Zip Code: 1'5•9 County: i1JC4 ice
Office Tele No.- 919 3-d\ 31 Cell No.: 1 Iq us
E. STATUS OF APPLICANT
Private:
Slate:
Federal'
Commercial!
Native American Lands: -
F.INJECTION PROCEDURE (briefly describe stow the injeeflvn wells) will be used)Tb C]f a a he. �'� �er1� 1�
1PC C ►, T art L tear hg-.tt vi
G. WELL CONSTRUCTION DATA
(I) Proposed date to be constructed: 3( 1 j I D Number of borings:
Approximate depth of each boring (feet): a`C)'
(2) Type of tubing to be used (copper, PVC, etc): J . 34 )' e 1 I fr) e
(3) Well casing. Is the well(s) cased? (cheek either (a.) Yes yr (b-) No below)
(a) Yes if yes, then provide casing information below
Type: _galvanized steel black steel plastic other (specify)
Casing depth: Fr= to feet (reference to land surface)
Casing extends to above ground __inches
(b) No Y\
(4) Grout Info (material surrounding well casing andlor piping):
(a) Grout type: Neat Cement Bentonite X1 Other (specify)
(b) Grout placement: Pumping Pressure Other
(e) °rout depth of tubing (reference to land surface): from U to (0 (feet)
If well bea casing, indicate grout depth: from to (feet)
G2UNIC SQW Notification of Went Form (Revised St2O 8) Pop 2

Apr 08 10 11:23a
i2J0L/4 tl i :1t3 '11'J1( 4 4
p.3
r o.u2t dal 11
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.
I. LOCATiori OP WELLS)
Attach too copies of maps showing the following information'
(I)
Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation at: and distances bet vicen 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 geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Tile Site Map must show the subject property in relation to the surrounding area by using at leant two fixed
reference points such as roads, streams, andlor highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal properly deed.
hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted ill 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 cosmplete.
2 am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. 1 agree to construct, operat- •f : ntak,.1 epair, and if applicable, abandon the injection well and
Fill related appurtenances in accordance Mil' t e . p .ecifications and conditions of thc Permit."
..wlL r
it! r:er/Applicant
Also
Alf
Print or Full Nam
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to
North Carolina DENR-DWQ
Aquifer Protection Section-1_1C Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone (919) 71S-6935
GPt11UIC SQW Notification of Lnrall a Bonn (Revised 8/200a)
RECEIVED r DENR; DWa
Agtiisat Proiertfon SAction
APR 2920W
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Boone, Olita
From:
Sent:
To:
Cc:
Subject:
Boone, Olita
Friday, April 30 , 2010 3:28 PM
'[e-mail]'; '[e-mail]'
Rogers, Michael; Godwin, Tonya
4826 Old Lake Trail
Attachments: SKMBT _60010043014060.pdf
Mr. Darch & Mr. Bowman,
We are in receipt of a 5qw appiication for 4826 Old Lake Trail, Hillsborough, NC (attached).
I need the following information to complete this application:
1. Owner's last name is not legible -let me know what it is.
2. Name of county in which this property is situated.
Thanks,
Olita A. F:soon ",
NC Dept of Environment and Naturnl Resources
Aquifer Protection Section
[phone]
(S Fi17·.5"058&, ·a::
Olita.Boone @ncdenr.gov
E-mail correspondence to and from this address may be subject to the North Carolina Pubiic Records Law and may be
disclosed to third parties.
1