WI0500264_GEOTHERMAL_20100602

Beverly Eaves Perdue
Governor
Jeffrey Mitchell
JoAnna Mitchell
1703 Kildeer Lane
Wilson, NC 27893
NA
NCDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
6i2/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0500264
1703 Kildeer Lane, Wilson, NC 27893
Dear M r & Mrs. Mitchell:
Dee Freeman
Secretary
On 5/12/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
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 Wilson 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.Rogers@ ncdenr. 1wv if you have any questions.
cc: Raleigh Regional Office -APS
APS Central Files -Pennit No. WJ0500264
Wilson County Health Dept.
Sincerely,
forQb~~
Supervisor
Boyette Well & Septic (John Boyette -1109 W. Nash St, Wilson, NC 27893)
B&J Plumbing (Marl~ Wethington -3517B Airport Blvd, Wilson, NC 27896)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Locatior:i: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opportunity I Affirmaiive Action Employer
Ni¥th Carolina
/vaturall!f
Permit Number WI0500264
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
Jeffrey & JoAnna Mitchell SFR
Location Address
1703 Kildeer Ln
Wilson
Owner
Owner Name
Jeffrey
Dates/Events
NC
D
27893
Mitchell
Central Files: APS_ SWP_
06/02/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
John H. Boyette
1109 W Nash St
Wilson
Major/Minor
Minor
Region
Raleigh
County
Wilson
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliati,on
Jeffrey D. Mitchell
1703 Killdeer Ln
Wilson
NC 27893
NC 27893
Orig lssu.e
06/02/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
06/02/10
Effective
06/02/10
Expiration
05/12/10
Re g ulated Activities
Heat Pump Injection
Outfall NU I .L
Waterbody Name Stream Index Number Current Class Subbasin
WI Ocoo�n�.
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE SQW WELL(S)
in Accordance With the Provisions of NCAC Title 15A 02C.0200
Print or type the required information and mail to address on the back page.
DATE: 61 7 /4e-, 20 (Q .
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (Le.
closed -loon)?
Yes Continue completing this form,
No Do Not complete this form, Complete other UIC application fortes for installing
either a 5A7 well (open -loop well injecting potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
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 wfauthority for signature):
(1)
(2)
Mailing Address: r~ 70 3 /r/ qr' err
City: - 14."1/.St.t-1 State: Zip Code: t 799 3 County: /�I%t rcr+
Horne/Office Tele No.: 319 --5? 3 _3 Cell No.:
Email Address: Website:
Physical Address of Well Site (if different than above): /703 / ,1e eir �d
City: j/r. I $W4 State:A/C - Zip Code; A n5 3 County: ist,i nevi
Home/Office Tele No.: Cell No.:
A. 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.: Cell No.:
Website Address of Company, if any:
RECEIVED i DENiZ r OWQ
AQui q'FpnTFrTifINRFCT1ON
MAY 12 2010
OPUIUJC 5QW Notitication of intent Form (Revised 8/2008) Page l

B. WELL DRILLER 1 FORMATION
Company Name: iG (ie We lS.cf rC �M C
Well Driller Contractor's ' ame: l# . 6t( J 1 •
NC Contractor Certification No.: Z, D r
Contact Person: �D•L [i~ 4 i Jj'i EMAIL Address: 1- if- 6o cat fie j Q *of. -Cow
Address: IIO T
City: Iwo- (Svc Zip Code: 7-10 3 County: (e r o•-�-
Office Tele No.: q5��i-Y? Cell No.: ( r .) a 2_
C. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:A:
Contact Person: illj f 144P11.._. co EMAIL Address; tin tPlat74..th...1'tw., ►7
Address: 3 *'l 7 _ L A J'rpcirf
City: 1.cli I5�wt Zip Code: 7f'91, County: L •./r'IS'
Office Tele No.: 7-53 7 ' Cell No.: AP, -3/S-6j�Y
D. STATUS OF APPLICANT
Private: Federal: Commercial:
State: Municipal: Native American Lands:
E. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
6 7 dose 4 P e1i
G. WELL CONSTRUCTION DATA [�
(1) Proposed date to be constructed: 5,I tq ho Number of borings: `r
Approximate depth of each boring (feet): 2_0D
(2) Type of tubing to be used (copper, PVC, etc): p,( _e_Alf e _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: _ __galvanized steel _black steel plastic other (specify)
Casing depth: From to feet (reference to land surface)
Casing extend:, above ground inches � �
(b) No ,%
(4) Grout Info (material. surrounding well casing and/or piping): ri4t41,00165
(a) Grout type: Neat Cement_ _ Bentonite Other (specify' _`
(b) Grout placement: Pumping Pressure Other ^ "i"t
(c) Grout depth of tubing (reference to land surface): from to (feet)
If well has casing, indicate grout depth: from to (feet)
R. 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.
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 welt(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
GPUNIC 5QW Notification of intent Form (Revised 812QQ8) Page 2

(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
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. l 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 ail related appurtenances in accordance with the approved specifications and conditions of the Permit."
[I
Sig! attire of Property Owner/Applicant
A_ts_ rk-v. 4 d LI , Owner
Print or Type Full Name and title
operty 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-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED I CE1R I QWQ
AQUl P'PR �T SECTION
MAY 12 2010
GPUIUIC 5QW Notification of Intent Form (Revised 81Z448) Pogo 3

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