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Home My WebLink AboutWI0300057_Regional Office Historical File Pre 2018 (3)MEMORANDUM TO: MOORESVILLE REGIONAL OFFICE DIVISION OF WATER QUALITY GROUNDWATER SECTION May 20, 2003. Evan Kane GW Section — Central Office FROM: Matt Heller SUBJECT: Post Construction Inspection and U1C System Status Change Jeff Martin Property Iredell County WI0300055 The U1C Group requested that the MRCS complete a post -construction inspection at the above -referenced location on February 18, 2002. The heat pump system was not activated until January 2003, On February 12, 2003, I visited the site, collected samples and completed the inspection of the well. I have attached the analytical results and the inspection report. During the inspection, I noted that the well did not appear to be accommodating the return water from the heat pump. Based upon subsequent discussions with the HVAC contractor, it was determined that the best course of action was to direct return water to the surface. Please refer to my April 17, 2003 letter for additional detail. The well owner has completed a GW/UIC-68 form, which is attached. Please cali me at (704) 663-1699 if you have any questions. a North Carolina Department of Environment and Natural Resources Division of Water Quality - Groundwater Section INJECTION FACILITY INSPECTION REPORT - FORM B INJECTION WELL PERMIT NO. WI0300055 DATE -ill 2f o3 NAME OF OWNER Jeff Martin ADDRESS OF OWNER 2Sfd f;iMd6ad L /Odr:r1.5 �r / ti G 2 et j t `) cnL (Street/ road or lot and subdivision, county, town) LOCATION OF INJECTION WELL (and source well(s), if applicable) SGTMY G r y 44cv‘4 (Street/ road or lot and subdivision , county, town, f different than owner's address, plus description of location on site) Potential pollution source 5 p{„ �-ti,,� Distance from well f Potential pollution source Distance from well Potential pollution source Distance from well Minimum distance of well from property boundary Quality of drainage at site �7ru�Tr FIooding potential of site he-✓ (good, adequate,poor) (high,moderate,low) GPS Data: Longitude: /3 ? DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, a north arrow) DESCRIBE INJECTION SYSTEM (vertical closed loop, uncased borehole or cased water well; separate source well and injection well; combination sourceland injection well;;/ or other description as applicabl A !/ez�/ c / l9JtofJG[/Ct/ -5C7.,'r fivr/�jf t/lY /7i' �/ r c /J c��., Z, rr er / r _ U..+S,' r 0 r / / ia'fa r /J >/''rr%rc 7; r'eiez�7cr 1i/e7 ! / Ver.3/01 GW/UIC-2 INJECTION FACILITY INSPECTION REPORT -FORM B (CONTINUED) WELL CONSTRUCTION Spate constructed Drilling contractor: Name Address 6//0 _orrp Z 6 y () // C� 1 r Ii1%G Il r ' II rJ Certification number 2 6 / C) Total depth of well Inspection point Casing Depth Diameter Height (A.L.S.) Grout Depth Screens Depth(s) Length(s) I.D. Plate Static water level Well yield Enclosure Enclosure floor (concrete) Sampling port (labeled) i j 6S Water tight pipe entry Well enclosure entry Vent Total depth of source well 1 S (if applicable) Measurement Meets minimum standards Yes No ,A 2 f (i0/71o,JiI.I / 1 .t, j i7 Comments %Iooi �c cr 77 F�� fie /4ti7464.1-er O c � / rSs 141 -LA /7 '1 a /5 Functioning of heat pump system (Determine from the owner if heat pump functions properly) INSPECTOR /i 7T WITNESS Office /6 Address WITNESS Address Ver.3/01 GW/UIC-2 North Carolina Department of Environment and Natural Resources Division of Water Quality - Groundwater Section INJECTION FACILITY INSPECTION REPORT - FORM B INJECTION WELL PERMIT NO. WI0300055 DATE -11 z f 02 NAME OF OWNER Jeff Martin ! ADDRESS OF OWNER / c %f S i:1 //� / Al L L (Fir"? (Street/ road or lot and subdivision, county, town) LOCATION OF INJECTION WELL (and source well(s), if applicable) �aM1 4 f (Street/ road or lot and subdivision , county, town, if different than owner's address, plus description of location on site) Potential pollution source pi,, fi�hj� Distance from well . Potential pollution source Distance from well Potential pollution source Distance from well Minimum distance of well from property boundary Quality of drainage at site g490,7'r Flooding potential of site /car-✓ (good, adequate,poor) (high, moderate,low) GPS Data: Latitude: 7-1. 5' '= -3 Longitude: *O 59 DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, a north arrow.) DESCRIBE INJECTION SYSTEM (vertical closed loop, uncased borehole or cased water well; separate source well and injection well; combination source and injection well; or other description as applicably)) "ri 5/ C / �gjCe/ (.c/C/ jc?..d , t .7 C97 //� r r l yC� / /1C r r ��. GT ; - '-,<ce- t-/4 vt,r///1 tom; Y c /1 A. 71, Ver.3/01 GW/UIC-2 INJECTION FACILITY INSPECTION REPORT -FORM B (CONTINUED) WELL CONSTRUCTION Date constructed jam,�� e-rrO Drilling contractor: Name Z Gy Q 1/ Cxr Address Certification number 2 6 y C) Total depth of well 3 65" Inspection point Casing Depth Diameter Height (A.L.S.) Grout Depth Screens Depth(s) Length(s) I.D. Plate Static water level Well yield Enclosure Enclosure floor (concrete) Sampling port (labeled) Water tight pipe entry Well enclosure entry Vent Total depth of source well (if applicable) SC5 Measurement Meets minimum standards Yes No /zs('d)yin, 4vn;In.9 07"✓ ,/ Comments 71, J f / 4 U e r r� // e ✓r;s /7 N a % Functioning of heat pump system (Determine from the owner if heat pump functions properly) INSPECTOR /14 % Office /(J WITNESS WITNESS Vera/0I Address Address GW/UIC-2 COLLECTOR(S) : hl IIELLER DATE: 2/12/2003 TIME; PURPOSE LABORATORY ANALYSIS BOD 310 mg/ L COD I1igh 340 mg/L COD Low 335 mg/L X Coliforrn MFFecal31616 1U Q1 /100m1 X Coliform: MFTotaI31504 2 Q1 /100m1 TOC mg/i Turbility NTU Residue., Suspended 530 mg/L Total Suspended solids mg/L pH units Alkalinity to pH 4.5 mg/L Alkalinity to pH 8.3 mg/L Carbonate mg/I. Bicarbonate mg/ L Carbon dioxide mg/ L X Chloride SU mg/L Chromium: Hex 1032 ug/L Color: True 80 c,u. Cyanide 720 mg/L COMMENTS: COUNTY : QUAD NO: IREIIELL n ROUTINE REPORT TO : MRO Regional Office n CHAIN OF CUSTODY E SAMPLE TYPE Owner. ,TEFF MART I 0 Location or Site: Description of sampling point Sampling Method: Remarks: DIVISION OF WATER QUALI Chemistry Laboratory Report! Ground Wat LE.0 E 1 VE irt) SAMPLE PRIORITY EMERGENCY MAR 1 4 2003 NC KEPI. Ur tidwriurifirENT AND NATURAL mamas ifoORESVfLLE REGIONAL OFFICE X Diss. Solids 70300 82 mg/L Fluoride 951 mg/I, Hardness: total 900 mg/L Hardness: (oon- arb) 902 mg/L Phenols 32730 ug/L Specific Cond. 95 umhos/cm2 Sulfate mg/L Sulfide 745 mg/L MBAS mg/L Oil and Grease mg/L Silica mg/ L Boron Formaldehyde mg/L NH3 asN610 mg/I. TKN as N 625 mg/L X NO2 tNO3 as n 630 0.46 mg/L P: Total as P 665 mg/L PO4 mg/L Ag-Silver 96566 ug/L X AI-Aluminum46557 53 ug/L As -Arsenic 46551 ug/L Ba-Barium 46558 ug/L X Ca -Calcium 96552 12 mg/L Cd-Cadium 96559 ug/L X Cr-Chromium46560 25U ug/L X Cu- Copper 1042 1100 ug/L X Fe- Iron 1045 SOU up,/L Hg- Mercury 71900 ug/L X K-Potassium46555 1.1 mg/L X Mg- Magnesium 927 4.8 mg/L X Mn-Manganese 1055 10U ug/L X Na- Sodium 929 4.2 mg/L X Ni-Nickel 10U ug/l. X Pb-Lead4656r4 IOU ug/L Se -Selenium ug/L X Zn_Zinc 96567 26 ug/L Lab Number : 3C0137 Dale Received : 2/13/2003 Time Received : 9:30 AM Received By • C5 3 1 I S 9,-- eleascA D S y Date reported : 3/12/2003 Organochlorine Pesticides Organophosphorus Pesticides Nitrogen Pesticides Acid herbicides Semivola tiles TPH-Diesel Range Volatile Organics (VOA bottle) TPI I -Gasoline Range TPH-BTEX Gasoline Range 380137 GROUNDWATER FIELD/LAB FORM County Quad No Serial No. Lat. Long. Report To: ARO, FRO, 4R RO, WaRO, WiRO, WSRO, Kinston FO, Fed. Trust, Central Off., Other: SAMPLE TYPE Water ❑ Soil ❑ Other SAMPLE PRIORITY Routine ❑ Emeraencv ❑ Chain of Custody North Carolina Department of Environment and Natural Resources DIVISION OF WATER QUALITY -GROUNDWATER SECTION Lab Number l317 Dale ReceivedTime. Rec'd By: From:Bus, ourie Hand Del., Other: Data Entry By: Data Reported: Ck: Shipped by: Bus, ouri ndpet., Other: Collector(s): mil, r Date 01'3 Time 7(3 /5-- Basel` ine, Complaint, Compliance, LUST, Pesticide Study, Federal Trust, Other: (24C_____ FIELD ANALYSES Owner ir-,//' /Yr.-7 c. r sue' pH 433 �z_._4/ Spec. Cond.0 / 2 7 at 25°C Location or Site 0 2 an , r Temp.ln 1�'./ °C Odor /764-<, Description of sampling point f� 7` k"7C : Appearance G (..e ep r Sampling Method Air / / p fz ample Inlery Field Analysis By: 4-2.fj/r // r Remarks IPumo ail°r. etc Pumping ime, air temp., etc, LABORATORY ANALYSES BOO 310 mg/L COD High 340 mg/L COD Low 335 mg/L Coliform: MF Fecal 31616 1100m1 Coliform: MF Total 31504 1100m1 > TOC 600 mg/L Turbidity 76 NTU Residue, Suspended 530 mgfL pH 403 units Alkalinity to pH 4.5 410 mg/L Alkalinity to pH 8.3 415 mg/L Carbonele 445 mg/L Bicarbonate 440 mg/L Carbon dioxide 405 mg/L Chloride 940 mg/L Chromium: Hex 1032 ugfL Color: True 80 CU Cyanide 720 rngtL ab Comments Purpose; Diss. Solids 70300 mg/L Fluoride 951 mg/L Hardness: Total 900 mgfL Hardness (non-carb 902 mg/L Phenols 32730 ugll Specific Cenci, 95 uMhoslcm Sulfate 945 mg/L Sulfide 745 mg/L. Oil and Grease mg/L • NH3 as N 610 mg/L TKN as N 625 mgiL NO3 + NO3 as N 630 mg/L P: Total as P 665 mg/L Ag-Silver 46566 ugfL Al -Aluminum 46557 ugfL As -Arsenic 46551 trail. Ba-Barium 46558 ug/L . Ca -Calcium 46552 mg/L Cd-Cadmium 46559 ugfL ); Cr-Chromium 46559 ugfL Cu-Copper 46562 ugfL 74.. Fe -Iron 46563 ugh_ Ho -Mercury 71900 ugfL --[ /?< K-Potassium 46555 mg/L Mg -Magnesium 46554 mg/L ,>[ Mn-Manganese 46565 ugfL Na-Sodium 46556 . mg/L 4 Ni-Nickel ugfL Pb-Lead 46564 ugfL Se -Selenium ugfL Zn-Zinc 46567 ugfL Organochlorino Pesticides Organophosphorus Pesticides Nitrogen Pesticides Acid Herbicides PCBs Semivoralile Organics TPH-Diesel Range Volatile Organics (VOA bathe) TPH-Gasolino Range TPH-BTEX Gasoline Range LAB USE ONLY Temperature on arrival: GW-54 REV. 12/87 For Dissolved Analysis-submil filtered sample and wrilo 'DIS' In block. COUNTY : QUAD NO; [BEDELL REPORT TO : NIRO COLLECTOR(S) : M HELLER DATE: 2/12/2003 TIME: PURPOSE: LABORATORY ANALYSIS Regional Office BOD 310 mg/L COD High 340 mg/L COD Low 335 mg/L X Conform: MF Fecal 31616 I Q1 /100m1 X Conform: MFTotal 31504 3 Q1 /100m1 TOC rug/1 Turbitity NTU Residue., Suspended 530 mg/L Total Suspended solids mg/L pH units Alkalinity to pH 4.5 mg/L Alkalinity to pH 8.3 mg/L Carbonate mg/L Bicarbonate . mg./L Carbon dioxide mg/L X Chloride 5U mg/L Chromium: Hex 1032 ug/L Color. True 80 c.u. Cyanide 720 mg/L COMMENTS Owner: Location or Site: Description of sampling point Sampling Method: Remarks: DIVISION OF WATER QUALITY Clicndstry Laboratory Report! Ground Water Q SAMPLE PRIORITY 0 ROUTINE Li CHAIN OF CUSTODY l l SAMPLE TYPE JEFF MART EMERGENCY ECEIVE MAR 1 4 2003 NC OEM. �` itl�vf�at►naaw��lr • tRSOURCES latiOR OFFICE X Diss. Solids 70300 84 mg/L Fluoride 951 mg/L Hardness: total 900 mg/L Hardness: Snun-carb) 902 mg/L Phenols 32730 ug/L Specific Cond. 95 umhos/cm2 Sulfate mg/L Sulfide 745 mg/L MBAS mg/L Oil and Grease mg/L Silica mg/ L Boron Formaldehyde mg/ L NH3 as N 610 mg/L TKN as N 625 _ mg,/L X NO2 +NO3asn630 0.46 mg/L P: Total as P 665 mg/L PO4 mg/L AR -Silver 96566 ug/L X AI-Aluminum46557 50U ug/L As -Arsenic 46551 ug/1. Ba-Barium 46558 ug/L X Ca -Calcium 46552 13 mg/L Cd-Cadium 46559 ug/L X Cr-Chrontium46560 25U ug/L X Cu- Capper 1042 50 ug/L X Fe-lron.1045 50U ug/L Hg- Mercury 71900 ug/L X K-Potassium 46355 1.1 mg/L X Mg-Magnesium927 4.7 mg/L X Mn-Manganese 1055 10U ug/L X Na- Sodium 929 4.1 mg/L X Ni-Nickel IOU ug/L X Pb-Lead 46564 10U ug/L Se -Selenium ug/L X Zn_Zine46567 10U ug/L Lab Number : 3G0138 Date Received : 2/13/2003 Time Received : 9:30 AM Received By : DS RI �r cleased Sy : ' A Date reported : 3/12/2003 Orga nochlorine Pesticides Organophosphurus Pesticides Nitrogen Pesticides Acid Herbicides Semivolatilcs TPH-Diesel Range Volatile Organics (VOA bottle) TPH-Gasoline Range TPH-BTEX Gasoline Range 3E0138 GROUNDWATER FIELD/LAB FORM County Quad No Serial No. Lat. Long. Report To: ARO, FRORRO, WaRO, WiRO, WSRO, Kinston FO, Fed. Trust, Central Off., Other: Shipped by: Bus, Ca Colleclor(s): FIELD ANALYS S pH 4m • 6 Tempo') Y.6 eC Appearance Field Analysis By: LABORATORY ANALYSES SAMPLE TYPE A Water ❑ Soil ❑ Other SAMPLE PRIORITY +Routine ❑ Emeroencv 0 Chain of Custody cl�and Del., Other: i /rl Purpose: Date _/e _ Time ,/e s r Baseline, Complaint, Compliance, LUST, Pesticide Study, Federal Trust, Other:_LY C_ (cirdu one) North Carolina Department of Environment and Natural Resources DIVISION OF WATER QUALITY -GROUNDWATER SECTION Lab Number tS Spec. Cond.94 /L3 Odor r4' ,�//"r- 8OD 310 mglL COD High 340 mglL COD Low 335 mg/L v< Caliform: MF Fecal 31616 1100m1 oliform: MF Total 31504 1100m1 'TOG 600 mgIL Turbidity 76 NTU Residue, Suspended 530 mglL pH 403 units Alkalinity to pH 4.5 410 mglL Alkalinity la pH 8.3 415 mglL Carbonate 445 mglL Bicarbonate 440 mg/L Carbon dioxide 405 mg/L Chloride 940 mg1L Chromium; Iiox 1032 ug!L Color: Truo B0 CU Cyanide 720 mg/L Owner .� /7/•rfi at 25°C Location or Site z�,) Z-2.4,-;,` Al it Description of sampling point_ T� �,� Sampling Method �; ,y Remarks ber. etc) Date Received 1 Time: Rec'd By: rom:Bu Couria , Hand Del., Other: Data Entry By: Ck: Data Reported: Sample interval )4,.Diss. Solids 70300 mg/L Fluoride 951 mglL Hardness: Total 900 mg/L Hardness (non-carb 902 mglL Phenols 32730 ug/I Specific Cond. 95 uMhoslem Sulfate 945 mg/L Sulfide 745 mg/L Oil and Grease mg/L NH3 as N 610 mglL TKN as N 625 mg/L X NO7 s NOJ as N 630 mglL P: Total as P 665 mg!L ab Comments GW-54 REV. 12187 For Dissolved Analysis -submit filtered sample and write "DIS" In block. (Pumping Time, air lemp„ de.) Ag-Silver 46566 ug/L 74, Al -Aluminum 46557 uglL As-Arsonic 46551 uglL Be -Barium 46558 ug/L X Ca -Calcium 46552 mglL Cd-Cadmium 46559 uglL Cr-Chromium 46559 ug/L T Cu-Copper 46562 uglL Fe -Iron 46563 ugfL Hg-Mercury 7.1900 uglL '� K-Potassium 46555 mglL Mg-Magnosium 46554 mg1L Mn-Manganese 46565 ug/L . L. Na-Sodium 46556 mg/L X_ Ni-Nickel ug1L X Pb-Load 46564 uglL Se -Selenium ug/L x Zn-Zinc 46567 ug1L Organochlorine Pesticides Organophosphorus Pesticides Nitrogen Pesticides Acid Herbicides PCBs Semivolalile Organics TPH-Diesel Range Volatile Organics (VOA bottle) TPH-Gasatine Range TPH-BTEX Gasoline Range USE ONLY Temperature I �� Temperature on arrival: Michael F. Easley, Governor William G. Ross Jr., Secretary North Carolina Department of Environment and Natural Resources Alan W. Klimek, P.E. Director Division of Water Quality GROUNDWATER SECTION April 17, 2003 Jeff Martin 280 Farmstead Lane Mooresville, North Carolina 28117 Subject: Underground Injection Well Permit WI0300055 280 Farmstead Lane, Mooresville Iredell County, N.C. Dear Mr. Martin: On February 12, 2003, I inspected your water supply well. At the time, this well served as a supply well for your home and as a supply and return well for your heating and cooling system. At the time of the inspection, I noted that the well was unable to accommodate the return water from the heating and cooling system. I later learned that the well is artesian and flows under natural pressure. As a result of my inspection, I recommended to your contractor that return water from the heating and cooling system be directed to. the surface and that the well head be modified to prevent water from flowing at all times. The well head modification is a requirement of the well construction rules, which state that: "every artesian well that flows under natural artesian pressure shall be equipped with a valve so that the flow can be completely stopped. Well owners shall be responsible for the installation, operation and maintenance of the valve." I reinspected your well on April 16, 2003. The recommended modifications appear to have been made. A wet area in the vicinity of the well suggests that there is minor leakage from the well head. You may want to consult with your contractor to see if there is any way to address this problem. Since you are no longer injecting water into the well, you are not required to maintain an underground injection permit. To verify the inactive status of the system, please complete and return the attached form to my attention within 30 days. Division of Water Quality / Groundwater Section / Mooresville Regional Office Phone: (704) 6-1699 Fax: (704) 6636040 919 North Main Street, Mooresville, NC 28115 Internet: ittp://ow.ehnr.state.nc.us ATA NCDENR Jeff Martin April 17, 2003 Page Two If you have questions, please call me at (704) 663-1699, ext. 202. Sincerely, jils----- Matt Heller, P.G. Regional Supervisor Enclosure cc: Evan Kane - RCO NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES DIVISION OF WATER QUALITY, GROUNDWATER SECTION STATUS OF INJECTION WELL SYSTEM Permit Number: Wro 3 D4D 5 5 Permittee Name: Vec- /X ^f Address: v236 •Faacilis Lave RECEI\.IED MAI 1 4 2003 Ivy DEPT. OF 1`v ENt miecs✓J�kc /V e- 2 31/ 7 AO SYLLE R`` RESOURCES 4��`?�=fi��...L.� REuioT>:/� OFFICE Please check the selection which most closely describes the current status of your injection well. In addition, please provide the requested information. 1) — Weil is still used for injection activities. 2) Well is not used for injection but is used for water supply or other purposes. 3) Injection discontinued and: a) Well temporarily abandoned b) Well permanently abandoned c) Well not abandoned If you checked (2), describe the well use (potable water supply, irrigation, etc), including pumping rate and other relevant information. ofadle- weaLtie 5 vie wa- So v•Pce. gr7L / Afit9 If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well. (Include a description of how the well was sealed and the type of material used to fill the well if permanently abandoned): Certification: (For well abandonment) "I hereby certify, under penalty of law, that I am personally responsible for the proper abandonment of any injection well as required in Title 15A NCAC 2C .0214 Criteria and Standards Applicable to Injection Wells." Signature Date Certification: (For information verification) "I hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted in this document, and that to the best of my knowledge the information is true, accurate, and complete." x n Signat1iJre Date S/I3/03 ver.3/03 GW/U IC-68 MEMORANDUM To: From: DMSION OF WATER QUALITY GROUNDWATER SECTION February 13, 2002 Matt Heller, L.G., Regional Goundwater Supervisor Groundwater Section Wilmington Regional Office Mark Pritzl iQ- Mark.Pritzl@ncmaiLnet Hydrogeological Technician 11 UIC Group Groundwater Section Raleigh Central Office RECEIVED FEB 1 8 2002 NC DEPT OF ENVIRONMENT Mr/NATURAL RESOURCES MOORESVILLE REGIONAL OFFICE Re: Issuance -of a Open -Loop Geothermal Injection Well System (Type 5A7): Permit Number WI0300055 to operate a well for the injection of an open -loop ground -source heat pump system has been issued to Jeff Martin, in Mooresville, North Carolina. 1. Please inspect the injection well site to verify that the location and construction plans submitted in the application are accurate and the NCAC Title 15A 2C .0200 standards are being complied with, using the enclosed Injection Facility Inspection Report (form B) as appropriate. 2. Collect samples from the influent and effluent sampling ports and submit the results to the CO-UIC. You are requested to return the completed Injection Facility Inspection Report (form B) to the CO-UIC by March 15, 2002. If the inspection can not be accomplished by this date, please inform the CO-UIC. The UIC group greatly appreciates MRO's assistance with this review. If you have any questions regarding this review or the UIC program, please contact me at (919) 715-6166 or Evan Kane at (919) 715-6165. cc: CO-UIC Files Enclosures `NAP, North Carolina Department of Environment and Natural Resources 7 Gregory J. Thorpe, Ph.D. Acting Director � Division of Water Quality O 'C January 31, 2002 Mr. Jeff Martin 280 Farmstead Lane Mooresville, NC 28117 Dear Mr. Martin: In accordance with your application dated December 18, 2001, we are forwarding Permit No. WI0300055 for the construction and operation of a geothermal heat pump injection system at 280 Farmstead Lane, Mooresville, North Carolina, in Iredell County. Water samples will be taken at the influent and effluent sampling ports of this geothermal heat pump system after construction is complete. Please note, if these sample results exceed groundwater quality standards, it is the well owner's responsibility to take corrective action as stated in Title 15A Subchapter 2C, Section .0206. This permit shall be effective from the date of issuance until February 28, 2007, and shall be subject to the conditions and limitations stated therein. In accordance with NCAC Title 15A, Subchapter 2C, Section .0213(h), the well owner is responsible for submitting a record of well construction within 30 days of completion. The well construction data for every well constructed for this project should be submitted on the GW-1 form and this form is enclosed for your convenience. If you have any questions regarding your permit please feel free to contact me at (919) 715-6165 or Mark Pritzl at (919) 715-6166. cc: CO-UIC Files • MRO-UIC Files En closures f: R Customer Service 1 B00 623-7748 Sincerely, Evan O. Kane Hydrogeologist Underground Injection Control Program Division of Water Quality / Groundwater Section 1636 Mail Service Center Raleigh, NC 27699-1636 Phone: (919) 733-3221 Fax: (919) 715-0588 Internet: http://gw.ehnr.state,nc.us 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 Jeff Martin FOR THE CONSTRUCTION AND OPERATION OF A TYPE 5A7 INJECTION WELL, defined in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(A), which will be used for the injection of heat pump effluent. This system is located at 280 Farmstead Lane, Mooresville, in Iredell County, North Carolina, and will be constructed and operated in accordance with the application received on January 9, 2002, 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 February 28, 2007, and shall be subject to the specified conditions and limitations set forth in Parts I through X hereof. yN, Permit issued this the t2- day of TY, Uc•Tia , 2002. 06C-� LA) -AS Ted L. Bush, Jr., Assistant Chief Groundwater Section Division of Water Quality By Authority of the Environmental Management Commission. Permit No. WI0300055 Page 1 of 6 ver.3/0 1 GW/UIC-5 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 be constructed in such a manner that water from land surface cannot migrate into the gravel pack or well screen. 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 injection well shall have permanently affixed an identification plate. 8. A completed Well Construction Record (Form GW-1) must be submitted for each injection well, to the Division of Water Quality (Division), within 30 days of completion of well construction. PART II - WELL CONSTRUCTION SPECIAL CONDITIONS At Ieast forty-eight (48) hours prior to constructing each injection well, the Permittee shall notify the Groundwater Section -Underground Injection Control (UIC), Central Office staff, telephone number (919) 715-6165. 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 Permit No. WI0300055 Page 2 of 6 ver.3/0I GW/UIC-5 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 I. The injection facility shall be effectively maintained and operated at all times so that there is no contamination of groundwater which 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. 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 Groundwater Section -Underground Injection Control (UIC), Central Office staff, telephone number (919) 715-6165. 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. Permit No. W10300055 Page 3 of 6 ver.3/0 1 GW/UIC-5 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 Mooresville Regional Office, telephone number (704) 663-1699, any of the following: (A) Any occurrence at the injection facility which 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. 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. Permit No. WI0300055 Page 4 of 6 ver.3/01 GW/UIC-5 PART VIII - PERMIT RENEWAL The Permittee shall, at least three (3) months 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)(1), 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) The 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) Drilled wells 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, neat -cement shall be injected into the well completely filling it from the bottom of the casing to the top. (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. Permit No. WI0300055 Page 5 of 6 ver.3/01 GW/UIC-5 (G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified in 15A NCAC 2C .0213(h)(1) within 30 days of completion of abandonment. 3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to: Groundwater Section-U1C Staff DENR-Division of Water Quality 1636 Mail Service Center Raleigh, NC 27699-1636 PART X - OPERATION AND USE SPECIAL CONDITIONS Water samples will be taken at the influent and effluent sampling ports from the geothermal heat pump system after construction is complete. If the sample results reveal violation(s) of groundwater standards, it is the well owner's responsibility to take corrective action as stated in Title 15A North Carolina Administrative Code 2C .0206. In addition, the well owner shall take immediate actions including those actions that may be required by the Division of Water Quality such as repair, modification, or abandonment of the injection facility. Permit No. WI0300055 Page 6 of 6 ver.3/01 GWIUIC-5 Jeff Marlin UIC W&I - 0300055 Subject: Jeff Martin UIC Well - 0300055 Date: Mon, 24 Mar 2003 09:07:07 -0500 From: Matt Heller <Matt.Heller©ncmail.net> Organization: NC DENR - Mooresville Regional Office To: evan.kane©ncmail net Hi Evan I spoke w/ the heating contractor for this site today. This is the artesian well I mentioned a while back- According to the contractor, they have directed the effluent to the land surface and do not plan on reinjecting into the well in the future. I received the analytical results from my earlier sampling. There is a trace of total colitorm in both influent and effluent and a copper spike in the effluent (may be due to minimal purge time since sample was collected in basement). I am planning on stopping by soon to reinspect the wellhead (which has been sealed off and now has a vent with a ball check valve). I will forward a copy of the results and the inspection report to you. If you need me to do anything else, please let me know. Matt Matt Heller - Matt.Heller@ncmail.net North Carolina Dept. of Environment & Natural Resources Div. of Water Quality - Ground Water Section 919 N. Main St. Mooresville, NC 28115 Ph; (704) 663-1699 Fax: (704) 663-6040 Matt Heller <Matt. HellerOncmail.net> Regional Supervisor NC DENR - Mooresville Div, of Water Quality - Ground Water Section 1 011 3/24/0 8:07 AM 100Z1t0 'AM. l-MO °R flE ul[171M `[ZZ£'££G �61 G) '0N auayd MI-6691 t DN `4$pini - iaivaz) oal,uas 1i*[N 9E91 ''uog33S aais +punoi0 ua$uM 30 (111!iima ay) o7 lsul$uo ay714wgos 3.1.WI '1'13m iau1. JNLLDIT 1L SNOD P10S1I1d :iO a>311,1.V e,. .- Ii:1NMO ` -13M 3HL XL (Ii1(IIAOUd Nll3H SVH CI11O33 1 SIHJ. JO MOD V -WILL(INV 'SQi[VO V.1.S NO .1..111213.SNOD '1'18M'DI OYON1 VS 1 1 LLIM 8011VULIODDV NI U:LLaf11LL$NIOD SVM 1' I:lM SIH.I..LVH I. A31.1.1193 AE1311 411001 c)snO--1 :SNIIVI'11at1 '9C �i o1J �W0.1d .id 01 woi f 1�1u 7z!S q'1d'a :)I0Vd1HAVdD/0NVS 'SI .uT -U} •1 0J. 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E OR IAN NORTH quad [Quad jofol d 2000 Maps a la carte, tnc. - All rights reserved Use of this site is governed lay o e about your privacy - please consult our P h cy, taternen for details, Martin UIC Permit #W)03t1©055 Subject: Martin UIC Permit #W10300055 Date: Fri, 15 Mar 2002 11:16:34 -0500 From: Matt Heller <Matt.Heller@ncmail.net> Organization: NC DENR - Mooresville Regional Office To: markpritzl@ncmail.net Hi Mark I phoned Jerry Atkinson, the builder for the Martin Residence. He indicated that the system would not be hooked up for at least two months. I told him I would call him back on May 30 unless I heard from him sooner. Matt Matt Heller - Matt.Heller@ncmail.net North Carolina. Dept. of Environment & Natural Resources Div. of Water Quality - Ground Water Section 919 N. Main. St. Mooresville, NC 28115 Ph: (704) 663-1699 Fax: (704) 663-6040 Matt Heller <Matt.Heiler@ncmail.net> Regional Supervisor NC DENR - Mooresville Div. of Water Quality - Ground Water Section 1 of 1 0211:16 AM Potential pollution source Potential pollution source Page 1 of 2 North Carolina Department of Environment and Natural Resources Division of Water Quality Groundwater Section PRECONSTRUCTION INJECTION FACILITY INSPECTION REPORT -FORM A INJECTION WELL PERMIT NO. WI NAME OF OWNER ADDRESS OF OWNER DATE /-: 2_ C 2 1JcCc MarV+n 7;1%50 CM+..CA ne. M resV,{lz rf c. - ii`) 044,1117i (Street/ road or lot andsfabdivision, county, town) LOCATION OF PROPOSED INJECTION WELL (and source well(s), if applicable) SEA rT (Street/ road or lot and subdivision , county, town, if different than owner's address, plus description of location on site) IQ cr 5i"toctJ. P s C. { L TA. At Distance from well lap+` Distance from well Potential pollution source Distance from well Minimum distance of proposed well from property boundary — 26-U Quality of drainage at site cd cu,+2. Flooding potential of site law (good,aiquate,poor) (high,moderate,low) DRAW SKETCH OF SITE (Show property boundaries, buildings, wells, potential pollution sources, roads, approximate scale, and north arrow) S/ra- /41711° `-/ /1,9 /C/71?-oAJ /j 4 0o-62 Ver.3/01 GW/UIC-1 Page 2 of 2 PRECONSTRUCTION INJECTION FACILITY INSPECTION REPORT - FORM A (cont.) GPS Data: Latitude: 35 3 Li 2 q, Zb3S 6 Longitude: $0 ° S I-- 3 g . 75I Z7 t COMMENTS a/. // 4 a-, ,�cil�-t¢� 7`o /1 4/n73,/. R a f 77/1! t /„ d ,1 L /er Gt 04 - 5 / J y I !& ��✓! /� b rl ! INSPECTOR II I ' iLlice le Office i` rrcuresui WITNESS Address Ver.3/0 1 GW/UIC- 1 MEMORANDUM To: From: DIVISION OF WATER QUALITY GROUNDWATER SECTION January 14, 2002 Matt Heller, L.G., Groundwater Supervisor Groundwater Section Mooresville Regional Office Mark Pritzl 9h�= Mark.Pritzl@ncmail.net Hydrogeological Technician II UIC Group Groundwater Section Central Office RECEIVED JAN 16 2002 NC DEFT. OF ENVIRONMENT AND NATURAL RESOURCES MOORESVILLE REGIp'NAL OFFICE Re: Request for review of new injection well permit application (type 5A7 open loop geothermal.) The CO-UIC has received a new application by Atkins Custom Homes, LLC for the construction and operation of an injection well located at 280 Farmstead Lane, Mooresville, NC. The proposed injection well will be part of an open loop geothermal heat pump system, therefore a type 5A7 well. 1. Please review the application and submit any comments to CO-UIC. Retain the application for your UIC file. 2. Please inspect the proposed injection well site to verify that the location and construction plans submitted in the application are accurate and that the NCAC Title 15A 2C.0200 standards are being complied with, using the enclosed Preconstruction Injection Facility Inspection Report -Form (A) as appropriate. Please return any comments immediately upon application review. You are requested to return the completed Preconstruction Injection Facility Inspection Report -Form (A) to the CO-UIC by Febuary 15, 2002. If the inspection can not be accomplished by this date, please inform the CO- UIC. The UIC Group appreciates your assistance in the review and evaluation of this permit application. Please contact me if you have any questions or comments at (919) 715-6166 or Evan Kane at (919) 715-6165. cc: UIC Files Enclosures F WA7'`C Michael F. Easley, Governor +O 9Q William G. Ross Jr., Secretary `O G North Carolina Department of Environment and Natural Resources ✓ Gregory J. Thorpe, Ph.D. Acting Director Q -C Division of Water Quality January 14, 2002 Mr. Jerry Atkinson Atkinson Custom Homes, LLC 490 River Ridge Lane Lexington, NC 27295 Dear Mr. Atkinson: Your application for a permit to use a well for the injection of geothermal heat pump . effluent has been received and is under review. A mernber of the Groundwater Section's Mooresville Regional Office staff will be contacting you to arrange an inspection of the injection well and collect water samples as part of the review. If you have any questions regarding the permit or injection well rules please contact me at (919) 715-6166 or Evan Kane at (919) 715-6165. cc: CO-UIC Files MRO-UIC Files Customer Service 1 800 623-7748 Sincerely, 44.411-AS Mark Pritzl Hydrogeological Technician Underground Injection Control Program Division of Water Quality / Groundwater Section 1636 Mail Service Center Raleigh, NC 27699-1636 Phone: (919) 733-3221 Fax: (919) 715-0588 Internet: http://gw.ehnr.state.nc.us NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION WITH A HEAT PUMP SYSTEM Type 5A7 and 5QM Wells In Accordance with the provisions of NCAC Title 15A.: 02C.0200 Complete application and mail to address on the back page. TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY DATE: IS � 20 Ca A. SYSTEM CLASSIFICATION Please check column which matches proposed system. (1) - (2) (3) B., PERMIT APP Name: Address: City: L Type 5A7 wells inject water used to provide heating or cooling for strucares Type 5QM wells contain a subsurface system of continuous piping, that is isolated from the environment and circulates a fluid other than potable water. This includes systems that circulate additives such as antifreezes and/or corrosion inhibitors. Type 5QW wells contain a subsurface system of continuous piping that is isolated from the environment and only circulates potable water. If you selected this well type, then complete form GW-57 CL, Notification Of Intent To Construct A Closed -Loop Geothermal -Water Only Injection Well System. ICANT 3 �fJ 'sCf✓ State: Nc' Zip Code: Telephone: 5'4% O74' At"-, 336_..7S7 5i97/ C. PROPERTY OWNER (if different from applicant) Name: Address: City: Telephone: //' °/ 7 STATUS OF APPLICANT Private: Federal: State: Municipal: Native American Lands: Ne County: Zip Code7 County: GW-57 HI' (Jan, 2000) Commercial: E. FACILITY (SITE) DATA (Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial). Name of Business or Facility: Address: City: Zip Code: County: Telephone: Contact Person: F. HEAT PUMP CONTRACTOR DATA Name: lte.0 Address: ciO 7 C_04- p O krakc. City: Scat bo,ry Zip Code: 2.12,1q7 County: Telephone: '70M Z'7 q6-"qr Contact Person: G. INJECTION PROCEDURE (Briefly describe how the injection well(s) will be used.) We r Will be exi-ra , firci4 b k I t 1AaeLi, GW'GOAkc e.10031ti kecd - 'pomp , -t-Lb r d -f-o -gyp of- ,ie q H. WELL USE Will the injection well(s) also be used as the supply welI(s) for the following? (1) The injection operation? (2) Personal consumption? I. CONSTRUCTION DATA (check one) Cotts\ iV G+io rl YES X YES X NO NO EXISTING WELL being proposed for use as an injection well. Provide the data in (1) through (7) below to the best of your knowledge. Attach a copy of Form GW- 1 (Well Construction Record) if available. PROPOSED WELL to be constructed for use as an injection well. Provide the data in (1) through (7) below as PROPOSED construction specifications. Submit Form GW-1 after construction. (1) Well Drilling Contractor's Name: a �i- k T d`t (2) . Date to be constructed: D11e (O/ll10 1 Number of borings: Approximate depth of each boring (feet): (3) Well casing: Is the well(s) cased? NC Contractor Certification number: 1 (a) YES X If yes, then provide the casing information below. Type: Galvanized steel Black steel Plastic X Other (specify) Casing depth: From 0 to 3 ft. (reference to land surface) Casing extends above ground 12 inches (b) NO n n A (4) Grout (material surrounding well casing and/or piping): (a) Grout type: Cement X Bentonite Other (specify) (b) Grouted surface and grout depth (reference to land surface): (5) around closed loop piping; from X around well casing; from 0 to (feet). 20 (feet). Screens (for Type 5A7 wells) (a) Depth: From to feet below ground surface, (6) N.C. State Regulations (Title 15A NCAC 2C .0200) require the permittee to make provisions for monitoring wellhead processes. A faucet on both influent (fluid entering heat pump) and effluent (fluid being injected into the well) lines is required. Will there be a faucet on: ) the influent line? yes no (b) the effluent line? yes*X no aela ie v� 1 itrs - Pp I ©r 4v c ( Do. un, boLte. " 7) SOURCE WELL CONSTRUCTION INFORMATION (if different from injection well). Attach a copy of Form GW-1 (Well Construction. Record). If Form GW-1 is not available, provide the data in part K (1) of this application form to the best of your knowledge. NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS. PROPOSED OPERATING DATA (for Type 5A7 wells) (1) (4) Injection rate: Injection Volume: Injection Pressure: Injection Temperature: K. INJECTION FLUID DATA (1) (2) Fluid source (for Type rock/sediment unit will t Depth: 3C0.+` Average (daily) �+ i gallons per minute (gpm). Average (daily) g_ gallons per day (gpd). Average (daily) ‘' 30 pounds/square inch (psi). Average (January) ° F, Average (July) 70, ° F. 5A7 wells) If underground, from what depth, formation and type of he fluid be drawn (e.g., granite, limestone, sand, etc.). Formation:__ Rock/sediment unit: t atrailI Chemical Analysis of Source Fluid (for Type SQM wells) Provide a complete listing of all chemicals added to the circulating h uid: INJECTION -RELATED 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 supplementaryinformation. GW-57 HP (Jan, 2000) P. 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 Iand rests ownership in the landowner in the absence of contrary agreement in writing.) If the property is owned by someone other than the applicant, the property owner hereby consents to allow the applicant to construct each injection well as outlined in this application and that it shall be the responsibility of the applicant to ensure that the injection well(s) conforms to the Well Construction Standards (Title 15A NCAC 2C .0200) M. 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 welI(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. N. 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 Pemiits O. CERTIFICATION "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." GW-57 HP (Jan, 2000) 74. e of Well 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. Si It 922 ( gnatur o i rope Owner rtY If Different From Applicant) Please return two copies of the completed Application package to: UIC Program Groundwater Section North Carolina DENR-DWQ 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 715-6165 egg ta srs Pock r�Cornier= Pressure Tank (20-4Opse Mallet Wx-_35Q.._ WELL DATA Depth 355 Static„„II__,.ftcat ND nor) REQUIREMENTS lim»etic Heat Punnp ,.__gpn Lriesttort a_pp++ WELL PERFORMANCE At ,.1L-___a¢w era Irli rf 1s tc .St_ _rt static must house s circulator pump controls, fit valve sxpanslo tank PUMP Lift 0_15,. ,ft Lift Static2n ft Lift, 40 pslp,L._ft Urft: S1 . WELL SUMP TOTAL LIFTi( .__ft TOTAL Flctx__ZQ_,con WELL DESIGN IS BASED UPON © PRELIMINARY ESTIMATE NOT Final Donlon) ® ACTUAL WELL LOG INFORMATION Veil Log dated 10-12-01 N,Bolllrg text Note Well Pump Goulds 18GSiO or equal pump Please submit selected well pump curves for engineering review before installation Pipe sixes are critical, Do not change Hydronlc Heat Pump Accumulator c SET BLEED RATE AT 3 pm, 20 C OF THE HP's 15 ppm BLEED AT <43•F TO POND ? 31E Contract Point - HY Other trim Options are contact Water t4 Eneri Donpstic Hot Water Connections by Ptursber CONTROLS Select Aquastat Control From Trim List ELECRICAL 288/830 vac, bA Ft at._.50_ Amps Single Phase 4th Wire Earth Band is Required NOTE there Is NO Irrigation requirement, If Irrigation is required well pump requirements will change. If irrigation is r � equlerd at a total o ... ••• .......... ..... ... ... • ............... LOTS 48, 49 AND 50 UNDER COMMON OWNERSHIP OF JEFF MARTIN ................ ..... .4= 7!"" ..... ... ... ....... ...... ..... .... ................. . ........ . SEPTIC FIELD LOCATED ACCROSS POND —700 FEET SOUTH AND WEST OF HOUSE FARMSTEAD LANE EMERGENCY BLEED 3GPM RELEASE INTO EXISTING SPILLWAY • • ace sce7 86 - •••