WI0300143_Regional Office Historical File Pre 2018

Beverly Eaves Perdue
Governor
City of Charlotte
Michelle Haas
600 East Fourth Street
Charlotte, FL 28202
I WA
NCDENEZ
North Carolina Department of Environrnentand Natural Resources
Division of Water Qualit
Coleen H. Sullins
Director
3/9/2010
ill C� C�6OdG
MAR 10 2010
-Thn
NC DENR MRO
DWQ - Aquifer Protection
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0300143
3725 Ellington
Charlotte, NC 28202
Dear Ms. Michelle Haas:
Dee Freeman
Secretary
In accordance with the application submitted to the. Underground Injection Control (UIC) Program that was received on 2/16/2010, the
Aquifer Protection Section (APS) acknowledges your intent to construct a closed -loop geothermal water -only injection well system
for the operation of a ground -source heat pump located at 3725 Ellington, Charlotte, Mecklenburg County, NC 28202. This system is
deemed permitted by rule (North Carolina Administrative Code Title 15A, Subchapter 2C, Section .0211(u)(2)). However, please
note 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).
Please notify the Mooresville Regional Office at [phone] at least 48 hours prior to well installation. Additionally, it is
recommended that you contact the Mecklenburg County Health Department, as they may have additional construction or permitting
requirements for this type of system. If you modify your system at any time, including the addition of antifreeze, corrosion inhibitors,
or any other substances to the circulating fluid, you must contact the APS to verify compliance withapplicable rules.
Thank you for submitting this notification. If you have any questions please call me at [phone].
Sincerely,
Scorl_e_
Michael Rogers
Environmental Specialist
GPU-Aquifer Protection Section
cc. Mooresville Regional Office - AP '
APS Central Files - Permit No. WI0300143
Mecklenburg County Health Dept.
Janice Scott (Midsouth Geothermal LLC) 8275 Tournament Dr Ste 185, Memphis, TN 38125
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: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: wvvw.ncwateraualitv.orq
An Equal Opportunity \ Affirmative Action Employer
North Carolina
Vat atiiy

Central Files: APS SWP
03/08/10
Permit Number WI0300143
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Status Project Type
Active New Project
Version Permit Classification
1.00 Individual
Primary Reviewer Permit Contact Affil
michael.rogers
Coastal SW Rule
Permitted Flow
Facility
Facility Name
City of Charlotte - 5QW
Location Address
3725 Ellington
Charlotte
Owner
Major/Minor
Minor
Region
Mooresville
County
Mecklenburg
NC 28202 Facility Contact Affiliation
Owner Name Owner Type
City of Charlotte
Dates/Events
Government - Municipal
Owner Affiliation
Michelle Haas
600 E 4th St
Charlotte
NC 28202
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
03/08/10 02/16/10 03/08/10 03/08/10
Regulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin

02/15/201ei 11:55 9017489097
MID -SOUTH GEOTHERMAL PAGE 0'2/Ott
NORTH CAROLINA•
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 50W 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.
g
DATE ; 1 S , 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 (Le.
closed -loop)?
Yes N Continue completing this foma.
No Do Not complete this form. Complete other UIC application forms 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 OWNERS)/APPLICANT(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 f r signature):
C . o air C_.
(1) Mailing Address:
State: IiJ?Zip Code: 0 County:
Home/Office Tele 64 ~33(.0 5Lo1Shh ,. o ' e G`1 ot( S
Email Address:AV\PASOC i'C'`h"Wet ite na, t,l.S
(2)
Physical {Addres{s ofjWell Site (if different than above): ") I Yl 1 �, LL
City: C1C r 1 oLte, State:108, Zip Code: D) County: j`V1eAdQYI. bL c9
Home/Office Tele No.: 'T Coll 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 Naine:
Contact Person: EMAIL Address:
Address:
City State: Zip Code: County:
Office Tele No.: Cell No.:
Website Address of Company, if any:
GPU/UIC 5QW Notification of Tntcnt Form (Revised 8/2008) _ Page 1

0R/15/2010, 11:55 9017489097
MID -SOUTH GEOTHERMAL PAGE 03/04
C. WELL DRILLER INFORMATION
Company Name: 101 I t11 1! 1 G-e.84 i , L LC
Well Driller Contractor's Name: it `aSP i.
NC Contractor Certification No.: n o 1&\ Q 5-- A
Contact Person: L OS\ e e- Co r EMAIL Address: peo±k€ 1A, k () U�✓_� ( f
Address: R �� 5 `Mu , ;1C�. MQ 11+ b � S4e , t �,j^
City: v�r J A pn LS Zip Code: `3 ! �� County: S Y 1e' LJ L f
Office Tele No.: �f egg'-9.b6Z5 Ce11 No.: I
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Narne:K\ J SDL C-e64142n.Ck\ L l�
Contact PersoEMAIL Address: —
Address: (3.sn
City: \MAP bttvplktS .Zip Code: County: CAR'
Office Tele No.: CO--1\- % cf OCi Cell No.:
E. STATUS OF APPLIC.A.NT
Private: Federal: Commercial:
State: Municipal: x Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
C� bs-e c.) —\cop - C'1-e k Sc. rC
\es\- t\.
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: \t1 \
l Number of borings:
Approximate depth of each boring (feet): 3CJi
(2) Type of tubing to be used (copper, PVC, etc): III 4U P E.-: -\)ket3 -ke
(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 extends to above ground inches
(b) No '
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite )( Other (specify).4`
(b) Grout placement: Pumping Pressure Other ^ �"
(c) Grout depth of tubing (reference to land surface): from CJ to ?CZ') (feet)
If well has casing, indicate grout depth: from to (feet)
GPU/U1C 5QW Notification of intent Form (Revised 8/2008)
Page 2

02/16/•2010 11:55 9017489097
MID -SOUTH GEOTHERMAL
PAGE 04/041.
R. CZ1ON REZ TED EQUIPMENT
Attach a lipmen showing the ettaineasing layout yr pxoposed modlfis ion of the i rdection
IMP exterior
14• .1. ,t•
0. ,, �,,
aasoCinied wfdh the iaje ion operation. The mks brochure y provide el
mentary
LOCATION OF MUM
Attach tev0 Cople'a of maps showing the following in%raiastan:
(1) Include a Site Map (can be drawn) showing: tradiugs, property lInes, surface water bodies, potential
sources of groundwater contamination and the orientation of and dismay
betweany es tfg well(') or waste disposal lignites such as septic lass or drain sl� the located 44111i1120(1the ProPeted `fiat or
geothermal; heat pomp well system Label all f a re clearly and telmiguig.
The Site Map must show ale subject property .in relation to the
surroUnding reference points suc h thuds, streams, and/or highway iota ectlaas. t least two fa7eed
J. CEAT1p CATION
(2)
New TMs Penult Application must be wed by Egli person appearistg on the
recorded legal prop deed.
.1 hereby o rt iy, under peneity of law, that X have perky examined and am fhulilier with the iniblmatIon
- submitted in this document and all enachmems thereto and that based on my imply of those individuals
immediately responsibly for obtaining said iftrroarion, i believe tat the inlbrmation is true, acctnate and complete,
x am aware tat there ere significant penalties, including the possibility of none and
lituprisonteterxt, for *obtaining
foist mfbmzatiot. X agree to cO St ectr operate, maintain, zepair, endWar/pike/Me, abate the lnIIeetiou well
all tektted Ices in ice with the approved Speciecedona and conditions of the Permit"
' 1 I OL.6-41-•
Signature ofProperty Owner/Applicant
a as Sri PraL4cfi
'Print Type full Name and title
Signature oi•Propert}' ®wu lA,ppi at
p'tltut or Type Full Name- and title
signorine of Authorized A8 if
Print or Type Putl Noma and tint!♦
Please return two ooples Of the completed Application package' to:
Now Carolina. p=:DWQ
> • Pa rteetion n-VIC Program
1636 Mail Sonia Cuter"
Ram, NC 27699-1636
Telephone (919) 733.a221
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