WI0300184_Regional Office Historical File Pre 2018

Central Files APS SWP
10/18/11
Permit Number WI0300184
Permit Tracking Slip
Program Category
Ground Water
Status Project Type
Active New Project
Permit Type Version Permit Classification
Injection Water Only GSHP Well System (5QW) 1.00 Individual
Primary Reviewer Permit Contact Affiliation
eric,g,smith
Coastal SW Rule
Per Flow
siiity
Facility Name
Jacob Deal SFR
Location Address
1113 Gregory Ln
Statesville NC 28677
Owner
Randall Cutter
6105 Rest Home Rd
Claremont
NC 28610
Major/Minor Region
Minor Mooresville
Owner Name
Owner Type
Individual
Jacob Deal Owner Affiliation
County
lredell
Affiliation
Jacob Deal
1113 Gregory Ln
Statesville NC 28677
Dates/Events
Orig Issue
10/18/11
App Received
10/07/11
Regulated Activities
Heat, Pump injection
Outfai l
Draft Initiated
Scheduled
Issuance
Public Notice Issue Effective Expiration
10/18/11 10/18/11
Waterbody Narne Stream Index Number
Current Class
Subbasin

C E
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Govemor Director Secretary
10/19/2011
Jacob P. Dean
1113 Gregory Lane
Statesville, NC 28677
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10300184
1113 Gregory Lane, Statesville, NC 28677
Dear Mr. Dean:
On October 7, 2011, 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(11)(2). Additionally, you should contact the Iredell 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 [e-mail] if you have any questions.
Sincerely,
OLct.6,00ruL-
for Debra Watts
Supervisor
cc: Mooresville Regional Office - APS
APS Central Files - Permit No. WI03001 84
Iredell County Health Dept.
Go! Green Drilling, Inc (Randall Cutter)
JP Plumbing Sc Heating
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:1-877-623-67,48
Internet wwuv.newraterouality.orq
An Equal Opportunity 1 Ainrmative Action Employer
NorthhCaroii._�la
fat 1' r

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C. WELI! DRILLER INFORMATION
Company Name: Go! Green Drilling, Inc.
Well Driller Contractor's Name:
NC Contractor Certification No.: 2818-A
Randall E. Cutter
Contact' Person: Randall Cutter
Address: 6105 Rest Home Rd.
EMAIL Address: randvaaoareendrillina.com
1
City: Claremont Zip Code: 28610 County: Catawba
Office •Fele No.: 828-367-1293 Cell No.: 828-228-1695
D. HEAT TUMP CONTRACTOR INFORMATION'(if different than driller)
Company Name: 7P Piumbin2 & Heating
Contact' Person: EMAIL Address:
Address: 235 North Center Street
City: Statesville Zip Code: 28677 County: Iredell
Office Tele No.: [phone] Cell No.:
!
E. STATUS OF APPLICANT
Private X Federal: Commercial:
l
State: .1 Municipal: Native American Lands:
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F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Water ONLY closed loop geothermal vertical loops
G. WELLICONSTRUCTION DATA
(1) Proposed date to be constructed: 10/] 0/2011
Number of borings: 4
Approximate depth of each boring (feet): 170'
(2) Type of tubing to be used (copper, PVC, etc): High Density Polvethelene
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) 1 Yes if yes, then provide casing information below
Typ galvanized steel _black steel plastic _other (specify)
Casing depth: From to feet (reference to land surface)
Casi l g ca.-tends to above ground inches
(b) No X
(4) Grant Info (material surrounding well casing and/or piping): •
I
(a) Grout type: Neat Cement Bentonite X Other (specify) Thermal -Enhanced
(b) Grout placement: Pumping X Pressure Other
(c) Grout depth of tubing (reference to land surface): from 0 to 170 (feet)
If well has casing, indicate grout depth: from to (feet)
GPU/UIC 5QW Notification of intent Form (Revised 8/2008)
i
•
Page 2

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR.
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELL(S)
In Accordance with the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the hack page (please .Print or TNpe information).
DATE: October 6
20 1 1 ki-1-071:01%14
Well Type Confirmation: Does the proposed system circulate potable r only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closecirloop)?
Yes X Continue completing this form,
No Do Not complete this form. Complete other UIC application forms for installing either a
3A7 wefl (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 antifreen or corrosion inhibitors).
A. PROPERTY OWNERS)/APPLICANT(S)
List melt Property Owner listed on property deed (if owned by a business or govermnelfl agency,to
entity and a representative wlauthority for signature): , J
(1) Mailing Address : 1113 La. c
City: Statesville State: NC Zip Code: 28677
Home/Office Tele No.:
County: ire
Cell No.: c70,1) 902-3979
Email Address: jacobiriPsph,coin Website: wpsnhcortt
(2) Physical Address of Well. Site (if different than above: Same
City: State: Zip Code: , Cou
Home/Office Tele No,: Cell No.:
E. AUTHORIZED AGENT OF OWNER,. IF ANY (if the Permit Applicant does not own the subject propeny.
attach a letter from the property owner authorizing Agent to install and operate UIC well)
.Company Name:
Contact Person:
Address:
City:
State:
EMAIIL Adcires:s;
Zip Code:
Office-Tele No.:
Website Address of Company, ifany:
(PUILIC 5cAV Nolincanzm of intr.rv., i'orm (Rtwisecl 8120)g)
Linty:
Cell No.:
RE4444,', DV-43
A474,,r4;4:44‘ ,74',444 -44 "4'7'44, SF TON 142,,ez.
2011.

Il. 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. 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 200 feet of
the geothermal heat pump well system. Label al! features clearly and include a north arrow.
€I'he 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
4
(2)
Noe: This`Permif',�pplieitiiiii*ustbe`srgnediiy;eieliperon'-agpcariilg.on;ttie
�` 're tit a iileg pr:operioiea
I
"I here,y 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 approved specifica ' d conditions of the Permit."
'inure orProperty Owne7Applicant ' -�
, . i � e oi
Print or Type Full Name and title
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-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636 RECEIVED/ OENR / NV..?
[phone] UiF p'ppll ��l I i S7C i IDS!
GPU/UIC 5QW Notifiaiion of Intent Form (Revised 8/2008)
OCT 0 E 2011
Page 3

Jacob Deal
1113 Gregory Ln.
Statesville, NC 28677
Boreholes will be 20' apart. No existing water wells or septic system on this site. City sewer
and water.
RECEIVED I IMO.

Rogers, Michael
From: Randall Cutter [[e-mail]]
Sent: Friday, October 07, 2011 9:10 AM
To: Rogers, Michael
Subject: 5-QW application for deal residence
Attachments: Deal - 5QW Geothermal Well Application - Water.pdf; Deal - Borehole Layout.pdf
Mike,
I have been trying to fax the attached 5-QW to Tonya but she said their fax is not working and to email it to you.
Please see attached.
Thanks,
Randall E. Cutter, CGWP
IGSHPA Accredited
Go! Green Drilling, Inc.
6105 Rest Home Rd.
Claremont, NC 28610
828-367-1293 (office)
828-228-1695 (cell)
[e-mail]
www.GoGreenDrilling.com
1

Rogers, Michael
From: Randall Cutter ([e-mail]]
Sent: Friday, October 07, 2011 1:15 PM
To: Rogers, Michael
Subject: RE: 5-QW application for deal residence
Michael,
Boreholes GL-3 & GL-4 are 16.5' from the utility building. GL-1 is 30+' from the house.
If you need anything else, please let me know.
Thanks,
Randall E. Cutter, CGWP
IGSHPA Accredited
Go! Green Drilling, inc.
6105 Rest Home Rd.
Claremont, NC 28610
828-367-1293 (office)
828-228-1695 (cell)
[e-mail]
www.GoGreenDrilling.com
From: Rogers, Michael fmailto:michael.rogers5ncdenr.aovl
Sent: Friday, October 07, 2011 11:56 AM
To: Randall Cutter
Subject: RE: 5-QW application for deal residence
How far are the borings from any structures? We prefer at least a minimum of 15 feet.
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality- Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
http://r ortal.ncdenr.org/web/wa/apsfgworo/permit-apolications#geothermApps
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
From: Randall Cutter fmailto:randvegonreendrilling.com7
Sent: Friday, October 07, 2011 9:10 AM
To: Rogers, Michael
Subject: 5-QW application for deal residence
Mike,
I have been trying to fax the attached 5-QW to Tonya but she said their fax is not working and to email it to you.
Please see attached.
Thanks,
1

Randall E.Cutter, [GVVP
|G5HPAAccredited
Go! Green Drilling, Inc.
610SRest Home Rd.
Claremont, NC28GlD
828'367-1293/ofhce\
828-228'1695(ceH)
namd°@gngnaen�7iUi1ng,com
vvww.GmGreenDhUimg.con3
2