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HomeMy WebLinkAboutWI0500278_GEO THERMAL_20100726Permit Number WI0500278 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 2015 Starterwood Lane Location Address 2015 Starterwood Ln Hillsborough Owner Owner Name Ralph Dates/Events NC 27278 Wayne Hutchins Central Files: APS_ SWP_ '1 Permit Tracking Slip Status Active Project Type New Project 07/26/10 Version 1.00 Permit Classification Individual Permit Contact Afflllatlon Richard A. Simmons 60 Drill Rig Dr Buchanan Major/Minor Minor Region Raleigh County Orange Facility Contact Affiliation Owner Type Individual Owner Affiliation Ralph Wayne Hutchins 612 Croom Ct Chapel Hill VA 24066 NC 27514 Orig Issue 07/26/10 App Received Draft Initiated Scheduled Issuance Public Notice Issue 07/26/10 Effective 07/26/10 Expiration 07/23/10 Re g ulated Activities Heat Pump Injection Outfall N: II I. Waterbody Name Stream Index Number Current Class Subbasin Beverly Eaves Perdue Governor Ralph Wayne Hutchins Mary Lynne Hutchins 612 Croom Court Chapel Hili, NC 27514 ~A --;!'-_~_.I. NCDENR North Carolina Department of Environment and Natural Resources Division of Water Quality Coleen H. Suliins Director 7/26/2010 Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System Pennit No. WI0500278 2015 Staterwood Lane, Hillsborough, NC 27278 Dear Mr. & Mrs. Hutchin s: Dee Freeman Secretary On 7/23/2010, 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 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 (919) 715-6166 or Michael.Rogersra mcdenr.iwv if you have any questions. Sincerely, for~t\-~ cc: Ralei)!h Regional Office -APS APS Central Files -Pennit No. WHJ5002h Orange County Health Dept. Supervisor RA Simmons -Stephen Brooks, 60 Drill Rig Dr., Buchanan, \I A 24066 Superior Mechanical , Jnc-PO Box 877. Randleman. NC 27317 AQUIFER PROTECTION SECTION 1636 Mail Service Center, Raleigh , North Carolina 27699-1636 Location: 2728 Capital Boulevard , Raleigh. North Carolina 27604 Phone : 919-733-3221 \ FAX 1: 919-715-0588; FA X 2: 919-715-6048 \ Customer Service: 1-877-623-6748 Internet: www.ncwaterguality.org An Equal Opportunity\ Affirmative Action Emp loye; NiTihCarolina ~Naturally NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM TYPE 5QW WELLSS) In Accordance With the Provisions ofNCAC Title 5A 02C.0200 Print or type the required information and mail to address on the back page. DATE: i7 . j 20 to I D 5Coo&il 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. closed-Ioop )? Yes Continue completing this form. 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 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 wlauthority for signature): Qie ne L.oi Mar' i.linne } 4-i1-1;nS (1) Mailing Address: L,1 C-Y ' rr CO IC+ City: C4-1c el )4- LI State: NC ip Code: 51 ii County: O.. Home/O€fice Tele No.: 9 S5S5 Cell No.: q j cj - &SD ' Email Address: tiIhul'6►in5,0 bJJI Website: • ra{- (2) Physical Address of Well Site (if different than above): 4,9015 r} 'r• i.Jcc d City }}il 15jpor State: NC Zip Code: Z1 2-1 a County: P cci ry e Home/Office Tele No.: 919- 9 0 9 - ?885 Cell No.: 919 9E-88 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: - Contact Person: EMAIL Address: Address: City: State: Zip Code: County: Office Tele No.: Cell No.: Website Address of Company, if any: TELEWbD 1 DENR I D► C GPIJIUIC 5QW Notification of Intent Form (Revised 812008) AQIJIIFFP-PRfypt'TIrim 5 'nitt4 Page i JUL 2 3 2010 C. WELL DRll,LER INFORMATION CompaeyNmne: RA Sim]';~ ~r~\~ ~ :J:oc. Well Driller Contractor's Name:; = ~I 00 NC Cmmactor Cemfication No.: ~~( A VJ C. 035 gg Contact Person:~hen; EMAIL Address: 5, 'oca2ks e5 iromlflS&1'l I,~ .. . . w~ Address: (po l)n l\ R1'9 Or l ~{;... City: Buc.bt..tVVAQ ZipCode:a4o{pL, County: Bo+c:too i ± Office Tele No.: $YD-~54-~gG CellNo.: 540-400 -4Yl l D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller) CompanyName: c".~\J4>Cr i c l" [YJe.c,.ba,ni CpJ 1 ::+nC.. Contact Person: /1..ur:ti :> }±o \ l j ?&5 ~C4b EMAIL Address: I I of) in ~~ mC'..9, -CCY?l Address: '?· D , f3 D'{-: ?>2 r, City: Wtldlerna (\ Zip Code: N C. County: _Tu,..=:,,.:..-h ..... do-.) ..... p;.,:;..t_~..__ ____ _ OfficeTeleNo.: BZ,(p---Y98-'2t>D9 Cell No.: 33(p· ,3$4 4 ~:39(.p E. STATUS OF APPLICANT F. G. Private: State: Federal: Municipal: __ Commercial: _JL!.. Native American Lands: INJECTION PROCEDURE (briefly describe how the injection well(s) will be used) WELL CONSTRUCTION DATA (1) Proposed date to be constructed: _:I ......... f> .... \D...._ ___ Number of borings: __ 4 __ _ Approximate depth of each boring (feet): 350 -C + (2) Type of tubing to be used (copper, PVC, etc): ---p-==~=-------------- (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 X . (4)Grout Info (rnaterial surrounding well casing and/or piping): (a) Grout type: Neat Cement~ Bentonite _)(_ Other (specify) _____ _ (b) Grout placement: Pumping Pressure_____._ Other_ (c) Grout depth of tubing (reference to land surface): :frornS'\Jtlru.e,. to -350 (feet) If well has casing, indicate grout depth: from ___ to ____ (feet) <iPU/UIC SQW Notification of Intent Form (Revised 8/2008) Page2 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. L 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 corrtainination and the orientation of and distances between the proposed well(s) and any existing wells) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of the geothermal heat purnp well system. Label all features clearly and include a north arrow. (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 1 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 specific ations and conditions of the Permit." Signatre of Property Owner/Applicant Print or Type Full Name and title emu/ Signat e ofpert�i Owner/Applicant Print or T Full N c and title r 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 (919) 733-3221 RECEIVED J DENR I DWQ AQUIFFR PRrliFt7Trr7N 3.PCTION JUL 2 3 7010 GPUMC 5QW Notification of Intent Form (Revised 8/2008) Page