WI0500278_GEO THERMAL_20100726

Permit 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 [phone] 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 : [phone] \ 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 [phone]
RECEIVED J DENR I DWQ
AQUIFFR PRrliFt7Trr7N 3.PCTION
JUL 2 3 7010
GPUMC 5QW Notification of Intent Form (Revised 8/2008)
Page