WI0500279_GEO THERMAL_20100802

Perm it Number WI0500279
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
8717 South Lowell Road
Location Address
8717 S Lowell Rd
Bahama
Own er
Owner Name
Carl
Dates/Events
NC 27503
Erickson
Orig Issue
08/02/10
App Received Draft Initiated
07/30/10
Re g ulated Activities
Heat Pump Injection
Outfall NULL
Scheduled
Issuance
Central Files: APS_ SWP_
08/02/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Glen A. Darch
13109 Bold Run Hill Rd
Wake Forest
Major/Minor
Minor
Region
Raleigh
County
Durham
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Carl Erickson
8717 S Lowell Rd
Bahama
NC
NC
Public Notice Issue
08/02/10
Effective
08/02/10
27587
27503
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Carl J. Erickson
Donna S. Brown
8717 South Lowell Road
Bahama, NC 27503
NA
MCDE~
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
8/2/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
PennitNo. WI0500279
8717 South Lowell Road, Bahama, NC
Dear Carl & Donna:
Dee Freeman
Secretary
On 7/30/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onh
geothennal injection well system for the operation of a ground-source heat pump located at the address referenced above. An
individual pennit 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 fonn and associated maps have been compietely 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 .021 l(u)(2). Additionally, you should contact the Durham 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 {9.19) 715-6166 or Michael.Rogers(a\ncdenr. 1mv if you have any questions.
cc: Raleigh Regional Office -APS
APS Central Files -Permit No. WI0500279
Durham County Health Dept.
Sincerely,
O~A.~
for Debra Watts
Supervisor
Glen Darch -Glen A Darch Well Drilling -13109 Bold Run Hill Rd , Wake Forest, NC 27587
Steve Bowman -Bti'W!l1an Mechanical Services, Inc. 145 Technical Court, Gamer, NC 27529
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 I Customer Service : 1-877-623-6748
Internet: w1-.wncwaterguality.orq
An Equal Opportunity I Affirmative Actio n Employ er
NOnehC lin ort aro a
JVaturall!f
i)s,)\?09--)01
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NO kk1CATION OF INTENT TO CONSTRUCT A CJ OSED-LOOP GEOTE ERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELL(S)
In Accordance with the provisions ofNCAC Title 15A; 02(10200, please
complete this notification and mail to address on the back page (please Pritd or Type information).
DATE
Well Type C:orrfrrmation: Does the proposed system circulate potable water only (no additives) in,
continuous piping that completely isolates the fluid from the envisoitent (i.e.
closed -loop 1?
Yes / Continue ccmpjeting this form.
No Do Not complete this Form. Complete other UIC application forms for installing
either a 5A7 well (overt -loop well krijclitig potable water into the aquifer) or a 5QM well (closed -
loop well containing Additives such as R-22, ethanol, or other anti fi ee-rx or corrosion inhibitors).
PROPERTY OWNER(S)!A )P xCA NT(5)
List each Property Owner listed on property deed (if owned by a business or government agency, State name of
entity and a representative NY/auditor-sty for signature): nir 4 5 ,- _ ,.}!2_®14..4y
'4 e.:751/, 6-04-54*+'
Mailing Address, g 7i 7
City: /3'+e 4414•: ty_ State/VG Zap Coder 7593 County:Duf4.4
Home/Office Tele No.: ( yq) ',7/- 4 -2 2 Celihla. /9Jg ^ J / ._
Email Address; pte t€fIr1/ 61' witc
(1)
(2)
Physical Address of Well Site (ir'diftererit than above)' -._ -
City: State: Zip Code:
HorneJOface Te1e No
Cell No.:
County: _
MIA
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 Persarl_
A ddreas: _ Ctty
Once Tale No.: - -
EMAIL Addrers:
State: Zip Code:
Website Address of Company, if any: -
GSUNIC 5QW Notification of luau► Form (Revised 3/2OO6)
C aunty'
RE'CE/11 i 7ti'R i DWO
400,Fgp pAr]7rr-
JUL 30208
Page 1

C. WELL DRILLER INFORMATION
Company Name:Glen A Darch W~ll_Qrilling
Well Driller Contractor's Name: Glen Darch
NC Contractor Certification No.: 3900A
Contact Person"-: -"G~l~en~D~arc=h,_ ___ ----'E""'M~A...,JL~A-'-'d"'-!d~res.s~dweildrilling @aol.com
Address: 13109 Bold Run Hill Rd. _____ _
City: Wake Forest __ Zip Code: 27587 _____ County: Wake __ _
Office Tele No.: [phone] Cell No.: [phone] __ _
D. H1U T PUMP CONTRACTOR TNFORMA TION (if different than driller)
Company Name:Bowman Mechanical Services Inc
Cont.act Person: Steve Bowman EMAil.. Address:
bowmanmechanical@ bellsouth.net
Address: 145 Technical Ct. __ ._
City: Garner_ Zip Code: 27529 _____ County: Wake_
Office Tele No.: [phone] Cell No.: [phone]
B. STATUS OF APPLICANT
Private: _X_ Federal: Commercial:
St.ate: Municipal:__ Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G.
I<> _Q~rate a heat pump for residential heating / cooling / domestic water heater
WELL CONSTRUCTION DAT A
( 1) Proposed date to be constructed: ------'Ce"'--'-{ 4J....1-{ IL..0 ____ Number of borings: ;;J.. ~c ;--..., Approximate depth of each boring (feet):_L,~~..rt..:~=-------
(2) Type of tubing to be used (copper, PVC, etc): _RE 3408 polyethylene
(3) Well casing. ls the well(s) cased? (check either (a.) Yes!!! (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: __galvaniz.ed 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 (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ · Bentonite _ X ___ Other (specify) __
(b) Grout placement: Pumping__X_ Pressure__ Other __
(feet) ( \;) Gruul depth of tubing (reference to land surface): from __ to _
If well has casing,·indicate grout depth: from ___ to ____ (feet)
N. INJECTION -RELATED F:QtlfPrkIENi
Ailet:h s diagram showing the enf;tneering i,iyuut or proposed modification of the injection equipment elan extcrinr
pipingitubing assuciatecl with the injection operation. Thn reanufnchurer's brochure may provide supplementary
inlnrtnahoy .
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(*) mild
any existing well(s) or waste disposal facilities such as septic ranks or drain fields located within 200 feet of
the geothermal heat pump well system. Label all features clearly and include a north arrow
(2) The Site Mep 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 ,Appltcatton must be signed by each person appearing on the
recorded legal property deed.
"I herby certify, under penalty of law, that I have personally examined and am familiar with the infortnatiou
submitted iu this document and all sltac.ltrnents thereto aod that, based on Iny inquiry of those individuals
immediately responsible for obtaining said information, 1 believe that the information is true, accurate and complete.
1 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 uijectton well and
all related appurtenances in aacordance with the approsaii ctfityi nd conditions 9fthe Fermit"
_t*
Signature of Proper( owner AI pphicant
!C
�r4Q / � �RrG'So+ti
Print or Type Full Naive and title
16-70-4-;/1.4
signature of Property 0wnerJApplican
Print or Type Full Name and title
Signature of Authorized Agent, if anv
Print or Type Foil Name and title
Please return two copies of the Completed Applit_3tion paccage to
North Carolina DENR-DWQ
M uifer Protection Section-131C Program IO
1636 Mail Service Canter R IVED 11° 1 C11
Raleigh, NC 27699-1636 Ai�o'pa �4`n
Telephone [phone] JUL '� V
i�pl it J%C 5Qw tvotiEc Liar of intro form tyLcGtsed gr^O(y

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