WI0500284_GEO THERMAL_20100907

Permit Number WI0500284
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
349 McCullough
Location Address
349 McCullough Rd
Cedar Grove
Owner
Owner Name
Alfred
Dates/Events
NC 27231
R Loeblich
Orig Issue
09/07/10
App Received Draft Initiated
08/27/10
Re g ulated Activities
Heat Pump Injection
Outfall NU LL
Scheduled
Issuance
Central Files: APS_ SWP_ 3
09/07/10
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Raleigh
County
Orange
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Alfred R. Loeblich
4301 Manor Field Way#102
Raleigh NC 27612
Public Notice Issue
09/07/10
Effective
09/07/10
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NA
MC DE NR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Alfred R. Loeblich
Wendy Aldwyn
4301 Manor Field Way #102
Raleigh, NC 27612
Coleen H. Sullins
Director
9/7/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0500284
349 McCullough. Cedar Grove, NC 2 7231
Dear Alfred & Wendy:
Dee Freeman
Secretary
On 8/27/2010, 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 Jong 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 ofthe North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .021l{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.Ro2:ers (CV.ncdenr.1mv if you have any questions.
cc: Raleigh Regional Office -APS
APS Central Files -Permit No. Wl0500284
Orange County Health Dept.
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Sincerely,
0~ A.~
for Debra Watts
Supervisor
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity I Affirmative Action Employer
NOnehC 1· ort aroma
JVaturall!f
h
tikA0 ")).'d &:;t.kc0 :2-CCT
DEPARTMENT Ok ENVIRONMENT AND NA RESOURCES
NORTH CAROLINA
NOTLFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 50W WELLS I
In Accordance With the Provisions of NCAC Title I5A 02C.0200
Print or type the required information an i mail to address. on the buck page.
DATE: *1-A 24� CA( -(c.SNciY11S---Vt
�
Well Type Confirmation: Docs the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environrne.nt (i.e.
closed -loop)?
Yes ' h Continue completing this form.
No Do Not compiem this foam. Compete other UIC application forms for installing
either a 5A7 well (open -loop well .11.. tiny potable water into the aquifer) or a SQM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNERSWAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthori.ty for signature): At-
B.
(1)
(2)
Mailing Address:
vtlti„ \eiza---
City' XN\4.N.5\----- State: _AC Zip Code:7'1it-A L County;
Home/Office Tele No.: ( VID :" OA 5 Ceill1To.: S'+ktL
Email AddressS Websitc:
Physical Address of Wdl Site (if different than above): k �0(
Ci y— State: Zip Code: County:
Home/Office Tele No.: _ Ce l
c44.6.%CkAll"-"Zitgr,e1
AUTHORIZED AGENT OF OVV'NEH, 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 Ntnne: _
Contact Person:
Address: _
City: State:" _ Zip Cod
Office Tele No.: _
Wehsite Address of Company, if any:
M (uLL,E46-i4-
s
EM AIL Address:
Gri1/1_11C 5QW Noilfseation of matt i 6sm [Ftavisni R(2008)
County
Cell No.:
P2ge
Td WkJ2t7:OT TTOE ET 'UPI" V617b602616 : 'ON 3htDHd
13.LddeOEWOH : W❑dJ

Phelps Realty
919-732-1188
vr:Wrrtse. CO ENV ntTH
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P �1
Aug 2710 09:56a
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15— (5I6b n.
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WELL. DRILLER ENFORNf.ATION
Company Nam:
Wel: Oats- Centractvr's Marto,
NC Canon ar etrEicettenNo.;
CalzitaGt Perm:
r\c) \)&iiAttcArc.
Alas:
City; Ccde:
Cc int0-:
Office TaIc No.: Ceti No,:
MCAT PUMP CynIACTOR Drront.MATION difI'ereut than dx ar)
Company Name: W kaki"/I-N 0
Cvsstact tco,-1 "hVN+) R.`` V 1 iy't' Agtremz:
?§.ddcas:
City; Z., Code: Comfy`.
Office Tele No.: Cell No.:
STATTJS Q IICANT
Private:
State:
Mom:
Coromctvial:
Native Arse:fcer Latds: —
INJECTION PROCEDLTRE C ieflyy des=i1t4 iscw the injection t'eW) will be me)
VrCLL, CONSTRUCTION DATA.
(t) Proposed date to be ru ted:
AtTroxiatIn depth of ca ti bothg (fee*
(0) Typo of tubing to be used (wpm, P'W C, ete):
.
N sznl- of iaarirtae
2CO
�kC
(3) Y4 t7l casbg. T,s tha 9,,e11(s) eased? (chock either (a.) Yes 2 ib.) N4 below•)
(a; Yes if yea. (ben Trovtda casing irfarrnatinc belcw
Type: ._ alvanrir steCi _tlask tteel.�`. 3.c�it'se: fapecify)
Casing d.ptn: Flom to _Ie:t (rv`e_svicc to surface.)
Caskg extends to above ground 4aCha4
(b) No
(4) Grua Info (cat=sl surrounding well rasing an&tor pirsing)
Qraat t►Yt: [`feat Comm_ entnnite Cfncr(specify)
Or=p1ascmCnt { t t g. :3cs3ure_. _ Other
07otit depth of tubi g (,tafete+c+. to land surface): iry n L' b to S
If well has cuing, int ioate grout depth: fnro to
(a)
(s)
(Q)
1\__G\dii,-Qs_ Pi°
t.t
3 — .4—<1
GPL;IMC SQW .N1c..tticui n w+Sntrlr. Fra-z [pev!int MODS)
(fcC•x
ff)
RECEIVED r DENR I DWQ
AQUIFFR PROTFCTION SECTION
AUG 27 2010

H. INJECTION -RELATED EQUTh'N<JIVT
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 snowing the following information:
(1) Include a Site Map (can be drawn) showing: buildings, property lines, surface writer bodies, potential
sources of groundwater contarrnination and the orientation of and distruice.s 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'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. CERTIFICA'i1ON
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, undor penalty of law, that I have personally examined and am familiar with the informations
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 arc significant penalties, including the possibility of fines and imprisonment, for submitting
false information- I agree to consiniCt, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with ,f e approved specificatind conditions of the Permit."
Signs' a of Property Owner/Applicant
Ai.red P��►�.
Print or Type Full Name and title
Signature of Propy Owner/ApPicant
Af cl�
Print or Type- 1t11 Name and title
Signature of Authorized Agent, if any
Print or Type Full Narne and title
two c. trs ofhe completed Application package,_
North Carolina DENR-DWQ
Protection Section-U1C Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPtjlulc• 5()W Nnrifcation of [ntc3!r t urm (Rcvised 12.E -
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Orange County Property Search Page 1 of 2
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PIN#: 9849485661
TMBL#: 2.13, 11L
TRACT#: 275889
Property Owner:
LOEBLICit ALFRED RICHARD
III
& WENDY A ALDWYN
*NOTE: INTEREST OWNERS
Owner's Mailing Address:
4301 MANOR FIELD WAY
#102
RALEIGH
NC, 27612-3776
Legal Description:
2 TONY W MCCULLOCK
P105/37
Administrative
Assessed Values
Miscellaneous Information
Tax Account#: 312892
Assessed Land Size: A19.25
Buildings Assessed:
PIN Status: A
Land Value: $114538
Assessors Status: A
Total Use Value: $4
Rate Code: 16
Buildings Value: $0
Rate Code Information
(Revenue Dept, )
Total Valuation: $114538
Descendants
Ancestors
Liftk to Old GlS_website-
5
http://gis.ca.orange.nc.us/land/queries/account.asp?PIN=9849485661 8/20/2010

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http://gis.co .orange.nc. us/land/ queries/account.asp ?PIN =984948 5 661 8/20/2010
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349 MCCULLOUGH RD
CEDAR GROVE NC 27231 -
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Cedar Grove, 349 McCullough Road, NC - Google Maps Page 1 of 1
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Cedar Grove, NC 27231
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