WI0500286_GEO THERMAL_20120518

Beverly Eaves Perdue
Governor
AVA
NCDEMR~-
North Carolina Department of Environment and Natural Resources
Division ofWater_Quality_
Charles Wakild, P. E.
Director -
May 18, 2012
North Carolina State University
Campus Box 7232 B, Holladay Hall
Raleigh, NC 27695
Subject: Notification of Rufo Revisions Affecting
Closed-Loop Geothermal Injection Well Permit Holders
Permit Number: WI0500286
To Whom it May Concern:
Dee Freeman
Secretary
Our records indicate that you currently hold a permit for a closed-loop geothermal injection well
system. This letter is to inform you that on May 1, 2012, the North Carolina Administrative
Code Title 15A Section 2C .0200 entitled "Well Construction Standards -Criteria and
Standards Applicable Injection Wells" were revised. These revisions affect all permits issued
for injection wells including geothermal wells.
This letter is also to inform you that your closed-loop geothermal injection well(s) have become
"permitted by rule." Therefore, you are no longer required to renew your current permit
and the permit will be valid indefinitely as long as the wells are active and are operated in
accordance with the revised rules referenced above._ Please keep in mind that if you abandon
the wells, a record of abandonment must be submitted to the Division of Water Quality. You
may view the revised rules on our website at http ://portal.ncdenr.org/web/wg/aps.
If you have any questions regarding your current permit or the rule revisions, please feel free to
contact our underground injection control staff at [phone].
Sincerely,
Eric G. Smith, P.G.
Hydrogeologist
cc: UIC Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] I FAX: [phone]
Internet: www .ncwaterquality.org
An Equ al Opportuni ty\ Arr:rmative Action Employe r
One
North Carolina
JVaturall!I
Permit Number WI0500286
Program Category
Ground Water
Permit Type
..
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
NCSU Chancellor's Residence
Location Address
1570 Main Campus Dr
Raleigh
Owner
Owner Name
NC
North Carolina State University
Dates/Events
27607
Orig Issue
09/17/10
App Received Draft Initiated
08/31/10
Scheduled
Issuance
Central Files: APS_ SWP_
09/21/10
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Joshua Niles Robertson
8228 Kerr Chapel Rd
Elon NC 27244
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Kevin Macnaughton
Campus Box 7232 B Holladay Hall
Raleigh NC 27695
Public Notice Issue
09/17/10
Effective
09/17/10
Expiration
08/31/15
Re gulated Activities Re quested/Received Events -----------------------
Heat Pump Injection RO staff report received 08/31/10
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
Permit Number WI0500286
Program Category
Ground Water
Permit Type
Injection Mixed Fluid GSHP Well System (5QM)
Primary Reviewer
michael .rogers
Coastal SW Rule
Permitted Flow
Facili
Facility Name
NCSU Chancellor's Residence
Location Address
1570 Main Campus Dr
Raleigh NC
Owner
Owner Name
North Carolina State University
Date s/Events
27607
Scheduled
Orig Issue App Received Draft Initiated Issuance
08/31/10
Regulated Activities
Heat Pump Injection
Outfall r~tJL i...
Central Files : APS_ SWP_
09/14/10
Permit Tracking Slip
Status
In review
Version
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Joshua Niles Robertson
8228 Kerr Chapel Rd
Elon NC 27244
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affillatlon
Owner Type
Government -State
Owner Affiliation
Kevin Macnaughton
Campus Box 7232 B Holladay Hall
Raleigh NC 27695
Public Notice Issue Effective Expiration
Reauested(Received Events
RO staff report received 08/31/10
Waterbody Name Stream Index Number Current Class Subbasin
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Pereue Coleen H. 5uiltns Dee Freeman
Governor Director Secretary
September 17, 2010
Kevin MacNaughton
North Carolina State University
Campus Box 7232 B.
Holladay Hall
Raleigh, NC 27695
Subject: Issuance of Injection Well Permit
Permit No. WI0500286
Issued to North Carolina State University
Wake County
Dear Mr. MacNaughton:
In accordance with your application received August 31, 2010, I am forwarding Permit No. W10500286
for the construction and operation of a vertical closed -loop geothermal mixed -fluid heat pump injection
well system to be located at North Carolina State University, Chancellor's Residence, 1570 Main Campus
Dr., Raleigh, Wake County, NC 27607. This permit shall be effective from the date of issuance until
August 31, 2015. and shall be subject to the conditions and limitations stated therein.
Please pay special attention to the following sections in Part II of the permit:
Part 11.1- At least forty-eight (48) hours prior to constructing system, the Permittee shall notify the
Aquifer Protection Section's Underground Injection Control (U1C) Program Central Office staff,
telephone number [phone], and the Raleigh Regional Office Aquifer Protection Section
Staff, telephone number (919) 791 - 4200.
Part 11.2- When installing the borings, maintain at least a 25 foot setback from the residence, if
possible.
Part VIL2- Submit copies of the Well Construction Completion form (GW-1) within 30 calendar
days of completion of installation of geothermal well(s).
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days prior to its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Quality. if you have any questions regarding your permit or the Underground Injection
Control Program please call me at [phone].
AOUIFER PROTECTION SECTION
1636 Mai! Service Center, Raleigh, Mort Carolina 27699-1636
Location: 2728 Capita! Boulevard, Raleigh, North Carolina 27604
Phone: [phone] r, FAX 1: 919.715-058B; FAX 2! 919-715.6048 %Customer Bervice:1-877-823-6748
Internet wwv.r.ncwetemualitv.org
An Ego, OpO iuniv 1 Affirmative Acrian Employer
ort
i3e
hCarolina.
Naturally

cc: Jay Zimmerman -Raleigh Regional Office
Central Office File -WI0500286
Wake County Environmental Health Dept.
Tom Paonessa -Morrissey Mechanical, Inc.
Attachment( s)
2
Sincerely,
~d .
,-Michael Rogers, P.G~
Environmental Specialist
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other applicable
Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
North Carolina State University
FOR THE CONSTRUCTION AND OPERATION OF 12 TYPE SQM INJECTION WELL(S), defined in Title
lSA North Carolina Administrative Code 2C .0209(e)(3)(F), for the purpose of operating a vertical closed loop
geothermal mixed fluid heat pump system. This system is located at North Carolina State University,
Chancellor's Residence, 1570 Main Campus Dr., Raleigh, Wake County, NC 27607, and will be constructed
and operated in accordance with the application received August 31, 2010, and in conformity with the
specifications and supporting data, all of which are filed with the Department of Environment and Natural
Resources and are considered a part of this permit.
This permit is for Construction and Operation of an injection well and shall be in compliance with Title ISA of
the North Carolina Administrative Code 2C .0100 and .0200 plus any other applicable Laws, Rules, and
Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until August 31, 2015, and shall be
subject to the specified conditions and limitations set forth in Parts I through IX hereof.
Permit issued this the 17th day of September 2010.
h oleen H. Sullins, Director t Division of Water Quality
By Authority of the Environmental Management Commission.
Permit WIOS00286 UIC/SQM
ver. 03/2010
Page 1 of 5
PART I -WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and criteria specified
in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200)_. Any noncompliance with
conditions of this permit constitutes a violation of the North Carolina Well Construction Act and is
grounds for enforcement action as provided for in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the conditions of
this permit, the approved plans and specifications, and other supporting data.
3. Each injection well shall not hydraulically connect separate aquifers.
4. Each injection well shall not be located in an area generally subject to flooding. Areas that are generally
subject to flooding include those with concave slope, alluvial or colluvial soils, gullies, depressions, and
drainage ways.
5. Each injection well shall be afforded reasonable protection against damage during construction and use.
PART II -WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight ( 48) hours prior to constructing system, the Permittee shall notify the Aquifer
Protection Section's Underground Injection Control (UIC) Program Central Office staff, telephone
number [phone], and the Raleigh Regional. Office Aquifer Protection Section Staff, telephone
number [phone].
2. When installing the borings, maintain at least a 25 foot setback from the foundation of the residence, if at
all possible.
3. The location of each of the system manifolds shall be recorded by triangulation from three permanent
features on the site (e.g., building foundation comers) and shown on an updated Site Map. The Permittee
shall retain a copy of this record on site.
4. One well identification tag per grouping or 'cluster' of wells shall be permanently affixed to the heating
and cooling unit or other nearby permanently fixed location in accordance with 15A NCAC 2C .0213(g).
PART III-OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials and rate of injection, as
described in the application and other supporting data.
2. This permit is not transferable without prior notice to, and approval by, the Director of the Division of
Water Quality (Director). In the event there is a desire for the facility to change ownership, or there is a
name change of the Pennittee, a formal permit amendment request must be submitted to the Director,
including any supporting materials as may be appropriate, at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Pennittee of the responsibility of complying with any and
all statutes, rules, regulations, or ordinances, which may be imposed by other local, state, and federal
Permit WI0500286 UIC/SQM
ver. 03/2010
Page 2 of 5
agencies, which have jurisdiction. Furthermore, the issuance of this permit does not imply that all
regulatory requirements have been met.
PART IV-PERFORMANCE STANDARDS
1. The injection facility shall be effectively maintained and operated at all times so that there is no
contamination of groundwater that will render it unsatisfactory for normal use. In the event that the
facility fails to perform satisfactorily, including the creation of nuisance conditions or failure of the
injection zone to adequately assimilate the injected fluid, the Permittee shall take immediate corrective
actions including those actions that may be required by the Division of Water Quality such as the repair,
modification, or abandonment of the injection facility.
2. The Permittee shall be required to comply with the terms and conditions of this permit even if compliance
requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to surface or
ground water resulting from the operation of this facility.
PART V -OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times.
2. The Permittee must notify the Division and receive prior written approval from the Director of any
planned physical alterations or additions in the permitted facility or activity not specifically authorized by
the permit. '
3. At least forty-eight ( 48) hours prior to the initiation of the operation of the facility for injection, the
Permittee must notify by telephone the Aquifer Protection Section's Underground Injection Control (UIC)
Program Central Office staff, telephone number [phone]. Notification is required so that Division
staff can inspect or otherwise review the injection facility and determine if it is in compliance with permit
conditions.
PART VI -INSPECTIONS
L Any duly authorized officer, employee, or representative of the Division of Water Quality may, upon
presentation of credentials, enter and inspect any property, premises, or place on or related to the injection
facility at any reasonable time for the purpose of determining compliance with this permit, may inspect or
copy any records that must be maintained under the terms and conditions of this permit, and may obtain
samples of groundwater, surface water, or injection fluids.
2. Division representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with the
injection facility activities.
Permit WI0500286 UIC/SQM
ver. 03/2010
Page 3 of 5
PART VII -MONITORING AND REPORTING REQUIREMENTS
1. All required documentation shall be submitted to:
Aquifer Protection Section -UIC Program
DENR-Division of Water Quality
1636 Mail Service Center and
Raleigh, NC 27699-1636
Ph# 919-715-3221
Aquifer Protection Section
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699
[phone]
2. A completed Well Construction Record (Form GW-1) for each injection well must be submitted to the
Aquifer Protection Section Central Office and the Raleigh Regional Office within 30 days of completion
of well construction. Copies of the GW-1 form(s) shall also be given to the Permittee and retained on site
to be made available for inspection.
3. A copy of the site map updated with manifold locations required in Part 11.2 of this permit shall be
submitted to the Aquifer Protection Section Central Office and the Raleigh Regional Office within 30 days
of completion of well construction.
4. Any monitoring (including groundwater, surface water1 or soil sampling) deemed necessary by the
Division of Water Quality to insure surface and ground water protection will be established and an
acceptable sampling reporting schedule shall be followed.
5. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge of the
occurrence, to the Raleigh Regional Office, telephone number [phone] any of the following:
(A) Any occurrence at the injection facility that results in any unusual operating circumstances;
(B) Any failure due to known or unknown reasons that renders the facility incapable of proper
injection operations, such as mechanical or electrical failures;
(C) Any loss of refrigerant in the system, regardless of the origin of the loss;
(D) Any recharging of the refrigerant system.
6. Where the Permittee becomes aware of an omission of any relevant facts in a permit application, or of any
incorrect information submitted in said application or in any report to the Director, the relevant and correct
facts or information shall be promptly submitted to the Director by the Permittee.
7. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take such
immediate action as may be required by the Director.
PART VIII -PERMIT RENEW AL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the Permittee shall
submit an application to renew the permit 120 days prior to its expiration date.
Permit WI0500286 UIC/SQM
ver. 03/2010
Page 4 of 5
PART IX-CHANGE OF WELL STATUS
1. The Permittee shall provide written notification within 15 days of any change of status of an injection
well. Such a change would include the discontinued use of a well for injection. If a well is taken
completely out of service temporarily, the Permittee must install a sanitary seal. If a well is not to be used
for any purpose, then that well must be permanently abandoned according to 15A NCAC 2C .0213(h)(l).
Notification shall be submitted to the addresses given in Part VII.1 of this permit.
2. When operations have ceased at the facility and a well will no longer be used for any purpose, the
Permittee shall abandon that injection well in accordance with the procedures specified in 15A NCAC 2C
.0214, including but not limited to, the following :
(A) All casing and materials may be removed prior to initiation of abandonment procedures if the
Director finds such removal will not be responsible for, or contribute to , the contamination of an
underground source of drinking water.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom from
obstructions that may interfere with sealing operations.
(C) Each well shall be thoroughly disinfected, prior to sealing, if the Director determines that failure
to do so could lead to the contamination of an underground source of drinking water.
(D) Each well shall be completely filled with cement grout, which shall be introduced into the well
through a pipe that extends to the bottom of the well and is raised as the well is filled.
(E) In the case of gravel-packed wells in which the casing and screens have not been removed, the
casing shall be perforated opposite the gravel pack, at intervals not exceeding 10 feet, and grout
injected through the perforations.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been created,
each well shall be abandoned in such a manner that will prevent the movement of fluids into or
between underground sources of drinking water and in accordance with the terms and conditions
of the permit.
(G) The Permittee shall submit a copy of the Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(l) within 30 days of completion of abandonment. Copies shall be
submitted to the addresses given in Part VII.1 of this permit.
Permit WI 0S00286 UIC/SQM
ver . 03/2010
Page 5 of 5
Ro g ers, Michael
From:
Sent:
To:
Cc:
Subject:
Mr. Paonessa,
Zimmerman , Jay
Tuesday, August 31, 2010 4:22 PM
tom [e-mail]
Rogers, Michael; Watts, Debra
NCSU Chancellor's Residence 5QM UIC wells
I spoke to Michael R·ogers this afternoon and after our discussion it was agreed that you may begin installation of the
SQM injection wells. It is requested yo _u do the following:
1. Maintain a 25 ft setback from the foundation if at all possible.
2. Ensure the wells are constructed and boreholes installed in such a manner so as to prevent entrance of
contaminants, to include stormwater runoff, from entering the borehole. In the event a borehole is constructed
but tubing is not grouted in place by the end of each day, that measures are used to prevent stormwater from
overnight rain events from entering the borehole.
3 . Do not begin operation of the system until such time as you either have the permit or we otherwise approve
(such as for testing purposes).
Please let Michael or me know if any questions or concerns.
Sincerely,
Jay Zimmerman
E-mail correspondence to and from this address may be subject to the North Carolina Public R ec ord s Law and may be di sclo sed to
third parties .
From: Zimmerman, Jay
Sent: Thursday, August 26, 2010 11:14 AM
To: '[e-mail]'
Subject: Injection well rules
Here is the link to the injection well rules. Let me know if any questions.
http://h2o.enr.state .nc .us /aps/gp u/document s/15A 2C 0200 1feb97.pdf
Sincerely,
Jay Zimmerman
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.
1
AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
September 8, 2010
Kevin Macnaugton
North Carolina State University
Campus Box 72321 B Holladay Hall
Raleigh. NC 27695
Subject: Acknowledgement of Application No. WI0500286
1570 Main Campus Drive
Injection Mixed Fluid GSRP Well System (5QM)
Wake
Dear Mr. MacNaugton:
Dee Freeman
Secretary
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and
supporting materials on August 31, 2010. This application package has been assigned the number listed above and will be reviewed by
Michael Rogers.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the
maximum efficiency in processing permit applications, the Division requests your assistance in providing a timely and complete
response to any additional infotmation,requests.
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final action by the
Division. Please also note at this time, processing permit applications can take as long as 60 - 90 days after receipt of a complete
application,
If you have any questions, please contact Michael Rogers at 919-715-6166, or via e-mail at michael.rogers(ncdemr.gov, If the
reviewer is unavailable, you may leave a message, and they will respond promptly. Also note that the Division has reorganized. To
review our new organizational chart, go to htto:llh2o.enr_state.nc.usldocumentsldwo orachart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAIUNG INQUIRIES ON This PROJECT.
Sincerely,
c) •J'J
for Debra J. Watts
Supervisor
cc; Raleigh Regional Office, Aquifer Protection Section
Triad Drillers - Joshua Robertson - 8228 Kerr Chapel Rd, Elan, NC 27244
Morrissey Mechanical - Toni Paonessa - 8804H Gulf Court, Raleigh, NC 27617
Permit Application File WI0500286
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] l FAX 1: 919-715.0588; FAX 2: 919-715.60481 Customer Service: 1-877-623-6748
Internet: www.nwxater1t ality.om
hn Equal Opportunity I Affirrnaiivu Action Employer
No thCarotin a
Naturally

MORRISSEY MECNANICAI. INC.
August 30, 2010
North Carolina DENR-DWQ
Aquifer Protection Section
UIC Program
1636 Mail Service Center
Raleigh, NC 27699-3221
Mr. J. Zimmerman:
Per our conversation, we had started a standard permit form to drill a vertical closed loop,
water only, geothermal system at the Chancellors residence located on the property of NC
State University at 1570 Main Campus Drive, Raleigh, NC 27607. As of Thursday,
August 26, we had to switch from water only fluids and instead use mixed fluids
containing water and Ethanol. This was based on the manufacturers warranty and the
equipment that we have changed to.
We would like to start drilling as soon as we can while waiting for the permit to be
issued. Morrissey Mechanical, Inc. will not introduce any of these mixed fluids into the
geothermal vertical loops that are located in the ground until permit is finalized. We need
your approval either in an email or letter to begin this process. Time is of the essence on
this project and your cooperation would be greatly appreciated.
Thank you,
�-
Tom Paonessa
Geothermal Division Manager
Morrissey Mechanical, Inc.
919-795-4805 cell
-i; ,lialllLaliif llrnail.ctiom
/13u4-U1 Gulf Ct - }.neigh - Nnrth Ciirrilina - 2" fit'* -- 90-4(9-6646
Serving the Triangle fur Over is Years
717)

NORIB CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION WITH A GEOTHERMAL HEAT PUMP SYSTEM FOR:
TYPE SOM WELL{S)
X New Permit Application OR ____ Renewal (check one)
I
DATE: J> / 3co I I 0 . 20 ~ I -
PERMIT NO. Yt(05EX'A$£o (leave blank if NEW permit application)
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business ~v-en! agency, state name of
entity and a representative w/authority for signature): j/ IJ/llll ~& (~
Un , r:-t'JL o/-XMia ,&lfl-t'.f!/41t<,t,l,l/i1/V
(1) Mailing ~esJ: 11/C. v.7mf tlt1t~
City: /?l/l1£t j --Y State:l!!f.__zipCode: J.:.7& 9J 7
County: ~
Home/Office Tele No.: '1/'7 ,.. ;J ~--_ 2-72 2--Cell No.:
EMAILAddress:&vw-H{,;.ell/~ijft,t#JV(J'IA 1/2dq.
CJ,/~c,,e 1/M.-r IZ--es, U,Sl( · . C ~
(2) Physical Address of .. Site (if different than above): / 570 ('{)@:, rv Qw:}y'.'.'.X.f S ~ .Vrl,.
City: ful\ ~ L~ H State: ~Cz ip Code: ~ 7 & c, 7 county: W e-lc•e .
Home/Office Tele No.: Cell No.:
EMAIL Address: _____________ _
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)
C.
Company Name: /V(_" J'z;?;l-r-!9 t/t21 'Ve/fZJ/ fy : _
ContactPerson: l <11111n ll?'A1CIVAY-"J JZ?v EMAILAddress: A evitz _m#C/1/~(X-,tx>
Address: Cf'¥,.,,✓ !lox 7~j ....2 ,//3 k'(};/~81 M& NL cf(,,(_ ddv
City: ;i;: / <. t."'a-i State: /1-C zip Code: ,:). 7t:? ~ .S County: k/i,... .f e.
·//,), ,· -,.,_,7·? Office Tele No.: :fl 7 ,~ £/ J -,-. ~ .,,L Cell No.:
Website Address of Company, if any: ____________ _
STATUS OF APPLICANT
Private: ~ Federal:
State: Municipal:
Commercial:
Native American Lands:
C>
..
-·., ~ .
.. u. ~
"' :;;.:i --:-
""CfJ TI
:71C-.. o, -·· r,-;!;; ..
C"o-:·,
N c,
GPU/UIC SQM Well Permit Application (Revised 7/2008)
Cl
Address:
D. WELL DRILLER INFORMATIO �� ry
Company Name: i. i a 0 c_. 4 ' a c
.s At,b 2&
Well Drilling Contractor's Name:
NC Contractor Certification No.:11 6 i
Contact Person: J .l : EMAIL Address:
City: /- Z eV/ /VC Zip Code: - 9 ounty_ - -
Office Tele No.: 336- L/p1 ` J / CeI1 No.: 3 — y-. Q 7
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: -/1 /0 ..7f' 15 •J C �I �%F' f1/�477 J (dye_ .Z "rC --y�
Contact Person: bpi fl'1 ,4�' f9,D� e 3J I'% EMAIL Address: rryt0 r.lft cl i ff r)
Address: o! o Loe au( / cT i[� [.ii.ph [9 it/
City: /24-1/e / f �, - Zip Code: • 71. (7 County: kt )&C?7 -1 L-- 6-44 i
Office Tete No.: 4/ / -C(r 4; it tr ' [ Cell No.: 67% r di WCZ.j----
F. INJECTION PROCEDURE (briefly describe/how the injection well(s) will be used);
G. WELL CONSTRUCTION DATA (Slip to Section H if this is a Permit RENEWAL)
(1) Proposed date to be constructed: h),Aa Number of borings:
Approximate depth of each boring (feet): ??.,
(2) Chemical additives to be used in closed -loop system (only those chemicals indicated have been approved):
R-22 - _propylene glycol ethanol other (other additives will
need prior approval by NCDENR before use)
(3) Type of tubing to be used (upper, PVC, etc): J el e/i/. 1,4 6;17/Z —/ / �` �J i3q
(4) Well casing. Is the well(s) cased? (check either (a.) YES or (b.) NO below) G
(a) YES if yes, then provide casing information such as type (steel, PVC, plastic, etc.), diameter.
droll. and extent of casing appearing above ground: Tif a-f,/ / / a e -�
1 wieed . rS7 /' % h_e
(b) NO Hole( , c� fT:42
(5) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement Bentonite = Other (specify)
(b) Grout depth of tubing (reference to land surface): from to n ``fit.' (feet)
If well has casing, indicate grout depth: from to - (feet)
H. 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.
GP[i/UJC 5QM Well Permit Application (Revised 7/2008) Page 2

I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(i)
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 1000 feet of the
geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) Include a topographic map of the area extending one mile from the property boundaries and
indicate the facility's location and the map name_
J. POTABLE WATER WELL(S)
Are there any potable water well(s) on the subject property or adjacent properties? YES NO
If Yes, than indicate location on attached map(s).
K. 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,1 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, proved specifications and conditions of the Permit."
of Property Owner/Applicant
If<EYit l Ac.NAnoG,HTCh4
Print or Type Full Name f j J r ~4 r ,J L S rgje
Signature of Property Owner/Applicant
Print or Type Hill Name
Signature of Authorized Agent, if any
Print or Type Full Name
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section
L]IC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
'telephone [phone]
GPUI[IIC 5QM Well Permit Application (Revised moos)
Page 3