WI0500303_GEO THERMAL_20101021

Permit Number
Program Category
Ground Water
Permit Type
/ //
WI0500303
Central Files: APS_ SWP_
10/21/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (5QW)
Version
1.00
Permit Classification
Individual
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit 1
Facility Name
Christina L. Smart SFR
Location Address
3625 Country Cove Ln
Raleigh
Owner
Owner Name
Christina
Dates/Events
NC 27606
L Smart
Orig Issue
10/21/10
App Received Draft Initiated
10/13/10
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall NU L
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
Glen Adam Darch
13109 Bold Run Hill Rd
Wake Forest
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Christina L. Smart
Owner
3625 Country Cove Ln
Raleigh
NC
NC
Public Notice Issue
10/21/10
Effective
10/21/10
27587
27606
Expiration
Stream Index Number Current Class Subbasin
RA
~CDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Christina L. Smart
Andrew D. Smart
3625 Country Cove Ln.
Raleigh, NC 27606
Coleen H. Sullins
Director
10/21/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0500303
3625 Country Cove Ln.
Raleigh, NC 27606
Dear Mr. and Ms. Smart:
Dee Freeman
Secretary
On 10/13/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-on h
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 .021 l(u)(2). Additionally, you should contact the Wake 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.Ro gers (ci>ncdenr.1Iov if you have any questions.
~('.~~~D
for Debr~tts
Supervisor
cc: Raleigh Regional Office -APS
A.PS Central Files -Pe1mitNo.WI05003Ql
Wake County Health Dept.
Glen Darch (Glen A. Darch Well Drilling, 13109 Bold Run Hill Rd., Wake Forest, NC 27587)
Steve Bowman (Bowman Mechanical Services, Inc., 145 Technical Ct., Garner, 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 www.ncwaterouality.org
An Equal Opportur.iiy \ Affirmative Action E::iployer
One, •. N ortnCarollna
/Vatural/11
V
NORTH CAROLINA = "
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCD$Ntt):
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELLjS)
In Accordance with the provisions of NCAC Title I5A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or Type information).
DATE: October 6.2010
Well Type Confirmation: Does the proposed system circulate potable water on1' (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes _X_ Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well iniecting 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 (i f owned by a business or government agency, state name of
entity and a representative w/authority for signature): Christina L. Smart & Andrew D. Smart
(1)
Mailing Address: 3625 Country Cove Lane
City: Raleigh State: /IC Zip Code: 27606 County: Wake
Home/Office Tele No.: 1919) 755-0371 Ce1I No.:
Email Address: andrewsmartuTPatt.net Website:
(2) Physical Address of Well Site (if different than above):
City: - State: Zip Code: County:
Home/Office Tele No.: Cell No.:
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:
GPUIUIC SQW Notification of Intent Form (Reviser! 8C1008) Page l

C. WELL DR1LLEll INFORMATION
Company Name:GJen A Darch WeJ1 Drining
Well Driller Contrador's Name: G1en Dareh
NC Contractor Certification No.: 3900A
Contact Person: Glen Dareb lN.Ail, Addn;ss:gdwelldrJ1jng@ankgm
Address: 13109 Bold Run Hill Road
City: Wake Forest Zip Code: ~ Co1Jnty: ~
Office Tele No.: (919) SS6-S9S9 Cell No.: [phone]
D. BAT POMP CONTRACJ'OR JNll'ORMATION (if dilfeleat dlaa driller)
.Company Name:Bclwmap Mechanical Services Inc
Contact Person: SmvP-Rmupum EMAIL .Address;·bawman [e-mail]
Address: 145 Technical Ct.
City: Gamer Zip Code: 27529 County. Wake .
Office Tele No.: (919) 172-27S9Cell No.: [phone]
B. STATUS OP APPLICANT ·
Private:X Federal: Commeroial:
State: Munieipal: _ Native American Lands:
F. INJECTION PROCEDURE (briefly descn"be·how 1he iqjection well(s) wll1 be used)
G.
To operate a W pmgp forre.,idegtial bpting/mqling/dqmestic watvr Jw!ter
WELL CONSTRUCl'JON DATA
(l)Proposeddatetobeconstructed:. !~h · ,,(0u o Numberofborings: d--.
Approximate depth of each boring (feet):_J ...... ._.~ ...... D~'---
2 Type of tubing to be med (coppert PVC, etc): RB 3408 po)ytbylene
(3) Well casing. Is 1he well(s) cased? (check either (a.) Yes m: (b.) No below)
(a) Yes __ if yes, then provide~ information below
Type:.__galvanin,dsleel_bJacksteel_plastic_other(speciiy)
Casing depth: F~m ___ to. _ ___.feet (reference to larid surface)
Casing extends to above ground inches
(b) No X
(4) Orout Info (material surrounding well casing and/or piping):
(a) Grout~: Neat Cement__ Bentonite X Other (specify)_
(b) OroutplaGement: Pmnping_X Pressure__ Other __
{c) Grout depth of tubing (reference to land surface): ftom O to ~D
If well bas casing, indicate grout depth: ftom ___ to __ {ieet)
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.
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 wetl(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 paints 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 I 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 specifications and conditions of the Permit."
Signature of Property Owner/Applicant
CLIristirla L.—Smart
Print or Type Full Name and title
Signature of Property Owner/Applicant
Andrew D. Smart
Print or Type Full Name and title
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]
GPI.ifU]C 5QW Notification of Intent Form (Revised 8/20O8) Page 3

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