WI0500311_GEO THERMAL_20101119 (2)

Permit Number
Program Category
Ground Water
Permit Type
Wl0500311
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Richard & Ellen Brearley SFR
Location Address
113 Kilt Way
Durham
Owner
Owner Name
Richard
Dates/Events
NC 27712
Brearley
Orig Issue
11/19/10
App Received Draft Initiated
11/09/10
Re g ulated Activities
Heat Pump Inj ection
Outfall ;-:'.J I L
Scheduled
Issuance
Central Files: APS_ SWP_
11/19/10
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
M inor
Region
Raleigh
County
Durham
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Richard Brearley
113 Kilt Way
Durham
NC
NC
Public Notice Issue
11/19/10
Effective
11/19/10
27587
27712
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coieen H. Sullins Dee Freeman
Governor Director Secretary
11/19/2010
Richard Brearlev-
Ellen Brearlev
113 Kilt Way
Durham_, NC 27712
Subject: Acknowledgement of Intent to Construct Type SOW Injection We11 System
Permit No. WI0500311
113 Kilt Way_ Durham. NC 27712
Dear Mr. & Mrs. Erear]ey:
On 11/9/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water only
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 we]1 construction standards specified in North
Carolina Administrative Code Title I5A 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 Tide 15A Section 2C Subchapter .0211(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 [phone] or Micbael.Rouers:ulncdenr.Eov if you have any questions.
Sincerely, °Oak,
for Debra Watts
5 upervisor
cc: Raleith Regional Office- APS
APS Central Files - Permit No. W UUS00311
Durham County Health Dept.
Gicn A. Derch Well Drilling 1 Glen Darchy
Bowman Mechanical Services, loc. (Sieve Bowman)
AQUIFER; PROTECTION SECTION
1636 Mali Service Center. Raleigh, North Carolina 27699-1635
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] i FAX 1: 91-715-058B. FAX [phone]{148 i Customer Service: 1-B77-623.6748
lmemat: www.n: eaateraualltv.crc
An EquP1 xportim.:/ i Arrlrmaiwe A; on r:r•urinyer
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 50W WELL(S)
In Accordance With the Provisions ofNCAC Title 15A 02C.0200
Print or type the required information and mail to address on the back page.
DATE:
zoJ \NIT O S a.Th
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 -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 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 inhihitors).
A. PROPERTY OWNER(S}IAPPLICANII'(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlantherity for signature): Fife--] i
(l)
Mailing Address: I13 K% /1
City- [.l,l�1Am star: Zip Code: 9 1Z County. ))urh Am
Home/Office TeleNo.: L f r-763(p CellNo.:
Email Address: C 1 c ektr e <. C VAebsite:
(2) Physical Address of Well Site (if different than above):
City State: Zip Code: _ _ County:
IlonielOid`ice Tcle 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.
GPLIAS1C iQW Notification of Intent Form (Revised 8/24O5) Page

C.. WELL DRILLE'R llUOIDIATION
Company Name:Glen A Dareh Well Drilling
Well DriDer Qmtractor's Name: Glen Darch
NC Contractor Certification No.: 3900A
Con1act Person: Glen Dan:h F.MA1L Address:gdwelldrHling@aplmm
Address: 13109 Bold Run Hill Road
City: Wake FgestZip Code: 27Sfrl County: Wake
Office Tele No.: (919) ~56-5959 Cell No.: [phone]
D. BEA~ J'UMPCONTllACl'OR BVORMATION (lfdlffea• tna dljller)
-Company ~!Rowman -Mechanical Services Inc
Contact Person: Steve Bowman EMAIL AdtJi:ep~-bowman mephpnicaJ@hellmuth.n
Address: 145 Technical Ct.
City: ~ Zip Code: 27~ County: Wake _
Office Tele No.: (919) m-2759 Cell No.: [phone]
B. STATUS OJI' APPUCANT
Private: X Federal: Commercial:
State: Municipal:_ Native Amerroan:Lands:
:,. INBCTION PROCEDlJIR (briefly descnoe·how 1he iqjection well(s) will be used)
G.
To operate a W mmm for m,idgmal lpmngtconling/domesticwater Jwrter
WELLCONSTRUcrtONDATA
(l)Proposeddatetobeconstructed:. 10/ 2-~ J ,:> Numberofborings: d
Appmximate depth of each boring (feet): d.. i: S
2 Type oftnbing to be used (copper. PVC. etc): RB 3408 polythylene
(3) Well casing. Is the weD(s) cased? (check ei1her (a.) Yes K (b.) No below)
(a) Yes __ ifyes, then provide~ information below
Type: _ __galvanized sleel _black steel__pJastic_· 01her(specity)
Casing depth: F~ ____ to _ ____,feet (refenmce to lmicl surface)
Casing extends to above ground __ ~inches
(b) No X
(4) Orout IDfo {material surmunding well casing and/orpiping):
(a) Grout type: Neat Cement__ .Bentonite X
(b) Grout plrmt: Pumping_X Pressure __
(c) Grout depth of tubing (reference t.o land surfilce): ftom
Other (specify)_
Other
0 to J-."+S
If well has casing, indicate grout dep1h: fium ___ 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.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following mtbrmation:
(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 wells) or waste disposal facilities such as septic thnko 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. 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 far 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 t approved specifications and conditions of the Permit."
roc
Signature of Property Owner/Applicant:.
L�n Ada e 0.+-1 e'-'\
NIA or Type Full Name and titre
Signature of Property Owner/Applit
vl 1"—e C1/4.Ct Q-‘
Print or Type Full Name and title
Signature of Authorized Agent, if any
?tint 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]
GPU/UIC SQW Notification of Intent Form (Revised 8/2008) Page 3

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