WI0500313_GEO THERMAL_20110110 (2)

Permit Number WI0500313
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
F iliv
Facility Name
Neal & Beth Carlton SFR
Location Address
5500 Shealtiel Way
Rougemont
Owner
Owner Name
Neal
Dates /Eve nts
NC 27572
McGe Carlton
e
Scheduled
Orig Issue
11/22/10
App Received Draft In itiated Issuance
11/10/10
Rec1 ulated Activities
Heat Pump Injection
Outfall i·::JLL
Central Files: APS_ SWP_
01/10/11
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
Orange
Facility Contact Affiliation
Owner Type .
Individual
Owner Affiliation
Neal McGee Carlton
5500 Shealtiel Way
Rougemont
NC
NC
Public Notice Issue
11/22/10
Effective
11/22/10
27587
27572
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 5QW WELLS)
In Accordance with the Provisions ofNCAC Title 15A 02C.0200
Pant or type the required information and mail to address on the back page.
DATE:
20 I D5OC 3i3
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 Continue completing this form.
No Do Not complete this form. Complete other UIC application fortes far 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 inhibitors).
A. PROPERTY OWNERS)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authorie for si ature): Akq/ /Pfd7ee £4f-! h A) cr'
Co-/ fottl
(l)
(2)
Mailing Address: S00 � e ?//ram- /
city. o creA en / sttteiVe Zip code:2;76' 7. - County: )r-42. i' e
Home/Office Tele No.: 'Y%r 3, l / e Ce11 No.:i%9'-- 2112 ""‘ 7 2-
Email Address: / Website:beA
Plex
Physical Address of Well Site (if different than above):
City:
Home/Office Tele No.:
State:
Zip Code: _ -
Cell No.:
County:
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.: Ce11 No.:
Websitc Address of Company, if any:
[3PLSIUIC 5QW Notification of inirn[ Form (Revised 8/29O8) Page

• I
C. WELL DJHIJ,XRJNFORMA'ffON
Company Name:Glen A Darch Well Drilling
Well Driller Contractor's Name: Olen Darcb
NC Contractor Certification No.: 3900A
Contact Person: Glen Dareh BMAD.. Address:gdwelldrilling@anlcom
Address: 13109 Bold Run Hill Road
City: Wake Fon:st Zip Code: 275&7 Courity: Wake
Office Tele No.: (919) ~56-5959 Cell No.: [phone]
D. BEAT PUMPCONTRAC,ORINPORMATION (if dlffeleat tlla ..._,
-Company Namf!!Rowman Mechapical Services Inc
Contact Person: S1evl'l RnwmAQ EMAIL Address:·bowman [e-mail]
Address: 145 Technical CL
City: Garner Zip Code: 27529 County: Wake .
Office Tele No.: [phone] Cell No.: [phone].
B. STATUS OP APPLICANT .
Private: X Federal: Commercial:
State: Municipal:_ Native A.merkai Lands:
F'. INJECrION PROCEDUltE (briefly descnoe 0bow the hpmon -well(s) will be used)
G.
To operate a W pump fur ,mWentiA1 Jwatimycooling/domestic water heater
Wl!LLCONSTRUcrJON DATA
(I)Proposeddaleto becomtructed: l c/i~fri> Numberofborings: d\
Approximate depth of each boring (feet): 13:-5 I
2 Type of tubing to be used (copper, PVC, etc): RE 3408 polytbylene
(3) Well casing. Is the well(s) cased? (check either (a.) Yes![ (b.) No below)
(a) Yes __ if yes, then provide~ information below
Type:. ___galvanized steel _black steel__plas1ic_o1her(specify)
Casing depth: F~ ___ to __ feet (reference to laiid surface)
Casing exmds to above ground __ inches
(b) No X ..
{4) Orout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite X Other (specify)_
(b) Grout placement Pwnping__X Pressure__ Olher __
(c) Grout depth of tubing (refermK:e to land surface): from a+ 5 to 0
Ifwell has casing, indicate grout deplb: from • to ~(feet)
8. 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.
1. 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(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 pinup well system. Label all featupa, 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, andlnr 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 examine(' and am familiar with the information
submitted in this document and ail 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, far submitting
false information_ 1 agree to construct, operate, unaintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved peci1cations and corm of the ?'errnit."
arty Owner/Applicant
Sig
i-
Print or Type Full Nam and title
Signature of Property Owner/Applicant
erfrfCPA—
Printt or Type Full Name and title
-77
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]
GPU/U[C 5QW Modification or Intent Form (Revised 8/2008)
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