WI0500319_GEO THERMAL_20101201

Permit Number '
Program Category
Ground Water
Permit Type
WI0500319 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Alexandra McCormick SFR
Location Address
3214 Mossdale Ave
Shannon Plaza
Owner
Owner Name
Alexandra
Dates/Events
NC 27707
Price McCormick
Orig Issue
12/01/10
App Received Draft Initiated
11/16/10
Reaulated Activities
H eat Pump Injection
Outfall ~:: J;_'...
Scheduled
Issuance
Central Flies: APS_ SWP_
12/01/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual ·
Permit Contact Affiliation
Ryan Brazill
72 Wester Way
Bunn
Major/Minor
Minor
Region
Raleigh
County
Durham
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
NC
Alexandra Price McCormick
3214 Mossdale Ave
Durham
Public Notice Issue
12/01/10
NC
Effective
12/01/10
27508
27707
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
•~A JT#.;;~~
NCDE NR
North Carolina Departmen t of Environmen t and Natural Resou rces
Division of Water Quality
Beverly Eaves Perdue
Governor
Alexandra Price M c Cormick
32 14 Mossdale Avenue
Durham, N C 27707
Coleen H. Su lli ns
Directo r
12 /1/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0500319
3214 Mossdale A venue , Durham, NC 277 07
Dear Ms. McCormick:
Dee Freeman
Secretary
On 11/16/2010, 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 pennit 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 ISA 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 v iolation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title ISA Section 2C Subchapter .02 ll(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 Michael.Rm!ers1iv.ncdenr .2:ov if you have any questions.
cc : Raleigh Regional Office -AP S
APS Central Files -Permit No. W10500319
Durh am County Health Dept.
Brazill Drilling (Ryan Brazill)
Bowman Mechanical Services, Inc. (Stephe11 Bowman)
AQUIFER PROTECTION SECTION
1635 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Sincerely,
0Ui1l_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 .ncwa te rguality.org
An Equal Opportunity\ Affirmative Action Employer
N<grth Carolina
JVaturnll!I
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-OW WELDS)
in Accordance with the provisions ofNCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or Type information)_
DATE: 10"- I _ , 20 10
Well Type Conflnnalion: Does the proposed system circulate potable water ❑nl (no additives) in
continuous piping that completely isolate:, the fluid from the environment (i...
closed -loop)?
Yes
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 inhibitors).
A. PROPERTY OWNER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): _A It? j,.,, . t , -\rA , i «_ PCOC L rri7 I C K.
I a Mailing Address: , 2.1 . A' a5_5da
City: fat.ti rY1 State! N CZip Code: ,: 7 7O i County: U,_.� lr•'�1
11oine/Office Tele No.;
Email Address: r, Website:
)nt No.: ' l 1‘ i - C 3 J tE .
'AleA rt(Ara,'vvlec4 ; rr ti ri tt ( ee# t t
(2) Physical Address of Well Site (if different than above):
City: State: _ Zip Code: County:
HoineiOffice 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 LAC well)
Company Name:
Contact Person: EMAIL Address;
Address:
City: State: _ Zip Code: County:
Office Tele No.: Cell No.:
Website Address of Company, if any:
GPL11U1C 5QW Notification of Intent Form (Revised 8/2008)
Page I

C. WELL DRILLER INFORMATION
Company Name: -0 ~ ~ ~
Well Driller Contractor's Name: A 0/n ~
NC Contractor Ce1tification No.: cR o?~ ~~--~---------------------
Contact Person: &.¥1/b ~t.f2J.£. EMAILAddress:
Address: '1;J. ~ ~
City: {;:)u~ Zip Code: o?76()9 County: J_, ...... ~'---'='-=c.....:.=-=---~------
Office Tele No.: Cj/9 49t -b!JJ'.3 Cell No.: 9t "J '7;/tP-l/Gl'3
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
C N Bowm an Mechanical Services, Inc. ompany ame: ______________________ ------.---~-,--...----~
bowmanmech anical@b e lrsouth.net
Contact Person.-'-: __ S_t _e .c.,.ph_en_B_o_wm_a_n ______ ~E=M=A'-"=IL~A=d=d~re=s=s: ___________ _
Address: 145. Technical Ct.
City: Garner 27529 Wake Zip Code: _____ County: _____________ _
Office Tele No.: 919-772-2759 Cell No.: -----------
E. STATUS OF APPLICANT
Private: ~
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
ci l &
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: l O-IP Number of borings: -~----
Approximate depth of each boring (feet):· ..... ;? _____ 8~0~'-----
(2) Type of tubing to be used (copper, PVC, etc): \?12.~ U-.ha.fvn_.t
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: __ galvanized steel __ black steel_plastic __ other (specify)
Casing depth: From ___ to ___ feet (reference to land surface)
Casing extends to above ground ___ inches
(b) No :i___
(4) Grout Info cfn~terial surrounding well casing and/or piping):
Grout type: Neat Cement __ Bentonite Other (specify)
Grout placement: Pumping__ Pressure Other
-------(a)
(b)
(c) Grout depth of tubing (reference to land surface): from ___ to ____ (feet)
If well has casing, indicate grout depth: from to (feet) ---------
GPU/UJC 5QW Notification of Intent Fonn (Revised 8/2008)
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:
(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 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 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.
T 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
i ,' u:._+nr
Print or Type Full Name and title
Signature of Property Owner/Applicant
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]
GPUIJUIC 5QW Notification of Intent Fonti (Revised 8/2008) Page 3

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REFERENCES