WI0500348_GEO THERMAL_20110126

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CDEMR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Rand y Chambers
905 West Markham Avenu e
Durham, NC 27701
Division of Water Quality
Coleen H. Sullins
Director
1/26/2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No . WI0500348
905 West Markham Avenue, Durham, NC 27701
Dear Mr. Chambers:
Dee Freeman
Secretary
On 1/24/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onh ·
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 .02ll(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.Ro2:ers(cil.ncdenr. 1rnv if you have any questions.
cc: Raleigh Regional Office -APS
APS Central Files -Permit No. Wl0500348
Durham County Health Dept.
Triad D1illcrs, lnc. (Josh Robertson)
Morrissey Mechanical, lnc (Tom Paonessa)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2i28 Capital Boulevard, Raleigh, North Carolina 27604
Sincerely,
Ut~c1~
for D ebra Watts -
Supervisor
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Inte rnet: www .n cwateroualit v.org
None, C 1. ortn aroma
/Vatuta/~tf
,:_r, Equal OpportJn it y \ Afi1rma:ive Action Employer
II
FROM MorriSSey Mechanical
PHONE NO. : 919 469 6gpt19
Jan. 15 2011 11.:9 1M P4
I
1
NORTI I cAROI.INA
1)}.PA YMENT or ERUViltONMirNT AND NATURAL l ESOURCF:S
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GWTUERMA
WATER -ONLY INJECTION WELL SYSTEM
TYPE SOW WELLS'
In Accordance With the Provisions f NCAC Title NSA 02C.0200
Print or type the raistired information and nail to address on the back page.
DATE: J -1,?.. , 20 a
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (;.e.
closed -loop 17
Yes Continue completing this farm
No Do Not complete this form. Complete application forms for g
either a 5A7 well (open -loop well injecting potable r o the aquifer) or a 5QM v (closed- •
loop weal containing additives such as R-22, ethanol, o r antifreeze or corrosion irk ':tors).
PROPERTY OWN (S)/APPLICANT(S)
List each Property U► er fisted on property deed Of owned by a i isi
entity and a representative wlauthority for signature):
or government agency, state name of
(l )
Mailing Address: q(9,s--- V/& r� /i t7�'Y1 �7
City: 1>JCr► State:/V ZipfCode X rj C9 l County:
Home/Office Tele No.: 9/? r q/7 "'/''// Cell No.:
Email Address: Wehsite:
(2) Physical Address of Weil Site (if different than above);
City:
State: Zip Cod
Home/Office Tele No.:
$. AUTHORIZED AGF�T OF OWNER, IF ANY (if the Pewit
attach a letter from the roperty owner authorizing Agent to insta
Company Name:
Contact Person: -- ,MA
Address:
City: _ State: Zip Code:
Office Tele No.:
Website Address of Company, if any:
CPCTMC $QW Noti$cuion of Wont Iwrm (Revised &/20U8)
County:
No..
it does not own the su
prrare UIC well)
MSS:

FROM : MorriSSey Mechanical
PHONE NO. : 919 469 6649 Jan. 15 22111.11.:C40AM PS
•
C.
WELL DRiLLl K INFORMATION
Company Name:
Well Driller Contractor's Name:
NC Contractor Certification
Contact Person:
Address:
~� 1' w c
.S( i-cSL!� ,t�t.%
ifNo.:
' .
J EMAI1. ddress:I/1'I.4W
City: 2. ! Zip Code: A -
Office Tele No.:
eerie..
Cell Nu;
caur,r:
-'&1-3173
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: ( -[ CS i Y ► e. g i12 1 c —L .. ` ,M(
Contact Person: T 1 f # WeSS4 EMAIL Address: 1 Pr `Il I DTI
��]
Address: 75n
f 1 f`IZeCes&i An f 4 • t • C.[. 1 C 1 /N
103 1'r `e664 J6�W
City: �"� ;- Zip Code: c 7(e (7 , county: 1 "' ( /f. 1444
Office Tele No.: , r • ' L ( Cell No.: C1/ 9 r 79
E. STATUS OF ' ` LICANT
Private: Federal: Commercial:
State: Municipal: Native American Lands:
F. INJECTION ROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: `7 '/ r Number of Drinks:
Approximate depth death boring (feet): caJam.' �,c
(2) Type of tubing to be used (copper, PVC, etc): ((� / � l f 3 *Vg
{3) Well casing.Is the well(s) cased? (check either a.) Yes or I r'F ( (b_ } is below) ,� � ..
(a) Yes if yes., then provide casing information below
Type: _galvanized steel black steel plastic other (specify) - 11
Casing depth: Prom to feet (reference to land surface)
Casing extends to alrGe ground inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping):
(A) Grout type: Neat Cement BentonOther (specify)
(b) Grout piaerment~ Pumping Pressure_ Other
(c) Grout depth of tubing (reference to land surface): In
to 2'.] (feet)
If well has casing., indicate grout depth:Ai-oral to (feet) .
O?Wi.71C 5QW Notifecaiioo oflnteni Fonm (Rcviscd $/ZGO8)
Pap 2

FROM : Morrissey Mechanical
PHONE NO. : 919 469 6649
H. INJECT ION -RELATED EQUIPMENT
Jan. 15 2011 1 BAM.2
Attach a diagram showing the engineering layout of proposed modification of the injectiort.O4InipMent and exterior...,
piping/tubing associated with the injections operation. The manufacturer's brochure may provide jupplernentary
intonnastion.
L 'LOCAT%ON 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 dies,
sources of groundwater contamination and the orientation of and distances between the proposed Aka)
any existing wells) or waste disposal facilities such as septic tanks or drain fields located within.200 feet►d
the geothermal heat pump well system. Labe] all features clearly and include a Werth arrow, xRala; r
(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 Cp each person appearing nu the
recorded legal property deed.
14
"I herebycertify, under penaltyof law, that I have } .:
fy. peT�;n+411Y examined and am familiar With the a information
submitted in this document and all attachments thereto and that, 'based on my inquiry of thdse individuals' + -
immediately responsible for obtaining said information, l believe r t information is true, eccuratk4ccomplet 3
l am aware that there are significant penalties, including the past •, of fines and imprisoranont', bmittin
false information. 1 agree to construct, operate, maintains, repair; , . supliCable; abandon the in "' welt and
a#1 related appurtenances in accordance with the app - )ed speciftc& y . aico trans f the Perm ,
s,
Signature of P
Print or Type FulI]ame an title
Signature of Prgpbrty f IA.prliccrt
Print or Type Full Name
Signature of Authorized
Print or Type Full N- tits
please return two copies of the cornpletpd on package to:
North Carolina 1)
Aquifer Protection Seoti
1636 Mail Semi
Raleigh, NC 27
Telephone [phone]
GPVi)IC SQW Nod&ca[iva of intent Form (Reviv- 8/2008)
r.
1

FROM : Morrissey Mechanical
•
f''lr::N`iei it! Isi�i's�rt�s �y' g�'ljt3�ii'�i lL
ltt:24,$5nikai1i ftpi��?R7 uY1!e°.'.i`;1•
,Bone:
Date:
urveyed by: !f ./l
NvW coint:'"uViOri
bal.r
k,•••
Cent Nam
Addresx-
Phone:. - -1
GeoOesigtter per r:rt ! by
Soil conditiors:
Special conditions end requirements:
Owner's preference cn tocatiml oo loop:
► CUlte pope.? Ms exista ttuttures, future
n. AIWA. and servteaf.
Aign ioCate tha get* tmit earth loop, paieuatson er,g.
PHONE NO. : 919 469 6649
IIN���SEY NE6NI1116AL.1MC.
.'�.. ?- .Rfr:,i•o'.. , !I -!Ai.4 r"y.,: 1-' •i ..^.�P4i7 '15 o;� 9n.�
Permit number:
•
Retrofit
CI Water Well
DePm
u iigy piled'
i Natural Gas
Propare
sty sews
PrNate Sewer
c.JEastirnante
j Fuei Linea
J,}w $prttssr
u Dram Tile
`i SIN. Faanris'illon
43 unit ioa
Exiatirg cor ping unit
:,i: Pond
Avg, Pad'
nerrth
Other...
4

FR❑1'1 ; Morrissey F1echan i ca 1
PHONE NO. : 919 469 6649
Ian. 15 2011 10:58IRM P1
1 '
Date:
Fax Cover Sheet
MORRISSEY
MECHANICAL INC.
7517 Precision Drive
Suite 101 & 103
Raleigh, NC 27617
P.O. Box 80755
Raleigh, NC 27623.
[phone] Office
[phone] Fax
To:. c'-177 J CGst 1 a► ) 5- CIE-4
From: 1TO 'Gt c, rl 8.S.�
# of pages (inc. covertheet):
Comments: