WI0500355_GEO THERMAL_20110224

Permit Number
Program Category
Ground Water
Permit Type
WI0500355
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Gilbert Alan Young SFR
Location Address
2124 Averette Rd
Wake Forest
Owner
Owner Name
Gilbert
Dates/Events
NC 27587
Alan Young
Orig Issue
02/24/11
App Received Draft Initiated
02/21/11
Re a ulated Activities
He at Pum p Inj ection
Outfall ~,i: l' _!
Scheduled
Issuance
Central Files: APS_ SWP_
02/24/11
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
Wake
Facility Contact Affiliation
Owner.Type
Individual
Owner Affiliation
Gilbert Alan Young
2124 Averette Rd
Wake Forest
NC
NC
Public Notice Issue
02/24/11
Effective
02/24/11
27587
27587
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdu e
Governor
Gil ber t Alan Voung
2124 A verette Road
Wake Fore!>t, NC 27587
BA
MCDENR
North Carol ina Departmen t of Environ men t and Natural Reso urces
Division of Water Quali ty
Coleen H. Suli ins
Director
2/24/2 011
Subject: Acknowledgement ofintent to Construct Type 5QW Injection Well System
Permit No. WI0500355
2124 Averette Rd, Wa k e Forest, NC 27587
Dear Mr. Young :
Dee Freema n
Secretary
On 2/21/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl y
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 WakC' 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 ,a\ncde-nr.gov if you have any questions.
cc: Raleigh Regional Office -APS
. APS Central Files -Permit No. \VI0500355
Wake County Health D ept.
G len A Darch W e ll D riliing
Bowman Mech anical Services, Inc.
AQUIFER PROTECTION SECTION
1536 Ma] Service Center, Raleigh, North Caroiina 27699-1635
Location: 2728 Capital Eoutevard , Raleigh. North Carolina 27604
Sincerely,
/b,Q~~
Supervisor
Phone : [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwateraual1iV.o ro
A1 Eau2i Oppartun :ty \ .U.ffirm2·:ve Action E:nployer
None . _ 1'
.l orti1Laronna
,?vaturallJ/
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 of NCAC Title 15A 02C.0200
Print or type the required information and mail to address on the hack page.
DATE: 1j 1 I 0
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 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)/API'LICANT(S)
List each Property Owner listed on property deed (if owned b)( a business or government agency, state name of
(i\ €( Yes n
entity and a representative sty/authority for signature):
(1)
Mailing Address: P2- l k \iff *1(. d -
City: \AO-Ve nn State C- Zip Code: 2.156-7 County: W O
Home/Office TeleNo.: "1 LR -ScA- S302 Coll Na.: 1 [ 4 - 3a40 - -q 7 7
Entail Address: Website:
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code:
County:
Ilome/Offtce Tele No.: Cell No.:
R. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter fi oLn 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, daily: DAC
Aquifer Diniectt jyt�`j lion
CPU/UTC 5QW Notification of intent Form (Revisozi 8/2008) Paw i
�7 [
�

C. WELL DRILLER INFORMATION
Company Name:Glen A Dareh Well Drilling
Well Driller Contractor's Name: Glen Darch
NC Contractor Certification No.: 3900A
Contact Person: Glen Darch EMAIL Address:[e-mail]
Address: 13109 Bold Run Hill Road
City: Wake Forest Zip Code: 27587 Count}': Wake
Office Tele No.: [phone] Cell No.: [phone]
D. HEAT PUMP CONTRACTOR INFORMATION fd' different than drDler)
·Company Name:Bowman Mechanical Services Inc
Contact Person: Steve Bowman EMAIL Ad<:li'ess:: bowman mechanical@ bellsouth.net
Address: 145 Technical Ct.
City: Gamer Zip Code: 27529 Counfy: Wake
Office Tele No.: [phone] Cell No.: [phone]
B. STATUS OF APPUCANT ·
Private: X Federal: Commercial:
State: ____._ Municipal:__ Native American Lands:
F. INJECTION PROCEDURE (briefly descnl>e how the injection well(s) will be used)
To operate a heat pump for residential hearinf!icooling/dqmestic water heater
G. WELL CONSTRUCI'ION DATA \
(1) Proposed date to be constructed: I l l 'J\ \ 0 Number of borings: ~
Approximate depth of each boring (feet):_ ..... 3'-'-'5~0'"----
2 Type of tubing to be used (copper, PVC. etc): RE 3408 polythylene
(3) Well casing. Is the well(s) cased? (check either (a.) Yes m: Cb:) No below)
(a) Yes ___ if yes, then provide casing information below
Type: __galvanized steel __ black steel__plastic __ otber (specify)
Casing depth: From ___ to --~feet (reference to lmid surface)
Casing extends to above ground inches
(b) No X
( 4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite X Other (specify) __
(b) Grout placement: Pumping_X Pressure__ Other
( c) Grout depth of tubing (reference to land surface): from 35 D to Q_
If well bas casing, indicate grout depth: from ___ 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 operatiorn. The manufacturer's bmchure 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-
(?) 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 individw'ls
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 aFpr specifications and conditions of the Permit."
Signature of Property Owner/Applicant
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 -UDC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Aquifer %Act*
RECEIVED / 1eNii 1 oweJ
Fa 2111,
GPU1[ICC 5QW Notification of Intent Form (Revised 8/2048)
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