WI0500364_GEO THERMAL_20110328

Permit Number
Program Category
Ground Water
Permit Type
WI0500364
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Cerine Hill SFR
Location Address
108 W Lively Ct
Cary
Owner
Owner Name
Cerine
Dates/Events
NC
Orig Issue
03/28/11
App Received
03/11/11
Regulated Activities
Heat Pump Injection
Outfall f\;J• :
27511
Hill
Draft Initiated
Scheduled
. Issuance
Central Files: APS_ SWP_
03/28/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Joshua Niles Robertson
8228 Kerr Chapel Rd
Elon·
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Cerine Hill
108 W Lively Ct
Cary
NC
NC
Public Notice Issue
03/28/11
Effective
03/28/11
27244
27511
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
AriA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
3'28.201 1
Cerine Hill
1U W. Lively Court
ury, NC 2751
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No, WI0500364
1 []:i W. Lively Court. Can. NC 27511
Dear
On 3'1112011, 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:
The injection well system contains only potable water,
3. 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 cnnstitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally. you should contact the Wake 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.Rwiers( ncdenr.uov if you have any questions.
Sincerely,
C
for Deb Watt
Supervisor
ac: Ralci<_•it Regional Office - APS
APS Central Files - Permit No. W IO5O0 364
tivake County Health Dept.
"iriai DriIIoff: (Jotinua krrbcrtgon
Crabbe 7erviCC Company t Ray Evans]
+.OJIFwP °R3TECTION SECTION
1636 MEi'. b?rvi Cerw. Raleigr,, North Caro'-na 2769;.13
Locanry d '2u Cusiial 6oi ipvarti, Ralaigh- North Catuima 276
Pr,cne. 1: iT'-7i!-C 58 FAX [phone] as!omerService 1-377-62.3-6748
+ntarr�er vomy.ncwaierfluaSitv.orr
Noi mCarolina
'7ati ra if

03/11/2011 08:41 3354215085
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Triad Drillers
8228 Kerrs Chapel Road
Elon, NC 27244
Phone: [phone]
Fax: [phone]o85
MEWED 1 DENR 1 IWQ
1035FR.PROTFr.TInN SECTION
MAR 11 'ail
To: Sec.- Date: 3\ tt\
From: 30s\e-\ Phone: _
Pages: 4 - cam— Fax: °\1. k -1 3 - 9 413
Comments:

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�xav EIRILLEFiS PAGE 93/e1
NORTHCAROrI
DEPAF,THEN't OF mintawnwrA1+TD)JATURf . RESOURCES
NOT)FIC.A TON OF INTENT TO CONSTRUCT A -LOOP
WATER -OM INJECTION WELL Mani
TYP . SOW WELL(S)
r Awe WW1 the Fraviskcos of NCa c Title 15A o2GV2OO
Prdr7 arare, 5herelairad dash mid mail to address oti the bast,
DATE: / 12fd .9i 20_,LL
mat Type Coraf rrtsaciws: Dow ttte proposed system cumulate ale cak (no additives) in
awns piping that completely isolates tlae Exalt the environment (i.e.
muse loop)?
Tea Conti= co nplating thin Rum.
No Dol'Ot notnpTete this fna7at. Complete other VIC app iratou farms for installing
either a 5A7 well { -l4ap well infecting potableemirs' into the aquifer) ar a' 5QM wen (ctoaed-
loop well coz o: aing additives such as R 22, ethanol, ar der ssmteeze or corrosion inhibitors).
A. PROPERTY PERTY owiro {Syiarrucafr(S)
List each Pray arty Owner &at on yiroyertv deed CFI' owned by a heti= or loveroment agetcy, state mune of
entity and a representative wfa4thcritty for signxsare): re r r fl P 1
() Melling Addrurti 403 a). tly-
0_
City: ; Cary �y p Scud: p Code: 7'/ 1 / CountY� .
Home/OTEcc Tele Na ` d L
(2)
Erroll Adoinss:
pbzisicw tickets a£Wmj Site (if afferent t'ent than )i r e
city: State:Zip Code: Cc m1y;
liornetotEce Tele No: Cad
IL AUTHORIZED AZT OF OWNER. JE Ivor ±i±tbe Eezazt Applicant floes not own the nobjeer pm: ,
attach a leder keen the property owner auk Agent to ill and operate WC veil)
Company Name:
CantsctPeraan:
AddF
Car She: ,Zip Cady
Office Teta Ala-
Wensire Adirass.7fCornp my. ifXV!
I AIL Address:
GPWUIC iQW tifire is 1 Istat arms)
isJ

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Zaoz/o03
83%92/2011 22:32 n54215385
TRIAD 1)I0XLL Ra . PAt: 7}2/83
G. WELL MILER L' iFoRM TION
Company Name* r
Well Met Co ctar's3I4uas= lh5I1u P - a- erism
NC Coorractot Corlifrosdort No.; Z / 4
Gamest Per.
Asa $ tr s
counw: 625t4 /I
CRY F414 p Cede:
Office TaleNo.: No.:, 6 -+ 2f -I Coll No.: Raa. - + '
D. BEAT PUMP CONTRACTOR 1:0011 JAT!ON (if difr t tbsti driller)
cornpapy Now'
Co taetPetsori•
A4dI S 34 tr . AA -
Zip Code; aZF4F- Cy;
office Tole No.: , 4i 5 Cell No,:, k "ZrZ
E. STATUS OP A,FIUC T
Prveta: &di a]: C erdal_
State: tmiaiSal Nve American Inds:
Address. retyeakitheseruke.EAK
F INJECTION PROCEDURE (bald y desPribc bow the iron weI(s) will be u)
r;
GF. WELL CONSTRIX:nQNDATA
(1) Propose d date to be constrtles& 1—Af / II Number of borings: Z
APProlime 4e7ih god bdrimg (fist): IMO r f j
of t� to be (Poppet, PVC, ): . „ _ hap ., �� R-�r /q
(3) We1 - Isfie w (s) hosed? (obeckezif r asi[ ) Yee (a.) No below),
(s) Yes Vyes, then pznvxdde =lag mark below
Type: _galvanized stoat _b3aak steel_, ,plaistiv _rkuer (spa*)
Cg d p ! Rota to ibet(rdemego W land Suft d)
Casing etteUdsto ohm gutted _Inaba •
(4) Chat Itlfo (rookelot sorro coding %TXI easing. aori/er pip g„);
(a) Grout type: Neat Cent Bentonite O E 3)
CO Grout pew es:neat Presstue der k•
(c) aim depth of t:bit t; re= to bad surface): from 0 .to` () (feet)
If well bas Basin& indicate gout depth: from to VIM)-
GpEWIC 5QW toedseeiar'tc�firrt yeast (Rrriaed mop . C�\`E � ai1- rlZ ,�t b
an 3 /'3ob ca F ir+�+ .

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TRIAD tiRT.L..ER.s ppOE 03t03
EL INJECTION -RELATED LATED EQUJ t NT
Attach a diagram sheaving the meowing layout or proposed rUodific anon ante injection tgt>ipanent and e t or
piping/tubing associated. with the injecxiot opetrlion. The meuufsetercr's brochure may provide suppletrtenyy
Laformatatam
I. LOCATION OFF M
Attach two twits of maps Sri g the following inforriatinzu
i€occude a Site map (con be dream) sheavinz Waage., property liras. surface Water bodes. prgeattial
sources of g uumdwarer cenhuninistice. and the urieutrvn of and,distalrea bctwcen the proposed well(s) and •
say exist g wells® or waste dispersal facilities such as septic tanks or draiatelds located vei tWu 200 teat of
the geothermal, keel pimp well system. Lab trail reeves clearly and include a asal etigtiw, - -
The Site Map mug show the subject property In rely to the semoundiag area by•usiug at least two davd
reale= points such as roads, screams, zindiar highway tatinseetions.
(I)
()
CERTIFIF;A11424
Nett This Permit Appllnation mast he signed by pelt person appearing ea ate
receftled legal preisarty deed.
yl hereby Csisify, AttslAt peaaiity of lava, that I have persceailiy =reinedow, 1 mIHar with teninform ion
sz+bmitted in this dice l and all tt aotan�')stud and that, based
out my inquiry of hose inctividuaLs
iaAedisteiy'responsible for obta ier g said irdermatlan, I Wien that the inforownina as time, =mak and oomph .
am aware t3tat'tkhete are iuoludu g the possibility of funs and iceprisaninentt *Ir anhiathig
tie to fOomatinn. I agre, to Joanna, apace, eaionisn, repair, mad if applicable, abandon the injectim well and
sil I E4 appurtenances in eccardsnee •with she approved specifications ate conditions of the Pamit0
S gnattu$ Pxoperty O► nerappliran+t
LL,,•
1l
Pest or Type I?1d1Nmue mod tide
Signalise af'Propettty Owttm/IApp1icarnt
irjtpe Nuns awlt1
Slgaaizre of Authorized Agent, wavy
Pict or Type Pull Name a d title
Please renwri two copies of the completed Applicstioupachage top.
T+itrrttl t tpt pl la DENR DWQ
Aquifer lP 'at ectiva Section -MC Ptegrem
1636 Mail Sea -vies Cater
Raleigb, NC 27699-1636
Ttlepl6to to (9i,9) 733,3221
CRAM sgw uti&c&ticm ontM coma Ern a 8/2005)

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