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Home My WebLink AboutWI0500380_GEO THERMAL_20110509Permit Number Program Category Ground Water Permit Type WI0500380 / Injection Water Only GSHP Well System (5QW) Primary Reviewer michael.rogers Coastal SW Rule Permitted Flow Facilit Facility Name AIA NC Chapter Location Address 14 E Peace St Raleigh Owner Owner Name NC 27601 American Institute of Architects NC Chapter Dates!Events Orig Issue 05/09/11 App Received Draft Initiated 05/03/11 Re !:!ulated Activities Heat Pump Injection Outfall NULL Scheduled Issuance Central Files: APS_ SWP_ 05/09/11 Permit Tracking Slip Status Active Project Type New Project Version 1.00 Permit Classification Individual Permit Contact Affiliation Janice Scott 8275 Tournament Dr Memphis Major/Minor Minor Region Raleigh Co unty Wake Facility Contact Affiliation Owner Type Non-Government Owner Affiliation David A. Crawford 115 W Morgan St Raleigh TN NC Public Notice Issue 05/09/11 Effective 05/09/11 381250851 27601 Expiration Waterbody Name Stream Index Number Current Class Subbasin AtrigrA NCDENR North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Coleen H. Sullins Dee Freeman Governor Director Secretary 5/912011 American Institute of Architects, NC Chapter Attn: David A. Crawford 116 W . Moran Street Raleigh. NC 27601 Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System Permit No, WI0500380 14 East Peace Street. Raleigh, NC 27601 Dear Mr. Crawford: On 5/3/2011, 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: 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 .02I3, 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 1SA 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 (919) 715-61 66 or Michael.Rouers'rtncdenr.2ov if you have any questions. Sincerely, ��[[jj OueL�yk3,00i,Le (or Debra Watts Supervisor ec. Raleigh Regional Office - APS APS Central Files - Permit No. W10500380 Wake County Health Dept. MidSouth Geothermal, LLC (Janice Scott) AQUIFER PROTECTION SECTION 1636 Mali Servica Center, Raietgh, North Cantina 2769 -1636 Locatoor- 27 2t, Capital 3ouwvard, Ralaiati. North Carolina 2?5N Phone! 919-733-3221 +.FAX.1 919-715-0588; FAX 2! 919-715-6048'$Customer ServIce:1.877-6623-6746 Internet: Www.newaterounlitv.o- An Erma' DpaarinPr1Afrrmarva Ar..;:ar Employer One North Caroiina ;Val/trey RECEIVED F DEMR 1 OWD Meet Protoction Sertion W4 03 2011 NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM TYPE 5QW WELL(S) In Accordance With the Provisions ofNCAC Title 15A 02C.0200 Print or type the required information and mail to address on the back page. DATE: 2125 , 2011 '\N O 3C 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 _X Continue completing this form. No Do Not complete this form. Complete other UIC application forms for installing either a 5A7 well (open -loop well infecting 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): (1) Mailing Address: City: State: ! Zip Code: _ County:___ Home/Office "1 ele No.: Cell No.: Email Address: Website: (2) Physical Address of Well Site (if different than above): 14 East Peace Street City: Raleiill State: NC Zip Code: 27601 County: Wake Home/Office Tele No.: nla Cell No.: n/a 16. 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.: Cell No.: Website Address of Company, if any: GPUIEIIC 5QW Naliflcation of Intent Form (Revised 8/2008) Page 1 C. WELL DRILLER INFORMATION Company Name: MidSouth Geothermal, LLC Well Driller Contractor's Name: Stanley Setzer NC Contractor Certification No.: NC 2185A Contact Person: Janice Scott EMAIL Address: jscottamidsouthgeothermal.coax Address: 8275 Tournament Dr. Suite 185 City: Memphis Zip Code: 3125 County: Shelby Office Tele No.: 901-748-9095 Fax No.: 901-748-9097 D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller) Company Name: MidSouth Geot)termal. LLC Contact Person: Janice Scott, Off. Mer EMAIL Address:jscotfd midsouthgeohennal.com Address: 8275 Tournament Drive, Ste 185 City: Memphis Zip Code: 38125 County: _ Shelby Office Tele No.: 901-748-9095 Fax No.: 901-748-9097 STATUS OF APPLICANT Private: Federal: Commercial: X State: Municipal: Native American Lands: F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used) Closed -Loop Feothemmal water source heat_pump G. WELL CONSTRUCTION DATA (1) Proposed date to be constructed: _after _March 15th Number of borings: 20 Approximate depth of each boring (feet): 300 ft (2) Type of tubing to be used (copper, PVC, etc): I-IDPE plastic pipe (3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below) (a) Yes xx if yes, then provide casing information below Type: x galvanized steel black steel plastic other (specify) Casing depth: From _0 to 300 feet (reference to land surface) Casingextends to above t'"��r ground inches � + �� 111 (b) No (4) Grout Info (material surrounding well casing and/or piping): co (a) Grout type: Neat Cement Bentonite X other (specify) (b) Grout placement: Pumping cp Pressure Other (c) Grout depth of tubing (reference to land surface): from to (feet) If well has casing, indicate grout depth: from 0 __ to 300 (feet) GPUIUiC 5QW Notification of Intent Form (Revised 8/2008) Pge 2 H. INJECTION-RELATED EQUIPMENT REC61V~D / DE:NR I DWQ Aquifer Protection Section ';f O 3 2011 Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior piping/tubi,ng associated with the injection operation. The manufacturer's brochure may provide supplementary information. I. LOCATIONOFWELL(S) Attach two copies of maps showing the following infonnation: (I) Include a Site Map (can be drawn) showing: buildi,ngs, 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 ~ 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 th.ereto 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, 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 spe cifications and conditions of the Permit." ,,,--.,/-/ / Signature of Property Owner/Applicant >{'" ~ r-,xr-c V1,.e_ 'l>rr~ Print or Type Full Name and title Signature <>f 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 (919) 733-3221 GPU/UIC 5QW Notification of Intent Fonn (Revised 8/2008) Page3 iw '.{.Hi j�ylTli`..GiF 7ik "4-:....;H�;Fiili 00 .41 RECEIVED) aErtii Aquifer Prot Section MA'Y 0 3 an NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM TYPE 50W WELLS) In Accordance With the Provisions of NCAC Title 15A 02C.0200 Print or type the required information and mail to address on the back page. DATE: 2/25 s 2011 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 X_ Continue completing this form. No Do Not complete this forth. Complete other UIC application forms for installing either a 5A7 well (open -loop well inieeting 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)/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/authority for signature): (1) Mailing Address: City: State: Zip Code: County: Home/Office Tele No.: Email Address: Cell No.: Website: (2) Physical Address of Well Site (if different than above): 14. East Peace Street City: Raleigh State: NC hip Code: 27601 County: Wake Home/Office Tele No.: n/a Cell No.: nla 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.: Cell No.: Website Address of Company, if any: GPUMC SQW Notification et -Intent Form (Revised 8/2008) Page t C. WELL DRILLER INFORMATION Company Name: MidSouth Geothermal. LLC Well Driller Contractor's Name: Stanley Seger NC Contactor Certification No.: NC-2 1 85A Contact Person: Janice Scott EMAII., Address: 'sec a'imids° ea al cam Address: 8275 Tournament Dr. Suite 185 City: Memphis Zip Code: 38125 County: Shelby Office Tele No.: 901-748-9095 Fax No.: 901-748-9097 D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller) Company Name: MidSoutb Geothermal, LLC Contact Person: Janice Scott. Off. Mgr EMAIL Address:jscottfu)midsauthecothermal.com Address: 8275 Tournament Drive Ste 185 City: Memphis Zip Code: 38125 County: Shelby Office Tele No.: 901-748-9095 Fax No.: 901-748-9097 E. STATUS OF APPLICANT Private: Federal: Commercial; x State; Municipal: Native American Lands: F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used) Closed -Loop geothermal water source heat pump G. WELL CONSTRUCTION DATA (1) Proposed date to be constructed: after March 15th Number of borings: 20 Approximate depth of each boring (feet): 300 ft (2) Type of tubing to be used (copper. PVC, etc): HDPE plastic pipe (3) Well casing_ Is the well(s) cased? (check either (a.) Yes or (b.) No below) (a) Yes xx if yes, then provide casing information below Type: x___gaivanized steel black steel_ plastic other (specify) Casing depth: From O to 300 feet (reference to land surface) Casing extends to above ground inches (b) No (4) Grout Info (material surrounding well casing and/or piping): (a) Grout type: Neat Cement Hentonite other (specify) (b) Grout placement: Pumping_ Pressure Other (c) Grout depth of tubing (reference to land surface): from _ to (feet) If well has casing, indicate grout depth: from 0 to 300 (feet) GPUIUIC SQW Notification oflntent Form (Revised 8/200$) Page 2 RECEIVED I OF M 1- V Aquifer Prot ctian section HAY 0 3 MI 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. L 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. I,abel 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. 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 approved 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-UIC Program 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 733-3221 GPU/LJIC 5QW Notification of Intent Fonn (Revised 8r2008) Pap 3 yF a 1^ I • • Fi\ HVAC SITE PLAN