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Home My WebLink AboutWI0500383_GEO THERMAL_20110610Permit Number Program Category Ground Water Permit Type WI0500383 / Injection Water Only GSHP Well System (5QW) Primary Reviewer michael. rogers Coastal SW Rule Permitted Flow Facilit Facility Name Scott Chilcote SFR Location Address 106 Greyhorse Dr Cary Owner Owner Name Scott Dates!Events NC 27513 Chilcote Scheduled Orig Issue 05/10/11 App Received Draft Initiated Issuance 05/02/11 Re C1 ulated Activities Heat Pump Injection Private residence, single family Outfall NULL Central Files: APS_ SWP_ 05/10/11 Permit Tracking Slip Status Active Project Type New Project Version 1.00 Permit Classification Individual Permit Contact Affiliation Scott Chilcote Owner 106 Greyhorse Dr Cary Major/Minor Minor Region Raleigh County Wake Facility Contact Affiliation Owner Type Individual Owner Affiliation Scott Chilcote Owner 106 Greyhorse Dr Cary NC NC Public Notice Issue 05/10/11 Effective 05/10/11 27513 27513 Expiration Waterbody Name Stream Index Number Current Class Subbasin ATA NCDENIZ North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Coleen H. Sullins Dee Freeman Governor Director Secretary 05/10/2011 Scott Chilcote Ester Lumsdon 106 Greyhorse Dr. Cary, NC 27513 Subject Acknowledgement of Intent to Construct Type 5QW Injection Well System Permit No. WI0500383 106 Greyhorse Dr. Cary, NC 27513 Dear Mr. Chilcote: On 05/02/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-Ioop water-onlh 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 .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) 715-6166 or Michael.Roizersia,ncdenr.uov if you have any questions. cerely, or DebYa Watts Supervi cc: Raleigh Regional Office - APS APS Central Files - Permit No. W10500383' Wake County Health Dept. Torn Paonessa (Warren -Hay Mechanical Contractors, Inc., 214 Millstone Dr., Hillsborough, NC 27278) John Boyette (Boyette Well & Septic, Inc., 1109 W. Nash St., Wilson. NC 27893) AQUIFER PROTECTICC SECTION 1636 Mai! Service Center, Raleigh, North Carolina 27699-1636 Location:; 2728 Capiral Boulevard. Raleigh, North Carolina 2760A Pnone: 919-733-3221 t FAX i. 919-715-05136: FA" 2' 919795-60481 Customer Service: i-£77-623-674£ Internet www,ncwaterauaflrOra k i cogs' ttomoorw., ti Af it iai:ve r cuo =maoa: One NorthCarolina atiffaI4y 05/02/2011 09:47 9197328550 WARREN HAYi. -trM~ PAGE 01/05 . tJV-LV __ ~ ~ ~ - NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOUR~ES NOTIFlCATION OF lNTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL WATER-O NLY INJECT.ON WELL SYSTEM TYPE 50 W 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. lJATE: __ _____:_4•=29,c__ __ ___, 2011 A. Well Type Conjirmatio11.: Does the proposed system circulate potable water only <no additives~ in continuous piping that completely isolates the ~uid from the environment (i.e. clo~ed-loop)? @ontinue oompleting this form . No· Do Not complete this fonn. Complete other UIC application.forms for installing either a 5A7 w~ll ~-loop well.injecting potable water·into the aquifer) or a 5QM well (closed- loop well containing additives such a::; R-22, ethanol, or other antifreeze or corrosion inhibitors). PROPERTY OWNER(S)/Al'PLICANT(S) · · · ~ List each Property Owner listed on property deed (if owned by a business or government age ~ate name of entity and a representative w/authority for signature): ( co 1'! wJ Ii C.;> rt (1) . -d-l,S\3 MailingA~ess: /t)(p ~£<-tJtkoe Je, 0 ~ 7 ~ City: (_;!9,,2,,'( .:State: NC zip Code:.d-2./-16 : :county: It;/.&-/~ Home/Office Tele No.: · 9/9~ 3f (} "~S-[j;Eeii No.'. 9'ff,.~.ft-5'rL_'f l:: Email Address: f't:s tfCU/1 ea B,, Webs ite'. ; ti/ V,,{;l/lP'tJ • C(lWt. : : (2) Physical Address of.Well Site (if.diffei:ent than above): _______ _ City: ________ :. State: __ Zip Code: ______ County: ____ _ Home/Office Tele No.: -----------""'Ce~l=l.N=o.,_,_.: __ -'-------- :B. AUTHORIZED AGENT OF OWNER,.-IF ANY .(if the Permit Applicant does nQt ~\\'n the subject property, attach a letter from the property owner authorizing Agent to in.stall and operate Ult ~ell) . . . ' Company Name; ____________________________ _ Contact Person.~: ~---------------E=MA-'=-==IL....,A=dd=r-=es=s~: _________ _ Address: ------------------------------- City: _________ State: __ Zip Code: ______ County: __ _ Office Tele No.: Ce li No .'. ____ ----->,=.,..-"-'-"=._ _________ _ GPU/UlC 5Q~ Notification of Intent Form (Revised 8/:Z008) Website Address of Company, if any: _____________ ___,,,___,. IVELJ / DE 1 er Prot ~-NR I n,M -e,,11,Jn s J:fAY O 2 ZO/ Page 1 0 100 200 400 Feet Field Valise PIN 0754234355 Real Estate ID 0i74663 Map Name 075413 Owner LUMSOON. ESTHER M CHILCOTE, SCOTT N Mailing Address 1 105 GREY HORSE DR Mailing Address 2 CARY NC 27513-3447 Mailing Address 3 Deed Book 13805 Deed Page 0125 Deed Date 12/23/2009 Deeded Acreage 0.28 Assessed Building Value 5303,114.00 Assessed Land Value $110,000.00 Total Assessed Value $413,114.00 Billing Class INDIVIDUAL Property Description L028 PRESTON HIGHLAND PH1 SC3 BM 1988-01197 Heated Area 2937 Site Address 106 GREY HORSE DR City Cary Township CARY Year Built 1992 Total Sale Price $330,000,00 Sale Date 1212312009 12:00:00 AM Type and Use Single Family Design Style Conventional Land Class RESIDENCE-c 10 ACRES -HOME SITE Old Parcel Number 516-00000-0166 Mir WAKE L 11I f NI •' 05/02/2011 09:47 9197328660 WARREN HAY PAGE 02/05 C. 'WELL DRILLER LNIFORIKATION f Company Name: /6Q r `e _f tfl- tV Well Driller Contractor's Name: C7 d NC Contractor Certillca#irnt No.. Contact Person: (;.4" EMAIL Address: Address: /lo 9 !,V. &KW c7' City: P%lfiti,, Zip Code: 02_203_ County: It c! Moe Tele No.: awr}l 2.'257 - kirrCell No.: j-'2. ) 3 7 --)29p D. HEAT PUMP CONTRACTOR INFORMATION (if d erent than driller) Company, Name: ►a!Z .07 ,t 2 �e Contact Person; ore Fri / fed 6 # EMAIL Address: 0/7f .111'+C�'d> 'Address: �/q or lsi e ,aft • Imo► i —Rae? - r City: Alai? 11.4011,e Zip Code: t2.72 7t9 County: iaeit e Office Tele No.: I " 7.& ` V$G 2- Cell No.: ` /9 - Fff r 02/ E. STATUS OF A CANT Private: Federal: State: Municipal: Commercial: Native. American Lands: F. INJECTION PROCEDURE (briefly describe how the injection well(t) will be used) "- LTIA 14.!0-477;4'C— efrcred arve --- > ..c ".4037.Sc--- 02-4 G. WELL CONSTRUCTION DATA �r f (1) Proposed date to be constructed: ti 3 J/ Numberof borings: A. Approximate depth of each haring' Beet)! Sod' _ (2) Type of tubing to be used (copper, PVC, etc): S — /1 i4 34'c'f ec ',4 (3) Well casing. Is the well(s) cased?(check either (a) Yes or (b.) No below) 'r'GJ y e' (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 sturfaace) Casing extends to ve groetnd inches (b) No (4) Grout Info (material surrounding well casing and/or piping): (a) Grout'type: Neat Cement ntonite V Other (specify) (b) Grout placement: Pumping Pressure Other (c) Grout depth of tubing (reference to land surface); from 75— ` to 30Q (feet) If well has casing, indicate grout depth: from to = (feet) GPIJAIIC S QW Notification of intent Form (R7vised 812008) Page 2 '05/02/2011 09:47 9197328660 WARREN HAY PAGE 03/05 H. iIN,IECTION-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: (I) C2) Include a Site Map (cm 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 ail features clearly and include a north airow. 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. d. 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 air►: 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, l 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 approd specifications and conditions of the Permit." Signature of property Cywner/Applicant 310ti t f C - 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 t' : North Carolina Q Aquifer Protection Section-UIC Program 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 733-3221 Q'UItflC 5QW Notification of -Intent Form (Revised 8/2008) Page 3 05/04/2011 15:18 9197328660 WARREN HAY PAGE 01/03 214 M0.iatone Drive rimeraugr NC 27278 Ph;f915S)732-4 2 rex-9'f9) 732-8.850 Warren -Hay Mechanical Contractors Inc. Fax /04: Tor 4/1From:Px: Rig fi i 6 o S Pages, 3 Phone: Rate: SJ �I d, 1 I �e�• cc: J 0 Urve t lt'• For Rview. 0 Pimaa Comment fJ' P ease ROtgy 0 Please Retycia / /01/164e. ii(e cri,;,-ma- . ALF,060 - 017/ei /OP, eldieri - �1,ey i%�ccH �� 05/04/2a11 15:18 9197328660 WARREN HAY N PAGE 03/03 H. INJECTION -RELATED EQU1TMENT 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 heal pump well system. Labe) all features clearly and include a north 3rraw. (2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed reference points suck[ as roads, streams, and/or highway intersections, J. CERTIFICATION Note: This Permit Application must be signedby 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 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 ircprisoumen , 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 appro d specifications and conditions of the Permit." Signature of property }t tii. v.,ner/Applicant Print or Type Pull Name and title 44/111411.4-- Signature of Property xcer/Applicant �s i, sit a-ii Print or Type l ul i Name and title Signature of Authorized Agent, if any Print or Type Full Nalne and title Please return two copies of -the completed Application package to: North Carolina DENR-DWQ Aquifer Protectiou Section-U1C Program 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 733-3221 GPLJGIC SQW Notification of Iniznt Form (Revised 8t2008) Page 3 05/02/2011 09:47 9197328650 WARREN HAY PAGE 04/05 @5102/2011 09:47 9197328660 WARREN HAY PAGE 05/05 • r �t.1a1 I.:" l •lrf sr SEAL - ecr Tr a :lot .44 Off drr.‘Y ,i ''rd F•��r• J y z go r 4 "der. . ; =tt" M WYw J.1 y,yr ":1 p1'7��r #AYiifo ;o•'` I, Vekrrd4sWlilrne ,,ohnaon1 hereby certify that this map is correct and that the buildings lie wholly An the let and that- here are ❑o encroachments 4f other buildings an the avid lot. ]� Resi(tet'�ed SurvoyF CAW,..r± G-149 6 This map is not for recording. SURVEY FOR IGO /-1-.' fir'• .1i#1 7 A'ee / 16A-- z7ally VERNON WAYNE JOHNSON •e o ksdwry Wive ENGINEERING Rani .N.G. 27603iSU VEYLNC a•q, 772 d6+a : F7Arzeo7 r Rogers , Michael From: Sent: To: Cc: Subject: Tom- Rogers, Michael Tuesday, May 03, 2011 2:59 PM 'Tom. Paonessa@warren-hay.com' Godwin, Tonya Chilcote and Randall 5QW geothermal wells We received the Notification Of Intent for the above persons. However, the forms are incomplete. The notifications need to be signed by each person appearing on the property deed. For Chilcote, Esther Lumsden also needs to sign. For Randall, Libby Thomas also needs to sign. Please e-mail or fax (919-715-6048) the revised signature pages with the referenced names. Thanks Michael Rogers, P.G. (NC & FL) Environmental Specialist NC Div of Water Quality-Aquifer Protection Section (APS) 1636 Mail Service Center Raleigh, NC 27699-1636 Direct Line (919) 715-6166; Fax 715-6048 (put to my attn on cover letter) http://portal.ncdenr.org/web/wq/aps/gwpro/permit-applications#geothermApps E-mail correspondence to and from this address may be subject to the Norlh Carolina Public Records Law and may be disclosed to third patties 1 Date: Permit No.: Reviewer: Req uestor: REQUEST FOR COMPLETE INFORMATION FROM REVIEWER ekk) SOW �p \Y\crj Jc Owner Name \c5 COnv oLA-16-- Owner Mailing Address Owner Facility Address Missing map/survey Fees outstanding Fee required Regulated activity Permit type Other: