WI0500404_GEO THERMAL_20110722

Permit Number
Program Category
Ground Water
Permit Type
WI0500404 /
Injection Water Only GSHP Well System (SQW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Jonathan & llsy Chappell SFR
Location Address
17 42 Nottingham Rd
Raleigh NC
Owner
Owner Name
Jonathan
Dates/Events
27607
Chappell
Orig Issue
07/22/11
App Received Draft Initiated
07/21/11
Re g ulated Activities
Heat Pump Injection
Outfall N~L'.
Scheduled
Issuance
Central Files: APS_ SWP_
07/22/11
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
Jonathan Chappell
701 W Ln Steet -Apt 102
Raleigh
NC
NC
Public Notice Issue
07/22/11
Effective
07/22/11
27587
27603
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
tivrA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
7/2212011
Jonathan Chappell
llsy Chappell
701 West Lane Street — Apt 102
Raleigh., NC 27603
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10500404
1742 Nottingham Road. Raleigh, NC 27607
Dear Mr. & Mrs. Chappell:
On 7/21/2011. the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-onl.
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(0(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.Ro,.:ersraincdenr.env if you have any questions.
Sincerely,
600luL
/in• Debra Watts
Supervisor
cc: .Raleigh Regional Office - APS
APS Central Files - Permit No. WT05013404
Wake County Health Dept.
Glen A. Dare!) Well Driiiing (Glen Darch)
Bowman Mechanical Services, Inc. (Sieve Bowman)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, RaieioI. North Carolina 27695.1636
Location:2726 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] I FAX 1; 919-715.O586; FAX 2; 919.-715-6046 l Customer Service: 1.877-623-5748
Internet: www.nrwatercuality.oro
Ar Espial p, mrtrnily Aitirria8ua Ac&ie Erinlpyr.-
Gn:
NolTh Carolina

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
JUL 2 i 2011
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELLS)
In Accordance with the provisions ofNCAC Title 15A: 0200200, please
complete this notification and mail to address on the back page (please Print or Type information).
DATE: : - . I
20 f 1 i co L--1-0 O
Well Type confirmation: Does the proposed system circulate potable water onk (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 OW'NER(S)/AFPLICAY l'f�y
List cash Property Owner listed on property deed (if owned by a business or governmentl agency, state name of
entity and a representative w/authority for signature): tlj Q' ! AS', e� Fl t, p,�l
(I)
(2)
Mailing Address:
7e i t / L.. IL
AP+ ram
City: _ _ � _ State_ /P(Zin Code. Z Z P . County: L' r.
Home/Office Tele No.: Cell No.: . l `7 u. fi 7- 4. 7
Email Address:I Isc�;
F�-6i��/ �• . ruf(4site:
Physical Address of Well Site (if dilfereiit than above): / 12 A/c' I A�' he, d
City: R State: PC Zip Code: ,Z 74;0 ; County: WA ke.-
(2) Physical Address of Well Site (if diFferennt than above):
City: (2.r..:( f
l-Tome/Office Teie No.:
/12 Ala/II.,; jr'ti, 2d
State: ijC Zip Code: _ x 760 County:
Cell No.:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a fetter from the property owner authorizing Agent to install and operate U?C well)
Company Name:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
State: Zip Code:
County:
Cell No.:

C. WELL DRILLER INFORMATION 3 goo -4
�j
Company Name: _ fiat-, • �e // 0 //- C C—
Well Driller Contractor's Name: G-- �"�,� ,r4 L2Or c . 4 eve/I 'fir; //i C
NC Contractor Certification No.: 3,00 -
Contact Person: 6 ram^ /9 Pr G EMAIL Address: We o ' I - ®° Qo/ Cry „
Address: 1j ' 9 soa ' u 4 h� II ,Q I
City: lkfar� �'r&S r Zip Code: Z 7- 7 County: i /a
Office Tele No.: { 9 3-1(-6 t -_ 7 ` , Cell No.: 7/5) 41 Z-7 ` 9 93 /
-- 3,613 9
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: r 4
Contact Person: ' /moire 1304.p.,46,, EMAIL Address: teLv,-p 4.1 r'i 'pry/! i'S)v. v.
Address: / !' 5- :re c �+ C CI / Ca yr 1�
City: G-OrZip Code: 77 C z ai County: (yak
Office TeleNo.: (19) 77Z-Z75) CellNo.: 09) 779 -92 YY
E. STATUS OF APPLICANT
Private:
State:
Federal: Commercial:
Municipal: Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
/ �. C (� c.
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: - / 3/ ' / Number of borings: 3
Approximate depth of each boring (feet):
7-5
(2) Type of tubing to be used (copper, PVC, etc): 1flt5
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(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 surface)
Casing extends to above ground inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite 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 to (feet)
or'
9Tti
tr
GPUIUIC 5QW Notification of intent Form (Revised 8/2008) Page 2

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.
I. LOCATION OF WELL(S)
Attach Iwo copies of maps showing the tollowing information:
(I) Include a Site Map (can he 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.
(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.
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 am familiar with the information
submitted in this doduinent 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 imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection welt and
all related appurtenances in accordance with the approved specificat s and conditions of the Permit."
Signature of Property OwneN.Applicant
1,1
Print or Type rip Name and title
s
Signature of Property f rierJA ppl i c)t
115
Print or Type Fuli Name and title+
...a.iuCLU L. VI I iupcity .JwlICT7htpp11C�l r 1l
i5
Print or Type Fuif,i 'ame and tit
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
Tolnrdsnsso (fl % "11c en►r
JUL 21 2011

m
a
4
0 25 50 100 Feet
FMud
Yoke
PIN
0795715687
Real Estate ID
0378581
Map Name
079520
Owner
CHAPPELL,
JONATHAN & ILSY
M
Mailing Address 1
701 W LANE STAPT
102
Mailing Address 2
RALEIGH NC
27603-1497
Mailing Address 3
Deed Book
13952
Deed Page
0999
Deed Date
05/03/2010
Deeded Acreage
0.34
Assessed Building
$0.00
Value
Assessed Land Value
$353,600.00
Total Assessed Value
$353,600.00
Billing Class
INDIVIDUAL
Property Description
L0302 BUDLEIGH
BARBER SECTION
BM2009-00621
Heated Area
Site Address
1742 NOTTINGHAM
RD
City
Raleigh
Township
RALEIGH
Year Built
0
Total Sale Price
$0.00
Sale Dale
Type and Use
Design Style
Land Glass
VACANT
Old Parcel Number
463—
F
WAKE
COUNTY
NORTH CAROL II.A

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Y.lrr ifltj L F J
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04‘
s,
�' •"PIN*
411
446
r ,.44
Ieli
ibmgir.Ar
4na
QI~h ii ;flirt
•
ri
G_earflian}�rer
7:
0 200 400 800 Feet
Mgt
Asko
PEN
0795715697
Real Estate ID
0378881
Map Name
079520
Owner
CHAPPELL,
JONATHAN & ILSY
M
Mailing Address 1
701 W LANE STAPT
102
Mailing Address 2
RALEIGH NC
27603-1497
Marring Address 3
Deed Book
13862
Deed Page
0999
Deed Date
06103/2010
Deeded Acreage
0.34
Assessed Building
$0.00
Value
Assessed Land Value
$353,600.00
Total Assessed Value
$353,600.00
Billing Class
INDIVIDUAL
Property Description
L0302 BUDLEIGH
BARBER SECTION
BM2009-00621
Heated Area
Site Address
1742 NOTTINGHAM
RD
City
Raleigh
Township
RALEIGH
Year Built
0
Total Sale Price
$0.00
Sale Date
Type and Use
Design Style
Land Class
VACANT
Old Parcel Number
463—
r
WAKE
COUNTY
NORTH CAROL -I NA