WI0500407_GEO THERMAL_20110805

Permit Number
Program Category
Ground Water
Permit Type _
WI0500407 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Jeffrey & Diane Pettus SFR
Location Address
2390 Chicken Bridge Rd
Pittsboro NC
Owner
Owner Name
Jeffrey H
Dates/Events
27312
Pettus
Scheduled
Orig Issue App Received Draft Initiated Issuance
08/05/11 07/25/11
Ret1ulated Activities
Heat Pump Injection
Outfall ,,':Ji._L
Central Files : APS_ SWP_
08/05/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Billy Clayton
4137 Moores Mill Rd
Spencer VA
Major/Minor
Minor
Region
Raleigh
County
Chatham
Facility Contact Afflllatlon
Owner Type
Individual
Owner Affiliation
Jeffrey H. Pettus
2390 Chicken Bridge Rd
Pittsboro NC
Public Notice Issue
08/05/11
Effective
08/05/11
24165
27312
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
r
r41
ATA,
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coieen H. Sullins Dee Freeman
Governor Director Secretary
8/5/2011
Jeffrey H. Pettus
Diane D. Pettus
2390 Chicken Bridle Road
Pittsboro, NC 27312
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0500407
2390 Chicken Bridge Road_ Pittsboro. NC 27312
Dear Mr. & Mrs. Pettus:
On 7/25/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -on) 1
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,
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 Chatham 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.RoQerstamcdenr.aov if you have any questions.
Sincerely,
0
for Debra Watt
Supervisor
cc: Raleigh Regional Office - APS
APS Central Files - Permit No. W10500407
Chatham County Health Dept.
Dana Clay ma — Aqua Drill, Inc.
Bryan Boer - Boer Brothers
A0111FER PROTECTION SECTION
1636 Mail Service Center. Raleigh, Notts Carolina 27699.1E36
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone' 91 73 -3221 i FAX l: 919.715-0588, FAX 2: 919-715-6046 i Customer Service: 1 877.623-6718
Internet; www.ncwateroualitv.or;
.Jl tC:lu. [1Cp0r1,!91:>! Affin ati Aci;ia rinooy,-r
&o,ew
_One
N o th Caroiitla
Nth
y

NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Amebae With the Provisions of 15A NCAC 02C .0200
pOSFD-LOOP WATER -ONLY GEOTHXRIKAL INJECTION WELL
These wells circulate potable water only as part of a geothermal heating and cooling system.
These walls are `permitted by rule" and do not require m individual permit when they are construcbxl is
pu:Airklanfx. wiib the rules of 1 SA NCAC 02C .0200 and this Natioe is aAnn#ttrd prior toconstruction_
Print or Yjee Inforotonon mad WI to the Alone oas ali.IsstFogg
DATE: 1 — ; , 204 PERMIT NO. L, L I OO 0) Oa be filled in by DWQ}
A. STATUS OF WELL OWNER (choose one)
N individual Residence / Business/Organintion
Gott: State Municipal County Federal
B. WELL OWNER — For individual residences, list each owticr an property deed. For all others, state name of
entity Aoil name of person delegated authority to sign on behalf of the business or agency:
SEFFe e-i /- . ]fie' -`ant
-.6i4t :. i)er"12e S
Mailing Address: .Z31 o ebiteic6 J v r@-e66e 4"Aw
clay: f , rr$ y cue o Starr+/ Tip Code: L 73 • z County: G 4?W.4 t
Davy Tale No.: 9 i4 -.54Z -70141 aO7-6Cr3 Cell No.1
EMAIL Address: jA cepe i' eyhet rji C3i^'- Fla Na.'
Cii4 b efie d6 ►Zs+«bdrtelr.ri., l ec.
C. LOCATION OF WELL SITE — Where the injection yells are physically located:
(1) Paacel Identification Number (PIN) of well site: County:
(2) Physical Address (if different than mailing address): f
City: State: i Zip Cade:
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: A64.1.4'.J ,L./ 666
NC Well Drilling Contradict Certification No.: 2—� )' 74
y Nne 27 4 6Via L J�
Contact ..—/, '7j) EMAIL Address: eit..1-tt-* @. /(AftrAccr .,/
Address: y!s /l40D4--GS
city: fk A/C _ Zip Co _ SS see: fecounty: . 4•R-
Ofice Tele No.: 374 76/ 7 V 7 Cali No,: 3 - APO 16 gaxNo.: 3. r-' 20-9 7 Ci
cffU U C SQrov Notiaartkrn Monied 3/ rtt201 i )
RECEIVED 1 DENR 1 DWO
Aquifer Protection Section
JUL 25 201!

II'.
= &~:; £zthu5 lie;;:::= c,,,, I ;,i~
A~ )Q-:\ & l:\ vvy S t-f kl , .ff 3 33 ~
City: (R;,J{t),:,✓O ZipCode: ?-15 ID State:NC.Q)unty: 0 (vy~ 0
OftkeTeleNo.: "l\'\-'\}"t-q'fNa CellNo.; 4\U -{,1 1 ,4.Lt1 7_Fu,a.,No........_,: ----\
WELL CONSTRUCTION DATA
(1) Numberofboringstobecom&ructed•: 3 Deplbofeacbboring(feet): 2., ~ (J/ £.I(,
• .(f m.rttng water 8ttpp/y wells wlH be 1111ed then provide the lnfortNJlkJn In mm (4) bdtlw.
(2) rype of tubing to be uscc1 (steel. PVC, etc): --'-'/1 ..... '4 .... A'--'c_-_______ _
(3) Well casing. If the weU(s) will me casina then plOVido 1be lm! (steel, PVC, etc.~ rurmtrr ,.loJdb.
andmaJ! ofcasingappearingabovegrouod: _____________ _
(4) Grout (material S\ll'IOUDCling well casing and/or pipmg):
(a) Orouttype: Cement_ Bemonite••-Odler(specify) "Tll€~,#l,, G /l(}'•e? I /T ,%..v""[.
"8Jllloodag.,.._p,u1.awriMccis._ ..... 10 ISANCAC2C.02U(d)(l)(A), wlliclt.....-acmaalttypeFM,6/ 7. (4A.lf!J
(b) Grout dep1b of tubing (refaaice to 1ancl surface): ftom __ to ___ (feet)
If well has casing. indicate gl'OUt depCh: &om __ to ___ (feet)
G. W&LL LOCATIONS-Maps must be scaled or o1herwise accuramly indicale distances and orientations of
features located wi1bin 1000 feet oftbe iqjeetion wll(s). Label an w,,.,, 'jlgrly apd iQclude a north anow.
(1) AUach. a site-apeci& map showing the locatiom of1he following:
• Proposed injection MIis • 8uildinp • Property boundaries
• Slar1iM:e waaea-bodia • wau:r supply wells
• Septic 1IDks and auociaaed spray inigation sites, drain. fields. or repair areas
• Existing or potential IOUl'CCIS of groundwater CC)llbllHination
(2) Auacb a topograpllie map of the area emncHng l/4 mile ftom the iqecdon well site 1bat indicales the
filcility•s location and the map name.
NUTE: 11, .,.cao, -..,,,,,...,,.. ofi!I .. ,,.,..,,.,,....,,,.,,.,, 11aa .. ...,.,,. aDf ,_ ,,,_.,_, ~ ..,.,u1,,_ • weiwNr ~ o,s .,...._ ~~ * lfflfKlll1 ea 6e w,d,al bJ
,,,,.,, MIW or IIMtm. ...... ,,J tiw wdr b,,... ,_,, J .. Nlllltlluw, ...... .,. ... odl#
.... _, Ml .. k ...... bl ~ ...... Alll,, • ...,_., c:a N Ml«td ..... .,,~ cd ■lllU'J # . ...,,.,. ...
•
GPUJUICSQWNod& llliae(ltffl1Dd3111120IJ)
iSA NCAC 02C .02110) requires that all lit applications shall be signed as follows:
1. for a calibration: by a responsible corporate off;
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency. by either a principal executive
officer or ranking publicly elected official;
4. fur all others: by the well owner (which Ili aJ1 parsons listed on than gtrestoiv deed).
If ao setboriad agent la mina on half of the *irptkxat, thew *apply a letter signed by the
applic.aat that matters and authors ea their agent to alga this appikatioa ea tuber WW1.
"I hereby cm*, under penalty of law, that I have personally ermined and asa familiar with the information
submitted in this document and all atturhmaus thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said infixmation, 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 ootistruN, operate, maintain. repair, and if applicable, abandon the
igjection well and all related appurtenances in accords= with the approved specifications and conditions of
the Permit."
ia-ac-e)
Sig w�Property Ownerapplicant
_7e—r y- ;Le. /d e -r—rccs
Print or Type Full Name
‘1..—
Signatare of Property Owner/Applicant
Pe *•i
Print or Type Full Name
Signature of Aulharired Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED l DENA 1 ❑WO
Aqu',te Protection Sedon
JUL 2 5 MI
Of'UR IIC 5QW Not n (lxeriEcd 3l18Wi 1) Pees 3

: ?Verge tait
*VW
Oggiiii3.41 amain: ea
1,1 immi•••, • •
- •
141:=4:ihosir
Iltripprestiii mut& Ng
. - .
S 2111121441V
147.1W
41P'Srirle
*Ott'
I I,
5. #1 :
O. tio4r44.
'tecotr.
Inle-115 w, lac move 4-14,,,3
paproca 541ro
III NEW FiraiIA
ESS riaiiitc*NciotARtiA .60 pri) e r
*cia, Itlivetto
AC H t T.15 1 Pe,
11111104411Wasit 11111170,11111•0111M •
ALW1101r.
11014160111011.11Mit
riatalbsimeasimedritahrisa ZUNAStOjrcustrJeo
psa