WI0500408_GEO THERMAL_20110805

Permit Number
Program Category
Ground Water
Permit Type
WI0500408 /
•'
Central Files: APS_ SWP_
08/05/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (5QW)
Version
1.00
Permit Classification
Individual
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Kevin & Tammy Keshler SFR
Location Address
1066 Redbud Rd
Pittsboro
Owner
Owner Name
Kevin
Dates/Events
NC 27312
Keshler
Orig Issue
08/05/11
App Received Draft Initiated
07/25/11
Re g ulated Activities
Heat Pump Injection
Outfall r Jd
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
Joshua Niles Robertson
Driller Well
8228 Kerr Chapel Rd
Elon NC
Major/Minor
Minor
Region
Raleigh
County
Chatham
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Kevin Keshler
1066 Red Bud Rd
Pittsboro
Public Notice Issue
08/05/11
NC
Effective
08/05/11
27244
27312
Expiration
Stream Index Number Current Class Subbasin
ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
8/5/2011
Kevin Keshler
Tammy Keshler
1066 Redbud Road
PitEsboro, NC 27312
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI4544408
1066 Redbud Road. Pittsboro. NC 27312
Dear Mr & Mrs. Keshler:
On 7/25/2011, 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 constriction 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 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 Michaei.RoQers wncdenr.gov if you have any questions,
A '6wna
for Debra Watts
Supervisor
cc: Raleigh Regional Office - APS
APS Central Files -Permit No. W1050040
Chatham County Health Dept.
Triad Drillers
M orrissev Mechanical
AQUIFER PROTECTION SECTION
1636 Nia:! Service. Center, Raleigh, North Carolina 27699.1636L
Location. 2 728 Capital Boulevard, Raleigh. North Carolina 27604
Phone! 919-733-3221 l FAX 1: 919-715458E: FAX 2: 919-715-B0461 Customer Service: 1-577-B23.6748
Internet work nCwateraualit .or
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FROM : Morrissey Mechanical
PHONE NO. : 91.9 469 6649 Jul. 16 2011 05:49AM P1
NOR Ti: C:ARC ,E A
DE.I'_A fMEN r OF E,NV IRONMENT AND NIk7'['RA . ?U SOURCES
JUL nE 4DII
NOTJ ICAT4OIi OE INTENT TO CONSIRVCT A CLOSED -LOOP GEOTHERMAL
WATER-O_NLY INJECTION WELL SYSTEM
TYPE SOW W L 4S1
Tr, Accordr nr:c Vail the Provisions of NCAC Tide k SA 02C_0200
Print or xve the required informodori and tn,xil to address art the 1ctc) gage.
DATE: , 21 i05-
Wei! Type Confirms rio : .Does the proposed system circulate pottle water (July (no additives) in
continuous piping that completely isolates the, f1xudfrom the environment (i.e.
closed -loot)?
Yes �_._ Continue completing this form,
No Do Not complete this form. Complete other WC appli:ation forms for installing
either a 5A7 well (am -loop well potable wet :r into the aquifer) or a 5QM well (closed -
loop well containing add gives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A< PROPERTY OWNER(S))AFPLICANT(S)
List t t c i Prope; tv Owner listed on property deed (if owned by a business or government agency. slam mare o
seer
entity and a representative wlauthority for signature):
(1)
(2)
Mailing Address! 1 O(DIe EK.A. f3(1 Rd
City: �: _7fil_ State:%, Zip Code: County:
Home/Office 'teie No.: Cell N y.: .
Emil Addrese:
Physical Address of 1Ne21Site (if different than above):
City: _ State: Zip ode: County:
HomeIOf;cice Tele No.: Cell No,:
$. AUTHORIZED AGENT Of OWNER, W ANY (if the Permit Applicant dOes is t Loma a sale, parnaerty.
sucha letter from the property owner authorizing Agent to instill and operate UIC weir!)
Company Name:
Contact Person: _ EMAtir.. A ' ens:
Address:
City: State: _ Zip Code: County: _
Office rele No.: Call No.:
Website Address of Company, if any: _

FROM : Morrissey Mechanical
PHONE NO. : 919 469 6649 Jul. 16 2011 e5:48RM P2
JUL 25 2011
C. WELL DRILLER .114FORMATASTh
Company Name:
-Trion
Wel.' Dr tticr C'on:racto;'s Name:
NC Contractor Ce; ificatio,3 No.:
Contact Person: a- _ EMAIL. A 4ress!
Address:
City: _Ea)._ - - Zip Code:a21.94County:
Office Tele No. 33 Y
D. HEAT PUMP CONTRACTOR Di-FORMAT/ON (if different than driller)
Company histii [! -kt ll c%[ ]
Contact Person: C hot is1_ IL Address: �--
` � � rs
Address: _Pa_ QQo7c. S
City: g q l C`LOPN._, Zip Code: 76_ County:
Office Tele No.: jg 5q .. , Ceti No.: 911 7
E. STATUS OF APPLICANT
Private: Federal: Commercial:
State: _ Municipal: Native American Lands:
F. gNTECI`!ON PROCEDURE (briefly describe how the injection weil(s) wilt be used)
G. WELL CONSTRUCTION DATA
(1) Proposed dace to be constructed:
Approximate depth of each boring (feet):
(2) Type of tubing to be used (copper, PVC, etc):
Number of borings:
75
(3) Well casing,. Is the well(s) cased? (check either (a.) Yes(b.) Pio below)
(a) Yes i." yes, then provide casing information Mow
Type: _____galvanized steel black steel p?ast c _other (specify)
Casing depth: From to feet (reference to land surface)
Casing extends to above grOwtd inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping):
Bentonite
Pressure
(n)
lb)
(c)
Grout type: Nest Cement
Grout placermenI: Ramping
Grout depth of tubing (reference to land surface): from 75, to •S J"i Q (feet)
If well ;az casing, indicate grout depth: from to (feet)
Other (specify)
Other

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FROM : Morrissey Mechanical
61799 5917 616
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FROM : Morrissey Mechanical
PHONE NO. : 919 469 6649 Jul. 16 2011 05: 45AAM P4
N.QZ R-ed 13° R