WI0500422_GEO THERMAL_20110825

Permit Number
Program Category
Ground Water
Permit Type
WI0500422 I
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Faciiitv
Facility Name
Sun River Builders -Sassafras Hill
Location Address
1507 Sassafras Hill St
Durham
Owner
Owner Name
Sun River Builders Inc
Dates/Events
NC 27712
..
Scheduled
Orig Issue App Received Draft Initiated Issuance
08/25/11 08/24/11
Ret1ulated Activities
Heat Pump Injection
Outfall ,,iu:_L
Central Files: APS_ SWP_
08/25/11
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
NC
County
Durham
Facility Contact Affiliation
Owner Type
Unknown
Owner Affiliation
Barnette C. Crabtree
27587
5102 Durham Chapel Hill Blvd Ste 201
Durham NC 27707
Public Notice Issue
08/25/11
Effective
08/25/11
Expiration
Waterbody "Name Stream Index Number Current Class Subbasin
NA MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Sun River Builders, Inc.
Barnette C. Crabtree
5102 Durham Chapel Hill Road
Suite 201
Durham, NC 27707
Coleen H. Sullins
Director
8/25i201 l
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0500422
1507 Sassafras Hill Street, Durham, NC 27712
Dear Mr. Crabtree:
Dee Freeman
Secretary
On August 24, 2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onlv
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 .021 l(u)(2). Additionally, you should contact the Durham 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.Rog:ers(@ ncdenr.E!OV if you have any questions.
cc: Raleigh Regional Office -APS
APS Central Files -Permit No. WJ0500422
Durham County Health Dept.
Bowman Mechanical Services. Inc.
Glen A. Darch Well Drilling. LLC
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Sincerely,
(o,Q~_)\. ~
Supervisor
Phone: [phone] \FAX';: 919-715,0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterauali tv .o rg
An Equal Opportunity I Affi:mative Action Employer
rTOnehC . _'\lort . arolma
{?vaturall!f
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of ISA NCAC 02C ,0200
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of l 5A NCAC 02C .0200 and this Notice is submitted prior to construction.
DATE:
Print or Type Information and Mail to the Address on the Last Page.
Z'g► j del , 20_..L
PERMIT NO. VJI O€ (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence
Government: State Municipal
Business/Organization.
County
Federal
B. WELL OWNER - For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
Mailing Address: Si 19.2 . u Ai r II Ch4y(/ y/r 610 ( / -Get z a
City: ) 9 r%'r State: AC- Zip Code: 2,74 ? County: Qiq 4 41.
Day Tele No.: R l' 241 j 1413 _Cell No.: 4'1q 2q/ /4/3
EMAIL Address: RI esie f t etufaltI )141 ea'"? Fax No.: egg .317 1 e t >
C. LOCATION OF WELL SITE- Where the injection wells are physically located:
(I) Parcel Identification Number (PIN) of well site: Og35 -02-(o(0 10149 ^County:.17(4I0r' 6 41
(2) Physical Address (if different than mailing address): 1 �C) �S C _S a (Cl 5)1,,ce i
City: ci)tir- k4�n
State: NC Zip Code: 02 77/
D. WELL DRILLER INFORMATION Well Drilling Contractor's Name: C /e, /4 74,-C Wef/L-,14 II C
NC Well Drilling Contractor Certification No,_ 390o`A
Company Name: C 4 A 6 D4.04 Weil 4.-`, Ai- 6. ( C
Contact Person: G t'0.., 4 Da- 014 EMAIL Address: 5we/iair.y/> Gas/Crs.„
Address; / 3IG i Rod 6'; i'1 ,4/
City: tvtly1tt Evros./ Zip Code: z 7s r2_ State: "( County: W4 k. o
Office Tele No.: Cii9) Ste'- 3939 Cell No.: &/ V 4I1-2.- ` `33) Fax No.: 0') -ri' 2R35
GPUIU1C 5QW Notification (Revised 3/18/2011) Page 1

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: ___ B_o_wm __ a _n _M_e_c_h_a_n_i_c_a_l_S_e_r_v_i_· c_e_s_, _I _n _c_. _______________ _
Contact Person: EMAIL Address:[e-mail]
Address: ___ 14_5_T_e_c_h_n_ic_a_l_C_t_. ________________________ _
City: Garner Zip Code: 2 7 5 29 State: _N_C _County: _w_ak_e _______ _
[phone] F [phone] Office Tele No.: -Cell No.: ----------~_ax~N~o~.:~-------
F. WELL CONSTRUCTION DATA
(1) Number ofborings to be constructed*: 7_ Depth of each boring (feet): __ l_-:s--; __ 0 ____ _
* If existing water supply wells will be used then provide the information in item (4) below .
(2) Type of tubing to be used (steel, PVC, etc): __ /I_O_P_l"f_ ... ________ _
(3) Well casing. If the well(s) will use casing then provide the~ (steel, PVC, etc.), diameter, depth,
and extent of casing appearing above ground:
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement__ Bentonite** ~ Other (specify) _______ _
** By selecting bentonite grout, a variance is hereby requested to ISA NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from ..Src to IS-(} (feet)
Ifwell has casing, indicate grout depth: from ____ to _____ (feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearl y and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GJS website. Typically, the property can be searched by
owner name or address. The location of tlte wells in relatioll to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showil~g topographic contours or
elevation data.
GPU/UIC 5QW Notification (Revised 3/18/2011) Page 2
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
1 SA NCAC 02C .021 1(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
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. for all others: by the well owner (which means all persons listed on the property deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"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 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
?ar'ne& C C i4ce C r �rlf
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4
Print or T e Fu11 N.; e jc
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pse
Signature of Property Owner/Applicant
Print or Type Full Name
Signature of Authorized 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]
GPU/UIC 5QW Nntifieation (Revised 3118/2011) Page 3

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GoMAPS - Durham County NC Public Access
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Stream!La ndDitches
DITCH
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Highways
Parcels
Surface_Watar_ Polygons
Manic Ipa I_8 oundaries
Chapel Hill
Durham
Morrisville
Raleigh
Tuesday, August 2 2011
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