WI0500439_GEO THERMAL_20111206

Rogers, Michael
From:
Sent:
To:
Subject:
Attachments:
Good morning Mike,
-
Guy Veni [[e-mail]]
Tuesday, December 06, 2011 9:23 AM
Rogers, Michael
Wf0500439
Nelson, Daniel.pdf
Attached you will find GW-lb for subject permit and final drawing.
If you have any questions or need any additional information please let me know.
Thank you,
Guy Veni
American Environmental Drilling, Inc.
324 Fields Drive, Suite C
Aberdeen, NC 28315
Office 910-944-3140
Fee.; 910-944-3150
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NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -:Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2730 A
1. WELL CONTRACTOR:
Kelly Grant
Weil Contractor (Individual) Name
American Environmental Drilling, Inc
Well Contractor Company Name
STREET ADDRESS 324 fields Drive, Suite C
Aberdeen NC 28315
City or Town State
1910 )- 444-3140
Zip Code
+Arpaoc Perna rioter
2. WELL INFORMATION:
SITE WELL. ID* (if applicable) A B-C-D
STATE WELL PERM1T:7 (if applicable) WI050043a
DWQ or OTHER PERMIT Cif applicable) W/I-04184
WELL USE (Check Applicable Box) Monitoring 0 Municipal/Public 0
Indust/tat/Commercial 0 Agricultural ❑ Recovery 0 Injection 0
Irrigation 0 Other ® (list use) GEOTHERMAL
DATE DRILLED 1 1-16/12-2-11
0 PM
ORANGE
TIME COMPLETED 12:40 AM
3. WELL LOCATION:
CITY: CARRBORO COUNTY
208 WILD TURKEY TRAIL
((Street Name, Numbera, Community, Subdivision, Lot No.. Parcel, Zip Lode)
TOPOGRAPHIC f LAND SETTING:
(81Slope ❑Valley OFlat °Ridge ❑Other
(check appropriate box)
LATITUDE 3 °
Nfay be in degrees, 1
minutes, seconds or
Ma decimal format
LONGITUDE 0 ° _
La- ttitude/loaylude source: OOPS ❑ Tnpogrephie map llacatlan of
well must be shown on a USGS ropo map and attached 1C this form
it not using GPS)
4. FACILITY- is the name of the business where the wet is located.
FACILITY ID a (If applicable)
NAME OF FACILITY
STREET ADDRESS
City or Town State Zip Code
CONTACT PERSON DANIEL K. NELSON
MAILING ADDRESS 208 WILD TURKEY TRAIL
CHAPEL HILL NC 28516
City orTown State
f ]-
Zip Code
YES 0 NO rig
FT.
_
Area code - Phone number
5. WELL DETAILS:
a. 1,I lH 1421 Ei -1
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
(Use "+" If Above Top of Casing)
d_ TOP OF CASING IS FT. Above Land Surface
*Top of casing terminated attar below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm) METHOD OF TEST
f DISINFECTION: Type Amount
g. WATER ZONES (depth):
From 85 To 140 From To
From To From To
From To From To
5. CASING:
Depth Diameter Thickness/ material
Weight
From To FL
From To Ft.
From To FL
7- GROUT: Depth Material Method
From 2 To140 Ft. GROUT TREMIE
From To FL
From To Ft
8. SCREEN: Depth Diameter Slot Size Material
From To Fl. in. in.
From To Ft In. in.
From To Ft et. in.
9. SAND/GRAVEL PACK:
Depth Sloe Material
From _ To Ft.
From To FL
From To Ft.
10. DRILLING LUG:
From To Formation Description
0 5 ORANGE BROWN CLAY
5 24 TAN CLAY
24 30 TANNISH ORANGE CLAY
30 88 TAN CLAY
66 B4 WEATHERED ROCK
84 140 GRAY BLUE ROCK
11. REMARKS
Potable water geothermal loops.
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
75A NCAC EC, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL GIiG�J ER.
%S .iJ,{ --- 1ZS.11
SIGNATUREf: CERTIFIED WELL CONTRACTOR DATE
Kelly Grant
PRtNTEC1 NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. (919) 733-701S ext 568.
Form GW-1
Rev. 7/C5

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Permit Number
Program. Category
Ground Water
Permit Type
WI0500439 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility
Facility Name
Daniel & Denise Nelson SFR
Location Address
208 Wild Turkey Tri
Chapel Hill
Owner
Owner Name
Daniel
Dates/Events
NC
K
27516
Nelson
Scheduled
Orig Issue
10/25/11
App Received ·oraft Initiated Issuance
10/06/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
10/25/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Guy Veni
324 Fields Dr
Aberdeen
Major/Minor
Minor
Region
Raleigh
County
Orange
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Daniel K. Nelson
101 Rossburn Way
Chapel Hill
NC
NC
Public Notice Issue
10/25/11
Effective
10/25/11
28315
27516
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Daniel Nelson
Denise Nelson
l O l Rossbum Way
Chapel Hill, NC 27516
A~A ;;-;;;-,!"~~ ... MCDEMR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
10/25i201 l
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0500439
208 Wild Turkey Trail. Chapel Hill, NC 27516
Dear Daniel and Danielle:
Dee Freeman
Secretary
On October 10 , 2011, .the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-on!
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 .02ll(u)(2). Additionally, you should contact the Orange 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 gers@.ncdenr. eov if you have any questions.
cc: Raleigh Regional Offi\:e -APS
APS Central Files -Permit No. WI0500439
Orange County Health Dept.
.American Environmental Drilling, Inc. (Guy Veni)
B &THY AC Services, Inc. (Aaron Horton)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
tioerely,
f&,D,bra~I\.~
Supervisor
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterauality.org ·
An Equal Opportunity \ Affirmative Action Employer
None., C 1. onn aroma J\7atura!tu
GPITILTIC 5QW Notification of Intent Form (Revised 812008)
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-OW WELL(S)
In Accordance with the provisions of NCAC Title 15A: 02CO200, please
complete this notification and mail to address on the back page (please Print or Type information).
DATE:
, 2009 apCat
Well Type Confirmatlan: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes 3t 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 additkes such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNERS)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): Nelson Daniel K. — Aaron Horton, representative
(1)
(2)
Mailing Address: 101 Rossbum Wa,
City: Chpel ljill State: NC Zip Code: 2716 County
Home/Office Tele No.: 9
� � -. — ?�L,l Cell No.:
Email Address: Website:
Physical Address of Well Site (if different than above): 208 Wild Turkey Trail
City: Chapel Hill State: NC Zip Code: 28546 ;) l 9L County Orange
Home/Office Tele No.: Cell No.:
H. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: B&T HVAC Services_ Inc.
Contact Person: Aar: n ! i+mon _ _ EMAIL Address! bandthvac+i4bcltsottl_.T►ei
Address: _ v92 Horton Pond Road
City: Apex State: NC Zip Code: 27523 County: Wake
Office Tele No.: 0I9-362-5846 Cell No.: 919-942-0380
Website Address of Company, if any:
RIECENED 1 DENR I DWQ
Aquifer Protection Section
OCT 0 0 2011
Page I

C. WELL DRILLER JNFORMATION
Company Name: American Environmental Drillin g. Inc.
WeU Dri]]er Contractor's Name: -=G=aetan==o_._N-=._.V"""e=ni;....._ _________________ _
NC Contractor Certification No.: 3285-A _.;..____, ........ ____________________ _
Contact Person __ G ___ u.,,._y--'V....aeru=-· -----------=E=MAIL=-==-=A=d=dJl=e=ss=:....cgu=y.__,@""'tae==d=i.bi=·=z _____ _
Address: 324 Fields Drive Suite C
City: Aberdeen Zi p Code: 28315
Office Tele No.: 910-944-31 40
County: ..::M:;::o~o::e..:re"------------
Cell No.: 910-690-7569
D. BEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: B&T HVAC Services, Inc.
Contact Person: _;:A~aro~n!,$r,H~ort!;5o;!n!:========~E~MA~IL~A~ddll~e~ss~:=lib~an~d~th~v~ac~r,~7'~he~l1~so~u~tl~l . .!.::ne::!.t __ _
Address: 992 Horton Pond Road
City: Apex State: NC Zip Code:---'2::.:7.:.52:::3 ______ County: _W;..;...;;;;;;ak=e _____ _
Office Tele No.:.--'9::..,1=9....::·3=62.._-=SS~4~6 ___ -=Ce=l=l N~o= . .._.: 9:....aol.:::...9·..::..94...:..:2::....-0=3=8=-0 ____________ _
E. STATUS OF' APPLICANT
Private: ....x_
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) wi11 be used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: October Number of borings: .... 2=--~3 ___ _
Approximate depth of each boring (feet): ~1;.;..3.;._7-_2_05;__ __ _
(2) Type of tubing to be used (copper, PVC, etc): ;;.P....:..o"""ly...;::E:.:;th;:::.,y..:.Je;..;.n....:..e _________ _
(3) Well casing. ls the well(s) cased? (check either (a.) Yes!! (b.) No below)
(a) Yes ___ if yes, then provide casing infonnation 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 X
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite _x__ Other (specify) ______ _
(b) Grout placement: Pumping_X Pressure__ Other __
(c) Grout depth of tubing (reference to 1and surface): :from S to bono m (feet)
If well has casing. indicate grout depth: from ___ to ____ (feet)
GPU/UJC 5QW Notification of Intent Form (Revised 8/2008) Page2
EL. 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.
L LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(I)
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 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.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deeed.
'`l hereby certify, under penalty of law, that l 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 . conditions of the Permit."
der ,uaChcti ! •ettrt
Signature of Property Owner/Applicant
1CL 6 s 1 456-[Af
Print or Type Full Name and title
Signature of Property r/Applicant
Lin Gz.. r\ici&ttsik agwvr
Print or, Full Name and title
$+rail tare u# Attlhorixed 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
Telephone [phone]
RECEIVED I ❑ENR DWQ
Aquifer Protection Section
OCT 06 ant
QPUIUIC: SOW Notification oftntcni Form (Revised S12008)
Page 3

•
•._ ...._.... ....,. -- —r case _ ..
Bedroom Septic System Layout
Stoneybrock Subdivision, Lot 018
�n :c, Tore Kemp
c.
� •- fix e,• yt. I
Vs
Wei X'', �ti� ' roc
Site
4i
L
Systen= dual Pressure Manifold
Ones 1-7, C4
,innovative Product
03 Son LTAR
a0" Trench Bottorff
Repot^ not required since Lot
-as recorded to 1975
jae
r
rr_
s44`
r
GRAPHIC SCALE
sot
co
a '4
J
Sg a 60 120
Mot a Survey
ydutflaggied in f3QLd
U er level
Wa not czar any flan
except where d rakrws and
wvpkbe pksta�les are gdrio to
919-T3
Project * 23

Bedroom Septic System Layout
0 Stoneybrook Subdivision, Lot 018
o Tom Kemp
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C5
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eze
aC x =
c O
Ton
V O -
•i.,. ;_ t-� to zro
Site
C �
trZp yl
Dual Pressure Manifold
1-7, C42O')
Innovative Product
0.3 Solt LTAR
O' Trench Bottom
Repair not required she tot
�'4as recorded In 1975
c-r
GRAPHIC SCALE
7' — 60'
ti
j
o - t
44)
a
Belo* a Survey
elayeut in field
with laserr level
ADD not dear any
except where aims and
supply Unes ere goino to
be installed •
Cerrtral Corlalina
91,--791-113113
Project * 23

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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATIQN OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
' WATER-QNLY INJECTION WELL SYSTEM:
TYPE 5-0 W WELL(S)
In MCQl'(WlQO wJtb th# prqvJsioiu ofNCAC Title 1$A: 02C,0200, please
complete this notification and mail to address on the back page (please Print or~ information).
DATE: _______ , 2009
Well Type Conjlrmllllon: Does the proposed system circulate potabJe water onl y (no additives) in
· continuous piping that completeJy isolates the fluid from the environment (i.e.
cJosed-Joop}?
Yes -A Continue completing this fonn.
No __ Do Not complete this fonn. Complete other UIC application forms for installing
either a SA 7 well ~ .. Joop well iQ.iestio& potable water into the aquifer) or a SQM well (closed-
Joop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List a Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): Nelson Daniel K. -Aaron Horton, re presentative
(1) Mailing Address: 101 Rossbum Wav
City: Chgpe] Hi]] State: g_ Zip Code:,_ ... 27 ..... 5 .... 16..__ __ County _____ _
Home/Office Tele No.: Cell No.: -----------------------
Email Address: Website: --------------------------
(2) Physical Address of Well Site (if different than above): 208 Wild Turkey Trail ------''----------City: Chape l Hill State: NC Zip Code: 28516 County _O_ran_ge __ _
Home/Office Tele No.: ------------=C=el:.:...1 N"""o=•c:....: _________ _
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: B&T HV AC Services . Inc.
Conawt Person: Aaron Horton
Address: 99 2 Horton Po nd Road
EMAIL Address: bandthvac @bellsouth.net
City: Apex State:~ Zip Code: 27523 County: _W_ak_e _____ _
Office Tele No.: .... 9_.l...,9--=-3 ... 6 __ 2-__ 5"""84-"6 _____________ C ___ e=ll--N.a.ao __ .: __ 9..a.;19"""-.:;_94=2;....-0 ... 3 __ 80 _______ _
Website Address of Company, if any: _____________ _
GPU/UJC SQW Notificati.on oflntcnl Fonn (RevlKd 8/2008)
RECEIVED /'DENR / DWO
Aquifer Protection Sectio ri,age 1
OCT O 8 2011
C. WELL DRU,J~ INPORMATION
Company Name: Ameri can Environmental Drillin g, Inc.
Well Driller Contractor's Name: _O=ae..:::tan=o .:..:N..,_. V~en~i _________________ _
NC Contractor Certification No.: 3285-A ----=..;ac=...;;..;... ___________________ _
Contact Person _G __ u.,_y __ V __ eru=·--------------=E=MAIL=-==-=-A=d=dress~=:...,_gu::.,Yc,,;;@.i.ae=d=i=.b=iz:,__ ____ _
Address: 324 Fiel ds Drive, Suite C
City: Aberdeen : Zjp Code : 28315 County: .:.:M.:.:O:.:.Or:.::e _________ _
Office Tele No.: 910-944-3 140 Cell No.: 910-690-7569
D. BEAT PUMP CONTRACTOR INF'ORMA TION (if different than driller)
Company Name: B&T HV AC Services, Inc.
Contact Person: -,_AlilillifiilOniillul'lie .. £19,.._111P--=-=-==a;!E;:MA~I!:!!L;a;A=ldmidi!ilrer.llssl&loi ~ba~n~d,r,:,:th:..,vaacillo@~b~e..r,;!ls~o~ut~h;1;1,n~et.__ __
Address: 992 Horton Pond Road
City: Apex State: NC Zip Code: ---=2..,_7=52=3 ___ County: _W-'-ak=e _____ _
Office Tele No.: .... 9""'1 ... 9...:;·3=62,_-=58 ... 46'--_----=Ce=l-l N'""'o= ..... : 9'""'1"'-9-"""94..:..2:;..;-0=3=80=---------------
E. STATUS OF APPLICANT
F.
G.
Private: ...x_
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
WELL CONSTRUCTION DATA
( 1) Proposed date to be constructed: October Number of borings: -'2=-·=--3 __ _
Approximate depth of each boring (feet): _1_37_-_2_05 ___ _
(2) Type of tubing to be used (copper, PVC, etc): _P_ol.._y_E_th...,y_le_n_e _________ _
(3) Well casing. Js the well(s) cased? (check either(&.) Yes m: (b.) No below)
(a) . Yes ___ if yes, then provide casing infonnation 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 X
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement_ Bentonite _x,_ Other (specify) _____ _
(b) Orout placement: Pumping X Pressure__ Other __
(c). Grout depth of tubing (reference to land surface): from 5 to ]2ottom (feet)
If welJ has casing. indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification oflnumt Fonn (Revised 84008) Page2
U. 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.
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 tines, 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,
J. 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 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 conditions of the Permit."
Sri. A ail LI1 ii Lils r
Signature of Property Owner/App ;caniit
l EL. .06 5izttO, 434aJ'
Print or Type Full Name and title
Signature of Property (]wr}er/Applicant
Pei4 Ga. 3.1\16 ttAtt
Print or/ ,e Full Nime and title
Si
F W F2rrr—J
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
Telephone [phone]
GPIJRUIC 5QW Notification of Intent Foam (Revised 5/2008)
RECEIVED / DENR / DWQ
Aquifer Protection Sidon
OCT 06 20lPase3

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