WI0500456_GEO THERMAL_20120124

Permit Number
Program Category
Ground Water
Permit Type
WI0500456 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coa•tal SW Rule
Permitted Flow
Facility
Facility Name
Thomas & Nancy Hurtgen SFR
Location Addresa
220 so·uthwind Ln
Hillsborough NC 27278
Owner
Owner Name
Thomas Hurtgen
Dates/Events
Scheduled
Orlgl11ue
01/24/12
App Received Draft Initiated Issuance
12/02/11
Regulated Activities
Heat Pump Injection
Outfall NULL
_,
Central Files: APS_ SWP_
01/24/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Clasalflcatlon
Individual
Permit Contact Affiliation
David J. Brown
1908 Hamptonville
Hamptonville
Major/Minor
Minor
Region
Raleigh
County
Orange
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Thomas Hurtgen
230 Southwind Ln
Hillsborough
NC 27020
NC 27278
Public Notice Issue Eff ctl ve
01/24/12
Expiration
01/24/12
Waterbody Name Stream Index Number Current Class Subbaaln
Beverly Eaves Perdue
Governor
Thomas Hurtgen
Nancy Hurtgen
220 Southwind Lane
Hillsborough, NC 27278
AW'A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, PE
Director
1/24/2012
Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System
Permit No. WI0500456
220 Southwind Land, Hillsbor ough, NC 27278
Dear Mr. & Mrs. Hurtgen:
Dee Freeman
Secretary
On 12/2/2011, the Aquifer Protection S.ection (APS) received notification of your intent to construct a closed-loop water-only
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 Orange County Health
Department.as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulatio~s may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or [e-mail] if you have any questions.
cc: Raleigh Regional Office -APS
APS Central Files -Pennit No. W10500456
Orange County Health Dept.
Louis Heating & Cooling"Svcs, Inc (Louis Agnolutto)
Yadkin Well Company (David Brown)
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Raleigh, North Carolina 27699 -1636
Location : 512 N. Salisbury St, Raleigh, North Carolina 27604
Phone : [phone] \ FAX: 919'807-6496
Internet www.ncwatergualily.org
An Equal Opportunity I Affinnative Action Employer
Sincerely,
l'l 7in fL 8corvl 'J;:~atts
Supervisor
. One ·•·• • NorthCarobna )Vaturatn·• ............ W:
Dec. 2, 2011 3:15PM
LULUS HEAI EN'a & l;UULIN(i,
No. 1417 P. 2/4
NORTH CAROLINA
DEPARTMENT OP B VIRONM2NT AND NATURAL R2SOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP. GEOTHERMAL
WATER -ONLY INJECTION WELL S'ZSTEIVI
TYPE 5QW WELL'S),
In Accordance With thhe Provisions ofNCAC ride 15A 02C.02M
Prinz or type the required information and mail to address or: the berxcpage.
DATZ: -c. 20 \ \ISI, O93CQ L 5(
Well Type Confirmation: Does the proposed system circulars potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (Le.
olosed-loon]?
Yes I/Continue completing thus form.
No Do Nor complete this form. Complete other TUIC application forms for i istal.lixmg
either a 5A7 well Coven -loop welt ir.jectig potable waver into the aquifer) or a SQM well (closed-
Ioop well containing addi'dys such as R-22, ethanol, or other antifreeze or carrosioa inhibitors).
A. PROPERTY OWNER(S)IAPPLICA. T(S)
List each Property Owner listed on property deed (if owny,,'bv a business or exit screwy, state name of
entity attd a represerative wlauthority for signature
(l)
Mailing Address: ,, ; D t)TX GU//,I , f ci
City: /1/S.‘R$ ,41 _ Stateof 2ip Code::) [ :. County:42,631/1
cqii) Home/Office Tele No.- , (/ , I'J Cell No.:
Email Address:U
(2) Physical Address of Well Site, (if different than, above):
City: Slate: Zip Code: County:
Horec/Offico Tele No,:
Cell No
B. AUTROPJZ D AGENT OE OWNER, if ANY (if the Permit Applicant does not own The subject property,
smell a. letter from. the property owner authorizing Agent to ingrall aod operate UIC well)
Company Name: % S'
Contact Personi VS, aCpCk V EMAIL Address'.•
Address:��]���
City: '`<-. State:'- '.lip Code:. County: -1/4-'e
Office Tele No.: - ` `:\ '3 Cell No.:
Website Address of Compa y, i#'anyti {-y , c;,;
uENR 1 d
Aqu}�i pro�o n So!"r
•rr. V.,.._ .6 _.��._1 �h,...b,
DEC 0 a 2011

Dec, 2. 2011. 3:15PM LUU1S HLAL INU UUUL1NG,
No, 1417 P. 3/41
C. WELL DRILLER INFOR,'VIATION
Company Name: �0_6%,kk. l���"]C�.t•5 ` 4-C�C
UVe1l Driller Contractor's Name:
NC Contractor Cez ificadon No.: ` '
ConttacPersoni_C ----x-, EMA . ddres6: [ *.t
Address: ' ►RG'�
City \\06--t-, -,LV\e, Zip Code: "D-10- County: 0,4 L.c�
Office Tele No.: '3 .144A- '`\`kO Cell No.:
Xi. HEAT PUMP CONTRACTOR INTORMATXON (if different than driller)
Company Name:
Contact Person: • O VI'S. d 14/ 2?
Address: 55713 /4/6 /7.5/4'
City: Ie42X f7I2 /VI° Zip Code 7County:
Office Teie No,: gyr— 7)- 5 Cell NO.'
E. STATUS OF A.PPLICANT
Private:
State:
Federal:
Municipal:
Commercial.:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe now the injection well(s) will be used)
E. WELL CONSTRUCTION DATA 1 �u
1Z_
(1) Proposed date to be constructed: it Number of borings:
Approximate depth of each boring (feet):
(2) Type of tubing to be used (copper, PVC, etc): � t ' C C� x''r•�--��+
(3) Well casing, Is the well(s) cased? (check either (a.) 'des or C e'm
(a) Yes _ if yes, then provide Casing information below QR— 1 1
Type: _galvanized steel black steel��iastze other (specify)
Casing depth: From to feet (reference to land surface)
Casing extends t4,bove gtouu3 inches
(b) Na
(4) Grout Info (material suxrauncling well casing and/or piping):
(a) Grout type: Neat Cement Bentonite Other (specify)
(b) Grout placement; Pumpih Pressure Other
(c) Grout depth of tubing (refer to land surface): from 13 to c6 (feet)
If well has casing, indicate grout depth: from to (feet)
GPZ;ICfil:.50W lk•Intirlatinn of frlfpx S annnoN

Dec, 2. 2011 3
15Pm LUur HtAl tN & LUULiNU
No. 1417 P. 414
FA. IN.IECTlON-RELATRD EQUIP ENT
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 OlE' WEL (S)
Attach two copies of maps showing the following information:
(2)
hiclude a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the admiration of and dxstaures between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tames or drain fields located witsr 2O0 feet of
the geothermal heat pump 'vucil system. Label all featuxes clearly and 7 n �ude a north arrow,
The Site Map must show the subject property in relation to the surrounding area by usiTg at least two fixed
reference points nob as roads, streams, andlor highway intersections.
J. CERTN1CATION
Note: This Permit Application must be signed by. each person appearing on the
recorded legal property deed.
"I hereby certify, mad r penalty of law, that I have personally examined and am familiar with the information
submitted is this documcrxt and all attachments theresta and that, based on my inquiry of hose individuals
iamnediarely responsible for obtaining said information, I believe that the information is true, accurate and complete.
I an: aware that there axe significant penalties, including the possibility of fines and ixnpnsonment} for submitting
([false inforniatioA. I agree to constxvet, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurrenannoes ir. accordance with the approved apeci4eaiions and conditions of the Permit."
Ss,--*--_, e-er14-r, ..-i,
Signature of Property Owne Applican
Th6"44•3 • r
Paint or Type Full Name and title I
I
�laiAGemuey U1V VlL .4 •`� 4LL�� LJ �^'Lp![}ll ll �laLGl1� J , J
Print or Type P/t Naxce and title
Signature of Authorized Agent; if any
Print or Type ]?loll Name and title
Please return two copies of the completed Application package to:
North Carolina DENR DWQ
Aquifer Protection Sectfnn-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED DENR I OWD
Actuger Prose 4 r %ecsioe►
DEC 0 2 ?fill
GPUCTIC SQW Notincstion of lareut Po= atvi cd 8/2008)
"age 3.

No1417 P. 5
Dec. 2. 2011 3:15PM
—rLta)
22-a j 4.wa"Ai". - 61/4 Agfavq(i7k
tuzie-
(-id(
dp
613
1g.
ewe. Gf �'e "art 4.11Ncir. PO' 0nyl per4x /l]i'Ik

Dec. 2. 2011 3.15PM No.1417 P. 1
FACSIMILE TRANSMISSION FORM
}SATE: r2 / / 14 TIME: _REF. NO LOG NO.
TO: )" L I _WO vs- se,
COMPANY NAME
7 4 ct ov O a
ATTENTION DEPL
FROM: VaAtiN eUU CQ
COMPANY NAM
0 DSJ! C1 Orot-
FAYNO. PLEASE
• Bigamy
(IA*) fA?
tAx NO. PLEASE
❑ RUSH
INDIVIDUAL DEPL
NUMBER OF PAGES sr PLEASE ORIGINATOR'S
INCLUORIG THIS SHEET REPLY BY SIGNATURE
MESSAGE: f
„of
'I�G n�t airs �
"FOR ALL YOUR WATER NEEDS"
YADKIN WELL. CO.. INC.
$9O0 HAMPTONVILL£ ROAD
HAMPTONVILLE. NC 27020
[3AVID S. RROWN. VICE PRES.
TOLL FREE (90O) 248;935S
OFFICE 13361 488.4440
FAX S3351 463.4040
RES <33fi1 d69.4B39
-*GOD MEWS AMERCCA • ODD LOYCS YOU'
RECEIVEL
DEL 0 2 Nil
PLEASE INFORM US MMMED1RE1.Y IF YOU DO NOT RECEIVE FACSIMILE IN FULL