WI0500465_GEO THERMAL_20120126

Permit Number
Program Category
Ground Water
Permit Type
WI0500465 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Jeffrey & Stefanie Reed SFR
Location Address
1672 Legendary Ln
Morrisville
Owner
Owner Name
Jeffrey
Dates/Events
NC 27560
Reed
Scheduled
Orig Issue
01/26/12
App Received Draft Initiated Issuance
11/18/11
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
01/26/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Kevin Letchworth
Driller Well
PO Box 1958
Wendell
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Jeffrey Reed
1672 Legendary Ln
Morrisville
NC
NC
Public Notice Issue
01/26/12
Effective
01/26/12
27591
27560
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Jeffrey Reed
Stefanie Reed
1672 Legendary lane
Morrisville, NC 27560
NA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P.E.
Director
January 26, 2012
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0500465 .
1672 Legendary Lane, Monisville, NC 27560
Dear Mr. & Mrs. Reed:
Dee Freeman
Secretary
On 11/18/2011, the Aquifer Protection Section (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 Garolina
Administrative Code Title 15A Section 2C Subchapter .02ll(u)(2). Additionally, you should contact the Wake 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 [e-mail] if you have any questions.
cc: Raleigh Regional Office -APS
APS Central Files -Pennit No. WI0500465
Wake County Health Dept.
NW Poole Drilling & Well Co (Kevin Letchworth)
Evangelist Service Company (Bill Evangelist)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] I FAX: [phone]
Internet ·www.ncwaterquality.org
An Equal Opportunity\ Affirmative Action Employer
S:f\erely, I}_.,...,._ \J r~,tfi A. uw~
forDe~;~s
Supervisor
One . . .. North Carolina
/v.a/ural/11
\
FROM :ESC { -•
FAX NO. :9193625783 Nov. 17 2011 05:21PM Pl
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER .. ONLY INJECTION WELL SYSTEM
TYPE 5 0 W WELL(S)
In Accordance With the Provisions ofNCAC Title 15A 02C.0200
Print or type the required tnfunnation and mail to address on the back page.
DATE: _...ullt___:_-.....:./__,_7 ___ , 20...LL ~D S c:o-floS
Well Type ConflnnaJion: Does the proposed system circulate potable water onl y (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e .
closed-Joo p)?
Yes){__ Continue completing this form.
No __ Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well ~-loop well injecting potable water into the aquifer) or a 5QM well (closed-
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibit.ors).
A, PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, slate name of
entity and a representative w/authority for signature): Je,+£~ I/ /le.gL
Sf e[411, e II flq £__
(1)
(2)
Mailing Address; /b 7-l ~~ ~
City: tftt,. ((1 su, If< State: At!k. Zip Code:
Home/Office Tele No.: _ '1.t 1 .,. °33'"' ~ //fl)
Email Address j e-fk.,.,,/ !±c+<€_ Website:
j.,t11.«t'/ .ca.-,.
Z.. ~ .£~ a County: ~k
CellNo.: &/2--S,gz-frrl/
'
Physical Address of Well Site (if different than above): _____________ _
City: _________ State: __ Zip Code: ______ County: ____ _
Home/Office Tele No.: Cell No.: ----------------"~~'-'-----------
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a Jetter from the property owner authorizing Agent to inst.all and operate UIC well)
Company Name: ____________ ~----~---~-------
Contact Person~: ---------------=E;,,;M..,A-.;.,l,.,,,L:.-,_A_._,,d,,,,,d,._,re,,,,ss.._: _________ _
Address: _____________________________ _
City: ________ State: __ Zip Code: ______ County; _______ _
Office Tele No.: Cell No.:
Website Address of Company, if any:. _____________ _
RECE:iVED ' J::NR I JWQ
AQUll=l=P. PROTFr.r1n~, q!=C-lON
NOV 1 8 2011
I •
FROM :ESC FAX NO. :9193625783 Nov. 17 2011 05:21PM P2
C. . WELL DRILLER INFORMATION
Company Name: . /IJ w eoo 1. <."' Dti,w. '~ & t-,Wet.c.. lo
Well Driller Contractor's Name: --+M~E-o-c"~'~~~l'-'e--'11'""'c.-'-l'---'-W_~'--'o/B'-'-~-----------
NC Contractor Certification No.: _2----=t '--3'"'"$"'--'-"'~'--------------------
Contact Person: kev ,:.. @ 4\60 r,.,f #: EMAIL Address:
Address: f,o~ 0;o )( l ,a8
City: \A)('H0e-t(. Zip Code: Z'.) r,; / County: __ W_A-t:....c..._ce-c..___ _______ _
Office Tele No.:,f~ 1,,_CJ.n3 Cell No.: ________ _
D. HEAT PUMP CONTRACTOR INFORMA T.1.0N (if diffe.-ent tha11 driller)
CompanyName: t1J 14,1r;,,;urr--'S?'t!~v,te ~""'f--;.
Contact Person: ~1 lA. t!i,111we,e't1$'l EMAIL Address:
Address: H<1 I P:::Jctiez.of:\. ~IQo
City: lA{?~~ Zip Code; 2 ,f 2 ..3 County: _C_*_lf'T1_'R_I"_"'-_______ _
Office Tele No.: e,11'-$b2 .. -m O Cell No .: ~---~~---
E. STATUS OF APPLICANT
Private: -JS __
State:
Feder~l;
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G~Ji#K lo,ff\. cU)s e,n ~es:.
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: / J-16-1 I Number of borings: ~-2.-~-
Approximate depth of each boring (feet): _ _..J,.YoQ _______ _
(2) Type of tubing to be used (copper. PVC, etc): PG
(3) Well casing.. Is the well(s) cased? (check either-(a-.)-Y~es~o_r _(b-.@---=N...-be-,-,o-w_) _____ _
(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 a.hove ground ___ inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite _x___ Other (specify) f.,_Jt..,o. Jlh,tJ
(b) Grout placement: Pwnping_[__ Pressure__ Other __
(c) Grout depth of tubing (reference to land surface): from _J>_ to 'f()() (feet)
If well has casing, indicate ~rrout depth: from ___ to ____ (feet)
FROM :ESC FAX NO. :9193625783 Nov. 17 2011 05:22PM P3
II. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering l.ayout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
infonnation.
L LOCATION OF WELL(S)
Attach two copies or maps showing the following infonnation:
(1) 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 dearly 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 hjghway intersections.
J. CERTIFICATION
Note: This Permit Application most 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 infonnatjon 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, mrontain, repair, and if applfoable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conditions of the Permit."
~/4&,,{ ~ perty Owner/Applicant
0<:++ ~v -4, /{gg,t
Print 9f Type FutiNke a:ridtitle
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signaru:re of Authorized Agent, if any
Print or Type Full Name and tit1e
Please ret\JTn two copies of1he completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center RECEIVED I DENR; DWQ
l'\QUIFl=R"PR()Tr:rr1n~1 ~c:-c,1m•
Raleigh, NC 27699-1636
Telephone [phone] NOV ! 8 2011
FRCr 1 :ESC
FAX ND. :91935257 3 Nov. 17 2011 05:22PM P4
201
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