WI0500470_GEO THERMAL_20120131

Permit Number WI0500470
Program Category
Ground Water
Permit Type
ll
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Jake Jaquiss SFR
Location Address
115 Carramore Ln
Durham
Owner
Owner Name
Jake
Dates/Events
NC 27704
Jaquiss
Scheduled
Orig Issue
01/31/12
App Received Draft Initiated Issuance
12/12/11
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files: APS_ SWP_
01/31/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Jake Jaquiss
Owner
115 Carramore Ln
Durham NC
Major/Minor
Minor
Region
Raleigh
County
Durham
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Jake Jaquiss
Owner
115 Carramore Ln
Durham
Public Notice Issue
01/31/12
NC
Effective
01/31/12
27704
27704
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman
Governor Director Secretary
01/31/2012
Jake Jaquiss
Cheryl Jaquiss
115 Carramore Ln.
Durham, NC 27704
Subject Acknnwledgement of Intent to Construct Type SQW Injection Well System.
Permit No. W10500470
115 Carramore Ln.
Durham, NC 27704
Dear Mr. Jaquiss:
On 12/12/2011, 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 Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(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 [e-mail] if you have any questions.
for Deb
Supervi
cc: Raleigh Regional Office - APS
APS Central Files - Permit No, W10500470
Durham County Health Dept,
Derry Huneycutt (Derry's Well Drilling, Inc., 44283-A Hwy 24/27/73 E, Albemarle, NC 28001)
Scott Fluette (Fluette Heating & Air, P.O. Box I413, Graham, NC 27253)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh. North Carolina 27604
Phone: [phone] FAX: [phone]
Internet. www.ncnraterq+Ia1ity.ora
An Equal Opporhinity l Affirmative Action Employer
One
N rth Carolina
)'aturaIfM

~<:fXf-/'l 0 ----------NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A 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 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Print or Type Information and Mail to the Address on the Last Page.
DATE: December 6 , 20_11 _ PERMIT NO. ________ (to be filled in by DWQ)
A. STATUS OF WELL OWNER ( choose one)
Non-Government: Individual Residence XX Business/Organization __
Government: State Municipal __ 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:
· 1 a..k -e.. o V\ d Ch. e c~ ( : \ a , ~ u ,, s s
Mailing Address: [ I S Ca. rrO-m o C e Ln
City: 0 1, r h, d--"YY\ State:~ip Code: ~77 0 L/ County: {j V C h ~
Day Tele No.:
1
Cell No.: S 9 o -7 3 O 5 ~~(
EMAIL Address: '2:J °"1) u I S S e ... J')'\A c. c..Cl vn Fax No.:
C. LOCATION OF WELL SITE-Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: a I O t 1 °I County: D vrh. ~
(2) Physical Address (if different than mailing address): ________________ _
City: ________________ State: NC Zip Code: ________ _
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: ----"'D::..::e=rr'---'y-"H=u=n=e,.,_y=cu=tt:..:...._ ________________ _
NC Well Drilling Contractor Certification No.: --=2-=-66=3'-'A'----"-------------------
Company Name:. ___ =D-=e=rr'-'-y-='s~W~e=ll-=D"-"r-=il=li=ng=•c...=I=nc=-----------------------
Contact Person: Derry Hune ycutt EMAIL Address: derr [e-mail]
Address: --~44~2~8~3~-A~H~e_,_y_2_4/_2~7~/7~3-=E~----------------------
City: Albemarle Zip Code: 28001 State: NC County: -----==S~ta~n=le,.,_y __ _
Office Tele No.: 704-982-3070 _______ Cell No.: _704-985-6135 _ "'-F=ax'-=-N"'-=o-=-=-·=------
RECEIVED I DENR / DWQ
GPU/UIC 5QW Notification (Revised 3/18/2011) Aquifer Protection Section Page I
DEC 12 2011
E. !TEAT PUMP CONTRACTOR INFORMATION (if different than dr' er)
!
Company Name: Fi V if c_ `' 2� t' be
Contact Person: Sc_, f+ J- i if DTI -e, �] EMAIL
Address: f' b /3 fax 1 El
City: 6fl2Aarr? Zip Code: vZ70-53 State: A/C County:
Office Tele No.: .33 4--- .3-10 — 4f Yg t
334,— 51� " Cell No.: FaxNo.:
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: 3 Depth of each boring (feet):_300'
* 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): HOPE
(3) Well casing. If the well(s) will use casing then provide the type (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** _XX _ Other (specify)
" By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from _300 _ to _0 (feet)
If well 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 clear') and include a north arrow.
(1) Attach a site -specific map showing the locations of the following:
* Proposed injection wells
* Surface water bodies
* Buildings
* Water supply wells
* Property boundaries
* 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 GIS webslte. Typically, the property can be searched by
owner name or address. The location of the wells hi relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a `layer' can be selected showing topographic contours or
elevation data.
GPUMC 5QW Notification (Revised 3/18/201 t) Page 2

II. CERTIFICATION (to be signed as required below or h\ that persoin's authorized agent)
i 5A NC AC 02C .0211(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 (__hick 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.
"1 herd)} certify, under penalty of law, that 4 have personals} examined and am familiar with the information
submitted in this document and all attachments thereto and that, ba,.eri on my inquiry of those individuals
immediately responsible for obtaining said information. l believe that the information is true. accurate and
complete. 1 air aware that there are significant penalties. including the possibility of tines and imprisonment.
for submitting false information. 1 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 o
Pr+peri t nvnler!Applicant
Ro �14 (,b) 3 -SS
Print or Type Full Name
Signature of ProirLrtt: yhw
Print or Type Full Name
'Applicant
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]
r ut. ri sQ Notification (ltrvi.aed 3r i ar?nt t )
RECENI_D / DE I Oki
Aquifer Protiz4tion Sedum
brE I2?OP

le envN a1
-00_135 rs et-yti

Acia Wi/Dco-ood-00
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman
Governor Director Secretary
01/31/2012
Jake Jaquiss
Cheryl Jaquiss
115 Carramore Ln.
Durham, NC 27704
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10500470
115 Carramore Ln.
Durham, NC 27704
Dear Mr. Jaquiss:
On 12/12/2011, 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 ail 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 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.Rouers(encdenr.gov if you have any questions.
cc: Raleigh Regional Office - APS
APS Central riles - Permit No. W10500,170
Durham County llealtii Dept.
Derry Huneycutt (Derry's Well Drilling, Inc., 44283-A Hwy 24/27/73 E, Albemarle, NC 28001)
Scott Fluette (Fluette Heating & Air, P.O. Box 1413, Graham, NC 27253)
AQUIFER PROTECTION SECTION
1636 Mail Service Canter, Raleigh, North Carolina 27599.1636
Location: 512 N. Salisbury St, Raleigh, North Carolina 27604
Phone: 919$07-6454 l FAX [phone]
Internet: www.ncwaterqualittorq
An Equal Oppar{unay 1 Affirmative Action Employer
Noe
rthCarolina
Naturally

,-
Godwin, Ton ya
From:
Sent:
To:
Cc:
Subject:
Attachments:
Mr. Jaquiss,
' .
Godwin, Tonya .
Monday, February 20, 2012 10:17 AM
'rjaqµ[e-mail]'
Smith, Eric
5QW Injection Well Ack Letter -115 Carramore Ln. -WI0500470
DOC022012.pdf
Attached is the SQW acknowledgement letter for 115 Carramore Ln.
Have a great day.
Tonya Godwin
NC Dept of Environment and Natural Resources
Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
919-807-6301 (Office)
919-807-6496 (Fax)
Ton ya.Godwin @ncdenr.gov
Email correspondence to and from this address may be subject to the North Carolina Public Records Law and
may be disclosed to third parties.
l
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