WI0500472_GEO THERMAL_20120131

Permit Number
Program Category
Grouqd Water
Permit Type
WI0500472 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Eric Noble SFR
Location Address
6872 Stagville Rd
Bahama
Owner
Owner Name
Eric
Dates/Events
NC 27503
Noble
Scheduled
Orig Issue
01/31/12
App Received Draft Initiated Issuance
12/13/11
Regulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files : APS_ SWP_
01/31/12
Permit Tracking Sllp
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Eric . Noble
Owner
6872 Stagville Rd
Bahama
Major/Minor
Minor
Region
Raleigh
NC
County
Durham
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Eric Noble
Owner
6872 Stagville Rd
Bahama
Public Notice Issue
01/31/12
NC
Effective
01/31/12
27503
27503
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
ATI
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P. Dee Freeman
Governor Director Secretary
01/31/2012
Eric Noble
Laurie Noble
6872 Stagville Rd,
Bahama, NC 27503
Subject: Acknowledgement of Intent to Construct Type 5QW injection Well System
Permit No. WI0500472
6872 Stagville Rd.
Bahama, NC 27503
Dear Mr. Noble:
On 12/13/2011, 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 h 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 Michael.Ragersrd)nedenr.gov if you have any questions.
erely,
1
for Dt ra %1;atts
Supervisor'
cc: Raleigh Regional Office - APS
APS Central Files - Permit No. W10500472
Durham County Health Dept,
Josh Robertson (Triad Drillers Inc., 8228 Kerns Chapel Rd., Elon, NC 27244)
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury SI., Raleigh, Norlh Carolina 27604
Phone: [phone] I FAX: [phone]
Internet wuvw.ncwateraualitv.org
Art Equal Opportunliy Ai7rrnative Arbon Emp:uyer
No ehCarolina
thrall

PHONE Na. : 919 459 6649 Dec. 93 2011 10:52PM P1
FROM : Morrissey Mecham ieat
WO5aDLIP,
NOR .rH (:ARO..1.J»
.f1=,t'�. '1 L►r?. "1 OE ENVIRON3vEN'i.AND'NAT'L)RA}. it :SOUR€'FS
i` OTTFt . ATIO! 1 OF INTENT TO CONS' 'S ter A CLOSED -LOOP CEOTRERM&.L
ArATJ R.ONLY INJECTION WELL SYSTEM
rt
TYPE SOW Vitj,,US)
Est Avort anee With the Provisions of NCAC Title t 4A. O?.C.O20O
Print or type the required i, I rmation and mailiv address on the bock page.
1
1
DATE: �� j� , 204
WO Type Confirmation: Does the proposed system circulate potable water pn4v (no additives) in
continuous piping that completely trial ass rha fluid from the environment (Lan_
closed -low)?
Yes Continua completing this form.
Do Not complete this form. Complete other MC applit:ation forms for installing
either a }A 7 wali (noert-loop well i altig potable water into the aquifer) or a 5%4 well (closed -
loop well cottta ring additives such as R. 22, ethanol, or other antifreeze or corrosion inhibitors).
A_ PROPERTY O'WN R(S)IAIP LICANT(S)
List each Prop:rry Owner fisted on property deed (if owned by a business or government agen , stern,, name of
entity and a representative wlauthority f r signature): ry C ?� uC? e, 1f i'7 .
(I) Mailing A ddr ss:
City!
State:,', Zip Code: County:
of
H ome/Office 'Tele No., q i 9 730 ` 3 lb 7 T. CeU No.:
Email Address: ----- Website: -�
(2) Physical Address of Weil Sire (if d'stTerent than above):
City: State: Zip Code: _ County:
Home/Office 7'ete No.: C'eli
B. AFTTHoRIZED AGENT OF (OWNER, IT ANY (if the Permit Applicarn does not own t_he subject property,
attach a letter from the property owner authorizing Agent to install and operate WIC well)
Company Name_
Contact Person; EMAIL Addte :
Address: _
City_ State: Zap Code: _ County:
Office TeIe No,: G II No.:
Website Address of C=ompan i, if ai?v =—�-- —

FRDNI : Morrissey Mechanical
PHONE NO. : 919 469 5549 Dec. 03 2011 10:53RM P2
C. WELL DRILLER INFORMATION
Comps ri) Name- r Of:;.derc TA(
well Diner font_rdctor's Na
'NC Cootraetcr Curtlik.carion Na.:
Contact Person: aOS 4i i li� i' 1^I. F='MAJ, £ _
Address: j
City: iW Zip Code: 99 Csinnty:
Office Tele No.: 33LG • 4a)- 35 3 Cell No.;
D. MEAT PUMP CONTRACTOR S NF'OLMATION (if different than driller)
Company Name- ..
Contact Person: _ MAIL Add e s;
Adds -es .,
City: Zip Code: County:
Office Tete No.; Cell Na-'
E. STATUS OF APPLICANT
Private: Federal: Commercial:
State: Municipal: Native American Lands:
F. INJECTION PROCI IRE [briefly clesarive how the injection well(s) win be used)
G. WELL CONS 1 RUCTION DATA
(I) Proposed dare to be constructed: _ . 11.9 - ] Number of borings:
Approximate depth of each boring (feet): . 3 r1
(2) Type: of tubing to be used (opper, PVC, etc): J21 z i d B,
3
(3) Well casing. Is the weii(s) cased? (check either (a.) Y or (b.) No below)
(a) Yes if yes, then provide casing information Mow
Type: _,gsivanized steel black steef____plas-tio -other (specify)
Casing depth: Frurn to feet (reference to lewd surf )
Casing extends to above ground inthori
(b) No
(4) Grout Info (material sLrrounding well casing and/or piping):
(a) ;taut type: Neat Cement czttortite Otier (specify)
(bi Gt'out placement: Pumping.,'\ Pressure Other
(c) Grout depth of tubing (ref'ere v to land surf rce:): from '.o 37 (feet)
If Welt has casing, indicate grout depth: from TO (feet)

FROM : Morrissey Mechanical
PHONE NO. : 919 469 6649 Dec, 03 2011 10: S3AN P3
H, iNJA,C'Tttiii►-1#tr't.: t'F:i1 a;141,I I'MC NT
Attu a diagram .phoNv 47s, ;ire ergineering 14y4,Iut , r.7posed .:rutElficArdon of the inaction eyaiipree=2f ,2ad exterior
prpipglttti+int; 3�sz.xiared Nitlr the hip aion operation. 'Tifactui' is brachurc mity pr.wid4 stip#sl�i utar;'
infOrmati on
L LOCATION (» WEUL- .(S)
Attach two tvopie of mks shoving the following in$2anuarinec
(I) Include a Site Map (c:an, De dxawa) nng: builatop., proper r titoes, .,mace woobodies, potential
sources of graupdwater COOtarni ation aid ilae orlerita ors of and distehtes bavieen the proposed wta(s) and
any existb wetl(s) or walste disposal facilities such es septic ,Ics or Brash fi Eds located whin 7% feet of
du, gectherriheat pturp wal! system Label ail feat rt s clear!) and tc e rnrth artQw.
(�) � site !Asp most show the subject property in relwian to the surrounding at by using at lea-4 twc teed
reference point such as nds, stream& and/or highway intersections.
J. CERTIFICATION
NaVe: This Permit Application mast be signed by ask peraou appeariag on the
recorded Legal property mod.
henehy tent:, under penalgi of law, that 1 have personalty examined and a2tra famiNat with lase inf&rmation
submitted in this document and all artatmeatS thereto and drat, based on my inquiry of thove. ;indIvi s
icimediately responsible for obtaining said information, k betieve that the information iacCiatt.Olfco!gtl
I. am aware that there are signii;z penahies, including the possibility of firsts and imprisonment, fiat subpitOg
false int'orntatitsn l agree to construct, eperaii., maintain, repair, unit abandon the inje beet tideil and
all related appurtenatIM in taxordanee with t appravd scil cations and ceindilioos of the Portrait„
Lure of Property OwneriAppiicarst
MitglE k • No8LF_
Print or Type Pull Aroma and title
Signature of Property Ovmar/Applicant
Print or Type rilli Name. arid ide
Pxemse return two copiez of the completed Applicattan pozicage u►=
North Carolina ittEN1t.-DWQ
Aquifer Protection Section-VIC Program
163.6 Mail Service Center
Raleigh, Ne 27699-1636
TmietiMitie. (W) 733-3221

FRAM : Morrissey Mechanical
PHONE NO. 919 469 6649
Dec. 03 2011 10:54AM P4
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