WI0500476_GEO THERMAL_20111024

NORTII CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM
TYPE SOW WELL(S)
In Accordance With the Provisions ofNCAC Title ISA 02C.0200
Print or type the required information and mail to address on the back page.
DATE : October, 24th 20 11 ' --\J...TI.OS0O'-J1<_p
. .
.)
r.-
--1
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-loon)?
Yes _x_ Continue completing this form.
No ___ Do Not complete this form. Complete other UIC application forms for installing
either a SA 7 well (Qrum-loop well injecting potable water into the aquifer) or a SQM well ( closed-
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/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 w/authority for signature): Walter & Gerda Hanek
(1) MailingAddress: 3805A University Drive
City: Durham State: ~Zip Code: 27717 County:_ Durham
Home/Office Tele No.: Cell No .: +52 1 (222) -536-J.690
Email Address:
walter.hanek@gmail .com
Website:
(2) Physical Address of Well Site (if different than above): Starterwood Lane
City: Hillsborough State: NC Zip Coqe: 27278 County : Orange
Home/Office Tele No.: Cell No,:
8. 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)
CompanyName: Spyglass Building Company
Contact Person,;_ Rod McLamb EMAIL Address : [e-mail]
Address: 310 1/2 W Franklin St
City: Chapel Hill State: NC Zip Code: 2 7 516 County: Orange
Cell No.: 919. 422. 9804 Office Tele No.: 919. 341. 3910
Website Address of Company, if any: www. SpyglassBuildingCo. com
GPU/UIC 5QW Notification oflntent Form (Revised 8/2008) Page I
C.
D.
WELL DRILLER INFORMATION
Company Name: G..l_
Weil Driller Contractor's Name:
NC Contractor Certification No.:
A. /)Arc)'
on1I.; LLC
c.1/ 4 D cI
'?900 —A
Contact Person; (r Ae,. A ave A
EMAIL, Addres,s: 9 of tn, e/14 4 j E 6:31:r
Address: / 3 /p i Id f yr u Pd in,q7
City: i+/R let Farr 51 Zip Code: 2 7 5 '7 County: NC
Office Tele No.: CM) 5-51- 5973 Cell No.: (1/9) v z 7_ - 3/
HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Cho Lma ■
rcStrv.cas
Contact Person; S'irve eow..,q^
Address: /15 f8cAAlcQ! Coo,/
City: 6:-ittrn & Zip Code: Z 7S 19 Countr tyr
7%1-z� ��`
Office Tele No.: 9f3) � tF,,Cf1 No.: /�) 9 79 z 9y
WAIL Address;
E. STATUS OF APPLICANT
Private: I-' Federal: Commercial:
State: Municipal: Native American Lands:
F.
F4k019)5-51- 3939
.-."A^.-,ems itt,�'�G�I�.l.���
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: _ Number of borings:
Approximate depth of each boring (feet): 300
(2) Type of tubing to be used (copper, PVC, etc): I/O p
(3) Well casing. Is the well(s) cased? (check either (a.) Yes QiC (b.) No below)
(a) Yes if yes, then provide casing information 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
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite ,k Other (specify)
(b) Grout placement: Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from 4 to - 0 (feet)
If well has casing, indicate grout depth: from
to (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 812008) Page 2

H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
pipinglltrbing associated with the injection operation. Tfie manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1)
Include a Site Map (can be drawn) snowing: 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 wells) 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 nor1#t_arraw.
(2) The Site Map trust 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 guh 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 flit my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the infortnation is true, accurate and complete.
I atn aware that there are significant penalties, including the possibility of fines and irnprisotnnent, 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 apppaved specifications and conditions of the Permit."
a4teL
Signature of}'roperty OwnerfApplicant
dt i. T6-1? M9A'
Pratt or Typo Full Name and title
6,(161 42A,tik
Signature of Property 01vner/Applicant
Ge-7?pg ##A16.74
Print or Type Full Name and title
pra
Rod McLain!): 61•C.p.
UAW MI11113, iTJ3A
Signature of Authorized Agent, if auy
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-tflC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
OPUIUIC SQW Noliticalien of latent Form (Revised 8f208B) Pagel

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HILLSBOROUGH, NC
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CONSTRUCTION
DOCUMENTS
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Orange County NC GIS
Page 1 of i
Orange County, NC GIS
Orange County NC CIS
9623842024 9643941313 164394979i 935;0 ?12 t'`3142451
0723 " 965313224B
995203212E
9642637110 9843923140-.:.:!
98426126E9
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96E2E97108
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http://server2.co.orange.nc.us/OrangeNCGlS/defau:t.aspx
10/24/201 1

Permit Number WI0500476
Central Fifes: APS SWP
02/01/12
Permit Tracking Slip
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Status Project Type
Active New Project
Version Permit Classification
1.00 Individual
Primary Reviewer Permit Contact Affiliation
eric.g.smith Rod McLamb
Coastal SW Rule
Permitted Flow
Faoili: ;
Facility Name
Walter & Gerda Hanek SFR
Location Address
2024 Starterwood Ln
Hillsborough NC 27278
Owner
Owner Name
310 112 W Franklin St
Chapel Hill NC 27516
Major/Minor Region
Minor Raleigh
County
Orange
Facility Contact Affiliation
Owner Type
individual
Walter Hanek Owner Affiliation
Walter Hanek
Dates/Events
❑rig Issue
02/01/12
App Received Draft Initiated
12/22/11
Regulated Activities
Scheduled
Issuance
Heat Pump Injection
Outfali NULL
310 1/2 W Franklin St
Chapel Hill NC 27516
Public Notice Issue Effective Expiration
02/01/12 02/01/12
Waterbody Name Stream Index Number Current Class Subbasin

Beverly Eaves Perdue
Governor
Walter & Gerda Hanek
310 ½ W. Franklin Street
Chapel Hill, NC27516
AW'A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P.E.
Director
February 1, 2012
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
PermitNo. WI0500476
2024 Starterwood Lane; Hillsborough, NC 27278
Dear Mr. & Mrs. Hanek:
Dee Freeman
Secretary
On 12/22/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl y
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 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 -Permit No. Wl0500476
Orange County Health Dept.
Spyglass Building Company (Rod McLamb)
Glen A Darch Well Drilling, Inc. (Glen A Darch)
Bowman Mechanical Services (Steve Bowman)
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.ncwaterguality.org
An Equal Opportunity\ Affirmative Action Empioyer
SO'iittA.&mL
for Debra Watts
Supervisor
. One . . .• NorthCarohna )Vat11.tally
RECEIVED/ OENR / owa .
AQUl,\:t=R·PROTFr.TtON SECitON
tDEC 2 2 20H
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 information and mail to address on the back page.
DATE : October, 24th 20 11 ' --\J\JJ:. oi; fX:JL-t 7 ll
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-looQ)?
Yes _x_ 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 additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/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 w/authority for signature): Walter & Gerda Hanek
(1) Mailing Address: 310 1/2 W Franklin Street
City : Chapel Hill
Home/Office Tele No.:
State: NC Zip Code: 2 7 516 County :_ Orange
Email Address:
walt~r.hanek@gmail com
Website:
Cell No · +52 1 (222) -536-J 69o
(2) PhysicalAddressofWellSite(ifdifferentthanabove): 2024 Starterwood Lane
City: Hillsborough State: NC Zip Code: 27278 County: Orange
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 letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: Spyglass Building Company
Contact Person~ Rod McLamb EMAIL Address: [e-mail]
Address: 310 1/2 W Franklin St
City : Chapel Hill State : NC Zip Code: 2 7 516 County : Orange
Cell No.: 919. 422. 9804 Office Tele No .: 919. 341. 3 91 o
Website Address of Company, if any: www. SpyglassBuildingCo. com
GPU/UIC 5QW Notification of Intent Fonn (Revised 8/2008) Page 1
C. WELL DRILLER INFORMATION
CompanyName: Glen A. Darch Well Drilling, LLC
Well Driller Contractor's Name: Glen A. Darch
NC Contractor Certification No.: 3900-A
RECEIVED/ DENR I DWQ
AQUIFi=R·PROTFr.TJON S£CTJON
DEC·J .2 2011
ContactPerson~ Glen A. Darch
Address : 13109 Bold Run Hill Road
EMAIL Address: gdwelldrilling@aol com
City : Wake Forest Zip Code: 27587 County : Wake
Office Tele No.: 919. 556. 5959 CellNo.: 919 422 .9931 Fax: [phone]
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
CompanyName: Bowman Mechanical Services
ContactPerson~ Steve Bowman
Address : 145 Technical Court
EMAIL Address: [e-mail]
City: Garne r Zip Code : 27529 County : Wake
Office Tele No.: 919. 772. 2759 C81Uoie .: ___ F_a_x_:_9_1_9_._7_7 _9 _. 9_2_9_4
E. STATUS OF APPLICANT
Private: x
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: A5t >t ~\ ffAc."'MA!-Number of borings: __ 3 __ _
Approximate depth of each boring (feet): --------300'
( 2) Type of tubing to be used (copper, PVC, etc): __ H_D_P_E ___________ _
(3) Well casing. Is the well(s) cased? (check either (a.)Yes m: (b.) No below)
(a) Yes ___ if yes, then provide casing information 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 )(
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement __ Bentonite x Other (specify)
(b) Grout placement: Pumping __ Pressure Other __
(c) Grout depth of tubing (reference to land surface): from SFC to 300 (feet)
If well has casing, indicate grout depth: from to (feet)
GPU/UIC 5QW Notification of Intent Fonn (Revised 8/2008) Page2
RECEIVED / O NR / OWQ
AOUlFFP PRfITMrTI(rN sl=tZoN
DEC 22 2O1
11, 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.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1)
(2)
Include a Site Map (can be drawn) shoving: buildings, property lines, surface water bodies, potential
sources of grouurhvater contamination and the orientation of and distances between the proposed ►vcli(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 jacludc north arrow.
The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roods, streams, and/or highway intersections,
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing an the
recorded legal property deed.
".I hereby certify, under penalty of law, thal 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 constrict, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the nppved specifications and conditions of the Pennit."
0.41-e-k/
Signature operly Owner/Applicant
A0 TER M9,vA'
Print or Type Full Name and title ]a 424,4
Signature of Property ❑wnet/Applicant
Print or Type Full Name and title
Rod McLamb
04i0ySigned 4r red Mcua%
pry:., I @ Md.nt oap, ba prrmyco�.p,�,,
e.*ra.KNrd,00n 71ho•.+us
2046 -WIT
Signature of Authorized Agent, if any
of ?nygias nUslding Company
Print or Type Full Naive and title
Please return two copies of the completed Application package to:
North Carolina DENI2-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
(7P131UTC 5QW Notification of intent Norm (Revised WON)
PagF 3

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Orange County NC GIS
Page 1 of I
RECEIVED / DENK i u1'ru
AQAFFR PRnTFC..Ti(1N SECTION
DEC 22 2011
Orange County/ NC GIS
Orange County NC GIS
9843941 ?.13 394979 9353046212 5314345
9043812869
9842709133
9653132248
9653632120
6E301121 98530172301
9843909E25
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9642998361
9542982872
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4296395 J 96E2179260
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9652096853
831230
935324803
9653228384
913553214125
9653196029
9852197629
9652197294
9652280538
298507
9652087431
9852061262
5218447
9352270812
9342979540 1g85207651521726
92271VOr52'73
53327568
5653324096
53307
R29652392755
91523774
9652287660
935227893
185238549
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3516g
9353403525
9352597108
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524688
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10/24/2011

07/15/21311 16: fD5 919E443e06
CR*KiE trj ENV HLTH PAGE �� t
l� on k os,
Fri. 1t1,111.1Z4id
Ali STerr 6 � i
ORANGE COUNTY ENVIRONMENTAL HEALTH
ADDENDUM FOR GEOTHERMAL WELL APPLICATIONS
APPLFCArTnhs Fat WELLS ARE COSSIDEI!Fo INCOMPLETE. rtTTrt. THE vO .i.riwlNG 14VORMAT1O'V 18 PROVIDED
To THE ORANGE COUNTY ENVIRONVIENTA I. HEALTH St er1ON:
L. Will the well tic:
w Closed Loop (water only circulation)
Sithmit copy of DWQ SQW application
❑ Closed Loop (mixed fluid Circulation)
Submit copy of DWQ SQM application
[] Open Loop (discharge back to groundwater)
Submit copy of DWQ 5A7 application
❑ Open Loop (discharge to surface)
a•Fa DWQ application needed
2. Number of Wells to be constructed:
3. Site plan requirements:
9,1- G'4'4. 300
A1'1 'Tow
Vertical Sore
Submit a site pan showing the proposed:
a. Well locations and the route of the piping to the house;
❑ Angie Bore
Submit a site plan showing the proposed
a. well locations
RECEIVED I DENR 1 DWQ
AQUIPR pRMFCTIC]N SECT14ti
DEC 2 2 1011
b. Direction of hare
c. Route of piping to the house
NOT,: d1l portian.t of the propared angle hnrehole must meet rho horizontal setbacks required by
"Orange County Groundwater ProtecIton Ruler,
4. Well construction profile diagram indicating;
a. Borehole dimensions. (Diameter and Depth) 6 k 3° 41
}
- For angle bores, show angle, and length of proposed bore;
It. Grouting materials: ac:.7 ; e''1s 7u C. 1-11) 51-A &
e. Pipe material and dimensions;
d. Proposed depth of bore ,3 O 0 —
e. Submit soil pH test results or Cathodic Protection detail% for metallic
piping
5,
Chemical additives/refrigerant rype that will be used in closed loop
system: