WI0500485_GEO THERMAL_20120216

Permit Number.
Program Category
Ground Water
Permit Type
WI0500485
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facili
Facility Name
Patrick & Laura Kavanaugh SFR
Location Address
3009 Hartwell Pond Dr
Hillsborough
Owner
Owne.rName
Patrick
Dates/Events
NC 27278
Kavanaugh
Scheduled
Orig Issue
02/16/12
App Received Draft Initiated Issuance
02/09/12
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_
02/16/12
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Glen A Darch
13109 Bold Run Hill Rd
Wake Forest
Major/Minor
Minor
Region
Raleigh
County
Orange
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Patrick Kavanaugh
2325 Stagecoach Dr
Hillsborough
NC
NC
Public Notice Issue
02/16/12
Effective
02/16/12
27587
27278
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
,t:: if
Governor
Patrick .Kavanaugh
Laura Kavanaugh
2325 Stagecoach Drive
Hillsborough, NC 27278
AWA
MC EHR
Director
February 16, 2012
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0500485
3009 Hartwell Pond Drive, Hillsborough, NC 27278
Dear Mr. & Mrs. Kavtmaugh:
Secretary
On February 9, 2012, 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 weli 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 Michael.Rogers@ncde:irr.gov if you have any questions.
cc: Raleigh Regional Office -APS
APS Central Files -Permit No. WI0500485
Orange County Health Dept.
Glen Darch -Glen A. Darch Well Drilling
Steve Bowman -Bowman Mechanical Services, lnc.
iGJS ; ... ~-:,:! Suh;~;.; GoL/fJ ;·~al';:Jg;i, !~~ t:1 Ca;-.:.<1t: '.t:;'df). 1~_;_)
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] I FAX: [phone]
Internet: www.ncwaterguality.org ·
An Equal Opportunity I Affirmative Action Employer
Sincerely,
0(1-lfi A-6rou
forD~;;~s
Supervisor
-•One.... . . North Carolina W_aturall!f. ·
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: Z /g , 20 // PERMIT NO. \14-0S ` otitS (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non -Government: Individual Residence _X_ 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 an behalf of the business or agency:
r4'ty ar1a v
Mailing Address: Z 3Z,5 S e C aac,< /)r —
City: //t /'- '6o,C [, State; NC Zip Code: 1.7Z- 78 County:
Day Tele No.: (/9f c�, 6'?Z — / 310 Cell No.:
i,. /.
EMAIL Address: k1 Q I1ff/1A G94 S [�' em O+ ax No.:Caw,
C. LOCATION OF WELL SITE — Where the injection wells are physically located:
(1) Parcel Identification Number (PIN) of well site: vas- 313 3 9 I _ _ County: Or Art t
(2) Physical Address (if different than mailing address): O `) //Cu-At€, //
City: /0/S4 Or-gu State: NC Zip Code: Z.72,78
D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: Glen A Darch Well Drilling LLC
NC Well Drilling Contractor Certification No.: 3900-A
Company Name: Glen A Darch Well Drilling LLC
Contact Person: Glen A Darch
Address: 13109 Bold Run Hill Rd.
City: Wake Forest Zip Code: 27587 State: NC
EMAIL Address: a dweIldrilling:itaol.com
County: Wake
Office Tele No.: [phone] Cell No.: t9191422-9931 Fax No.: t9191556-3839
GPIJ/UIC SQW Notification (Revised 3/18/2011) Page 1

E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: Bowman Mechanical Services Inc.
Contact Person: S/eve Bow ma,., EMAIL Address: bowmanmechanical(@ bellsouth.net
Address: 145 Technical Court
City: Garner Zip Code: 27529 State: NC County: Wake
Office Tele No.: [phone] Cell No.: Fax No.: {919) 779-9294 ----------
F. WELL CONSTRUCTION DATA z... / (1) Number of borings to be constructed*: _____ Depth of each boring (feet): __ 3_7_'5" _____ _
* 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~ (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** X Other (specify) _______ _
** By selecting bentonite grout, a variance is hereby requested to ISA NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from Sfc to 37.S-(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 clearl v and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* 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 website. Typically, the property can be searched by
owner name or address. The location of the wells in 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.
GPU/UIC 5QW Notification (Revised 3/18/201 I) Page2
CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .021 1(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 execut
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed an the ploperty deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by
applicant that names and authorizes their agent to sign this application on their behalf.
"l hereby certify, under penalty of law. that 1 have personally examined and am familiar with the informat
submitted in this document and all attachments thereto and that. based on my inquiry of those individi.
immediately responsible for obtaining said information, I believe that the information is true, accurate
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonm{
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable. abandon
injection well and all related appurtenances in accordance with the approved specifications and condition!
the Permit."
4
mature of Property Owner/Applicant
j
t�- a i<vt tAR t-f �-t
Print or Type Full Name
viao,,,..D
ignature of Property Owner/Applicant
Lq-'- I - vc
Print or Type Full_Name
Signature of Authorized Agent, if any
Print or Type Full Name
abmit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]

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NOT FOR RECORDATION OR CONVEYANCE -
SEE PLAT: "Revision of Lots 1C—R and 1U—R
Property of JOHN W. HARTWELL"
Plat Book 100, Poge 157
S 845926' E
5.00 Am
Lot 1A
"Division of Tract No.1
Property of
JOHN W. HARTWE1L"
2011052-21 P6 79 pg 169
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Lot 2
"Division of Property of
JOHN W. HARTWELL"
PS 83 pg 111
a
a
PLOT PLAN
PROPERTY OF
Patrick Kavanaugh
and
Laura Kavanaugh
I, Steve F. Yuhasz. L-2793. certify that this plat
was drown from en aaturd field surrey performed
under my direction and supervision that meets or
exceeds the requirements of a pose A survey in
accordance with the Standards of Practice for
Land Surveys in the state of North Carolina.
Information on imprarements was provided by the
Witness my hag and seal this tatdoy of
August. 2011
a Surveyor
9INGHAM TOWNSHIP
ORANGE COUNTY
NORTH CAROEL NA .
AUGUST 18 2011
100
SCALE 1=1OO
J 100
200
Existing Iran Stake
Aron Stake Set
Mathematical Pt.
NOTE Amos by coordinate computation.
NOTE: This survey was performed far the express and exclusive
purpose of showing the physical relationship between the
property boundaries acid the improvements thereon.
ENT �Q
yrund e7 uT�fRIlQ, .77t0.
226 S. Churton St., illlisborough. NC 27278
[phone] Rag. No. C-512

Page 1 of 1
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Created on 2/6/2012. Orange County, North Carolina.
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2/6/2012

Orange County, North Carolina - Address Inquiry
Page 1 of 2
ORANGE COUNTY NORTI-I CAROLINA
Address Record for PIN 9852373397
For questions about 2009 property values, please go to the Revaluation Paae.
Building InFormation
Property Ownership and Hlstory Inautry
GIS Mao
2009 Property Values
2009 Total Market Value:
$75250
2009 Total Use Value:
$0
Street Address
3009 HARTWELL POND DR.
Place
Building/Unit Number
Zip Code
2727E
Address Jurisdiction
OC
Lot
Address Status
Tax Rate Code
10 - County Tax + Orange Grove Fire Tax
Current Owner
KAVANAUGH PATRICK G
Comments
03
http://serverLco.orange.nc.us/Addresses/AddressDetai1.asp2AddrID=14934 2/16/2012