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HomeMy WebLinkAboutWI0500514_GEO THERMAL_20120424Permit Number Program Category Ground Water Permit Type WI0500514 Injection Water Only GSHP Well System (5QW) Primary Reviewer eric.g .smith Coastal SW Rule Permitted Flow Facili Facility Name Brad Salcedo & Katherine Norton SFR Location Address 1904 S Lakeshore Dr Chapel Hill Owner Owner Name Brad Dates/Events NC 27514 Salcedo Scheduled Orig Issue 04/24/12 App Received Draft Initiated Issuance 04/23/12 Regulated Activities Heat Pump Injection Outfall NULL Central Files : APS_ SWP_ 04/24/12 Permit Tracking Slip Status Active Project Type New Project Version 1.00 Permit Classification Individual Penn it Contact Affiliation Dave Greer 2901 Bertrand Ave #2117 Durham Major/Minor Minor Regiori Raleigh County Orange Facility Contact Affiliation Owner Type Individual · - Owner Affiliation Brad Salcedo 1904 S Lakeshore Dr Chapel Hill NC NC Public Notice Issue 04/24/12 Effective 04/24/12 27705 27514 Expiration Waterbody Name Stream Index Number Current Class Subbasin AAA '�i NCDERR North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman Governor Director Secretary April 25, 2012 Brad SaIcedo Katherine Norton 1904 South Lakeshore Drive Chapel Hill, NC 27514-2028 Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System Permit No. WI0500514 1904 South Lakeshore Drive, Chapel Hill, NC 27514 Dear Brad & Katherine: On April 23, 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 well system as long as the following conditions are met: 1. The injection welt 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 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 (919) 807-6406 or Michael.Roeers!nincdenr.wv if you have any questions. Sincerely, Cwt. £ for Debra s Supervisor cc: Raleigh Regional Office - APS APS Central Files - Permit No. W10500514 Orange County Health Dept. Dave Greer — (3reer's Service Co., Inc. Derry Hunncycutt - Derry's Well Drilling, Inc. AQUIFER PROTECTION SECTION 1636 Mail Service Center, Raleigh, North Carolina 27699-1636 Location: 512 N, Salisbury St, Raleigh. Not Carolina 27604 Phone 919-8074464 l FAX: 913-8074496 Internet www,ncwaterquality.ara North Carob na An Egaal Opponanity 1 Affirm Acton Emonyer NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM TYPE 5QW WELL(S) In Accordance With the Provisions of NCAC Title 15A 02C.0200 Print or type the required information and mail to address on the back page. RECEIVED/0 APR 2 :1 ENRiDWQ 2012 DATE: L , 20SL t 0' o� s Li Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in continuous piping that completely isolates the fluid from the environment (Le. closed -loop)? Yes /Continue completing this form. Aquifer Pratec ion Sect No Do Not complete this form. Complete other MC 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 awned by a business or goverznnentrey, stag f entity and a representative w/authority for signature):.1RAc .S L-C-1Sa J hot w a mak-rail (1) Mailing Address: 1 R c S L.,N. V.e5L4 t' PC City: �' L i U_, State: /ice Zip Code: ; 75 L ti2.2w County: 0 PW6G Cell No.: N A + S— (43 Home/Office Tele No.: (i :70 ( lR ' Li0-71-1 Email Address: bre& .SRLC..Etto Website: N4.41 ave. cot" (2) 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 letter from the property owner authorizing Agent to install and operate UIC well) Company Name: CZ 'S S ee.l}Ct7 Co, j we - Contact Person: ►JE t�Et►`d� EMAIL Address: '-` yy. �ataY i?c3Y {tal yam Address:lOtlet?7L ► t- 117 City: J¢kA State:,jMc__ Zip Code: A-- 7O cS County: X )D44 Office TeIe No,: ( Kt) 544 2V la_ an No.: L 1 ‘S 5$i,S Website Address of Company, if any: W w W GPU/UIC 5QW Notification of Intent Form (Revised 8/2005) Page I C. WELL DRILLER INFORMATION CompanyName: 1)e;£,'2..\./'S WEL..L '\:>-el L\JJ\lb \NC.... I Well Driller Contractor's Name: "Deusi L . H MN e:Ya.rrr NC Conh·actor Certification No.: _..,.;2~&k~~'3~-..... A~------------------ Contact Person: :QtoJH HUN,$h' CJIT EMAIL Address: -O&ep.y $ '-" at:, '.Pt.itc.wc, ~~-'°" Address: YY.183 -A AJ L , HWY ;).Y -'l.7-,3 City: AL1\€AMQ,\..G I NS.. . Zip Code: 180:> I County: S:[AJJ LG'i CO . Office Tele No.: bo4) 1&1-1070 Cell No.: (_7C>'-V <.?&S-eor~s D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller) . - Company Name: (~S. Se::(b)tc.S C O • t lA.)C, • Contact Person: 'vA\lE C"--,~-eiL EMAIL Address: ~ °l\.e.~·'(' ~ <asro:TS.-S~lct::"• ~ Address: .Q.C}o \ ::mruwo A:\)e . ~ ~A \7 City: S)\"1L\'\,AM-Zip Code: ~Wo5" County: _'pu--"-------"_._P<__.\-V:\M~-------- Office Tele No.: {q\oi ) 5:f\-(-2{,.5"0. Cell No.: (9t~) "] 3.()-S~t.P-5 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) ~;~o]H~l\C., \.,\el\C' '"CVAvS~~. (J-:l «2B1: f A(c) G. WELL CONSTRUCTION DATA (1) Proposed date to be constructed: lo-A'{~\\, Zo \l. Number of borings: _z ___ _ Approximate depth of each boring (feet): 3 :SO;-E:l\G-\- (2) Type of tubing to be used (copper, PVC, etc): -~H~Q'O~ll'---'f~B~--------- (3) Well casing. Is the well(s) cased? (check either (a.) Yes QI (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 X ( 4) Grout Info (material surrounding well casing and/or piping): Bentonite (a) (b) (c) Grout type: Neat Cement __ Other (specify) ------- Grout placement: Pumping~ Pressure Other . Grout depth of tubing (reference to land surface): from So/ 0 to __,,.___,::....__ (feet) If well has casing, indicate grout depth: from ___ to ____ (feet) GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 2 H. 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: (I) 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 wells) 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 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 highway intersections. J. CERTIFICATION Note: This Permit Application must 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 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 construct, operate, maintain, repair, and if applicable, abandon the injection well and all related appurtenances in accordance with the approved specifications and coyitipns of the Permit." Signature of PropepZvv Owner, Applicant 8 '441-A Site-4 CAD Print or Type Full Name and title Sin rope:* Owner/Applicant h7 bdV1 P or Type Full Name and title tore of ro c.C2 Sigriatuzzad.aint, if any 'DAL)VQ W C?1 - / V& - &Vail Print or Type Full Name and title Please return two copies of the completed Application package to: North Carolina DENR-DWQ Aquifer Protection Section-UIC Program 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 733-3221 tea. co- i 1N - RECEIVEDIDENRIDWQ APR 2 31u1a Aquifer Protection Section GPil1UIC 5QW Notification of Intent Form (Revised 8/2OQ8) Page 3 Wednesday, April 18, 2012 Katherine Norton/Brad Salcedo 1904 S. Lakeshore Dr. Chapel Hill, NC 27514-2028 Subj: Agent Authorization To whom it may concern, We the undersigned do appoint and authorize: David W. Greer Greer's Service Company, Inc. 2901 Bertland Ave. Unit 2117 Durham, NC 27705 as our agent as it pertains to any and all aspects of the installation of the geothermal heating and cooling ~ystem in our home. This includes the placement and construction of closed-loop geothermal water-only injection well(s) (type SQW), and the placement of the equipment, piping, ducting, etc. RECEIVED/DENR/DWQ APR 2 3 2012 Aquifer Protection Section rf "-- de !�� 'QiIre ▪ '"---.. 1 PORCH Po Z — PIPE E vim` i W. G. AUTRY LAND SURVEYOR 1708 SIX GABLES ROAD DURHAM NC, 27712 PHONE/FAX: (919) 477-1423 Lot 23 Block F ,Plat Title LAKE FOREST ESTATES Pb• / Db. 7 Pg. 2 -Iron found • Iron set 0 Mon. O Moth Paint + Noll x — No true lines cut Property lines traversed. — this is a c[ass A survey. (No useoto!e hors. Control found within 2,000 --This survey is a representation of conditions existing of this time and is not for recording purposes. — LemnFinn ni nrn hrranrl nn vialhla avGi.nAs nr infnrrnnhinn LOT 22 79' 3O E 2I355, ALL / / I POOL A jE' / FATIQ� LOT 23 28111.92 sq,ft. (0.64536 ocres) N 82°Q r49" W 229.,67' LOT 24 CLIENT or OWNER FERNANDO BRAD SALCEDO Book 7 knowledge on information calculated b Witness my this 26 dog To the best mops) this PITCH 7 LOw DRAINAGE AREA i "NOTE: —SAN, SEWER LINE SHOWN 01 ARE TAKEN FROM MANHOLE ! nr'A"rinNia Iti rfn! r5 TNr LOT 22 vr� 41� • PRE °29'80', E 213.50, N 4134R��E' PORCH M.H. # 2 PPE �, -- D TPPE- CN i W. G. AUTRY LAND SURVEYOR 1709 SIX GABLES ROAD DURHAM NC. 27712 PHOf /FAX: (919) 477-1423 Lot 23 Block F ?lot Title LAKE FOREST ESTATES g. 2 -iron found • Iron set C Hon. CI Moth Point .1. Nail x — No true lines cut. Property fines traversed. —this is a class A survey, (No useable hare. Control found within 2,000 —This survey is a representation of conditions existing at this time and is not for recording purposes. — Lnen1Inn nr 'Iifir+Inn if nhnwn nrm hnamA An vInihla wutriwnrA nr infnrmntlnn 1 Eck P(3° AREA / r j PATIO j gook 7 knowledge an Information calculated b Witness my this 26 day To the best mops) this _ LOT 23 28111.92 sq.ft. (0.64536 acres) N 82°024g" W 2,25,27• LOT 24 CLIENT or OWNER FERNANDO BRAD SALCEDO [SITCH / LOW -DRAINAGE -AREA i °NOTE: —SAN. SEWER LINE SHOWN Ot ARE TAKEN FROM MANHOLE 1 nnAT1MIS IN f r) f1 TI-W NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM TYPE 5QW WELL(S) In Accordance With the Provisions of NCAC Title 15A 02C.0200 RECEIVEMEN Print or type the required information and mail to address on the backpageAgtliTTr Protection DATE: I A(p_1 L. , 20 L 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 -loop)? Yes /Continue completing this form. Sediell No Do Not complete this form. Complete other LTIC 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 wlauthority for signature): R.kp tL CASAC) VirCill el-tN e N 0 Zra W (1) (2) Mailing Address: Ti' L4 S. b't 612AS City: 0 11.(... State: /U__ Zip Code: ; -TS (Ld - 221f County: d ]66: Home/Office Tele No.: ( tO 7 - CeIl No.: Lq Coq — (POg Email Address: bra& .e Website: N14 Lime- co." Physical Address of Well Site (if different than above): sgoit`- 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 letter from the property owner authorizing Agent to install and operate UIC well) Company Name: ( 'S 5 e .A its Co. %A.( - Contact Person: 'DME GR' EMAIL Address: l if..', t' arely}-SeNicia-, Address: ,..a l hee7G4U 4.1ff - 9117 City: TluQ.t.A(A State:A Zip Code: ).:1-1 O 5 County: TX) }4i'IM Office Tele No.: (°I 1t1) 544 21.jCL CeIl No.: t ct tc0 7 ,0— ] S Lai Website Address of Company, if any: {AAA') . Gr'-EE - cx]t+r► • GPU,iIUIC 5QW Notification of Intent Form. (Revised 8/2008) Page 1 . ' C. WELL DRILLER INFORMATION Company Name: :s)E;£(2..'·l'S WEt.\., ~it L\.JJ\lb \NC..,. I Well Driller Contractor's Name: 1)~ L ~ HUN <EYc.uTr NC Contractor Certification No.: -~2=-----;;&/4----=-_..3..__-___.._A_,__ _________________ _ Contact Person: '.Q\:'::OJH HlHJ6c./ CJTI EMAIL Address: 'P&RJl.V $ I.\> 8l.> 'CtiL'-Wi 4)~t».l Address: YY c?-83 -A tv .C . '1 wY .9-Y -'l, -, '3 City: AL\\'Bt,MQ,\.G I N.!. . Zip Code: :J.800 t County: StA-}J L~ C.O Office Tele No.: (-,oLt) 1P,2-'lo70 Cell No.: (7<>'-0 '-l&$-fol"S:S: D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller) . - Company Name: (~S. Se€,iJ{c.S C O •1 lAJC,. Contact Person: C")A,\)E (")~--ea... EMAIL Address: d 'l~ 'f e ~1ra:,:-S. ..... S~\CE°• a:j Address: 290' :m-ruwo Al}'e . ~ ~\ n City: 's:)\l L\-\N": Zip Code: ~:l,774':> County: _'m~~P!~l:Y\M~-------- Office Tele No.: ('H°t) S1f4-2t,.S-Q.. Cell No.: C '1 t't) :::Z '3:.0 -S~(;5 E. STATUS OF APPLICANT Private:~ State: Federal: Municipal: __ Commercial: Native American Lands: F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used) G ·eo"]t~t\t. t\eltC -cvAvS~. (.,H eB:C f A(c J G. WELL CONSTRUCTION DATA (1) Proposed date to be constructed: 'JOA'{t.\\, io \Z. Number of borings: _'2,. ___ _ Approximate depth of each boring (feet): 3 :5 0 / c<;\(H- (2) Type of tubing to be used (copper, PVC, etc): -~r\~9'1....,._ __ -'e~B~--------- (3) Well casing. Is the well(s) cased? (check either (a.) Yes Q! (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 X ( 4) Grout Info (material surrounding well casing and/or piping): (a) (b) (c) Grout type: Neat Cement __ Bentonite Other (specify) ______ _ Grout placement: Pumping~ Pressure Other . Grout depth of tubing (reference to land surface): from 0 to ~ so' (feet) If well has casing, indicate grout depth: from ___ to ____ (feet) GPU/UIC 5QW Notification of Intent Form. (Revised 8/2008) Page2 H. 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) 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 clearly and include a 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 roads, streams, and/or highway intersections. J. CERTIFICATION Note: This Permit Application must be signed by each person appearing on the recorded Iegal 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 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 construct, operate, maintain, repair, and if applicable, abandon the injection well and all related appurtenances in accordance with the approved specifications and cop{iitij, ns of the Permit." Signature of PropepCi Owner/Applicant "R t/4/ J v 8 Jl £44 ('2J Print or Type Full Name and title Sign7— AilNittN7--N1-01L. ture of operty Owner/Applicant P or Type Full Name and title Signatu r ee ,.+�,� .;. , if any '1C.3144...tC1 1%14.1n • G e Print or Type Full Name and title Please return two copies of the completed Application package to: North Carolina DENR DWQ Aquifer Protection Section -MC Program 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 733-3221 yJc-. ra- INC' • RECEIVEDIDENR/DWO APR 2 3 201? Aquifer Prottcfon Section GFUIUIC 5QW Notification of Intent Form (Revised 8/2008) Page 3 Wednesday, April 18, 2012 Katherine Norton/Brad Salcedo 1904 S. Lakeshore Dr. Chapel Hill, NC 27514-2028 Subj: Agent Authorization To whom it may concern, We the undersigned do appoint and authorize: David W. Greer Greer's Service Company, Inc. 2901 Bertland Ave. Unit 2117 Durham, NC 27705 as our agent as it pertains to any and all aspects of the installation of the geothermal heating and cooling system in our home. This includes the placement and construction of closed -loop geothermal water -only injection well(s) (type SQW), and the placement of the equipment, piping, ducting, etc. Katherine Norton Brad Salcedo RECENED!DENRJDWQ APR 232012 Aquifer Protection Section Date tidk ate LOT 22 r., 4._ S q A1.3 c.v..9 --- .---, ���� r l r` E 223.50, aRrve ,:I J a— �y "�i - , � Lt —�~ d 9 �i i r' o .4 ob 0 0 PIPE MICH— i AW. G. UTRY LAND SURVEYOR 1708 SIX CABLES ROAD DURHAM NC. 27712 PHONE/FAX: (919) 477-1423 Lot 23 Block F Wot 'Title LAKE FOREST ESTATES / Db. 7 Pg. 2 ',und • Iron set 0 Mon. D Math Point + Nail x lines cut. Property lines traversed, •lass A survey, (No useable horz. Control found within 2,000 a rapresentattion of conditions existing at this time and is 'ing purposes. •k i1 dthman nr• hnanrl nn v101.40 avirtronr. nr Snfnr mntinn #2 Tv Tr LOT 23 28111,92 sq.ft. (0.84536 acres) N 82°02'49" W 229.27' LOT 24 CLIENT or OWNER FERNANDO BRAD SALCEDO at ouo, knowledge an Intormatian calculated tr Witness my this 26 day To the best mops) this ERCH / LOW-ORAf13AGE AREA i a; *NOTE: -SAN. SEWER LINE SHOWN Ol ARE TAKEN FROM MANHOLE I nnATlnNm IN rim n 7Nr Er-7 P ......_8 f� a�� �� C PARKINGA.1� wve a cv v./m -zci Q Ld-, rr.i ..r..__ 1. m‘,.-z, C -"k�� I PIPE DITCH i W. G. UTRY LAND SURVEYOR f708 six GABLES ROAD DURHAM NC. 27712 PHONE/FAX: (919) 477-1423 Lot 23 Block F '4iaL Title L7Ai<E FOREST ESTATES / Db. Pg. 2 ',und • Iron set 0 Mon 0 Moth Point + Noii x lines cut. Property Ones traversed 'toes A survey. (No useable hare. Control found within 2.000 . a representation of conditions existing at this time and is •M9 Purposaehnw. if n hn+nrf nn vl.lhin nui,lnnnn nr 1nlnrmMinn f PORCH LOT 22 WAIT P001. 4,9EA J r PATIO LOT 23 28111.92 sq.ft. (0.64536 acres) N 82°02'49„ )7 229.27' LOT 24 CLIENT or OWNER : FERNANDO BRAD SALCEDO Book 7 knowledge an Information cokcWated b Witness my this 26 day To the best mops) this 1.4 O TCH / LOW -DRAINAGE AREA _ T i *NOTE.. —SAKI. SEWER LINE SHOWN 01 ARE TAKEN FROM MANHOLE flCATIllhit Ihl FIFI rt 'NW