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 !��
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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,
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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
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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._
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q A1.3 c.v..9 --- .---, ���� r l r` E 223.50,
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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
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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
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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