WI0600063_GEO THERMAL_20120530

MEMORANDUM
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DMSION OF WATER QUALITY
GROUNDWATER SECTION
May 30, 2002
'l'!'f
To: Charles Stehman, Ph. D, L.G., Regional Groundwater _Supervisor
Groundwater Section
Wilmington Regional Office
From: Mark Pritzl MP [e-mail]
Hydrogeological Technician II
illC Group
Groundwater Section
Raleigh Central Office
Re: Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection Well
System (type SQW injection well.)
Notification to construct and operate a well for a closed-loop geothermal heat pump system has
been filed by John Konarski in Swansboro, North Carolina and a copy of the Notification is
enclosed for your files. This injection well system is deemed permitted by rule (NCAC Tl5A:
2C.21 l(u)2) and no regulatory action is necessary. If you have any questions, please contact me
at [phone].
cc: CO-UIC Files
Enclosures
WAT Michael F. Easley, Governor
'To. William G. Ross Jr., Secretary
G North Carolina Department of Environment and Natural Resources
r Gregory J. Thorpe, Ph.D.
—I Acting Director
-r Division of Water Quality
May 30, 2002
John Konarski
1095 Cedar Point Blvd.
Swansboro, NC 28584
Dear Mr. Konarski;
In accordance with the notification submitted on May 23, 2002; the Groundwater Section
acknowledges your intention to construct a closed -loop geothermal water -only injection well
system for the operation of a ground -source heat pump. The system as described in your
notification will not require an injection well permit and is deemed permitted by rule (North
Carolina Administrative Code Title 15A: 2C.0211(u02). The Underground Injection Control
{UIC) Group has added your site to our inventory. If you modify your system, please contact the
Groundwater Section to verify compliance. Thank you for submitting this notification.
If you have any questions regarding geothermal heat pump wells please feel free to contact Mark
Pritzl at [phone].
cc: CO-UIC Files
WIRO-UIC Files
ATA
Customer Service
1 800 623.7748
Sincerely,
Evan O. Kane
UIC Program Manager
Division of Water Quality / Groundwater Section
1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax [phone] Internet: http:/lgw.ehnr.state.nc.us

r
C...tteret heating & Cooling, Inc.
151 Cedar Point Blvd.
Swansboro, NC 28584
[phone]
[phone] fax
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THIS FAX CONTAINS PAGE(S) INCLUDING THE FAX COVER SHEET. IF YOU DO NOT
RECEIVE ALL THE PAGES; PLEASE US AT THE ABOVE TELEPHONE NUMBER.
COMMENTS

E. FACILITY (SITE) DATA
. (Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commesaial).
Name of Business or Facility:
.Address:
City: State: Zip Code: County:
Telephone: '. Contact person:
Standard Industrial Cocle(s), SIC, which describes oommercial facility:
F HEAT PUMP CONTRACTOR DATA
Name: Cad-te Re at }Jaq Coaling. Xz c . --
Address: 15I Cedar Pt4.n t B1 Ld .
City. Swan L oro State: `NC .Zip Code: 2 8 5 8 4 County r„ rf e t,I.
Telephone: (z ?) .393-771.2 Contact Person: John M. White . Jr.
G. CONSTRUCTION DATA. (check ode)
EXISTING WELL(S) being proposed for use as a ground -coupled heal pump
well(s). Provide the information in (1) through (3) below to the best of your
knowledge. Attach a copy of Form GW- 1 (Well Coostructton..Redordd) if
available.
X PROPOSED WELL(S) to be constructed for use as a ground -coupled heat pump
well(s). Provide the information in (1) ttuough (3) below as PROPOSED
construction specifications. Submit Form.GW-1 after construction.
(1) Well Drilling Contractor's Name: Gary N _
NC' Contractor Certificatiori number; 7 0 83
Date to be constructed: 5 — 3 0 — 3 ► . 2 0_0 2 Number of borings: J
Approximate depth of each boring (feet):
(2) Well casing; Is the well(s) cased?.
(a) YES . If yes, then provide the casing information below.
Type: Galvanized. steel;; BIack•steel Plastic Other (specify)
Casing. depth: From to ft. (reference to land surface)
(3)
7 f� '
Casing extends above ground inches
(b) NO x
Grout (grout the vertical length of the borehole to a minimum depth of 20 feet:bl.s,):
(a) Grout tyke: Cement Bentonite x Other (specify)
(b) Orbuted,surface and grout depth (reference to land surface):
_ around closed loop Piping; from , . 0 to 2 Oa (feet).
around well casing; from , to (feet).
NOTE: THE WELL DREE,LIND CONTRACTOR CAN SUPPLY THE DMA FOR EITHER E usTIl4a OTt
PROPOSED WELLS tF Tit* ?NTDRMATlO i ES IJNAV AILABLE EY OTHER MEAN,.
Ver.3/0I GWIt31C-57 CL Page 2 of 4

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP=
GEOTHERaIVIAL WATER —ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
c
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
This is riot the proper form to be used for injection wells in an open -loop geothermal system.
Do not use this form for systems that circulate anv substances other than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: may A , , 2002
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES
If yes, then continue completing this form.
NO If no, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Use A Well(s) For Infection With A Heat
Pump System, should be completed.
B_ SYSTEM FLUID Will any additives be introduced to the system's circulating heat transfer
fluid? This includes, but is not limited to corrosion inhibitors and/or antifreezes.
YES
If yes, do not complete this form. Form GW-57 HP, Application Far
Permit To Construct AndJOr Use A Well(s) For Injec:ion With A Heat
Pump System, should be completed.
NO X if no, then continue completing this form,
C. PROPERTY OWNER
Name: _lohry Knna rsk i
Address: 1095 ('Qtiar Poi ni Blvd_
CitY: Swan cboro State: luc zip Code: _ 2 E 5 R 4
County: Carteret Telephone:[phone]
D. STATUS OF PROPERTY OWNER
Private: X Federal: Commercial;
State: Municipal: Native American Lands:
VeI.3/41 GW/UIC-57 CL Page 1 of 4

E. FACILITY (SITE) DAT A
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: ______________________ _
Address: _____________________________ _
City: _________ State : __ Zip Code : _____ County: ____ _
Telephone: __________ Contact Person: ____________ _
Standard Industrial Code(s), SIC, which describes commercial facility : ________ _
F. HEAT PUMP CONTRACTOR DATA
Name : Carteret Beating & Cool ing. Inc.
Address: 1 51 Cedar Poi n t Blvd ,
City: Swansboro State: _BQ_ Zip Code: 28584 County: Carteret
Telephone : [phone] Contact Person: John M. White Jr.
G. CONSTRUCTION DATA (check one)
(l)
X
EXISTING WELL(S) being proposed for use as a ground-coupled heat pump
well(s). Provide the information in (l) through (3) below to the best of your
knowledge. Attach a copy of Form GW-1 (Well Construction Record) if
available.
PROPOSED WELL(S) to be constructed for use as a ground -c oupled heat pump
well(s). Provide the information in (1) through (3) below as PROPOSED
construction specifications. Submit Form G W-1 after construction.
Well Drilling Contractor's Name : __ _,G .......... a ..... r-,1y'---'N'-'-"-.__._S,__,w_,_,a ........ i..,n.______.S ..... r .......... ______ _
NC Contractor Certification number: _ ____.,...,._,,..,__,_ ______________ _
Date to be constructed: 5 3 o 31 _? o Q? Number of borings: __ __,_ _____ _
Approximate depth of each boring (feet): ___ _.L?__..0,_,_,__1 ___________ _
(2) Well casing: Is the well(s) cased?
(a) YES If yes, then provide the casing information below .
Type: Galvanized steel __ Black steel __ Plastic __ Other (specify) ____ _
Casing depth: From ___ to ___ ft. (reference to land surface)
Casing extends above ground ____ inches
(b) NO _x._
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.\.s .):
(a) Grout type: Cement__ Bentonite __x_ Other (specify) _______ _
(b) Grouted surface and grout depth (reference to land 1!fbce ): ,t.P.
--X-around closed loop piping; from _o__ to~ (feet).
__ around well casing; from __ to __ (feet).
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THJS INFORMATION rs UNAVAILABLE BY OTHER MEANS .
Ver.3/01 GW/UIC-57 CL Page 2 of 4
H. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout 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 maps .
(1) 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 ground-coupled heat pump well system. Label all
features clearly and include a north arrow.
(2) location map referencing the site to two nearby permanent reference points (such as roads,
streams and highway intersections).
J . PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(1) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits
K. CERTIFICATION
Ver.3/01
"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 ground-source heat pump system and all related appurtenances in
accordance with the approved specifications and conditions of the Permit."
If authorized agent is acting on behalf of the well owner ,
please supply a letter signed by the owner
authorizing the above agent .
GW/UIC-57 CL Page 3 of 4
L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
rights in the well being constructed. A well is real property and its construction on land rests
ownership in the landowner in the absence of contrary agreement in writing.)
If the property is owned by someone other than the applicant, the property owner hereby consents to
allow the applicant to construct each injection well as outlined in this application and that it shall be
the responsibility of the applicant to ensure that the ground-source heat pump system's well(s)
conforms to the Well Construction Standards (Title 15 NCAC 2C .0200)
Ver.3/01
I/
Please return two co es of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW/UIC-57 CL Page 4 of 4
LAND USE
IMPROVEMENT PEiL
MIT
OWNER: /(t4'5 Ky
ADDRESS:
54,41,1,4.C.7?-5pY
PROPERTY LOCATION: .td`•
TYPE STRUCTURE: / g SC
NO. BEDROOMS. 3 NO. THS: -7--
WATER SOURCE: R
GARBAGE GRINDER: YES ( ) NO (0'
AUTO DISHWASHER: YES ( ) NO ({,�
AUTO WASHING MACHINE: YES { NO ( )
Pere. Rate (b applicable): L1St , �
SIZE OF TANK: �f 1X874 I Nf L
NO. LINES: 3 WIDTH:' �j b
TOTAL: 5 [�Z a� ! /50 G 1'S • FT.
TOTAL LEN�'l'H: /Q' 4542G'7 FT,
HORIZONTAL DISTANCE FROM WELL: pi FT.
NOTICE: Construction must comply with all state
and local regulations. Do not install well until
well site has been approved- Do not cover any
portion o tem until approval or •final inspection•
IMPRO EM T�PERiT
ENVIRONMENTAL HEALTH DIVISION
CARTERET COUNTY HEALTH DEPARTMENT
BEAUFORT, N.C. 28516
M.a LO PfIHTtN6 CO.. MOMEMEAO CITY, M- C•
ENVIRONMENTAL HEALTH DIVISION
CARTERET COUNTY HEALTH DEPARTMENT
- 1696
PHONE: 3 ,3 - TO' DATE
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Carteret -Craven Electric Membership Corporation is hereby requested to install
underground electric service to the premise of the -undersigned. It is understood that such
installation will be governed by the Policies and Service Rules & Regulations of the EMC.
In order to facilitate the installation of the underground electric service, it Is agreed and
confirmed that the location of the underground service as shown below will not disturb or
damage any- buried -objects; such as peptic tanks-septio-tank<drairt4ields;•gr°ease.traps or
grease trap drain fields, yfater lines, gas lines; oil lines or any other buried objects.
The undersigned agrees to ass me full ,responsil i:l#ty fOrthe: replacement or repair of any
buried object if the installation of the underground electric service is done in accordance
with the above drawn and designated route.