WI0600065_GEO THERMAL_20101021

Permit Number
Program Category
Ground Water
Permit Type
WI0600065 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Lester Ray Phillips SFR
Location Address
124 Kingsway Dr
Dunn
Owner
Owner Name
Lester
· Dates/Events
NC 28334
Ray Phillips
Orig Issue
10/21/10
App Received Draft Initiated
10/13/10
Re gulated Activities
Heat Pump Injection
Pri vate re s idence, single family
Outfall NULL
Scheduled
Issuance
Central Files : APS_ SWP_
10/21/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Lester Ray Phillips
Owner
PO Box 1477
Dunn NC
Major/Minor
Minor
Region
Fayetteville
County
Harnett
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Lester Ray Phillips
Owner
PO Box 1477
Dunn NC
Public Notice Issue
10/21/10
Effective
10/21/10
28335
28335
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
NA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves .Perdue
Governor
Lester Ray Phillips
P.O. Box 1477
Dunn, NC 28335
Coleen H. Sullins
Director
10/21/2010
Subject: Acknowledgement oflntent to Construct Type SQW Injection Well System
Permit No. WI0600065
124 Kingsway Dr.
Dunn, NC 28334
Dear Mr. Phillips:
Dee Freeman
Secretary
On 10/13/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl
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 ISA 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 Harnett 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.Ro gers @ncdenr. 1wv if you have any questions.
cc: Fayetteville Regional Office -APS
Harnett County Health Dept.
~~-~Q
forDebr~
Supervisor
John Boyette (Boyette Well & Septic, Inc., 1109 Nast St. NW, Wilson, NC 27893)
Steve Bowman (Bo"Yman Mechanical Services, Inc., 145.Technical Ct., Gamer, NC 27529)
APS Central Fib -Perm l~o~ \\ 10 6000 €:1
AQUIFER PROTECTION SECTION
163G Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588 : FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterauality.org
An Equal Opporiunity \ Affirma:ive .'\c;ion Employe r
NirthCarolina
/vaturall!f
\AILc&YDfh ----
NORTH CARQUNA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELL (S) 0
C> n
In Accordance with the provisions ofNCAC Title 15A: 02C.0200, please -I
complete this notification and mail to address on the back page (please Print or Tvpe informatio lli
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2~: DATE: \0 -_5 , 20 ,o
-···
C) (l'l ·-=-
Well Type Co11firmatio11: Does the proposed system circulate potable ,vater onh· (no additive ~ r
continuous piping that con.;ipletely isolates the fluid from the environment (i.e.
closed-loo p)?
Yes __ Continue completing this fmm.
No ___ Do Not complete this form . Complete other lJlC application forms for installing
either a SA 7 well (open-loop ,veil in jecting 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)/APPLICA.1~T(S)
II
List each Property Owner listed on property deed (if owned b\ a b~ess or Rern;nent ~gency, state name of
entity and a representative \-\)authority for signature): L.os-7ev · /'\A Y '· j-..1 '1 • ~ l , t2f •
(l) Mailing Address: 1), D 'fJ ~'/ J 9 ') ?
City: P u" I) State: fJ, C, Zip Code: '2 q--15 6= County: ,j/9. 01JL..-:+f-
Home/Offtce Tele No.: '11 0-~Cj()_, J~CJ.-6 CellNo.:9/CJ-gcf(/-/2 ~.:::?§7
Email Address: __________ \\c.:._1=eb=s'-"it:!Ce-'-: _____________ _
(2) Physical Address of Well Site (if differenuhan above): IQ Y J< ,'"i...r0~y D)'-.,
City: 1)Q . f) I\ State: JV, ( Zip Code: fJ qs.£ l-/ County: f/q rnJ,ff
Home/Office Tele No .: 9/0 -8"?<Q..-} y;C/ '1 Cell No.: i !CJ-8'1 Y--6~1~
B. AUTHORIZED AGENT OF O"1'NER, IF A:!'l"Y (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:--------------------------------
Contact Person ;;...: ---------------=E=MA-=-=-I=L""'A'-="d=dr"""e-=ss'"'": __________ _
Address: _________________________________ _
City: _________ State: __ ZipCode: ______ County:
Office Tele No.: _________________ _,,,C""'e""ll...._N..:..:'oe..:..,._: __________ _
Website Address of Company, if any : _______________ _
IL 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.
1[. LOCATION OF WELL(S)
Attach two copies of maps showing the following information.
(l)
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
(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. andior hieliw-aintersections
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"1 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 responsiblefor obtaining said information. I believe that the information is true, accurate and complete.
1 atn aware that there are sianificarrt penalties, including the possibility of fines and imprisonment, for submitting
false information. 1 agree to construct, operate.,inaintain. repair, and if applicable. abandon the injection well and
all related appurtenances in accordance with the a protiV speci *ions and conditions of the Permit."
�.l 1' 114—
Signature of Foperh' Owner/Applican ,
�.sf r iAy 1'4Y11:�
Print or Type Full Name and title
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
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 [phone]

SEP-16-2010 07:35 From:
B9/13/2010 09:49 9197793294
To:9197799294
P.2/3
PAGE 82/03
C. WELL MILLER LER LIFO1ivt4TIO?
Company Dame; : C f eA77 ,"',
Well Driller Contractor's Marne; . Q
NC Contractor Cartkf cation No: 2 2 5
Contact Person' w t Z_EMAIL Addres;:_ t?Oft
Address: —�� ZU ft Gs
City. I L SPA Zip Code: JC- Comm _ 0,1 I L. Spa.)
Office Ida No Cell No.: -25-„if jj Dom- D
HEAT PUMP CONTRACTOR (if different than driller)
C".nrnpan} Nan]e: Bowman Mechanical. Ser ices, Inc.
MAIL. Add►essbolymas tecbBnical@bellso ]th.net
Con-ac: Person: Steve Bowman
Address: 145 Technical c,t
Czt►: Zip Code: 2729
Garner
Cousin=. Wake
Office Take No . 919 772--2759 Ce}i No,:
L. STATUS OF APPLICANT
Private: X,
State: i))
redered: Commercial:
Municipal: Native Arncriean Lands.
F. INSECT ION PROCEDVRE l'krief' describe how the injection we:its) +ill be list
WELL CONSTRUCTION DATA /9v6- 3/, Ja" a Ott, evx �]
(11 Proposed date to be constructed: 7 .24Clo Nurnb r of borings: — +
ApproXint art depth of each bariz►g (Teel): tr0
(2) Type cf tubing to be used (copper, PVC. Cc):
Po
(3) Weil casing. Is the well(s) cased'? [chscit either (a.) Yes Syr .) Kio belo
Cal Yee i[; es, then prot'ide casing itttinsdtion below
Type: galvanized steel biac1C sleek_plastic other l spect7)
Casing depth: from to feet t.reference to land surface)
Casing exlertds to above grzttnd incites
(b) No
(4) Grout info (material surrounding well casing ar'or pipng):
(a) Grout type: Near Cement,...._ f Bentonite Other (spec
(b) Orout piacerne tt: Pfur:pinR ✓ Pressure Other
(vj Grout depth of tubing (reference to trend surface; from - to
If -well has cans. indicate grout depth: frOM to
.70, SAS N.
I5-0 ( i
C%etl

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