WI0600076_GEO THERMAL_20110426

Permit Number
Program Category
Ground Water
Permit Type
WI0600076 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal.SW Rule
Permitted Flow
Facilit
Facility Name
Murchison Road
Location Address
1200 Murchison Rd
Fayetteville
Owner
Owner Name
NC
• Fayetteville State University
Dates/Events
28301
Central Files : APS_ SWP_
04/26/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Mac Mccrary
PO Box 639
Ravenel SC
Major/Minor
Minor
Region
Fayetteville
County
Cumberland
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Steve Arndt
Director Physical Plant
Fayetteville NC
29470
283014298
Orig Issue
04/26/11
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
04/26/11
Expiration
04/20/11 04/26/11
Re gulated Activities
Hea t Pump Inj ection
Outfall ,<:_JL L
Waterbody Name Stream Index Number Current Class Subbasin
AVA
NCDENR
North Carolina Department of Environmen t and Natura l Resou rces
Divis ion of Wat er Quality
Beverly Eaves Perdue
Governor
Fayetteville State U n iversit y
Robert Botley, VC for Busin ess and Fimm ce
1200 Murc h ison Road ·
Fayett evill e, NC 28301
Coleen H. Sull ins
Di rector
4/2 7/2 011
Subject: Acknowledgement oflntent to Construct Type SQW Injection Well System
Permit No. WI0600 076
1200 M urchison Road , F ayetteville, NC 2 8301
Dear Mr. Botley:
Dee Freeman
Secretary
On 4/20/2011, 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 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 C umberland 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 !!en,/cv ncdenr .!!ov if you have any questions.
cc: Fayetteville Regional Office -APS
AP S Central Files -Permit No. WT0600076
Cumberl an d County Health Dept.
Edge Solutions (Mac McCrary)
AQUIFER PROTECTION SECTION
1636 Mail Service Cenie.r, Raleigh, North Carolina 27699-163G
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Sincerely,
forDQ~IGJ3o&u
Supervisor
Phone: [phone] \ FAX 1: 919-715-0SeB: FAX 2: 919-715-60481 Customer Service: 1-877-623-6748
Internet www .ncwaterauali lv.orc
A~ Equal OpportJn:ty \ Affirma:,ve Ac'.·on Employ ee
N~rth Carolina
J\]aturall!I
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE SQW WELL(S)
In Accordance With the Provisions of NCAC Title 15 A 02C.0200
Prix or type the required inforrnarto►r and mail to addrE•.rs on the back page.
DATE: 21 ,{ S
'rD it
D Lo3i(-P
Well Type Confirmation: Does the proposed system circulate potable water oniv (no additives) in
continuous piping that cornpletzly isolates the fluid from the environment (i.c.
closed -loop)?
Yes "Continue completing this form.
No Do Not complete this form. Complete outer UIC application forms for installing
either a 5A7 well (open -loop well infecting 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 OW'IER(Sy&PPL1CANT(S)
List each Property Ow-ner listed on property deed (if owned by a business or government agency, state name or
entity and a representative wlauthority for signature): Ka ye77-Evte-i-t" S; pie ilivrd sir r
(1) Marling Address: 1200 Murchison Road _
City; Fayetteville State: NC Zip Code: 28391 County: C'imber .and
(2)
Plante/Office Tele No.: f,) 67Z-- 1431 C'dll No..
Email Address: r-c.Qxa t+'kSk. A, Website;
i240 lard R7
Physic:a! Address of Well Site (if different than above): LANcrpori L. sei0J .7�. Prztge
City: Pay& viler _ Starr: NC Trip Code: a330i County: C rz ,
Homr/Oftice Tele No.: _ Ceti No.:
AUTHORIZED AGENT OF OWNER. IF ANY (if the Permit Applicant does jmt own the subject property.
attach a letter from the property owner authorizing Agent to install and operate 1.51C well)
Company Name:
Comact Person: EMAIL Address:
Address:
City- state: Zip Code: County:
Office Tele'' o.; C'ell
Website Address of Company, if any:
GPLi/UIC' 5QW No:i lcarioo of rtent Form(SRev=sed! S/20O$
RECEIVED I DENR 1 DWQ Page
Aquifer Dmmrlion Section
APR 20 2011

C. WELL DRILLER INFOR.i'1.ATION
CompanyName: €D &f S o;,,.1.1r10N •; _________ _
C I (] " ,,/! ii AA ,# ---.--WeU Driller Contractor's Name; 11t:Ft)el)_ /<..tty /Y/(tc.., me,<,A,H?y .L _.1. __
NC Contractor Certification No.: __ -.cl,,,l,,,J"Z!:..,':3~-~d::..Jl~-~A...!------------------
Contact Person: IVJA-C.. M~v EMAIL Address: f/1dL€ 0 ~.s .. •/~µ5 . oi.S ~ ~
Address: ft:) Bo x 6 31
City: P...1wf;Nd'L , Sc.. Zip Code: J.t/"{90 County: C,/')d.r/~-br,, 5 c ;
Office Tele No.: 8'J3r 5"!i.4-fiS";J.f:, Cell No.: 8'{3-i.:15 ... f.3f;.S
D. HEAT PUMP CONTRACTOR I:'IFORlvIATION (if different than driller)
Company Name: __ JO 8e iJe/c,y.,.1NC'l) '--,-&;, "'"e
Contact P-erson: EMAIL Address:
Address: ______________________________ ~-
City: _________ Zip C.ode: -~-~ County: ____________ _
Office Tele No.: Cell No.: _________ _
E. STATUS OF APPLICA.i'lilT
F.
G.
Private: Federal: Commercial:
State:~ Municipal: __ Nati've American Lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Ot1tl1 ) r,kr.,t;;n 41t1'9 Hm-74:rwl C-mr),,,;;..-h vrly Teis,-r.:,tz
$v1~h/yrEj~ sy.s ¼m~--------------
WELL CONSTRUCl'lONDATA
(1) Proposed date to be constructed: M/!rfU-H ,l,.o u Number of borings: __ /_· __
Approximate depth of each boring (feet):_~~_S_O ____ _
(2) Type oftubi1,g to be used (copper, PVC, etc): _....,H~-•=·D....,P~.""-'---------------
(3) Well casing. Is the weH(s)cased? (check either (a:) Yes or (b.) No below)
(a) Yes .... if yes, then provide casing information below
Type: _. __ $alvanized Steel __ black steel_plastic_. _other (specify)
Casing depth: From_. ___ to ___ feet (reference to land surface)
Casing extends to a~ove ground inches
(b) No X
(4) Grout Info (material surrounding well casing and/or piping): l~cl~ &-n:,.k
(a) Grout type: Neat Cement_:-. Bentonite
(b) Grontplacement PumpingX__ Pressure __
Other (specify) ~~-=~ IQ"i~e ~~5o.
-ii,/;. u,,,
Other__ ·
(c) Grout depth oftubing(reference to land surface): from __ o __ to :250 (feet)
If well has casing, indicate grout depth: from NP. to i.,11; (feet)
GPU/UIC :SQW Notification of Intent 'Form (Revised 812008) Page1_
H. INJECTION -RELATED EQUIPMENT
Attach a dia ram 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 WELLS)
Attach two copies of maps shuwine the following inforrnstion:
(I) Include a Site Map (can be drawn) showing' buildings, property lutes, surface water bodies. potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing weli(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system Label ail f a.ttues 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 ixed
reference points such as roads, streams, andlor 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 an familiar with the information
submitted in this document and ail 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 Char there are significant penalties, including the possibility of fines and imprisomnent, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable. abandon the injection well and
ail related appurtenances in accordance with the approv Specifications and conditions of the Permit
02/28/11.
Sigsi.ure of Property Ow*r'r!Applicaut
Robert Batley VC For Business and Finance
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 Pull Name and title
Please return two copies of the convicted Application package to:
North Carolina DENR DWQ
Aquifer Protection Section -LTC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU!UiC 5QW Notification of inter./ Form (Revised 8R008)
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111251010

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL. RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
1 AT1 R-ONLY INJECTION WELL SYSTEM
TYPE SQW WELL(S1
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Mint or npe the rerfrrirerf (nform triorr and moil to Address on the hock page.
DATE: / 16 . 20 1r
Well Type Confirma4ion: Does the proposed system circulate potable wattr only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loon)?
Yes Continue completing this form.
No Do Not complete this form. Complete other llIC application forms for installing
either a 5A7 well (nnen-loop well in-etin 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)IAPPLICA? T(S)
List each Property Owner fisted on property deed (downed by a business or government agency, state name of
entity and a representative w/authority for signature): FAyen-Dili-Le sr jg 14vA_v ,r7'y
(I)
Mailing Address: 1200 Murchison Road
Fayetteville NC 28301 Cumberland
City: State: Zip Code: County:
Honme/Offce Tele No.: ( b) g•72— I13I Cell No.:
Entail Address: r acj 149.1444 eA ltlebsite:
120C3 A'tu a.cH:sem, da4-n f -T
(2) Physical Address of Well Site (if different than above): Z.ANGno.v St- 111,vsa-vr► L• i utr 3a. izi e
City: �pvc'4vvf% State: Al C. Zip Code: c)53oi County: CwR • drub
Home/Office Tele No.: Cell No.:
B. AUTHORIZED AGENT OF OWNER. IT ANY (if the Permit Applicant does noo own the subject property,
attach a letter from the property owner authorizing Agent to install and operate L'IC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City: State: Zip Code: County:
Office Tele No.: cam.:
Website Address of Company, if any: RECE1 VIED, D MR 1 DIMO
GPLJUIC SQN' F ou ication of lrucut Form (ReVseii 8J20osl
Aquifer i'rofPrtira>n Section
A_,P!1 20 zLtPael

C. WELL DRILLER lt'\FOR..t"1ATIO~
CompanyName: £7) fi.o;,,..v,16N5
Wen Driller Contractor's Name: C /, /:~ /<./h/ 'l MtrG ,., /J/lc.C&.»t?y .I /1
NC Contractor Certification No.: 3.3dl-A ,_1
1
________________ _
Contact Person: IVIA:t:r Mc:Cv, ... 1~--l?)I'. Elv1AIL Address: JYJ,U({'3, eds,:s,.1/~
Address: ft) Be x 631
City: P-./tvf;NffL. , Sc... Zip Code: ;n'19o County: c,{,ar/~--h:, 1 5 L ;
Office Tele No.: 843-5$-:--5'5';).{;, Cell No.: Bl./3-t25 .... 9:313_,;--
D. HEAT PUMP CONTRACTOR I'.~FORl'\1ATJON (if different than driller)
Company Name: 7o Ee ve-/ex;.,v.~;,"V,;,7\~..__-_...,!~...>,e;e,:.S:e.1,___,(,,.Q.::::· ::.."'CLe ____________ _
ContactPe~on_: ______________ __,E~•MA'--=--'~Il~-~A=d=dt=es=s=: __________ _
Address: ____________________________ ~---~
City: _________ ZipCode: ____ County: -------------'--
OfficeTele No.: Cell No.: _________ _
E. STATUS OF APPLlCAi""'IT
F.
Private: Federal: Commercial:
State:~ Municipal: __ Native American Lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
O'(}e.{.,) clrxtr> Yl~p . ·t:'tm. 7kr~.,,:,+rvtfy r~.--r.-,R-
Sv,-M,ht)ltE~ sys~-----------
WELL CONSTRUCTIONDATA
(l}Proposed date to be constructed: {1/JIWU-H ;lo ii Number of borings: __ I_· __
Approximate depth of each boring (feet):_~;;J_S_O ____ _
(2) Type of tubing. to be \lsed (copper, PVC, etc): _ _.H'-'-, ,_..,Z>_,P~E=----------___ _
(3)Well casing. Is the we!l(s) cased? (check either (a.) Yes Q! (b.) No below)
(a) Yes . ___ if yes, then provide casing infonnation below
Type: __ galvanized steel __ b1ack 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) Grout type: Neat Cement_·__ Bentonite Other (specify) ~~-=~ tlli~e (>;o~~o.
-. . .. '' \b5. i~
(o) Grout placement: Pumping_L Pressure __
( c) · Grout depth of tubing (reference to land surface): from
tf well has casing, indicate grout depth: from
Other __
O to :250 (feet)
NP< to Al/If (feet)
G:PU/UIC 5QW Notification ofh1teot Fonn (Revised 8i2008) Page2
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/aibina 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 (cat be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination mid the orientation of and distances benveen 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 purnp 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 al 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 un 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 rhea are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. I are to constrict, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approv specifications and conditions of the Perinit"
02/28/11
/Applicant
Robert Batley VC For Business and Finance
Print or Type Full Narne 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 rennrn 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]
GPLltUIC 5QW Notification of intent Form (Revised 812008)
REEL' Uk 4 !CVO
�C.1tN+r PrEt'rfF3ttWi1
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Map of
1200 Murchison Rd
Fayetteville, 'sic 28301-4252
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