WI0600081_GEO THERMAL_20110928

Permit Number
Program Category
Ground Water
Permit Type
WI0600081 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael .rogers
Coastal SW Rule
Permitted Flow
Facilitv
Facility Name
Duane Kenneth McLaughlin SFR
Location Address
2081 Harnett Central Rd
Angier
Owner
Owner Name
Duane
Dates/Eyents
NC -27501
Kenne McLaughlin
th
Scheduled
Orig Issue App Received Draft Initiated Issuance
09/28/11 09/22/11
Reoulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Central Files: APS_ SWP_
09/28/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Duane Kenneth McLaughlin
Owner
2081 Hamett Central Rd
Angier NC
Major/Minor
Minor
Region
Fayetteville
County
Harnett
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Duane Kenneth McLaughlin
Owner
2081 Harnett Central Rd
Angier
Public Notice Issue
09/28/11
NC
Effective
09/28/11
27501
27501
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
AVA
MCDEN R
North Carolina Departmen t of Environment and Natura l Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Duane K. McLaugh~in
Debra J. McLaughlin
2081 Hamett Central Rd.
Angier, NC 27501
Coleen H. Sullins
Director
09 /28 /2011
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0600081
2081 Harnett Central Rd.
Angier, NC 27501
Dear Mr. McLaughlin:
Dee Freeman
Secretary
On 09 /22/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
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 i(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 e.ers @ncdenr.gov if you have any questions .
cc : Fayetteville Regional Office -APS
A PS C entraLFiles -~R-ermit-No .. WI0_6_0_0_Q8.l
Harnett County Health Dept.
j cer_el y, , () -~ , __ < W
S(~~~lv
forD~atts
Superviso r
Hany Lechworth (N.W . Poole Well & Pump Co., 3500 Rolesville Rd., Wendell, NC 2 759 1)
Steve Bowman (Bowman Mechani c al Services, 145 Technical Ct ., Garner, NC 27529)
AQUIFER PROTECTION SECTION
1636 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 I Customer Service: 1-877-623-6748
Internet: www.ncwaterouali t\/.o rci
A~ Equal Opportunity\ Affirma:i~e Action Employer
NOnehC .. op: .. arollna
/Vaturalfll
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
In Accordance With the Provisions of 15A NCAC 02C .0200
CLOSED -LOOP WATER -ONLY GEOTHERMAL INJECTION WELLS
These wells circulate potable water only as part of a geothermal heating and cooling system.
These wells are "permitted by rule" and do not require an individual permit when they are constructed in
accordance with the rules of 15A NCAC 02C .0200 and this Notice is submitted prior to construction.
Print or Type Information and Mail to the Address on the Last Page.
DATE: IVZ, 20 1/ PERMIT NO. (to be filled in by DWQ)
A. STATUS OF WELL OWNER (choose one)
Non -Government: individual Residence i Business/Organization
Government: State Municipal County Federal
B. WELL OWNER For individual residences, list each owner on property deed. For all others, state name of
entity and name of person delegated authority to sign on behalf of the business or agency:
Qaft Art KtuJ4 MI[. f✓gy1.
Dgbtpt 3'oy rc Att LA,Jyk1: „)
Mailing Address: 2Q 8 14ft r jr + Ce,. 4-r4- I rm.) A
City: 14 : ,e
State: IIJ� Zip Code: a275o L County: 14A-toe11-
Day Tele No.: 9 L9 ('1-1553 Cell No.: ?) 7 770 -. 73 73
EMAIL Address: dkr\ 1331 e 4v L, coiti Fax No.:
C. LOCATION OF WELL SITE - Where the injection wells are physically located: D 04
(1) Parcel Identification Number (PIN) of well site: 0 641 '" / 3 - 9Yf97F County: Ae
(2) Physical Address (if different than mailing address):
City: , State: NC Zip Code:
GPI IRTIC 50W Nntificidion {Revised 1/1R/20111
RECEIVED I OENR r DWQ
AQUIF R PR(T!"F[: T ION SFCTIQN
SEP22ZOil
Pave 1

D. WELL DRILLER INFORMATION
Well Drilling Contractor's Name: ! "
/004-4
NC Well Drilling Contractor Certification No.: L 933 /9 C 2 VV4
Company Name:
Contact Person: /#/�y L� G� w '4
Address: 3 5 b° o,..s i« 12.p ,e
EMAIL Address: 16]4 £ Nit/ 12. w.cl/o,
City: 2'11.11 Zip Code: z75,/ State: 'VC County: tfla ,e
Office Tele No.: Lr ) z'C-92Z3 Cell No.: FaxNo.: NV Z.II- B)
E. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: ► Oiv"ctr\
Contact Person: EMAIL Address:
Address:
City: Zip Code: State: County:
Office Tele No.: Ce11 No.: Fax No.:
F. WELL CONSTRUCTION DATA
(1) Number of borings to be constructed*: Z Depth of each boring 2. Z
(feet):
* If existing water supply wells will be used then provide the information in item (4)
below.
(2) Type of tubing to be used (steel, PVC, etc): // PE
(3) Well casing. If the wells) will use casing then provide the tie (steel, PVC, etc.), diameter. depth,
and extent of casing appearing above ground:
{

(4) Grout (material surrounding well casing and/or piping):, ·\J
(a) Grout type: Cement__ Bentonite** ~ther (specify) _______ _
** By selecting bentonite grout, a variance is hereby requested to 15A NCAC 2C .0213(d)(l)(A), which requires a cement type grout.
(b) Grout depth of tubing (reference to land surface): from S/Z-e. to G-LO(feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
G. WELL LOCATIONS -Maps must be scaled or otherwise accurately indicate distances and orientations of
features located within 1000 feet of the injection well(s). Label all features clearly and include a north arrow.
(1) Attach a site-specific map showing the locations of the following:
* Proposed injection wells * Buildings * Property boundaries
* Surface water bodies * Water supply wells
* Septic tanks and associated spray irrigation sites, drain fields, or repair areas
* Existing or potential sources of groundwater contamination
(2) Attach a topographic map of the area extending 1/4 mile from the injection well site that indicates the
facility's location and the map name.
NOTE: In most cases, an aerial photograph of the property parcel showing property lines and structures can be
obtained and downloaded from the applicable county GIS website. Typically, the property can be searched by
owner name or address. The location of the wells in relation to property boundaries, houses, septic tanks, other
wells, etc. can then be drawn in by hand. Also, a 'layer' can be selected showing topographic contours or
elevation data.
H. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .02I 1(b) requires that all permit applications shall be signed as follows:
I. for a corporation: by a responsible corporate officer;
2_ for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
3. for a municipality or a state, federal, or other public agency: by either a principal executive
officer or ranking publicly elected official;
4. for all others: by the well owner (which means all persons listed on the property deed).
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the
applicant that names and authorizes their agent to sign this application on their behalf.
"I hereby certify, under penalty of law, that I have personally examined and ain 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. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the approved specifications and conditions of
the Permit."
Signature of Property Owner/Ap leant
Print or Type Full Name
Signature of Property Owner1A ppli t
Print or Type Full Name
Signature of Authorized Agent, if any
Print or Type Full Name
Submit the complete application package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED DEM I iJWQ
AOUIFFR PPi1TFr:TInN ?,EC11014
SEP 22 Zell
GPU/LIC 5QW Notification (Revised 3/18/2011) Page-4

HARNETT coves lEALTH DEPARTMENT N 2 � .. 6910
ENVIRONMENTAL HEALTH SECTION
CERTIFICATE OF COMPLETION I OPERATIONAL PERMIT
Name: (owner) 1..c.i�r"42_ at $"mew installation E eptic Tank
Property Location: SR# %4/D 3 a Repairs Q trif cation Line
Subdivision Lot #
Contractor: L2.4...`-g etivI Registration #
Easement with Plumbing. U Garage: <
Water Supply: ❑ Well f2 lic ❑ Community
Distance From Well: 0 ft. #-
Following are the specifications for the sewage disposal system on above captioned property.
Type of system: ❑ Conventional 4 Dther
Size of tank: Septic Tank: 706 gallons
Subsurface No. of 3exact length
Drainage Field ditchea French Drain:
PERMIT NO. 5617
Linear feet
• o']
Pump Tank:
gallons
width of depth of
119Oft. ditches ft. ditches /?_ l in.
Date: 0.7 - r ! 3
Inspected by _� .
En
nm.en.tal Health Specialist
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