WI0700062_GEO THERMAL_20031117

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
November 17, 2003
To: Willie Hardison, Regional Groundwater Supervisor
Groundwater Section
Washington Regional Office
From: Betty G. Wilcox ;J,I/
Central Office
Re: Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection Well
System. (Type 5QW.):
Notification of intent to construct and operate a closed-loop, water only injection well system for
a geothennal heat pump (Type 5QW injection well) has been filed by Michael and Marlene
Gavlak at 107 Newport Court, Chocowinity, North Carolina. A copy of the notification is
included with this memo. This injection well system is deemed permitted by rule (15A NCAC
2C.021 l(u)2) and no further regulatory action should be necessary. If you have any questions
about this notification, please contact me at [phone].
cc: CO-UIC Files
Enclosures
Michael F_ Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of Water Quality
November 17, 2003
Michael and Marlene Gavlak
107 Newport Court
Chocowinity, NC 27817
RE: Notification of intent to construct Type 5QW injection wells
Dear Michael and Marlene GavIak:
in accordance with the notification you submitted to the U1C Program on November 14, 2003,
the Groundwater Section acknowledges your intent to construct seven dosed -loon geothermal
water -only injection wells for the operation of a ground -source heat pump. The system as
described in your notification is deemed permitted by rule (North Carolina Administrative Code
Title 15A: 2C.0211(u)(2)) and will not require an injection well permit from the state, but you
should check with your county health department prior to constructing the system because they
may have additional construction or permitting requirements for this type of system. If you
modify your system at any time, please contact the Groundwater Section to verify compliance
with applicable rules,
Thank you for submitting this notification, If you have any questions regarding geothermal heat
pump wells or injection well rules please contact me at [phone].
Sincerely,
Betty G. Wilcox
Environmental Chemist 1I
Permits and Compliance Unit
cc: Washington Regional Office
U1C-CO files
N. C. Division of Water Quality 1 Groundwater Section
1636 Mail Service Center Raleigh, N.C. 27699-1636
Phone [phone] Fax: [phone] Internet: http:/fgw.ehnr.;tate.nc.us
Customer Service
1-877-623-6748

NLU-5-2003 16:46 FROM: MURIE1 BUILDERS 252-946-75E9
T❑:1919ET03 P:2je
NORTH CAROLINA
13LPARTv1ENT OF t;IVVIRONMENT ANT/ NATURAL RESOLIRCILS
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP
GEOTHERMAL WATER. -ONLY. Llri i ECTION W ELL SYSTEM
(GROUND COUPLED HEAT PIJMP)
Type 5QW Wells
In Acordsnco with Itie piuvttiom al`NC'r C' Thli ISA: tiar:.O?.OD
Complete opplicutian and mail to srkin- s on the balk pie.
'lids Is oath'.I*oper lurm to be used For Injection wells le no usiebtaxtothertaal
%mot vie this farm Rtr.yptem that circulate am labstrttel otter tlreli x trr.
TO. DIRECTOR, NORTH CARROLINA TMV1SION CiT WATLIL QUALITY
DATE: jjeagediee _5 20,1
A, SYSTEM CL.ASNIFICAT1QN I oeg the prupetsed sy!rtem cirGuhttc potable Water in cnniinuoun
piping th,1t completely icr iatec the tluid from the envirufuwiP !
t.:
VE?S Ifyt . then confirm: a tt,pletin; this, loan.
a
+.a
NO
if na. do twt luklipleto this forms. Form ti W •S7 HP..7ppilrarlon For
Permit To climb -ma A rrcd b- Mnr et We1ll's) For b jjctioo With A FIcuf
Pwl:p Sv i m, ihauf[1 he completed.
11. SYSTIiM FLUID Will any rulditihcs be introduced to rhr aiylltett'x uk mating her Ir*ntras
fluid? This includes. but ix nn[ Ifmited to C4lrtosFon inbibiloras erndlur TIfr e2rs,
YES If yeti, do not 4utnpinte this form, Form GW-S7 HP. ApPifeatiort For
Prg,nie iu Con,r'r r And/Or Lae ri If elif.) For Igjecriurr With A Heat
trrrrrp,Swtcnr. xhoula br,+connplatod.
NO
C. PrROPNRT'Y OWNER
Ft no, then continue cot ttadng this Farm,
Name: 0/ C E6-AV LA k
Address: ,_122_11 p.,Pd , l er
City: ,c4644 4&4► ITS' 5rrin; (G zIp Code: 7..+ _► 7
calm?: ,K EALIES Izr Telephcm 8 [ ,:-aaliy/ j{ e 11�
1). STATUS OF PROPERTY CWNeR
Priwito . ^ Fexiernl: Commercial:
State: Municipal Native American Lands:
Vcr.3fls I
?98Z 9A£ OW6
CAM/CO iC'I Nike f 0'4
DWIllIaa •a m way t•t' se Ezez-.I 'AnN

NOV-5-E003 16:47 FkiJi"1: MURIEL BUILDERS 25E-945-75E9
TC : 19109692700 P : 3, 9
F, FACILJ7Y (Si'1'E) DATA
(Fill out ONLY if this Status of Owner io Nederal, SIatc:, Muiircipni or ennsrtiureiaD.
Nutria of UYsfsi fr t ':..,,,, .. —.,- "- -----
Address,
------
City: 5iu dip C xle: __......_,... _ _ coiddy:. ___
Telepbon . ` - _ Cr}atat . W eali- ' rfL' _
3 tS C ingiutttrit)tra[s)4 sic, which fret Thbes tC j is ,.
F HEAT PUMP WWI R ACTOR D]A rA
Narrw: 1.X.0._&!4-._..a_.,M! flO t ( 4.,
i�(Undress: _ __., 9 e. . , ,s_i
City 4/461.,4fight SiAlw Li11G- Gip Lode: ,_ Courtly: ,dr
'� :.TeIepharte: 2 - ‘1� -, S auvact Person: 01 4 st v 23 erudeTr
Ire "a
t3. CONSTRUCTION DATA (elrtxk onr)
EXIWIINQJ WLLla($) bring proposed for use as a ground- up1od hat pump
t+JJI(ri). Provide the ieftentaiirbn in ( i) throw (3) Wow to /ffv bast of yarn
knowledge. Attach 1l copy of Forrn Grit/-i (Welt Cnnstniut n Rwaard) sf
aumilahle.
PROP
Fii(7J'USIEaQ WELL(S) to be catlauuctcd tier use as a ground-raupksni hat pump
ws;ll(s). ihtwidc Om Information in (11 *tough (31 balm um PROPOSED]
r:utlstntctiou spvcificsticrrts. 5ubniil 2-or11iiW.1 allot. ccinsnuctLun.
(I) Weil Dr"iihrir C:arrtrnr:iur'u Nurns r P _ f j -
NC Cm:10 Ln .. iIIictiliurr ntirrthor; a /5
Date I be wrtetnic.tod: // /Q -03 Number of borings: _
Approximate depth ot►achi boring (Cunt);_ _,Q,__
(2) Well casing; la the wdll(a) eased?
(a) YES Um. then prawidc the casing irlformnlion ()crow.
Typc: Calvar07,r4strrel_ �._ kick steel Fin;tic._ -_. Other (specify))
Casing, de]stb: From to it (ra ercri to !soil Sufi cc)
Caning oxtcnda atom grnuntt _ inches
(b) NO A
(.3) Great (grout the ver'tield length afthe borcholu a minimum dapsh or20 Cm' b,1j.):
(a)
lb)
(irtuat type; Ce rarnt__ aorrruftitsr _ DM!!CT (Peci f'x) .,6.fe firr{,r.r'a! :e2Pelf
(1rtu►tod surfh►x and grout depth (reference to land airtime): !�
,C_ Around cloned loop piping; ism 4. to j o r3 Mot),
airttwid well easing; from --- to (feet),
NOTE: THE WELT. ICI-AT A( rl7R c'ANeuePe.Y Ttm nArA FOR EMIR EXIST1Wtt e]R
► it.0 5Fl)Wtil.ts IF rills I pi"WtMATIUH In UNA VA lLA1itF tiv prtIfal kinAto,
Ver.sldll aw u:c. 'r t: i.. Plop of 4
Z987: 9t'1 016 Wti TO:Bra iif8cit.-5.:'-•Ar H

NOU-6-2003 1.6:47 FROM:MURIEL 8t1ILDERS 252-946-7569
{
TO; 191098927t00 R:4/9
H. t,NVICT1*,N-AELATfsD EC}UIPMENT
Attach a diagram showing the iwttginacrina layout ar the ir>te:cr,ion Ggtiipntcnt and exterior piping/ruiing
sxiwtusiatood with the injautian ❑p rstiurl. 1 he rrtnnui' .turet's broc:huris may tmivide sutlplerentary
information.
1, LOCATION OF W EEL1.(S) Attach twn imam.
(1) Which; a site map kean be drawn) rwliowlilg; buildings, properly limes %Once wean bodies,
potential sources of groundwater ccnitarn inailiva and the orientation of and diaroneoa between
the proposed wall(s) and any existing walks! or wnSte disposal facilities ape;l+ sx t«afpdc /nolor
or drain ficish Ioastad within 200 red of the ground-coupkd drat ptrwyip well system. Labe all
faamirtat ckxrly and include is math wow.
(2) location map reforming he riirc to two nearby panuatril reference Mots (sends 10 weds.
elmarns and hiy► t ry i rsccdoa9)
PERMIT LIST Attach u list of all parrrnin ur aanstcuruon appxavals thm .,rc ratted to the Rise.
btampine Inetudu:
(1) Ftazardoun Waste Mawigtmcat program permits under RCP:A
(2) NC Division of Wince Quality lrua•13lscltarrc permits
(3) Sewage Trees rwi:nt and Piupoaral Permits p. rc, ,ss: ijxfa sr 0,47t- q
![. CI'/'t71CATION
hcroby ccFOY. umber penalty o1 aw, that I Iuva peraoyrnity cumhied and am %tidier with thr
iafomtutatInn submitsod si tidy document and all nitaehonnia therein and that, /basted all my itltatiry of
thaao iodividunlu imm:dintcdy rervonsibla !or obtaining said infisrneuion.1 helium that the iutormesion
is not, accurate urate told complete. 1 am arras dux there are eigeifiettat penalties, iaic1vdinio the punnibilil
Qf fines and ilR7priacremeralt for itubtrirtin4 fat e i+gt'osmatiou. C agree to construct. OPenitc. mnin aim.
mp sir, and it applicrhts, ahundes the ground-emm hptl pump system and all related eppartertenuer. to
accordance with the npprovcd specifications and condititme artbe Permit."
Ver.3IO➢
Srd'ad Z9+3r 94E 016
0/1111111Ure se Well Owner or Arathnriizd Aleut)
micaAEL 6AvtAt
If authorized agent is a alilg an he/wife)! thr well owner.
',Wee .srwppty a leiter signed by the owner
authorizing mire above cream
OW/Lilt•57 C1
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N131J-5-20a3 1E:48 FROM: r1JRIEL BUILDERS 252-94-7529
TO:19109892700 P:5/9
zit
L. CONSENT OF PROPER IT OWNER (Owner mono any person wit« holds the t' a re other property
rights in the well being constructed. A well in to property and its u,rsatruetiott on land !esiS
ownership in Mc landowner in Ow tsbncnce of contrary ogr :ment in writing.)
Var.3N l
l tilu propeny is owned by samosa/lc Drina than We pphcnttt, the property owner busby consents to
allow tho applicant to construct each ir;jcction well as uuiGtwd in this application and Otat it shall be
the ri mponeibdity of the applioura ttx cost= that the ground -source ear Mrrib system'a wrolf(s}
wnfbm:Is La the Wei/ Construction Standards ( floe ISA NCAC 2C .0200)
iSiinatUre Of Properly Owncr Irbi flbr tut From Applicant
it Mari. c-v.
?lease trtunt two copies of the completed Application package. to:
U IC Program
Groundwater Section
North Carolina DENT( -DWI)
1636 Mall Service Center
Raleigh, NC 27699.1636
Telephone [phone]
01WIJIC-57 CI. Page of 4
Z9SZ 90£ 016 w0 2v; eve 290Z-2 -norm

ND0-5-2003 16:48 FROM: MR! EL BUILDERS 252-946-7569
TO:19109892700 P:6J5
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NOU-6-2003 1649 FROM:MURIEL BUILDERS 252-946-7569
TO:1910989E700 PC7,9
!TY Etitza)
PHASE 1, SECTION 15
\..e■'‹e
E
1114,
•:4%? •
12•i,
Ak
k AZ.
• reezits„
• -019-
!TM MAP 15 FOR tFORILKROPil PURPcie(E5 atm-
NOT MR RECCIIDATION, CC*NEYAtOtes, on 8Ame
ViCINITY OAP NOT TO SCALE)
SURJE GT
LOT Se
I '
i
ft.r14IC
f)! 4:0 WORT • 2141, I a. It
if'
4McKEM&CREED
Ftta es.10. PSC 5
Picstil MOM MR
1152; [phone]
Fitt (2152) 53.1-65S1
SCALE 1° -•?•- 2001'
600

BEAUFORT COUNTY, NC
INSPEG°flQNS DEPARTMENT
vT
NOTICE
This Ce
has been issued to
for the erection of
es that a building Permit
GOV UV
i�tl�ul10�
Located at fO dWEWPCIr ! ci g r
H.D. # li B.P. # fAVIS
Date
7. 543
By '. &&1grt
REQUIRED INSPECTION
BUILDING
Footing
Framing
Insulation
Final
ELECTRICAL
Temporary Service
Rough -In
Final
HEATING & A/C
Rough
Venting
Final
PLUMBING
Sewer
Rough
Final
This notice must be posted in a conspicuous place an the job,
during the entire project.
80L2G T6T.:©1

ThisPermit Card To Be Posted On Site
TOWN OF CHOCOWINITY
ZONING PERMIT
444TRUCTION OF A BUILDING
[ ) ALT RATIDH OF AN B STING BUILDING
( ) ERECT, MOVE, EXTEND, D, OR ENLARGE A SIGNN
ZONE:
ADDRESS: /off 11(444e,p.r cG V1PF
X.-Airnitu
{ ) PLACZKENT OF MOBILE 1WML
4 ) REPAIR OF AN EXISTING BUILDING
( )INSPECTIONS C31 LOT (SEWER)
PERMIT NUMBER:
DATE:
75'?'
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