WI0700065_GEO THERMAL_20040924

MEMORANDUM
To: David May
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
September 23, 2004
Washington Regional Office
From: Thomas Slusser--:z15 _
Central Office
Re: Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection Well
System. (Type 5QW.):
A Notification of intent to construct and operate [9] closed-loop, water only injection wells for a
geothermal heat pump (Type 5QW injection well) system has been filed by Cieszko Construction
Company in Havelock, Craven County, 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
Wr6 7-Q()O 05
Michael F. Easley, Governor
William G. floss Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Director
7 -{ Division of Water Quality
153 't'�= Coleen H. Sullins, Deputy Director
-1 Division of Water Quality
_tea
September 24, 2004
Martin G. Cieszko
Cieszko Construction Co., Inc.
249 US Highway 70 W
P.D. Box 690
Havelock, NC 28532-0690
RE: Notification of intent to construct Type 5QW injection wells
Dear Mr. Cieszko:
In accordance with the notification you submitted to the Underground Injection Control (UIC)
Program dated September 16, 2004, the Aquifer Protection Section acknowledges your intent to
construct 9 closed -loop 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 1SA: 2C.0211(u)(2)) and will not require an injection well
permit from the state. However, 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, including the addition of antifreeze,
corrosion inhibitors, or any other substances to the circulating fluid, you must contact the Aquifer
Protection 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,
-24144-e4 -
Thomas Slusser -
Hydrogeological Technician II
UIC Program
cc: David May, Washington Regional Office
NCDENR
N. C. Division of Water Quality / Groundwater Section
t636 Mall Service Center Raleigh, N.C. 27699.1636
Phone: [phone] Fax: [phone]$S Internet http:llgw.char.state,nc.us
Customer Service
I-877-623-6748

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOT'
GEOTHERMAL WATER —ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page_
This is not the proper form to be used for injection wells in an open -loop geothermal system.
Do not use this form for systems that circulate an substances other than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: 16 Sept: , 20 04
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES x 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 Wells) For Injection 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 For
Permit To Construct And/or Use A Welk-4 For Injection With A Heal
Pump System, should be completed.
NO X If no, then continue completing this form.
C. PROPERTY OWNER
Name: Cieszko Construction Company. Inc
Address: 249 US Hwy 70 W, P C7 Rnx f190
City: Havelock, State: NC Zip Code: 28932--06_90
County: Craven Telephone: ?52-447 _2096 Fax: 252-447—Q R7 _ -
D. STATUS OF PROPERTY OWNER
Private: X Federal: Commercial:
State: Municipal: Native American Lands:
Ver.3/01 GW/UIC-57 CL Page 1 of 4

E. FACILITY (SITE) DATA
(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: 4 1�t ,t -- r't y.t 11
i' �,��177 -► ] •_
Address: 13 G {_' ,a ( Or; V€
City: O L.d f y State: A/C- Zip Code: 213. - County:
Telephone: 7/ 9 - 7.20 In 7 Contact Person: T n Fv 7 " C /1
G. CONSTRUCTION DATA (check one)
(l)
EXISTING WELL(S) being proposed for use as a ground -coupled heat 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 Construction Record) if
available.
PROPOSED WELL(S) to be constructed for use as a ground -coupled heat pump
well(s). Provide the information in (1) through (3) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
Well Drilling Contractor's Name: 'L) sr
NC Contractor Certification number: 2 /.555
Date to be constructed: C C r ! `.O syNumber of borings: 9
Approximate depth of each boring (feet): e , dva
(2) Well casing: Is the well(s) cased?
(a) YES If yes, then provide the easing information below.
Type: Galvanized steel Black steel Plastic Other (specify)
CR- ing depth: From to ft. (reference to land surface)
Casing extends above ground inches
(h) NO X
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.l.s.):
(a)
(b)
Grout type: Cement Bentonite Other (specify)
Grouted surface and grout depth (reference to land surface):
V around closed loop piping; from p to ;,add (feet).
_ around well casing; from to (feet)_
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BV OTHER MEANS.
Ver.3/41 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 pennits 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 oflaw, 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."
(Signature ofWell Ownero
Martin G. Cieszko, President
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 of4
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 15A NCAC 2C .0200)
Ver.3/01
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UICProgram
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW/UIC-57 CL Page4of4