WI0700066_GEO THERMAL_20030512

ME:MORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
May 12, 2003
To: Willie Hardison, Regional Groundwater Supervisor
Groundwater Section
Washington Regional Office
From: Mark Pritzl ftlP Mark.Pritzl<@ ncmail.net
Hydrogeological Technician II
UIC Program
Groundwater Section
Raleigh Central Office
Re: Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection Well
System (type SQW injection well.)
Notification to construct and operate a well for a closed-loop geothermal heat pump system has
been filed by Mr. Hardison in New Bern, North Carolina and a copy of the Notification is
enclosed for your files. This injection well system is deemed permitted by rule (NCAC T15A:
2C.21 l(u)2) and no regulatory action is necessary. If you have any questions, please contact me
at [phone].
cc: CO-UIC Files
Enclosures
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina . _partment of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
May 12, 2003
Mr. Tomas Hardison
4105 Homestead Drive
New Berri, NC 28562
RE: Notification of intent to construct Type 5QW injection wells
Dear Mr. Hardison:
In accordance with the notification you submitted to the UIC Program on May 9, 2003, the
Groundwater Section acknowledges your intent to construct two 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 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].
cc: UIC-WARD files
UIC-CO files
'MA
OENR
Customer Service
1 800 623-7748
Sincerely,
Mark Prilzl
Hydrogeological Technician
UIC Program
Division of Water Quality / Groundwater Section
1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet http:llgw.ehnr.state.nc,us

NORTH CAROLINA J 1
DEPARTMENT OF ENVIRONMENT AND NATIJRAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP
GEOTHERMALWATER-ONLYINJECTIONWELLSYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
In Accordance with the provisions ofNCAC Title 15A: 02C.02QO
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 any substances nther than water.
TO: DIRECTOR., NOR'IH CAROLINA DMSION OF WATER QU¥,ITY
DATE: ,Y-,23,,.-CJ_?, 20_
c:i
A. SYSTEM CLASSIFICATION Does,the proposed system circulate potable water in continuofii ci
piping that completely isolates the fluid from the environment? ~ fJ;;;, . , , l=-o~,.,
✓ · ... • -< c:n
YES _ If yes, then continue completing this form. 1 2 !.?: \.0 t::)<
~fTl
~o NO Ifno, do not complete this form. Form GW-57 HP,Application For5:c M,
Permit To Construct And/Or Use A Well(s) For Injection With A He~ ~~
Pump System, should be completed. •• ~::::o
.c-....
. ~ -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 Well(s) For Injection With A Heat
Pump System, should be completed.
NO V If no, then continue completing this form.
C. PROPERTY OWNER
D.
Ver.3/01
Name: ·/(9 U1 ~R d '.,Se-d
Address: ~ &/1?£$#//:d P«://e:
City: &d&a;,; State: ~ Zip Code: _...,z...,,· 8."'-""':6'--'(;,~-----
County: /;RduE;.; Telephone: ---=2.=<.=-=--Z._---=.S;._1_.¥._-~~._o----"-7 .,.&''---------
STATUS OF PROPERTY OWNER
Private: V Federal: Commercial:
State: Municipal: __ Native American Lands:
GW/UIC-57 CL Page I of4
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: _________ ContactPerson: ___________ _
Standard Industrial Code(s), SIC, which describes commercial facility: ________ _
F. HEATPUMPCONTRACTORDATA
Name: c1~9zf7 1 I~ e CLt;'. G.1 µ-~.
Address: __ _J~ __ S/..
City:..:)qd(..s.:wv./1/G:: State: _K_ Zip Code: 2'8$90 County: CJ;vs/o.J
Telephone: 9/0r.3S-3" z'c;iyp Contact Person: n /7Ct'£ Sp,/Tf;
G. CONSTRUCTION DATA (check one)
✓
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.
(1) WellDrillingContractor'sName: S14r1.fu1z..d' L dt:v£Eh d (/
NC Contractor Certification number:__;_/Vc...:.......::c::....._-...... Z_t:J___..B~2=-----------
Date to be constructed: i-.3 0 -0.3Number of borings~ __ 3 ______ _
/
·/r I' Approximate depth of each boring (feet): ____ __.__.J_ .:..:.:> _________ _
(2) Well casing: Is the well(s) cased?
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel __ Black steel~ Plastic __ Other (specify), ____ _
Casing depth: From ___ to ___ ft. (reference to land surface)
Casing extends above ground ____ inches
(b) NO L
(3) Grout (grout the vertical length of the borehole to a minimum depth of20 feet b.l.s.):
(a) Grout type: Cement__ Bentonite ✓ Other (specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
✓ around closed loop piping; from O to I~ (feet).
__ around well casing; from __ to __ (feet).
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF nns INFORMATION IS UNAVAILABLE BY OTHER MEANS.
Ver.3/01 GW/UIC-57 CL Page 2 of4
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 permits 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 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 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."
atu.re of Well Owner or Authorized Agent)
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 othe.r 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.)
Ver.3/01
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)
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW/UIC-57 CL Page 4 of4
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