WI0700067_GEO THERMAL_20041022

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William P. Kemp, III
P.O. Box 12425
New Bern, NC 28561
October 22, 2004
Michael F. Easley, Governor
William G. Ross Jr., Secretary
No rt h Carolin a Dep art ment of En vi ronm ent and Nat ural Resourc es
Alan W. Klimek, P.E. Director
Div ision of Wate r Quality
Ref: Notification of intent to construct Type 5QW injection wells
Dear Mr. Kemp:
In accordance with the notification you submitted to the UIC Program dated October 18, 2004, the Aquifer
Protection Section acknowledges your intent to construct [5] closed-loo p geothermal water-onl y injection wells
for the operation of a ground-source heat pump . The system as described in your notification is deemed
pem1itted by rule (North Carolina Administrative Code Title 15A: 2C.021 l(u)(2)) and will not require an
injection well permit from the state, but you should check with your county health department prior to
constmcting 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 .
Please contact me at [phone] or Evan Kane at [phone] if you have any questions regarding
geothermal heat pump wells or injection well mles.
Aquifer Protecti o n Secti o n
In tern et : http ://h2 o.en r.s ta te .nc .us
1636 Mail Service Center
272 8 Capital Bouleva rd
Best Regards,
Thomas Slusser
Hydrogeological Technician II
Underground Injection Control Program
Raleigh, NC 27699-1636
Rale igh, NC 27604
Phone [phone] I Customer Se rvice
Fax [phone]
Fax [phone]
An Equal Opportunity/Affirmative Action Employer -50% Recycled/10% Post Consumer Paper
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP
GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
In Accordance with the provisions ofNCAC 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 ~eothermal system.
Do not use this form for systems that circulate an y substances other than water .
TO: DIRECTOR, NORTH CAR OLINA DMSION OF WATER QUALITY
DATE: JO-/Y,Of , 2004
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 Well(s) 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 Well(s) For Injection With A Heat
Pump System, should be completed.
NO X If no, then continue completing this form.
C. PROPERTY OWNER
Name: \,<J; JL· A:½ f. K£)1 f' JIC
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Address: P,C2..!_ Ll-4-z S-· 7
city: NE il & r K 1tr state: Af..£::_ zip coc1e : ~z_.!?~S'~t__J ____ _
County: C I. A ,r E:N Telephone: Z. S 2 -t '3 '7-I i f i
D. STATUS OF PROPERTY OWNER
Federal: Commercial: Private: X
State: Municipal: __ Native American Lands:
Ver.3/01 GW/UIC-57CL Page 1 of4
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JOB (SITE) DATA
(FRI out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: / J + A E hi
Address: if ; -I- f S 1-4
City: E r','. State: N [ Zip Code: Z z Z County: r !} re.
Telephone: - . .3 7— 71. Contact Person: C , .1. el G Standard Industrial Code(s), SIC, which describes commercial facility.
HEAT PUMP CON TRACTOR DATA
Name: Climate Control Heating do Cooling Co.. Inc.
Address: 102 Middle Street
City: Jacksonville
Telephone: [phone]
State: NC Zip Code: 28546 County: Onslow
Contact Person: Michael Hadlcv
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 (4) below to the best of your
knowledge. Attach a copy of Form GW-1 (Well Construction Record) if available.
X PROPOSED WELL(S) to be constructed for use as a ground -coupled heat pump
well(s) . Provide the information in (1) through (4) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
(1)
(2)
Ver.3/01
Well Drilling Contractor's Name: Sanford L. Sweeting
NC Contractor Certification number: NC — 2082
Date to be constructed 0 Olt Number of borings:
Approximate depth of each boring (feet):
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 X
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet
(a) Grout type: Cement Bentonite X Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
X around closed loop piping; from 0 to 200 (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 BY OTHER MEANS.
ig. 06 be/5
200
GWIUTC-57CL Page 2 of 4

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.
H. 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).
(3)
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
"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 inforrnation is true,
accurate and complete. I am aware that there arc 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."
d=_r,�C�
(Signature of Well Owner or Author z d Agent)
!f authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent
Ver.3/01 GWIUTC-57CL Page 3 of 4

L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
Ver.3/01
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)
(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-57CL Page4of4
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