WI0700071_GEO THERMAL_20040505

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
May 5, 2004
To: Willie Hardison, Regional Groundwater Supervisor
Groundwater Section
Washington Regional Office
From: Thomas Slusser -rS:5
Central Office
Re: Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection Well
System. {Type 5QW.):
Mr. and Mrs. Cockran at 105 Goose Castle Terrace, Currituck County, has filed a NOTIFICATION OF INTENT To CONSTRUCT AND OPERATE A CLOSED-LOOP, WATER ONLY INJECTION WELL SYSTEM FOR A GEOTHERMAL HEAT PUMP (TYPE 5QW INJECTION WELL). 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 F.nviranrnent and Natural Resources
Alan W. Klimek, P. E. Director
Division of Water Quality
Coleco H. Sullins, Deputy Director
Division of Water Quality
May 5, 2004
Leslie and Jerry Cockran
105 Goose Castle Terrace
Currituck, NC 27929-9668
RE: Notification of intent to construct Type 5QW injection wells
Dear Mr. and Mrs. Cockran:
In accordance with the notification you submitted to the UIC Program dated April 30, 2004, the
Groundwater Section acknowledges your intent to construct 5 closed -loop geothermal water-onlv
injection wells for the operation ofa 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. 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 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' Willie Hardison, Regional Groundwater Supervisor
Washington Regional Office
UIC-CO files
Sincerely,
),(//4,6-eA
Thomas Slusser
Hydrogeological Technician lI
Underground Injection Control Program
N. C. Division of Water Quality / Groundwater Section
1636 Mail Service Center Raleigh, N.C. 27 i99-1636
Phone: [phone] Fax: [phone] Internet: httpJlgw.ehnr,state.nc.us
Customer Service
1.877-623-6748

03/18/2034 13:44 919-71g-3588
NCI)E&NR/ WATER '' lAL PAGE 02
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LQQT
GEOTILERMAL WATER -ONES INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
in Aaeurdan ce with tl ;envisions of NCAC Tine 15A: 02C.0200
Complete application awl mail to address on the back page.
This is pg the proper form to be used for injection wells In an oner oan geothermal system.
Da not use this farm far systems that ci etdate yliymilistanees other *n water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: 'T - 3 f , 20Q it
A. SYSTEM. CLASSIFICATION Roes the proposed system circulate potable water m continuous
piping that completely isolate the fluid ft= the
YES \'If yes, then continue completing this forte.
NO lino, do not complete this form. Form OW-57 HP, Application For
Permit To Canstruc And/Or Use A Weir{sj For Injection With A Feat
Pwnp System, should be completed.
B. SYSTEM FLUID Will any additives be introduced to the syste:n's circulating heat transfer
Mile This includes., but is not limited to corrosion inhibitors and/or antifreezes.
YES _ If yes, do not complete this farm. Form OW-57 HP, Application For
Permit To Construct And/Or Efse A Wells} For httection With ,R Haut
PUMP System, ahId be completed.
NO i/ Ifn0. then continue completing this fem.
C. PROPERTY OWNER
Name: s r.r 1
Adams: L a7 / �SF L A 5-rC.aL 7 4cJ
City: r Sr Ys State; ec/. r. Zip Coda: '-`7.=I
Carroty: CvR! i (v (-lc Telephone; . 5 - G, 3
D, STATLFS OF PROPERTY OWNER.
Private: V Federal: Commercial:
State: Municipal; Native American Lands;
Ver,3/01 Ow1UIC-57 CL Page ! of 4

03/18/2004 13: 44
919-731c-0588
NCDE2,NR/WATER n$JAL PAGE 03
E. FACILITY (SITE) DATA
(Fall out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Fecrhty:
Address:
City: State: Zip Code Copy:
Telephone: Camtact Parson:
Standard Industrial Code(s), SIC, which describes commercial li lity:
F. HEAT PUMP COl l'RACTO. DATA
Name: L �/.[c� ``li•+�__
Adding: 2 CC S.z D1r414 ! VI: ..
City: CA/CSA-State: v4- Zip Code: 3 County:
Telephone: 75 I- 461-- 7. Gal Contact Pam; gr.Il ce
G. CONSTRUCTION DATA (check one)
EXIST1NQ W$LL(S) being proposed for use as a ground -coupled heat pump
walks). Provide the iaibnratim m (I) tiro* (3) below to the best of your
]mowledge. Attach a copy of Form GW-1 (Well Coition Record) if
available.
PROPOSED WELL(S) to be constructed ibr use as a ground -coupled heat pump
wefl(s). Provide the infgniEi a in (1) through (3) below as PROPOSED
lion agpeaffications. Submit Farm OW-i after constructive
(1) Well Drilling Contractor's Name: 1 L SI d P _v 1c 1
NC Contractor bon number: 2 S S ,
Dale to be coasnucted: 5— '1 Number o£ bores:
Approidanate depth of each boring (feet): ? I o r-
(2) 'Well casing Is the wells) cased?
(a) YES If yes, then provide the ding information below.
Type: Oalvsaized steel Blank steel Plastic Other (specify)
Casing depth: From to ft (reference to land surface)
Caning extends above ground inches
(b) NO
(3) Grout (grout the vertical Iength of the borehole to a minimmu depth of 20 feet b.i.s.):
(a) Clrout type: Cornett Bsntonne 7 Othcr (specify)
(b) Grouted s (reference to land surface):
v"--around closed loop piping; from ' , to -2.14 (feet).
mound well Casio; from to (feet),
NOTE THE WSJ- DP. J4NO (=WRAC== CAN SUPPLY THE DATA FOR 13rricsiEMSIINii oR
PROPosED warns n, THU INF RMAnoN L4 LINAV.MXAB $ BY OMER MEANS.
V ar.3/01 GWIUrC-57 C 1. Page 2 of 4

e3118/2084 13:44 919-70588
NCDE&HR/ TER -"AL
I
PAGE 84
flON RELATIE,D EQUIPMENT
NT
Arleen a diagram showing the engineering layout of the injection equipment and exterior ping
associated with the Tejccion operation The manufacturer's brochure may provide
L LOCATION OF WELL(S) Attach two maple.
(1) Include a alrte map (can be drawu) showing: bindings, property lines sure water bodies,
potential sources of grotmdwater contamination and the orientation of and distances between
the; proposed. well(s) and aey existing well(s) or waste disposal facilities witch as septic tan
or drains fields located within 200 feet of the ground coupied heat pump well system. Labe' all
features clearly and include a north arm.
(2) location map refbrencieg the site to two nearby permanent reduce points (such as roads,
streams and highway intersections).
PERMIT LIST: Attach a list atoll permits or constrncti,on approvals that arc related to the site.
Examples include-
{1)
(2)
(3)
Hazardous Waste Management program permits under RCRA
NC Division of Wad Quality Non -Discharge permits
Sewage Treatment end Disposal Permits
K.. CERTIFICATION
Ver.3/i 1
"I hereby certify, underpeaalty oflaw, that I have personally examine[and inn familiar with the
motion submitted in this document and ail attachments thereto and that, based of my inquiry of
those Individuals immediately responsible fbr obtaining said information, I believe that the information
is true, aocucate and complete. I ant aware tbst there are significant penalties, including the possibility
of fires and imprisonment, for submitting false iofisrmation. I agree to construct, operate, numiitaim,
mpair, acid if appticseble, abandon the ground -source heat pump system and all related appurtenances in
accordance with the approved speci$cerlo s and conditions of the Permit"
ofWell Owner or Authorized Agent)
!f author •. - : agent is acts on behalf of the well owner,
please suppf5+ a letter Arai by the owner
authorizing the above agent.
GWIEAC 7 C.L Page 3 of 4

03/18/2004 13: 44 919-7)-''t-0588 NCDE&NR/WATER . -f:JIJAL PAGE 05
L. CONSBNT OF PROPERTY OWNER (OWou means any person who holds the fee or 01ter property
rights in tm. well being construc!ed. A wall . is ftllllproperty,and ita 1:0DIUUCUCJIUJD. land nm
ownmhip in the landowner in the absence of eo11trary agreement :iQ writing.)
Ver.3/01
If1he propar:ty is owned by 11omc0J1e otbar than the applicant, the property awnerh«wy OOD$Cll1tS ta
allow the appliADt to~ eachn,Jection well as outlined m thit applieation am that it shall bo
tho responsibility of the applicant to emun: thlt the ground-soun,o beat pump system's well(s)
con.fu.m:vs to tho Well C011itn2ction Standards ('1'"1,1:le JSA NCAC-2C .0200)
(Sianatme Of Property Owner If Different From Applicant)
Please retom two copies of tho c:ompleti:d Application package to:
tJICProgram
Groundwater Sectlon
North Carottna DENR-DWQ
1636 Mail Servlce Center
Raleigh, NC 27699-1636
Telephone ·[phone]
GW/fJIC-'7 Cl.. Pap4of4
03/09/04 TUE 10:52 FAX [phone]
Gildersleeve
a001
Let- 81
CURFUTUCK COUNTY
PLANNING AND INSPECTIONS
Site Plan Re
Permit Number, s do
Appr'orrd M Mr
ApprarrdAi Holed
74
Drrllird % Remhnit
74
/41V4'
Date
rgAie
es I in
� rz�r•
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/dose.
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_50-'t; ·-\ 1.. "-A
(/4:,-80 6;~'---( (.L4( J--/'{f-R_.f) v.jgrf£LJ_
fib -?s-(f_-,L 1 CLA-7
<,3S--l'/o So~r G,'!£< ClA7
11/o-2.,,a S/Wb/Sllf_it/ GfllUL-WAeD)
,f I ...
a3I18/2s64 i3 c,r 715-053x[3 1215,`w
NORTH CAROLINA
DEPARTMENT OF ENAGLOTNENT AND NATUkAL RESOURCES
NOTITTCATION07 ME " ` TO CONSTRUCT A !CMaraQ
GEO1HERIVIAL HALTEMA INACTION WELL SYSTEM
(GROUND COUPLED )EAR' me)
T'ot KW Wye
Iva -AztttOCC FECPMeall JafNCAC Tim 1SA: U2C O2OO
Ckvent crohniewriand nsiES aldress ca the hack page.
Tbk 4.7 :dat plepae Earat to be vsti iiiiYfr4gettitswas to ea pa opseotIlemasi sptern.
NAISAME tkb tom the Maar nt12 eztvizte
TO: DIRE aOIEi, D I ONK QII WATER QUALITY
1/-3
A. SYb tEh! CLAS i CATION Yoe f propzsed system cfrailstd parable VOW a ti ns
piping diet canpktmly iroletta t the cervironment1
virM tl= mailatt.'--'ffileiting this tam,
NO zn, tic, tot or4l thla Tam Farm GW-57 B(P, Application For
Patna Th C'oWta-ton fir Use A WoLf(s) Far Nation FFIth 4 !few
▪ Sow& ald be comileted.
to 13. SYS1714H► W M Ekay 0,derkiwfs ioltimduced to the sydtter u bait t3' rife:
WC This f ,'t1?t sSuot Ham' tt corselet u Whims =Nov entifrecZa.
cJ
r-a
mtg
YW �__.. sa#x s firm. Farm ' 7-y i BP; A :icatii r For
P srea To COMA Vd "Or rise A Wsli(s) Far !nft tfoPith 4 Hew
heisp:SYslow, thotfiti be
NO' , them o e istxs thisate.
G PRO '"Y OWNER,
D.
Mom
I ( _ Act5g Cas;yfd^
1341irr e-- ft= yr- Zip Cade: D-1/2--7
man et, e = trietak&: a. D.. 32 - S :i
TATUS OP PROPSKIY OW1182.
ems: dal..:
stew: tineicipalz NkeiWe Amy L5:
UW0.70-37Faze! of

031113l2004 13:74 •7}.5-Ndts►3
NCCQ.StdR/flail" UAL
P
E. PACU.J1 Y (W) DATA
(raU out ONLY if titt Stews of a4st31, Ste, Municipal or Commercial),
Nati& anktntie_ .
Address: .
City: Stet;_.. _ Zip Cods:..... —
Standard Inauttiol t, s), art 'RUA d cri eauiroeroisdreality:
F. HEAT
FRO r COX-TRACTOR�Tt
Nam: e, ., y_ = 4Fr i -
.4.24:toess: 3'iy-� -
City: Chi # PMkz sa c j Zip Code: �3 s Crst
Tr'.,t e: ' • z '#Q 71, ,A Pam: EAE _ c2- �41G.1•
c, T —
O. OONSTRUCTICV DATA (s ie tk ong)
lei lifO ` i (5) Wog proposed fbr use as a gime:id-coupled hod prop
well(o), Previde ete4 tAbrZatiMi.im (1) trough (3) bet* to the best ' your
1,440. Athich oveY of Pon GW 1 (Well C n lemma if
'iPRO 0SII WISLU,S)4.7 be onestreeted for use as a grouturkoopled ham e
s:,il(a). Petyr &tiff:motde r (1) through (3) b4low rmorost ?
%talt Form OW-1 after ee .
(1) WAD:tang i;ontreatu's Ne..11K
{
NC Cafflovimr -'
tiate to .enneeerk . 5 " Number of borings:
Approx7min6 dapt!:. of oeut nj (f4e)
(2) Weil mai= wet(i) ogat2
(a) Y If yoa, then provide the etainformation below.
Type; Oki Ridged aG i AIk Acel Plastic Other ( ,y') — -
Casing Ica: Proms ►n fL (tztfetente to land fie)
Caging tortwAia abe-oe wand inches
(o) NO
() Gm (sec vertical tom& at breeliolo to s minima depth. al: feet l s.):
(a) G Guava Bentanfro t, Other ( ) -
(b) &fouled surface uod grout d (ssfurenee to land a x):
Vance olowd 1 s fivel B to 210 (*et).
�Irma taai• itaz to (
144Yl";~- "1"III 7/Plyrx anxrn'" .":=0Q.
MIS t IMAIAL 1 ."K LRMFAVANABLEBY CenTia &TAW
ONTOC-3 Paw 2 oi' 4

83/18/20e4 13:44 t 715--S
r4Gixe.sNR/WA 'E Olt PAGE 1
FL =N TON-E Ul l�N'
Av.-sobtt disgam knowing cmginnettitg ikront of -the injection eqaipmant an erector pipkw tr
relax:ism:1,d with a.. hnietterz L'pt 'IAL- rrawafictireet brodhe racy provide supplemeofm7
infoonatim
i. LOCATION O '. .L Attach o-, 9 MS41ki,
V►) kirk 41 (ram to ;sly: buildings, property lines sew whet boo
pcxYnfni gcratm of gemnactsocer otistrAination aed tine erinotaition of cad dikes betur;.
tip propotaad well(s) ttarl toy a well(a) or wa.ste dkposig xicii#ies suab et refaie
or ct 110/14 ioetaci 'AWN Ofw. o tg filed heat p€np well spun_ s t rein
&gm&dysnd Lulu&£mow,
(2) location rtitp refaitackg V1 tie two warty pansoneur ThSttin2C4 pc (seas& is rortZ,
Me= and highway kitmaectkins).
r. W'r UST: A e Est & an or coOsrattion approvals that arc related to the Att.
Examples twin&�
I))Menattni Waft rtisperozha under RCRA
(2) NC Dile:WetofW r permits
(3) Sewage sad Dirposal Peattiu
K. TMCATION
.ebY aCirdrY, fi xity d���' , thst. I hum pa/aerially .e ediaa4 am Emitter wilt, A;-.
raaLion subanitt4" this doettealat nw.1 thereto aed that, based as ray i y •
thoie kaagaittlY �� fax. obtainingsaid informrdien. 1 ham -drat the infe=don
is :. 1 tnt t thw il=ve are sigoirannt peraatdas, ice: ix ag the p tr; v
of s cad impliatmmfast, for infiximation. I awed to construct opelttik r3fir, ,
Win, egad itcrillienble, -ounce bur pump system mod all rehrtad appunt
9.taoedeozs with the fired Ott .. awl eoaditmas of the Pit_"
\k ■
agent it acting on e gee well-Orme",
piedtd se p*) a Jaw aped fry the Liwrior
nothing the above ggenr.
V r31O1 {'s9GILY(C47 CL Peg& 3 of 4

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03/00/04 TUE 10:52 FAX, 74614082 i:dageeoe
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752/1200
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CURFEMICK COUNTY
PLANNititi AND INSPSCIIONZ
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