WI0700075_GEO THERMAL_20030130

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
January 30, 2003
To: Willie Hardison, Regional Groundwater Supervisor
Groundwater Section
Washington Regional Office
From: Mark Pritzl MP Mark.Pritzl @ncmail.net
Hydrogeological Technician II
UIC Program
Groundwater Section
Raleigh Central Office
t.
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 the National Park Service in Buxton, North Carolina and a copy of the Notification
is enclosed for your files. This injection well system is deemed permitted by rule (NCAC Tl 5A:
2C.21 l(u)2) and no regulatory action is necessary. If you have any questions, please contact me
at [phone].
cc: CO-UlC Files
Enclosures
North Carolina
Michael F. Easley, Governor
William G. Ross Jr., Secretary
,Jartment of Environment and Natural Resources
Alan W. Klimek, P.E, Director
Division of Water Quality
January 31, 2003
Lawrence Belli, Superintendent
1 401 National Park Drive
Manteo, NC 27954
Dear Mr. Belli:
In accordance with your notification received on January 30, 2003; the Groundwater Section
acknowledges your intent to construct a closed -loop geothermal water -only injection well
system for the operation of ground -source heat pump. This system as described in your
notification will not require an injection well permit and is deemed permitted by rule (NCAC
Title 15A: 2C.0211(u)2)
Please note, if you propose to introduce any additive such as a corrosion inhibitor or anti -freeze
to your system, you will need to submit an injection well permit application for a Type 5QM
mixed fluids geothermal heat pump system as required by NCAC Title 15A: 2C.0211. It would
then be necessary to await the issuance of a Type 5QM permit for your system prior to
introducing any additive to your system.
The Underground injection Control (UIC) Group has added your site to our inventory. Thank
you for submitting this notification. If you have any questions regarding geothermal heat pump
wells please feel fret to contact me at [phone] or Evan Kane at [phone].
cc: John Gibson, Nation Park Service Hatteras
CO-UIC Files
WARO-UIC Files
raa►
m
Customer Service
1 800 623.7748
Sincerely,
Mark Pritzl
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
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP
GEOTHERMAL-WATER-ONLY INJECTION WELL SYSTEM
{GROUND-SOURCE HEAT PUMP)
In accordance with the provisions of NCAC Title 15A: 02C.0211
complete notification and mail to address on the back page.
This is not the proper form for injection wells to be used in an open-loop
ground-source heat pump system. Do not use this form for systems-that
re-circulate any substances other than water below.the ground surface.
Type SQWWeUs
TQ DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: ;;2_ j J -14 ,.S ,-i-9-Z.S,o .3
Please type or print clearly.
A. SYSTEM CLASSIFICATION Does the proposed system re-circulate potable
water in continuous piping which isolates the fluid from the environment?
YES ~s, then continue completing this form GW-57 CL.
If no, do not complete this form. A form GW-57 HP
(Application For Permit To Construct And/Or Use A Well
For Injection With A Heat Pump System) must be completed.
B. SYSTEM FLUID Will any additives be introduced to the system's subsurface
piping, including but not l?JIUted to corrosion inhibitors or antifreezes?
YES If yes, do not complete this form. A form GW-57 HP
(Application For Permit To Construct And/Or Use A Well For
Injection With A Heat Pump System) must be completed.
N) ✓' Ifno, then continue completing this form GW-57 CL.
e--t+ 1-4
C PROPERTY OWNER
Name: /VA-ti 0/t/Jfl/._,,.. ;ti ~/2,/L.. ~ ~er ;--&/-~ 5
Address: L/0 3 7 S-l-,t C /~ ~ ~
city: B uSL--RMJ {A.J C!.-:=: Zip code: 2,;7 q O °(
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GW-57 CL (March 1997) Page 1 of 4
D. STATUS OF PROPERTY OWNER
Private: Federal: _
State: Public:
Commercial: Native American Lands:
E. FACILITY (SITE) DATA (Fill out ONLY if the Status of Property Owner is
Federal, State, Public or Commercial).
Name of Business or Facility: L i f
Address: 3 7 L-( a -; rr�c1� G o
j iv�a5�s"
Zip code: 7 -)e' v ar County:
Telephone:a 5 . - 9 9 449 9i‘ Contact Person:
Standard Industrial Code(s) which describes Commercial facility.
F. HEAT PUMP CONTRACTOR DATA
Name: �F972'0 1 w�
Address: /Cl) 9 , / . (2 Sr(
City: ( f 07W C° G 72- f p code: 7 9 t� 6- e +'
County: _ Telephone: S -' S 3 5' - 51' %
Contact Person:
G. WELL USE Will the system well(s) also be used as the supply well(s) for
your personal consumption?
YES NO
H. CONSTRUCTION DATA (CHECK ONE)
EX[STING WELL(S) being proposed for use as a ground -source 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.
PROPOSED WELL(S) to be constructed for use as a ground -source
heat pump well(s). Provide the information in (1) through (4) below
as PROPOSED construction specifications. Submit Form GW-1 after
construction.
GW-57 CL (March 1997) Page 2 of 4

(1) Well Drilling Contractor's Name: /9i N 1� S"rzr,l.) p,_,wP :.i,' ,—Z c—L p
NC Driller Registration number. 4
(2) Date to be consnucted:' A P L�
Approximate depth of each boring:
Number of borings:
(3) Well casing: is the well(s) cased?
(a) YES If yes, then provide casing information below.
Casing type: Galvanized steel — Black steel _ Plastic
Other (specify)
Casing depth: from to ft. (reference to land surface)
(b) ND
(4) Grout (material sun-ounding well casing and/or piping):
(a) Grout type: Cement ; Bentonite L-
Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
around closed -loop piping; from d totem ft.
around well easing; from to ft_
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
H. LOCATION OF WELL(S) Attach two maps.
(1) a site map (can be drawn) showing 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 -source heat pump well system.
(2) a location map referencing the site to a labeled road intersection.
GW-57 CL (March 1997) Page 3 of 4

I. CER 1 I 1CATION
"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 any 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
well(s) and all related appurtenances in accordance with Title 15A NCAC
Subchapter 2C Section .0200."
(Signature �f Owner or Authorized Agent)
Please supply a letter signed by the owner
authorizing the above agent, if authorized agent is signer.
J. 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 land owner in the absence of
contrary agreement in writing.)
If the property is owned by someone other than the operator, the property
owner hereby consents to allow the operator to construct a ground -source heat
pump system as outlined in this notification and that it shall be the responsibility
of the operator to ensure that the ground -source heat pump system's well(s)
conform to the Well Construction Standards (Title 15A NCAC Subchapter 2C .0200)
(Signature of Property Owner if Different From System Operator)
Please return the completed Notification package to:
UIC Program
Groundwater Section
North Carolina DEBNR-DWQ
P.U. Box 29578
Raleigh, NC 27626-0578
(telephone: [phone])
GW-57 CL (March 1997) Page 4 of 4