WI0700078_GEO THERMAL_20010119

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) o
Type SQW Wells
In Accordance with the ·provisions ofNCAC Title 1 SA: 02C.0200
Complete application and mail to .address on the back page.
N
This is not the proper form to be used for injection wells in an open-loop geothermal syste~
Do not use this form for systems that circulate any substances other than water. o
TO: DIRECTOR. NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: :) J lf p , 20Qj_
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES
NO Ifno, do not complete this form. Fonn GW-57 HP,App/icaJionFor
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 inlnoitors and/or antifreez.es.
YES If yes, do not complete this fonn. Fonn 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 ~If no, then continue completing this form.
C. PROPERTY OWNER
Name: 4a, 1,/t:, /;e_ -C~wtl ,J . C m r,-, , C, I J •
Address: ~ C, ,,)? ,?, K c' 1,-c.o I b~ &f} '
City: A~ l..,s ', State: l'I. C., Zip Code: _:~:...;7:...,?~):...::0:;__ _____ _
County: 11;;..j.f~Bc c:O Telephone: -=--;-=s-c...;;>-.:.__---=-f;=G,'-,;J._-......:..:;1;;,..~o _..oe-______ _
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D. STATUS OF PROPERTY OWNER
Private: Federal: Commercial: __
State:~ Municipal: __ Native American Lands: __
GW-57 CL (Jan. 2000) Pagel of4
E. FACILITY (SITE) DATA
(Fill out ONLY if the S lus of Owner is Federal, State, Municipal or Conmercial).
Name of Business or Facility. ,)-: rr3
Address: f . ;
City: State: _ Zip Cade: County:
Telephone: Contact Person: (� �. gs e. e �r e 1/
Standard Industrial Code(s), SIC, which describes commer iai facility:
F. HEAT PUMP CONTRACTOR DATA
Name: `7:' % 7ivC24 AIL)1 7
Address: r t' t i 1
City: 4: klSrtham` State: ip Code 1 rib County:
Telephone: Z S1-7 -C c Y- 42G 7 Contact Person: n gri,e
G. CONSTRUCTION DATA (check one)
(1)
EXISTING WELL(S) being proposed for use as a ground -coupled heat pump
well(s). Provide the information in (t) through (4) below to the best of your
knowledge. Attach a copy of Form G W-1 (Well Construction Record) if available,
PROPOSED WELL(S) to be constructed for use as a ground -coupled hear pump
well(s) Provide the information in (I) through (4) below as PROPOSED
construction specifications. Submit Form GW-1 after construction
/y^ 1/d 165/;-'
Well Drilling Contractor's Name: //AJKS di)/ /04-- GZ.4--
NC Contractor Certification number. 2 O 1
Date to be constructed: 1.) J Z1t O) Number of borings: / 2- 2--
Approximate depth of each boring (feet): 5.P 0 D
1
(2) Well casing: Is the well(s) eased?
(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 g ound inches
(b) NO
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.Ls.):
(a)
Grout type: Cement Bentonite i — Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
around dosed loop piping; from to - (feet).
around well casing; from to (feet).
NOTE: THE WELL MULLING CONTRACTOR CAN SUPPLY T I-IE DATA RIR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
GW-57 CL (}an, 2000) 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. LOCA TJON 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 beat pump well system. Label aJI
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 approvais 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 Treabnent and Disposal Permits
K. CERTIFICATION
"I hereby certify, under penalty of law, that I have peI'Si>naJly examined and am familiar with the
information submitted in this docwnent and all attachments thereto and that, based on my inquiry of
those individuals immediately responsible for obtaining said information, I believe that the infonnation
is true, accurate and complete. I am aware that there are significant penalties, including the posSJ'bility
of fines and imprisonment, for submitting false infonnation. 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 oftbe Pennit."
GW-57 CL (Jan. 2000)
-~-/J../CJ2.dm ~~-( -0f Well Owner o f Authorized A~)
if authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
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 ISA NCAC 2C .0200)
GW-57 CL {Jan, 2000)
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 (919) 71S-6165
Page4of4