WI0700083_GEO THERMAL_20020111

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
January 11, 2002
To: Willie Hardison, Groundwater Supervisor
Groundwater Section
Washington Regional Office
From: Mark Pritzl /Y...() [e-mail]
Hydrogeological Technician II
UIC Group
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 Bruce and Sandy Tripp in Greenville, 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
o��F WArEAQ�
UJ r
Bruce and Sandy Tripp
5130 US 264 East
Greenville, NC 27834
Bear Mr. & Mrs. Tripp;
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
November 2, 2001
Gregory J. Thorpe, Ph.D.
Acting Director
Division of Water Quality
In accordance with the notification submitted on November 1, 2001; the Groundwater Section
acknowledges your intention to construct a closed -loon geothermal water -only injection well
system for the operation of a ground -source heat pump. The system as described in your
notification will not require an injection well permit and is deemed permitted by rule (North
Carolina Administrative Code Title 15A: 2C-0211 (u)2). The Underground :injection Control
Group has added your site to our inventory. If you modify your system, please contact the
Groundwater Section to verify compliance. Thank you for submitting this notification.
If you have any questions regarding geothermal heat pump wells please feel free to contact me at
[phone] or Evan Kane at [phone].
cc
N NR
Customer Service
1 840 623-7748
Sincerely,
Mark Pritzl
Hydrogeological Technician 11
Underground Injection Control Program
CO-UIC Files
WAR4-UIC Files
Division of Water Quality 1 Groundwater Section
1636 Mail Service Center Raleigh, NC 27699-1636
Phone: (919] 733-3221 Fax: [phone] Internet: http:llgw.ehnr.slate.nc.us

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) C2
v �
Type SQ W Wells
&
In Accordance with the provisions of NCAC Title 15A: 42C.0200 v
1M
Complete application and mail to address on the back page. �c
This is not the proper form to be used for injection wells in an oMn-loop geothermal system.
Da aot use this form for systems that circulate any substances other than water. 00
c
x
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER (QUALITY
DATE: J 0 - ZA , 20-0 L-
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 AndlOr Use A Well For Injection With A Heal
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 AndVDr Use A Well(s) For Injection With 14 Heat
Pump System, should be completed.
NO X If no, then continue completing this form.
C. PROPERTY OWNER
Name: a r-L,-� -i A-,
Address: 5 / -3 0 t--.5_ 2:�F
City: K;- e k/v�,[ e- State:
County: ire Telephone:
D. STATUS OF PROPERTY OWNER
Private. Federal:
State: Municipal:
AJt-Zip Code: fir' �
Commercial: _
Native American Lands:
GW-57 CL (Jan, 2000) Page I of 4

I
E. JOB (SITE) DATA /V j Ir
(Fill out ONLY if the sta'J of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: _____________________ _
Address: ____________________________ _
City: __________ State: __ Zip Code: ____ County: ____ _
Telephone: __________ Contact Person: ___________ _
Standard Industrial Code(s), SIC, which describes commercial facility : _______ _
F . HEAT PUMP CONTRACTOR DATA
Name: Climate Control Heating & Cooling Co., Inc.
Address: 102 Middle Street
City: Jacksonville
Telephone: [phone]
State: NC Zip Code: 28546 County: Onslow
Contact Person: =M=ic=h=a=ec:;..l =H=a=d =le.,_y ______ _
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) Well Drilling Contractor's Name: _San_f_or_d_L_._S_w_e_e_tin_· _g _________ _
NC Contractor Certification number: NC -2082 ---------------
Date to be constructed: }~,, iq,, Ol Number of borings: _ _..0.__ _____ _
....., ,/'di. I Approximate depth of each boring (feet):. ___ .vLJ__.:::1u:;__ ___________ _
(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 .....aX;.;;a.._ __
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.l.s.):
(a) Grout type: Cement __ Bentonite ...x_ Other (specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
_x__ around closed loop piping; from .JL to ..1Q_ (feet).
__ around well casing; from __ to __ . (feet).
NarE: THE WELL DRil..UNG CONTRACTOR CAN SUPPLY THE DATA FOR ETIHER EXISTING OR
PROPOSED WELLS IF 1HIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
GW-57 CL Gan, 2000) Page2 of4
G. 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)
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
"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"
GW-57 CL Gan, 2000)
uthorized Agent)
If authorized agent ts acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
Page3of4
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 15A NCAC 2C .0200)
GW-57CL
(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]
Oan, 2000) Page 4 of 4
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