WI0700104_GEO THERMAL_20070305

Donald Streinz
346 Town Hill Road
New Hartford, CT 06057
March 5, 2007
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
Subject: Aclmowledgement of Intent to Construct Type 5QW Injection Well System
Injection Water Only GSHP Well System (5QW)
Deemed Permit No. WI0700104
Donald F. Streinz SFR
Dare County
Dear Mr. Streinz:
Iri accordance with the application submitted to the Underground Injection Control (UIC) Program which
was received on March 1, 2007, the Aquifer Protection Section (APS) acknowledges your intent to
construct a closed-loop geothermal water-only injection well system for the operation of a ground-source
heat pump. This system is located at 54107 Sandpiper Drive in Frisco, North Carolina.
This system is deemed permitted by rule (North Carolina Administrative Code Title 15A, Subchapter 2C,
Section .021 l(u)(2)) and will not require an injection well permit from the State. It is recommended that
you contact the Dare County Health Department, as 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 APS
to verify compliance with applicable rules.
Thank you for submitting this notification. Please call Qu Qi at [phone], or email him at
[e-mail] if you have any questions regarding geothermal heating or injection well rules and
regulations.
Sincerely,
~vv ~~,
Jesse Wiseman
Aquifer Protection Section
Enclosures
cc: Washington Regional Office -APS
A.PS Central Files -Deemed Permit No. WI0700104
Ni"ithCarolina ;
/Vatura/ly i
J Aquifer Protection Section
Internet: www.ncwaterguality.org
1636 Mail Service Center
Location: 2728 Capital Boulevard
An Equal Opportunity/Affirmative Action Employer-50% Recycled/10% Post Consumer Paper
Raleigh, NC 27699-1636
Raleigh, NC 27604
Telephone:
Fax 1:
Fax2:
Customer Service:
[phone]
(919) 7 I 5-0588
[phone]
[phone]
-02/19/2007 14:40 9103531060 CLIMATE CONTROL PAGE 03
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTEXCT A CLOSE -
GEOTHERMA.L WATER —ONLY INJECTION WELL SYSTEM
(GROUND COUPLED 1 CA T' DUMP)
Type SQW Wells
In Accordance with the provisions of NCAC Title 15A: 02C.d 200
Complete application and rmlil to address or the back page,
This is not the proper form to be used for injection wells in an [pen -boon geothermal system.
Do not use this foroi for systems that circulate any substances other than water,
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: Feb. lei. , 2047
A� SYSTEM C1,A.SSTFTCAT 0 Does the prcp(xqed system cim.tlatu potable water in continuous
piping that compieely isolates the fluid from t# c environment'
YES X If yes, than continue completing thi.9 form.
NO ff no, do Yo compictc this form, form QVr -57 HP. Application I br
PermPf To Co sttm.ivt Amd 0r Me A We 11(c , For InjecIion Wiih 4 Hear
1'r.ar:p S vem. should be completed.
13. SYSTEM FLUID Will ant additives he introduced to the systetn's circulating heat transfer
fluid? This lmhadc�-,, but is not lrmitod to corrosion inhibitors atri -or antifreezes
YES If vcs, do not complete this form, Farm G W-S7 HP. Application For
1'ermit To Coravmvt And,Or Use A Wel ffi) T,or Injecrion With A Near
Pump System, should be completed.
NO .Y If aa, than cvtitirnre cvrnplOIi rig this form.
C, PROPERTY OWNER.
Name: i QiV ' c
Address: ;�f�, � • //a, f ,L :—
City:A(g:w h�yAje aA State:C—'L�Zip Cade: 0 o:� e- 5-
County- �elephone:
La rC,4-1
D. STATUS OF PROPERTY OWNER
Pdvay..- x Federal: Commercial:
State.- � � Municipal: Native American Lands:
GW-57 t"L (..)an, 2(9)0) Page i of

02/19/2007 14,40 9103531060 CLIMATE CONTROL PAGE 04
E JUB (S1TF) DATA —1-
Name: arY_-'��_ �7`R 6;7,:N rr
Atldress: �.5�+ :PiP�`r .cLIt1�
Q a'e L . State: NC Zip Codc;,77 3 C Dungy: 4��
Tcllphmc: _ Contact Person;
�Zs'L Z-e7Z—
FF J MAT PUMP CONTRACTOR DATA
Name: Climate Control Heau gg & Cooling Co- Inc.
Address; 10Middle St
City. Jacksonville_ _ Slate: NC Zip Codc; 28-546_ Couj*y Onslow
Telephonc: (9)0) 35-90411 Contact Parson: Mike H dle�
G. CONSTRUCTION DATA (check. ono)
_.� EXISTING WEU,.(S) being proposed for use as a ground-caup)od hcat pump
►vell(s), Provide the information in (1) through (4) below to the best of'your
knowledge. Attach a copy of Forth GW-1 (We)l Comtruction 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 (t) below as PROPOSED
construction specifications. Submit Form OW-1 Ifter construction,
(1) Well Drilling Contmctor`s Name: C:s as#al f3eothem�tal
NC Contractor Certification number: NC — 2092�5'cgrd Svseetin_
Date to to be constructed: March 2007_ Niunbor of borings 9
Approximate dopth of each boring (fee*--- 240'
(2) Well casing: Is the well(q) =cd'2
(a) YES , if vos. then provide the casing information below -
Type: Galvanizzd SteelBlack steel Plasti", Other (specify)
Casing depth: From to R, (refcrence to land surface)
Casing extends above ground inches
(b) N, 0 x
(3) Grout (grout the vcrtica€ lcnnth of the borehole to a minimum depth of 20 feet h,1.s-):
(a) Groat type-. Comot— i3errtanite _A_ Oti cr (speccfy)
(b) Crrouted surface and gotic d-cpth (refcrencc to lane - surface):
X around closed loop piping; from 0 to 240 (feet),
around well casing: from to —— (-feet).
NOTE: 'rttL «1L•LL ORtLLTNG CONTRh.CTi7R. CAN sr.Wt,Y THF 73ATA r, aR r:r-rt4tck Z:)(15'PENGCAR
1`rt0rWY.D WF N IF THIS TN-FORVATION IS I NA-V A I %Awi-, n) OTHER WEANS,
GW-V CL [Jan. 2000) Pagc 2 d4

~2/19/2007 14:40 9103531060 CLIMATE CONTROL PAGE 05
H. INJECTION-RELATED EQUTPMENT
Attach a diagram showing the engineering Jayout of the injection equipment and exterior piping/tubing
as~ociatcd with the injection operation . TI1e manufacturer's bri:,churc may provide su.pplem.entaJ)·
information.
J. LOCATION OF WELL(S) Attach two maps.
( 1) Include a site map (can be drawn) showing: buildings, property lines surface water bodies,
potential sources o.f groundwater contamination and tl1e orientation of and distances between the
proposed well(s) and any existing weJI(s) or waste dis~osal 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 n.-fcrcncing the site to two nearby permanent reference points (such as roads.
streams and highway intersections).
J. PERMIT UST: Attach a fist o.f all permits or constn.iction. a:,provals that are related to the site.
ExamplFJs include:
(J) Hazardous Wa.<rte Management program permits under RCRA
(2) NC Division O'rWater Quality Non-Discharge pcnnit:;
(3) Sewage Treatment and Disposal Permits
K. CERTIFICATION
··1 hereby certify. under penalty oflaw, that J have personally examined and am familiar with the
information submitted in this document and all attachments ttcrcto and that, based on my inquiry of those
individuals immediately responsible for obtaining said information, I believe that the information is trne,
accurate and complete. I am aware that there are significant p,~nalties. including the poosibjJity of:fincs
and imprisonment, for submitti:ns fa.lsc information. l agree t(, construct, operate, maintain:, repair. and if
applicable, abandon the ground-source heat pump system and a.11 re1ated appurt<manccs in accordance
with the approved speci:ficatfons and conditions of the Permit,.,
OW-57 CL (Jan .. 2000)
---~ ~~-
(Signature of Well Owner or A.OW~~ Agent)
(f authorized agen1 is acti1 011 behalf of the well ,,wner,
please .w.,pply a letter signed by the awnet
autJrmizing the above agem.
Page 3 of 4
�0211912007 14:40 9103531060 CLIMATE CONTROL PAGE @6
L- CONSF,NT OF PROPERTY OWNER (Owner means any pemon who holds the Foe or other property
rights in the well being coustnjocd. A well is real property wt its constuctioit on land rests Ownership in
the landowneT in the absence of contrary- agreement in «Thing. i
if the property is owned by someone other than the applicant the pmperty owner hereby coiiserns to
allow the applicant to construct ewh injection well as outlined in this application and that it shall be the
respornsibdir of the applicant to ensure that the ground -source heat pump systom's well(s) coTiforrns to
the WVf Construction Standards (Titio 15A SCAC 2C MOO)
(Signature Of Property Owner if Diffurmt From Applicant)
Please return two copies of the completod Applicatiou package tw
U 1C Program
Groundwater Sectiola
North Carolina UENR-FOWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW-57 0, (Ism 2000) Page 4 of 4

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