WI0700112_GEO THERMAL_20080402

Permit Number
Program Category
Ground Water
Permit Type
WI0700112 / Central Files : APS_ SWP_
04/02/08
Permit Tracking Slip
Status
In review
Version
Project Type
New Project
Injection Water Only GSHP Well System (5QW)
Permit Classification
Individual
Primary Reviewer
michael.rogers
Permitted Flow
F ff v
Facility Name
Patricia Broom SFR
Location Address
Moor Shores Lot 132
Kill Devil Hills
Owner Name
Patricia
r):i f's/Events
NC 27948
L Broom
Scheduled
Permit Contact Affiliation
Patricia Broom
3132 Bay Dr
Kill Devil Hills NC
Major/Minor
Minor
Region
Washington
County
Dare
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Patricia Broom
3132 Bay Dr
Kill Devil Hills NC
27948
27948
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
03/31/08
Requlated Activities
Outfall NULL
Waterbody Name
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f~
L,.I (l__ 0
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Stream Index Number Current Class
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Subbasin
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP
GEOTHERMAL WATER-ONLY INJECTION WELL SYSTEM
(GROUND COUPLED BEAT PUMP)
Type 5QW Wells
In Accordance with the provisions ofNCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
RECEIVED/ DEN / DWQ
AQU1~R·~nri:r.r1 1; Ai:nTION
MAR 3 -.. -.·.1,
This is !!!!!,the proper form to be used for injection wells in an opep .. Igqp geothermal system.
Do not use this form for systems that circulate anv substances other than watel".
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: ~c,,\-\ VS"" • 200~
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES .A_ If yes, then continue completing this fonn.
NO If no, do not complete this fonn. Form GW-57 HP, Application For
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 inhibitors and/or antifreezes.
YES If yes, do not complete this fonn. Fann 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 ¼_ If no, then continue completing this fonn.
C. PROPERTY OWNER
Name: f?A..TR \C..\ ~ L . BR. OOM
Address: 3 t 3 ~ A Y Cfl.
City: \(..\\.,I.,,-:O'-,-r.rv \\ .... \-\\U...$ State: 1-J c.. Zip Code: _1,,-?_,9,....._.:/~i~-----
County: D£?(l.fe. Telephone: L~'Z.--'-fiO -1 o '-{I../
D. STATUS OF PROPERTY OWNER
Private:~ Federal: Commercial:
State: Municipal: __ Native American Lands:
Revised 7 /06 OW/UIC-57 CL Page 1 of4
E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility; _____________________ _
Address: ___________________________ _
City: ________ State: __ Zip Code: ____ County: ____ _
Telephone: _________ ContactPerson: ___________ _
Standard Industrial Code(s), SIC, which describes commercial facility: _______ _
F. HEAT PUMP CONTRACTOR DATA
Name: cv-rz \ s I~ ('(\ e (...~~ \. (.A:L:..
Address: -z..o:1q I\J~vJ i3i:k;,.J ~..,
City: \<..1 u-()~>Ha...Vw..+,.5 State:~ Zip Code: 1-1 Cj 4'.6 County: Df\RE
Telephone; -z.q-z.._ 4 'i' Q --0"> 3'j'C Contact Person: ___.C.. .... l::\~R....,\=S,___S...-..n ..... ~ _____ "'-"'--=----/l.,.""""""" __
0. CONSTRUCTION DATA (check one)
X
EXISTING WELL(S) being proposed for. use as a ground~coupled heat pump
well(s). Provide the information in (1) through (3) below to the best of your
knowledge. Attach a copy of Fonn GW-1 (Well Construction Record) if
available.
PROPOSED WELL(S) to be constructed for use as a ground~coupled heat pump
well(s). Provide the information in (1) through (3) below as PROPOSED
construction specifications. Submit Fonn GW-1 after construction.
(I) Well Drilling Contractor's Name: Ta N v AR..f'/\~~~G I\}&,-
NC Contractqr Certification number: ___ # __ ~__,'8"--0_i-f--'-----------
Date to he constructed: 3 } ~ ~ Number of borings: --·-~-------
Approximate depth of each boring (feet): __ Zro __ ·_o_-. _P~'I' _________ _
(2) Well casing: Is the well(s) cased?
(3)
NOTE:
Revised 7/06
(a) YES lfyes, then provide the casing infonnation 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 2S.1__
Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.l.s. ):
(a) Grout type: Cement__ Bentonite}i_ Other (specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
XJ around closed loop piping; from O to Z..S:: (feet).
__ around well casing; from_ to __ (feet).
THE WELL DRILLING CONTRACTOR CAN SUPPLY TIIE DATA FOR ElnIBR. EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
GW/UIC•57 CL Page2of4
H. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the iajection equipment and exterior piping/tubing
associated with the injection operatiQn. The manufacturer's brochure may provide supplementary
information.
I. 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 weH(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).
J. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the si te.
K.
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
CERTIFICATION
RECEIVED / OENR / DWQ
AQUIFER·P~mFr.TlnN S~CTION
MAR 3: _,..,w
"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 inquicy of
those individuals inttnediately responsible for obtaining said infonnation, 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."
(Signature o
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
Revised 7/06 GW/Ulc.s7CL Page3 of4
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WILLIAM S. JONES. FI.. AI.S_ PA.
CWAPNIC SCALE _ I" = 40' 303 WEST ARCHDALE STREET
KILL DEVIL HILLS, N.C. 27948
O 20` 4'd P [phone] F (252) 44 I -0925
DATE: 4 -II-07 SCA[ E! 1 " 40, OWN BY: SOB FILE NO. 07146

Auniication Reviewer: M 1
Pre -Review: Conducted? [Yes ❑ No
4�v
O.K. to PTUCeSS? [2YeS ❑ No
If No, What Action Is Needed? ❑ Pre -Review Return
❑ Hold, Pending Receipt of Addinfo.:
Name/AMation of Person Contacted:
w •'t
Date(s) of Contact: _ ❑ By Phone ❑ By E-Mail ❑ By Letter
Owner. ❑ Existing ZU-nknown Owner Type Non -Gov't ( Ind. or ❑ Org) ❑ Gov. -Municipal
❑ Gov. -County ❑ Gov. -State ❑ Gov. -Federal
FacilitvlOaeration:Proposed ❑ Existing ❑ Facility ❑ Operation
Regulated Activities:
AnnlicationlPermit-.
rmft Type.
Injection Water Only GSHP Well System (5QW)
❑ Injection Mixed Fluid GSHP Well System (5QM)
❑ Injection Tracer Well (5T)
❑ Injection Experimental Technology (5X25)
❑ Injection In situ Groundwater Remediation Well (5I)
❑ Injection Heating/Cooling Water Return Wcll (5A7)
❑ Injection Other Wells (5Z)
❑ Injection Aquifer Recharge (5R21)
Project Type. [TIN. ew ❑ Major Mod. ❑ Minor Mod. 1�❑ Renewal ❑ Renewal wl Mod.
Notes: _�. c L+ L LC1ti�. �. �, a d- t .1..1,t-L i F+i �.c r� �L L �i_ N C J-'a Ci r i 4 r
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(P FOAI: BIMS 10/04/2007

TRANSMISSION VERIFICATION REPORT
`17CN
05/12 11:49
912529753716
0�ry0: 01: 31
04
OK
STANDARD
TIME : 05/12/2008 11:51