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Home My WebLink AboutWI0700134_GEO THERMAL_20090409Permit Number Program Category Ground Water Permit Type I > WI0700134 / Injection Water Only GSHP Well System (5QW) Primary Reviewer michael.rogers Permitted Flow Facillt Facility Name Barbara Perry Location Address 200 River Rd Winton Owner Owner Name Barbara Dates/Events NC 27986 Perry Orig Issue App Received Draft Initiated 03/31/09 Re g ulated Activities Outfall ,,;u u. Scheduled Issuance Centra l Files : APS_ SWP_ 04/09/09 Permit Tracking Slip Status In review Project Type New Project Version Permit Classification Individual Permit Contact Affiliation Major/Minor Minor Region Washington County Hertford Facility Contact Affiliation Owner Type Individual Owner Affiliation Barbara Perry 200 River St Winton NC Public Notice Issue Effective 27986 Expiration Waterbody Name Stream Index Number Current Class Subbasin JE,'A NCDEMR North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Governor Barbara Peny 200 River Street Winton, NC 27986 Coleen H. Sullins Director 4/9/2009 Subject: Acknowledgement oflntent to Construct Type SQW Injection Well System Permit No. WI0700134 200 River Road Winton, NC 27986 Dear Ms. Perry: Dee Freeman Secretary In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on 4/9/09, the Aquifer Protection Section (APS) acknowledges your intent to construct a closed-loop geothermal water-onl v injection well system for the operation of a ground-source heat pump located at 200 River Road, Winton, Hertford County, NC 27986. This system is deemed permitted by rule (North Carolina Administrative Code Title 15A, Subchapter 2C, Section .021 l(u)(2)). However, it is recommended that you contact the Hertford 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. If you have any questions please call me at (919) 715-6166. Sincerely, ~-8-~ . ~ ,f'IA Michael Rogers cc: Washington Regional Office -APS ~ -Environmental Specialist GPU-Aquifer Protection Section APS Central Files -Permit No. WI0700134 He1tford County Health Dept. Gary Hughes (Gary's Elec Svc -PO Box 312, Colerain, NC 27924) AQUIFER PROTECTION SECTION 1636 Mail Service Center, Raleigh, North Carolina 27699-1636 Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604 Phone: 919-733-3221 I FAX 1: 919-715-0588; FAX 2: 919-715-6048 I Customer Seivice: 1-877-623-6748 Internet: www.ncwaterguality.org An Equal Opportunity\ Affirmative Action Employer Nirthcarolina JVaturallu Beverly Eaves Perdue Governor Barbar Ferry 200 River Street Winton, NC 27986 Subject: �� f.rv:„w� r..w■ NCDENR North Carolina Department of Environment and Natural Resources Division of Water Quality Coleen H, Sullins Director Permit No. 070( 200 River Road Winton, NC 27986 Dear Mr. & Mrs. Perry: 4/9/2009 of Intent to Construct Type 5QW Injection Well 1134 Dee Freeman Secretary In accordance with the application submitted to't-ke Underground Inject' n Control (UIC) Program that was received on 3/31/2009, the Aquifer Protection Section (APS) ad iowledges your tent to construct a closed -loop geothermal water- o� injection well system for the operation of a groun ounc�eak-p ump located at 200 River Road, Winton, Hertford County, NC 27986. This system is deemed permitted by e h Carolina Administrative Code Title 15A, Subchapter 2C, Section .0211 (u)(2)). However, it is recommended that you contact the Hert/ubstances alth Department, as they may have additional construction or permitting requkernents for this type of you fy your system at any time, including the addition of antifreeze, corrosion inhibitors, or any athe to the rculating fluid, you must contact the APS to verify compliance with applicable rules. Thank you for submitting this notification, If yoylave any questions please call nlwl at (919) 715-6166. Sincerely, Dait R - x1•'� `'Michael Rogers Environmental Specialist GPU-Aquifer Protection Section cc: Washington Regional O fte - APS APS Central Files - Permit No. W10700134 Hertford County Health Dept. Gary Hughes (Gaiy's Electrical Service - Pa Box 31.2, Colerain, NC 27924) AQUIFER PROTECTION SECTION 1635 Mall Service Center, Raleigh, North Carolina 27699-1635 Location:2728 Capital Boulevard, Raleigh, North Carorina 27604 Phone: 919-733-3221 I FAX 1: 919-715-0588: FAX 2: 919-715-6048 l Customer Service: 1-877-623-6748 Intemet www.rrcwatemuai�o� An Aqua, Oppwupity 1 AfFrmaiive A*pn Empoer One NorthCarolina Naturally 03131/09 3:5o PM ivi ar e4 ua uvvap .►ettrey A. tizagg tb1-q,e1-z1 U0 RECEIAP f DENff F9W AQUjFFR' PnTPrTl0N RFUION PEAR 31209� NORTH CAROUNA DEPARTNTENT OF ENVIRONMENT AND NATURAL RESOURCES (NCIiENR) NOT01CATiON OF WFENT TO CONSTRUCT A CLOSED-LCOOP GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM: UPE 5-OW WELDS r hi AccordanLe with tho provision of NCAC Title l5k 02C.O200, please comple[e this notiFtatioe and mMIto address on the hack; page (plant Print or T,yRee informatioij). D4.Tia: _ �z.q 7� Well Type Conjir "ian: Does the proposed sysrem circulate: potable wserer ortlt (no addititie%) in continuous piping tits! completely isolates the fl!trid from the enviyormient (i.e. closed -loop}`! Yes k Continue completing this fonn, No Do Not complete this form. Complete other UIC application forms for instit.11ing either a 5A7 well (oqpen-]oop, well gjt2! W potable water into the aqusfer) or a 5QM well (c.losed- loop •well cnotainina i dditivcs such as R.-22, ethanol, or other antifreeze or cormmon inhibitors). A. PROPERTY OWNER(S)IAPFUCANT(S) List each P.mperry Owner listed on property dead (if owid by apuginesa ��r�avemnaent agentky, state name of �y entity and a representative w/authority Car signature). .) (t) Mailing Address: City: �}t'y_ _ State: & Zip C ode. ��5"�f"� C.outuy: f 'r :r'� j Homc/Office Tele No.: /, — (2) Physical Address of Well Site (if different than above):. zata _F_ t- City: W t y�4 T—O ► j I lom&0f ice Tele No,-. State: ►JC rip Code. Cell No. County: AU VI] ]RtZED AGENT OF OWNER, IF ANY (iflhe Pcrmit Applicant does not own the s�shject prope::ty�, l Y! fig_ ttach a lmr froth the property owncr azttttorixing Agent to i n" f and operate U IC well) Company Name` COnt= Persan` Address: City:....__ Office Teie No.: State- Website Address of Company, if any: GPLf1iAC S¢IY i�Fr�tifiraliannrintent Fereu [Re��:sexl 8�2Up8] Zip Linde: EMAIL Address:- - __ County_ 'Mgt i 03124/09 05:04 PM P2NKSTON PUMP & Page 4 W31109 3:50 PM Malz4 Uj Uoluap .ierrrey A. blegg 101-4z l -d IV* p.n Page 2 C. WELL DRILLER INFORMATION Company Name:.. Well Driller Contractor's Name: c;� NC Contractor Certification No,- �' � _� `11 — A Contact Persona_ Cf+ S-,-A G 6-- _ EMAIL -Ad sq, 'Ne-0QR Address: _1 ca `f f J 2 ,a _ �L. �Jb City: CD - SAPICC.A zip Code:'ZZ- _ "L L- County: Office Tele No.: _ Cell No_: 7) 7- 4 3$ � D. REAT PUMP CONTRACTOR JNPORMAATION (Wdiffmot than drilier) Company Name:- _ 6 pp-�- EMAIL Address: -- _ Address: - City: COLIA-5aA, Ili Zip Code: 7j 1-.: County: ❑ffice •rele No.: �-3�—� 2� Cell No.: E. STATUS OF APPLICANT Private: Iwederal: �� CnAr�merc:�l: 51Bte: Municipal: Native American lands: F. INJECTION PROCEDURE (briefly describe haw the injection weli(s) will be used) G. WELL CONSTRUCTION DATA (1) Proposed date to be ccrostrtsct�od: ?-l_ •±�1 .� ]Number of lx�ri� s: Approximate depth of each boring (feet):-_Z n q (2) Type of tubing to be used (copper, PVC, etc): 14DP r-- (3) Well easing. is the well(s) rased? (check either (a.) Yes or (b_) No below) (a) Yes if yes, Then prc%side casing information below Type: _gaivanized steel black steel -- plz�stic other (specify) Casing depth; From to feet (reference to land surfnee) Casing ex s above ground � inches (b) N (4) Grout Into (material surrounding well casing anchor piping) (a) Grout type_ Neat Cement Bentonit Other (specify) (b) Grout placement: Pumping Pressure Other (c) Grout depth of tubing (rcfmnce to tand surfikc): train 0to 2 q 0 ucet) If well has cming, indicate Wout depth: from - to (feet) CiR MIC SQW Nndf catimb of IntcnL P&M (Revised F12008) 03/24/09 05:08 PM PINKSTON PUMP & Page 2 Page 5 03/31/09 3:51 PM Page 3 1vier tjt uu mlvop uerrrey A. ztagg 101,4[ 1-21W p.0 kL INJECTION -RELATED EQUIPMENT Attach a diagram showing the mginearing layout or Aropused mod ificution of the injection equipiriont anti exterior piping/li-ehing associated with the 4&ction operation. T11c 1nar1ufiW1urur's brocliure may provide supplementary information, Y. LOCATION OF WELL(S) Attach two copies of maps showing the fotlowing information: (1) Include a Site Map (case be drawn) showing: buildings, property lines, surface water bodies, potentLil sources of groundwater contamination and the oriunta.tion ofand distancev between the proposed weli(s) and any existing well(s) or waste disposal facilities such as septic tanks or drain feids ]ncated within 200 feet of the geothermal heat pump well system. Label all feutureS clearly and inc ude at.,pg0 arrow. (2) 7'#re Site Map must show the subieat property in relation to the surrool;ding Fuca by using at least two fixed reference points such as roads, streams, and/or highway itrtersections. .I. CERTIFICATION Note: This Permit Application roust be signed by each pe7rsort appearing n a the recorded legal property deed. "I hereby certify, under penalty rf law, that T have personally examined and am famifiar with the inforina3tion submitted in this docusneni and all attachments thereto and that, based on my inquiry of those individmh immediately responsible for obtaining said infvmhatian, T be]ieve that the information is true, accurate and complete. 1 atrt aware that there are significFstrt peaaltics, inciudirte the pmmsibllity of fines and imprisonment, for submitting false information. I agree to CanSYt' ML operatc, maintain, repair, and if applicable, abartalon the injection well and all related appurtenances in accordance with the approveA specifications d conditions of the Parmit.' "!'ijgnatum ofPrnperty Ownet/Ap'plicani ! 5 � =� R. Fit4 00r' PPhnt�ar `type Fuf L Name and title erty Signature Cif_�p r_ dwnerlAppiicant - - CEIV�� 1 flETR P�U �� PR�� ,� �n Print nr `f ype Full Name iz d title' Si hum of Authorized Agent, if any Prinz or Type Full Name. and title Please return two copies of the c:arnpleted Application package In: Nor4 i Carullian lD1E.NR-DWQ Aquifier Protection Section-UI C Program 1636 Mail Service Center Raleigh, NC 2-1699-1636 Telephone (919) 715-69:15 GPWLIIC $ u W NotiFicW10a of holm! rnme [Rovi5led 8/2006 Pogo 03/24/09 05:05 PM PINKSTON PUMP & Page s 03/31/09 3:50 PM roar /-,4 uzj uu:ubp JaMey H. Stagg fta1-4z7-Zlvs AwFF rlmoli WM+ON MAR 312D 09 NORTH CARO INA DEPAR T MM-- T OF "; WRONMENT AND NATURAL RESOURCES (NCDENR) NOT10FICATION OF INTENT TO CONSTRUCT CT A QJOSED-LOOP GCOTHMUW AL WATE111 ONLY INJECTION WELL SYSTEM: TYPE 5-0W WELL(S) lsl Atcordastce with the provisinns of NCAC Title 15A: 02C.0200, plean complete this notification and mail to address on the bank page (please Print or Tyne information). RA.M- _3t��! _ _ . 20_0 Weld Type Confirmation: Does the proposed system circulate potable w-arer oin (no additives) in continuous piping that completely isolates the fluid from the: en-kironment (i.e. closed-Ino Yes Continue coxrrpleting this form. No ❑o Not complete this forian- Complete other UIC application forms for installing either a 5A7 well (open -loop well injecting potable water into the ogesifer) or a 5QNi well (closed - loop well vagitaining 0ditives such as R-22, ethaxwl, or other antifreeze or cnrrosiost inhibitors). A. PROPERTY OWNER(S)JAPPLICANT(S) List eaelt Property 0wtser listed on properly deed (if nw(,Td by a j uslncss orr, state name of entity and a representative wlauthority for signature:): _] Oily: L� G_i`'. State: zip Code: 7� %�! r� � calmly: Homelafiice Tele No.: Cell Nq': • 5! ,. U2 mo w, -_.. _ Email Address: --.---.._ . Welrszte: M `ate (2) Physical Address of Well Site (if different than above): 2_Q_Q _ t V ;g-1 __ CJS T City; i ?.,Ii—D ^j_..-.....____ stare: !ldC_ Zip Code: _ _ County_ 1-fornelaff3ce Tele hfo_: Col) No.: -- Ni AS. �AVTHOKM ED AGENT OF OWNER, IF ANY (if the Pennit Applicant does nisi uwn the subject property, ttach a letter from the property ownct' authorizing A,gentto install and operate UIC well) Company Name: Contwt Verson: Address: City: —EMAIL Address: _ State: Zip Code: County : Office TeL- Niti.: _ Cell Nm. Website Address of Company, if any: c1pultilC 4QW iVetyftegtinnaftnbmt Porno (Revnsod 812009) ?W I =24109 05:04 Ply PINKSTON PUMP & Page 4 03/31109 3:50 PM Mar zq u& W:unp JOMOy A. atagg Page 2 C. WELL ,DRILLER IM1iFORMATION Company Name:- - 3�C, • A. AGENC%LY C- Dell Driller Contractor's Name:W W. Conftuctor Certification No,: 3 '56' P4 Cotrsact Persirn 'E (' 3T1 6 G- _ ENIA lL Address:. �CTc c?�s r .t r`�► Address: _ J e `t` L__r_ V!_4_ t A l r City: C�SAPIfP4C. V-A ,dip Code:'`S11-, County: - Office Tele No.: - — _ Cell Na_: 7.�-7 4 ,'% —'9 jJ Z_ d. HEAT PUMP CONTRACTOR INFORMATION (if diffemat than driller) Company ContactPerson: R LJO HI-f sEMAIL. Address: — - Address: C ` C1 ( D-'" 3 1-L City: CO E,45P—A71J _ Zip Code: 7,1'1-2= . County' Office 'l'eie No.: C:ell No.; U. STATUS OF APPLICANT Private: federal; Commercial. State: municipal: Native Americans Latids: F. 1Q►laIFMON PROCEDURE (briefly dmeribc how the injection wells) will be used) G. WELL CONSTRUCTIaN DATA (1) Proposed date to be constructed- --Number of bmiogs: � ... Approximate depth of each bori rig (feet)._. _ Z,C)D (2) Type of tubing to be used (copper, PVC, ate): _ROPE (3) N&Wl casing;. is the weli(s) cased? (check wither(a.) Yes yr (b.) No below) (a) Yes if yes, them provide cawing information below ,type: __govanized steel lalack steel__ plastic other (specify) Casing depth: From to feet (reference to land surface) Casing exte s t above ground inches (b) No (4j grout Info (mpterial surrounding well using and/or piping \4 (a) Eirourtype: Neat Cement Sentonit� Other (specify) (b) Grout placement: Pumping Pressure Other (c) Grout depth of tubing (reference to land surfice): from . - Q - to _�i� {feet] If well has casing, indicate gout depth: from to - .(feet) Gt'UUC SQW Nodfiticst;4o oflatwt Plum (t? eviwd VAN) Page 2 03/24/09 05:05 PM PINK5TON PUMP & Page 5 03/31/09 3:51 PM Page 3 Mar Z4 UI-{ Ut7'Lr*p JeTTtey R, Zmagg (01-4L1 Z IU0 P.a N. INJEC"llxON-RELATED EQVWMENT Attach a diagram showing the engineering layout or propusm) modification of the injection equipinent and exterior pipingli ibing associated with the injection operation. The rnauufactumr's brochure may provide supplementary information. I. LOCATION OF WELL(S) Attach twee copies of maps showing the following information; (1) include a Site Map (can he drawn) showing: buildings, property lines, surface water booties. potential sources Qfgroundwatcr contan3ination dmd the: orieertation of and distances betwean the proposed well(s) and any existing wells) or waste disposal facilities sucb as septic tanks or drain fields located within 200 feet of the geothermal Beat pump well system. Lab& all-l6auires clearly and incIgor,aino*h arrow. (2) The Site Map must show The subject property in relation to the surrounding area by using at least two fixed reference points such as roads, streams, and/or highway intersections. d. CKWIFICATION Note: This Permit Application ion ntust be sigued by cock person appearing an the recorded legal property deed "i humby rectify, under penalty of taw, that I have pr:r amily examined and am familiar with the inforinmion submitted in this document and all attachments thereto and that, hased on my inquiry at those individuals immediately responsible for obtaining said. information.. I believe that the information is trite, accurate and complete. 1 am aware that there are significaM penalties, including the passibility of lines and imprisonment, for submitting faise information. E agree to constnict, operate, maintain, repair, and if applicable, abandon the b-ijectlon well and all related nppt}rtertartces in accordance with the approved speci Rcat* orm-W conditions of the Permit. ;gria.tureofProperty Owner/Applicant Print or Type Ful l /Marne and title JOL Signatum of Property i]wsxerlEl }�plicartt — — R Print or Type FulI Name and title Siinaiure of Authorized Agent, if any Print or Type FUII Name and title Please ruuru two copies ofthe completed Applicatinn package to: North Carafiun DENWDWQ Aquifer Protection Scction-UIC'Program 1636 Mail Service Center fWeig&, NC 27699-1636 Telephone (919) 71.5-6935 GPLVUIC 5 Q W NU Alfica3oaof Intcai Form (Ravised 912") Pst$e 3 03124/09 05:05 PM PINKSTON PUMP & Page 6