WI0700179_GEO THERMAL_20100621

Permit Number Wl0700179
Program Category
Ground Water
Permit Type
Central Files: APS_ SWP_
06/21/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Injection Water Only GSHP Well System (5QW)
Version
1.00
Permit Classification
Individual
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Tom Jenkins SFR
Location Address
2606 Wills Dr
Elizabeth Cty
Owner
Owner Name
Tom
Dates/Events
NC 27909
Jenkins
Orig Issue
06/21/10
App Received Draft Initiated
06/07/10
Reg ulated Activities
Heat Pump Injection
Outfall NULL
Waterbody Name
Scheduled
Issuance
Permit Contact Affiliation
Major/Minor
Minor
Region
Washington
County
Pasquotank
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Tom Jenkins
2606 Willis Dr
Elizabeth Cty
Public Notice Issue
06/21/10
NC
Effective
06/21/10
27909
Expiration
Stream Index Number Current Class Subbasin
Aye--, ► U.
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Doe Preernan
Govemor director Secretary
6,'2112010
Tani. Jenkins
2606 Willis Drive
Elizabeth City. NC 27909
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10700179
2606 Willis Drive. Elizabeth Cite, NC 27909
Dear Mr. Jenkins:
On 61712010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water-oniti
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met;
1. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Camlim Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina.
Administrative Code Title 15A Section 2C Subchapter .0211{u}(2). Additionally, you should contact the Pasquotank County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Rogers. ,amcdenr.gov if you have any questions.
Sincerely,
for Debra Watts
Supervisor
cc: Washingwrl Regional Office - AP5
APS Central Files - Permit No. W107a0l 79
Pasquorank County Health Dept.
Ward & Son — 221 Charles Strut, Elizabeth City, NC 27909
AQUIFER PROTECTION SECTION
1636 Mail 5erva, Center, Raleigh, North Carolina 27699-1636
Laeabon:2728 Capital Boulevard, Raleigh, Nonh Carolina 276g8
Phoney 919-733-3221 1 FAX 1: 919-715-0588; FAX 2! 919.71MD48 t Customer Service; 1-877-623.6748
Intemet: www.nmatermualitv.oru
An Equal Ow7wlty i Athnalire AC w crtrployer
NorthCarolina
Aw rally

\N \ ~ -r---i, '& ~ t7
N~TH 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)
Type SQW Wells
In Accordance with the provisions ofNCAC Title ISA: 02C.0200
Complete application and mail to address on the back page.
This is not the proper form to be used for injection wells in an open-loop geothermal system.
Do not use this form for systems that circulate an y substances other than water.
TO: DIRECTQ~, NQ_~!lf_QA_RQJ,INA DIVISION OF WATER QUALITY
DATE: b -3 20 .112_
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES -AL-If yes, then continue completing this form.
NO If no, do not complete this form. 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 ttansfer
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 And/Or Use A Well(s) For Injection With A Heat
Pump System, should be completed.
NO --l(;_ If no, then continue completing this form.
C. PROPERTY OWNER
Name: MM "Sf.tJ f<. IN~
Address: ;t'2 0 ~ \AIII I IS l>R •
City: f_i,1z ll-·B.E::·n-1 CI r..,, State: .Af.._C-. Zip Code:_..2-"--7-'----'-'1--'=0 _ _,_9 ____ _
County: :PAS~vo:TAJJK. Telephone:(;;t.5~-~;i..-) ............. ~.,..._/ 9.._-_QO~i-0 _______ _
D. STATUS OF PROPERTY OWNER
Ver.3/01
Private: -X-
State:
Federal: Commercial:
Municipal: __ Native American Lands:
GW/UIC-57 CL ktl,i::,.,,l:.u, Ul:NK LJWQ Page 1 of 4
AQUIFJ:R·PROTFr.TION SECTION
JUN O 7. 2010.
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: _________ Contact Person: ____________ _
Standard Industrial Code(s), SIC, which describes commercial facility: ________ _
F . HEATPTTMP CONTRACTOR DATA
Name: \{\/ARD~ 6oAI
Address: ,;ia,.. \ CI-\..A R,Lt.,S ST.
City: fttz..(fRf!J! c~·T~ State: .ALL Zip Code: ..a. 7 'fo 9 County: '?trSC:NcT.4AJ k.
Telephone: :;[ =-3 -(Q589 Contact Person: 0Ac..k.'6.lf1R.D oR, D1t4Rk CA-l'l.TvJRtGi~T
G. CONSTRUCTION DkTA (check one)
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 Form 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 Form GW-1 after construction.
(1) Well Drilling Contractor's Name: Wf.s-r \tJ.4--rt:RW.E:.U l)\s\L.L1';4.Gq (Prn::y wE-••:;;r)
NC Contractor Certification number: a,s-5 ( ---~--------------
Date to be constructed: -0-.2.olO Numberofborings: ___ J/,,_ ____ _
Approximate depth of each boring (feet): a_m r L 8-ppfb)(.
(2) Well casing: Is the well(s) cased?
(3)
(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 $_
Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.l.s.):
(a) Grout type: Cement__ Bentonite ..A)_ Other (specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
¼._ around closed loop piping; from O to olQO (feet).
__ around well casing; from __ to __ (feet).
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
Ver.3/01 GW /UIC-57 CL Page 2 of4
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. 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).
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
Ver.3/01
"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."
.if authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
GW/UIC-57 CL
RECEIVED / DENR / OWQ
AQUIFl=RPROTFrTION ~F.:CTION
JUNO7201O 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 .0240)
r �
(Signature OcfPr; y Owner4f 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]
Kc�EIVLI I DENR I DWD
AQUVl -R M)TFrTIM -RF60H
Ver.3101 GWIUIC-57 CL Page 4 of 4

F�O�
RECEIVED I OENR I DWO
JUN 4 7 20ID