WI0700193_GEO THERMAL_20101011 (2)

Permit Number WI0700193
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
420 East River Street
Location Address
420 E River St
Colerain
Owner
Owner Name
Norman
Dates/Events
NC 27924
F Perry
Orig Issue App Received Draft Initiated
09/29/10
Re g ulated Activities
Outfall NULL
Scheduled
Issuance
·-'
Central Files: APS_ SWP_
10/11/10
Permit Tracking Slip
Status
In review
Project Type
New Project
Version Permit Classification
Individual
Permit Contact Affiliation
Gary Hughes
PO Box 312
Colerain NC
Major/Minor
Minor
Region
Washington
County
Bertie
Facility Contact Affiliation
Owner Type
Individual •
Owner Affiliation
Norman F. Perry Ill
PO Box 237
Colerain NC
Publlc Notice Issue Effective
27924
27924
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governo r
Norman F. Peny III
PO Box 237
Colerain, NC 17924
~A -----"""~~ MCDEN
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullin s
Directo r
10 /11/20 10
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0700193
420 East River Street Co lerain , NC 27924
Dear Mr. Perry:
Dee Freeman
Secretary
On 9/29/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onl v
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
Carolina 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 .021 l(u)(2). Additionally,· you should contact the Bertie 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.Ro2:ers(ciJ.ncdenr,gov if you have any questions.
cc: Washington Regional Office -APS
APS Central Files -Pennit No. WI0700193
Bertie County Health Dept.
Sincerely,
O~fL~.
for Debra Watts
Supervisor
C&G Well Drilling, Inc (Charles Menefee) 2257 Santa Fe Arch. Virginia Beach, VA 23456
Gary Electrical Service, lnc. (Gary Hughes) PO Box 312, C olerain. NC 27924
AQUIFER PROTECTION SECTION
1636 Mail Service Center. Raleigh , North Carolina 27699-1636
Locaiion: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone : [phone] I FAX 1: 919-715-0588; FA~ 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterguality.org
An Equal Opporiun;;y I Afii rmaiive Ac!ion Emp loyer
N~rthCarolina
Jvaturally
Sep 29 10 12:13p C $ G Well Drilling
7574266008 p.1
NORTH C:AROLINA
DEPAR- S ENT OF ENVIRONMENT AND NATURAL RESOLiRCES (NCDENR)
NOTIFICAT N OF INTENT TO CONSTRIUCT A 1CLi3SEI)-LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-OW WELL45)
I ceordance with the provisions ofMCAC Title 15N 02( .0200, please
c0tnplule this iiication and naail to address on the lack pine (please Print or 2:ym information),
I
DATE: 20 r"IG \N1 0-1 w--uq 3
I
Well 7)VeCon ion- Does the proposed system circulate potable ~+later 2nl► (no additives) in
continuous piping that Completely isolates the fluid from the environment (i.e.
cic►wd-loon)?
Yea Continue completing this form.
A.
No ❑o Not complete this farm_ Complete other UIC application forms for installing
either a 7 well o art -loop well iftiecting potable water into'the aquifer) or a 5QM well (closed -
loop we i containing additives such as R-22, ethanol, or otlwr anti freeze or corrosion inhibitors).
PROPERTY Q NER(S)IAPPLICANT(S)
List such Properi Owner listed on property deed (if owned by a
entity and a rep s native wJauthority for signature): � 4 rfti
C.ity�
Home,
Email
{a} Physic
City_ _
Homo
H. AUTHORIZE
attach a tatter f
Company Nam
C"Untact l*e". tl
Address:
oily: -_.--_
i:ltfice Tele No
Wehisk Addre
r� State:-,4/ C Zip Code: 2
or government agency, state name of
1Z
ice Tele No.. Cell) No.: 252
Irvss: -- --- Website:
I
I
ddress of Well Site (if different than above):
(t-A- ys StateA/C/ Zip Coda: -2 County: 2pefi,e-
ce `l ele Div.: _ Ce;(
i
(;ENTOF OWNER, IF ANY (i['the Permit Applic:Il dogs not own the subject p►opetty,
the property owner authorizing Agent to install and dWrate UiC well )
EMAti.
--------------- . _ . State: Zip Cade — - - � .-----County: - --
ol'Company, ifany:
�__._,_
AQ IFFP tlrrl- -
';Fr 1� :� ',I

Sep 29 10 12;13p C & G Well Drilling
7574266008 p.2
C. WELL DRILLER
Company Name: �
Well Driller Contra(
NC Contractor Certi
Contact Person:
A ddress:�� s
City:
office'rele No.:
U
E.
F
HEAT PUMP (
Company Name:
Contact Person:
A ddr ess_ �
City: _iP A
Office Tele No..
RM ATION
Name:
an No.:
/ Zip Code: �i=County
`•- c - o-.? Cell No.: " a 2 Z ..?
C3'OR INFORMATION (if different thsn drill )
I�%C 60-c,-A C_ .`Cam{ ��,� Cam' - C-
� Cyr EMAIL. Address.
Zip Cade:? !,t_ County: 'e
s ,20 Cell No.: � S 2 ` _�? q, / %
STATUSOFAPP ANT
Private:r Fcderal:
Slate.• Municipal: _
Commercial:
Native American Lands:
INJECTION PROODURE (briefly describe haw the injection we]1(s) will be used)
G. WELL CONSTR
(1) Proposed date i
A Dvrox[m
(2) Type oflubing
(3) Well casing. Is
(a) Yea
Type: , __jgaiv
Casing depth: F
Casing extends t
(b) No
(4) Grout info (mate
(a) Grot
(b) Grot
(c) Gro�
TION DATA
e constructed: _ �- fr, Number of burin
depth of each baring (feet):(
be used (copper, PVC, etc): ,
well(s) cased? (check either (a.) Yes or( .) No Belo
if yes, then provide casing information be nw
zed steel black steel____plas1lc other (speci
n to feet (reference to land surface
bone ground inches
ial surrounding well casing and/or piping):
type: Neat Cement Bentonite
placernent: Purnpin Prcmrc
depth of tubing (reference to land surface): from
If well has casing. indicate grout depth: From _
(specify)
— to (feet)
to (feet)

Sep 29 10 12:13p C & G Well ❑tilling 7574266008 p.3
09/29/10 T : 55 AM tiery s t.Lecr nip be t,v iuuU I r a+J r
Z"R 4+ ru vv. 4 1. r Ip U de gvefl Unlling 7674766COA sy
S,
ff. YNSECTION-RlELA
Attach a diagram
pipinwtubing ass
i nforrttation.
L LOCATION OF w
Attach twn copies
(1) Include a
sources af.
any extsttn;
the �eotlter
(2) The Site Nf
reforet= P
J. CERTMCATION
Notet This Ferri
recorded
"i hemby certify_
submitted in this
imn-wdiaely respc
I am aware that it
false information.
all related apperk-
EQU rPATrgT
rig the e4naeTing layout or proposed modification t-e {rejection equipment and exterior
f with the injection operation. The manufacturer's ' xhurc rr+FAy provide suppletntfll2m
:ps showing the following information- j
Rap (can be drawn) showing: hu:ldings. property +lines, surface water bodies- patentiatf
dwater contmninatiort and t3tc crieatmion or Arid d ces between &,e proposed wetl(s) and
W ar waste disprsa] facili6m such as septic tankin;
drain fie IcL- located within 200 feet of
rat pump well system. Labe; ail l features clearly a;_lude a frorth -arrow,
uA show the subject property in relation to the -w" ding area by usinp at least two fixed
such as roads, streams, andJor highway intersclions, l
pplicadon must be signed by each person
property deed.
. penalty of law. that i have persorsaily examined
m ent and all tatrach me n is thereto and that baav
for obtaining said information, I believe that the in
e significant penalties, includingthe possibility of
me to consbxuct, operate, maintain. mpair, maid if api
in aretrr&rice with the appr ed Ycifcatiorn a4d
i
Signature of Pr4och3, t?wrter/App
Print or Type Full Name err Vile,
an the
id am familiar with the in;ormalian
m my inquiry of those individGals
nation is true, accurate and complew.
es and imprisonment, for st:brnitting
able, abandon the infection well' and
edit ions of t he Pcrm it-"
Signature of Property Owner/A 1 cant
Print or Type Full Name and WE
Signature- of A Ahcrixed ent,1I any
Prim nr Type Full blame and titt I D
lease return two copies of thr completed Appl
North Carolina DENR-DWQ
Aquifer Proton Section-UXC Prog
1636 Maid Service Center
kaleigh, NC 276,99-1636
Telephone [phone]
to:
RECEIVED I DENR ! MO
AQUIrFR PPOTl' Y04 IrrC7IrN

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