WI0700250_GEO THERMAL_20111024

Permit Number
Program Category
Ground Water
Permit Type
WI0700250 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facmt
Facility Name
Raymond Horn SFR
Location Address
4503 River Shore Dr
New Bern
Owner
Owner Name
Raymond
Dates/Events
NC 28560
Horn
Scheduled
Orig Issue
10/24/11
App Received Draft Initiated Issuance
10/07/11
Regulated Activities
Heat Pump Injection
Outfall l\iJLL
,
Central Files : APS_ SWP_
10/24/11
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Mike Hadley
Driller Well
102 Middle St
Jacksonville NC
Major/Minor
Minor
Region
Washington
County
Craven
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Raymond Horn
4503 River Shore Dr
New Bern NC
28546
28560
Public Notice Issue Effective
10/24/11
Expiration
10/24/11
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
Raymond Horn
4503 River Shore Drive
New Bern, NC 28560
A.VA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins
Director
10/2 5/20 11
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0700250
4503 River Shore Drive, New Bern, NC 28560
Dear Mr. Hom:
Dee Freeman
Secretary
On October 07, 2011, 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 .02ll(u)(2). Additionally, you should contact the Craven 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 @ncdenr.eov if you have any questions.
cc: Washington Regional Office -APS
APS Central Files -Pennit No. WI0700250
Craven County Health Dept.
Coastal Geothennal (Mike Hadley)
Climate Control Heating & Cooling, Co. (Dale Walker)
AQUIFER PROTECTION SECTION
1636 Mail Service Genier, Raleigh , North Carolina 27699-163 6
Location: 2728 Capital Boulevard , Raleigh. North Caroli na 27604
Sincerely,
fb,~m,A -~
Supervisor
Phone: [phone] \ FAX 1: 919-715-0588; FAX 2: 919-715-604B \ Customer Service : 1-877-623-6748
Internet: www.ncwatemual hy.o rg
An Equal Opportur.:!; \ t\ffirrnative Actic~1 Employer
N~1rthCarolina
Jvaturall!f
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-OW WELL(S)
In Accordance with the provisions of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or Type information).
DATE: 03 October 2011 �'J� ❑� 009c�)o
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -louts)?
Yes X Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well in'et cting potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R 22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): Raymond Horn
(1)
(2)
Mailing Address: 4503 River Shore Drive
City: New Bern State: NC Zip Code: 28550 County. Craven
Home/Office Tele No.: 2524744503 Cell No_:
Email Address:
Physical Address of Well Site (if different than above):
City:
HomelOffice Tele No.:
State: Zip Code:
Ceplezrox
County:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person:
Address:
City: State:
Office Tele No..
Website Address of Company, if any:
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008)
EMAIL Address:
Zip Code: County:
RECEIVED 1 DENR I DWp
Aquifer Erole %Dn SecUon
OCT 0 7 2011 page i

..
C. WELL DRILLER INFORMATION
Company Name: ___ -=-C~oas=ta=l~G~e~o~th=e~rm~al ___________________ _
Well Driller Contractor's Name: -==S=an=fi=o=rd=-=S-'-'w=e=et=inc:,:g,.__ _______________ _
NC Contractor Certification No.: 2082 ____________________ _
Contact Person: Mike Hadle y EMAIL Address: mhadle y@ bizec.rr .com
Address: 102 Middle Street
City: Jacksonville Zip Code : 28546 _____ County : Onslow __ _
Office Tele No.: ~9~10~-~35~3~-9~0~4--'-0 _______ Cell No.: 910-376-1100
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name:Climate Control Heating & Cooling Co., Inc.
Contact Person~: =D~al=e~W~al=k=e=r _______ =E=MA~=IL~A=d=d~re=ss=:=dw~al=k=er'""@-=cl=im=a=t=e-~c-=-o=ntr~ol~-1=· n=c~.c~om=
Address: 102 Middle Street
City : Jacksonville _____ Zip Code : 28546_ County: Onslow _________ _
Office Tele No .: 910-353-9040 Cell No.: 910-376-0513 ---':...:..::;....::...ac.=...=...,=--------
E. STATUS OF APPLICANT
Private: _lL
State:
Federal:
Municipal: __
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loo p Geothermal Heat Transfer Systems
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: =O-=-ct=o=b=er'""2""0c..:1-=-l _______ Number of borings: 1:
Approximate depth of each boring (feet): 250
(2) Type of tubing to be used (copper, PVC, etc): ______________ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes Q! (b.) No below)
(a) Yes ___ if yes, then provide casing information below
Type: _galvanized steel __ black steel __ plastic __ other (specify)
Casing depth: From ____ to ___ feet (reference to land surface)
Casing extends to above ground ___ inches
(b) No X
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Bentonite X Other (specify) ____ _
(b) Grout placement: Pumping X Pressure Other
( c) Grout depth of tubing (reference to land surface): from_ O __ to_ 250 ___ (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC SQW Notification of Intent Form (Revised 8/2008) Page2
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification 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 copies of maps showing the following information:
(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 geothermal heat pump well system. Label all features clearly and include a north 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.
J. CERTIFICATION
Note: This Permit Application must he signed by each person appearing on the
recorded legal property deed.
"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 injection well and
all related appurtenances in accordance with the approved specifications and_conditions of the Permit."
Signature of Property Owner/Applicant
Print or Type FulI Name and title
Signature of Property Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ RECEIVI-D 1 t7ENR I pwp
Aquifer Protection Section-UIC Program Aquifer Proto,-,tlon Sectton
1636 Mail Service Center 4 r T 4 7 2011
Raleigh, NC 27699-1636
Telephone [phone]
GPi3/MC 5QW Notification of Intent Form (Revised 8/2008) PW3

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Raymond Horn
4503 River Shore Drive
New Bern, NC 28S60
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WATER
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4503 River Shore Drive
New Herr.. NC 28560
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