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Home My WebLink AboutWI0700263_GEO THERMAL_20120206Permit Number Program Category Ground Water Permit Type WI0700263 , Injection Water Only GSHP Well System (5QW) Primary Reviewer eric.g.smith Coastal SW Rule Permitted Flow Facilit Facility Name Robert Wright SFR Location Address 198 Murray Ln Oriental Owner Owner Name Robert Dates/Events NC 28571 Wright Scheduled Orig Issue 02/06/12 App Received Draft Initiated Issuance 01/13/12 Regulated Activities Heat Pump Injection Private residence, single family Outfall NULL Central Files: APs_· _ SWP_ 02/06/12 Permit Tracking Slip Status Active Project Type New Project Version 1,00 Permit Classification Individual Permit Contact Affiliation Robert Wright Owner 198 Murray Ln Oriental Major/Minor Minor NC Region Washington County Pamlico Facility Contact Affiliation Owner Type Individual Owner Affiliation Robert Wright Owner 198 Murray Ln Oriental Public Notice Issue 02/06/12 NC Effective 02/06/12 28571 28571 Expiration Waterbody Name Stream Index Number Current Class Subbasin KUHR North Carolina Department of Environment and Natura Division of Water Quality Beverly Eaves Perdue Charles Waitild, P.E. Governor Director 021[»012 Robert Wright 198 Murray Ln. Oriental, NC 28571 Subject. AdwMedgesment ofInt+nt to Cgnstmct TI pe SQW injection Well System PermitNo.MY700263 198MMWIm. Oriental, NC 28571 Dear]W Wsilght: Resources Dee Freeman Secretary On 01/13/2012, the Aquirer Protection Section WS) received nodkation ofyotn intent to construct a closed -loop water geothemtal injections well system for the operation of ground. -source heat pump located at the address referenced above. An individual pernak is not rcg4ed for the construction and operation ofthis type ofgeothelr W injection well system as long as the fallowing conditions at a met 1. The °jectionwell system censors only potable water, z The injection well system is constructed in accordance with well construction standards specified in North Carolina Administrative Code'lli le 15A Section 2C Subchapter .0213, and 3. The zi* red notification form and associated maps have been completely and accurately submitted. Failure to comply wkh all of these conditions constittrtes a violation of the Nat Carolina Well Construction Act and North Carolina Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact Ike Pamlico Coo q Health Department as they may have addudonal requirements far this type of system. Noacamphance wgti applicable state, cotay, or municipal soles and regulations may result in the assessmem of6dpenalties. Please contact NW Rogers at (919) 807-6406 or Nfiehaei.RW; em Aeringov i'you have any questions, 2 7 sue,• �,:r1— cc: Washington Regional Office - APS MIS C 4mral files - PeRAN"o. V0070026- ParnEco County Health Dept, Dale Walker'(CHmateControlHeating&Cooling, 102Iv#icldle St., Jacksonville, NC 28544) AQUIFER PR(YrECTION SECTION 1636 Mall Service Center, Raleigh, North Carmine 27699-1636 Location: 512 N. Salisbury St., Ralegh, North Carolina 27604 Phone: 9IM07-64641 FAX: 919-807-6496 Intamet kv�vyv,ncwaterouaUtr.ora An Equal Oppalurrlty 1 Aifin-ngm A*n Employer W118 cortlicarouila aturaZzy TO: A. C. NORTH 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 5QW WeUs In Accordance with the provisions ofNCAC Title 15A: 02C.0200 Complete application and mail to address on the back page. This is not the proper form to he used for injection wells in an open -loop geothermal system. Do not use this form for systems that circulate any substances other than water. DIRECTOR, NORTH CAROLINA DMSION OF WATER QUALITY DATE_ January 12 , 2012 SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous piping that completely isolates the fluid from the environment? YES x If yes, then continue completing this form. NO If no, do not complete this form- Form GW-57 HP, Application For Permit To Construct And1Or Use A Welt(s) For Injection With A Heat Pump System, should be completed. 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 form. Form GW-57 HP, Application For Permit To Construct And10r Use A We11(s) Far Infection With A Heat Pump System, should be completed - NO x If no, then continue completing this form. PROPERTY OWNER Name: Robert Wright Address: 198 Murray Lane City: Oriental _ State: NC Zip Cade: 28571 County: Pam1 i co Telephone: _ - _ 2 5 2- 2 5 9 -13 5 8 STATUS OF PROPERTY OWNER Private: X State: Revised 5/45 Federal: Municipal: GW/CFIC-57 CI. Commercial: Native American Lands: Page i of 4 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 . HEAT PUMP CONTRACTOR DATA Name: Climate Control Heating & Cooling Address: 102 Middle St City: Jacksonvi l le State:~ Zip Code: 28546 County: Onslow Telephone: 910-353-9040 Contact Person: Dale Walker G. 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 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: _s_a_n_f _o_r_d_S_w_e_e _t _i _n_g __________ _ NC Contractor Certification number: 2 0 8 2 ------------------- Date to be constructed: 1-2 6 - 2 012 Number of borings: _3 _______ _ Approximate depth of each boring (feet): ------------------250' (2) Well casing: Is the well(s) cased? (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 X (3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.l.s.): NOTE: Revised 5/05 (a) Grout type: Cement__ Bentonite X Other (specify) _______ _ (b) Grouted surface and grout depth (reference to land surface): __ around closed loop piping; from O to 2 5 0 (feet). __ around well casing; from __ to __ (feet). THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR PROPOSED WELLS IF TIIlS INFORMATION IS UNAVAILABLE BY OTHER MEANS. 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 W ELL(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 we] l(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 "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" t (Signature of Well Owner of Authorized Agent) !f authorized agent is acting on behalf of the well owner, please supply a letter signed by the owner authorizing the above agent. Revised 5105 GWIMC-57 CL Page 3 of 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 ISA NCAC 2C .0200) Revised 5/05 (Signature Of Property Owner If Different From Applicant) Please return two copies of the completed Application package to: UICProgram Aquifer Protection Section North Carolina DENR-DWQ 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone (919) 715-6182 GW/UIC-57 CL Page4 of4 Robert Wright 198 Murray Lane Oriental, NC 28571 ELECTRIC MURRAY L NE WELL BORES Robert Wright 198 Murray Lane Oriental, NC 28571 ELECTRIC MURRAY LANE WELL BORES SEPTIC Google M2P Flap 1 Of 1 Go, sic rr r�4 Yy i r k a. dlGuucksh L� w >WE61C YandCfl:ErG i ANian: a gaybo,.y GlartSpr �6 - r% Stc.new.0 LA9Bi Arapahoe now MCAS �e Y Part 102 Middle St, Jacksonville. 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