WI0800055_GEO THERMAL_20040209

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
February 9, 2004
MEMORANDUM
To:
From:
Re:
Charlie Stehman, Regional Groundwater Supervisor
Groundwater Section
Wilmington Regional Office
Evan Kane /] l
Central Office"'l.f-
Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection Well
System. (Type 5QW):
Notification of intent to construct and operate a closed-loop, water only injection well system for
a geothermal heat pump (Type 5QW injection well) has been filed by William Sherrod of
Southport, North Carolina. A copy of the notification is included with this memo. This injection
well system is deemed permitted by rule (15A NCAC 2C.021 l(u)2) and no further regulatory
action should be necessary. If you have any questions about this notification, please contact me
at [phone].
cc: CO-UIC Files
Enclosures
F \NA
Michael F. tasiey, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
r
Alan W_ Klimek, P, E. Director
Division or Water Quality
0 ^,
Colton H. Sullins, Deputy Director
Division of Water Quality
February 9, 2004
Mr. Bill Sherrod
224 River Road
Southport, NC 28461
RE: Notification of intent to construct Type 5QW injection wells
Dear Mr. Sherrod:
In accordance with the notification you submitted to the UIC Program on [date], the
Groundwater Section acknowledges your intent to construct seven closed -loop geothermal water -
only injection wells for the operation of a ground -source heat pump. The system as described in
your notification is deemed permitted by rule {North Carolina Administrative Code Title 15A:
2C.0211(u)(2)) and does not require an injection well permit from the state, but you should check
with your county health department as well because 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 Groundwater Section to verify compliance with applicable
rules.
Thank you for submitting this notification, If you have any questions regarding geothermal heat
pump wells or injection well rules please contact me at [phone].
Sincerely,
Evan D. Kane, L.G.
Underground Injection Control Program Manager
Enc losure
Cc: Groundwater Section - Wilmington Regional Office
CO-UIC files
N�'EhR
N. C. Division of Water Quality 1 Groundwater Sec Lion
1636 Mail Service Center Raleigh, N.C. 27699-1636 Customer Service
Phone. (9 i9) 733-32? I Fax: (919) 715-p588 Internet: http://gw.chnr.state.nc.us 1-877-623-6748

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 SQW Wells
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Camplete application and mail to address on the hack page.
This is not the proper form to be used for injection wells in an gpen-loon geothermal system.
Dona# use this form for systems that circulate any substances other than vLter.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: X 4 , 204;�.
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in condauous
piping that completely isolates the fluid from the en► uonment?
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 AndlOr Use A Well(s) For Injection With A Heat
Pump System, should be completed.
13_ 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 AndlOr Use A We11(s) Far Injection With A Heat cz, �
Pump System, should be carnpleted. r-
NO X If no, then continue completing this form_ C°Cn
z
} ti�
C. PROPERTY OWNER
Name:
Address: 3 : v&" w
City: State: G Zv- Code �- x
Count�r g -z Telephone: f — `7' *t!—
D. STATUS OF PROPERTY OWNER
Private: X Federal: _
State: Municipal,
Ver.3/0l
Commercial:
Native American Lands:
GWIUIC-57CL
Page 1 of 4

'
E. JOB (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 & Coo ling Co., Inc.
Address: 102 Mi ddl e Street
City: Jacksonville State: NC Zip Code: 28546 County: Onslow
Telephone: [phone] Contact Person: =Mi=·c=h=ae=l~H=ta=dl=e,,__ ______ _
G. CONSTRUCTION DATA (check one)
Ver.3/01
____ EXISTING WELL(S) being proposed for use as a ground--coupled heat pump
well(s). Provide the information in (1) through (4) below to the best of your
knowledge. Attach a copy ofFonn GW-1 (Well Construction Record) if available.
--'-X"'----PROPOSED WELL(S) to be constructed for use as a ground-coupled heat pump
well(s) . Provide the information in (1) through (4) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
(1) Well Drilling Contractor's Name: =Sanfi=o=i::=d -=L~. =Sweetm-'-'--=·-g.,__ _______ _
NC Contractor Certification number: N"--'-=C'--__,2=0:..::.8=2 _________ _
Date to be constructed: 3 -0 'f Number of borings:--~-----
Approximate depth of each boring (feet): ___ -;._o_o __________ _
(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.):
(a) Grout type: Cement_ Bentonite_x_ Other (specify) _____ _
(b) Grouted surface and grout depth (reference to land surface):
__x_ around closed loop piping; from .JL_ to 200 (feet).
__ around well casing; from __ to __ (feet).
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF nns INFORMATION IS UNAVAILABLE BY CYfHER MEANS.
GW/UIC-57CL Page 2 of 4
& INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injection equipment and exterior pipwg/tubmg
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
H. 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). :-,
(3)
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
f�"t1J UKI IVVDR
"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 Pe
(Signature of Wiff Owner or Authorized ent)
W011'"em M 614&rrax
If authorized agent is acting on beha f of the well owner,
please supply a letter signed by the owner
authorizing the above agent-
Ver.3101 OW/WC-57CL Page 3 of 4

L. CONSENT OF PROPERlY OWNER (Owner means any person who holds the fee or other property
Ver.3/01
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 .0200)
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UICProgram
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW/UIC-57CL Page 4 of4
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