WI0800059_GEO THERMAL_20030509

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
May 9, 2003
MEMORANDUM
To :
From:
Charles Stehman, Ph. D., L.G., Regional Groundwater Supervisor
Groundwater Section
Wilmington Regional Office
Mark Pritzl [e-mail]
Hydro geological Technician II
UIC Program
Groundwater Section .
Raleigh Central Office
Re: Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection Well
System (type SQW injection well.)
Notification to construct and operate a well for a closed-loop geothermal heat pump system has
been filed by Mr. & Mrs. Hadley in Cedar Point, North Carolina and a copy of the Notification is
enclosed for your files. This injection well system is deemed permitted by rule (NCAC T15A:
2C.21 l(u)2) and no regulatory action is necessary. If you have any questions, please contact me
at [phone].
cc: CO-UIC Files
Enclosures
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina aartment of Environment and Natural Resources
Alan W, Klimek, P.E. Director
Division of Water Quality
May 8, 2003
Mr. & Mrs. Hadley
615 Independence Drive
Jacksonville, NC 28546
RE: Notification of intent to construct Type 5QW injection wells
128 Magens Way, Cedar Point, NC 28584
Dear Mr. & Mrs. Hadley:
In accordance with the notification you submitted to the UIC Program on May 8, 2003, the
Groundwater Section acknowledges your intent to construct two closed-Ioop 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 will not require an injection well permit from the state, but you should check
with your county health department prior to constructing the system because they may have
additional construction or permitting requirements for this type of system. If you modify your
system at any time, please 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,
6,,k, 1
Mark Pritxl
Hydrogeological Technician
UIC Program.
cc: UIC-WI1RO files
UIC-CC files
V_W
NT-ENNK
Customer Service Division of Water Quality 1 Groundwater Section
1 800 623-7748 1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet: http.11gw.ehnr.s1ate.ncus

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSER -LOOP
GEOTHERMAL WATER —ONLY INJECTION WELL SYSTEM
(GROUND COUPLED HEAT PUMP)
Type 5QW Wells
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 be used for injection wells in an open -loan geothermal system.w
cz
Do not use this form for systems that circulate and substances other than water.'
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
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DATE: `�� d 3 , 2ow
_
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuo
piping that completely isolates the fluid from the environment?
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YES X If yes, then continue completing this form.
x
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10
NO If no, do not complete this form_ Form OW-57 HP, Application For
Permit To Construct AndlOr Use A Well(s) For Injection With A Hear
P74mp 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 AndlOr Use A Well(s) For Injection With A Feat
Pump Systems, should be completed.
NO _ X l:f no, then continue completing this form.
PROPERTY OWNER
Name: ` ,J,,�. �- -
Address. G,15- F.
City: State: C- Zip Cycle:
co�rn€y: f3 �Js a' J Telephone: T�� - 3 7 -
STATUS OF PROPERTY OWNER
Private: X
State:
Federal: Commercial:
Municipal: Native American Lands:
GW-57 CL (Jan, 2000) Page I of 4

E. JOB (SITE) DATA
Name1t--
Address: 1-2- 01 A-ga tWY - -�-
City: dv i of State: lit— Zip Cade: County:
Telephone: `9 10 - 3 5-? - f' b ZR Contact Person: Wt� ►-
Standard Industrial Code(s), SIC, which describes commercial facility: PJ JA-
F HEAT PUMP CONTRACTOR DATA
Natne: Climate Control Heating & Cooline Co.- Inc. _
Address: 102 Middle Street _
City: Jacksonville _ State: NC Zip Code: 28546 County. Onslow
Telephone: [phone] Contact Person: Michael Hadk'%
G. CONSTRUCTION DATA (check one)
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 of Form GW-1 (Well Construction Record) if available-
X PROPOSED WELLS) 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: Sanford L. Swseting
NC Contractor Certification number: NC - 2082
Date to be constructed. _0 -3 Number of borings: � -
Approximate depth of each boring (feet)• 24C3 � —
(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 0 to 200 (feet) _
around well casing; from to (feet).
NOTE- THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOP, EITHYR F.XI917ING OR
PROPOSED WELLS tF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
GW-57 CL (lan, 2000) Page 2 of 4

G. 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.
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)
J. PERMIT LIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(I) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treattnent and Disposal Permits
K. CERTIFICATION
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the
infonnation 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
widt the appnwed specifu:ations and conditions of.the P-:~
(S~e I Owner or utborized Agent)
GW-57 CL (Jan, 2000)
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
Page 3 of 4
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 .0200)
GW-57CL
(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]
(Jan, 2000) Page 4 of 4
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PRELIMIP
SURVEY FOR MIKE HADLEY
' - THIS `IS TO CERTIFY THAT THIS MAP IS A
TRUE • REPRESENTATION OF 114E PROPERTY
HEREON A5 COMPILED BY ACTUAL SURVEY LOT 15 BLOCK _
OF THE P , ,. , THAT THERE ARE NO ueriruit PAY