WI0800061_GEO THERMAL_20010517

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
May 17, 2001
To: Charles Stehman, Ph.D., P.G. Groundwater Supervisor
Groundwater Section
Wilmington Regional Office
From: Mark Pritzl f\R, [e-mail]
Hydrogeological Technician II
UIC Group
Groundwater Section
Raleigh Central Office
Re: Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection \Veil
System (type SQW injection well.)
Notification to constrnct and operate a well for a closed-loop geothermal heat pump system has
been filed by Floyd Heath of 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] or Meliktu Fanuel at [phone] .
cc: CO-UIC Files
Enclosures
May 17, 2001
Floyd Heath
154 Sunset Drive
Cedar Point, NC 28584
Dear Mr. Heath:
Michael F. Easley
Governor
Wiliiams G. Ross Jr., Secretary
Department of Environment and Natural Resources
Kerr T. Stevens
Division of Water Quality
In accordance with the notification submitted on May 16, 200 t; the Groundwater Section
acknowledges your intention to construct a closed -loop geothermal water -only injection welt
system for the operation of a ground -source heat pump. The system as described in your
notification will not require an injection weII permit and is deemed permitted by rule (North
Carolina Administrative Code Title 15A: 2C.021 l(u)2). The Underground Injection Control
Group has added your site to our inventory. If you modify your system, please contact the
Groundwater Section to verify compliance. Thank you for submitting this notification.
If you have any questions regarding geothermal heat pump wells pleasc feel free to contact me
at [phone] or MeliktLL Fanuel at [phone].
Sincerely,
Mark Pritzl
Hydrogeotogical Technician II
Underground Injection Control Program
cc: MUM Files
WIRO-UIC Files
NENR
w
Customer Service Division of Water Quality I Groundwater Section
1 800 623-7748 1636 Mail Service Center Raleigh, NC 27699-1636
Phone: t9191733-3221 Fax: [phone] Internet: hdp:Tlgw.ehnr.state.nc.us

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 Wells
J in Accordance with the provisions of NCAC Title 75A: 02C.0200
Complete application and mail to address on the back page.
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This is not the proper form to be used for injection wells in an n n�-ioo geothermal system. Ea n ;;
Da not use this form for systems that circulate any substances other than water. r-a
Li'1 r�
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: , 20—O-Z
A. 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 AndlOr Use A Well(s) For Injection With A Heat
Pump System, should be completed.
B. 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 Wells} For Injection With A Meat
Pump ,system, should be completed.
NO X If no, then continue completing this form.
C. PROPERTY OWNER
Address:
City:(( fate: �ip
County: _Telephone:
D_ STATUS OF PROPERTY OWNER
Private: X Federal:
State: Municipal:
Code:
Commercial:
Native American Lands:
GW-57 CL Qan, 2000) Page I 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:
Telephone: -_ Contact Person: r
Standard Industrial Code(s), SIC, which describes commercial facility:
F_ HEAT PUMP CONTRACTOR DATA Pam,,
Name: ��' �r� f .1-+ rtry # _4o h p.,,
County:
Address: -I 6 je►' -V 1
City:404oytwrti State: aC - Zip Code: Z CoTty: _
- �
Telephone: IT -:771_Contact Person: 16
7-6-2-
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 WELL(S) to be constructed for use as a ground -coupled heat pump
wells). 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. Sweetin
NC Contractor Certification number: NC - 2082
Date to be constructed: � f&//r QI Number of borings:
Approximate depth of each boring (feet): w0
(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
Casing extends above ground
(b) NO X
ft. (reference to land surface)
inches
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feetb1s.):
(a) Grout type: Cement Bentonite X Other (specify)
(h) Grouted surface and grout depth (reference to land surface):
X around closed loop piping; from 0 to 20 (feet).
around well casing; from to (feet).
NOTE: THE waL DRILLING mNTRAcTUR rAN sUPPi.Y THE DATA FUR ETHER ExisTmG oR
FRUPo6ED wmLS IF TI m imzoRmAnoN is UNAV An AB x SY DTim MEANS.
GW-57 CL (Jan, 2000) Page 2 of 4

G. INJECTION-RELA TEO 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:
(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"
GW-57 CL Oan, 2000)
zed Agent)
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
Page3of4
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-570.
(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
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
I Maii Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t ��`� � ems'•
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT##:
1. WELL USE (Check Applicable Box)' Reside nfial ❑ Municipal ❑ Industrial ❑ grtc itural ❑M nitcrmg ❑
Recovery ❑ Meat Pump Water Injection ❑ Other 0 If Other, List Use: i°Cf i [a (,-eo rnr,a
2. WELL LOCATIONSShho ketch of L4e locatli nn below)
Nearest Town: — _ ` "! Caunry:
��iaJ_� of iV J �'� TC� 1►J� G� s
(Road Name and Numbsrs a Ity, or 5u division and tot No.) DRILLING LOG DEPTH
3. OWNER ��1_Irl _ From To 'Formation Description
Address 1 !!�L4 SLl s� _C. jot-, } . o jCfrr',�
�n —(lrae o u a o. �Llu SLAM Y1_r►t�
IV
City or Town State Zip Code `
4. DATE DRILLED I�Y'1rQ� f0. Q� �`TS
5. TOTAL DEPTH-
6. CUTTINGS COLLECTED YES[] NO®
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO® I d _Kod c
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface•
'ap of casing terminated aVor below land surface requires a varlance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm); METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
Amount
13, CASING: 3/y ,1
1?5e_.--,
loop Goo L.- .: rnmA
r ' (i)
�e
5 - ir­
Walt Thickness
Depth
Diameter or WeighflFl. Material
From
To
Ft.
From
To
Ft.
From
To
Ft.
14. GROUT:
From Q_
❑ept r
To d • v
Material Method
Ft. ' dC
From —To
IF
Ft.
15. SCREEN:
Depth
From —To
Ft
From
To Ft.
From
To Ft.
IS. SAND/GRAVEL PACK:
Depth
From
To
From
To
17. REMARKS:
Diameter Slot Size Material
in. in.
in. en.
in. In.
Ft.
Ft.
Size Material
If additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
art_ e *. .&
0 0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF -THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouad No: AGNATURE OF PERSON CONSTRUCyl14G THE WELL DATE
Submit original to Division of Water Quality, groundwater Section within 30 days
Serial No. GW-1 FIEV. 12199

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