WI0800064_GEO THERMAL_20041028

Frank Pruitt
1707 Forest Lane
McLean, VA 22101
October 28, 2004
Michael F. Easley, Governor
William G . Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
RE: Notification of intent to construct Type SQW injection wells
Dear Mr. Pruitt:
In accordance with the notification you submitted to the UIC Program on October 25, 2004, the Aquifer
Protection Section acknowledges your intent to construct 6 closed-loo p geothermal water-onl y injection wells
for the operation of a ground-source heat pump system. This system is to be constructed at 5905 Ocean Drive,
Emerald Isle, NC 28594, in Carteret County, according to the Notification submitted. The system as described
in your notification is deemed permitted by rule (North Carolina Administrative Code Title 15A:
2C.021 l(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
pennitting 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 Aquifer
Protection 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] or Evan Kane ?,t [phone].
cc: UIC-CO files
Aquifer Protection Section
lntemd : http ://h2o.enr.state.n c.us
1636 Mail Service Center
2728 Capital Boulevard
Sincerely,
Thomas Slusser
Hydrogeological Technician II
Underground Injection Control Program
Raleigh, NC 27699-1636
Raleigh, NC 27604
One N~,rhCarolina
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Phone [phone] Customer Service
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RECEIVED I DERR I DWQ
AkV4 F-tR PRO`PECTiON SECM14
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 ISA: 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 -loop geothermal system.
Do not use this form for systems that circulate my substances other than water,
RK43
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DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: /( -Z5--d � , 2004
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 forth. Form GW 5T HP, Application For
Permit To Construct AndlOr Use A Well(s) For Injection With A Heat
Pump System, should be completed.
SYSTEM FLUID Will any additives be introduced to the system's circulating beat 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 Heat
Pump System, should be completed.
NO X If no, then, continue completing this form.
PROPERTY OWNER
;r
Name: 74/4 �` -I IC !J/ L
Address: I ?f�7 4&ke
City: - State:
County: Telephone:
STATUS OF PROPERTY OWNER
Private: X Federal: _
State: Municipal-
I
f Zip Code: az-14 /
`d3- 2.YI - q,1, 7
Commercial:
Native American Lands:
Ver.3/01 GWIWC-57CL Page 1 of 4

ql0p1-41:9
57°`
E. JOB (SITE) DATA
Name e€� � : _ r. n1 AU
Address: � ¢ � 1TJC ��� _--` �� ►'_ _ _
City: j wl er,� �+ T� !t State: - Zip Code: Z S9 CQun
Telephone: 703 `Zf l - 73p,� Contact Person: r.+
Standard Industrial Cod*), SIC, which describes commercial facility: %UI
F. HEAT PUMP CONTRACTOR DATA
Name: Climate Control Hcatin_ & Gopling. Ca.. Inc__-
Address: 102 Middle Street__
City: Jacksonville State: NC Zip Code: 28546 County: Onslow
Telephone: [phone] _ Contact Person: Michael HadleA _
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
well(s) . Provide the information in (1) through (4) below as PROPOSED
construction specifications. Submit Farm GW-1 after construction.
(1) Well Drilling Contractor's Name: Sanford L. Sweetugg
NC Contractor Certification number: NC - 2082
Date to be constructed �'_� ' Number of borings: —
Approximate depth of each boring (feet): 200
(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 b1s.):
(a) Grout type: Cement Bentonitc 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 M- DATA FOR EITHER FYISTwe OR
PROK)SED WELLS IF THIS INT'OR-MATION IS UNAVAILABLE BY CrFHER MEANS.
Ver.3101 GWIMC-57CL Page 2 of4

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)
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 the Permit."
ignature of Wefl Owner or Authorized Agent)
If authorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
Ver.3101 GWIUIC-57CL Page 3 of 4

L. CONSENT OF PROPERTY 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 (fitle 15A NCAC 2C .0200)
(Signature Of Property Owner If Different From Applicant)
Please return two copies of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW/UIC-57CL Page4 of4
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SURVEY FOR
BRUCE Af. &_ "N.4 B. S'P�'.NC4-R �
FRdNK H, &-ALIZABETH S. PRUITT
L "LAUN COHL'N & GAYLE P. xrmmms
triercld isle REFERENCE: Lot 8 Sik. A
Carteret County Saar. r "SURF LANOINl
North Co•r o 1 t na COVE' (91k. 24) map• Book
scare r' - i 1-aaa i Carteret Cnunry
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__- RegdsTry
PATE PMI"PS- and ASSOCIATES. PA.
406 Cor1to r r Ave. P. M Box 914
Swansbor•o North Carolina
Project No, 04-41

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11M)l Maps & Directions
5905 Chman Dr. Emerald isle. NC 28594
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