WI0800065_GEO THERMAL_20020917

MEMORANDUM
..... ' . ' .... ;. .!
DMSION OF WATER QUALITY
GROUNDWATER SECTION
September 17, 2002
To: Charles Stehman, Ph.D., L.G., Regional Groundwater Supervisor
Groundwater Section
Wilmington Regional Office
From: Mark Pritzl fl~ [e-mail]
Hydrogeological 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 David & Lou.Ann Sekely in Newport, North Carolina and a copy of the Notification
is enclosed for your files. This injection well system is deemed permitted by rule (NCAC TISA:
2C.21 l(u)2) and no regulatory action is necessary. If you have any questions, please contact me
at [phone].
cc: CO-VIC Files
Enclosures
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
In Accordance with the provisions of NCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
This is not the proper form to be used far injection wells in an oMn-loogeothermal system.
Do not use this form for systems that circulate any -substances other than water_
TO:
n
DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: 1-14f , 20 d X--
SYSTEM CLASSMCATION Does the proposed system circulate potable water in continuous
piping that Completely isolates the fluid from the environment?
YES ILL 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.
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 Heat
Pump System, should be completed.
NO X If no, then continue completing this form.
C. PROPERTY O-rWnNER ,
Name: —VI- i �t�. �r . e-Q,
Address: J37 rt`+r <,- T �
City: A *A.J r1— State: N Zip Code:
County: Telephone: 175'4? � 2-2-
D. STATUS OF PROPERTY OWNER
Private_ X
State:
Federal: Commercial:
Municipal: Native American Lands:
GW-57 CL Gan, 2000) Page 1 of 4

E. JOB (SITE) DATA
~ottt ONLY if tfte Stat\ls 0£ Qwner is fqdeFal, Stat@, Mli-fl:icipal or Commercial). -
Name of Btts~s or Eacilitya=-
Addre~~ _ //'() (r-8 ~ /{ L~
City: ~,t-State: ~Zip Code: '28757t, County: lJ--:~f-
Telephone: __________ Contact Person: ___________ _
.Sta:ndaFd Iadustrial Code(s), SIC, which desccibes-remnrerciaTTacility:-=::: _______ _
F . HEAT PUMP CONTRACTOR DATA
Name: Climate Control Heating & Cooling Co., Inc.
Address: 102 Middle Street
City: Jacksonville
Telephone: (910 ) 353-9040
State: NC Zip Code: 28546 County: Onslow
Contact Person: -"M=i""""'ch __ a~e~l _H~a~d ..... le....,_y ______ _
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 Form GW-1 after construction.
(1) Well Drilling Contractor's Name: _San==f..c..or"'"'d~L="-'. S"-w_e""-'e~tin_· .._g,._ ________ _
NC Contractor Certification number: NC -2082 ;a...;...;:;....._==c.=...-----------
D ate to be constructed: __ ff-_._-_tJ_2--___ Number of borings:--~-----
-, -A / Approximate depth of each boring (feet): ___ ~ __ •v ___________ _
(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 2(0 (feet).
__ around well casing; from __ to __ (feet).
NOTE: 1HE WELL DRILUNG CONTRACTOR CAN SUPPLY 1HE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTIIER MEANS .
GW-57 CL Gan, 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 weil(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 (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.
Page3 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]
Oan, 2000) Page 4 of 4
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WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR UNDWMITAr) ?NAME (prtnq, .Z2 a 4,x-z�ar. t- � :-. �r _ CUTIFICATWX
WFJ�L ©oNTRACTOP, COMPA:W Tune _f- ,'A /C 14211 ,6,112X", y PHONE #
STATE WELL COWIMUCTION PBRMIT1ft —ASSOCIATED WQ PERMrf#
(if armlicxhie} (if applicable)
1. WELL USE (Check Applicable Box): Reskiential © MunicipaMbiic ❑ Industrial ❑ Ag€icu
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other a if Other, List Use
2. WELL LOCATI
Nearest Tows Ind j' _ County
(StrectName, N-sbem Cmanwity, Subdivision, Lot No., Zip Code)
3.OWNER: �C►�u►d S�1E
Address -e
t (Street or Route No.)
N eta ,br-t Nc Z �7
C Y or Tows State Zip Code
{ -- Z-3^S61`f
Arca code` Ph= number
4. DATE DRILLID
5. TOTAL DEPTH: 01�0, n ' _
6. DOES WELL REPLACE EXISTING WELL? YES © NP A
7. STATIC WATER LEVEL . ��_PT-
(1J8e "+" if AiwM Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Tog of cashtg iermioa" attar below land surface ngwm a
variance in accordance with 15A NCAC 2C .Q11&
9. YIELD (gpm). METHOD OF TEST
10. WATER ZONES (depth):
11. DISINFECTION: Type _ _ . Amount
12. CASING. Wall Thickness
Depth Diameter or WeighVTt. Material.
TopographicfUnd setting
❑Ridge ❑Slope ❑Valley i»iat
(e1>eck wropriate box)
Latitude/longitude of well 1pcation
(dsg�sninutaxlsecamds)
Latitudt'Jicingitude source:OGPSOTopographic map
(check box)
DEPM DRELLING LOG
From To Formation Descriotion
ne --fl
LOCATION SKETCH
Show direction and distance in miles from at least
two Stake Roads or County Roads. include the mad
numbers and common road names.
From To Ft
From To FL
From To— Ft
13. GROUT: Depth I Mate Method
_
f
From.12v— To j,o Ft.� _-- !�_
►�u
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
Fiom To Ft in, in.J
From Ta Ft. in. is
15. SAND/GRAVEL PACT:
t�
Depth Size Material
i
From To Ft
From To F#
t ---
16. REA ARKS: f Gee- 41eeC"C' n
T DC HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, W17i L
CONSTRUL`TRIN STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PRQV IDED TO THE WELL OWNER
OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 163611 90 Service center - Raleigh, NC
27699-1636 Phone No. (9I9) 733-3221, within 30 days. GW 1 REV. 07/2001

Michael F. Easley, Governor
Wiliam G. Ross Jr., Secretary
North Carolina riartment of Environment and Natural Resources
September 17, 2002
David & LouA.nn Sekely
137 Parker Ct.
Newport, NC 28570
Dear David & LouAnn:
Alan W. Klimek, P.E. Director
Division of Water Ouality
In accordance with your notification submitted on September 17, 2002; the Groundwater
Section acknowledges your intent to construct closed -loon geothermal water -only injection well
system for the operation of ground -source heat pump. This system as described in your
notification will not require an injection well permit and is deemed permitted by rule (North
Carolina Administrative Code Title 15A: 2C.0211(u)2). The Underground Injection Control
(UIC) 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 please feel free to contact Mark
Pritzl at [phone].
Sincerely,
Debra J. Watts
Permits & Compliance Supervisor
M. Ca-ulc Files
W1RO-U1C Files
VAX
RMOIA
Customer Service Division of Water Quality f Groundwater Section
1 800 623-7748 1636 Mail Service Center Raleigh, NC 27699-1636
Phone: t919j 733-3221 Fax: [phone] Internet: http://gw.ehnr.state.nc.us