WI0800068_GEO THERMAL_20040415

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
April 15, 2004
To: Charles Stehman, Regional Groundwater Supervisor
Groundwater Section
Wilmington Regional Office
From: Thomas Slusser<~
Central Office · ··
Re: 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 Mark and Julia Wax at 7516
Sound Drive, Emerald Isle, Carteret County. 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
\N A
0 Niilwavw`C
April 8, 2004
Mark and Julia Wax
7516 Sound Dive
Emerald Isle, NC 28594
Michael F. Easley, Govemor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
RE: Notification of intent to construct Type 5QW injection wells
Dear Mr. and Mrs. Wax:
Alan W. Klimek, P. E. Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Divis inn of Water Quality
In accordance with the notification you submitted to the Underground Injection Control (UIC)
Program dated March 31, 2004, the Groundwater Section acknowledges your intent to construct
seven closed -ion 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, 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.
Thant: you for submitting this notification. If you have any questions regarding geothermal heat
pump wells or injection well rules please contact me at [phone].
cc: Charles Stehman, Grondwater Supervisor
Wilmington Regional Office
UIC-CO ft ks
Sincerely,
i
Thomas Slusser
Hydrogeological Technician 11
UIC Program
N. C. Division of Water Quality J Groundwater Section
1636 Matz Service Center Raleigh, N.C. 27699-1636 FLbstomer Service
Phone: [phone] Fax: [phone]H 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 SYSTE.M
(GROUND COUPLED HEAT PUMP)
~
In Accordance with the provisions ofNCAC Title 15A: 02C.0200
Complete application and mail to address on the back page.
This is !!fil_the proper form to be used for injection wells in an open-loop geothermal system.
Do not use this form for systems that circulate an substances other than water.
TO : DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: 5 ...-3 I , 2o_Q_:f
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES -A,-If yes, then continue completing this form.
NO Ifno, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or 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 And/Or Use A We/l(s) For Injection With A Heat
Pump System, should be completed.
NO -A-If no, then continue completing this form.
C . PROPERTY OWNER C) .-
:i,.
" :::0 Name: !JfAft £, WA:Y
Address: • 7S'd, Sou,JI) J);e..-
City: €°MG1,trltf $/£ State: _.!::._ Zip Code: 1--_!!_f-____ _
County: CM~#'I Telephone: __'J,SJ --}S{--33/L
I
N
D . STATUS OF PROPERTY OWNER
Ver.3/01
Private: j;._
State:
Federal: Commercial:
Municipal:__ Native American Lands:
GW/UIC-57 CL Page 1 of4
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E. � (SITE) DATA
Name of Busi ess or Facility: r JLI.�rA- W/ll'fluSi�
Address: Z Sep _
City. �,-r��I' s _ Stater C' Zip Code: J �Q Countya7F
Telephone: Z �SV-334S7 Contact Person: 00>c -
Standard Industrial Code(s), SIC, which describes commercial facility: /V/14-
F. HEAT PUMP CONTRACTOR DATA
Name: el; 6 4( �fd r,
Address: Q ?� 1 Y . ' c.
City: - ra. +n.� �. e- State:
"Telephone: `
G. CONSTRUCTION DATA (check one)
I' C�Lip Cade, _ 'runty: i
Contact Person:
If
F ISTING WELL(S) being proposed for use as a ground -coupled heat pump
well(s). Provide the information in (1) through (3) below to the best of your
knowledge. Attach a copy of Form GW-1 (Well Construction Record) if
available.
K. PROPOSED WELL(S) to be constructed for use as a ground -coupled heat pump
well(s). Provide the information in (1) through (3) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
(1) Well Drilling Contractor's Name: t -
7 � c1
{
NC Contractor Certification number: 2- I
.*-Y-(
Date to be constructed: _� a Number of borings:
4m`
Approximate depth of each boring (feet): � —
(2) Well casing: Is the well(s) eased?
(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 _24-
(3) Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.l.s.):
(a) Grout type; Cement Bentonite ' Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
_,X_ around closed loop piping; from a to Zo C) (feet).
NOTE:
around well casing; from to (feet).
THE WELL DRH I ING CONTRACTOR CAN SUPPLY THE DATA FOR EnTmR masTING OR
PROPPOSED'WEUS IF TFIIS MFORMATION IS UKAVAILABLE BY OTHER MF- INS.
Ver.3M OWIMC-57 CL Page 2 of 4

H. 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
infonnation.
I. LOCATION OF WELL(S) Attach two maps.
( l) 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).
J. PERMIT LIST: Attach a li st of all permits or construction approvals that are related to the site.
Examples include:
( l) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits
K. CERTIFICATION
Ver.3/01
"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 Pennit."
~/;-e""'fit-bo,,,.#~er'----o-r _A_u_th_o_ri_ze_d_A-ge-n-t)-
Jfauthorized agent is acting on behalf of the well owner,
please supply a letter signed by the owner
authorizing the above agent.
GW/UIC-57 CL Page] 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)
Ver.3/01
(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-57 CL Page 4 of4
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