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Home My WebLink AboutWI0800071_GEO THERMAL_20041109NORTH 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 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-loop geothermal system. Do not use this form for systems that circulate any substances other tha n wate r . TO: DIRECTOR, NORTH CAROLINA DMSION OF WATER QUALITY DATE: /0 -f--20~ A SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous piping that completely isolates the fluid from the environment? B. YES --2{_ If yes, then continue completing this form. NO If no, 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. o ~ SYSTEM FLUID Will any additives be introduced to the system's circulating heat t&sfer fluid? This includes, but is not limited to corrosion inhibitors and/or antifreezes. < I \.0 YES If yes, do not complete this form. Form GW-57 HP, Application F-% Permit To Construct And/Or Use A Well(s) For Injection With A Hellt Pump System, should be completed. -::- NO ~ Ifno, then continue completing this form. w CJ1 C. PROPERTY OWNER Name: b So Address: IJ City: __,,_,.,__.__,,,::.:...u.t..L>.1,..1,,:L..L..lL-'---=----- County: -'-"--'-""-"<----'----'-"....:,..c_..:....,.cY<c...u....::Telephone: _ ___.,..,_,_~__.____.___._,__,"-'-' ________ _ D. STATUS OF PROPER'IY-ewNER --· ver.3/01 Private: A State: Federal: Commercial: Municipal: __ Native American Lands: GW/UIC-57 CL Page 1 of 4 ., f-- A F G. FACILITY (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: County: Telephone: Contact Person: Standard Industrial Code(s), SIC, which describes commercial facility: HEAT PUMP CONTRACTOR DATA Name; Z, Unk? tE,\: � oi' . Address: _f D E am 1 ZZ g 1K City: t,: t t_ rJ State: N C. Zip Code: Telephone: t p7qG - (o f f Contact Person: CONSTRUCTION DATA (check one) 1 � County. 1 \4 " Fin in rn,4 w !. , L- i A77r. Vf11— EXISTING 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 (Weil Construction Record) if available. 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. Subunit Form GW-1 after construction. (1) Well Drilling Contractor's Name: fir' --0 W r ,P 7' i ,j NC Contractor Certification number: Date to be constructed: ]0' r D Number of borings: Approximate depth of each boring (feet): 2-06 01 (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 (a) Grout type: Cement Bentonite _L1 Other (specify) (b) Grouted surface and grout depth (reference to land surface): �(. around closed loop piping; from 0 to 2-00 (feet). around well casing; from to (feet). NOTE: TI-M, WELL DRMLLNTG CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR PROPOSED WELLS IF THIS INFORMATION IS UNAVAT"MLE BY OTHER MEANS, Ver.3/01 GWIIUIC-57 CL Wage 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 information. I. 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). 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 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 e are significant penalties, including the possibility of fines and imprisonment, for submitting fa.op~.--·~~· ation. I agree to construct, operate, maintain, I repair, and if applicable, abandon the groun -ourc h t pump system and all related appurtenances in accordance with the approved specification d nditi s f th rnri f." (Signature of Well 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. GW/UIC-57 CL Page 3 of4 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 1and rests ownership in the landowner in the absence of contrary agreement in writing.) Ver.3/01 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 ISA NCAC 2C .0200) (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 (919) 715-6165 GW/UIC-57 CL Page 4 of4 n?Sn.� Maps & Directions Start: 4000 Market St, Wilmington, NC 28403 End: Pembroke Jones Dr, Wilmington, NC 28405 Total Distance, 5.4 Miles Estimated Total Time: 9 minutes fia!uri T �Nia�salR' , re.�� ieehaalagx 1 % �o vftmow N�r o f ; T ? ~ og ".,apPcrirlt e!1 [ per,: rQ- �Nevu#ana�r'�Lr420A In`ROatfonal�, 1 � ..I. _ s 7 s F" wrd .. y._ }•- A�I i„ 4.._�,f" Imo,.. h^ --•-.7''`� .'-j.y�'+,9- �- f i't4 A' .Al ��,sta �gS-�ia� '+'F' j ' ,�- .Fr' � �, r r a •ti �� , M1 • • f�� End'17 \ •+/ a ]4 ��'y 4 �r 1 7 _ ► r {y77 y� Bell �- 7k_ " $2004Micro59R C91p $�2009.Fi�v1loh,alid}arGUT;II c ; `. �� I Dir'el loons Start: Depart 4000 Market St, Wilmington, NC 28403 on US-17 [US-741 (East) 1: steep RIGHT onto US-74 [Eastwood Rd] 2: Tum LEFT (North) onto Local road(s) 3: Road name changes to Pembroke Jones ❑r End: Arrive Pembroke Jones ❑r, Wilmington, NC 28405 Mlles Maq 1.5 3.0 C Q.1 0.9 CW004MIMOOMOlp 02003 N2xAO,andNGOT. Your right to use maps and routes generated on the MSN service is subject at all times to the M5N Terms of Usk Data credits, copyright and dis�aimer. http:llmappoint.msn.coml(nzoelsnrukf ijmegoj 1 fba55)IPrintRoute.aspx?&StartName=4000+Mark... 7/22/2004 O'Brien Service Co. Inc. Heating & Air Conditioning 3308 Enterprise Drive P.O. Box 12788 Wilmington, NC 28405 License #?3062 9]4799681] 910 799 5884 Fax obrien@bizec,rr.com E It's Hum 7b Stap A r' r :7� 1, 4SN Maps & Directions - Map Print Page 1 of 1 I msn� Maps & Directions Pembroke ]ones Dr, Wilmington, NC 28405 Ga"ur,rgg Micesalt' ' #tapPoint�'' %sitaala�r i MapPoInt' -n aCArhd,,J 0 �k � COO 412004MinnOHCOlp 02003 NWiE0.a¢aJor6ofum. Your rioht to use n]d and rouEes aen rated an th .M$"ni i �t+b&LaLa11 iz tSLt MSy_.TQr[ns_if rise... Dao a'ed-�s,_mpYrigtt._arLd disc aimer. http://mappointmsn.com/(wgOpdtzgGmgo3 i 45pdOe l wjw)/PrintMap.aspx?MPMtd=M&L=... 11/4/2004