WI0800079_GEO THERMAL_19970904

NORTH CAROLINA
ENVIRONMENTAL MANAGE!v!ENT COMtvllSSION
DEPARTMENT OF ENVIRONM&'IT, HEALTH, AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP
GEOTHERMAL-WATER-ONLY INJECTION WELL SYSTEM
(GROUND-SOURCE HEAT PUMP)
fu accordance with the provisions of NCAC Title 15A: 02C.0211
complete notification and mail to address on the back page.
This is not the p roper form for injection wells to be used in an oven-loov
ground-source heat pump system. Do not use this form for systems-that
re-circulate any substances other than water below the ground surface.
Type 5QW Wells
TQ DIRECTOR, NORTH CAROLINA DIVISION OF W AIBR QUALITY
. 19 _fl_
Please type or print clearly.
A. SYSTEM CLASSJFICATION Does the proposed system re-circulate potable
water in continuous piping which isolates the fluid from the environment?
YES ./ If yes, then continue completing this form GW-57 CL.
N) Ifno, do not complete this form. A form GW-57 HP
(Application For Permit To Construct And/Or Use A Well
For Injection With A Heat Pump System) must be completed.
B. SYSTEM FLUID Will any additives be introduced to the system's subsurface
piping, including but not limited to corrosion inhibitors or antifreezes?
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YES If yes, do not complete this form. A form GW-57 HP
(Application For Permit To Construct And/Or Use A Well For
Injection With A Heat Pump System) must be completed. •
✓ If no, then continue completing this form GW-57 CL.
C. PROPERTY OWNER
Name: ---=-W~, )'--m-'-1 .....,.1 b'-'-"'rJ_tto~'--l.J-.b'--1_,"1-t---'A,,;;-~_L½---r-------
Address: --'-'Y,_t)•_,_,lli?=-.,Y...~<3_._9j...____· ---=~_,_\ 0=--.a.Q_nl"<..el»-__ ~~--'--. _____ _
City: ~if ll 'Y\~~
County: _______ _
Zip code: c1 M6 ) -6B~cl
Telephone: 9 (0 -3L\ ~-7 id5
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D. STATUS OF PROPERTY OWNER
Private: - Federal: ,t n3 - OLA ..1-f �- t'>-(XVJ �'IJ �,-U � RLL 1).)(—
State: Public:
Commercial: Native American Lands:
E. FACkLITY (SITE) DATA (Fill out ONLY if the Status of Property Owner is
Federal, State, Public or Commercial).
Name of Business or Facility:
Address: ►'.0. i'1`I
City: ' i m Zip code:- W' County:
Telephone:9lD-3y1-2M!S� Contact Person: #R�
Standard Industrial Code(s) which describes Commercial facility:
Name: 1J Lr -yLS
Address:"
City: ,r•�a E� �}A Zip code: -
County: Telephone: x - 3 4-*1
Contact Person: J'
G. WELL USE Will the system well(s) also be used as the supply well(s) for
your personal consumption?
YES— No
H_ CONSTRUCTION DATA (CHECK ONE)
EMSTING WELL(S) being proposed for use as a ground -source 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.
PROPOSED WELL(S) to be constructed for use as a ground -source
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:VE� LLC
NC Driller Regisr. tration number.17.SS
(2) Date to be constricted: 7—
Approximate depth of each boring:
Number of bonngs:
(3) Well casing: Is the well(s) cased?
(a) YES If yes, then provide casing information below.
Casing type: Galvanized steel Black steel _ Plastic
! Other (specify)
Casing depth: from to ft. (reference to land surface)
(b) NO
(4) Grout (material surrounding well casing and/or piping):
(a) Grout type: Cement,,; Bentonite_;
Other (specify)
(b) Grouted surface and groat depth (reference to land surface):
around closed -loop piping; from to _ ft.
around well casino; from to L
NOTE_ THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR ETITiER EX5TTNG OR
PROPOSED WELLS IF THLS WORIMATION IS UNAVAILABLE BY OTHER MEANS.
H. LOCAMN OF WELL(S) Attach two maps.
(1) a site map (can be drawn) showing 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 204 feet of the
ground -source heat pump well system.
(2) a location map referencing the site to a labeled road intersection.

I. 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 inquixy of those individuals
immediately responsible for obtaini g said information, I believe that the
information is true, accurate and complete. I am aware that there are
Significant penalties, including the possibility of fixes and imprisonment,
for submitting false information. I agree to construct, operate, maintain,
repair, and if applicable, abandon the ground -source heat pump system
well(s) and all related appurtenances in accordance with Title 15A NCAC
Subchapter 2C Section .020V
(Signature of Owner or -Authorized -Agent)
Please supply a letter signed by the owner
autlwrizing the above agent, if authorized agent is signer.
J. CONSENT OF PROPERTY OWNED (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 land owner in the absence of
contrary agreement in writing.)
If the property is owned by someone other than the operator, the property
owner hereby consents to allow the operator to construct a ground -source heat
pump system as outlined in this notification and that it shall be the responsibility
of the operator to ensure that the ground -source heat pump system's wells)
conform to the Well Construction Standards (Title 15A NCAC Subchapter 2C .0240)
(Signature of Property Owner if Different From System Operator)
Please return the completed Notification package to.
LTIC Program
Groundwater Section
North Carolina DEHNR-DWQ
P.O. Box 29578
Raleigh, NC 27626-0578
(telephone: [phone])