WI0800080_GEO THERMAL_19971029

State of North Carolina
Department of Environment,
Health and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Wayne McDevitt, Secretary
A. Preston Howard, Jr., P .E., Director
GROUNDWATER SECTION
October 29, 1997
Mr. Dave Ames
Virginia Energy Services
3200 West Moore Street
Richmond, VA, 23230
Dear Mr. Ames:
As you requested during our site visit on Tuesday, October
21 st , 1997, I have enclosed a copy of the North Carolina Well
Construction Standards applicable to injection wells (NCAC Title
15A Section 2c.0200).
During this visit we also discussed North Carolina's requirement
for well driller registration. In order to clarify our
discussion, please note that NCAC Title 15A Section 2c.0103
requires that every person, firm and/or company engaged in drilling
wells in North Carolina must be registered with the NC Department
for Environment and Natural Resources. Therefore, even if you are
registered as a well driller, the person/company that you contract
to actually drill the well must also be registered. If you have any
questions please feel free to contact me at [phone].
Sincerely,
~ (2___-
Amy Axon
Underground Injection Control Program Manager
Groundwater Section
cc: UIC Files
Enclosure
Groundwater Section
P.O. Box 29578, Raleigh, North Carolina 27626-0578
2728 Capital Blvd., Raleigh, North Carolina 27604
C:\old computer\WPDOCS\SITELETT\vesrul.wpd
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Ut tf. GROWW WATER SEC.
97 SEP-4 PH f: 48
NORTII CAROLINA
ENVlRONi\1ENTAL .MAJ.'{AGENfENT cm,,fMISSION
DEPARTMENT OF ENVIRONMENT, HEALTII, AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP
GEOTHERlvIAL-WATER-ONLY INJECTION WELL SYSTEM
(GROUND-SOURCE HEAT PUl\lIP)
In accordance with the provisions of NCAC Title 15A: 02C.02 l l
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 ooen-looo
ground-source heat pump system. Do not use this form for systems ·that
re-circulate any substances other than water below the ground su,face.
Type 5QW Wells
TO: DIRECTOR, NORTH CAROLINA DMSION OF WATER QUALITY
DATE: S:~, l . 19 q7
Please type or print clearly.
A. SYSTEM CLASSIF1CATION Does the proposed system re-circulate potable
water in continuous piping which isolates the :fluid from the environment?
YES
N)
✓ If yes, then continue completing this form GW-57 CL.
If no, do not complete this form. A form GW-57 HP
(Application For Permit To Construc t And/Or Use A Well
For Injection With A He:i.t 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?
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 He:i.t Pump System) must be completed. •
/ If no, then continue completing this form GW-57 CL.
C. PROPERTY OWNER
Name: \V 1 \ tv1 1
1
f\c ~.J 1-lou.b\0~ ~ ~~ ~
Address: f_ l) ~O)l 899 810 {)r,'11~ sW
City: l~}~ \n,-.,,('-$. W Zip code: ;:;lS 46~ -0811
\J
County:_______ Telephone: t/10-3l.f {-,78S'
D. STATUS OF PROPERTY OWNER
N(),J-fr 6 ~/~w-.;o"t'1.. C,o <pw-ci.k~,J ~--~ bd H.U.b,; ~
Private:
State: __
Federal: __
Public: __
Commercial: ___ _ Native American Lands: ___ _
E. FACILITY (SITE) DATA (Fill out ONLY if the Status of Property Owner is
Federal. State, Public or Commer~ial).
Name . of Business or Facility: __ ~_J\_.,J'--k.-~,.J_-'-'P ...... l="-C:k-=-----------
Address: _ ..... P.~. t ..... ')"-. D.?f=...__,.B~<f9...,_____,__ _______________ _
City: t,,J: (rn ;cc,:h,.J Zip code: d 8 lf6;;;t_ County:, _____ _
Telephone: '1 I 0-1 q I-119:S-Contact Person: 1 I/ t>e-c.Ur
Standard Industrial Code(s) which describes Commercial facility: ____ _
F. HEAT PUMP CONTRACTOR DATA
Name: Jes Er-a.re,,\..\ [;.,,r,.;l<~ I L.L(_ , )
Address: 2>d-9£? l,u,9.-'t;,-j vt1t:i~ E;~
City: K--l<l\~ , \/A--Zip code: _;;i_3_~_~_o ____ _
County: _______ _ Telephone:. flx:d -36"9 .-.;l.occ X---.S <IS-
Contact Person: ___ C, ____ ( ;_~ __ '1&-__ µ_,.J ____ _
G. WELLUSE Will the system well(s) also be used as the supply well(s) for
your personal consumption?
YES __ NO /
H. CONSTRUCITON DATA (CHECK ONE)
/
EXISTING WELL(S) being proposed for use as a ground-source heat
pump well(s). Provide the infonnation in (I) 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
consnuction.
(1) Well Drilling_ Contractor's Name:_~V~c~S=,,_L _LC., _______ _
NC Driller Registration number: ---'1_7_S_5' _________ _
(2) Date to be constructed: · /0/f//7-ld-/fa7
Approximate depth of each boring:_~2~o~o=-----
Number of borings:_..,.,IJ .... 3.__ __
(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) N) ✓
.(4) Grout (material surrounding well casing and/or piping):
(a) ·Grout type: Cement_; Bentonite ✓;
Other (specify) _____ _
(b) Grouted surface and grout depth (reference to land surface):
✓ around closed-loop piping; from O to ,RD O ft.
_ around well casing; frqm. ___ to ___ ft.
NOTE: THE WELL DRILLlNG CONTRACTOR C.<\i'\f SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF 1HIS IN"FOR.J.\1ATION IS UNAVAILABLE BY OTHER MEAJ.'JS.
H. LOCATION 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 200 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 oflaw, 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 offines 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
Subchaprer 2C Section .0200." f;i r/1.),.._j,, ~ '! /q /c; )
/ (Signature Qf Owner er ,liitllomed Agen t)
Lon fy ~fi tJ $e-bt-
P lease sup~ a letter signed by the owner
authorizing the above agent, if authorized agent is signer.
J. 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 land owner in the absence of
contrary agreement in writing.)
If the property is owned by someone ·other than the operator, the property
O\Vller 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 well(s)
conform to the Well Construction Standards (Title 15A NCAC Subchapter 2C .0200)
(Signature of Property Owner if Different From System Operator)
Please_ return the completed Notification package to:
UICProgram
Groundwater Section
North Carolina DEHNR-DWQ
P.O. Box 29578
Raleigh, NC 27626-0578
(telephone: [phone])