WI0800096_GEO THERMAL_20040615

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
June 15, 2004
To: Charles Stehman, Regional Groundwater Supervisor
Groundwater Section
Wilmington Regional Office
From: Thomas Slusser~_s
Central Office
Re: Receipt ofNotification for a Closed-Loop Geothermal Water-Only Injection Well
System. (Type 5QW.):
Susan and Robert Frank have filed a Notification of intent to construct and operate a closed-loop,
water only injection well system for a geothermal heat pump (Type 5QW injection well) at 141
South Permuda Wynd, North Topsail Beach, NC in Onslow County. A copy of the notification is
included with this memorandum. This injection well system is deemed permitted by rule (15A
NCAC 2C.021 l(u)2) and no further regulatory action should be necessary. Ifyouhaveanyquestions
about this notification, please contact me at [phone].
cc: CO-UIC Files
Enclosures
Michaei F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resourees
Alan W. Klimek, P. E. Director
Division of Water Quality
Coteen H. Sullins, Deputy Director
Division of Water Qttatity
June 16, 2004
Susan and Robert Frank
5828 Bayberry Lane
Raleigh, NC 27612
RE: Notification of intent to construct Type 5QW injection wells
Dear Mr. and Mrs. Frank:
In accordance with the notification you submitted to the UIC Program on June 8, 2004, the
Groundwater Section acknowledges your intent to construct [7] closed-l000 geothermal water -only
injection wells for the operation of a ground -source heat pump at 141 South Permuda Wynd, North
Topsail Beach, NC 28445, in Gnslow County, The system as described in your notification is
deemed permitted by rule (North Carolina Administrative Code Title 15A: 2C.421 i (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.
Thank you for submitting this notification. Please contact me at [phone] or Evan Kane at
[phone] if you have any questions regarding geothermal heat pump wells or injection well
rules.
cc: Charles Stehman, Groundwater Supervisor
Wilmington Regional Office
UIC-CO files
Best Regards,
Thomas Slusser
HydrogeoIogical Technician H
Underground Injection Control Program
W
N. C. Division of Water Quality 1 Groundwater Section
1636 Mail Service Center Raleigh, N.C. 27699-1636 Customer Service
Phone: [phone] Fax: [phone] Internet: hitp:/lgw.chnr.state.nc.us 1-877-62M7748

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP
GEOTHERMAL WATER -ONLY INJECTION WELL SYSTEM
(GROUND COUPLED BEAT PUMP)
Type 5QW Welts
1n Accordance with t}zc provisions of NCAC Title 15A: 02CA200
Complete application and mail to address on the }rack page.
This is not the proper form to be used for injection wells in an open-1geothermal system.
Do not use this form for systems that circulate any substances other than water.
TO. DIRECTOR., NORTH CA.ROLINA DIVISION OF WATER QUALITY
DATE: (o r .; , 200 f
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES X If yes, then continue completing this form_
NO If no, do not complete this form. Force GW-57 HP, Application For
Permit To Conamci And1Ur 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 force. Form GW-57 HP, Application For
Permit To Construct AndlOr Use A Wells} For Injection With A Feat
Pump System, should be completed.
NO X If no, then continue completing this form,
C. PROPERTY OWNER
Nanw: eJ1
Address,City:
,I, -
Co
urtly: r L .- —
l ►'"�
` State:
Telephone: _
D. STATUS OF PROPERTY OWNER
Private: X Federal: _
State: Municipal
e-ZIPCode: .2-62
Commercial:
Native American Lands:
Ver.3/01 GWnJIC-57CL
Page I of 4

E. JOB (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: lfo/vf ~ t.,...,.d",1--A/ F;~k_
Address: IL/J 5aL-Lf-l----Pe.,·--,.y1 t>-<J?,4-WL .'1'Jl
City: Ni)-rKfi>~SA--c-J Qe:;;;c State: Ji)i Zip Code: :?:::('"i'~County: M $!aw
Telephone: Z/Jq,. jY16-001Y: Contact Person: t?or-F/,1-,Vfc
Standard Industrial Code(s), SIC, which describes commercial facility : _______ _
F. HEAT PUMP CONTRACTOR DATA
Name: Climate Control Heating & Cooling Co .• Inc.
Address: 102 Middle Street
City: Jacksonville
Telephone: [phone]
State: NC Zip Code: 28546 County: Onslow
Contact Person: Michae=· ==1-=H=adl=ey __________ _
G. CONSTRUCTION DATA (check one)
Ver.3/01
____ EXISTING WELL(S) being proposed for use as a ground-coupled heat pump
well(s). Provide the infonnation in (I) through (4) below to the best of your
knowledge . Attach a copy ofFonn 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 Fonn GW-1 after construction.
(I) Well Drilling Contractor's Name: =Sanfi=o=r=d=L~. =Sw~eenn=·=g....._ _______ _
NC Contractor Certification number: NC -2082 ~~~~----------
Date to be constructed: __ ,~G_.---_o...,t _____ Number of borings: __ 7-+-------
Approximate depth of each boring (feet): ___ 7.,-o __ CJ _________ _
(2) Well casing: Is the well(s) cased?
(a) YES __ If yes, then provide the casing infonnation 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 200 (feet).
__ around well casing; from __ to __ (feet).
NOTE: THE WEU, DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WEILS IF nns INFORMATION IS UNAVAILABLE BY OTHER MEANS.
GW/UIC-57CL Pag~ 2 of4
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.
(I) 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 fucilities such as septic tanks or drain
fields located within 200 feet ofthe ground-coupled heat pump well system. Label all features
clearly and include a north arrow.
(2) location map referencing the site to two nearby pennanent 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) Ha7.ardous Waste Management program pennits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Pennits
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 m and all related appurtenances in accordance
with the approved specifications and cond.itio of the enni "
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-57CL Page 3 of 4
. ..
L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
Ver.3/0l
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)
(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 Semce Center
Raleigh, NC 27699-1636
Telephone [phone]
GW/UIC-57CL Page 4of4
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