WI0800097_GEO THERMAL_20010208

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
February 8, 2001
MEMORANDUM
To: Charles Stehman, Ph.D., P.G.
Groundwater Section
Wilmington Regional Office
From: Mark Pritzl f1 ~[e-mail]
Hydrogeological Technician II
UIC Group
Groundwater Section
Raleigh Central Office
Re: Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection Well
System Type SQW.
Notification to construct and operate 5 injection wells for a geothermal heat pump system has
been filed by Max Gilliam in the City of Jacksonville, North Carolina and a copy of the
Notification is enclosed for your files. The injection well system is deemed permitted by rule
(NCAC T15A: 2C.21 l(u)2) and no regulatory action is necessary. If you have any questions,
please contact me at [phone] or Meliktu Fanuel at [phone].
cc: VIC Files
Enclosures
Michael F. Easley
Governor
Williams G. Ross Jr., Secretary
Department of Environment and Natural Resources
February 8, 2001
Max Gilliam
1051 Seechtree Road
Jacksonville, NC 28546
Dear Mr. Gilliam:
Kerr T. Stevens
Givisian of Water Quality
In accordance with the notification submitted on January 31, 2001; the Groundwater Section
acknowledges your intention to construct a closed -loon geothermal water -only injection well
system for the operation of a ground -source heat pump. The system as described in your
notification will not require an injection well permit and is deemed permitted by rule (North
Carolina Administrative Code Title 15A: 2C.0211(u)2). The Underground Injection Control
Group has added your site to our inventory. If you modify your system, please contact the
Groundwater Section to verify compliance. Thank you for submitting this notification.
If you have any questions regarding geothermal heat pump wells please feel free to contact me
at [phone] or Meliktu Fanuel at [phone].
Sincerely,
Mark Pritzl
Hydrogeological Technician 1I
Underground Injection Control Program
cc: CO-UIC Files
WIRO-UIC Files
A04
0 b NO
Customer Service Division of Water Quality 1 Groundwater Section
1 800 623-7748 1636 Mail Service Center Raleigh, NC 27699-1636
Phone: [phone] Fax: [phone] Internet- httpJ/gw.ehnr.state.nc.us

NORTH 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 of NCAC 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 systecn.
Do not use this form for systems that circulate any substances other than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: 1,17 , 20_
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment'!
YES If yes, then continue completing this form.
NO If no, do not complete this form. Form GW-57 HP, Application For
Permit To Construct AndlOr Use A Wells) 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 Coits Ir stet And10r Ilse A We11(s) For Injection With A Heat
Pump System, should be completed.
NO _7)( If no, then continue completing this form.
C. PROPERTY OWNER
Name: 4
Address: e a
City: %d^!L4 IGr State: C- Zip Code:
County, DIVs a&u Telephone:
D. STATUS OF PROPERTY OWNER w
Private: Federal: Commercial:
State; Municipal: Native American Lands: w-
-
GW-57 CL (]an, 2000) Page I of +4

E. 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:
Telephone: Contact Person:
Standard Industrial Code(s), SIC, which describes commercial facility:
F. HEAT PUl
Name:
Address: City: „A_
Telephone:
M
CONSTRUCTION DATA (check one)
(1)
(2)
(3)
County:
EXISTING WELL(S) being proposed for use as a ground -coupled 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,
PROPOSES] 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 Form GW-1 after construction.
Well Drilling Contractor's Name: 44"" 4tdrul
NC Contractor Certification number:
Date to be constructed: '` Number of borings:
Approximate depth of each boring (feet): 2,40d Of
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
Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b.l.s.):
(a) Grout type: Cement Bentonite A Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
around closed loop piping; from _ to 2716 (feet).
around well casing; from to (feet).
!VOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTr]tiG OR
PROPOSE] WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
GW-57 CL (lan, 2000) Page 2 of

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 arid 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
"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
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 specificatio nd con 'tions of the Permit."
GW-57 CL (Jan, 2000)
,
re of Well Owner 1 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.
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 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 WeU Construction Standards (Title 15A NCAC 2C .0200)
GW-57 CL (Jan, 2000)
(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]
Page4 of4
North Carolina • Department of Environment and Natural Resources - Division of Water Quality . Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WILL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION N.
STATE WELL CONSTRUCTION PERMIT#,-
1. WELL USE (Check Applicable 9ox): Residentlal ❑ Municipal ❑ Industrial ❑ Agricultural El Monitoring El Recovery ❑ Heat Pump Water Injection ❑ Other If Other. List Use: . �,n,I
2. WELL LOCAT (Show sketch of Jhe location below)
Nearest Town: ie _ County: 4 '
(Road Name an NUrnoefs. Community. or Subdivision n Lol No.) DRILLING LOG
3- OWNER --r cj<- From To
Address �019p 0 f -`"--w— a -t — l=J -.
itSd►��1 l�C� tree `�Jar 4� o. r Gd 3
� fr.
City p(Town -� State zip Cade
4. DATE DRILLED YYS
5. TOTAL DEPTH,
6_ CUTTINGS COLLECTED YES 7_) NO[7
7. DOES WELL. REPLACE EXISTING WELL? YES ED NO❑
8. STATIC WATER LEVEL Below Top of Casing: ^ FT.
(Use `+' If Above Top of Casing)
9, TOP OF CASING I5 Ff. Above Land Surface'
'Top of casing terminated atlor below land surface requires a variance In accor-
dance with 15A NCAC 20,0118
1 t7. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING: G-� ti�YV1ri, iC �-
%r wall Thickness
Depth Diarneter or Weight/Fl. Material
From—To—Ft.—
From— Ta Ft.
From To Ft.
14. G ROUT:
Depth r Ma edal _ Method
From To _ 1 b Ft.'�--
From To Ft.
15. SCREEN:
Depth
From
To
From
To
From
To
1E. SAND/GRAVEL PACK:
Depth
From
To —
From
To
17. REMARKS:
Diameter Slot Size Material
Ft In. —in.
Ft._ in. in.
Ft. In. in.
Size Material
— FL
_ Ft.
DEPTH
Format on Description
r _
r v i7
;•s
� r-y
If additional space is needed use hack of form
. 0 LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
■
100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPYF THIta RE dkll Hw$ N PROYIDED TO THE WELL OWNER,
FOR OFFICE L]SE ONLY _ _ � • .�'� ' `'% �`�,' � -7 r r'�
Quad No: r
Submit on
Serial No.
6NATURECPIVERSON CONSTRUCTING THE WELL DATE
to Division of Water Quality. Groundwater Section within 30 days
GW•1 REV. 12199

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