WI0800098_GEO THERMAL_20000902

DIVISION OF WATER QUALITY
GROUNDWATER SECTION
August 2, 2000
MEMORANDUM
To: Charles Stehman, Ph. D., P.G.
Groundwater Section
Wilmington Regional Office
From: Mark Pritzl (I\P. [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 3 injection wells for a geothermal heat pump system has
been filed by Mr. & Mrs. Heatherly 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 Tl5A: 2C.21 l(u)2) and no regulatory action is necessary. If you have any questions,
please contact me at [phone] or Amy Axon at [phone].
cc: UIC Files
Enclosures
7WA
NCDENR
JAMES B. HU14T JR'."
GOVERNOR
HILL HOLMAN
SECRETARY David &. Michele Heatherly
703 Doris Ave.
Jacksonville, NC 28540
KERR T STEVENS
DIRBGTOR :Dear Mr. & Mrs. Heatherly:
NORTH GAROLINA DEPARTMENT OF
ENVIRONMENT AND NATuFtAL RESOURCES
August 2, 2000
DIvIS1ON OF WATER QUALITY
In accordance with the notification submitted on your behalf by Climate Control
Heating & Cooling, dated July 31, 2000; the Groundwater Section acknowledges
your intention to construct a closed -loop geothermal water-orilv injectionwells 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 Amy Axon at [phone].
Sincerely,
Mark Pritzl
Hydrogeological Technician II
Underground Injection Control Program
CO-UIC Files
WIRO-UIC Files
GROUNDWATER SECTIOsi
1636 MAIL SERVICE CENTER, RALEWH, NC 27699-1636 • 2728 CAPITAL, 8LVO., RALE IGH, NC 27s04
PHONE [phone] FAX 91 A•71 S-OS9S
AN EQUAL OPPORTVNITY ! AFFIRMATIVE ACTION EMPLOYER • SO% RECYCLEO110% POST -CONSUMER PAPER

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) co -
Type 5QW Wells
In Accordance with the provisions of NCAC Title I5A, 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 ripen -loop geothermal systeD.
Do not use this form for systems that circulate any substances other than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: 2000
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES K If yes, then continue completing this form.
I.?
NO If no, do not complete this form. Form GW-57 HP, Application For
Permit To Construct AndlOr Use A Well(s) For Injection With A Heat
Pump System, should be completed.
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 Construct AndlOr Use A Well(s) For Injection With A Heat
Pump System, should be completed.
NO If no, then continue completing this form.
PROPERTY OWNER
Name: i- `-
Address: '7 o [
City: ; aY Vt
Y4 I'A 4- (V---
) e State
County: Wv 0
Telephone: _
D. STATUS OF PROPERTY OWNER
Private: Federal:
State: Municipal:
GW-57 CL (Jan, 2000)
At, Zip Code: L e3-4-L7
lff— 1i -S'-- 4 Y 7 s—
Commercial:
Native American Lands:
Pagel 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 PUMP CONTRACTOR DATA 1
Name: L! 11L%A-tr. �, f9.' I• p J le-5C fl
County:
City: L-d►4 v, !!e— State: / C­ Zip Code: 2 " `� County:
Telephone: 11 n F L E� r 6 f o Contact Person:G. CONSTRUCTION DATA (check one)
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.
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 Form GW-1 after construction. r
(1) Well Drilling Contractor's Name: elj_Me�
�r 9
NC Contractor Certification number: Z d 2_-
Date to be constructed: 4 r a © Number of borings: 3
(2)
(3)
Approximate depth of each boring (feet):
Well casing: Is the well(s) cased?
(a) YES
Type: Galvanized steel_
Casing depth: From
/s
If yes, then provide the casing information below.
Casing extends above ground
(b) NO
Black steel Plastic
Other (specify),
to ft. (reference to land surface)
inches
Grout (grout the vertical length of the borehole to a minimum depth of 20 feet b1s.):
(a) Grout type: Cement Bentonite _X_ Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
4 around closed loop piping; from () to 2,0 (feet).
around well casing; from to (feet),
NOTE: THE WELL DPJLLlNG CONTRACTOR CAN SUPPLY THE, DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION 1S UNAVAILABLE BY OTHER MEANS.
GW-57 CL (Jan, 2000) Page 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 arid the orientation of and distances between
the proposed well(s) and any ex,isting 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 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 system and all related appurtenances in
accordance with the approved specifications and conditions of the Permit."
GW-57 CL (Jan, 2000)
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 Well 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]
Page 4 of4
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