WI0800102_GEO THERMAL_20040902

DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
August 2, 2004
MEMORANDUM
To:
Through:
From:
Charles Stehman
Wilmington Regional Office
EvanKane U--
Central Office
Jesse Wiseman .....J vJ
Central Office
Re: Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection Well
System. (Type 5QW.):
Notification of intent to construct and operate a closed-loop, water only injection well system for
a geothermal heat pump (Type 5QW injection well) has been filed by Danny Plymell in
Jacksonville, North Carolina. A copy of the notification is included with this memo. This
injection well system is deemed permitted by rule (ISA NCAC 2C.021 l(u)2) and no further
regulatory action should be necessary. If you have any questions about this notification, please
contact Evan Kane at [phone].
cc: CO-UIC Files
Enclosures
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Michael F. Easley, Govemor
August 2, 2004
Danny Plymell
605 Chandler Ct.
Jacksonville, NC 28546
RE: Notification of intent to construct Type 5QW injection wells
Dear Mr. Plymell:
William G. Ross, Jr., Secretary
Alan W. Klimek, P.E., Director
In accordance with the notification you submitted to the LJTC Program on July 28, 2004, the
Aquifer Protection Section acknowledges your intent to construct four closed -loop geothermal
water -only injection wells for the operation of a ground -source heat pump. The system as
described in your notification is deemed permitted by rule {North Carolina Administrative Code
Title 15A: 2C.021I(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 Aquifer Protection Section to
verify compliance with applicable rules.
Thank you for submitting this notification. If you have any questions regarding geothermal heat
pump wells or injection well rules please contact Evan Kane at [phone].
Sincerely,
Besse W. Wiseman _
Processing Assistant
U1C Program
cc: UIC-WiRO files
UIC-CO files
Aquifer Protection Section
1636 Mail Service Center, Raleigh, {forth Carolina 27699-1636 One
2728 Caphat Blvd., Raleigh, North Carolina 27604 N� �7TD�l)1a
Phone, 919-733-32211FAX: [phone]Internet: http:Ilgw.chnr.state.nc.us
An Equal Cpponunity/Affirmative Action Employer — 50% Recycted110% Post Consumer Paper atumllff
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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 SQW Wells
In Accordance with the provisions ofNCAC 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 system.
Do not use this form for systems that circulate any substances other than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: ·J -7,f , 2rl)!j_
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES -P=-If yes, then continue completing this form.
NO Ifno, do not complete this form. Form GW-57 HP,Application For
Permit To Construct And/Or 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.
C.
D.
Ver.3/01
YES If yes, do not complete this form. Form GW-57 HP, Application For
Permit To Construct And/Or Use A Well(s) For Injection With A Heat
Pump System, should be completed.
NO ~ If no, then continue completing this form.
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PROPERTYOWNER o 2,3
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City: Ji;, J<i,,;v{; J/e_, State: ;Ve---Zip Code: ___ Z~f~(~, ~l{_<t, _____ r~_;;;;
County: ()JJs {tT"L,,J Telephone: _q,_,/_i)_-~3_-f_S-:_-_j~rJ~?~-----~=-~~tJ;
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STATUS OF PROP~RTY OWNER gf.
("'")
0 -; Private: --P,--
State:
Federal:
Municipal;_._.
GW/UIC-57 CL
Commercial: en '--'
Native American Lands:
Page 1 of4
E. ,(SITE) DATA
Name . Yo"M, A/I,u c C
City: 'JAG KsdA14 U�-- State: NCB Zip Code: SSG ty ()Ars (a%-,J_
Telephone: Contact Person:_ -1
Standard Industrial Code(s), SIC, which describes commercial facility:
F. HEAT PUMP CONTRACTOR DATA
Name; I c.vw,Ic�
Address: 11 9r_
City. kSd .Jrf• 1 c_ State: At_-2<ip Code: r Count
Tel ephoon gg � S� �d � Contact Person: i e.� e C 6.4
G. CONSTRUCTION DATA (check one)
MSTING WELL(S) being proposed for use as a ground -coupled beat pump
well(s). Provide the information in (1) through (3) below to the best of your
knowledge. Attach a copy of Form GWA (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 (3) below as PROPOSED
construction specifications_ Submit Form GW-1 after constru
ct
ion.
(1) Well Drilling Contractor's Name:��
NC Contractor Certification number: /Vill'
Date to be constructed: I Number of borings: -
Approximate depth of each boring (feet): 1C3�
(2) Well casing; Is the well(s) cased?
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel Btack steel Plastic Other (specify)
Casing depth: From to ft, (reference to land surface)
Casing extends above ground inches
(b) NO
(3) Grout (grout the vertical length ofthe borehole to a minimum depth of 20 feet b.1.s.):
(a) Grout type: Cement Bentonite )( Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
around closed loop piping; from to �Wi (feet).
around well casing; from to (feet).
NOTE- Tim war x DRa.LwG coNTRACTOR CAN gjpnY nm DATA FoR EIri11~,R ur smG oR
PROPOSM WELLS LF THIS WORMAVOM IS UNAVAUABLE BY OTHER MEAN&
Ver.3101 GWMC-57 CI. 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 and 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:
(I) Hazardous Waste Management program permits under RCRA
(2) NC Division of Water Quality Non-Discharge permits
(3) Sewage Treatment and Disposal Permits
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-sourc eat pump system and all related appurtenances in
accordance with the approved specifications an condi · ons of J '·" /
thorized Agent)
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-57 CL 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.)
Ver.3/01
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 Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GW/UIC-57 CL Page4of4
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