WI0800103_GEO THERMAL_20040421

MEMORANDUM DIVISION OF WATER QUALITY GROUNDWATER SECTION April 21, 2004 To: Charles Stehman, Regional Groundwater Supervisor Groundwater Section Wilmington Regional Office From: Thomas Slusser--7-f.s 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 Peter Rulon in Stella, North Carolina. A copy of the notification is included with this memo. This injection well system is deemed permitted by rule (15A NCAC 2C.021 l(u)2) and no further regulatory action should be necessary. If you have any questions about this notification, please contact me at [phone]. cc: CO-UIC Files Enclosures WID '60010.3
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April 21, 2004
Peter Rulon
220 North Holland Point Drive
Stella, NC 28582
Michael F. Easley, Governor
William G. Ross 1r., Secretary
North Carolina Depatment of Env!ronment and Natwal Resources
RE: Notification of intent to construct Type 5QW injection wells
Dear Mr. Rulon_
Alan W. Mitnek, P. E. Director
Division of Water Quality
Coleen H. Suilins, Deputy Director
Division oFWater Quality
In accordance with the notification you submitted to the UIC Program on April 13, 2004, the
Groundwater Section acknowledges your intent to construct 5 closed -loot? 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.4211(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. Ifyou 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. If you have any questions regarding geothermal heat
pump wells or injection well rules please contact me at [phone].
cc: Charles Stehrnan, Groundwater Supervisor
Wilmington Regional Office
UIC-CO files
Sincerely,
Thomas Slusser
Hydrogeological Technician li
UIC Program
Ar*b
NUDEMR
N. C. Division of Water Quality 1 Groundwater See lion
1636 Mail Service Center Raleigh, N.C. 27699-1636 �1-19'77Z23S-6�748
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Phone: [phone] Fax: [phone] lntemet: hrtp://gw.chnrstue.ne.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 1 SA: 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 -loon geothermal system.
Do not use this form for systems that circulate an substances ether than water.
TO: DIRECTOR, NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: 4 l 3 - 20 0 ff-
A. SYSTEM CLASSIFICATION Does the proposedsystem 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 UP, 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 Co ns true t A ndlOr Use A We11(s) For Injection With A Heat
Pump System, should be completed.
NO if no, then continue completing this form.
C. PROPERTY OWNER�v
Name: e. +t d "i
Address: r.
City: i-lip 11A. State: jlf er 2ils Cade; _ Y _
County: 6)c .i p w3 Telephone. Sr - 11 7 $
D. STATUS OF PROPERTY OWNER rn
Private: Federal: Commercial:
State: Municipal: Native American Lands:
Ver.3/01 GW/U [C-57 CL Page 1 of 4

E. FACILITY (SITE) DATA
(Pill out ONLY if the Sta s a Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility_
Address:
City: State: Zip Code: County:
Telephone: Contact Person:
Standard Industrial Code(s) SIC, which describes commercial facility:
F. HEAT PUMP CONTRACTOR DATArr
Name: 6 'tra 1 14f e, G [ =, L�
Address
City: ' sDl'- State: Zip Coder County: •ws
Telephone: loContact Person: 1 ; "Ez,
G. CONSTRUCTION DATA (check one)
(I)
(2)
(3)
NOTE:
EXISTING WELL(S) being proposed for use as a ground -coupled heat pump
well(s). Provide the information in (I) through (3) 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 (3) below as PROPOSED
construction specifications. Submit. Form GW-1 after construction.
Well Drilling Contractor's Narne:►�AJ]^�tY+
NC Contractor Certification number:Gf
Date to be constructed: Number of borings:
Approximate depth of each boring (feet): Z66 1P
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 toga 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):
Xaround closed loop piping; fmm V to 7,66 (feet).
around well casing; from to (feet).
THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA roR EJ I R F.7CISTWG OR
PROPOSED WELLS TF TTM INFORMATION IS UNAVAILABLE BY OTHER MEANS.
Ver.3101 GWIMC-57 CL. Page 2 of

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I.
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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.
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).
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
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 ail related appurtenances in
accordance with the approved specifications and conditions of the Permit"
(Signature of Well Owner or A-othorized Agent)
If authorized agent is acting on behalf ojthe well owner,
please supply a letter signed by the owner
authorizing the above agent.
Ver.3/01 GWIMC-57 CL Page 3 of 4

L. CONSENT OF PROPERTY OWNER (Owner means any person who holds the fee or other property
Tights 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:
U1C Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
ver.3101 GWUC-57 CL Page 4 of

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