WI0800107_GEO THERMAL_20010412

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
April 12,2001
To: Charles Stehman, Ph. D., P.G. Groundwater Supervisor
Groundwater Section
Wilmington Regional Office
From: Mark Pritzl fiP~ [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 injection well.)
Notification to construct and operate a well for a closed-loop geothermal heat pump system has
been filed by David & Sheila Stone of Sneads Ferry, North Carolina and a copy of the
Notification is enclosed for your files. This 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: CO-UIC Files
Enclosures
Michael F. Easley
Governor
Williams G. Ross Jr., Secretary
Department of Environment and Natural Resources
April 1212001
David & Sheila Stone
711 Willbrook Circle
Sneads Ferry, NC 28460
Dear David & Sheila.
Kerr T. Stevens
Division of Water Quality
In accordance with the notification submitted on April 5, 2001; die Groundwater Section
acknowledges your intention to construct a closed -loon geothermal water-oiiv 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 Prit21
Hydrogeological Technician 1I
Underground Injection Control Program
cc: CO-UIC Files
WIRQ-UIC Files
Q*A
lit_ M!
Customer Service Division of Water Quality 1 Groundwater Section
1 800 623-7748 1636 Mail Service Center Raleigh, NO 27699-1636
Phone: [phone] Fax: [phone] Intemet: http:/1gw.ehnr.state.nc.u8

■
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSEWLOOP
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.
-0
This is not the proper form to be used for injection wells in an oWn_loon geothermal system_ rya
Do not use this form for systems that circulate any substances_ other than water. ••
N
TO:
A
lra
DIRECTD NORTH CAROLINA DIVISION OF WATER QUALITY
DATE: ri f f , 20 Of
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 Well(s) For h jection 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 X If no, then continue completing this form.
PROPERTY OWNER
Name: 4,+V;6( f` A e t /,#
Address: 7 /1 W- 1t ra a [ t r- a(t—
City:.SA64.4$ F51rr►1 State: Alc-- Zi Code: Z e*66
County: 0NJLy W Telephone: �Z7. 7191
STATUS OF PROPERTY OWNER
Private: X
State:
Federal: Commercial:
Municipal: Native American Lands:
GW-57 CL Gan, 2000) Page 7 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: _____________________ _
Address: ____________________________ _
City:. __________ State: __ Zip Code: ____ County: ____ _
Telephone: __________ Contact Person: ___________ _
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: (910 ) 353-9040
State: NC Zip Code: 28546 County: Onslow
Contact Person: Michael Hadley
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 (y'l/ ell 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 Form GW-1 after construction.
(1) Well Drilling Contractor's Name: =Sanf==o;;;..;rd;.:...L=..:....:. S::..,;w;.;...e=e==tin=· ::ca&.__ ________ _
NC Contractor Certification number: NC -2082
Date to be constructed: 1tttrJ...u ·l1=-.;·c..c=oc..,_l ....;;N=um-=:.=..._be_r _o_f _bo_nn_· -g-s: __ '/-___ _
,, dd , Approximate depth of each boring (feet):_1--______________ _
(2) 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 _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 i_ Other (specify) ______ _
(b) Grouted surface and grout depth (reference to land surface):
_x_ around closed loop piping; from ....!!_ to ..1!L (feet).
__ around well casing; from __ to __ (feet).
NOTE: TIIB WELL DRILUNG CONTRACTOR CAN SUPPLY THE DATA FOR Em--IER EXISTING OR
PROPOSED WELLS IF TiiIS INFORMATION IS UNAVAILABLE BY OTHER MEANS.
GW-57 CL (Jan, 2000) Page2of 4
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.
(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).
(3)
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
specifkations and conditions of the Permit~
_1____..ll::__-=----~-1,,~(l_i\.,_,,...._.,,__9"-J_._---___ _
GW-57 CL Gan, 2000)
(Signature of Well Owner or 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.
Page3of4
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-57CL
(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]
Gan, 2000) Page 4 of 4
North Carolina - Department of Environment and Natural Resources - Division of Water Quality • 6.-undwater Section
1636 Mail Service Center - Raleigh. N.C. 27699-1636-Phone {919) 733.3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITM
1. WELL USE (Check Applicabie eox): Resldentlal ❑ Municipal ❑ Industrial ❑ Agricuj turat El Monitoring ❑
Recovery ❑ Meat Pump Water Injection ❑ Other 0
II Other, List Use: Qe5e)
Ac3 fy�4 ovww
2. WELL LOCATID Show j etch he localion below)
Nearest Town: ounty:'
(Road Name and Nurnb Comm f ny, of Subdivision and Lot No.)
DRILLING LOG
DEPTH
3- OWNER � -F ` ice+ / , Ve__
711 Address !f
From To
t o al+on Description
I�yj'od
tees or H le o.
City or Town State Zip Code
` f
�V ,'l y
4. DATE DRILLED
5. TOTAL DEPTH �
�*�'.0
6. CUTTINGS COLLECTED YES ❑ NQ�g
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE
¢_ 0- O
_`�+' •. �, �� _
8, STATIC WATER LEVEL Below Top of Casing: FT.
(Use **'If Above Top of Casing)
9, TOP OF CASING IS FT. Above Land Surface'
'rap of casing terminated stlor below land surface requires a varlence in accor-
dance with 15A NCAC 2C .d1ld
1 p. YIELD (gpm): METHO❑ OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amounl
If additional space is needed use back of form
13. CASING: `
3z<t G+re,5ee- �C[�P
O[A �� trr+�t
j "ej
l
Wa�TTiicle ss
Depth
Diameter
or Welghl/Fl.
From
-To
Ft.
From
Tv
Ft.
From
To
Ft.
14. GROUT:
LOCATION SKETCH
alA� eAaT' (Show direction and distance from at least two Slate
Roads, or other map reference points)
,e ', G g
r Deplu
� ] o
0Ft.
Material Method + o
i 1
- - '
From
5..
.� T0
r-•�'rrC+{_'t�r,_,-r� r1ti', >�.
From
To
FL
_ 7 to' -ale
15. SCREEN:
1
Depth
Diameter Slot Size Material t -
From
To
Ft
in. in.
From
To
Ft.
In. in.
From
To
Ft,
in. In.
16, SANDIGRAVEL PACK:
Depth Size Malarial
From To Fi_
From To Ft.
17. REMARKS:
100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP F,TFi15/RECO PROVIDED TO THE WELL OWNER.
FOR DFF1Cf USE ONLY r 1 1
Ouad Na: ""
GNATURE of PERSON CONSTROCTING THE WELL DATE
Submit od ulal to Division of Water Duality, Grourndwater Section within 34 days
Serial No. GW-1 REV. 12/99
a
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