WI0800113_GEO THERMAL_20040513

MEMORANDUM
DIVISION OF WATER QUALITY
GROUNDWATER SECTION
May 13, 2004
To: Charles Stehman, Regional Groundwater Supervisor
Groundwater Section
Wilmington Regional Office
From: Thomas Slusser -ff~
Central Office
Re: Receipt of Notification for a Closed-Loop Geothermal Water-Only Injection Well
System. (Type 5QW.):
Mr. Arthur Williams at 1214 Hendricks Avenue in Onslow County, has filed a NOTIFICATION OF
INTENT To CONSTRUCT AND OPERATE A CLOSED-LOOP, WATER ONL Y INJECTION WELL SYSTEM FOR
A GEOTHERMAL HEAT PUMP (TYPE 5QW INJECTION WELL). 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
WI-o<ZOO!L3
Michael F. Easley, Governor
William G. Russ Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of Water Quality
May 13, 2004
Arthur Williams
1214 Hendricks Avenue
Jacksonville, NC 28540
RE: Notification of intent to construct Type 5QW injection wells
Dear Mr. Williams:
In accordance with the notification you submitted to the [.TIC Program elated May 10, 2004, the
Groundwater Section acknowledges your intent to construct 5 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.0211(u)(2)) and will not require an injection well permit from the state. However, 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 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 Stehman, Regional Groundwater Supervisor
Wilmington Regional Office
UIC-CO files
Sincerely,
eTj'� Aa4��4 �
Thomas Slusser
Hydrogeological Technician Il
Underground injection Control Program
N. C. Division of Water Quality 1 GroundwaterSoction
1636 Mai Service Center Raleigh, N.C. 27699.1636 Customer Service
Phone: [phone] Fax: [phone] Internet: httpJ/gw.chnr.state.nc.us 1-877-6Z3-6748

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 system.
Do not use this form for systems that circulate any substances other than water.
TO: DIRECTOR, NORTH CAROLINA DMSION OF WATER QUALfiY
DATE: .-.�-- I O , 20d?f
A" SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES X If yes, then continue completing this form.
NO If no, do not complete this form. Form GW-57 HP, Application For
Permit To Co n s tru c t A ndlOr Use A We11(y) For Injection Wile 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 h'or
Permit To Constn4ct And/Or Us A We11(s) Far Injection With A Heal
Pump System, should be completed.
NO X. If no, then continue completing this form.
C. PROPERTY OWNER c�
Name: t�� s r 1►�h"+- �'
Address: Z e Pre i r- kS C— +
;� Ui City: c Sd nJsrs l State: Afc—Zi Code: J '
by-' County: s Telephone:
D. STATUS OF PROPERTY OWNER
crt
Private: K Federal: Commercial.
State: Municipal: Native American Lands:
Ver.3101 GWIMC-57CI. /'age I af4
T A4(e'l N�
�1• ,e tl

E. JOB (SITE) DATA
(Fill out ONLY if the S ws 0► er is Federal, State, Municipal or Commercial).
NamC of Business or F 11
Address:
City: Late: Zip Code: County: -
Telephone: Contact Person:
Standard Indu Code(s), SIC, which describes commercial facility:
F. HEAT PUMP CONTRACTOR DATA
Name: Climate Control Heating c$ CoolintCo.. Inc. - --
Address: 102 Middle Street
City: Jacksonville - - State: NC _ _ _ Zip Code: 28546 County: Onslow
Telephone: 191_ 0) 353.9040 Contact Person: Michael Hadle.
G. CONSTRUCTION DATA (check one)
EXISTING WELL(S) being propose for use as a ground -coupled heat pump
well(s). Provide the information in (1) through (4) below to the hest of your
knowledge. Attach a copy of Form GW-1 (Well Construction Record) if available.
_x PROPOSED WELL(S) to be constructed for use as a ground�oupled 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: Sanford L. 5wecu%- _
NC Contractor Certification number Iys�2082
4— Date to be constructed: 3 ` i.��'1� Number of borings:
Approximate depth of each boring (feet): r
(2) Well casing. Is the well(s) cased?
(a) YES If yes, then provide the casing information below.
Type: Galvanized steel Slack 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.I.s.):
(a) Grout type: Cement Bentonde X Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
X around closed loop Piping; from 4 to 200 (feet).
around well casing; from to (feet).
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EF WR F_X1STTNU OR
PROPOSED WELLS IT ITUS INFORMATION is 'UNAVAILABLE $Y OTHER MEANS.
Ver-3101 GW/LJIC-37CL Page 2 of 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.
(I) 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 pennanent 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) Haz.ardous 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-source heat pump system and all related appurtenances in accordance
with the approved specifications and conditions
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-57CL Page 3 of 4
L. CONSENT OF PROPER1Y OWNER (Owner means any person who holds the fee or other property
Ver.3/01
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 (fitle 15A NCAC 2C .0200)
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-57CL Page4 of4
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