WI0800141_GEO THERMAL_20070309

Michael F. Easley. Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
March 9, 2007
Rick Wetherill
1 814 Azalea Drive
Wilmington, NC 28403
Subject: Acknowledgement of Intent to Construct Type SQW Injection Well System
Injection Water Only GSHP Well System (SQW)
Deemed Permit No. WI0800141
Rick Wetherill SFR
New Hanover County
Dear Mr. Wetherill:
In accordance with the application submitted to the Underground Injection Control (UIC) Program which
was received on March 8, 2007, the Aquifer Protection Section (APS) acknowledges your intent to
construct a closed-loop geothermal water-onl y injection well system for the operation of a ground-source
heat pump. This system is located at 1814 Azalea Dr in Wilmington, North Carolina.
This system is deemed p_ermitted by rule (North Carolina Administrative Code Title 15A, Subchapter 2C,
Section .021 l(u)(2)) and will not require an injection well permit from the State. It is recommended that
you contact the New Hanover County Health Department, as 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 APS to verify compliance with applicable rules.
Thank you for submitting this notification. Please call Qu Qi at [phone], or email him at
g u.g i@ ncmail.net if you have any questions regarding geothermal heating or injection well rules and
regulations.
Enclosures
cc: Wilmington Regional Office -APS
i\PS Cc:mral Fiks -Dc..:mcd Permit No. Wl08001 41
Aquifer Protection Section
Internet: www .ncwaterguali ty .org
1636 Mail Service Center
Location: 2728 Capital Boulevard
Sincerely,
Jesse Wiseman
Aquifer Protection Section
Raleigh, NC 27699-1636
Raleigh, NC 27604
Telephone:
Fax I:
Fax2:
An Equal Opportunity/Affirmative Action Employer-50% Recycled/10% Post Consumer Paper Customer Service:
Ni"ithCarolina
Jvaturnf/y
[phone]
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(9 I 9) 7 I 5-6048
[phone]
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 ofNCAC Title 15A: 02C.4200
Complete application and mail to address on the back page.
This is not the propel form to be used for injection wells in an open -loon geothermal system.
Do not use this form for systems that circulate any substances other than water.
TO: DIRECTOR., NORTH CAROL NA DIVISION OF WATER QUALITY
GATE: r 2007
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, theta continue completing this form.
NO If no, do not complete this form, Form GW-57 HP, Applicaiton For
Pe»nit To Construct And1Or Use A Well(s) For Injection With A Rea!
Pump, 'ystem, 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 l-1P, Appliration For
Permit To Construct And1Or Use A Well(s) For b jection With A Heat
Pump Svstein, should be completed.
NO If no, then continue completing this form.
C. PROPERTY OWNER
Name: fic� late.
Address: 1814 j l Ve-
City: i t ►A r State: KC Zip Code: 2-814
County: Reid Telephone:
D, STATUS OF PROPERTY OWNER
Private: Federal: Commercial:
State: Municipal: Native American lands:
Revised 5105 GW/UIC-57 CL Page I of

E.
F.
FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of Business or Facility: --.t\.l-",t---4-------------------1'4/ Address: ---:-----------"----L--------------------
City: _________ State: __ Zip Code: _____ County: ____ _
Telephone: __________ Contact Person :
Standard Industrial Code(s), SIC, which describes commercial facility: ________ _
HEAT PUMP CONTRACTOR DATA
Name: 'l> -~ '·e,p,,f~ Sf~\/iCe. <:.,o m.p ltrv Y
1
;r.,.re,
Address: 3 30 8 EM[E (?~ I$ fr ,o eNC.
City: f,JfWJ_f,,C{.&'IW_ State:~ Zip Code : LB ':-1:05 County: NtW ~ihJi::~
Telephone: fuoJ79cj.;'16 JI Contact Person: ~;Ji_1_,_l'Yt"""Ol~'f........=..W~t~t+l~fl-tn..,&L..C.C'""'"S..__ __ _
G. CONSTRUCTION DATA (check one) .
(1)
EXISTING WELL(S) being proposed for use as a ground-coupled heat pump
well(s). Provide the information in (1) through (3) below to the best of your
lmowledge. Attach a copy of Form GW-1 (Well 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 (3) below as PROPOSED
construction specifications , Submit Fann GW-1 after construction.
Well Drilling Contractor 's Name: SdJv±d rof. .s wee,:J--,,v c,
NC Contractor Certification number: o(O '8d----"'----'----------------
Date to be constructed: ~-/2-07 Number of borings: 7
~00 I Approximate depth of each boring (feet):. __ e;r-_______________ _
(2) Well casing: ls 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 of20 feet b.l.s.):
NOTE:
Revised 5(05
(a) Grout type: Cement__ Bentonite-1{_ Other (specify) _______ _
(b) Grouted surfaci:: and grout depth (reference to land surface):
~ around closed loop piping; from O to 2.DO (feet).
__ around well casing; from __ to __ · (feet).
THE WE LL DRILLING CONTRACTOR CA N SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEANS .
GW/UIC-57 CL Page 2 of4
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.
1, 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
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 imprisomnent, 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 specificatiand conditions of the Permit"
t
[U L b�i
(Signature of Well Owner or Authorized Agent)
ff authorized agent is acting on behalf'oj'the well owner,
please supply a letter sighed by the owner
authorizing the above agent.
Revised 5/05 G WIUIC-57 CL Page 3 of 4

L. CONSENT OF PROPERTY OWNED (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 shaII be
the responsibility of the applicant to ensure that the ground -source beat pump system's well(s)
conforrns to the Well Construction Standards (Title 15A NCAC 2C .0200)
(Signature Of Property Owner If Diffe -ent Frurn Applicant)
Please return two copies of the cotnpleted Application package to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mani Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Revised 5/05 GWIUIC-57 CL Pale 4 of 4

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Wilmington, NC 28403
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