WI0800143_GEO THERMAL_20070518

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
May 18, 2007
Robert & Rebecca Johnson
IO I Len South Drive
Jacksonville, NC 28546
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Injection Water Only GSHP Well System (5QW)
Permit No. WI0800143
Robert & Rebecca Johnson SFR
Onslow County
Dear Mr. & Mrs. Johnson:
In accordance with the application submitted to the Underground Injection Control (UIC) Program that
was received on May 16, 2007, the Aquifer Protection Section (APS) acknowledges your intent to
construct a closed-loop geothermal water-only injection well system for the operation of a ground~source
heat pump. This system is located at 101 Len South Drive in Jacksonville, North Carolina.
This system is deemed permitted by rule (North Carolina Administrative Code Title 15A, Subchapter 2C,
Section .021 l(u)(2)). However, it is recommended that you contact the Onslow 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
[e-mail] if you have any questions regarding geothermal heating or injection well rules and
regulations.
Enclosures
cc: Wilmington Regional Office -APS
APS Central Files -Permit No. WI0800143
Aquifer Protection Section
Internet: www.ncwaterguality.org
1636 Mail Service Center
Location: 2728 Capital Boulevard
Sincerely,
~W,-2---
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:
N]fthCarolina ;vaturally
[phone]
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Permit Number W10800143
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Wei) System (5QW)
Primary Reviewer
jesse.wiseman
Permitted Flow
Facility Name
Robert & Rebecca Johnson SFR
Location Address
101 Len S Dr
Jacksonville NC 28546
Cenlral Files: AP5 SWf
05/21/07
Permit Tracking Slip
Status
Project Type
In review
New Project
Version
Permit Classification
Individual
Permit Contact
Affiliation
Robert
Johnson
101 Len S Dr
Jacksonville
IBC 28545
MajorlMinor Region
Minor Wilmington
County
Onslow
Facility Contact Affiliation
Owner Name Owner Type
Individual
Robert Johnson Owner Affiliation
Robert Johnson
101 Len 5 ❑r
Jacksonville NC 28545
Scheduled
orig Issue App Received Craft Initiated Issuance Public Notice Issue Effective Expiration
05/16/07 - /61 0/10,
Rettulated Activities I
ouffall
Waterbody Name Stream Index Number Current Class Subbasin

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 %ith the provisions of NCAC Title i 5A: 02C.0200
Complete application and mail to address on the track page.
This is not the proper form to he used for injection wells in an open -loop geothermal syste.m.
Do not use this form for systems that circulate ariv substances other than water
TO. ❑IRECTOR, NORTH CAROLINA ❑IVISION OF WATER QUALITY
DATE: May 141 . 2007
A. 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 Constnwi And'Or Use A Well(s) For Injection With A Hear
Pwnp ,Svstem, should be completed.
B SYSTEM FLUID Will any additives be introduced to the systetn'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 Infection With A Dent
Pump .Vstem, should be completed.
1q0 K If no, then continue compacting this torm-
C PROPERTY OWNER
Name: Robert & .Becky 3ohnson -
Address 101 Len South Dr. -
City. Jacksonville State: NC_ Zip Code: 28546
County:Onslow Telephone:[phone]-5818
D. STATUS OF PROPERTY OWNER
Private: ._ Federal. _
State — Municipal.
G W-57 CL (Jan_ 2000)
Commercial;
Native American Lands:
Page 1 of 4

E. JOB (SITE) DATA
Name: same ----------Address: ----
City: State: NC Zip Code: County:_ ---
Telephone: Contact Person: _ ~ ___ _
F HEAT PUMP CONTRACTOR DATA
Name: Climate Control Heating & Coolin!! Co .. Inc ..
Address: 102 Middle St.
City: Jacksonville State: NC_ Zip Code: 28645 _ County: Onslow
Telephone: [phone] 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 (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 (4) below as PROPOSED
construction specifications. Submit Form GW-1 after construction.
(1) Well Drilling Contractor's Name: Co~a=s=tal~G~e~ot=h=ermal=~---------
NC Contractor Certification number: NC -2082 Sanford Sw.:..:....::.:ee=t1=·n:;[f~----------
Date to be constructed: June, 2007_ Number of borings: _5 ____ _
Approximate depth of each boring (feet):_200 __________ _
(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 of20 feet b.l.s .):
(a) Grout type: Cement __ Bentonite _x__ Other (specify) --------
(b) Grouted surface and grout depth (reference to land surface):
_x_ around closed loop piping; from _Jl_ to 200 (feet).
__ around well casing; from __ to __ (feet).
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR EITHER EXISTING OR
PROPOSED WELLS IF THIS INFORMATION IS UNAVAILABLE BY OTHER MEA..1'1S .
GW-57 CL (Jan, 2000) Page 2 of4
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout of the injcction equipment and e\-tenor piping/tubing
associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
1. LOCATION OF WELL(S) Attach two maps.
(1 t Include a site map (can be dra-wn) shoe??& 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 wvithin 200 feet of the ground -coupled heat pump well system. Label all features
clearly and include a north arrow.
t?) location Wrap referencing the site to two nearbv permanent reference points (such as roads,
sire ms 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 inquire 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 possibihit_v of fines
and imphsownent, 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 74-11"s of the Permit_'
(Signature of Well Owner or Authorized Agent)
If aullaorized agent is acting on behalf of the well owner.
please supply a feller signed by the owner
authorizing the above agent.
GW-57 CL (Ian, 2000) Page 3 of 4

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-57 CL
(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]
(Jan, 2000) Page 4 of 4
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