WI0800155_GEO THERMAL_20080609

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Kt~EIVED I DENR / OWQ
AQUIFER"PROTFr.r,oN SECTION
JUN.~ezooa
Michael F. Easley, Go.vemor
William G . Ross Jr., Sec r etary
North Carolina Department of Environment and Natural Res o urces -.., P'\:==~~""<'
Debra Pressley
Vice President, Operations
Lower Cape Fear Hospice and Lifecare Center
1406 Physicians Drive
Wilmington, NC 28401
June 3, 2008
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
PermitNo. WI0800155
Lower Cape Fear Hospice and Lifecare Center SFR
1406 Physicians Drive
Wilmington, NC 28401
Dear Ms. Pressley:
Coleen H. Sullins Di r ector
Division of Water Q u ality
In accordance with the application submitted to the Underground Injection Control (UIC) Program that
was received on May 19, 2008, 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 located at the site referenced above. 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 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. If you have any questions please call me at [phone].
Enclosures
cc: Wilmington Regional Office -APS
APS Central Files -Permit No. WI080015 5
New Hanover County Health Dept
Brian Cox-T. A. Woods Heat Pump Contractors
Coastal Geothermal
Aquifer Protection Section
Internet: www .ncwaterguality.org
1636 Mail Service Center
Location : 2728 Capital Boulevard
~ ~
Michael Rogers .
Environmental Specialist
GPU-Aquifer Protection Section
Raleigh, NC 27699-1636
Raleigh, NC 27604
Telephone:
Fax!:
Fax2:
An Equal Opportunity/Affirmative Action Employer-50% Recycled/10% Post Consumer Paper Customer Service:
rfo"fthCaro Jina
;Natural/If
{919) 733-3221
[phone]
[phone]
[phone]
NC DEPARTMENT OF ENV & NATURAL RESOURCES
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
1636 MAIL SERVICE CENTER
RALEIGH NC 27699-1636
Coastal Geothermal
102 Middle Street
Cedar Point, NC 28584
NIX:tE.
$00.42Q
06l04r2CD8
Mailed ron 2'76U7
US POSTAGE
8i O!~/OIS/09
R~TURN TO SENDER
NO MAI~ REC~PTACLE
UNABLE TO FORWARO
Permit Number W10800155
Program Category
Ground Water
Permit Type
Injection Water Only G S H P Well System (5t4W)
Primary Reviewer
m ichaei. rogers
Permitted Flow
, -}IIP
Facility Name
Lower Cape Fear Hospice & Lifecare Center
Location Address
1406 Physicians Dr
Wilmington NC 28401
LVI 1E11
Owner Name
Lower Cape Fear Hospice & Lifecare Center
Central Files: APS SWP
0510 /08
Permit Tracking Slip
Status
Project Type
In review
New Project
Version
Permit Classification
Individual
Permit Contact Affiliation
Donna
Wilkes
1406 Physicians Dr
Cape Fear
NC 28401
MajorlMinor Region
Minor Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Unknown
Owner Affiliation
Debra Pressley, Operations President
V Ice
1406 Physicians Dr
Cape Fear NC 28401
Scheduled
Orig Issue App Recelvea Draft initiated Issuance Public Notice Issue Effective Expira[lan
0511 spas
Reouiated Activities
Heat Pump Injection
CGetfall NULL
Waterbody Name Stream Index Number Current Class Sudbasin

Michael F. Easicy, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins Director
Division of Water Quality
.tune 3, 2008
Debra Pressley
Vice President, Operations
Lower Cape Fear Hospice and Lifecare Center
1406 Physicians Drive
Wilmington, NC 28401
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. W10800155
Lower Cape Fear flospice and Lifecare Center SFR
1406 Physicians Drive
Wilmington, NC 28401
Dear Ms. Pressley:
In accordance with the application submitted to the Underground injection Control (U1C) Program that
was received on May 19, 2008, the Aquifer Protection Section (APS) acknowledges your intent to
construct a closed -loop geothermal water-onl% injection well system for the operation of a ground -source
heat pump located at the site referenced above. 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 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. If you have any questions please call me at [phone].
Enclosures
cc: Wilmington Regional Office - APS
APS Central Files - Permit No. WI0800155
New Hanover County Health Dept
Brian Cox — T. A. Woods Heat Pump Contractors
Coastal Geothermal
LC77
Michael Rogers
Environmental Specialist
GPU-Aquifer Protection Section
Sinoerel%
N� Carolina
,]�tamilil
Aquifer Protection Section 1636 Mail Service Center
Internet: tivww.newaseraualitv.org Lo ation; 2728 Capitol Boulevard
An Equal OpporluniVIAtlfrmstiYa Action Employer— 50% Recycled110% Post Consumer Paper
Raleigh, NC 27699-1636 Telephone: {919) 733-3221
Raleigh, NC 27604 Fax 1: [phone]
Fax 2: [phone]
Customer Service. [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 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 -loon ,geothermal system.
Do not use this form for systems that circulate any substances other than water.
TO: DIRECTOR, NORT=CA DIVISION OF WATER QUALITY
DATE2"
oti
A. SYSTEM CLASSIFICATION Does the proposed system circulate potable water in continuous
piping that completely isolates the fluid from the environment?
YES A If yes, then continue completing this form.
NO If no, do not complete this form. Form GW-57 HP, Application For
Permit To Coinstruct AndlOr Use A Well(s) 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 antiGeezes.
YES
NO
C. PROPERTY OWNER
Name: La oer-
Address:
City. rKi
County: w3
III
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 complete&
If no, then continue completing this irri.
STATUS OF PROPERTY OWNER
Private: Federal: _
State: Municipal.
Commercial: 4
Native Americans Lands:
Ver.3/01 GWMC-57 CL Page 1 of 4

E. FACILITY (SITE) DATA
(Fill out ONLY if the Status of Owner is Federal, State, Municipal or Commercial).
Name of B mess or F ility: LOW"- 'CPC '&$'r C 4r
Address:
City -Lod + +" AJ State: Ak_ Zip Code: 2 H81 Coun, ':/I% .i d rre r
Telephone: 1 6X� 4 Contact Person: _ e�+rA►,� 1�t7 r �KGS
Standard Industrial Code(s), SIC, which describes commercial facility.
F HEAT PUMP CONTRACTOR DATA
Narne:--r, A. AAMAS
Address: 1 r
City: i t i i►1 State: 1J"e- Zip Cade: S County:r+r
Telephone: 1161 - Contact Person: A ri 44 C_dX -
G. CONSTRUCTION DATA (check one)
EXISTING WELL(S) being proposed for use as a ground -coupled ]real pump
weil(s). Provide the information in (1) through (3) below to the best of your
knowledge. Attach a copy of Form GWA (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,-I after construction. 1
(1) Well Drilling Contractor's Name. -
NC Contractor Certification number: 2,0
-
Date to be constructed: �kN� Number of borings:
Approximate depth of each boring (feet): 25-a
(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
(3) Grout (grout the vertical length of the borehole to a minimurn depth of 20 feet b.l.s.):
(a) Grout type: Cement I3entonite �( Other (specify)
(b) Grouted surface and grout depth (reference to land surface):
around closed loop piping; from ❑ to (feet).
around well casing; from to (feet).
NOTE: THE WELL DRILLING CONTRACTOR CAN SUPPLY THE DATA FOR HrFHER E3L I WG OR
PROPOSED WELLS W TIIIS WORMATTON 15 UNAVAILABLE BY OTTIER MEANS.
Ver.3101 GWAAC-57 CL Page 2 of 4

REU1V[0; OENR1OWQ
A'7 JV_ R PP)Wf it of
H.
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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(&) or waste disposal facilities such as septic tanks
ordrain 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).
PERMITLIST: Attach a list of all permits or construction approvals that are related to the site.
Examples include:
(1) "azardous 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 all related appurtenances in
accordance with the approved specification>.Krsr? Ovditions of the Permit"
(Signature of Well owner or Autho ' .ed Agent)
2f authorized agent is acting on behcrlf o the wel1 owner,
please supply a letter signed by the owner
authorizing the above agent.
av� f st t- � "'n
D -ebra
2
Ver.3101 GWIt_IIC-57 Cl, Page 3 of 4

RECZD i DEINR! DWO
MAY $ 7 LUU8
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 ofcoatrary agreement in writing.)
Ifthe 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 small be
the responsibility of the applicant to ensure that the ground -source heat pump system's well(s)
conforms to the Well Construction Standards tNCAC_U�.0200}
r
(Signature Of Property Owner IfDi ' gentFmm Applicant)
Please return two copies of the completed Application package to:
UIC Program
Groundwater Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigli, NC 27699-1636
Telephone [phone]
Ver.3101 CMUC•57 Ci., Page 4 of

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1406 Physicians Dr
10 Wilmington, NC 28401
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DATE, TIME
FAX ND./NAME
DURATION
PAGE(S)
RESULT
MODE
TRANSMISSION VERIFICATION REPORT
06/04 09:23
94512251
00:03:15
10
DK
STANDARD
ECM
TIME 05/04/2008 09:25
NAME NCDE&NR/WATER QUAL
FAX [phone]
TEL [phone]
DATE,TIME
FAX NO./NAME
DURATION
PAGE(S)
RESULT
MODE
TRANSMISSION VERIFICATION REPORT
05/04 09:27
9180055515 71
00:03:14
10
OK
STANDARD
ECM
TIME 05/04/2008 09:30
NAME NCDE&NR/WATER QUAL
FAX [phone]
TEL [phone]