WI0800173_GEO THERMAL_20090924

-Perm~_Num~r L-WI0800173 /
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (SQW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
Graylyn Terrace
Location Address~
3214 Graylyn Ter
Wilmington
Owner
Owner Name
Martin
Dates/Events
NC 28411
Wade Allen
Central Files: APS_ SWP_
09/24/09
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Martin Wade Allen
Owner
3214 Graylyn Ter
Wilmington NC
Major/Minor
Minor
Region
Wilmington
County
New Hanover
. Facility Contact Affiliation
OwnerType
Individual
Owner Affiliation
Martin Wade Allen
Owner
3214 Graylyn Ter
Wilmington NC
28411
28411
Orig Issue
09/24/09
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
09/24/09
Effective
09/24/09
Expiration
09/22/09
Re g ulated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
HA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue
Governor
Martin Allen
Katherine Allen
3214 Graylyn Terrace
Wilmington, NC 28411
Coleen H. Sullins
Director
9/24/2009
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0800173
3214 Graylyn Terrace
Wilmington, NC 28411
Dear Mr. & Mrs. Allen:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (UlC) Program that was received on
09/22/2009, 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 3214 Graylyn Terrace, Wilmington,
New Hanover County, NC 28411. 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].
~{~Ro~ ~o{W,o
cc: Wilmington Regional Office -APS
APS Central Files -Permit No. WI0800173
New Hanover County Health Dept.
Environmental Specialist
GPU-Aquifer Protection Section
Nate Carr (O'Brien Heating and Air, 3308 Enterprise Dr., Wilmington, NC 28405)
James Cornette (Applied Resource Management, P.C., P .O. Box 882, Hampstead, NC 28443)
AQUIFER PROTECTION SECTIOf~
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] I FAX 1: 919-715-0588; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opporiur:·; \ Affirmative Action Employer
None.IC l' ort1 arouna
J\Jaturat/11
NORTH CAROLiNA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELL{S'I
In Accordance with the provisions ofNCAC Title I5A. 02C.0200, please
complete this notification and mail to address on the back }gage (please Print or Type information).
DATE: J }.! 2007
Weil Type Confirmation: Does the proposed system circulate potable water on1% (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop i?
Yes -,X— Continue completing this form_
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well iniergin potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWN)ER(S)IAPPLICANT(S)
List eac Property Owner listed on property deed (if owM�of
abusiness orgovernment agefncy, state name cif
entity and a representative wlauthority farsignature): a6 p2aiT e?
(1) Wailing Address, 0,gel _(jrn�z Lt,7 lrel-a GQ•
City: Wljft StaIte:� Zip Code: Zxz County: I��is1
Home/Office Te No.: 55 3 Cell No.: 0- 5r G
Email Address: Website:
(2) Physical Address of Well Site (if different than above):
City:
Home/Office Tele No.:
State: Zip Code:
Cell No.:
County:
H. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the popery owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City:
State: Zip Code:
bounty:
Office Teie No.: Cell No_:
Wrbsite Address of Company, if any:
G P U U I C SQW NokificaGon aftn[Eut Form tltevised 8/2008)
RECEIVED i DENR I DWQ
Aquiffr Protedion Section
SEP 2 2 Z009
Page 1

C.
E.
F.
WELL DRILLER INFORMATION
Company Name: �1
Well Driller Contractor s Name: ll
NC Contractor Certification No.:
7
Contact Person. � &W.5_ L.Pl �T�— EMAAJL_Address:
Address-,
City: ArrsAkacer _ Zip Cade; IV County:
Office TeleNo-: jjo -,2V:j/ Celt No.: q10
HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company
r,
Contact Person: 1 V14�c atr, _ j EMAIL. Address: Cja k DCX ► V7 . C& -,
Address- - S309 61-76-rr _ jDr . _ —
City, 11i'+zrn Zip Code: 2,N4S'— County: A)g W 1eyI e,!
Office Tele No.:9�0 - �9q - C r� Cell No.: I / a -- 4/1/ 3 - --724
STATUS OF APPLICANT
Private: X Federal:
State:
Municipal:
Commercial:
Native American lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
CC.
G. WELL CONSTRUCTION DATA
(I) Proposed date to be constructed: Number of borings:
i
Approximate depth of each baring (feet): 2.0b
(2) Type of tubing to be. used (copper, PVC, etc): )j V PE _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes at (b.) No below)
(a) Yes if yes, then provide casing information below
Type: _____,galvanized steel black steel Plastic other (specify)
Casing depth: From to feet (reference to land surface)
Casing extends to above ground inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite Other (specify)
(b) Grout placement. Pumping Pressure Other
(c) Grout depth of tubing (reference to land surface): from U to �Qp (feet)
If weIl has casing, indicate grout depth: from to (feet)
GPUAM 5QW NotiRcafion of Intent Fom (Revised 8/2008) Page 2

H. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(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 geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and aH 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 injection well and
all related appurtenances in accordance with the approved specifications and conditions of the Permit." ~.a~
Signature of Property Owner/Applicant
K½ -\-t,\e. V1. \A€_ ~ \ \f-½., -i:)u.J V\~
~~4:;VJ /41£
S(gnatureo.Property{)wner/ Applicant
1"1 1{.ck-1 lt)J L 4-0&t-ZJw~
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENRuDWQ
Aquifer Protection Section-VIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone (919) 715u6935 RECEIVED/ DENR / owa
Aquifer Protection Section
GPU/UIC 5QW Notification oflntent Fonn (Revised 8/2008) SEP 2 2 2009 Page3
New Hanover County
Page I of I
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R-041e PARIa; R04415-014-012-600 Sales CURRENT RECORD
ALLEN KATHERINE G MARTIN W 3214 GRAYLYN TER
i of 1
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Data Copyri9ht New Hahover Canty [Dbdaimerj [PrivecY Pallcy] last Updated' 14 5ap 2009
7 5rte Design Copyright 1999-20W Akanda Group LLC. All dght5 re5crved.
s
htLp.//etax.nhcgov.corn/Forms/MapDatalet.aspx?slndex=0&idx=l &LMparent=20
9117i 2009

4..
Approximate Well Locations
Approximate Property Line
Approximate House Perimeter
Approximate Sewer Line
Zu-
s
(Votes:
1. Subject property and surrounding area are serviced by public sewer and water services.
2. Wells will be drilled 20' apart.
N
Adapted from New Hanover County GIS Map, September 2009.
TITLE: FIGURE:
SITE VICINITY MAP
vied source Manaa=rnt PC
riampftw, N Baas JOB: SCALE: DATE: 'DRAWN BY:
I91o12vo-2919FAx [phone] WW 1" = ---70' 09/17/09 DIVH

Ro gers, Michael
From:
Sent:
To:
Subject:
Attachments:
Mr. Rogers,
Diana Helias [[e-mail]]
Tuesday, September 22, 2009 11 :53 AM
Rogers, Michael
Type 5-QW Notice
Graylyn Terrace Geothermal.pdf
Please find attached to this message, a Notice of Intent for a geothermal loop system in Wilmington. Please let me know
if you need further information.
Thank you,
Diana Helias
Project Coordinator
Applied Resource Management, P.C.
WWW .ARM-PC .com
ARM's Waterworks
www.WaterWorksWells .com
910.270.2919
910.270.2988 Fax
P.O. Box 882
Hampstead, North Carolina 28443
1
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED-LOOP GEOTHERMAL
WATER-ONLY INJECTION WELL SYSTEM:
TYPE 5-QW WELL (S)
In Accordance with the provisions ofNCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Print or~ information).
DATE: :!tpk,nbv: J..I , 20J2!J_
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed-loo p)?
Yes _:j.___ Continue completing this form.
No ___ Do Not complete this form. Complete other UIC application forms for installing
either a SA 7 well ( open-loop well injecting potable water into the aquifer) or a SQM well ( closed-
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)/APPLICANT(S)
List each Property Owner listed on property deed (if owned bt a business or government agency, state name of
entity and a representative w/authority for signature): K.athU1/J l and tna1t117 Al/-Gn
(I) Mailing Address: 3 JJL/ CJ my f yr, Te..«a CL
City: UJ, /ni ,14ha St8'e:i'\J C. Zip Code: 2 3l/ // County: NtMJ l/4111Vu
Home/Office Te No.: 'U o ... ~8/p -?: ss 3 Cell No.: q;o --sza-1. J r, 3
Email Address: _________ W"-'-"-eb=s=it=e'-: ____________ _
(2) Physical Address of Well Site (if different than above): ______________ _
City: _________ State: __ Zip Code: ______ County: _____ _
Home/Office Tele No.: ___________ _;:C=-=e=ll'-"N..:..:o=.,_: __________ _
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name: _____________________________ _
Contact Person.-'-: --------------=E=MA=I=Lc.aA..:cd=d=re=s=s,_: __________ _
Address: ________________________________ _
City: _________ State: __ ZipCode: ______ County: _______ _
Office Tele No.: Cell No.:
Website Address of Company, if any: RECEIVED I DENR / DWO Aquifer Protection Section
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) SEP 2 4 2009 Pagel
C.
Ltd
E.
F.
WELL DRILLER INFORMATION
Company Name: A ml, Q
Well Driller Contractor's Name: J
NC Contractor Certification No.. -
Contact Person: EMAIL Address. ;:)rim— AC01 _ • Ad-
Address- Address: T o , c 892
City: --temp �G� Zip Cod+
Office Tele No.:�1%a
: N C County el
Cell No.:
HEAT PUMP CONTRACTOR 1 FORMATION (if different than driller)
^ 1. I r I A '
Company Narne:
r
Contact Person: Mom[ Ca fr J EMAIL Address-.
Address: 3308! 67krm it ►Pr. .
City: W i lm on Zip Code: �4� County:
Office Tele No_. WO ` 7?1 ' 641 / Ceti No.: 72e)
STATUS OF APPLICANT
Private: X Federal:
C • MI -M.-I
State: Municipal: Native American Lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
cc. .
�I0Jr1:� 1I:ZiIy lil��►i7VIM
(1) Proposed date to be constructed: 3bg Number of borings: 3
Approximate depth of each boring (feet): �QD
(2) Type of tubing to be used (capper, PVC, etc):
(3) Well casing. Is the well(s) cased? (check either (a_) Yes or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: ____galvanized steel black steel Vlastic other (specify)
Casing depth: From to
Casing extends to above ground
(b) No
feet (reference to land surface)
inches
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite Other (specify)
(b) Grout placement: Pumping_ Pressure Other
(c) Grout depth of tubing (reference to land surface); from D to 200 (feet)
If well has casing, indicate grout depth: from to (feet)
GPUIUIC 5QW Notification of Intent Form (Revised 0008) Page 2

H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification 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 copies of maps showing the following information:
(I) Include a Site Map (can be drawn) snowing: buildings, property lines, surface water bodies, potential
sources of groundwater contarnination 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 geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
L CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"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 lines and imprisonment, for submitting
false information. l agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conditions of the Permit."
LL-
Signature of Property Owner/Applicant
K\- - QSW VkW
Print or Type Full Name and title
Signature or' roperty Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please retum two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone] RECEIVED / DENR 1 DWQ
Aquifer Protedion Sect*n
SEP 24 200q
UPU[UIC SQW Notification of Intent Fomt (Revised VMS) Page 3

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PARID:R04415-014-012-000
ALLEN KATHERINE G MARTIN W 3214 GRAYLYN TER CURRENT RECORD
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (NCDENR)
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERXiiL
WATER -ONLY INJECTION WELL SYSTEM:
TYPE 5-QW, WELL(S�
In Accordance with the provisions of NCAC Title 15A: 02C,0200, please
complete this notification and mail to address on the back page (please Print or lype information).
DATE: Z 2001
Weft 7, pe Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (ix,
closed-tooy)?
Yes _ Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (oven -loop well injecting potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative wlauthority for signature): _ 2AUJI) e an V/ ■`I al&7
(1) Mailings Address; J
W G� .1
City: 11m, State: G .— Zip Code_County: Alue
HomelOffice Te Na.: _ ��� k& —F 51.3 p _Cell No., -r /U - s 26 —j 2 6 3
Email Address: Website:
(2) Physical Address of Well Site (if different than above):
City:
Home/Office Tele No.:
State: Zip Code:
County:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City: State: Zip Code:
County:
Office Tele No.: Cell No_:
Website Address of Company, if any: AW- er Proteftn Scion
it
SE P 2 4 2009
GPUIUIC 5QW Natification of Intent Form (Revised MOOS) Page

C. WELL DRILLER INFORMATION
Company blame: A—❑0h e xesaKLi i"w-4
Well canner Contractor s Name. _ I L Q e
NC Contractor Certification No.: -253114
Contact Person: :IaMLS EMAIL Address: VA On—
Address: T o,(3ax 992
City: ham as k-a d Zip Coder County: ?e 11
Office Teie No.: 110 - I Cell No.: f{89,
D. HEAT PUMP CONTRACTOR I FORMATION (if different than driller)
Company Name: -- ff
Contact Person�6'K can ' _ EMAIL Address: Q f!. [X ito &kj g , coop.,
Address: 5309 !�044-Ai S-L PC
City: W t i t n _ — — Zip Code: County: A)e W Ad
Office Tele No.: C��vtrp// Cel] No.: 91 D - 4(E{ 3 ­
E,
F.
STATUS OF APPLICANT
Private: /1 Federal:
Commercial:
State: Municipal: Native American Lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: J& 3 L09 Number of borings:
Approximate depth of each boring (feet):2i_ —
(2) Type of tubing to be used (copper, PVC, etc): HPPE— —
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: __--galvanized steel black steei_____plastic other (specify)
Casing depth: From _to feet (reference to land surface)
Casing extends to above ground inches
(b) No
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite
(b) Grout placement: Pumping_ Pressure
(c) Grout depth of tubing (reference to land surface): from
If well has casing, indicate grout depth.: from
6C.. .
Other (specify) 11�_
Other
_ to 200 (feet)
to — (feet)
GPU/UIC 5QW Notification of Intent Form [Revised 8/2008) Page 2

H. INJECTION-RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(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 geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must be signed by each person appearing on the
recorded legal property deed.
"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 injection well and
all related appurtenances in accordance with th.e approved specifications and conditions of the Permit."
~.G~
Signature of Property Owner/Applicant
~4 -\--V\e.vl\.A.e_ M\\½ -()u.J\.t\.~ Pri:::4~~J dm
S(gnatureo,Property0wner/Applicant
"'1 d ,--1~ w~-1(_, A-0£A-?Jw,Jt-
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
GPU/UIC 5QW Notification oflntent Fonn (Revised 8/2008)
RECEIVED/ DENR / DWQ
Aquifer Protection Section
SEP 2 4 2009
Page 3
view Hanover County
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profTe FARM, 904415-01"12-000
ALUN KATHERINE G MARTIN W
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3214 GRAYLYN TER CURRENT RECORD
tail
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a' -
Approximate Well Locations
Approximate Property Line
AnnrnAmntP Nn iGP PArimf:�,tpr