WI0800176_GEO THERMAL_20091119

Permit Number
Program Category
Ground Water
Permit Type
WI08001 76
Injection Water Only GSHP Well System (SOW)
Primary Reviewer
michael .rogers
Coastal SW Rule
Permitted Flow
Facilit,
Facility Name
Matthew Radack SFR
Location Address
6910 Finian Dr
Wilmington
Owner
Owner Name
Matthew
Dates/Events
NC 28409
Radack
Central Files: APS_ SWP_
11/19/09
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Matthew Radack
Owner
6910 Finian Dr
Wilmington
Major/Minor
Minor
NC
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Matthew Radack
Owner
6910 Finian Dr
Wilmington NC
28409
28409
Orig Issue
11/19/09
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
11/19/09
Expiration
11/16/09 11/19/09
Requlated Activities
Heat Pump Injection
Private residence, single family
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin
~A ;;-s-;,1'-__ _
NCDEMR
North Carolina Departmen t of Environment and Natural Reso urces
Division of Wa ter Qua li ty
Beverly Eave s Perdue
Governor
Matthew Radack
6910 Finian Dt.
Wilmington, NC 28409
Coleen H. Sull ins
Director
11 /19/2009
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0800176
6910 Finian Dr.
Wilmington, NC 28409
Dear Mr. Radack:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on
11/16/2009, 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 6910 Finian Drive, Wihnington,
New Hanover County, NC 28409. This system is deemed permitted by rule (North Carolina Admtnistrative 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 ad~itional
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].
~·~
for Mic::f&ogers
Environmental Specialist
GPU-Aquifer Protec~ion Section
cc: Wilmington Regional Office -APS
APS Central Files -Permit No. WI0800176
New Hanover County Health Dept.
Jim Cornette (Applied Resource Management, P .C., P.O. Box 882, Hampstead, NC 28443)
Chris James (Taylors Heating & Air, P.O. Box 826, Carolina Beach, NC 28428)
AQUIFER PROTECTION SECT!ON
1636 Mai! Service Center. Raleigh , North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] i FAX 1: 919-715-0588: FAX2: 919-715-6048 I Customer Service: 1-877-623-6748
Internet: www.ncwate ra uality.oro
An Equal Opportunity\ Affirmative Aciion Employer
No~i..c . 01u1 arolma
/vaturaltu
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- W WELLS)
1n 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 Type information),
DATE: November 12. 2009
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 -loofa )?
Yes X Continue completing this forth.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -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 OWNERS)/APPLICANT(S)
B.
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): Matthew Radack
(1) Mailing Address: 6910 Finian Drive
City: Wilmington State: NC Zip Code: 28409 County: New Hanover
Home/Office Tele No.: 910-793-9236 Cell No.:
Email Address:
Website:
(2) Physical Address of Well Site (if different than above):
City.
Hume/Office Tele No.:
State: Zip Code:
County:
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:
Office Tele No.:
State: Zip Code:
Website Address of Company, if any:
County:
Cell No.:
1. GPtU/LiTC 5QW Notification of Intent Form (Revised 8/2008) a i' = Page

C. WELL DRILLER INFORMATION
Company Name: A pp lied Resource Manag_ement. P.C.
Well Driller Contractor's Name: _H_. M_ic_h_a_el_S_a~g_e ________________ _
NC Contractor Certification No.: 2531-A
Contact Person-'-: ""'J=im=-=C'-"o=rn=e=tt=e __________ =E=MA==I=L'-'A==dd=r=e=ss=: -"J=im=--A==RM=®=t =b=el=ls"""o=u=th=.n=e=t __
Address: ---=-P~.O'-'.-=B'-'o=x~8'-'8=2~--------------------------
City: Ham pstead Zip Code: 28443 County: ---=-P~e=n~de-'-r ________ _
Office Tele No.: 910-270-2919 Cell No.: 910-512-4890
D. HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: ___ T~a ___ y~lo=r=s=H=e=a=ti=ng=&'-'A~ir ____________________ _
Contact Person_: _C_hr_i_s_J_am_es ___________ E_MA_I_L_A~dd-'-r~e~ss~=-----------
Address: ---=-P"""'.O'-'.-=B'-'o=x,....,8=-=2=6 _______________________ _
City: Carolina Beach Zip Code: 28428 County: --""'"N"""e""'"w~H=an=o"""v"""e"'"r ______ _
Office Tele No.: 910-458-5732
E. STATUS OF APPLICANT
Private: ____x_
State:
Federal:
Municipal: __
Cell No.: -----------
Commercial:
Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed loo p geothermal s ystem. Water onl y. grouted alon g the loo p's entiretv
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: 11/23/2009 Number of borings: -~5 ___ _
Approximate depth of each boring (feet): ____ 2~0~0_' _
(2) Type of tubing to be used (copper, PVC, etc): __ H_D_P_E ______ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes.!!! (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 X
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement __ Bentonite Other (specify) Thermex
(b) Grout placement: Pumping __ Pressure_X~ Other
(c) Grout depth of tubing (reference to land surface): from 0 to 200 (feet)
If well has casing, indicate grout depth: from to (feet)
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page2
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.
LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) include a Site Map (can be drawn) showing: buildings, property tines, 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. babel 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 constrict, operate, maintain, repair, and if applicable, abandon the injection welt and
all related appurtenances in accordance with tlle approved specificati s Tonditions of the Permit."
Signature ofProperty Owner/Applicant
. IV �- I +�V W C' (2�
Print or Type Full Name and title
Signature of Property own erlApplicant
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 EGE}ED 1 D+1R f DVK1
1636 Mail Service Center Aquiii2, pmtariop 8#►:I,*p
Raleigh, NC 27699-1636 NOV 10 2009
Telephone [phone]
GPUfUIC 5QW Notification of Went Form (Revised 8/2008) PBe 3

Finian Drive
Approximate Property Lines
Approximate Building Perimeter
Approximate Closed Loop Locations
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services.
2. Well locations are approximate and will be a minimum of 20' ❑part and 25' from the building.
3. Adapted from Google Earth and New Hanover County GIS Map, November 2009.
TITLE: SITE MAP FIGURE:
7 clfed Resource Marta ement r'C 6910 FINIAN DRIVE
kF-P.0. oxmps .OB: SCALE: DATE: DRAWN BY:
10) 270-2919 FAX [phone] Radack As Shown 1 1 1 /10/09 DNH

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Approximate Property Lines
Approximate Building Perimeter
Approximate Closed Loop Locations
Notes:
1. subject property and surrounding area are serviced by public sewer and water services.
2. Well locations are approximate and will be a minimum of 20' apart and 25' from the building.
3. Adapted from Googie Earth and New Hanover County GIs Map, November 2009.
TITLE: SITE MAP FIGURE:
lied Re9our�e Management f C 6910 FINIAN DRIVE
7k,P.O.Hampstead,JOB: SCALE: DATE: DRAWN BY:
910) 270-2919 FAX [phone] Radack As Shown 1 1 / 10/09 DNH

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