WI0800185_GEO THERMAL_20100301

Permit Number
Program Category
Ground Water
Permit Type
;l0800185 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
NCDOT facility Barbados Blvd.
Location Address
5504 Barbados Blvd
Castle Hayne
Owner
Owner Name
NCDOT
Dates/Events
NC 28429
Orig Issue
03/01/10
App Received Draft Initiated
02/17/10
Re g ulated Activities
Heat Pump Injection
Outfall N; JLL
Scheduled
Issuance
Central Files : APS_ SWP_
03/01/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Jim Cornette
PO Box882
Hampstead NC
Major/Minor
Minor
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Anthony Roper
1501 Mail Service Ctr
Raleigh
Public Notice Issue
03/01/10
NC
Effective
03/01/10
28443
276991501
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
lt.tp.;t(A
.Q;*•~-1.
:;-;-; "-" '
NCDENR
Nort h Carolina Department of Environment and Natural Resources
Division of Wat er Quality
Beverly Eaves Perdue
Governor
Anthony Roper -Deputy Secretary
North Carolina Department of Transportation
1501 Mail Service Center
Raleigh, NC 27699-1501
Coleen H. Sullins
Directo r
3/1/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0800185
5504 Barbados Blvd ..
Castle Hayne, NC 28429
Dear Mr. !loper: ..
De e Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on 02/17/2010,
the Aquifer Protection Section (APS) acknowledges your intent to construct a closed-loop geothermal water-onh injection well
system for the operation of a ground-source heat pump located at 5504 Barbados Blvd., Castle Hayne, New Hanover County , NC
28429. This system is deemed permitted by rule (North Carolina Administrative Code Title 15A, Subchapter 2C, Section
.021 l(u)(2)). However, please note boreholes shall not connect separate aquifers, which have differences in water quality (e.g .,
shallow surficial aquifers, saprolite , fractured bedrock, etc.) as specified in 15A NCAC 2C .0213(d)(8)(C).
Please notify the Wilm ingto n Regional Office at (910) 79 6-i2 15at least 48 hours prior to well installation. Additionally, 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 inhi bitors ,
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].
:r~ ~c¼,JfO
foe Mkhae~e"
Environmental Specialist
GPU-Aquifer Protection Section
cc : Wilmington Regional Office -APS
A"PS Central File -Permi t . ·o . . &5'. --'-'-New Hanover County Health Dept.
Jim Cornette (Applied Resource Management, P.C., P.O. Box 882, Hampstead, NC 28443)
Boris Sosa (Robert H Williams Heating and Air Conditioning, 6730 Amsterdam Way, Wilmington, NC 28405)
AQUIFER PROTECTION SECTION
1636 Mail Service Cente r, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh. North Carolina 27604
Phone: [phone] FAX 1: 919-715-0588 ; FAX 2: 919-715-6048 \ Customer Service: 1-877-623-5748
Internet: www.ncwaterqu ality .org
An Equal Opportt:~)y \ Affirmaiive Action Employer
_One C 1. North-aroma
J\Jaturalllf
aDlg5
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 of NCAC Title 15A: 02C.0200, please
complete this notification and mail to address on the back page (please Pratt or Type information).
DATE: FebruarN 2. 20 10
A.
B.
Well Type ConfrrmXion: Does the proposed system circulate potable water onl" (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes X Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well o en -loop well in'et cting 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).
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): North Carolina De attment of Trans ortation
Attn-. Mr. Anthony Roper. De u(� Secretary for Administration and Business Devel❑ ment
(1) Mailing Address: 1501 Mail Service
City: Raleigh State: NC Zip Code: 27b99-1501County: Wake
Home/Office Tele No.: 919-733-2520 Cell No.:
Email Address: Website:
(2) Physical Address of Well Site (if different than above): 5504 Barbados Blvd
City; Castle Hai pie State: NC Zip Code: 28429 County:
Home/Office Tele No.: Cell No.:
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:
Address:
City:
State: Zip Code:
Io��riF.V1i►T%r1r= A
County;
Office Tele No.; Cell No.:
Website Address of Company, if any; NED 1 DENR E UM
Aquifer Prak%tian Section
GPUIUIC 5QW Nodfication of intent Form (Revised 812008) FEB 17 2010 Page t

C. WELL DRILLER INFORMATION
Company Name: A pp lied Resource ManaQ.ement. P.C.
Well Driller Contractor's Name: -'H='-'. Mc.c=ic=h=a=el~S=a=g=e ________________ _
NC Contractor Certification No.: 2531-A
Contact Person"-: -=-J1=· m=-=C=o=m=e=tt=e __________ =E=MA~I=L~A~dd=r~e=ss~: ~J=im=-A.-=.RM=(w-----"b-=-el=ls~o~u=th=·=ne~t __
Address: P.O. Box 882
City: Hampstead 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 driIJer)
Company Name: Robert H Williams Heating and Air Conditioning
Contact Person: Boris Sosa EMAIL Address: Bo34Mille @ ahoo.com
Address: 6730 Amsterdam Way
City: Wilmin gton Zip Code: 28405 County: ---=N-"e~w-'--'--H=an==ov~e=r ______ _
Office Tele No.: 910-313-1011 Cell No.: __________ _
E. STATUS OF APPLICANT
Private: Federal: Commercial:
State:_X~ Municipal: __ Native American Lands:
F. INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
Closed Loo p geothermal s ystem. Water onlv. Grouted along the loo p's entiretv.
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: 2/15/2010 Number of borings: __ 4~7 __ _
Approximate depth of each boring (feet): __ ~2=6~0' ______ _
(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 2!: (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) _T=h=e=rm=ex"'----
(b) Grout placement: Pumping__ Pressure Other
(c) Grout depth of tubing (reference to land surface): from O to 260 (feet)
If well has casing, indicate grout depth: from ___ to ____ (feet)
GPU/UIC 5QW Notification of Intent Fonn (Revised 8/2008) Page 2
IL VUEMON-RELATED EQUIPMENT
Ammh a diagram showing the engineenng layout (tr prOPI Wd matli#iuidion ref the tnjmrmn etimpnitw. and mic.nnr
riringitubing associated with The injeetinn operation 'Me manufactwer ti hrochure ,nav pra,vldc supplem- cmarl
iniivrMation
1. LOCATION OF WELLIS)
Attach two copies of maps showing the following information-.
l I Inchide a Site Map Iran ter draivn.! .showing: hmkllurrs, pIl7l,eity biw.s, +urtwe water lvOie-i. ]xllenllal
suul'c:es of groundwsIer ca,ntamitttltiim and the on en tan on of and distanc►t, betwekm the proposed wellts) and
cmv C-mA ng wull(s) or waste disposal 1'aciiitics such as septic tattlh or drain fields icx:ated within 2tk1 feet of
thv gvothramul hvia pump ucli srstun. Label all l atures cleurh, and include a norlb urrl_m
L 21 The Site Map stiuy-t :chow the subject props-rty in rolattim to the suttt,undirlg, atea by using at kart Wio tilwi
IvIcri t" lumng ui:li sn t.wads ,1ruMi,l, .sndmT ltlghwa;v intemt.ho
.1. CERTIFICATION
;Vote: This Permit Appliration must be signed h► aacIt jwmon appearing on tItc
retarded legal properti deed,
'I 11'UmbF CCIS IiR . utldcr ]nuall� of lau , tliut i hu\ c persunaiii e\amizle i sitla utsz i'aiu.iliai ,% ilh the iu:rztttt;ttiou
xutnnitlyd in this dtwumcni and all AMICllfrll-1tl:c then:tu and rh[IL b.Iscd tin my inquiry is]' lhuse individuak
immediately responsibIc for obtain np said information- 1 helieve that the information is True, acetate and complete
t am mmirI' Ih0l ItKlC KV AgUlIKAanT tkualltc.3, imludmv Itw ]xombility !ri ltrws anti tvillosonincrll 1,11 •t.+lttutlltng
false tnliormation 1 agree to construct, Llperate, maintain, repair. and if applicable, abandon bite. in jechtm „ell and
all rclalcd appurtenances in accordance with the approved �pt�cif cation and coalitions of the Pvm it.'
4tgnsturc1of Prate Owner:!! pplwant
Print or lype t t l Name and tiile r�
4lrP_.ltt1F�':rt'lei� 1'r � !,�ltt�ti_'�l�lr}rt'irT;3
Print trr T, pv Full Name and uric
Stftimtmt of A-2ttlt+l hell Aatllr iI bloc
Fiin+ to T-, pe FAT j4wizc wid uiiL�
Viemtic mtI.im Iwo copies of the compleled Application rarkage to
Nurtli Curulina DENR-MVQ
Aquifer Protection Section-UIC Program
1636 Mad Service Center
Raleigh, NC 276"-I6311
Telephone [phone]
[iPi t �K: SQA- NfadikTrrn of Interd Dorm ti h cued 9:24iUKI hdgs ..;
RECEFVED / DENR 1 DW'Q
AquNer Protection SeMor7
FEB 17 2010

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5504 BARBADOS BLV CURRENT RECORD
323108.88.9250.000
5504 BARBADOS BLV
CASTLE HAYNE
6200
GOV-Exempt Government
911-Governmental
46.2
B-2-BUSINESS DISTRICT
(46.64 AC) PT TRS 4 5 6 7 HUTAFF DIV & LT 7 ISLAND PARK
FD
NC STATE OF
RALEIGH
NC
27699
THE DATA IS FROM 2009
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Data Copyright New Hanover County [Disclaimer] [Privacy Policy] Last Updated: 08 Feb 2010
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http://etax.nhcgov.com/F orms/Datalets.aspx?idx=2&slndex=2 2/16/2010
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