WI0800186_GEO THERMAL_20100326

RA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beveriy Eaves Perdue
Governor
James Williams
Vickie Williams
5441 Blue Clay Road
Castle Hayne, NC 28429
Coleen H. Sullins
Director
3i26/2010
Subject: Aclmowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WI0800186
5441 Blue.Clay Road
Castle Hayne, NC 28429
Dear Mr. & Mrs. Williams:
Dee Freeman
Secretary
In accordance with the application submitted to the Underground Injection Control (UIC) Program that was received on
3i10/2010, 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 5441 Blue Clay Road, 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, 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].
Sincerely, o~&-~
~1chael Rogers
cc: Wilmington Regional Office -APS
APS Central Files -Permit No. WI0800186
New Hanover County Health Dept.
Environmental Specialist
GPU-Aquifer Protection Section
Nate Care (O'Brien Heating & Air) 3308 Enterprise Drive, Wilmington, NC 28405
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Ra leigh, North Carolina 27699-1636
Location : 2728 Capital Boulevard , Rale igh . North Carolina 27604
Phone: [phone] \ FAX 1: 919-715-0588 ; FAX 2: 919-715-6048 \ Customer Service 1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity\ Affirmative Action Employe r
NOnehC 1· ort aro 1na
JVatura/~lf
Permit Number WI0800186
Program Category
Ground Water
Permit Type
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
James and Vickie Williams SFR
Location Address
5441 Blue Clay Rd
Castle Hayne
Owner
Owner Name
James
Dates/Events
NC 28429
Williams
Central Files: APS_ SWP_
03/26/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Nate Carr
Contractor Heat Pump
3308 Enterprise Dr
Wilmington NC
Major/Minor
Minor
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
James Williams
5441 Blue Clay Rd
Castle Hayne NC
28405
28429
Orig Issue
03/26/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
03/26/10
Effective
03/26/10
Expiration
03/10/10
Re g ulated Activities
Heat Pum p Injection
Outfall l\~l. _
Waterbody Name Stream Index Number Current Class Subbasin
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-OW 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 Tyne information).
DATE: February 15. 2010
Well 7} pe Confirmation: Does the proposed system circulate potable water onlN (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 (open -loop well iniecting 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): James and Vickie Williams
(1)
(2)
Mailing Address: 5441 Blue Cla4 Road
City: Castle Havne State: NC Zip Code: 28429 County: New Hanover
Home/Office Tele No.: 910- 675-3477 Cell No.: 910- 443-5999
Email Address: Website:
Physical Address of Well Site (if different than above)_
City:
State: Zip Code:
Home/Office Tele No,: Cell No.:
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: RECEIVED ! DENR 1 DVVQ
Aquifer protecgon Seeflon
GPUIUIC 5QW Notification of intent Form (Revised 812008) MAR 10 2M Page 1

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.: -----=2=5=-3-=-1--=--A=----------------------
Contact Person~: ~J=im~C-=-o=m=e=tt=e __________ =E=MA~I=L""'A~d=dr=e=ss=:--'J=im=-A~RM=@ ..... ~b~e=lls~o~u_th_.n_e_t __
Address: P.O. Box 882
City: Ham pstead Zip Code: 28443 County: __ .c:;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: O'Brien Heating and Air
Contact Person"-: -"-N=a=te=-C=arr:.:,._ __________ ---=E=MA=-"'I=L"--'A'--"-=d=dr=e=ss=:-"-N=a=te::c,;@=ob=r=ie=n=s=erv'--'--'-'ic=e"'"".c'""o=m=----
Address: 3308 Enterp rise Drive
City: Wilmin gt on Zip Code: 28405 County : ---=-N"""e'""'w~H=a=no=-v""'e~r ______ _
Office Tele No.: 910-799-6611
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 system. Water onl y. Grouted alon g the loo p's entire ly .
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: ~2=/=24"""'/""""1.a.0 ______ Number of borings: _6 ___ _
Approximate depth of each boring (feet):_"'""'2=5-=-0_' ______ _
(2) Type of tubing to be used (copper, PVC, etc): --=H=D=P~Ec,..._ __________ _
(3) Well casing. Is the well(s) cased? (check either (a.) Yes ill: (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)
(b)
(c)
Grout type: Neat Cement__ Bentonite Other (specify) _T=h=e=rm=e=x __
Grout placement: Pumping__ Pressure Other
Grout depth of tubing (reference to land surface): from 0 to 250 (feet)
If well has casing, indicate grout depth: from ____ to ____ (feet)
GPU/UIC 5QW Notification oflntent Form (Revised 8/2008) Page2
H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modificatiou of the injection equipment and extcri+ar
pipingltubing associated with the injection op= -at an. The manufacturer's brochure may provide supplementary
information.
11. LOCATION OF WELLS)
Attach two copies of maps showing the following information:
(1) include a Site Map (oaa be drawn) showing: buildings, property lines, sw&cc w:stcr bodies, potential
sources of groundwater epntamination and the orientstion of and distances between the proposed well(s) and
any existing wells) or waste disposal facilities such as septic tanks or drain fields located within 2100 fcct of
the geotherma3 heat pump wall 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
rcfercucx points such as roads, streams, and/or highway intersections.
J. CERTIFICATION
Note: This Permit Application must he signed by each person appearing on the
recorded legal property deed.
—1 hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and 41 attachments thereto and than, based on nay inquiry of those individuals
immcdiattly responmble 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 irr0sonment. for submitting
faisc Wormafion. I agree to construct, operate, maintain, repair, avid if applicable, abandon the injection well and
all related appurtenances in accordance with the approved specifications and conditioux of the Permit"
r
Signet of Property wncr/Applicant
Print or Type Full Name and -title
Signature of Property Owner/Applicant
V'I' Q � X- Wi iLO ens
Print or Type FulrName and title
Signature of Authorized Agent. if any
Print or Type Full Nnme and title
Please return two copies of the completed Application package to:
North Carolina DENR DWQ
Aquifer Protection Section-UTC Program
1636 Mail Service Center
Raleigh, NC 27699-1636 i L-EIVED) I )ENR + DWD
Telephone [phone] Aquifer Protamiort Sedon
GPUNIC 5QW Nodf:caeon of Iaten[ Form [Rovjsa3 8/2008)
MAR 10 200 %v;
SOS/SOS 6 V89S 661 016(xdI ) 01 33IA63S N3Ideo 0 81 'E2 (11HIM02-liD-d1fH

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Owner Address Parcel ID Advanced
PARIQ: R01300-008-004-003
WILLIAMS LAMES III REV LIV TR
Aerials R r F nn FW11
5441 BLUE CLAY RD CURRENT RECORD
R 1 7 of 35 M N
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List G I S Data Up date: 4-J a n-20 10
Data Copyright New Hanover County [Disclaimer] [Privacy Policy] Last Upolated: 01 Mar 2010
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PARID: ROU00-008-004-003
WILLIAMS JAMES Ill REV LIV TR
Parcel
Alt ID 324105.08.6757.000
Address 5441 BLUE CLAY RD
Unit
City CASTLE HAYNE
Zip Code
Neighborhood 2000
Class RES-Residential
Land Use Code
Living Units
Acres
Zoning
Legal
Legal Description
Tax District
10-1 Fam Res
1
1.09
R-15-RESIDENTIAL DISTRICT
( 1.08 ACRES) PT TR 7 HUTAFF LAND
FD
~--------~ Owners
Owner
City
WILLIAMS JAMES Ill REV LIV TR
CASTLE HAYNE
State
Country
Zip
NC
28429
THE DATA IS FROM 2009
5441 BLUE CLAY RD CURRENT RECORD
M ◄ I 7 of 35 j ► H
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8 Printable Summary
8 Printable Version
Data Copyright New Hanover County [Disclaimer] [Privacy Policy] Last Updated: 01 Mar 2010
Site Design Copyright 1999-2006 Akanda Group LLC. All rights reserved.
http:/ /etax.nhcgov_com/F orms/Datalets.aspx?mode=PROFILEALL&slndex=0&idx=7 &LM. .. 3/5/2010
Approximate Property Lines
Approximate Building Perimeter
Approximate Closed Loop Locations
Existing Well Location
N
i
Notes;
1. Subject property serviced by private well and off -site septic system.
2. Well locations are approximate and will be ❑ minimum of 20' apart and 25' from the building.
3. Adapted from Google Earth and New Hanover County GIS Map, March 2010.
TITLE: SITE MAP FIGURE:
:.lied Resource Management Fc 5441 BLUE CLAY ROAD
PO. Box 882, Hompstead, NC 28443JOB; SCALE; DATE; DRAWN BY:
[phone] FAX [phone] Williamst As Shown 31411 U DNH

W
it M
r7-Ld&. ,
- Approximate Property Lines
s -j 1A VIV. „f
41
Ash
Note: Adapted from Google Earth and New Hanover County GI5 Map, March 2010.
TITLE: OVERALL SITE MAP FIGURE:
7 s vlied IZeoource Management FC 5441 BLUE CLAY ROAD
❑mpsteu JOB: SCALE: !DATE: !DRAWN BY:
[910) 270-2919 FAX [phone] Williams As Shown f 3/4j 10 DNH