WI0800191_GEO THERMAL_20100413

Pe rm it Number WI0800191
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
Joseph Casper SFR
Location Address
1912 Hillsboro Dr
Wilmington
Owner
Owner Name
Joseph
Dates/Events
NC 28403
Casper
Central Files: APS_ SWP_
04/13/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Susan Casper
1912 Hillsboro Dr
Wilmington
Major/Minor
Minor
NC
Region
Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Joseph Casper
Owner
1912 Hillsboro Dr
Wilmington NC
28403
28403
Orig Issue
04/13/10
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue
04/13/10
Effective
04/13/10
Expiration
04/13/10
Re g ulated Activities
Heat Pump Inj ection
Private res idence, singl e fam ily
Outfall I L
Waterbody Name Stream Index Number Current Class Subbasin·
ir-f'A .-.-., __ _
NCDENR.
North Carolina Department of Environment and Natural Resources
Division of Water Qualiiy
Beverly Eaves Perdue
Governor
Joseph Casper
Susan Casper
1912 Hillsboro Dr.
Wilmington, NC 28403
Coleen H. Sullins
Director
4/13/2010
Subject: Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0800191
1912 Hillsboro Drive
Wilmington, NC 28403
Dear Mr. and Mrs. Casper:
Dee Freeman
Secretary
On 04/13/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-on!\
geothermal injection well system for the operation of a ground-source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met:
l. The injection well system contains only potable water,
2. The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .021 l(u)(2). Additionally, you should contact the New Hanover County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Rogers (amcdenr.eov if you have any questions.
~~
Tonya Gott
Office Assistant
cc: Wilmington Regional Office -APS
APS Central Files -Permit No . WT0800191
New Hanover County Health Dept.
Aquifer Protection Section
Nate Carr (O'Brien Heating and Air, 3308 Enterprise Dr., Wilmington, NC 28405)
Jim Cornette (Applied Resource Management, P.C., P.O . Box 882, Hampstead, NC 28443)
AQUIFER PROTECTIOt ! SECT iOr·/
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; FAX 2: 919-715-6048 \ Cusiomer Service: 1-877-623-6748
Internet: www.ncwaterquality.orq
Ari Equr 1 Opportunity\ Affirmalive Action Employer
One .
North Carolma
)Vaturattu
vxvgw191
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 ofNCAC Title 15A: 02C,0200, please
complete this notification and snail to address on the back page (please Print or Tyne information).
DATE: March 22. 2010
Well Type Confirmation: Does the proposed system circulate potable wager only (no additives) in
continuous piping that completely isolates the fluid from the environment (i_e_
closed -loon )?
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 in'ectin 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): Joseph and Susan Casper
(1)
(2)
Mailing Address: 1912 Hillsboro Drive
City: Wilmington State: NC Zip Code: 28403 County: New Hanover
HomelOffice Tele No.: 910- 763-0566 Cell No.:
Email Address: Website:
Physical Address of Well Site (if different than above):
City: State: Zip Code: County.
Home/Office Tele No.: Cell No.:
S. 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 llIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City:
Office Tele No.:
State: Zip Code.
Website Address of Company, if any:
County:
GMU1C 5QW Notificetian of Intent Form (Rwiwd 812008) RECEIVED 1 DENR 1 DWO Page 1
Aquhr Pre"on 5eelion
APR 13 Z011

C. WELL DRILLER INFORMATION
Company Name: Applied Resource Management. P.C.
Well Driller Contractor's Name: ~H=.,_. M=ic=h=a=e"'---1 S=a""g,_,,e'----------------------
NC Contractor Certification No.: ------=2=5=3-"'---1---"--A"'--------------------------
Contact Person: Jim Cornette EMAIL Address: Jim [e-mail]
Address: --~P~.O~·~B~o=x"'---8=8=2~--------------------------
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 driller)
Company Name: O'Brien Heating and Air
Contact Person.,_: -=-N_,_,a=te"-=C=arr=--------~E=MA~=IL=A=d=d=re=s=s:~N~a=t=e®=,o-=-b=ri=en=s=e"'---rv=ic=e~.c=o=m~--
Address: 3308 Enterprise Drive
City: Wilmington Zip Code: 28405 County: --~N~e~w~H=an=o"'"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 Loop geothermal system. Water only. Grouted along the loop's entirety .
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: 4/21/2010 Number of borings: __J___
Approximate depth of each boring (feet): __ .=2=50"'"'~------
(2) Type of tubing to be used (copper, PVC, etc): --"'-'HD=P_._E..__ __________ _
(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_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
Grout placement: Pumping____X_ Pressure
Other (specify) Grout (Thermex)
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 SQW Notification of Intent Form (Revised 8/2008) Page2
H. IN.IECTION-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
tnfbrmation.
1. 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 mast be signed by each person appearing on the
recorded legal }property deed.
"I hereby certify, under penalty of law, that I have personalty 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 wits pproved spe ificationnditions of the Permit."
11 I J l�r_
Print or Type Pall Name and title
signature of Property OwnerlA plit.ant
f 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-W Program
1636 Mail Service Center
Raleigh, NC 27699-1636- rtL-(;t:AVtu / Ur-M l UM
Telephone [phone] Pluifer Protection Sedlon
GPUIUIC 5QW Notification of Intent Form (Revised WOO8) APR 13 ZG19 rage 3

1, wo .
qa�
Approximate Property Lines
Approximate Building Perimeter
Approximate Closed Loop Locations
Brookh k-
ae� Road
Notes:
1. Subject property and surrounding area are serviced by public sewer and water services,
2. Well locations are ❑pproxirna#e and will be a minimum of 20' apart and 25' from the building.
3. Adapted from Google Earth and New Hanover County GI5 Map, March 2010.
TITLE' SITE MAP FIGURE.
ALt�;
2lied Resource Mana),,ement PICReSource Mann),,ement PIC _ . 1912 HILLSBORO DRIVE
O. Box 882, Hampstead, NC 28443 JOB: SCALE: DATE; DRAWN BY:
10] 270-2914 FAX [phone] Casper As Shown 3/25/10 ❑NH

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CASPER 10SEPH M SUSAN M 1912 HILLSSORO RD CURRENT RECORD
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http:lletax.nhcgov.com/Forms/MapDatalet.aspx?slndex=Q&idx=3&Limparent=20 3/26f2010